Pre-Operative Rank of Expectations for Shoulder Surgery (PRESS): A Novel Survey.

BACKGROUND: Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery. METHODS: The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of eight common expectations for elective shoulder surgery by importance and a 0-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as ASES, PROMIS PF, and PROMIS PI surveys. PROM surveys were administered six months postoperatively. RESULTS: Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete ADL's and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients that ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, while patients with instability were less satisfied. CONCLUSION: The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.

Postoperative Negative Pain Thoughts and Their Correlation With Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair: An Observational Cohort Study.

BACKGROUND: Pain and pain perception are influenced by patients' thoughts. The short form Negative Pain Thoughts Questionnaire (NPTQ-SF) can be used to quantify unhelpful negative cognitive biases about pain, but the relationship between NPTQ-SF scores and orthopaedic surgery outcomes is not known. PURPOSE/HYPOTHESIS: The purpose was to assess the relationship between negative pain thoughts, as measured by the NPTQ-SF, and patient-reported outcomes in patients undergoing arthroscopic rotator cuff repair, as well as to compare NPTQ-SF scores and outcomes between patients with and without a history of chronic pain and psychiatric history. It was hypothesized that patients with worse negative pain thoughts would have worse patient-reported outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In total, 109 patients undergoing arthroscopic rotator cuff repair were administered the 4-item NPTQ-SF, 12-item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Evaluation Form, and visual analog scale pain survey preoperatively between July 2021 and August 2022. The same surveys were completed ≥6 months postoperatively by 74 patients confirmed to have undergone arthroscopic rotator cuff repair. RESULTS: Preoperative NPTQ-SF scores did not show any correlation with the postoperative patient-reported outcomes measured in this study. Postoperative NPTQ-SF scores were statistically significantly negatively correlated with postoperative SF-12 Physical Health Score, SF-12 Mental Health Score, ASES, and satisfaction scores (P < .05). Postoperative NPTQ-SF scores were statistically significantly positively correlated with postoperative visual analog scale scores (P < .001). Moreover, postoperative NPTQ-SF scores were statistically significantly negatively correlated with achieving a Patient Acceptable Symptom State and the minimal clinically important difference on the postoperative ASES form (P < .001 and P = .009, respectively). CONCLUSION: Postoperative patient thought patterns and their perception of pain are correlated with postoperative outcomes after rotator cuff repair. This correlation suggests a role for counseling and expectation management in the postoperative setting. Conversely, preoperative thought patterns regarding pain, as measured by the NPTQ-SF, do not correlate with postoperative patient-reported outcome measures. Therefore, the NPTQ-SF should not be used as a preoperative tool to aid the prediction of outcomes after rotator cuff repair.

Tranexamic Acid and Holding Venous Thromboembolism Prophylaxis Morning of Surgery Do Not Decrease Transfusion Requirements in Patients Undergoing Anterior Intrapelvic Approach for Acetabular Open Reduction and Internal Fixation.

INTRODUCTION: The objective of this study was to determine factors that may affect transfusion rates for patients requiring an anterior intrapelvic (AIP) approach for an acetabulum fracture. METHODS: This was a multicenter retrospective comparison study (3 trauma centers at two urban academic centers). Patients who had an AIP approach for an acetabulum fracture without other notable same-day procedures (irrigation and débridement and/or external fixation were only other allowed procedures) were included. One hundred ninety-five adult (18 and older) patients had adequate records to complete analysis with no preexisting coagulopathy. The main outcome evaluated was the number of units transfused at the time of surgery and up to 7 days after surgery. RESULTS: Factors that were found to affect intraoperative transfusion rates were older age, lower preoperative hematocrit, longer surgery duration, and requiring increased intraoperative intravenous fluids. Factors that did not affect transfusion rate included sex, body mass index, hip dislocation at the time of injury, fracture pattern, AIP approach alone or with lateral window ± distal extension, Injury Severity Score, preoperative platelet count, use of tranexamic acid, and venous thromboembolism prophylaxis received morning of surgery. When followed out through the remainder of a week after surgery, the results for any factor did not change. DISCUSSION: In this large multicenter retrospective study of patients requiring an AIP approach, tranexamic acid and use of venous thromboembolism prophylaxis (or holding it the morning of surgery) did not affect transfusion rates either during surgery or up to a week after surgery. Older age, lower preoperative hematocrit level, longer surgery time, and increased intraoperative intravenous fluids were associated with higher transfusion rates. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. LEVEL OF EVIDENCE: Level 3, retrospective case-control study.

Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion.

OBJECTIVE: The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. DESIGN: Retrospective review. SETTING: Three level 1 trauma centers at 2 academic institutions. PATIENT SELECTION CRITERIA: Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). OUTCOME MEASURES AND COMPARISONS: Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery. RESULTS: 195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277-733] mL early versus 364 [IQR 160-661] delayed by Gross method, P = 0.017; 165 [IQR 99-249] g of Hgb early versus 143 [IQR 55-238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05). CONCLUSION: There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors and Characteristics of Recalcitrant Osteomyelitis After Initial Surgical and Antibiotic Treatment.

OBJECTIVES: To evaluate the injury, patient, and microbiological characteristics that place patients at risk for recalcitrant fracture-related infection and osteomyelitis despite appropriate initial treatment. DESIGN: Retrospective chart review. SETTING: Three level I trauma centers. PATIENTS AND PARTICIPANTS: Two hundred and fifty-seven patients undergoing surgical debridement and antibiotic therapy for osteomyelitis from 2003 to 2019. MAIN OUTCOME MEASUREMENTS: Patients were categorized as having undergone serial bone debridement if they had 2 separate procedures a minimum of 6 weeks apart with a full course of appropriate antibiotics in between. Patient records were reviewed for age, injury location, body mass index, smoking status, comorbidities, and culture results including the presence of multidrug-resistant organisms and culture-negative osteomyelitis. RESULTS: A total of 257 patients were identified; 49% (n = 125) had a successful single course of treatment, and 51% (n = 132) required repeat debridement for recalcitrant osteomyelitis. At the index treatment for osteomyelitis, the most common organisms in both groups were methicillin-resistant (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA). There was no significant difference in incidence of polymicrobial infection between the 2 groups (25% vs. 20%, P = 0.49). The most common organisms cultured at the time of repeat saucerization remained MRSA and MSSA; however, the same organism was cultured from both the index and repeat procedures in only 28% (n = 37) of cases. Diabetic patients, intravenous drug use status, delay to diagnosis, and open fractures of the lower leg are independent risk factors for failure of initial treatment of posttraumatic osteomyelitis. CONCLUSIONS: Successful eradication of fracture-related infection and posttraumatic osteomyelitis is difficult and fails 51% of the time despite standard surgical and antimicrobial therapy. Although MRSA and MSSA remain the most common organisms cultured, patients who fail initial treatment for osteomyelitis often do not culture the same organisms as those obtained at the index procedure. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The COVID-19 pandemic and follow-up for shoulder surgery: The impact of a shift toward telemedicine on validated patient-reported outcomes.

INTRODUCTION: The emergence of COVID-19 and its ensuing restrictions on in-person healthcare has resulted in a sudden shift towards the utilization of telemedicine. The purpose of this study is to assess patient satisfaction and patient-reported outcome measures (PROMs) for individuals who underwent follow-up for shoulder surgery using telemedicine compared to those who received traditional in-person clinic follow-up. METHODS: Patients who underwent either rotator cuff repair or total shoulder arthroplasty during a designated pre-COVID-19 (traditional clinic follow-up) or peri-COVID-19 (telemedicine follow-up) span of time were identified. PROMs including the American Shoulder and Elbow Surgeons standardized assessment form, the three-level version of the EQ-5D form, the 12-Item Short Form survey, and a modified version of a published telemedicine survey were administered to participants six months post-operatively via phone call. RESULTS: Sixty patients agreed to participate. There was no significant difference between the pre-COVID-19 and peri-COVID-19 groups in patient satisfaction with their follow-up visit (p = 0.289), nor was there a significant difference in PROMs between the two groups. In total, 83.33% of the telemedicine group and 70.37% of the in-person clinic group preferred traditional in-person follow-up over telemedicine. DISCUSSION: In a cohort of patients who underwent telemedicine follow-up for shoulder surgery during the COVID-19 pandemic, there was no difference in patient satisfaction and PROMs compared to traditional in-person clinic follow-up. This study indicates that while the majority of participants preferred face-to-face visits, patients were relatively satisfied with their care and had similar functional outcome scores in both groups, despite the large disruption in healthcare logistics caused by COVID-19.

Recent Advances in the Endoscopic Management of Gastro-esophageal Reflux Disorder: A Review of Literature.

Gastro-esophageal reflux disorder (GERD) is the most common gastrointestinal tract disorder with high morbidity and heavy economic burden. Despite being treated with high-dose proton-pump inhibitors or H2 receptor blockers, a considerable percentage of patients have GERD that is only partially controlled or refractory. The majority of these patients forego surgical treatment for fear of adverse outcomes, putting them at a financial disadvantage and causing loss of productivity. Untreated GERD is the sole known risk factor for developing Barrett's esophagus and esophageal adenocarcinoma if left untreated. With the advancement in therapeutic modalities in recent years, and given the issues such as medication compliance, the risk of adverse events with long-term antisecretory treatment, and fear of undergoing surgical treatment, endoscopic treatments such as Stretta and transoral incisionless fundoplication (TIF) have become a safe, cost-effective, and resilient option for the treatment of refractory GERD. Patients with refractory GERD ineligible for endoscopic therapies due to a large hiatal hernia can have their hiatal hernia corrected simultaneously with TIF (C-TIF). For the treatment of refractory GERD, endoscopic therapy is a viable and compelling option. Endoscopic therapies for refractory GERD patients are highly recommended due to their reproducible and standardized results as well as the potential to address the fundamental mechanical issue.

Low interobserver and intraobserver reliability using the Matta radiographic system for intraoperative assessment of reduction following acetabular ORIF.

INTRODUCTION: The system described by Matta for rating acetabular fracture quality of reduction following ORIF has been used extensively throughout the literature. However, the reliability of this system remains to be validated. We sought to determine the interobserver and intraobserver reliability of this system when used by fellowship-trained pelvic and acetabular surgeons to evaluate intraoperative fluoroscopy. METHODS: This is a retrospective evaluation of a prospectively collected acetabular fracture database at an academic level I trauma center. The quality of reduction of all acetabular fractures treated with open reduction internal fixation (ORIF) between May 2013 and December 2015 was assessed using three standard intraoperative fluoroscopic views (anteroposterior and two 45˚ oblique Judets). Displacement of ≤1 mm was considered to be an anatomic reduction, 2-3 mm imperfect, and >3 mm poor according to the system described by Matta. A total of 107 acetabular fractures treated with ORIF with complete intraoperative fluoroscopic images during that time period were available for review. Acetabular fracture reductions were reviewed by the operative surgeon at the time of surgery and subsequently reviewed by two fellowship-trained pelvic and acetabular surgeons. All reduction assessments were performed in a blinded fashion. The primary outcome measure was interobserver reliability for assessing reduction quality. This was evaluated using a weighted kappa (κw) statistic between each evaluator and the operative surgeon and a generalized kappa (κg) for all 3 surgeons. After a 6-week "washout interval," the surgeons reviewed the images again and intraobserver agreement was calculated using a weighted kappa statistic. RESULTS: Interobserver reliability based on the initial assessment was low (κg = 0.09); however, did slightly improve with the second assessment to fair (κg = 0.24). Intraobserver reliability ranged from slight (κw = 0.20) to moderate (κw = 0.53) among the surgeons. DISCUSSION: Low interobserver and intraobserver reliability was found when quality of reduction was assessed with intraoperative fluoroscopic images by the operative and two other pelvic and acetabular surgeons using the Matta system. Given the importance of an anatomic reduction on functional and radiographic outcomes, an accurate and reliable system for assessing intraoperative quality of reduction is essential.

Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores After Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection. METHODS: Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition. RESULTS: A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (ß = 0.275, P < 0.001). CONCLUSION: Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention. LEVEL OF EVIDENCE: III, diagnostic cohort study.

Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures.

OBJECTIVE: To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients. DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS: One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures. INTERVENTION: Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures. MAIN OUTCOME MEASURES: Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges. RESULTS: Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year. CONCLUSIONS: Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Outcomes of Massive Rotator Cuff Tear Repair: A Systematic Review.

BACKGROUND: With an increase in the treatment options available for massive rotator cuff tears, understanding the long-term outcomes of the chosen modality is important. QUESTIONS/PURPOSE: The purpose of this study was to systematically review the available literature on repair of massive rotator cuff repairs and learn the longevity of outcomes, the failure rate, outcomes after failure, and any contributing factors to poor outcomes or failure. METHODS: We conducted a systematic review of the MEDLINE, Cochrane, and Embase databases to find studies that investigated the long-term results of repair of massive rotator cuff repairs. Studies were excluded if they did not stratify results of massive tears, provide a definition for a massive rotator cuff tear, or report isolate patients with long-term follow-up. RESULTS: Six studies met the inclusion criteria, for a total of 472 shoulders; average patient age was 57.6 years. Follow-up ranged from 119 to 240 months. Outcome scores improved significantly following repair and were maintained throughout follow-up. The repair failure rate across studies was 39.2%. Patients who suffered retear had significantly worse outcome scores than patients with intact tendons at long-term follow-up. CONCLUSIONS: The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence. This review found repair of massive rotator cuff tears leads to long-term maintained improvements in outcome measures. Failure of repair is quite common, but results following failure are superior to preoperative outcomes.

Patellar Morphology and Osteoarthritis: A Cadaveric Analysis.

Previous studies have attempted to characterize patellar morphology and its relation to patellofemoral osteoarthritis but have utilized relatively small samples. We designed a large-scale cadaveric analysis to elucidate any potential relationship. Patellar morphology in 1,032 patellae was characterized using patellar facet concavity patterns initially developed by Wiberg and using the ratio of the lateral and medial facet lengths. Patellofemoral arthritis grading for specimens was previously completed based primarily on osteophytic burden. The average age at time of death was 56 ± 10 years. Wiberg's grading returned kappa values of 0.43 for intrarelator reliability and 0.27 for interrelator reliability. Using multiple regression analysis, Wiberg's type II was found to be correlated with patellofemoral arthritis (p = 0.003). Lateral to medial facet ratio measurements returned intraclass coefficients of 0.91 for intrarelator reliability and 0.85 for interrelator reliability. There was no association between lateral to medial facet ratio and osteoarthritis. Regression analysis between Wiberg's typing and lateral-to-medial ratio (L:M) resulted in a coefficient of determination of 0.14. To our knowledge, this is the largest study evaluating the relationship between patellar morphology and arthritis. Although there was a relationship between Wiberg's type II and patellofemoral arthritis, the Wiberg systems was not easily reproducible in our study and returned a correlation with arthritis different then anatomically expected. A more reproducible system of lateral to medial facet ratio was investigated but did not find an association with arthritic changes. Given these findings, we did not find a patella morphology grading system which is both reliable and valid in regard to association with patellofemoral arthritis.

No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis.

INTRODUCTION: Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur fractures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fellowship training. METHODS: A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers (January 1st, 1985-May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria. Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were included and graded by MINOR and Newcastle-Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI). RESULTS: There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR: 1.03; 95% CI: 0.25-4.23). Pooled data analysis revealed TAD > 25 mm (n = 310) was associated with higher odds of increased cut-out rate relative to TAD < 25 mm (n = 730) (OR: 3.72; 95% CI: 2.06-6.72). CONCLUSION: Our review suggests that cephalomedullary implant type (lag screw vs. helical blade) is not a risk factor for implant cut-out. Consistent with the previous literature, increased tip-apex distance > 25 mm is a reliable predictor of implant cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out. LEVEL OF EVIDENCE: Level III.

Graft choice or drilling technique does not influence outcomes of ACL reconstruction in patients over forty-five.

PURPOSE: To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45. METHODS: From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes. RESULTS: Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24-60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45-66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability. CONCLUSIONS: In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up. LEVEL OF EVIDENCE: Therapeutic IV, Case Series.

What are the risk factors associated with limited musculoskeletal health literacy in shoulder arthroplasty patients?

OBJECTIVES: Low health literacy is both pervasive in the United States and a substantial barrier to satisfactory patient care and the appropriate utilization of healthcare resources. This prospective study aims to evaluate the factors that contribute to limited musculoskeletal literacy in patients who undergo shoulder arthroplasty. METHODS: Ninety patients undergoing shoulder replacement surgery completed demographics and Literacy in Musculoskeletal Problems (LiMP) surveys. Scores of less than six were considered indicative of limited musculoskeletal literacy. RESULTS: The overall percentage of participants with limited musculoskeletal literacy was 38.8%. Multivariable logistic regression analysis with multiple imputation modeling demonstrated a significant positive relationship between patient income and adequate LiMP scores (p = 0.009) with an odds ratio of 1.15 (CI: 1.04; 1.28) while level of education (p = 0.173) and patient ethnicity (p = 0.830) among other patient characteristics did not have a significant relationship with LiMP scores. CONCLUSION: In patients undergoing shoulder replacement surgery, low income was the only variable found to be predictive of limited musculoskeletal health literacy scores. Therefore, when discussing the risks and benefits of shoulder arthroplasty, orthopaedic surgeons should be cognizant of the possibility that any given patient may not meet the threshold of adequate musculoskeletal literacy.

Does preoperative disease severity influence outcomes in reverse shoulder arthroplasty for cuff tear arthropathy?

BACKGROUND: The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA. METHODS: Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function. RESULTS: A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up. CONCLUSION: The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review.

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

Patient-Reported Outcomes Measurement Information System Scores Are Inconsistently Correlated With Legacy Patient-Reported Outcome Measures in Shoulder Pathology: A Systematic Review.

PURPOSE: To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care. METHODS: A systematic review of the available literature on PROMIS scores in shoulder care was performed. This review was accomplished per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS: A total of 11 studies that reported data on 1485 patients met inclusion criteria. There was a strong correlation between general function PROMs and the PROMIS PF for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and proximal humerus fractures. In addition, there was a strong correlation between PROMIS UE and legacy PROMs in patients with rotator cuff injury and shoulder instability. PROMIS instruments asked fewer questions than legacy PROMs (9.46 vs 12.99, respectively), took less time to complete (88.21 vs 96.53 seconds, respectively), had less floor effects in both PROMIS PF and UE (0.17% and 0.62% vs 2.89%, respectively), and had lower ceiling effects for PROMIS PF but not PROMIS UE assessments (0.17% and 6.37% vs 1.89%, respectively). CONCLUSIONS: This systematic review demonstrated PROMIS instruments have varying correlations with legacy PROMs measures for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and glenohumeral arthritis. PROMIS instruments do measure clinical outcomes faster and with fewer questions. Other than PROMIS UE v1.2 ceiling effects, PROMIS instruments have lower rates of floor and ceiling effects. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Does preoperative diagnosis impact patient outcomes following reverse total shoulder arthroplasty? A systematic review.

BACKGROUND: The indications for reverse total shoulder arthroplasty (rTSA) have expanded to include the treatment of a wide variety of shoulder pathologies, and there may be significant differences in patient outcomes based on preoperative diagnosis. METHODS: A systematic review of the orthopedic literature contained in the PubMed, Cochrane, and Embase databases was performed on November 14, 2019. Studies investigating rTSA indicated for 7 distinct preoperative diagnoses (massive rotator cuff tear [MCT] without glenohumeral osteoarthritis [GHOA], MCT with GHOA or cuff tear arthropathy, primary GHOA, inflammatory arthritis with MCT, failed shoulder arthroplasty, proximal humeral fracture [PHF], and sequelae following PHF) were included. The main outcomes of interest included functional outcomes (abduction, external rotation, and forward flexion) and patient-reported outcome measures (American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score). Because of significant variation in measurement and reporting, data on internal rotation were not extracted. In addition, radiographic outcomes and complication rates were extracted and recorded for each of the included studies. RESULTS: In total, 47 studies, comprising 2280 patients, met the inclusion criteria. Significant improvements in functional outcomes and patient-reported outcome measures were found across the preoperative diagnostic groups. There were no significant differences between the diagnostic groups regarding improvement between preoperative and postoperative values for the outcomes of interest, with the exception that the inflammatory arthropathy group had significantly less improvement in the Constant-Murley score than the primary GHOA and revision arthroplasty groups. Although there were few differences in improvement between groups, there were significant differences regarding the level of postoperative functional performance, which was not as consistent in the context of trauma or revision operations (ie, complex PHF, fracture sequela, and revision arthroplasty groups). CONCLUSION: Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. The groups with primary GHOA and MCTs with or without GHOA demonstrated the most reliable postoperative functional outcomes of the examined diagnostic groups. Postoperative outcomes were not as consistent in the context of trauma or revision operations, and these groups may benefit from a variety of modern advancements in rTSA, although further research into these modalities for these groups is needed. Finally, rTSA remains an important treatment option in the context of rheumatoid arthritis, with similar outcomes and complication rates compared with the 6 other operative indications.

Factors that influence inpatient satisfaction after shoulder arthroplasty.

BACKGROUND: It is important to distinguish satisfaction regarding the outcome of care and satisfaction with the delivery of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are modern assessments of hospitals and providers of delivery of care. The purpose of this study was to report inpatient satisfaction according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) scores after shoulder arthroplasty and to determine factors that influence them, as well as their correlation with surgical expectations, pain perception, quality of life, surgical setting, and functional outcomes. METHODS: All patients scheduled for a shoulder arthroplasty were prospectively asked to complete a demographic and initial shoulder assessment form, a shoulder surgery expectations survey, a pain catastrophizing scale, the SF-12 (12-item Short Form) survey, and a resiliency form (Resilience Scale 11). Patient satisfaction was measured with the CG-CAHPS and HCAHPS surveys. Legacy forms, patient-specific factors, type of surgery performed, location of surgery, length of hospital stay, and discharge disposition were evaluated on their ability to predict these survey scores. Linear regression was used to calculate correlations and predictions of continuous variables, and logistic regression was used to compared the satisfied vs. unsatisfied cohorts. RESULTS: The average HCAHPS and CG-CAHPS satisfaction scores for the population were 74.7 ± 20.7 and 82.1 ± 19.4, respectively. Nonsmokers had a mean HCAHPS score of 77.7 ± 22.0, whereas current smokers reported a mean of 59.6 ± 5.2 (P = .03). Patients who were discharged home had a mean HCAHPS score of 77.3 ± 21.9, whereas those discharged to a skilled nursing facility reported a mean of 59.3 ± 6.6 (P = .05). These same groups also had significantly higher odds of being satisfied with the hospital. No significant differences or higher odds were seen for comparisons between overall CG-CAHPS satisfaction and any of the patient-specific factors tested. There was no significant correlation between age, length of stay, pain (pain catastrophizing scale), resiliency (Resilience Scale 11), expectations (shoulder surgery expectations survey), or function (SF-12) and both the HCAHPS and CG-CAHPS satisfaction scores. CONCLUSION: Overall, 37 patients (74%) had CG-CAHPS scores that indicated satisfaction and 34 patients (68%) had HCAHPS scores that indicated satisfaction. Nonsmokers and patients discharged home after surgery report higher levels of inpatient hospital (HCAHPS) satisfaction after shoulder arthroplasty. Patients with high preoperative surgical expectations, pain perception, and resiliency are not generally more satisfied with the hospital or clinician. Preoperative diagnosis, location of surgery, and length of stay do not reliably impact satisfaction with the hospital or clinician. Inpatient HCAHPS and CG-CAHPS satisfaction does not correlate with legacy functional outcome measures and, therefore, may not be predictive of long-term functional outcomes.