Inaxaplin for Proteinuric Kidney Disease in Persons with Two APOL1 Variants.

BACKGROUND: Persons with toxic gain-of-function variants in the gene encoding apolipoprotein L1 (APOL1) are at greater risk for the development of rapidly progressive, proteinuric nephropathy. Despite the known genetic cause, therapies targeting proteinuric kidney disease in persons with two APOL1 variants (G1 or G2) are lacking. METHODS: We used tetracycline-inducible APOL1 human embryonic kidney (HEK293) cells to assess the ability of a small-molecule compound, inaxaplin, to inhibit APOL1 channel function. An APOL1 G2-homologous transgenic mouse model of proteinuric kidney disease was used to assess inaxaplin treatment for proteinuria. We then conducted a single-group, open-label, phase 2a clinical study in which inaxaplin was administered to participants who had two APOL1 variants, biopsy-proven focal segmental glomerulosclerosis, and proteinuria (urinary protein-to-creatinine ratio of ≥0.7 to <10 [with protein and creatinine both measured in grams] and an estimated glomerular filtration rate of ≥27 ml per minute per 1.73 m2 of body-surface area). Participants received inaxaplin daily for 13 weeks (15 mg for 2 weeks and 45 mg for 11 weeks) along with standard care. The primary outcome was the percent change from the baseline urinary protein-to-creatinine ratio at week 13 in participants who had at least 80% adherence to inaxaplin therapy. Safety was also assessed. RESULTS: In preclinical studies, inaxaplin selectively inhibited APOL1 channel function in vitro and reduced proteinuria in the mouse model. Sixteen participants were enrolled in the phase 2a study. Among the 13 participants who were treated with inaxaplin and met the adherence threshold, the mean change from the baseline urinary protein-to-creatinine ratio at week 13 was -47.6% (95% confidence interval, -60.0 to -31.3). In an analysis that included all the participants regardless of adherence to inaxaplin therapy, reductions similar to those in the primary analysis were observed in all but 1 participant. Adverse events were mild or moderate in severity; none led to study discontinuation. CONCLUSIONS: Targeted inhibition of APOL1 channel function with inaxaplin reduced proteinuria in participants with two APOL1 variants and focal segmental glomerulosclerosis. (Funded by Vertex Pharmaceuticals; VX19-147-101 ClinicalTrials.gov number, NCT04340362.).

Urinary Plasminogen as a Marker of Disease Progression in Human Glomerular Disease.

RATIONALE & OBJECTIVE: Glomerular disorders have a highly variable clinical course, and biomarkers that reflect the molecular mechanisms underlying their progression are needed. Based on our previous work identifying plasminogen as a direct cause of podocyte injury, we designed this study to test the association between urine plasmin(ogen) (ie, plasmin and its precursor plasminogen) and end-stage kidney disease (ESKD). STUDY DESIGN: Multicenter cohort study. SETTING & PARTICIPANTS: 1,010 patients enrolled in the CureGN Cohort with biopsy-proven glomerular disease (focal segmental glomerulosclerosis, membranous nephropathy, and immunoglobulin A nephropathy). PREDICTORS: The main predictor was urine plasmin(ogen) at baseline. Levels were measured by an electrochemiluminescent immunoassay developed de novo. Traditional clinical and analytical characteristics were used for adjustment. The ratio of urine plasmin(ogen)/expected plasmin(ogen) was evaluated as a predictor in a separate model. OUTCOME: Progression to ESKD. ANALYTICAL APPROACH: Cox regression was used to examine the association between urinary plasmin(ogen) and time to ESKD. Urinary markers were log2 transformed to approximate normal distribution and normalized to urinary creatinine (Log2uPlasminogen/cr, Log2 urinary protein/cr [UPCR]). Expected plasmin(ogen) was calculated by multiple linear regression. RESULTS: Adjusted Log2uPlasminogen/cr was significantly associated with ESKD (HR per doubling Log2 uPlasminogen/cr 1.31 [95% CI, 1.22-1.40], P<0.001). Comparison of the predictive performance of the models including Log2 uPlasminogen/cr, Log2 UPCR, or both markers showed the plasmin(ogen) model superiority. The ratio of measured/expected urine plasmin(ogen) was independently associated with ESKD: HR, 0.41 (95% CI, 0.22-0.77) if ratio<0.8 and HR 2.42 (95% CI, 1.54-3.78) if ratio>1.1 (compared with ratio between 0.8 and 1.1). LIMITATIONS: Single plasmin(ogen) determination does not allow for the study of changes over time. The use of a cohort of mostly white patients and the restriction to patients with 3 glomerular disorders limits the external validity of our analysis. CONCLUSIONS: Urinary plasmin(ogen) and the ratio of measured/expected plasmin(ogen) are independently associated with ESKD in a cohort of patients with glomerular disease. Taken together with our previous experimental findings, urinary plasmin(ogen) could be a useful biomarker in prognostic decision making and a target for the development of novel therapies in patients with proteinuria and glomerular disease. PLAIN-LANGUAGE SUMMARY: Glomerular diseases are an important cause of morbidity and mortality in patients of all ages. Knowing the individual risk of progression to dialysis or transplantation would help to plan the follow-up and treatment of these patients. Our work studies the usefulness of urinary plasminogen as a marker of progression in this context, since previous studies indicate that plasminogen may be involved in the mechanisms responsible for the progression of these disorders. Our work in a sample of 1,010 patients with glomerular disease demonstrates that urinary plasminogen (as well as the ratio of measured to expected plasminogen) is associated with the risk of progression to end-stage kidney disease. Urine plasminogen exhibited good performance and, if further validated, could enable risk stratification for timely interventions in patients with proteinuria and glomerular disease.

Examining the Trajectory of Health-Related Quality of Life among Coronavirus Disease Patients.

BACKGROUND: Recent studies have reported a reduction in health-related quality of life (HR-QoL) among post-coronavirus disease 2019 (COVID-19) patients. However, there remains a gap in research examining the heterogeneity and determinants of HR-QoL trajectory in these patients. OBJECTIVE: To describe and identify factors explaining the variability in HR-QoL trajectories among a cohort of patients with history of COVID-19. DESIGN: A prospective study using data from a cohort of COVID-19 patients enrolled into a registry established at a health system in New York City. PARTICIPANTS: Participants were enrolled from July 2020 to June 2022, and completed a baseline evaluation and two follow-up visits at 6 and 12 months. METHODS: We assessed HR-QoL with the 29-item Patient Reported Outcomes Measurement Information System instrument, which was summarized into mental and physical health domains. We performed latent class growth and multinomial logistic regression to examine trajectories of HR-QoL and identify factors associated with specific trajectories. RESULTS: The study included 588 individuals with a median age of 52 years, 65% female, 54% White, 18% Black, and 18% Hispanic. We identified five physical health trajectories and four mental health trajectories. Female gender, having pre-existing hypertension, cardiovascular disease, asthma, and hospitalization for acute COVID-19 were independently associated with lower physical health. In addition, patients with increasing body mass index were more likely to experience lower physical health over time. Female gender, younger age, pre-existing asthma, arthritis and cardiovascular disease were associated with poor mental health. CONCLUSIONS: We found significant heterogeneity of HR-QoL after COVID-19, with women and patients with specific comorbidities at increased risk of lower HR-QoL. Implementation of targeted psychological and physical interventions is crucial for enhancing the quality of life of this patient population.

Patients With Segond Fracture Demonstrate Similar Rates of Return to Sport and Psychological Readiness After Anterior Cruciate Ligament Reconstruction: A Matched Cohort Study at Minimum 2-Year Follow-Up.

PURPOSE: To compare clinical outcomes, rate of return to sports, and psychological readiness among patients undergoing anterior cruciate ligament reconstruction (ACLR) with and without concomitant Segond fracture. METHODS: We retrospectively identified patients who underwent primary ACLR from January 2012 to December 2020 with minimum 2-year follow-up. Exclusion criteria were additional ligamentous injury, age <16 years, or a concomitant lateral augmentation procedure. Preoperative knee radiographs were reviewed to identify Segond fractures. Identified patients were matched 1:2 to controls by age/sex/body mass index/graft type. Charts were reviewed for pre- and postoperative knee stability. Surveys administered included preinjury sport participation and return status, Lysholm score, Tegner activity scale, and ACL-Return to Sport Index (ACL-RSI), a metric of psychological sport readiness. Multivariable logistic regression was conducted to identify predictors of return to sport. RESULTS: There were 120 patients who were included in the final analysis (40 Segond, 80 controls) at a mean follow-up of 5.7 ± 2.4 years. A total of 52.5% of patients received bone-patellar tendon-bone autograft. The overall rate of return to sport was 79.5% in the Segond group compared with an 83.8% rate of return in the control group (P = .569). In total, 48.7% of the Segond group and 56.8% of the control group returned to their preinjury level of sport (P = .415). Lysholm (89.6 ± 10.3 vs 85.4 ± 16.7, P = .296), Tegner (5.7 ± 1.8 vs 6.1 ± 2.2, P = .723), and ACL-RSI (62.2 ± 25.4 vs 56.6 ± 25.4, P = .578) scores were similar between Segond and control groups. There was a single graft failure in the Segond group 5 years' postoperatively. Increasing ACL-RSI score was significantly predictive of return to sport (P < .001). CONCLUSIONS: Patients who had an ACL tear and a concomitant Segond fracture who underwent isolated ACLR without lateral augmentation procedures had similar clinical outcomes and rates of return sport compared with a matched isolated ACLR control group at minimum 2-year follow-up. There was no significant difference in psychological readiness between groups as measured by the ACL-RSI. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Comparable Clinical and Functional Outcomes Between Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation for Articular Cartilage Lesions in the Patellofemoral Joint at a Mean Follow-up of 5 Years.

PURPOSE: To assess clinical outcomes and return to sport (RTS) rates among patients who undergo osteochondral allograft (OCA) transplantation and autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI), for patellofemoral articular cartilage defects. METHODS: A retrospective review of patients who underwent an OCA or ACI/MACI from 2010 to 2020 was conducted. Patient-reported outcomes collected included visual analog scale for pain/satisfaction, Knee Injury and Osteoarthritis Outcome Score (KOOS), and RTS. The percentage of patients that met the patient acceptable symptom state for KOOS was recorded. Logistic regression was used to identify predictors of worse outcomes. RESULTS: A total of 95 patients were included (78% follow-up) with ACI or MACI performed in 55 cases (57.9%) and OCA in 40 (42.1%). A tibial tubercle osteotomy was the most common concomitant procedure for OCA (66%) and ACI/MACI (98%). Overall, KOOS pain was significantly poorer in OCA than ACI/MACI (74.7, 95% confidence interval 68.1-81.1 vs 83.6, 95% confidence interval 81.3, 88.4, P = .012), whereas the remaining KOOS subscores were nonsignificantly different (all P > .05). Overall, RTS rate was 54%, with no significant difference in return between OCA or ACI/MACI (52% vs 58%, P = .738). There were 26 (27%) reoperations and 5 (5%) graft failures in the entire group. Increasing age was associated with lower satisfaction in OCA and poorer outcomes in ACI/MACI, whereas larger lesion area was associated with lower satisfaction and poorer outcomes in ACI/MACI. CONCLUSIONS: Clinical and functional outcomes were similar in patients who underwent OCA or ACI/MACI for patellofemoral articular cartilage defects at a mean follow-up of 5 years. Patients who received OCA had a greater proportion of degenerative cartilage lesions and, among those with trochlear lesions, reported greater pain at final follow-up than their ACI/MACI counterparts. Overall, increasing age and a larger lesion size were associated with worse patient-reported outcomes. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee.

PURPOSE: The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS). METHODS: A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS) and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status. RESULTS: A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scores and lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001). CONCLUSION: Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return. LEVEL OF EVIDENCE: Level III.

More negative sagittal tibial tuberosity-trochlear groove distances are correlated with larger patellofemoral chondral lesion size.

PURPOSE: The purpose of this study is to assess the association between sagittal tibial tuberosity-trochlear groove (sTT-TG) distance and patellofemoral chondral lesion size in patients undergoing cartilage restoration procedures. METHODS: A retrospective cohort analysis of patients who underwent an osteochondral allograft transplantation or matrix-induced autologous chondrocyte implantation in the patellofemoral compartment, from 2010 to 2020, were included if they had patellofemoral high-grade lesions, magnetic resonance imaging (MRI) and minimum 2-year follow-up. The preoperative sTT-TG distance was measured independently on axial T2-weighted MRI sequences by two authors, each at least two weeks apart. Intraoperative lesion size was reported according to operative report measurements by the attending surgeon. An interclass correlation coefficient (ICC) was calculated to assess intra- and inter-rater reliability, and categorical data analysis and linear regression models were used to assess the relationship between sTT-TG and lesion size. RESULTS: A total of 80 patients (50 females) with a mean age of 31.5 ± 10.4 years, body mass index of 27.0 ± 5.9 kg/m2 and follow-up of 61.5 ± 21.4 months were included. A total of 107 lesions were present: 63 patients with unipolar (patella = 41, trochlea = 22) and 22 with bipolar lesions. The mean MRI defect size was 1.6 ± 1.0 cm2 and the mean intraoperative defect size was 3.8 ± 2.4cm2. Intra- (ICC: 0.99,0.98) and inter-rater reliability (ICC: 0.96) were excellent for both MRI defect size and sTT-TG measurements. The mean sTT-TG was -4.8 ± 4.9 mm and was significantly inversely related to MRI defect size (-0.45, p < 0.01), intraoperative patellar lesion size (-0.32, p = 0.01), total lesion area (-0.22, p = 0.04), but not trochlear lesion size (-0.09, p = 0.56). Multivariable regression demonstrated a more negative sTT-TG remained an independent variable correlated with larger MRI-measured patellofemoral defect sizes and intraoperative patellar lesions. CONCLUSION: A more negative sTT-TG was an independent variable correlated with larger patellofemoral lesions in patients undergoing patellofemoral cartilage restoration. LEVEL OF EVIDENCE: Level III, Diagnostic.

Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction.

PURPOSE: To investigate the rate of return to sports and sport psychological readiness between patients who underwent isolated MPFLR (iMPFLR) compared to a matched cohort of patients who underwent MPFLR with anteromedializing tibial tubercle osteotomy (MPFLR/TTO). METHODS: Patients who underwent primary MPFLR with or without TTO for recurrent patellar instability were retrospectively reviewed from 2012 to 2020 at a single institution. Preinjury sport and work information, Kujala, Tegner, Visual Analogue Score for pain, satisfaction and MPFL-Return to Sport after Injury (MPFL-RSI) score were collected. Two readers independently measured the tibial tuberosity-trochlear groove distance, Caton-Deschamps index and Dejour classification for trochlear dysplasia. Patients in iMPFLR and MPFLR/TTO groups were matched 1:1 on age, sex, body mass index and follow-up length. Multivariate regression analysis was performed to determine whether the MPFL-RSI was associated with a return to sport. RESULTS: This study included 74 patients at mean follow-up of 52.5 months (range: 24-117). These groups returned to sport at similar rates (iMPFLR: 67.6%, MPFLR/TTO: 73.0%, not significant [ns]), though iMPFLR patients returned more quickly (8.4 vs. 12.8 months, p = 0.019). Rates of return to preinjury sport level were also similar (45.9% vs. 40.5%, ns). Patients with Dejour B/C took more time to return to sport compared to patients with mild/no trochlear pathology (13.8 vs. 7.9 months, p = 0.003). Increasing MPFL-RSI score was significantly predictive of the overall return to sport (odds ratio [OR]: 1.08, 95% confidence interval [CI] [1.03, 1.13], p < 0.001) and return to preinjury level (OR: 1.07, 95% CI [1.04, 1.13], p < 0.001). Most patients in iMPFLR and MPFLR/TTO groups resumed work (95.7% vs. 88.5%, ns), though iMPFLR patients who returned to preinjury work levels did so more quickly (1.7 vs. 4.6 months, p = 0.005). CONCLUSION: Patients who underwent MPFLR with anteromedializing TTO demonstrated similar rates of return to sport and psychological readiness compared to an isolated MPFLR matched comparison group, though iMPFLRs returned more quickly. Patients with more severe trochlear pathology required more time to return to sports. LEVEL OF EVIDENCE: Level III.

Patient-reported allergies are associated with increased rate of postoperative stiffness after arthroscopic rotator cuff repair.

BACKGROUND: Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS: Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS: Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION: PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.

High Rate of Patient Satisfaction with Either Telemedicine or Traditional Office-Based Follow-Up Visit After Arthroscopic Shoulder Surgery.

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

Segond fracture: an indicator for increased risk of lateral meniscus injury in patients with acute anterior cruciate ligament ruptures.

PURPOSE: The purpose of this study was to investigate the incidence and anatomic distribution of meniscus injury in patients who have sustained acute ACL injuries with and without concomitant Segond fracture. We hypothesized that patients who have sustained a torn ACL with a concomitant Segond fracture would have a higher incidence of lateral meniscal injuries than patients with an isolated ACL injury. METHODS: Patients who underwent ACL reconstruction from 2012 to 2022 were retrospectively reviewed. Segond fractures were identified on knee radiographs. Inclusion criteria were age 18-40, injury during sports activity, and reconstruction within 90 days of injury. Sports activity, anatomic location of meniscus injury, and meniscus treatment were documented. Multivariable regression was used to identify predictors of meniscus injury/treatment. RESULTS: There were 25 of 603 (4.1%) patients who had an ACL tear with concomitant Segond fracture. The incidence of lateral meniscus injury in the Segond group (72%) was significantly higher than in the non-Segond cohort (49%; p = 0.024). A significantly smaller proportion of medial meniscus injuries among patients with Segond fractures were repaired (23.1%) compared to the non-Segond group (54.2%; p = 0.043). Multivariate analysis found patients with Segond fractures to have increased odds of lateral meniscus injury (OR 2.68; [1.09, 6.60], p = 0.032) and were less likely to have medial meniscus injuries repaired (OR 0.35; [0.15, 0.81], p = 0.014). Additionally, males had increased odds of lateral meniscus injury (OR 1.54; [1.08 - 2.91], p = 0.017), which were more likely to require repair (OR 1.48; [1.02, 2.14], p = 0.038). CONCLUSIONS: Among acute ACL injuries, the incidence of lateral meniscus injury is greater among patients with Segond fractures. Patients with Segond fracture were less likely to undergo repair of medial meniscal injuries.

Patients who undergo bilateral medial patellofemoral ligament reconstruction return to sport at a similar rate as those that undergo unilateral reconstruction.

PURPOSE: Lateral patellar instability is a debilitating condition not only to athletes, but also to a wide range of highly active individuals. Many of these patients experience symptoms bilaterally, though it is unknown how these patients fair with return to sports following a second medial patellofemoral ligament reconstruction (MPFLR). The purpose of this study is to evaluate the rate of return to sport following bilateral MPFLR compared to a unilateral comparison group. METHODS: Patients who underwent primary MPFLR with minimum 2-year follow-up were identified from 2014 to 2020 at an academic center. Those who underwent primary MPFLR of bilateral knees were identified. Pre-injury sport participation and Tegner score, Kujala score, Visual Analog Score (VAS) for pain, satisfaction, and MPFL-Return to Sport after Injury (MPFL-RSI) scale were collected. Bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, body mass index, and concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed regarding concomitant TTO. RESULTS: The final cohort consisted of 63 patients, including 21 patients who underwent bilateral MPFLR, matched to 42 unilateral patients at mean follow-up of 47 ± 27 months. Patients who underwent bilateral MPFLR returned to sport at a rate of 62% at a mean of 6.0 ± 2.3 months, compared to a unilateral rate of 72% at 8.1 ± 4.2 months (n.s.). The rate of return to pre-injury level was 43% among bilateral patients and 38% in the unilateral cohort. There were no significant differences in VAS pain, Kujala, current Tegner, satisfaction, and MPFL-RSI scores between cohorts. Approximately half of those (47%) who failed to return to sport cited psychological factors and had significantly lower MPFL-RSI scores (36.6 vs 74.2, p = 0.001). CONCLUSION: Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. MPFL-RSI was found to be significantly associated with return to sport. LEVEL OF EVIDENCE: III.

Barriers to Telehealth Utilization Among Patients of Limited Income with Chronic Conditions and a Gap in Care.

Objective: This study assessed barriers and facilitators to telehealth utilization among patients living in New York City public housing with chronic conditions and a gap in clinical care. Methods: Community health workers performed outreach to eligible patients by telephone between January and March 2021. Consenting respondents answered questions about telehealth barriers, including internet and cell phone access, ownership of digital devices, comfort with using digital devices, comfort with telehealth, cost, awareness, and availability of written materials in patients' preferred language. We obtained demographic and medical information from patients' electronic health records. We used multivariable logistic regression to estimate the association of barriers with the odds of self-reported prior telehealth utilization. Results: A total of 304 consenting patients participated in the program. The average patient had 3.1 telehealth barriers; 76% reported at least one barrier. Regression analysis showed sizable reductions in prior telehealth utilization associated with the barriers of unlimited cell phone minutes (odds ratio [OR]: 0.21 [0.05-0.88], p = 0.033), technological comfort (OR: 0.33 [0.13-0.82], p = 0.016), conceptual comfort with telehealth (OR: 0.15 [0.04-0.54], p = 0.004), and materials in the patient's preferred language (OR: 0.23 [0.07-0.79], p = 0.02). Discussion: With a high prevalence of telehealth barriers, patients with limited income, a chronic condition, and a care gap may benefit from greater technological access and supportive programs for awareness, telehealth comfort, and navigation support. Addressing telehealth barriers could increase the quality of medical care and improve health outcomes for this population.

Association of Vaccination with the Persistence of Post-COVID Symptoms.

BACKGROUND: Patients who have had COVID-19 often report persistent symptoms after resolution of their acute illness. Recent reports suggest that vaccination may be associated with improvement in post-acute symptoms. We used data from a prospective cohort to assess differences in post-acute sequelae of COVID (PASC) among vaccinated vs. unvaccinated patients. METHODS: We used data from a cohort of COVID-19 patients enrolled into a prospective registry established at a tertiary care health system in New York City. Participants underwent a baseline evaluation before COVID-19 vaccines were available and were followed 6 months later. We compared unadjusted and propensity score-adjusted baseline to 6-month change for several PASC-related symptoms and measures: anosmia, respiratory (cough, dyspnea, phlegm, wheezing), depression, anxiety, post-traumatic stress disorder (PTSD; COVID-19-related and other trauma), and quality-of-life domains among participants who received vs. those who did not receive COVID-19 vaccination. RESULTS: The study included 453 COVID-19 patients with PASC, of which 324 (72%) were vaccinated between the baseline and 6-month visit. Unadjusted analyses did not show significant differences in the baseline to 6-month change in anosmia, respiratory symptoms, depression, anxiety, PTSD, or quality of life (p > 0.05 for all comparisons) among vaccinated vs. unvaccinated patients. Similar results were found in propensity-adjusted comparisons and in secondary analyses based on the number of vaccine doses received. CONCLUSIONS: Our findings suggest that COVID vaccination is not associated with improvement in PASC. Additional studies are needed to better understand the mechanisms underlying PASC and to develop effective treatments.

Estimated Time to Maximum Medical Improvement of Intra-articular Injections in the Treatment of Knee Osteoarthritis-A Systematic Review.

PURPOSE: The purpose of the current study is to perform a systematic review of the literature and evaluate maximum medical improvement and minimal clinically important difference (MCID) of different injectables in the treatment of symptomatic knee osteoarthritis. METHODS: A systematic review was performed to evaluate maximum medical improvement and MCID in patients undergoing injections of different modalities for knee osteoarthritis. Demographic factors of the patients being reviewed were analyzed, with patient-reported outcomes as reported by visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) being used to evaluate the clinical trajectory of patients receiving intra-articular injections. RESULTS: Overall, 79 (level of evidence I: 79) studies met inclusion criteria, with 8761 patients. Corticosteroid (CS) injections, middle molecular weight hyaluronic acid (MMW-HA), and leukocyte-rich platelet rich plasma (LR-PRP) injections reached their maximum pain control at 4 to 6 weeks after injection, as measured by VAS. The lowest VAS scores were reached for low molecular weight hyaluronic acid (LMW-HA), high molecular weight hyaluronic acid (HMW-HA), and leukocyte-poor platelet rich plasma (LP-PRP) by 3 months after injection. Similarly, the WOMAC scores were lowest at 4 to 6 weeks after CS and MMW-HA injections, and at 3 months after HMW-HA and LP-PRP injections. LR-PRP demonstrated the most prolonged pain relief relative to the other injection types, with the lowest VAS score of all groups measured at final follow-up. LP-PRP showed the lowest WOMAC scores at final follow-up, one year post-injection. CONCLUSION: PRP injections provide continued pain relief at up to 1 year after injection. Corticosteroids and hyaluronic acid have good efficacy and are suitable for many patients but lack this longevity. LEVEL OF EVIDENCE: Level I, a systematic review of Level I studies.

High Rate of Satisfaction and Return to Play at 5-Year Follow-Up After Arthroscopic Superior-Labrum Anterior-Posterior Repairs.

PURPOSE: The purpose of this study was to evaluate the outcomes of patients 5 years postoperatively following arthroscopic SLAP repair, and to evaluate factors associated with satisfaction. METHODS: A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multilinear regression models were used to evaluate factors affecting postoperative satisfaction. RESULTS: Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport preoperatively. The mean follow-up was 86.4 ± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 ± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patients that had a biceps tenodesis. VAS during sport (P = .025), SSV (P < .001), and time to RTP (P = .0056), were associated with higher satisfaction. CONCLUSION: There was a high rate of satisfaction at 5-year follow-up, with excellent patient-reported outcomes but with one-tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their preinjury level, and overhead athletes took longer to RTP. LEVEL OF EVIDENCE: IV, case series.

Open Subpectoral Biceps Tenodesis May Be an Alternative to Arthroscopic Repair for SLAP Tears in Patients Under 30.

PURPOSE: The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years. METHODS: A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant. RESULTS: Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (P > .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; P = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; P = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; P > .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (P = .11). CONCLUSIONS: In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Distal posterolateral corner injury in the setting of multiligament knee injury increases risk of common peroneal palsy.

PURPOSE: The purpose of this study was to identify if the location of posterolateral corner (PLC) injury was predictive of clinical common peroneal nerve (CPN) palsy. METHODS: A retrospective chart review was conducted of patients presenting to our institution with operative PLC injuries. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. A fellowship-trained musculoskeletal radiologist reviewed the PLC injury and categorized it into distal, middle and proximal injuries with or without a biceps femoral avulsion. The CPN was evaluated for signs of displacement or neuritis. RESULTS: Forty-seven operatively managed patients between 2014 and 2019 (mean age-at-injury 29.5 ± 10.7 years) were included in this study. Eleven (23.4%) total patients presented with a clinical CPN palsy. Distal PLC injuries were significantly associated with CPN palsy [9 (81.8%) patients, (P = 0.041)]. Nine of 11 (81.8%) patients with CPN palsy had biceps femoral avulsion (P = 0.041). Of the patients presenting with CPN palsy, only four (36.4%) patients experienced complete neurologic recovery. Three of 7 patients (43%) with an intact CPN had full resolution of their clinically complete CPN palsy at the time of follow-up (482 ± 357 days). All patients presenting with a CPN palsy also had a complete anterior cruciate ligament (ACL) rupture in addition to a PLC injury (P = 0.009), with or without a posterior cruciate ligament (PCL) injury. No patient presenting with an isolated pattern of PCL-PLC injury (those without ACL tears) had a clinical CPN palsy. CONCLUSION: Distal PLC injuries have a strong association with clinical CPN palsy, with suboptimal resolution in the initial post-operative period. Specifically, the presence of a biceps femoris avulsion injury was highly associated with a clinical CPN palsy. Additionally, CPN palsy in the context of PLC injury has a strong association with concomitant ACL injury. Furthermore, the relative rates of involvement of the ACL vs. PCL suggest that specific injury mechanism may have an important role in CPN palsy. LEVEL OF EVIDENCE: IV.

Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies.

BACKGROUND: The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair. METHODS: Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability. RESULTS: Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%). CONCLUSIONS: Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

Telemedicine Utilization at an Academic Medical Center During COVID-19 Pandemic: Are Some Patients Being Left Behind?

Introduction: The purpose of this study was to examine the use of telemedicine at one academic health care center during the COVID-19 pandemic to identify opportunities to improve access to this novel delivery method of care. Methods: All patients who underwent telemedicine visits at one urban academic medical center between March 2020 and June 2020 were included. All departments were included including surgical and nonsurgical. Demographic data, primary language, and visit type were collected. Primary zip code was used as surrogate for socioeconomic status through use of the zip code median household income. The demographics of the New York metropolitan area were obtained through the U.S. Census Bureau and used as a control cohort. Results: A total of 362,413 telemedicine visits met inclusion criteria with the majority of visits performed in April and May; 127,851 (35.3%) and 110,166 (30.4%), respectively. The highest performing department was Internal Medicine, which performed 72,796 visits or 20% of the total cohort. In our cohort of telemedicine patients, 59.6% identified as White, 11.4% as Black, and 5.7% as Asian. This is less diverse than the overall population of the metropolitan area, which is 17.5% Black and 11.5% Asian. There was also a large gender gap in the utilization of telemedicine services in general, where women (60.2%) were more likely than men (39.8%) to utilize the virtual visits. In addition, although over a third of patients in the Metropolitan area have median household incomes of <50,000, this population only represented 13.6% of our total cohort. Conclusions: This study highlights both the capability of telemedicine to provide care at a large urban academic medical center during a pandemic in addition to identifying potential gaps in care with telemedicine. The disparities highlighted in our cohort stress the importance of outreach to non-White older patients of lower socioeconomic status.