Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review.

PURPOSE: To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up. METHODS: A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale. RESULTS: Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%. CONCLUSIONS: The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level III, systematic review of Level I-III studies.

How Fellowship Training Affects Complication Rate After Shoulder Arthroplasty: A Nationwide Assessment.

BACKGROUND: Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperation remains unknown. METHODS: The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. Only surgeons who performed a minimum of 10 cases were selected; and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00023 RESULTS: In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship- trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting am 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort. CONCLUSION: Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow has the lowest pooled complication rates overall.

Concomitant Treatment of High-Grade Cartilage Lesions Mitigates Risk of Meniscal Allograft Transplant Failure.

PURPOSE: To identify frequently studied significant preoperative risk factors for meniscal allograft transplantation (MAT) failure. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to conduct this systematic review. The database analysis was performed in May of 2022 and included PubMed, Embrace, and Cochrane. Studies between January 1, 2000, and January 1, 2021, were reviewed with search terms, including "meniscal," "meniscus," "transplantation," "transplant," and "allograft." Twenty-one full-text manuscripts met inclusion criteria of studies assessing preoperative risk factors for MAT failure defined as either clinical failure (Lysholm <65) or surgical failure (revision, removal, or conversion to knee arthroplasty). RESULTS: In total, 21 studies were included, comprising 47.6% with a Level of Evidence of Level III and 52.4% with Level of Evidence IV. The analysis involved 2,533 patients, and the mean final follow-up ranged from 2.2 to 20.0 years. The presence of high-grade cartilage defects was the only factor found predictive of MAT surgical failure in the majority of studies in which it was analyzed (5/7 studies, 71.4%). Four of the five studies that found high-grade cartilage defects to be a predictor of MAT surgical failure did not treat all cartilage lesions, while the 2 studies that found high-grade cartilage defects an insignificant predictor of MAT surgical failure treated all defects at the time of MAT. For clinical failure, no risk factors were predictive of MAT failure in the majority of studies, although smoking and concomitant ligamentous or realignment procedures were significant in 1 study. CONCLUSION: The presence of untreated high-grade cartilage appears to elevate the risk of surgical MAT failure; however, concomitant treatment of defects may mitigate their detrimental effect. There is no clear risk factor that consistently predicts clinical failure. Age, sex, BMI, knee compartment, time from prior meniscectomy, femorotibial alignment (after correction), concomitant cartilage procedure, and laterality do not routinely impact MAT failure. LEVEL OF EVIDENCE: Level IV, systematic review.

Consistent Indications and Good Outcomes Despite High Variability in Techniques for Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the current literature regarding the indications, techniques, and outcomes after 2-stage revision anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search was performed using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. Inclusion criteria was limited to Level I-IV human studies reporting on indications, surgical techniques, imaging, and/or clinical outcomes of 2-stage revision ACLR. RESULTS: Thirteen studies with 355 patients treated with 2-stage revision ACLR were identified. The most commonly reported indications were tunnel malposition and tunnel widening, with knee instability being the most common symptomatic indication. Tunnel diameter threshold for 2-stage reconstruction ranged from 10 to 14 mm. The most common grafts used for primary ACLR were bone-patellar tendon-bone (BPTB) autograft, hamstring graft, and LARS (polyethylene terephthalate) synthetic graft. The time elapsed from primary ACLR to the first stage surgery ranged from 1.7 years to 9.7 years, whereas the time elapsed between the first and second stage ranged from 21 weeks to 13.6 months. Six different bone grafting options were reported, with the most common being iliac crest autograft, allograft bone dowels, and allograft bone chips. During definitive reconstruction, hamstring autograft and BPTB autograft were the most commonly used grafts. Studies reporting patient-reported outcome measures showed improvement from preoperative to postoperative levels in Lysholm, Tegner, and objective International Knee and Documentation Committee scores. CONCLUSIONS: Tunnel malpositioning and widening remain the most common indications for 2-stage revision ACLR. Bone grafting is commonly reported using iliac crest autograft and allograft bone chips and dowels, whereas hamstring autograft and BPTB autograft were the most used grafts during the second-stage definitive reconstruction. Studies showed improvements from preoperative to postoperative levels in commonly used patient reported outcomes measures. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

Complication Rates After Medial Patellofemoral Ligament Reconstruction Range From 0% to 32% With 0% to 11% Recurrent Instability: A Systematic Review.

PURPOSE: To review the incidence of complications following primary medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. METHODS: A literature search was conducted by querying PubMed and Scopus databases from database inception through August 2022 according to the 2020 Preferred Reporting Items for Systematic Review and Meta-analysis guidelines using the terms "Medial Patellofemoral Ligament," "MPFL," "reconstruction," "patellar," and "instability." Inclusion criteria included studies reporting complications following primary MPFL reconstruction for recurrent patellar instability. Exclusion criteria consisted of studies reporting on patients undergoing concurrent osteotomy procedures, revision reconstruction, and biomechanical or anatomic studies. The incidence of specific complications was aggregated from the included studies. RESULTS: Twenty-eight studies, consisting of 1,478 patients (n = 1521 knees), with a mean age of 23.3 years (mean range, 19-34.3 years) were identified. The overall incidence of complications ranged from 0% to 32.3% of knees. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures occurred in 0% to 8.3% of knees, primarily in patients treated with full-length transverse tunnel or 2-tunnel techniques. All patellar fractures occurred in patients with patellar tunnels ranging from 4.5 to 6.0 mm in diameter. The incidence of postoperative knee stiffness/range of motion deficit ranged from 0% to 20%. Persistent anterior knee pain, ranged from 0% to 32.3%. CONCLUSIONS: Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees, primarily consisting of residual anterior knee pain. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures were reported in 0% to 8.3% of knees. Fractures primarily occurred with a full-length transverse tunnel or 2-tunnel techniques, whereas all fractures occurred with patellar tunnels ranging from 4.5 mm to 6.0 mm in diameter. LEVEL OF EVIDENCE: IV; Systematic Review of Level I-IV studies.

Costs of shoulder and elbow procedures are significantly reduced in ambulatory surgery centers compared to hospital outpatient departments.

BACKGROUND: Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs. METHODS: Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon's fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests. RESULTS: Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs. CONCLUSION: Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings.

An evidence-based approach to managing unexpected positive cultures in shoulder arthroplasty.

BACKGROUND: Unexpected positive cultures (UPCs) are very commonly found during shoulder arthroplasty when surgeons send intraoperative cultures to rule out periprosthetic joint infection (PJI) without clinical or radiographic signs of infection. Cutibacterium acnes is thought to be the most common bacteria cultured in this setting; however, the implications of an unexpected positive result are neither well defined nor agreed upon within the literature. The current review evaluates the incidence of UPCs and C acnes in reverse total arthroplasty; the clinical significance, if any, of these cultures; and various prognostic factors that may affect UPC incidence or recovery following PJI. METHODS: A systematic review was performed with PRISMA guidelines using PubMed, CINAHL, and Scopus databases. Inclusion criteria included studies published from January 1, 2000, to May 20, 2021, that specifically reported on UPCs, native or revision shoulder surgery, and any study that directly addressed one of our 6 proposed clinical questions. Two independent investigators initially screened 267 articles for further evaluation. Data on study design, UPC rate/speciation, UPC risk factors, and UPC outcomes were analyzed and described. RESULTS: A total of 22 studies met the inclusion criteria for this study. There was a pooled rate of 27.5% (653/2373) deep UPC specimen positivity, and C acnes represented 76.4% (499/653) of these positive specimens. Inanimate specimen positivity was reported at a pooled rate of 20.1% (29/144) across 3 studies. Male patients were more likely to have a UPC; however, the significance of prior surgery, surgical approach, and type of surgery conflicted across multiple articles. Patient-reported outcomes and reoperation rates did not differ between positive-UPC and negative-UPC patients. The utilization of antibiotics and treatment regimen varied across studies; however, the reinfection rates following surgery did not statistically differ based on the inclusion of antibiotics. CONCLUSION: UPCs are a frequent finding during shoulder surgery and C acnes represents the highest percentage of cultured bacteria. Various preoperative risk factors, surgical techniques, and postoperative treatment regimens did not significantly affect the incidence of UPCs as well as the clinical outcomes for UPC vs. non-UPC patients. A standardized protocol for treatment and follow-up would decrease physician uncertainty when faced with a UPC from shoulder surgery. Given the results of this review, shoulder surgeons can consider not drastically altering the postoperative clinical course in the setting of UPC with no other evidence of PJI.

The Associations of Spine Surgeon Training, Office Wait Times, and Social Media Presence with Reviews on Physician Rating Websites.

This study evaluated the associations of demographics and social media (SM) usage on physician review websites for spine surgeons in New Jersey and Pennsylvania. Three physician rating websites were accessed to obtain training history, number of ratings/reviews, and overall rating (0-5). Surgeon web pages and publicly searchable SM accounts on Facebook (FB), Twitter (T), and/or Instagram (IG) were recorded. Of 246 spine surgeons included, 95.9% had a personal/institutional website while 12.2% were present on at least one SM platform. Physician age was inversely correlated with Healthgrades.com (HG), Vitals.com (V), and Google.com (G) ratings (p < 0.0001). Physicians with SM had higher ratings on HG (p = 0.006) and V (p = 0.006). Spine surgeons with SM received more ratings, comments, and higher scores than those without SM. All review sites agree that SM presence correlated with the number of ratings and comments across physician review websites, suggesting SM may influence patient feedback. (Journal of Surgical Orthopaedic Advances 31(4):256-262, 2022).

Social media use by shoulder and elbow surgeons increases the number of ratings on physician review websites.

BACKGROUND: The use of physician review websites by patients is increasingly frequent. One potential way for shoulder and elbow surgeons to enhance their online reputation and attract patients is via social media, yet its impact is unknown. This study sought to analyze the effect of social media use on the number of online ratings and overall rating of shoulder and elbow surgeons. We secondarily studied variables affecting social media use. METHODS: The American Shoulder and Elbow Surgeons directory was probed to identify practicing surgeons. Surgeon evaluation data, including ratings, comments, and reviews, were compiled from 3 physician review websites (Google, Healthgrades, and Vitals). Google was queried to assess for a professional Facebook, Twitter, or Instagram account, as well as obtain information on surgeon training, practice location, and other demographic variables. RESULTS: A total of 646 surgeons met the inclusion criteria (93.8% male and 6.2% female surgeons). Overall, 37% had a professional social media account (Facebook, 23.1%; Twitter, 24.1%; and Instagram, 9.4%). Linear regression analysis showed that Facebook use correlated with an average increase of 48.6 in the number of ratings. No social media platform correlated with physician rating. The surgeons more likely to use social media were those who graduated residency in 2000 or later (40.8% vs. 29.2%), those who practiced in cities with higher populations (mean, 1188.9 vs. 708.4 [per 1000]), and those with more surgeons practicing in the same city (mean, 7.0 vs. 5.0). CONCLUSION: The majority of shoulder and elbow surgeons do not have a professional social media account. Those using this platform are younger and located in more populous cities with more competition. Having a professional social media profile was not correlated with ratings, but there was a positive association with the number of online ratings, and Facebook had the strongest association. Surgeon ratings are overwhelmingly positive with minimal variability; therefore, a high number of ratings confirms a surgeon's exceptional reputation. The residency graduation year, city population, and number of nearby surgeons affected ratings, although the absolute differences were minimal. For shoulder and elbow surgeons, a professional social media account correlates with an increase in the number of online physician ratings. Recent graduates practicing in competitive locations may feel increased pressure to leverage this in an attempt to build their practices.

Preoperative Corticosteroid Injections Are Not Associated with Deep Infection after Unicompartmental Knee Arthroplasty.

Prior to unicompartmental knee arthroplasty (UKA), corticosteroid injections (CSI) are a common nonoperative treatment for arthritis. It is unclear whether CSI prior to UKA impacts the likelihood of postoperative infection. This study sought to determine if there is a time- and/or dose-dependent relationship between preoperative CSI and postoperative infection. An administrative claims database was queried for patients undergoing UKA with more than 1 year of pre-enrollment and follow-up. Of 31,676 patients with a UKA who met enrollment criteria, 8,628 patients had a CSI 0 to 3 months prior to surgery, 111 had a CSI 3 to 12 months prior to surgery, and 22,937 never received an injection. Overall, 246 postoperative deep infections were reported (0.8%). Time-dependent and dose-dependent relationships were modeled using multivariable logistic regressions. Postoperative deep infections occurred in 64 patients with CSI 0 to 3 months prior to surgery (0.7%), compared with 0 patients with CSI 3 to 12 months before surgery (0.0%) and 182 controls (0.8%, p = 0.58). CSI within 1 month prior to UKA was not statistically associated with postoperative infection (p = 0.66). Two or more CSI within 3 months prior to UKA were associated with a twofold elevated odds of infection, compared with receiving a single injection (odds ratio [OR]: 2.08, p = 0.03). Univariable predictors of infection included younger age, increasing Charlson Comorbidity Index, smoking, asthma, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, liver disease, and obesity. Multivariable analysis controlling for these characteristics elicited no relationship between recent CSI administration and postoperative infection. CSI within 3 months of surgery (1.5%) or 3 to 12 months (1.8%) were associated with increased conversion to total knee arthroplasty (TKA) compared with those who did not receive an injection (1.1%, p = 0.01), although TKA for indication of periprosthetic joint infection was not statistically different (p = 0.72). Preoperative CSI within 3 months of UKA is not associated with postoperative infection, although significant medical comorbidity does show an association. Preoperative CSI is associated with increased conversion from UKA to TKA for noninfectious indications.

Meniscal Radial Tears: A Classification System Based on Tear Morphology.

Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded, coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-making.

Publicly Available Anatomic Total Shoulder Arthroplasty Rehabilitation Protocols Show High Variability and Frequent Divergence from the 2020 ASSET Recommendations.

Background: In 2020, the American Society of Shoulder and Elbow Therapists (ASSET) published an evidence-based consensus statement outlining postoperative rehabilitation guidelines following anatomic total shoulder arthroplasty (TSA). Purpose: The purpose of this study was to (1) quantify the variability in online anatomic TSA rehabilitation protocols, and (2) assess their congruence with the ASSET consensus guidelines. Methods: This study was a cross-sectional investigation of publicly available, online rehabilitation protocols for anatomic TSA. A web-based search was conducted in April 2022 of publicly available rehabilitation protocols for TSA. Each collected protocol was independently reviewed by two authors to identify recommendations regarding immobilization, initiation, and progression of passive (PROM) and active range of motion (AROM), as well as the initiation and progression of strengthening and post-operative exercises and activities. The time to initiation of various components of rehabilitation was recorded as the time at which the activity or motion threshold was permitted by the protocol. Comparisons between ASSET start dates and mean start dates from included protocols were performed. Results: Of the 191 academic institutions included, 46 (24.08%) had publicly available protocols online, and a total of 91 unique protocols were included in the final analysis. There were large variations seen among included protocols for the duration and type of immobilization post-operatively, as well as for the initiation of early stretching, PROM, AROM, resistance exercises, and return to sport. Of the 37 recommendations reported by both the ASSET and included protocols, 31 (83.78%) were found to be significantly different between groups (p\<0.05). Conclusion: Considerable variability was found among online post-operative protocols for TSA with substantial deviation from the ASSET guidelines. These findings highlight the lack of standardization in rehabilitation protocols following anatomic TSA. Level of Evidence: 3b.

A Systematic Review of Adverse Events and Complications After Isolated Posterior Medial Meniscus Root Repairs.

BACKGROUND: Medial meniscus posterior root (MMPR) tears are recognized as a substantial cause of disability and morbidity. However, meniscus root repair, regardless of technique, is not without potential complications. PURPOSE: To evaluate the reported incidence of complications and adverse events after isolated MMPR repair. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using Embase, PubMed, and Scopus databases with the following search terms combined with Boolean operators: "meniscus,""root," and "repair." Inclusion criteria consisted of level 1 to 4 human clinical studies in English or English-language translation reporting complications and adverse events after isolated posterior medial meniscus root repairs. The overall incidence of specific complications was estimated from the pooled sample of the included studies. RESULTS: Eleven studies with a total pooled sample of 442 patients were identified. The mean patient age was 58.1 years, while the mean final follow-up time was 37.2 months (range, 12-84.8 months). The overall incidence of complications was 9.7% (n = 43/442), with the most commonly reported complication being progressive degenerative changes within the knee (10.4%; n = 25/240; n = 5 studies). A total of 1.25% (n = 3/240) of patients who experienced degenerative changes required conversion to total knee arthroplasty. Repair failures were reported in 3.1% (n = 10/327; n = 8 studies) of patients. CONCLUSION: Repairing MMPR tears is critical in preventing accelerated progression of knee osteoarthritis in patients without significant knee osteoarthritis preoperatively. While this repair is still recommended and necessary in appropriate patients, this review found that the incidence of complications after isolated posterior medial meniscus root repair was 9.7%, primarily involving the presence of progressive degeneration, while repair failure was reported in 3% of patients.

Analysis of patient-directed search content and online resource quality for ulnar collateral ligament injury and surgery.

Background: Patients use the Internet to learn information about injuries, yet online content remains largely unstudied. This study analyzed patient questions posed online regarding ulnar collateral ligament (UCL) tears or UCL surgical management. Methods: Three separate search strings about UCL tear and UCL surgery were queried on the Google search engine. The 300 most commonly asked questions were compiled for each topic and associated webpage information was collected from the "People also ask" section. Questions were categorized using the Rothwell classification and webpages by Journal of the American Medical Association (JAMA) benchmark criteria. Results: The most frequent UCL tear questions were "how long does it take to heal a torn UCL?" and "what is nonsurgical treatment for the UCL?" The most frequent UCL surgery question was "can you retear your UCL after surgery?" The Rothwell classification of questions for UCL tear/UCL surgery was 55%/32% policy, 38%/57% fact, and 7%/11% value with highest subcategories being indications/management (46%/25%) and technical details (24%/25%). The most common webpages were academic (39%/29%) and medical practice (24%/26%). Mean JAMA score for all 600 webpages was low (1.2), with journals (mean = 3.4) having the highest score. Medical practice (mean = 0.5) and legal websites (mean = 0.0) had the lowest JAMA scores. Only 30% of webpages provided UCL-specific information. Conclusion: Online UCL patient questions commonly pertain to technical details and injury management. Webpages suggested by search engines contain information specific to UCL tears and surgery only one-third of the time. The quality of most webpages provided to patients is poor, with minimal source transparency.

Clinical outcomes, return to sport, and complications after isolated primary Latarjet versus Latarjet as a revision procedure: A systematic review and meta-analysis.

BACKGROUND: The purpose of this review was to compare clinical outcomes, return to sport (RTS), and complications in comparative studies examining patients undergoing primary Latarjet procedure versus Latarjet in the revision setting following soft tissue stabilization. METHODS: A literature search was conducted using PubMed and Scopus databases using Preferred Reporting Items for Systematic Meta-Analyses guidelines. Inclusion criteria consisted of level I to III human clinical studies reporting clinical outcomes (Visual Analogue Pain Scale [VAS]), RTS metrics, and complications in patients following primary versus revision Latarjet procedures. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: A total of seven studies, consisting of 1170 patients (n=1179 shoulders) with a mean age of 26.4 years, consisting of 91.9% males (n=1083/1179 shoulders), were identified. Mean final follow-up was 46.4 (mean range, 7.3-72.2) months. A total of 748 primary and 431 revision Latarjet procedures were analyzed. Complications were reported in 9.6% (range, 0%-24.2%) of patients undergoing primary and 20.2% (range, 0%-40.7%) in patients undergoing revision procedures (p=0.22). There was no significant difference in the RTS rate between patients undergoing primary (87.3%; range, 83.8%-92.1%) versus Latarjet as a revision procedure (78.9%; range, 60%-100%) (p=0.08). Moreover, no significant difference in postoperative VAS was observed in patients undergoing primary versus Latarjet as a revision procedure (p=0.21). Recurrent shoulder subluxation was significantly greater in patients undergoing revision (12.0%; n=31/259 shoulders; range, 0%-20.7%) compared to primary procedures (3.3%; n=27/511 shoulders; range, 0%-9%) (p<0.001). DISCUSSION: Patients undergoing primary and revision Latarjet demonstrated overall similar rates of complications and return to sport. Of clinical importance, Latarjet as a revision procedure possessed a risk of recurrent subluxation 3.6 times higher than primary Latarjet. While effective, patients should be counseled regarding the differing prognosis between Latarjet as a primary or revision procedure. LEVEL OF EVIDENCE: III; Systematic review and meta-analysis.

Patient-Directed Online Education for Carpal Tunnel Syndrome and Release: Analysis of What Patients Ask and Quality of Resources.

Purpose: This study classifies common questions searched by patients from the Google search engine and categorizes the types and quality of online education resources used by patients regarding carpal tunnel syndrome (CTS) and carpal tunnel release (CTR). Methods: Google's results were extracted and compiled using the "People also ask" function for frequent questions and associated web pages for CTS and CTR. Questions were categorized using Rothwell's classification with further topic subcategorization. Web pages were evaluated by using Journal of the American Medical Association Benchmark Criteria for source quality. Results: Of the 600 questions evaluated, "How do I know if I have carpal tunnel or tendonitis?" and "What causes carpal tunnel to flare up?" were the most commonly investigated questions for CTS. For CTR, frequent questions investigated included "How long after hand surgery can I drive" and "How do you wipe after carpal tunnel surgery." The most common questions for CTS by Rothwell classification were policy (51%), fact (41%), and value (8%) with the highest subcategories being indications/management (46%) and technical details (27%). For CTR, the most common questions entailed fact (54%), policy (34%), and value (11%) with the highest subcategories as technical details (31%) and indications/management (26%). The most common web pages were academic and medical practice. The mean Journal of the American Medical Association score for all 600 web pages was 1.43, with journals (mean = 3.91) having the highest score and legal (mean = 0.52) and single surgeon practice websites (mean = 0.28) having the lowest scores. Conclusions: Patients frequently inquire online about etiology, precipitating factors, diagnostic criteria, and activity restrictions regarding CTS/CTR. Overall, the quality of online resources for this topic was poor, especially from single surgeon practices and legal websites. Clinical relevance: Understanding the type and quality of information patients are accessing assists physicians in tailoring counseling to patient concerns and facilitates informed decision-making regarding CTS/CTR as well as guiding patients to high-quality online searches.

Rotator cuff repair: what questions are patients asking online and where are they getting their answers?

BACKGROUND: This study analyzed questions searched by rotator cuff patients and determined types and quality of websites providing information. METHODS: Three strings related to rotator cuff repair were explored by Google Search. Result pages were collected under the "People also ask" function for frequent questions and associated webpages. Questions were categorized using Rothwell classification and topical subcategorization. Webpages were evaluated by Journal of the American Medical Association (JAMA) benchmark criteria for source quality. RESULTS: One hundred twenty "People also ask" questions were collected with associated webpages. Using the Rothwell classification of questions, queries were organized into fact (41.7%), value (31.7%), and policy (26.7%). The most common webpage categories were academic (28.3%) and medical practice (27.5%). The most common question subcategories were timeline of recovery (21.7%), indications/ management (21.7%), and pain (18.3%). Average JAMA score for all 120 webpages was 1.50. Journal articles had the highest average JAMA score (3.77), while commercial websites had the lowest JAMA score (0.91). The most commonly suggested question for rotator cuff repair/ surgery was, "Is rotator cuff surgery worth having?," while the most commonly suggested question for rotator cuff repair pain was, "What happens if a rotator cuff is not repaired?" CONCLUSIONS: The most commonly asked questions pertaining to rotator cuff repair evaluate management options and relate to timeline of recovery and pain management. Most information is provided by medical practice, academic, and medical information websites, which have highly variable reliability. By understanding questions their patients search online, surgeons can tailor preoperative education to patient concerns and improve postoperative outcomes.

Custom, 3-Dimensional Patient-Specific Instrumentation in Anatomic Total Shoulder Arthroplasty: Part 3-Prosthesis Placement, Subscapularis Repair, and Postoperative Rehabilitation.

The proposed benefits of stemless humeral implants include greater bone preservation, decreased cortical stress shielding, less risk of diaphyseal stress risers, decreased surgical time, and greater ease of implant removal during revision surgery. In part 3 of this comprehensive technique series on the management of glenohumeral arthritis, we present our step-by-step surgical technique for use of a patient-specific 3-dimensionally printed glenoid drill guide, placement of a stemless anatomic total shoulder prosthesis, and subscapularis repair, and we highlight our protocol for postoperative rehabilitation.

Custom, 3-Dimensional Patient-Specific Instrumentation in Anatomic Total Shoulder Arthroplasty: Part 1-Preoperative Assessment, Preoperative Planning, and Guide Design.

Successful total shoulder arthroplasty relies on a multitude of factors specific to patients, implant selection, and surgical technique. Among technical factors, correct intraoperative placement of prosthetic components is paramount. Three-dimensional computed tomography has emerged as a vital tool, allowing surgeons to measure glenoid inclination, glenoid version, and humeral head subluxation more accurately and reproducibly. Several commercial preoperative planning software resources are available to determine the optimal size and positioning of prosthetic components yet do so at significant cost and with meaningful time constraints. At our institution, we have applied the principles of these technologies to develop a custom, 3-dimensionally printed glenoid guide for accurate placement of the central pin. In this technical note, we describe our evaluation of patients with glenohumeral arthritis, as well as our step-by-step procedure for designing and printing a custom patient-specific instrumentation glenoid guide for anatomic total shoulder arthroplasty.

Patients With Femoroacetabular Impingement Obtain Information From Low-Quality Sources Online and Are Most Interested in Conservative Treatment and Expected Recovery.

Purpose: To investigate the type of questions patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) are searching online and determine the type and quality of the online sources from the top results to each query by the "people also ask" Google algorithm. Methods: Three search strings pertaining to FAI were carried out through Google. The webpage information was manually collected from the "People also ask" Google algorithm. Questions were categorized using Rothwell's classification method. Each website was assessed using Journal of the American Medical Association Benchmark Criteria for source quality. Results: A total of 286 unique questions were collected with their associated webpages. The most common questions included: "How do you treat femoroacetabular impingement and labral tears without surgery?" "What is the recovery process after hip arthroscopy and are there limitations after surgery?" and "How do you diagnose hip impingement and differentiate from other causes of hip pain?" The Rothwell Classification of questions were fact (43.4%), policy (34.3%), and value (20.6%). The most common webpage categories were Medical Practice (30.4%), Academic (25.8%), and Commercial (20.6%). The most common subcategories were Indications/Management (29.7%) and Pain (13.6%). Government websites had the highest average Journal of the American Medical Association score (3.42), whereas Single Surgeon Practice websites had the lowest (1.35). Conclusions: Commonly asked questions on Google regarding FAI and labral tears pertain to the indications and management of pathology as well as pain control and restrictions in activity. The majority of information is provided by medical practice, academic, and commercial sources, which have highly variable academic transparency. Clinical Relevance: By better understanding which questions patients ask online, surgeons can personalize patient education and enhance patient satisfaction and treatment outcomes after hip arthroscopy.