Examining the Relationship Between Value and Patient Satisfaction With Treatment in Total Joint Arthroplasty.

Background: A shift toward performance, cost, outcomes, and patient satisfaction has occurred with healthcare reform promoting value-based programs. The purpose of this study was to evaluate the relationship between patient satisfaction and value with treatment in a cohort of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods: Value was determined by the relationship of treatment outcome with episodic cost. Measurements included both clinical outcomes and patient-reported outcomes. Participating surgeons took part in the modified Delphi method resulting in an algorithm measuring patient value. Treatment outcome, cost, and resultant value (outcome/cost) of both TKA and THA were evaluated using binomial logistic regression by adjusting for age, gender, body mass index, Charlson comorbidity index, tobacco, education, and income with patient-reported satisfaction as the outcome. Results: This study had a total of 909 patients (TKA n = 438; THA n = 471), with an average age of 67 (TKA) and 65 (THA) years. Patient satisfaction shared a significant positive relationship with treatment outcome for TKA (odds ratio [OR] = 1.53, confidence interval [CI] = 1.35-1.73, P < .001) and THA (OR = 1.93, CI = 1.62-2.29, P < .001). Higher value was associated with a significantly higher odds of patient satisfaction for both TKA (OR = 1.39, CI = 1.25-1.54, P < .001) and THA (OR = 1.70, CI = 1.47-1.97, P < .001). Conclusions: This study showed a positive relationship between treatment outcome but not cost with subsequent value and patient satisfaction. This method provides a promising approach to comprehensively evaluate outcomes, cost, and value of total joint arthroplasty procedures. This approach can help predict the probability of value-driven patient satisfaction.

Osteochondral Allograft or Autograft Transplantation of the Femoral Head Leads to Improvement in Outcomes but Variable Survivorship: A Systematic Review.

PURPOSE: To review patient-reported outcomes (PROs) and survivorship in patients undergoing osteochondral autograft or allograft transplantation (OAT) of the femoral head. METHODS: PubMed, Cochrane Center for Register of Controlled Trials, and Scopus databases were searched in November 2022 with an updated search extending to December 2023 using criteria from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the following keywords: (hip OR femoral head) AND (mosaicplasty OR osteochondral allograft OR osteochondral autograft OR osteochondral lesion). Articles were included if they evaluated postoperative PROs in patients who underwent OAT of the femoral head and had a study size of 5 or more hips (n ≥ 5). Survivorship was defined as freedom from conversion to total hip arthroplasty. For PROs evaluated in 3 studies or more, forest plots were created and I2 was calculated. RESULTS: Twelve studies were included in this review, with a total of 156 hips and a mean follow-up time ranging between 16.8 and 222 months. In total, 104 (66.7%) hips were male while 52 (33.3%) were female. Age of patients ranged from 17.0 to 35.4 years, while body mass index ranged from 23.3 to 28.1. Eight studies reported on osteochondral autograft transplantation and 4 studies on osteochondral allograft transplantation. Three studies reported significant improvement in at least 1 PRO. Survivorship ranged from 61.5% to 96% at minimum 2-year follow-up and from 57.1% to 91% at minimum 5-year follow-up. At a follow-up of less than 5 years, osteochondral allograft transplantation studies showed 70% to 87.5% survivorship, while autograft varied from 61.54% to 96%. CONCLUSIONS: Patients with osteochondral lesions of the femoral head who underwent osteochondral autograft or allograft transplantation demonstrated improved PROs but variable survivorship rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Patients Undergoing Revision Hip Arthroscopy With Labral Reconstruction or Augmentation Demonstrate Favorable Patient Reported Outcomes: A Systematic Review.

PURPOSE: To review current literature evaluating patient-reported outcomes (PROs) and survivorship in patients undergoing revision hip arthroscopy with labral reconstruction or augmentation. METHODS: A systematic review was performed with the following key words: (revision) AND (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (reconstruction OR augmentation OR irreparable). PubMed, Cochrane Trials, and Scopus were queried in October 2022 using the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Studies were included if they involved patients undergoing revision hip arthroscopy with labral reconstruction or augmentation and reported preoperative and postoperative PROs at minimum 2-year follow-up. Only original research articles were included. Survivorship was defined as a nonconversion to total hip arthroplasty. Outcomes present in 3 or more studies underwent further statistical analysis with forest plots. Heterogeneity of studies was evaluated using the I2 statistic. RESULTS: Five studies were reviewed, including 359 revision hip arthroscopies (335 with complete follow-up) with a follow-up that ranged from 2.2 to 5.2 years. Four studies reported on outcomes after revision labral reconstruction and 1 study reported on labral augmentation. Two out of 5 included studies evaluated for statistical significance between preoperative and postoperative outcomes. Three out of 5 studies reported a rate of at least 70% for achieving minimal clinically important difference in at least 1 PRO. At minimum 2-year follow-up, survivorship ranged from 93.5% to 100%. CONCLUSIONS: Patients that underwent revision hip arthroscopy with labral reconstruction or augmentation demonstrated improvement in PROs with mixed rates of achieving clinical benefit and rates of survivorship at minimum 2-year follow-up ranging from 93.5% to 100%. LEVEL OF EVIDENCE: Level IV, systematic review of level III to IV studies.

Return to Sport Using Corticosteroid Injections for Knee Pain in Triathletes.

Introduction Despite the prevalence of corticosteroid injections in athletes, little is known about their efficacy in triathletes. We aim to assess attitudes, use, subjective effectiveness, and time to return to sport with corticosteroid injections compared to alternative methods in triathletes with knee pain. Methods This is an observational study during the COVID-19 pandemic. Triathletes answered a 13-question survey posted to three triathlon-specific websites. Results Sixty-one triathletes responded, 97% of whom experienced knee pain at some point in their triathlete career; 63% with knee pain received a corticosteroid injection as treatment (average age 51 years old). The most popular attitude (44.3%) regarding corticosteroid injections was "tried them, with good improvement". Most found the cortisone injection helpful for two to three months (28.6%), or more than one year (28.6%); of individuals who found the injections useful for more than one year, four-eight (50%) had received multiple injections during that same period. After injection, 80.6% returned to sport within one month. The average age of people using alternative treatment methods was 39 years old; most returned to sport within one month (73.7%). Compared to alternative methods, there was an ~80% higher odds of returning to sport within one month using corticosteroid injections; however, this relationship was not significant (OR=1.786, p=0.480, 95% CI:0.448-7.09). Conclusion This is the first study to examine corticosteroid use in triathletes. Corticosteroid use is more common in older triathletes and results in subjective pain improvement. A strong association does not exist for a quicker return to sport using corticosteroid injections compared to alternative methods. Triathletes should be counseled on the timing of injections, duration of side effects, and be aware of potential risks.

Supraspinatus muscle architecture and physiology in a rabbit model of tenotomy and repair.

Chronic rotator cuff tears can cause severe functional deficits. Addressing the chronic fatty and fibrotic muscle changes is of high clinical interest; however, the architectural and physiological consequences of chronic tear and repair are poorly characterized. We present a detailed architectural and physiological analysis of chronic tear and repair (both over 8 and 16 wk) compared with age-matched control rabbit supraspinatus (SSP) muscles. Using female New Zealand White Rabbits (n = 30, n = 6/group) under 2% isoflurane anesthesia, the SSP was surgically isolated and maximum isometric force was measured at four to six muscle lengths. Architectural analysis was performed, and maximum isometric stress was computed. Whole muscle length-tension curves were generated using architectural measurements to compare experimental physiology to theoretical predictions. Architectural measures are consistent with persistent radial and longitudinal atrophy over time in tenotomy that fails to recover after repair. Maximum isometric force was significantly decreased after 16 wk tenotomy and not significantly improved after repair. Peak isometric force reported here are greater than prior reports of rabbit SSP force after tenotomy. Peak stress was not significantly different between groups and consistent with prior literature of SSP stress. Muscle strain during contraction was significantly decreased after 8 wk of tenotomy and repair, indicating effects of tear and repair on muscle function. The experimental length-tension data were overlaid with predicted curves for each experimental group (generated from structural data), exposing the altered structure-function relationship for tenotomy and repair over time. Data presented here contribute to understanding the physiological implications of disease and repair in the rotator cuff.NEW & NOTEWORTHY We utilize an established method to measure the length-tension relationship for the rabbit supraspinatus in normal, torn, and repaired muscles. We then perform architectural analysis to evaluate structural changes after tear and repair. Although peak isometric force is lower in the tear and repair groups, there are no differences in peak stresses across groups. These findings indicate persistent structural changes (both radial and longitudinal atrophy) and physiological deficiencies (decreased peak force and uncoupling structure-function relationship) after tenotomy that do not significantly recover after repair.

In vivo supraspinatus muscle contractility and architecture in rabbit.

The rotator cuff (RC) muscles are crucial in moving and stabilizing the glenohumeral joint, and tears can be functionally devastating. Chronic fatty and fibrotic muscle changes, which are nonresponsive to surgical tendon repair, are a focus of contemporary research. The rabbit model recapitulates key biological features of human RC tears, but function and physiology are poorly characterized; limited force and stress data are inconsistent with literature norms in other mammalian species. Here, we present an improved method to assess the physiology of the rabbit supraspinatus muscle (SSP), and we report values for healthy SSP architecture and physiology. Using female New Zealand White Rabbits (n = 6) under 2% isoflurane anesthesia, we surgically isolated the SSP and maximum isometric force measured at 4-6 muscle lengths. Architectural analysis was performed, and maximum isometric stress was computed. Whole muscle length-tension curves were generated using architectural measurements to compare experimental physiology to theoretical predictions. Maximum isometric force (80.87 ± 5.58 N) was dramatically greater than previous reports (11.06 and 16.1 N; P < 0.05). Architectural measurement of fiber length (34.25 ± 7.18 mm), muscle mass (9.9 ± 0.93 g), pennation angle (23.67 ± 8.32°), and PCSA (2.57 ± 0.20 cm2) were consistent with prior literature. Isometric stress (30.5 ± 3.07 N/cm2) was greater than previous reports of rabbit SSP (3.10 and 4.51 N/cm2), but similar to mammalian skeletal muscles (15.7-30.13 N/cm2). Previous studies underestimated peak force by ∼90%, which has profound implications for interpreting physiological changes as a function of disease state. The data that are presented here enable understanding the physiological implications of disease and repair in the RC of the rabbit.NEW & NOTEWORTHY We introduce an improved method to assess rabbit supraspinatus muscle physiology. Maximum isometric force measured for the rabbit supraspinatus was dramatically greater than previous reports in the literature. Consequently, the isometric contractile stress reported is almost 10 times greater than previous reports of rabbit supraspinatus, but similar to available literature of other mammalian skeletal muscle. We show that previous reports of peak supraspinatus isometric force were subphysiological by ∼90.

"Bumpy" ride for the female cyclist: A rare case of perineal nodular induration, the ischial hygroma.

INTRODUCTION: Cycling is known to cause groin pain, typically adductor/hamstring strains and "saddle sores" (skin abrasion, ulceration and/or folliculitis). Rarely does it result in pathological mesenchymal lesions. PRESENTATION OF CASE: We report a case of a 52-year-old female avid cyclist with chronic groin pain. Activity alteration, bike fit, and saddle modification did not ameliorate her symptoms. MRI revealed no hamstring or bony abnormality but demonstrated low T1/high T2 signal in the right perineum inferior to the ischial tuberosity. DISCUSSION: Perineal nodular induration, or "cyclist's nodule," is a reactive fibroblastic and myofibroblastic pseudotumor almost exclusively reported in male cyclists. PNI can become so nodular that it has even been referred to as an accessory testicle or "the cyclist's third testicle." CONCLUSION: We report an unusual case of PNI in a female cyclist and review the differential diagnosis of non-infectious soft tissue perineal pain in cyclists. Clinicians should be aware of this rare condition to avoid confusion with other mesenchymal lesions.

Acute Tubular Necrosis from Rhabdomyolysis from Leg Compartment Syndrome: A Case Report.

CASE: A 31-year-old male sustained acute compartment syndrome to his left leg after a low-energy fall and required a 4-compartment fasciotomy release. His immediate postoperative course was complicated by acute tubular necrosis (ATN) with creatinine elevated to 4.89 mg/dL from rhabdomyolysis. ATN was managed with aggressive hydration, sodium bicarbonate, and alkaline diuresis, and his creatinine levels improved. CONCLUSIONS: ATN from rhabdomyolysis is a rare complication of compartment syndrome that requires high suspicion and timely treatment to prevent further nephrotoxicity and the resultant increases in mortality. It is imperative for orthopedic surgeons to be aware of this potential complication.

The role of retrieval practice in memory and analogical problem-solving.

Retrieval practice (e.g., testing) has been shown to facilitate long-term retention of information. In two experiments, we examine whether retrieval practice also facilitates use of the practised information when it is needed to solve analogous problems. When retrieval practice was not limited to the information most relevant to the problems (Experiment 1), it improved memory for the information a week later compared with copying or rereading the information, although we found no evidence that it improved participants' ability to apply the information to the problems. In contrast, when retrieval practice was limited to only the information most relevant to the problems (Experiment 2), we found that retrieval practice enhanced memory for the critical information, the ability to identify the schematic similarities between the two sources of information, and the ability to apply that information to solve an analogous problem after a hint was given to do so. These results suggest that retrieval practice, through its effect on memory, can facilitate application of information to solve novel problems but has minimal effects on spontaneous realisation that the information is relevant.