Spine surgeon triage of new patient referrals: quantification of surgical conversion rate by clinic referral source.

BACKGROUND CONTEXT: In an effort to efficiently deliver high-value spine surgical care, spine surgery clinics may triage new patient referrals. A triage system with attending surgeon review of referred patient images may improve the surgical conversion rate (SCR) of a spine surgical clinic, and shift the distribution of new patients in clinic toward those most likely to derive benefit from surgery. PURPOSE: To quantify SCR and number of triage steps by referral source in a tertiary referral spine clinic where all referrals are triaged by attending surgeons. DESIGN: All spine surgery clinic patients seen for a new patient visit (NPV) at an academic medical center over a one-year period had their triage process and outcome (surgery or no surgery) reviewed. PATIENT SAMPLE: The 1398 new adult patients seen for elective spine pathology were queried. OUTCOME MEASURES: SCR was defined as the percentage of new patients who underwent elective spine surgery within 18 months of NPV. Triage steps were defined as an action item by triage staff (ie, obtaining patient records) or by the patient (ie, undergoing additional imaging). METHODS: All new patient visits were evaluated for referral source, number of triage steps, and triage outcome. Time from referral to NPV, and time from NPV to surgery were also recorded. SCR, triage steps, and time-intervals were calculated for each surgeon and referral source and compared. Statistical analysis of variance (ANOVA) was used to ascertain differences. RESULTS: The overall SCR for the 4-surgeon group was 41.6%. This ranged among the surgeons from 24.7% to 60.1%. The referral sources with the highest SCR were in-system spine advanced practice providers (APPs) and in-system physical medicine and rehabilitation providers. Spine APPs also demonstrated the smoothest referral process, requiring the fewest steps. CONCLUSIONS: Our findings provide a framework for assessment of triage processes at other institutions, as well as the impact of upgrades to our triage process as we work to improve triage efficiency. In the present study, referrals from providers familiar with spine pathology resulted in the highest SCR and fewest triage steps.

What Do Patients Encounter When Searching Online About Meniscal Surgery? An Analysis of Internet Trends.

Background: Many patients use the internet to learn about their orthopaedic conditions and find answers to their common questions. However, the sources and quality of information available to patients regarding meniscal surgery have not been fully evaluated. Purpose: To determine the most frequently searched questions associated with meniscal surgery based on question type and topic, as well as to assess the website source type and quality. Study Design: Cross-sectional study. Methods: The following search terms were entered into a web search (www.google.com) using a clean-install browser: "meniscal tear,""meniscus repair,""meniscectomy,""knee scope,""meniscus surgery," and "knee arthroscopy." The Rothwell classification system was used to categorize questions and sort them into 1 of 13 topics relevant to meniscal surgery. Websites were also categorized by source into groups. The Journal of the American Medical Association (JAMA) benchmark criteria (medians and interquartile ranges [IQRs]) were used to measure website quality. Results: A total of 337 unique questions associated with 234 websites were extracted and categorized. The most popular questions were "What is the fastest way to recover from meniscus surgery?" and "What happens if a meniscus tear is left untreated?" Academic websites were associated more commonly with diagnosis questions (41.9%, P < .01). Commercial websites were associated more commonly with cost (71.4%, P = .03) and management (47.6%, P = .02). Government websites addressed a higher proportion of questions regarding timeline of recovery (22.2%, P < .01). Websites associated with medical practices were associated more commonly with risks/complications (43.8%, P = .01) while websites associated with single surgeons were associated more commonly with pain (19.4%, P = .03). Commercial and academic websites had the highest median JAMA benchmark scores (4 [IQR, 3-4] and 3 [IQR, 2-4], respectively) while websites associated with a single surgeon or categorized as "other" had the lowest scores (1 [IQR 1-2] and 1 [IQR 1-1.5], respectively). Conclusion: Our study found that the most common questions regarding meniscal surgery were associated with diagnosis of meniscal injury, followed by activities and restrictions after meniscal surgery. Academic websites were associated significantly with diagnosis questions. The highest quality websites were commercial and academic websites.

The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial.

BACKGROUND: Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function. METHODS: Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs. RESULTS: Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05). CONCLUSIONS: Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

Recruitment rates and strategies in exercise trials in cancer survivorship: a systematic review.

PURPOSE: Despite clear evidence-based supporting a benefit to exercise on physical and psychological metrics in patients with cancer, recruitment to exercise trials amongst cancer survivors is suboptimal. We explore current recruitment rates, strategies, and common barriers to participation in exercise oncology trials in cancer survivorship. METHODS: A systematic review was conducted using a pre-defined search strategy in EMBASE, CINAHL, Medline, Cochrane Library, and Web of Science. The search was performed up to 28/02/2022. Screening of titles and abstracts, full-text review, and data extraction was completed in duplicate. RESULTS: Of the 3204 identified studies, 87 papers corresponding to 86 trials were included. Recruitment rates were highly variable with a median rate of 38% (range 0.52-100%). Trials recruiting prostate cancer patients only had the highest median recruitment rate (45.9%) vs trials recruiting colorectal cancer patients only which had the lowest (31.25%). Active recruitment strategies such as direct recruitment via a healthcare professional were associated with higher recruitment rates (rho = 0.201, p = 0.064). Common reasons for non-participation included lack of interest (46.51%, n (number of studies) = 40); distance and transport (45.3%, n = 39); and failure to contact (44.2%, n = 38). CONCLUSIONS: Recruitment of cancer survivors to exercise interventions is suboptimal with barriers being predominantly patient-oriented. This paper provides the benchmark for current recruitment rates to exercise oncology trials, providing data for trialists planning future trial design and implementation, optimise future recruitment strategies, and evaluate their own recruitment success against current practice. IMPLICATIONS FOR CANCER SURVIVORS: Enhanced recruitment to cancer survivorship exercise trials is necessary in facilitating the publication of definitive exercise guidelines, generalisable to varying cancer cohorts. PROSPERO REGISTRATION NUMBER: CRD42020185968.

Survey of blood flow restriction therapy for rehabilitation in Sports Medicine patients.

Background: Blood flow restriction (BFR) therapy has demonstrated benefits across a spectrum of musculoskeletal injuries, including improved strength, endurance, function, and reduction in pain perception. There is, however, no standardized application of BFR therapy among orthopaedic surgeons within the United States (US). Hypothesis: The indication and protocol for BFR therapy vary significantly across providers in the US. Methods: An online survey of 21 multiple-choice questions was sent to 3,281 surgeons listed on a large orthopaedic registry. A cross-sectional study was performed on all surgeons who successfully completed the questionnaire. Surgeons were queried on current or planned use of BFR, indications, contraindications, and peri-operative and non-operative management of sports-related injuries. Results: Overall, 250 physicians completed the survey, with 149 (59.8%) reporting current BFR use and 75.2% initiating use in the last 1-5 years. Most protocols (78.8%) utilize the modality 2-3 times per week while 15.9% use it only once weekly. Anterior cruciate ligament reconstruction (ACLR) rehabilitation was the most reported indication for initiating BFR therapy (95.7%) along with medial patellofemoral ligament reconstruction (70.2%), multiligamentous knee reconstruction (68.8%), meniscus repair (62.4%), collateral ligament reconstruction (50.4%), Achilles tendon repairs (30.5%), and meniscectomy (27%). Only 36.5% reported using BFR after upper extremity procedures, such as distal biceps repair (19.7%), ulnar collateral ligament elbow reconstruction (17%), rotator cuff (16.8%), and shoulder labrum repair (15.3%). For non-operative injuries, 65.8% of surgeons utilized BFR. Of those not currently using BFR therapy, 33.3% intended to implement its use in the future. Conclusion: BFR therapy has increased in popularity with most physicians implementing its use in the last 5 years. BFR was commonly utilized after ACLR. Clinical relevance: BFR allows light-load resistance to simulate high-intensity resistance training. This study describes US orthopaedic surgeons' common practice patterns and patient populations that utilize BFR therapy.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball.

PURPOSE: To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature. METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles. RESULTS: A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play. CONCLUSIONS: Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV, systematic review of level II-IV studies.

Blood Flow Restriction Therapy for 2 Weeks Prior to Anterior Cruciate Ligament Reconstruction Did Not Impact Quadriceps Strength Compared to Standard Therapy.

PURPOSE: To evaluate the efficacy of a 2-week home-based blood flow restriction (BFR) prehabiliation program on quadriceps strength and patient-reported outcomes prior to anterior cruciate ligament (ACL) reconstruction. METHODS: Patients presenting with an ACL tear were randomized into two groups, BFR and control, at their initial clinic visit. Quadriceps strength was measured using a handheld dynamometer in order to calculate peak force, average force, and time to peak force during seated leg extension at the initial clinic visit and repeated on the day of surgery. All patients were provided education on standardized exercises to be performed 5 days per week for 2 weeks between the initial clinic visit and date of surgery. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal thigh. Patient-Reported Outcome Measurement System Physical Function (PROMIS-PF), knee range of motion, and quadriceps circumference were gathered at the initial clinic visit and day of surgery, and patients were monitored for adverse effects. RESULTS: A total 45 patients met inclusion criteria and elected to participate. There were 23 patients randomized to the BFR group and 22 patients randomized into the control group. No significant differences were noted between the BFR and control groups in any demographic characteristics (48% vs 64% male [P = .271] and average age 26.5 ± 12.0 vs 27.0 ± 11.0 [P = .879] in BFR and control, respectively). During the initial clinic visit, there were no significant differences in quadriceps circumference, peak quadriceps force generation, time to peak force, average force, pain, and PROMIS scales (P > .05 for all). Following completion of a 2-week home prehabilitation protocol, all patients indeterminant of cohort demonstrated decreased strength loss in the operative leg compared to the nonoperative leg (P < .05 for both) However, there were no significant differences in any strength or outcome measures between the BFR and control groups (P > .05 for all). There were no complications experienced in either group, and both were compliant with the home-based prehabilitation program. CONCLUSIONS: A 2-week standardized prehabilitation protocol preceding ACL reconstruction resulted in a significant improvement in personal quadriceps peak force measurements, both with and without the use of BFR. No difference in quadriceps circumference, strength, or patient reported outcomes were found between the BFR and the control group. The home-based BFR prehabiliation protocol was found to be feasible, accessible, and well tolerated by patients. LEVEL OF EVIDENCE: Level II, randomized controlled trial with small effect size.

Psychosocial well-being and health-related quality of life in a UK population with Usher syndrome.

OBJECTIVES: To determine whether psychosocial well-being is associated with the health-related quality of life (HRQOL) of people with Usher syndrome. SETTING: The survey was advertised online and through deafblind-related charities, support groups and social groups throughout the UK. PARTICIPANTS: 90 people with Usher syndrome took part in the survey. Inclusion criteria are having a diagnosis of Usher syndrome, being 18 or older and being a UK resident. PRIMARY AND SECONDARY OUTCOME MEASURES: All participants took part in a survey that measured depressive symptoms, loneliness and social support (predictors) and their physical and mental HRQOL (outcomes). Measured confounders included age-related, sex-related and health-related characteristics. Hierarchical multiple linear regression analyses examined the association of each psychosocial well-being predictor with the physical and mental HRQOL outcomes while controlling for confounders in a stepwise manner. RESULTS: After adjusting for all confounders, psychosocial well-being was shown to predict physical and mental HRQOL in our population with Usher syndrome. Increasing depressive symptoms were predictive of poorer physical (ß=-0.36, p<0.01) and mental (ß=-0.60, p<0.001) HRQOL. Higher levels of loneliness predicted poorer mental HRQOL (ß=-0.20, p<0.05). Finally, increasing levels of social support predicted better mental HRQOL (ß=0.19, p<0.05). CONCLUSIONS: Depression, loneliness and social support all represent important issues that are linked with HRQOL in a UK population with Usher syndrome. Our results add to the growing body of evidence that psychosocial well-being is an important factor to consider in people with Usher syndrome alongside functional and physical impairment within research and clinical practice.