Distal Tibial Allograft for the Treatment of Anterior Shoulder Instability With Glenoid Bone Loss: A Systematic Review and Meta-analysis.

BACKGROUND: The use of a distal tibial allograft (DTA) for reconstruction of a glenoid defect in anterior shoulder instability has grown significantly over the past decade. However, few large-scale clinical studies have investigated the clinical and radiographic outcomes of the DTA procedure. PURPOSE: To conduct a systematic review and meta-analysis of clinical studies with data on outcomes and complications in patients who underwent the DTA procedure for recurrent anterior shoulder instability with glenoid bone loss. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A comprehensive search of major bibliographic databases was conducted for articles pertaining to the use of a DTA for the management of anterior shoulder instability with associated glenoid bone loss. Postoperative complications and outcomes were extracted and compiled in a meta-analysis. RESULTS: Of the 8 included studies with 329 total participants, the mean patient age was 28.1 ± 10.8 years, 192 (83.8%) patients were male, and the mean follow-up was 38.4 ± 20.5 months. The overall complication rate was 7.1%, with hardware complications (3.8%) being the most common. Partial graft resorption was observed in 36.5% of the participants. Recurrent subluxation was reported in 1.2% of the participants, and recurrent dislocation prompting a reoperation was noted in 0.3% of the participants. There were significant improvements in clinical outcomes, including American Shoulder and Elbow Surgeons score (40.9-point increase; P < .01), Single Assessment Numeric Evaluation (47.2-point increase; P < .01), Western Ontario Shoulder Instability Index (49.4-point decrease; P < .01), Disabilities of the Arm, Shoulder and Hand (20.0-point decrease; P = .03), and visual analog scale (2.1-point decrease; P = .05). Additionally, postoperative shoulder range of motion significantly increased from baseline values. CONCLUSION: The DTA procedure was associated with a low complication rate, good clinical outcomes, and improved range of motion among patients with anterior shoulder instability and associated glenoid defects.

Statistical Fragility Analysis of Open Reduction Internal Fixation vs Primary Arthrodesis to Treat Lisfranc Injuries: A Systematic Review.

BACKGROUND: There is a lack of consensus in the use of open reduction internal fixation (ORIF) vs primary arthrodesis (PA) in the management of Lisfranc injuries. Statistical fragility represents the number of events needed to flip statistical significance and provides context to interpret P values of outcomes from conflicting studies. The current study evaluates the statistical fragility of existing research with an outcome-specific approach to provide statistical clarity to the ORIF vs PA discussion. We hypothesized that statistical fragility analysis would offer clinically relevant insight when interpreting conflicting outcomes regarding ORIF vs PA management of Lisfranc injuries. METHODS: All comparative studies, RCTs, and case-series investigating ORIF vs PA management of Lisfranc injuries published through October 5, 2023, were identified. Descriptive characteristics, dichotomous outcomes, and continuous outcomes were extracted. Fragility index and continuous fragility index were calculated by the number of event reversals needed to alter significance. Outcomes were categorized by clinical relevance, and median FI and CFI were reported. RESULTS: A total of 244 studies were screened. Ten studies and 67 outcomes (44 dichotomous, 23 continuous) were included in the fragility analysis. Of the 10 studies, 4 studies claimed PA to correlate with superior outcomes compared to ORIF with regard to functional scores and return to function outcomes. Of these 4 studies, 3 were statistically robust. Six studies claimed PA and ORIF to have no differences in outcomes, in which only 2 studies were statistically robust. CONCLUSION: The overall research regarding ORIF vs PA is relatively robust compared with other orthopaedic areas of controversy. Although the full statistical context of each article must be considered, studies supporting PA superiority with regard to functional scores and return to function metrics were found to be statistically robust. Outcome-specific analysis revealed moderate fragility in several clinically relevant outcomes such as functional score, return to function, and wound complications.

A Diagnosis of Vitamin D Deficiency Is Associated With Increased Rates of Primary Patellar Instability and Need for Recurrent Surgical Stabilization.

BACKGROUND: Vitamin D has been proven experimentally to affect musculoskeletal health. The purpose of this study was to identify the relationship between vitamin D deficiency and patellar instability. HYPOTHESIS: Vitamin D deficiency is associated with an increased risk of experiencing primary patellar instability and recurrent patellar dislocation after primary surgical stabilization. STUDY DESIGN: Retrospective comparative study. LEVEL OF EVIDENCE: Level 3. METHODS: A 1:1 matched retrospective study of 328,011 patients diagnosed with vitamin D deficiency was performed using the PearlDiver database. Incidence of primary patellar instability was calculated according to sex and age. Rates of primary patellar instability and surgical stabilization for recurrent dislocation were calculated with sex- and age-specific stratifications. Multivariable logistic regression was used to compare the rates of primary injury and recurrent stabilization while controlling for demographics and medical comorbidities. RESULTS: A total of 656,022 patients were analyzed. The overall 1-year incidence rate of patellar instability in patients with vitamin D deficiency was 82.6 per 100,000 person-years (95% CI, 73.2-92.9), compared with 48.5 (95% CI, 41.4-56.5) in the matched control. Women were significantly more likely to experience primary patellar instability within 1 (adjusted odds ratio [aOR] = 1.45; 95% CI, 1.12-1.88) and 2 years (aOR, 1.31; 95% CI, 1.07-1.59) of hypovitaminosis D diagnosis. Patients aged 10 to 25 years with hypovitaminosis D were at greater risk of requiring recurrent patellar stabilization for both men (aOR, 2.48; 95% CI, 1.06-5.80) and women (aOR, 1.77; 95% CI, 1.04-3.02). CONCLUSION: Patients diagnosed with vitamin D deficiency experienced higher rates of primary patellar instability and have greater risk of requiring recurrent surgical stabilization for subsequent dislocations. CLINICAL RELEVANCE: These results suggest that monitoring and proactively treating vitamin D deficiency in the physically active patient may lower the risk of suffering primary patellar instability or recurrence after surgical stabilization.

Arm Health in Elite Collegiate Summer League Baseball Players Assessed by the Kerlan-Jobe Orthopaedic Clinic Score.

CONTEXT: Collegiate baseball players with professional aspirations often participate in summer leagues; foremost among them is the Cape Cod Baseball League (CCBL). Injuries acquired during the collegiate baseball season can be carried into the CCBL season and vice versa. OBJECTIVE: To assess the history of throwing arm injury and current functionality in midseason CCBL players. DESIGN: Cross-sectional study. SETTING: Online questionnaire. PATIENTS OR OTHER PARTICIPANTS: A total of 123 CCBL players participated. Qualifying athletes were ≥18 years old and were rostered CCBL players with remaining collegiate eligibility. MAIN OUTCOME MEASURE(S): After collecting background information, we used the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire to assess the history of throwing arm injury and current functionality. The maximum KJOC score is 100.0; higher scores correspond with greater functionality. RESULTS: The mean KJOC score was 86.6 ± 14.5 (n = 92); 24.5% (23/94) of players reported a prior diagnosis of throwing arm injury other than a strain or sprain. A total of 49 (49/96, 51.0%) players had undergone rehabilitation for a throwing arm injury, and 7 (7/96, 7.3%) had experienced a medical procedure. Players with no previous treatment (n = 41, mean KJOC score = 88.9 ± 19.0) more frequently demonstrated KJOC scores of ≥90 than players with such treatment (n = 55, 80.9 ± 17.1; P < .001). The 18 players with time-loss arm injury in the last year had lower mean KJOC scores (71.3 ± 20.0) than players with no injury or time loss (90.3 ± 9.8; P < .001). Similarly, players who reported current arm trouble (n = 15) had lower KJOC scores (71.6 ± 17.5) than players with healthy arms (89.5 ± 11.9; P < .001). CONCLUSIONS: The average KJOC score of the CCBL players was <90, with particularly low scores in athletes with prior arm injury and treatment.

Significant Association between a Diagnosis of Hypovitaminosis D and Rotator Cuff Tear, Independent of Age and Sex: A Retrospective Database Study.

PURPOSE: As high rates of vitamin D deficiency have been demonstrated in orthopedic patient cohorts, this study aimed to characterize the association between a diagnosis of hypovitaminosis D and primary rotator cuff tear (RCT), primary rotator cuff repair (RCR), and postoperative complications in different sex and age cohorts. METHODS: In this retrospective cohort study using PearlDiver, a nationwide administrative claims database, records for all patients aged 30 to 89 yr who received a diagnosis of hypovitaminosis D between January 1, 2011, and October 31, 2018, were queried. Rates of primary RCT, primary RCR, and postoperative complications including subsequent surgery were calculated within sex- and age-specific cohorts and compared with matched control cohorts using multivariable logistic regression. RESULTS: Among the 336,320 patients included in the hypovitaminosis D cohort, these patients were significantly more likely to experience an RCT (odds ratio (OR), 2.70; 95% confidence interval (CI), 2.55-2.85) as well as a full-thickness RCT (OR, 2.36; 95% CI, 2.17-2.56) specifically within 2 yr of their diagnosis. Women with hypovitaminosis D were more likely to undergo surgery to address their full-thickness tears (OR, 1.37; 95% CI, 1.09-1.74). There was no difference in the rates of revision RCR or irrigation and debridement. However, women with hypovitaminosis D were significantly more likely to undergo manipulation under anesthesia (OR, 1.16; 95% CI, 1.03-1.31). CONCLUSIONS: Patients diagnosed with hypovitaminosis D were significantly more likely to suffer from a primary RCT and to undergo manipulation under anesthesia within a year of their RCR. Although many risk factors for RCT are unmodifiable, vitamin D deficiency is a readily modifiable risk factor with several treatment regimens demonstrating positive effects on musculoskeletal health.

Peroneus Longus Tendon Autograft May Present a Viable Alternative for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To examine the available literature to better understand the objective and patient-reported outcomes using peroneus longus tendon (PLT) autograft compared with more commonly used autografts, such as the quadrupled hamstring tendons (HT), in patients undergoing primary for anterior cruciate ligament reconstruction (ACLR). METHODS: A comprehensive search of published literature in PubMed, Web of Science, Cochrane Library, Ovid, and EMBASE databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included patients undergoing ACLR with PLT autograft, inclusion of patient-recorded outcome measures, and availability in English language. Publications that included only biomechanical analysis or ACLR with use of allograft or combination grafts were excluded. RESULTS: A total of 16 studies (Level of Evidence range: I-IV) met inclusion criteria, with follow-up ranging from 3 months to 5 years. In the available case series, patient-reported outcomes ranged from Lysholm = 80.7 to 95.1, International Knee Documentation Committee 78.1 to 95.7. In prospective cohorts and randomized controlled trials, PLT performance was comparable with HT autografts (PLT/HT: Lysholm = 88.3-95.1/86.5-94.9, International Knee Documentation Committee = 78.2-92.5/87.4-93.4). The majority of PLT grafts diameters were equal or greater than HT counterparts with a mean of >8 mm (PLT/HT: 7.0-9.0 mm/7.65-8.5 mm). There was minimal donor-site morbidity associated with PLT harvest. CONCLUSIONS: Although limitations exist within the available literature, existing evidence suggests that PLT autograft routinely produces adequately sized grafts with comparable early outcomes to HT autograft and low risk of donor-site morbidity. However, the PLT autograft is yet to demonstrate superiority to any of the more-traditional autograft selections. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Light-Dark and Activity Rhythm Therapy (L-DART) to Improve Sleep in People with Schizophrenia Spectrum Disorders: A Single-Group Mixed Methods Study of Feasibility, Acceptability and Adherence.

People with a diagnosis of schizophrenia often have poor sleep, even when their psychotic symptoms are relatively well managed. This includes insomnia, sleep apnoea, hypersomnia, and irregular or non-24 h sleep-wake timing. Improving sleep would better support recovery, yet few evidence-based sleep treatments are offered to this group. This paper presents a mixed methods feasibility and acceptability study of Light-Dark and Activity Rhythm Therapy (L-DART). L-DART is delivered by an occupational therapist over 12 weeks. It is highly personalisable to sleep phenotypes and circumstances. Ten participants with schizophrenia spectrum diagnoses and sleep problems received L-DART; their sleep problems and therapy goals were diverse. We measured recruitment, attrition, session attendance, and adverse effects, and qualitatively explored acceptability, engagement, component delivery, adherence, activity patterns, dynamic light exposure, self-reported sleep, wellbeing, and functioning. Recruitment was ahead of target, there was no attrition, and all participants received the minimum 'dose' of sessions. Acceptability assessed via qualitative reports and satisfaction ratings was good. Adherence to individual intervention components varied, despite high participant motivation. All made some potentially helpful behaviour changes. Positive sleep and functioning outcomes were reported qualitatively as well as in outcome measures. The findings above support testing the intervention in a larger randomised trial ISRCTN11998005.

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury.

Background: Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability. Hypothesis: Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment. Study Design: Cohort study; Level of evidence, 3. Methods: Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables. Results: While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049). Conclusion: In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.

Arthroscopic Simulation in Orthopaedic Surgery Training.

Surgical simulation has become a commonly utilized and well-researched training adjunct in nearly all surgical specialties. Balancing high-quality orthopaedic surgical training in the face of work hour restrictions and efficiency pressures has become a challenge to educators and trainees alike. Surgical simulation is an opportunity to enhance such training and potentially permit trainees to be better equipped for the operating room. In orthopaedics, various low-fidelity, high-fidelity, and virtual reality simulation platforms are readily available to almost all trainees and permit simulation of a wide array of arthroscopic surgeries. In this review, we seek to highlight the potential utility of simulation-based training in orthopaedic surgery, the various types of available simulators, and review the evidence for simulator use.

Differences in the Medical Advisability of Online Pitching Recommendations for Youth Softball Players Based on Website Source.

Background: Guidelines regarding injury prevention in fast-pitch softball pitchers have yet to be widely adopted, risking the online dissemination of misleading advice. Purpose/Hypothesis: The purpose of this study was to assess the source and medical advisability of online pitching recommendations for youth softball players and highlight the risk of misinformation. It was hypothesized that many popular websites would contain content discordant with current medical guidelines regarding windmill softball pitching recommendations. Study Design: Cross-sectional study. Methods: A Google search using the phrase "youth softball pitching recommendations" was performed. Up to 100 websites were extracted and analyzed for website source type (commercial, medical/educational, or athletic organization) and informational quality (advisable, neutral, or discordant). The latter was determined with respect to the STOP Sports Injuries guidelines for arm injury prevention in youth softball players. Descriptive and inferential statistics were used to assess potential associations between website source type and the informational quality of content therein. Results: A total of 86 websites were included in the analysis. Website source type was significantly predictive of informational quality (P = .018). Among the 3 source types, medical/educational websites had the highest proportion classified as advisable (12/24 [50.0%]) and the lowest proportion classified as discordant (3/24 [12.5%]). Only 17.6% (6/34) of commercial websites were advisable, and advisable websites as a whole were more likely to be from medical/educational sources than athletic organization (P = .016) or commercial (P = .026) sources. The advisability rate among all websites was 25.6% (22/86). Although there was a significant association between position in the search results (first 10 vs remaining 76) and website source type (P = .006), there was no association between position and informational quality (P = .116). The first 10 websites, which trended toward greater advisability than the remaining 76 websites (P = .060), were more likely than the remaining websites to be medical/educational sources (P = .002). Conclusion: Website source type was significantly predictive of medical advisability. Medical/educational websites were the most advisable, while commercial and athletic organization websites were especially poor in their advisability. The overall advisability rate was only 25.6%. When making recommendations to patients, sports medicine providers should highlight the prevalence of discordant online softball pitching guidelines and take the opportunity to share medically advisable resources.

Young Age and Concomitant or Prior Bony Realignment Procedures are Associated with Decreased Risk of Failure of Osteochondral Allograft Transplantation in the Knee: A Nationwide Database Study.

OBJECTIVE: Osteochondral allograft (OCA) transplantation is a restorative surgical option for large, full-thickness chondral or osteochondral defects in the knee. Variability in outcomes reporting has led to a broad range of graft survival rates. Using rate of salvage surgery following OCA as a failure metric, the purpose of this study was to analyze the incidence and risk factors for failure in a nationwide cohort. DESIGN: The M151Ortho PearlDiver database was queried for patients aged 20 to 59 who underwent primary OCA between 2010 and 2020. Patients with prior cartilage procedures or arthroplasty were excluded. Kaplan-Meier survival analysis was performed to characterize cumulative rate of salvage surgery, defined as any patient subsequently undergoing revision OCA, autologous chondrocyte implantation (ACI), osteochondral autograft transfer system (OATS), unicompartmental knee arthroplasty (UKA), or total knee arthroplasty (TKA). Multivariable logistic regression was used to determine the effect of several variables on odds of salvage surgery. RESULTS: Around 6,391 patients met inclusion criteria. Cumulative 5-year salvage rate was 1.71%, with 68.8% in the first 2 years. Age 20 to 29 and concomitant or prior bony realignment procedures were associated with significantly decreased rate of salvage surgery (age-adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI], 0.24-0.99, P = 0.046; realignment-aOR = 0.24, 95% CI, 0.04-0.75, P = 0.046). CONCLUSIONS: In the largest OCA cohort studied to date, less than 2% of patients required salvage surgery. Young age and bony realignment were protective. These findings suggest that OCA in the knee is a durable cartilage-restoration procedure, especially in young patients with corrected alignment.

Lack of Consensus in Rehabilitation Protocols After Posterior Shoulder Stabilization.

Background: Posterior shoulder instability is being identified and treated more frequently by orthopaedic providers. After posterior shoulder stabilization, long-term outcomes in function and mobility are largely dependent on the postoperative rehabilitation period. Thus, it is important to assess the consistency between protocols at different institutions. Purpose/Hypothesis: The purpose of this study was to investigate the variability among rehabilitation protocols published by academic orthopaedic programs and their affiliates. It was hypothesized that there would be little consistency in the duration of immobilization, timing of functional milestones, and start dates of various exercises. Study Design: Cross-sectional study. Methods: Rehabilitation protocols after posterior shoulder stabilization that were published online from Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery programs and their affiliates were evaluated for recommendations on immobilization, exercises, activities, range of motion (ROM), and return-to-sport goals. Results: Of the 204 ACGME-accredited orthopaedic surgery programs, 22 programs and 17 program affiliates had publicly available rehabilitation protocols that were included for review. There were 37 programs (94.9%) that recommended the use of sling immobilization for a mean of 4.7 ± 1.8 weeks postoperatively. Active ROM of the elbow, wrist, and hand was the most common early ROM exercise to be recommended (36 programs; 92.3%). The goal of 90° passive external rotation demonstrated the widest range of recommended start dates (0-12 weeks postoperatively). Late ROM exercises and start dates varied between protocols, with the largest standard deviation found in achieving full active ROM (13.5 ± 3.6 weeks). Resistance exercises showed a wide range of recommended start dates. Bench presses and push-ups began, on average, at 13.1 ± 3.4 and 15.3 ± 3.2 weeks, respectively. Return to sport was recommended at 21.7 ± 3.6 weeks. Conclusion: There was a high level of variability in postoperative rehabilitation protocols after posterior shoulder stabilization among orthopaedic programs and their affiliates, suggesting that a standard protocol for rehabilitation has yet to be established.

A Diagnosis of Vitamin D Deficiency Is Associated With Increased Rates of Anterior Cruciate Ligament Tears and Reconstruction Failure.

PURPOSE: To characterize the association between a diagnosis of hypovitaminosis D and primary anterior cruciate ligament (ACL) tear, primary anterior cruciate ligament reconstruction (ACLR), and revision ACLR in different sex and age cohorts. METHODS: In this retrospective cohort study of the PearlDiver claims database, records were queried between January 1, 2011, and October 31, 2018 for all patients aged 10 to 59 years who received a diagnosis of hypovitaminosis D. Rates of primary ACL tears, primary reconstruction, and revision reconstruction were calculated for sex- and age-specific cohorts and compared with a control of patients without a diagnosis of hypovitaminosis D. Incidence rates for primary ACL injuries were calculated, and multivariable logistic regression was used to compare rates of ACL injury, primary reconstruction, and revision reconstruction while controlling for age, sex, Charlson Comorbidity Index, and several other comorbidities. RESULTS: Among the 328,011 patients (mean age 41.9 ± 12.6 years, 65.8% female) included in both the hypovitaminosis D and control cohorts, the incidence of ACL tears was 115.2 per 100,000 person-years (95% confidence interval [CI] 107.2-123.7) compared with 61.0 (95% CI 55.2-67.2) in the demographic- and comorbidity-matched control cohort. The study cohort was significantly more likely to suffer an ACL tear over a 1- (aOR 1.67, 95% CI 1.41-1.99, P < .001) and 2-year (aOR 1.81, 95% CI 1.59-2.06, P < .001) period. This trend remained for both male patients at the 1- (aOR 1.66, 95% CI 1.29-2.14, P < .001) and 2-year (aOR 1.68, 95% CI 1.37-2.06, P < .001) mark and female patients at the 1- (aOR 1.69, 95% CI 1.33-2.14, P < .001) and 2-year (aOR 1.80, 95% CI 1.51-2.14, P < .001) mark. Finally, patients with vitamin D deficiency had a significantly increased likelihood of undergoing a revision ACLR within 2 years of a primary reconstruction (aOR 1.28, 95% CI 1.05-1.55, P = .012). CONCLUSIONS: This study reports an association between patients previously diagnosed with hypovitaminosis D and significantly increased rates of both index ACL tears (81% increase within 2 years of diagnosis) and revision ACLR (28% within 2 years). These results identify a population with increased odds of injury and provide valuable knowledge as we expand our understanding of the relationship between vitamin D and musculoskeletal health. LEVEL OF EVIDENCE: Level III, retrospective database study.

Extensor Carpi Ulnaris Instability: A Comprehensive Review of Pathology and Operative Techniques.

The extensor carpi ulnaris (ECU) is primarily responsible for extension and ulnar deviation at the wrist. Secondary to repetitive loading of, or acute trauma to the flexed, supinated and ulnarly deviated wrist, the ECU tendon can be a common source of ulnar-sided wrist pain. Common pathology includes ECU tendinopathy, tenosynovitis, tendon instability, and tendon rupture. Extensor carpi ulnaris pathology commonly occurs in athletes and patients with inflammatory arthritis. Given the multitude of available methods to treat ECU tendon pathology, the aim of our study was to outline operative management of ECU tendon pathology, with emphasis on reviewing techniques for addressing ECU instability. We acknowledge a continuing debate between anatomical and nonanatomical techniques for ECU subsheath reconstruction. However, use of a portion of the extensor retinaculum for nonanatomical reconstruction is commonly used and demonstrates successful outcomes. Future comparative studies on ECU fixation are required to increase data on patient outcomes, to further define and standardize these techniques.

Virtual reality (VR) therapy for patients with psychosis: satisfaction and side effects.

BACKGROUND: Automated virtual reality therapies are being developed to increase access to psychological interventions. We assessed the experience with one such therapy of patients diagnosed with psychosis, including satisfaction, side effects, and positive experiences of access to the technology. We tested whether side effects affected therapy. METHODS: In a clinical trial 122 patients diagnosed with psychosis completed baseline measures of psychiatric symptoms, received gameChange VR therapy, and then completed a satisfaction questionnaire, the Oxford-VR Side Effects Checklist, and outcome measures. RESULTS: 79 (65.8%) patients were very satisfied with VR therapy, 37 (30.8%) were mostly satisfied, 3 (2.5%) were indifferent/mildly dissatisfied, and 1 (0.8%) person was quite dissatisfied. The most common side effects were: difficulties concentrating because of thinking about what might be happening in the room (n = 17, 14.2%); lasting headache (n = 10, 8.3%); and the headset causing feelings of panic (n = 9, 7.4%). Side effects formed three factors: difficulties concentrating when wearing a headset, feelings of panic using VR, and worries following VR. The occurrence of side effects was not associated with number of VR sessions, therapy outcomes, or psychiatric symptoms. Difficulties concentrating in VR were associated with slightly lower satisfaction. VR therapy provision and engagement made patients feel: proud (n = 99, 81.8%); valued (n = 97, 80.2%); and optimistic (n = 96, 79.3%). CONCLUSIONS: Patients with psychosis were generally very positive towards the VR therapy, valued having the opportunity to try the technology, and experienced few adverse effects. Side effects did not significantly impact VR therapy. Patient experience of VR is likely to facilitate widespread adoption.

Open treatment of posterior glenoid bone loss and bipolar bone loss.

Posterior glenohumeral instability is an increasingly common and challenging orthopaedic problem. While an arthroscopic soft tissue stabilization procedure (i.e., reverse Bankart repair) is effective in treating most cases of posterior instability, this procedure may be inadequate in shoulders with critical posterior glenoid bone loss (GBL), or in cases of an engaging reverse Hill-Sachs lesion. Thus, the purpose of the present manuscript was to report contemporary surgical approaches, techniques, and outcomes for the open treatment of glenoid or humeral head bone loss in posterior instability to help guide clinical decision making. Open osteoarticular augmentation procedures have emerged as a popular option to treat posterior bone loss, with bony auto- and allografts utilized from a variety of donor sites including iliac crest, scapular spine, acromion, distal clavicle, and distal tibia. The combination of glenoid retroversion and bone loss can be addressed with a posterior glenoid opening wedge osteotomy. Bipolar bone loss may be treated with a combination of the aforementioned techniques, in addition to a reverse remplissage, a modified McLaughlin procedure, or various arthroplasty-related options. Although short and mid-term outcomes are dependable, studies reporting long-term outcomes are sparse. Moreover, there is no current consensus regarding the most effective treatment of posterior shoulder instability in the setting of bone loss, and open surgical techniques continue to evolve. Further research is necessary to determine long-term effectiveness of these surgical options.

A review of economic evaluations of health care for people at risk of psychosis and for first-episode psychosis.

BACKGROUND: Preventing psychotic disorders and effective treatment in first-episode psychosis are key priorities for the National Institute for Health and Care Excellence. This review assessed the evidence base for the cost-effectiveness of health and social care interventions for people at risk of psychosis and for first-episode psychosis. METHODS: Electronic searches were conducted using the PsycINFO, MEDLINE and Embase databases to identify relevant published full economic evaluations published before August 2020. Full-text English-language studies reporting a full economic evaluation of a health or social care intervention aiming to reduce or prevent symptoms in people at risk of psychosis or experiencing first-episode psychosis were included. Screening, data extraction, and critical appraisal were performed using pre-specified criteria and forms based on the NHS Economic Evaluation Database (EED) handbook and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist for economic evaluations. The protocol was registered on the PROSPERO database (CRD42018108226). Results were summarised qualitatively. RESULTS: Searching identified 1,628 citations (1,326 following the removal of duplications). After two stages of screening 14 studies met the inclusion criteria and were included in the review. Interventions were varied and included multidisciplinary care, antipsychotic medication, psychological therapy, and assertive outreach. Evidence was limited in the at-risk group with only four identified studies, though all interventions were found to be cost-effective with a high probability (> 80%). A more substantial evidence base was identified for first-episode psychosis (11 studies), with a focus on early intervention (7/11 studies) which again had positive conclusions though with greater uncertainty. CONCLUSIONS: Study findings generally concluded interventions were cost-effective. The evidence for the population who are at-risk of psychosis was limited, and though there were more studies for the population with first-episode psychosis, limitations of the evidence base (including generalisability and heterogeneity across the methods used) affect the certainty of conclusions.

Clinical and cost-effectiveness of social recovery therapy for the prevention and treatment of long-term social disability among young people with emerging severe mental illness (PRODIGY): randomised controlled trial.

BACKGROUND: Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological or psychosocial intervention. AIMS: We aimed to test the hypothesis that adding social recovery therapy (SRT) to enhanced standard care (ESC) would improve social recovery compared with ESC alone. METHOD: A pragmatic, assessor-masked, randomised controlled trial (PRODIGY: ISRCTN47998710) was conducted in three UK centres. Participants (n = 270) were aged 16-25 years, with persistent social disability, defined as under 30 hours of structured activity per week, social impairment for at least 6 months and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over 9 months. The primary outcome was time spent in structured activity 15 months post-randomisation. RESULTS: We randomised 132 participants to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15 months increased by 11.1 h for SRT plus ESC (mean 22.4, s.d. = 21.4) and 16.6 h for ESC alone (mean 27.7, s.d. = 26.5). There was no significant difference between arms; treatment effect was -4.44 (95% CI -10.19 to 1.31, P = 0.13). Missingness was consistently greater in the ESC alone arm. CONCLUSIONS: We found no evidence for the superiority of SRT as an adjunct to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes.

Social recovery therapy for young people with emerging severe mental illness: the Prodigy RCT.

BACKGROUND: Young people with social disability and non-psychotic severe and complex mental health problems are an important group. Without intervention, their social problems can persist and have large economic and personal costs. Thus, more effective evidence-based interventions are needed. Social recovery therapy is an individual therapy incorporating cognitive-behavioural techniques to increase structured activity as guided by the participant's goals. OBJECTIVE: This trial aimed to test whether or not social recovery therapy provided as an adjunct to enhanced standard care over 9 months is superior to enhanced standard care alone. Enhanced standard care aimed to provide an optimal combination of existing evidence-based interventions. DESIGN: A pragmatic, single-blind, superiority randomised controlled trial was conducted in three UK centres: Sussex, Manchester and East Anglia. Participants were aged 16-25 years with persistent social disability, defined as < 30 hours per week of structured activity with social impairment for at least 6 months. Additionally, participants had severe and complex mental health problems, defined as at-risk mental states for psychosis or non-psychotic severe and complex mental health problems indicated by a Global Assessment of Functioning score ≤ 50 persisting for ≥ 6 months. Two hundred and seventy participants were randomised 1 : 1 to either enhanced standard care plus social recovery therapy or enhanced standard care alone. The primary outcome was weekly hours spent in structured activity at 15 months post randomisation. Secondary outcomes included subthreshold psychotic, negative and mood symptoms. Outcomes were collected at 9 and 15 months post randomisation, with maintenance assessed at 24 months. RESULTS: The addition of social recovery therapy did not significantly increase weekly hours in structured activity at 15 months (primary outcome treatment effect -4.44, 95% confidence interval -10.19 to 1.31). We found no evidence of significant differences between conditions in secondary outcomes at 15 months: Social Anxiety Interaction Scale treatment effect -0.45, 95% confidence interval -4.84 to 3.95; Beck Depression Inventory-II treatment effect -0.32, 95% confidence interval -4.06 to 3.42; Comprehensive Assessment of At-Risk Mental States symptom severity 0.29, 95% confidence interval -4.35 to 4.94; or distress treatment effect 4.09, 95% confidence interval -3.52 to 11.70. Greater Comprehensive Assessment of At-Risk Mental States for psychosis scores reflect greater symptom severity. We found no evidence of significant differences at 9 or 24 months. Social recovery therapy was not estimated to be cost-effective. The key limitation was that missingness of data was consistently greater in the enhanced standard care-alone arm (9% primary outcome and 15% secondary outcome missingness of data) than in the social recovery therapy plus enhanced standard care arm (4% primary outcome and 9% secondary outcome missingness of data) at 15 months. CONCLUSIONS: We found no evidence for the clinical superiority or cost-effectiveness of social recovery therapy as an adjunct to enhanced standard care. Both arms made large improvements in primary and secondary outcomes. Enhanced standard care included a comprehensive combination of evidence-based pharmacological, psychotherapeutic and psychosocial interventions. Some results favoured enhanced standard care but the majority were not statistically significant. Future work should identify factors associated with the optimal delivery of the combinations of interventions that underpin better outcomes in this often-neglected clinical group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN47998710. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 25, No. 70. See the NIHR Journals Library website for further project information.

Young people with social disability and non-psychotic severe and complex mental health problems are an important group. Their problems are often long-standing and they often have difficulty doing 'structured activity', such as work, sports and leisure activities (e.g. going shopping or to the cinema). They often avoid such activities because of anxiety or low mood. Other barriers may include financial and practical issues, and stigma from activity providers. Non-participation in structured activity increases the risk that mental health problems will continue and prevent these young people from reaching meaningful goals. We tested whether or not social recovery therapy might help. This is a talking and activity therapy, in which young people (participants) work individually with a social recovery therapy therapist. Social recovery therapy aims to help participants identify what activities they would like to do, practise spending more time doing them, and work through barriers to maintaining increased activity. By improving structured activity, young people feel more hopeful and better able to manage their symptoms. However, social recovery therapy has never been evaluated properly using the best research methods. The best way to evaluate treatments like this is a randomised controlled trial in which participants are allocated by chance, like tossing a coin, to have the new therapy or not to have the therapy. Both groups are followed up for a period to see if the new therapy works. We tested social recovery therapy in this way. We also tested whether or not it was cost-effective. We recruited 270 16- to 25-year-old participants in Sussex, East Anglia and Manchester. Participants had non-psychotic severe and complex mental health problems (not psychosis) and were doing < 30 hours of structured activity per week at the start of the study. All participants had enhanced standard care. This involved standard NHS treatment plus a full assessment and feedback from the study team, and a best practice guide to local support services that encouraged the best provision of standard evidence-based interventions. Half of the participants were randomly allocated to have social recovery therapy in addition to enhanced standard care over 9 months. All participants were invited to assessments 9, 15 and 24 months later. Therapists recorded the tasks and activities undertaken with participants. We asked both participants and therapists what they thought of the trial and the social recovery therapy. We found no evidence that adding social recovery therapy improved outcomes. Participants in both arms made large and clinically worthwhile improvements in structured activity and mental health outcomes. If anything, there was some evidence that people allocated to enhanced standard care improved more than those allocated to social recovery therapy plus enhanced standard care. The differences were small, however, and could have occurred by chance.

Psychological intervention, antipsychotic medication or a combined treatment for adolescents with a first episode of psychosis: the MAPS feasibility three-arm RCT.

BACKGROUND: When psychosis emerges in young people there is a risk of poorer outcomes, and access to evidence-based treatments is paramount. The current evidence base is limited. Antipsychotic medications show only a small benefit over placebo, but young people experience more side effects than adults. There is sparse evidence for psychological intervention. Research is needed to determine the clinical effectiveness and cost-effectiveness of psychological intervention versus antipsychotic medication versus a combined treatment for adolescents with psychosis. OBJECTIVES: The objective of Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) was to determine the feasibility of conducting a definitive trial to answer the question of clinical effectiveness and cost-effectiveness of these three treatment options. DESIGN: This was a prospective, randomised, open-blinded, evaluation feasibility trial with a single blind. Participants were allocated 1 : 1 : 1 to receive antipsychotic medication, psychological intervention or a combination of both. A thematic qualitative study explored the acceptability and feasibility of the trial. SETTING: Early intervention in psychosis services and child and adolescent mental health services in Manchester, Oxford, Lancashire, Sussex, Birmingham, Norfolk and Suffolk, and Northumberland, Tyne and Wear. PARTICIPANTS: People aged 14-18 years experiencing a first episode of psychosis either with an International Classification of Diseases, Tenth Revision, schizophrenia spectrum diagnosis or meeting the entry criteria for early intervention in psychosis who had not received antipsychotic medication or psychological intervention within the last 3 months. INTERVENTIONS: Psychological intervention involved up to 26 hours of cognitive-behavioural therapy and six family intervention sessions over 6 months, with up to four booster sessions. Antipsychotic medication was prescribed by the participant's psychiatrist in line with usual practice. Combined treatment was a combination of psychological intervention and antipsychotic medication. MAIN OUTCOME MEASURES: The primary outcome was feasibility (recruitment, treatment adherence and retention). We used a three-stage progression criterion to determine feasibility. Secondary outcomes were psychosis symptoms, recovery, anxiety and depression, social and educational/occupational functioning, drug and alcohol use, health economics, adverse/metabolic side effects and adverse/serious adverse events. RESULTS: We recruited 61 out of 90 (67.8%; amber zone) potential participants (psychological intervention, n = 18; antipsychotic medication, n = 22; combined treatment, n = 21). Retention to follow-up was 51 out of 61 participants (83.6%; green zone). In the psychological intervention arm and the combined treatment arm, 32 out of 39 (82.1%) participants received six or more sessions of cognitive-behavioural therapy (green zone). In the combined treatment arm and the antipsychotic medication arm, 28 out of 43 (65.1%) participants received antipsychotic medication for 6 consecutive weeks (amber zone). There were no serious adverse events related to the trial and one related adverse event. Overall, the number of completed secondary outcome measures, including health economics, was small. LIMITATIONS: Medication adherence was determined by clinician report, which can be biased. The response to secondary outcomes was low, including health economics. The small sample size obtained means that the study lacked statistical power and there will be considerable uncertainty regarding estimates of treatment effects. CONCLUSIONS: It is feasible to conduct a trial comparing psychological intervention with antipsychotic medication and a combination treatment in young people with psychosis with some adaptations to the design, including adaptations to collection of health economic data to determine cost-effectiveness. FUTURE WORK: An adequately powered definitive trial is required to provide robust evidence. TRIAL REGISTRATION: Current Controlled Trials ISRCTN80567433. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 4. See the NIHR Journals Library website for further project information.

Psychosis is a mental health problem that can involve hearing, seeing or believing things that others do not. Although many young people who experience psychosis recover well from their first episode of psychosis, others can have more serious, longer-lasting problems. There has not been a large amount of research into the treatment of psychosis in young people; therefore, it is important to test different treatments against each other in clinical trials. 'Feasibility' trials, such as the one we carried out [Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS)], test whether or not it is possible to run larger trials. MAPS was a small trial that was run in seven locations in the UK. People who were aged 14­18 years and experiencing psychosis were able to take part. Each participant was randomly assigned to receive psychological treatment (cognitive­behavioural therapy and optional family therapy), antipsychotic medication or a combination of both. All of the participants met with a trial research assistant three times for assessments about well-being and symptoms. Some clinicians, participants and family members were interviewed about their opinions of the trial and treatments. The trial also had patient and public involvement; service user researchers were involved in design, interview data collection, analysis and report writing. Sixty-one young people took part in MAPS, which was around 68% of our target number. In total, 84% completed the assessments with research assistants. The results showed that, overall, all treatments were acceptable to young people and their family members. However, a higher percentage of young people actually received the 'minimum dose' of psychological treatment than the 'minimum dose' of antipsychotic medication (82% vs. 65%). Results showed that it was possible to run a larger trial such as this. However, some changes would be required to run a larger trial, such as location (focusing on urban areas with well established early intervention in psychosis teams), increasing involvement of psychiatrists and increasing the age limit for participation to 25 years.