How Does Resorption Differ Among Single-Level and Multilevel Lumbar Disc Herniations? A Prospective Multi-Imaging and Clinical Phenotype Study.

STUDY DESIGN: Prospective, case series. OBJECTIVE: To identify and characterize any differences in specific patient factors, MRI findings, features of spontaneous disc resorption, and outcomes between patients with single-level and multilevel LDH. BACKGROUND: Lumbar disc herniation (LDH) is one of the most common spinal pathologies worldwide. Though many cases of LDH resolve by spontaneous resorption, the mechanism underlying this "self-healing" phenomenon remains poorly understood, particularly in the context of multilevel herniations. METHODS: A one-year prospective study was conducted of patients presenting with acute symptomatic LDH between 2017 and 2019. Baseline demographics, herniation characteristics, and MRI phenotypes were recorded before treatment, which consisted of gabapentin, acupuncture, and the avoidance of inflammatory-modulating medications. MRIs were performed approximately every three months after the initial evaluation to determine any differences between patients with single-level and multilevel LDH. RESULTS: Ninety patients were included, 17 demonstrated multilevel LDH. Body mass index was higher among patients with multilevel LDH ( P <0.001). Patients with multilevel LDH were more likely to exhibit L3/L4 inferior endplate defects ( P =0.001), L4/L5 superior endplate defects ( P =0.012), and L4/L5 inferior endplate defects ( P =0.020) on MRI. No other differences in MRI phenotypes ( e.g. Modic changes, osteophytes, etc .) existed between groups. Resorption rate and time to resolution did not differ between those with single-level and multilevel LDH. CONCLUSIONS: Resorption rates were similar between single-level and multilevel LDH at various time points throughout one prospective assessment, providing insights that disc healing may have unique programmed signatures. Compared with those with single-level LDH, patients with multilevel herniations were more likely to have a higher BMI, lesser initial axial and sagittal disc measurements, and endplate defects at specific lumbar levels. In addition, our findings support the use of conservative management in patients with LDH, regardless of the number of levels affected. LEVEL OF EVIDENCE: Level 3.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting.

BACKGROUND CONTEXT: Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated. PURPOSE: This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021. OUTCOME MEASURES: Thirty-day rates of serious and minor adverse events, readmission, reoperation, non-home discharge, and mortality. METHODS: A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) non-home discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences. RESULTS: Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs. 11.8%) and OP (92.7% vs. 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and non-home discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=0.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, non-home discharge, or death (p>.050 for all). CONCLUSIONS: Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND: In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS: White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS: A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION: Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.

The efficacy and safety of oral antibiotic treatment in patients with chronic low back pain and Modic changes: A systematic review and meta-analysis.

Background: This systematic review and meta-analysis aimed to summarize evidence regarding the effectiveness and safety of oral antibiotic intervention for chronic low back pain (CLBP) patients with/without type-1 Modic changes (MC1). Methods: AMED, CINAHL, Cochrane Library, Embase, and Medline were searched from inception to March 3, 2023. Randomized controlled trials (RCTs) or non-RCTs that investigated the effectiveness or safety of oral antibiotics in treating CLBP patients were eligible for inclusion. Two independent reviewers screened abstracts, full-text articles, and extracted data. The methodological quality of each included article were evaluated by RoB2 and NIH quality assessment tools. The quality of evidence was appraised by GRADE. Meta-analyses were performed, where applicable. A subgroup analysis was conducted to evaluate the RCTs and case series separately, and to evaluate the effect of removing a low-quality RCT. Results: Three RCTs and four case series were included. All Amoxicillin-clavulanate/Amoxicillin treatments lasted for approximately 3 months. Moderate- and low-quality evidence suggested that antibiotic was significantly better than placebo in improving disability and quality of life in CLBP patients with MC1 at 12-month follow-up, respectively. Low-quality evidence from meta-analyses of RCTs showed that oral antibiotic was significantly better than placebo in improving pain and disability in CLBP patients with MC1 immediately post-treatment. Very low-quality evidence from the case series suggested that oral Amoxicillin-clavulanate significantly improved LBP/leg pain, and LBP-related disability. Conversely, low-quality evidence found that oral Amoxicillin alone was not significantly better than placebo in improving global perceived health in patients with CLBP at the 12-month follow-up. Additionally, oral antibiotic users had significantly more adverse effects than placebo users. Conclusions: Although oral antibiotics were statistically superior to placebo in reducing LBP-related disability in patients with CLBP and concomitant MC1, its clinical significance remains uncertain. Future large-scale high-quality RCTs are warranted to validate the effectiveness of antibiotics in individuals with CLBP.

National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States.

Background: Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy. Purpose: To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region. Study Design: Descriptive epidemiology study. Methods: The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables. Results: During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]). Conclusion: Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.

Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors.

BACKGROUND CONTEXT: Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern. PURPOSE: This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. OUTCOME MEASURES: Hospital readmission within 30 postoperative days. METHODS: Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission. RESULTS: A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all). CONCLUSION: This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.

Improving Racial and Ethnic Disparities in Outpatient Anterior Cervical Discectomy and Fusion Driven by Increasing Utilization of Ambulatory Surgical Centers in New York State.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to assess trends in disparities in utilization of hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for outpatient ACDF (OP-ACDF) between White, Black, Hispanic, and Asian/Pacific Islander patients from 2015 to 2018 in New York State. SUMMARY OF BACKGROUND DATA: Racial and ethnic disparities within the field of spine surgery have been thoroughly documented. To date, it remains unknown how these disparities have evolved in the outpatient setting alongside the rapid emergence of ASCs and whether restrictive patterns of access to these outpatient centers exist by race and ethnicity. MATERIALS AND METHODS: We conducted a retrospective review from 2015 to 2018 using the Healthcare Cost and Utilization Project (HCUP) New York State Ambulatory Database. Differences in utilization rates for OP-ACDF were assessed and trended over time by race and ethnicity for both HOPDs and freestanding ASCs. Poisson regression was used to evaluate the association between utilization rates for OP-ACDF and race/ethnicity. RESULTS: Between 2015 and 2018, Black, Hispanic, and Asian patients were less likely to undergo OP-ACDF compared with White patients in New York State. However, the magnitude of these disparities lessened over time, as Black, Hispanic, and Asian patients had greater relative increases in utilization of HOPDs and ASCs for ACDF when compared with White patients ( Ptrend <0.001). The magnitude of the increase in freestanding ASC utilization was such that minority patients had higher ACDF utilization rates in freestanding ASCs by 2018 ( P <0.001). CONCLUSIONS: We found evidence of improving racial disparities in the relative utilization of outpatient ACDF in New York State. The increase in access to outpatient ACDF appeared to be driven by an increasing number of patients undergoing ACDF in freestanding ASCs in large metropolitan areas. These improving disparities are encouraging and contrast previously documented inequalities in inpatient spine surgery. LEVEL OF EVIDENCE: III.

Obesity in children with low back pain: implications with imaging phenotypes and opioid use.

BACKGROUND CONTEXT: Low back pain (LBP) is common in children and adolescents, carrying substantial risk for recurrence and continuation into adulthood. Studies have linked obesity to the development of pediatric LBP; however, its association with lumbar spine degeneration, alignment parameters, and opioid use remains debated. PURPOSE: Considering the increasing prevalence of pediatric obesity and LBP and the inherent issues with opioid use, this study aimed to assess the association of obesity with lumbar spine degeneration, spinopelvic alignment, and opioid therapy among pediatric patients. STUDY DESIGN/SETTING: A retrospective study of pediatric patients presenting to a single institute with LBP and no history of spine deformity, tumor, or infection was performed. PATIENT SAMPLE: A totasl of 194 patients (mean age: 16.7±2.3 years, 45.3% male) were included, of which 30 (15.5%) were obese. OUTCOME MEASURES: Prevalence of imaging phenotypes and opioid use among obese to nonobese pediatric LBP patients. Magnetic resonance and plain radiographic imaging were evaluated for degenerative phenotypes (disc bulging, disc herniation, disc degeneration [DD], high-intensity zones [HIZ], disc narrowing, Schmorl's nodes, endplate phenotypes, Modic changes, spondylolisthesis, and osteophytes). Lumbopelvic parameters including lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence and pelvic incidence-lumbar lordosis (PI-LL) mismatch were also examined. METHODS: Demographic and clinical information was recorded, including use of opioids. The associations between obesity and lumbar phenotypes or opiod use were assessed by multiple regression models. RESULTS: Based on multivariate analysis, obesity was significantly associated with the presence of HIZ (adjusted OR: 5.36, 95% CI: 1.30 to 22.09). Further analysis demonstrated obesity (adjusted OR: 3.92, 95% CI: 1.49 to 10.34) and disc herniation (OR: 4.10, 95% CI: 1.50 to 11.26) were associated with opioid use, independent of duration of symptoms, other potential demographic determinants, and spinopelvic alignment. CONCLUSIONS: In pediatric patients, obesity was found to be significantly associated with HIZs of the lumbar spine, while disc herniation and obesity were associated with opioid use. Spinopelvic alignment parameters did not mitigate any outcome. This study underscores that pediatric obesity increases the risk of developing specific degenerative spine changes and pain severity that may necessitate opioid use, emphasizing the importance of maintaining healthy body weight in promoting lumbar spine health in the young.

Trends in Outpatient Cervical Spine Surgery: Are There Emerging Disparities?

STUDY DESIGN: Retrospective analysis on prospectively collected data. OBJECTIVE: The purposes of this study were to (1) assess disparities in relative utilization of outpatient cervical spine surgery between White and Black patients from 2010 to 2019 and (2) to measure how these racial differences have evolved over time. SUMMARY OF BACKGROUND DATA: Although outpatient spine surgery has become increasingly popularized over the last decade, it remains unknown how racial disparities in surgical utilization have translated to the outpatient setting and whether restrictive patterns of access to outpatient cervical spine procedures may exist. METHODS: A retrospective cohort study from 2010 to 2019 was conducted using the National Surgical Quality Improvement Program database. Relative utilization of outpatient (same-day discharge) for anterior cervical discectomy and fusion (OP-ACDF) and cervical disk replacement (OP-CDR) were assessed and trended over time between races. Multivariable regressions were subsequently utilized to adjust for baseline patient factors and comorbidities. RESULTS: Overall, Black patients were significantly less likely to undergo OP-ACDF or OP-CDR surgery when compared with White patients ( P <0.03 for both OP-ACDF and OP-CDR). From 2010 to 2019, a persisting disparity over time was found in outpatient utilization for both ACDF and CDR ( e.g. White vs. Black OP-ACDF: 6.0% vs. 3.1% in 2010 compared with 16.7% vs. 8.5% in 2019). These results held in all adjusted analyses. CONCLUSIONS: To our knowledge, this is the first study reporting racial disparities in outpatient spine surgery and demonstrates an emerging disparity in outpatient cervical spine utilization among Black patients. These restrictive patterns of access to same-day outpatient hospital and surgery centers may contribute to broader disparities in the overall utilization of major spine procedures that have been previously reported. Renewed interventions are needed to both understand and address these emerging inequalities in outpatient care before they become more firmly established within our orthopedic and neurosurgery spine delivery systems.

Racial disparities in arthroscopic rotator cuff repair: an analysis of utilization and perioperative outcomes.

Background: There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 to 2019. Baseline demographics, utilization trends, and perioperative measures, including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission, were analyzed. Results: Of 42,443 included patients, 38,090 (89.7%) were White, and 4353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). In addition, logistic regression showed that Black or African American patients had increased odds of longer operative time (adjusted rate ratio 1.07, 95% confidence interval 1.05-1.08) and time from operation to discharge (adjusted rate ratio 1.19, 95% confidence interval 1.04-1.37). Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared with White patients (P trend < .0001). Conclusion: Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address the causes of these inequalities to provide equitable care.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis.

Background: The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players. Purpose: To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary. Results: Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar. Conclusion: RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

Evidence-Based Hamstring Injury Prevention and Risk Factor Management: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Hamstring injuries are common among athletes. Considering the potentially prolonged recovery and high rate of recurrence, effective methods of prevention and risk factor management are of great interest to athletes, trainers, coaches, and therapists, with substantial competitive and financial implications. PURPOSE: To systematically review the literature concerning evidence-based hamstring training and quantitatively assess the effectiveness of training programs in (1) reducing injury incidence and (2) managing injury risk factors. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1. METHODS: A computerized search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus with manual screening of selected reference lists was performed in October 2020. Randomized controlled trials investigating methods of hamstring injury prevention and risk factor management in recreational, semiprofessional, and professional adult athletes were included. RESULTS: Of 2602 articles identified, 108 were included. Eccentric training reduced the incidence of hamstring injury by 56.8% to 70.0%. Concentric hamstring strength increased with eccentric (mean difference [MD], 14.29 N·m; 95% CI, 8.53-20.05 N·m), concentric, blood flow-restricted, whole-body vibration, heavy back squat, FIFA 11+ (Fédération Internationale de Football Association), and plyometric training methods, whereas eccentric strength benefited from eccentric (MD, 26.94 N·m; 95% CI, 15.59-38.30 N·m), concentric, and plyometric training. Static stretching produced greater flexibility gains (MD, 10.89°; 95% CI, 8.92°-12.86°) than proprioceptive neuromuscular facilitation (MD, 9.73°; 95% CI, 6.53°-12.93°) and dynamic stretching (MD, 6.25°; 95% CI, 2.84°-9.66°), although the effects of static techniques were more transient. Fascicle length increased with eccentric (MD, 0.90 cm; 95% CI, 0.53-1.27 cm) and sprint training and decreased with concentric training. Although the conventional hamstring/quadriceps (H/Q) ratio was unchanged (MD, 0.03; 95% CI, -0.01 to 0.06), the functional H/Q ratio significantly improved with eccentric training (MD, 0.10; 95% CI, 0.03-0.16). In addition, eccentric training reduced limb strength asymmetry, while H/Q ratio and flexibility imbalances were normalized via resistance training and static stretching. CONCLUSION: Several strategies exist to prevent hamstring injury and address known risk factors. Eccentric strengthening reduces injury incidence and improves hamstring strength, fascicle length, H/Q ratio, and limb asymmetry, while stretching-based interventions can be implemented to improve flexibility. These results provide valuable insights to athletes, trainers, coaches, and therapists seeking to optimize hamstring training and prevent injury.

Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis.

BACKGROUND: Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS: A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable. CONCLUSION: Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care. LEVEL OF EVIDENCE: IV.

Same-Day Discharge Total Knee Arthroplasty in Octogenarians.

BACKGROUND: One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old. METHODS: This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed. RESULTS: Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days. CONCLUSION: Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.

Total Joint Arthroplasty Utilization After Orthopaedic Surgery Referral: Identifying Disparities Along the Care Pathway.

BACKGROUND: Although racial and ethnic disparities in total joint arthroplasty (TJA) have been thoroughly described, only a few studies have sought to determine exactly where along the care pathway these disparities are perpetuated. The purpose of this study was to investigate disparities in TJA utilization occurring after patients who had diagnosed hip or knee osteoarthritis were referred to a group of orthopaedic providers within an integrated academic institution. METHODS: A retrospective, multi-institutional study evaluating patients with diagnosed hip or knee osteoarthritis was conducted between 2015 and 2019. Information pertaining to patient demographics, timing of clinic visits, and subsequent surgical intervention was collected. Utilization rates and time to surgery from the initial clinic visit were calculated by race, and logistic regressions were performed to control for various demographic as well as health related variables. RESULTS: White patients diagnosed with knee osteoarthritis were significantly more likely to receive total knee arthroplasty (TKA) than Black and Hispanic patients, even after adjusting for various demographic variables (Black patients: odds ratio [OR] = 0.63, 95% CI = 0.55-0.72, P = .002; Hispanic patients: OR = 0.69, 95% CI = 0.57-0.83, P = .039). Similar disparities were found among patients diagnosed with hip osteoarthritis who underwent total hip arthroplasty (THA; Black patients: OR = 0.73, 95% CI = 0.60-0.89, P = <.001; Hispanic patients: OR = 0.72, 95% CI = 0.53-0.98, P <.001). There were no differences in time to surgery between races (P > .05 for all). CONCLUSION: In this study, racial and ethnic disparities in TJA utilization were found to exist even after referral to an orthopaedic surgeon, highlighting a critical point along the care pathway during which inequalities in TJA care can emerge. Similar time to surgery between White, Black, and Hispanic patients suggest that these disparities in TJA utilization may largely be perpetuated before surgical planning while patients are deciding whether to undergo surgery. Further studies are needed to better elucidate which patient and provider-specific factors may be preventing these patients from pursuing surgery during this part of the care pathway. LEVEL OF EVIDENCE: Level IV.

Prediction of lumbar disc herniation resorption in symptomatic patients: a prospective, multi-imaging and clinical phenotype study.

BACKGROUND CONTEXT: Symptomatic lumbar disc herniations (LDH) are very common. LDH resorption may occur by a "self-healing" process, however this phenomenon remains poorly understood. By most guidelines, if LDH remains symptomatic after 3 months and conservative management fails, surgical intervention may be an option. PURPOSE: The following prospective study aimed to identify determinants that may predict early versus late LDH resorption. STUDY DESIGN/SETTING: Prospective study with patients recruited at a single center. PATIENT SAMPLE: Ninety-three consecutive patients diagnosed with acute symptomatic LDH were included in this study (n=23 early resorption and n=67 late resorption groups) with a mean age of 48.7±11.9 years. OUTCOMES MEASURE: Baseline assessment of patient demographics (eg, smoking status, height, weight, etc.), herniation characteristics (eg, the initial level of herniation, the direction of herniation, prevalence of multiple herniations, etc.) and MRI phenotypes (eg, Modic changes, end plate abnormalities, disc degeneration, vertebral body dimensions, etc.) were collected for further analysis. Lumbar MRIs were performed approximately every 3 months for 1 year from time of enrollment to assess disc integrity. METHODS: All patients were managed similarly. LDH resorption was classified as early (<3 months) or late (>3 months). A prediction model of pretreatment factors was constructed. RESULTS: No significant differences were noted between groups at any time-point (p>.05). Patients in the early resorption group experienced greater percent reduction of disc herniation between MRI-0-MRI-1 (p=.043), reduction of herniation size for total study duration (p=.007), and percent resorption per day compared to the late resorption group (p<.001). Based on multivariate modeling, greater L4 posterior vertebral height (coeff:14.58), greater sacral slope (coeff:0.12), and greater herniated volume (coeff:0.013) at baseline were found to be most predictive of early resorption (p<.05). CONCLUSIONS: This is the first comprehensive imaging and clinical phenotypic prospective study, to our knowledge, that has identified distinct determinants for early LDH resorption. Early resorption can occur in 24.7% of LDH patients. We developed a prediction model for early resorption which demonstrated great overall performance according to pretreatment measures of herniation size, L4 posterior body height, and sacral slope. A risk profile is proposed which may aid clinical decision-making and managing patient expectations.

YouTube as a source of information on pediatric scoliosis: a reliability and educational quality analysis.

PURPOSE: To assess the reliability and educational quality of YouTube videos related to pediatric scoliosis. METHODS: In December 2020, searches of "pediatric scoliosis", "idiopathic scoliosis", "scoliosis in children", and "curved spine in children" were conducted using YouTube. The first 50 results of each search were analyzed according to upload source and content. The Journal of the American Medical Association (JAMA) Benchmark Criteria were used to assess reliability (score 0-4), and educational quality was evaluated using the Global Quality Score (GQS; score 0-5) and Pediatric Scoliosis-Specific Score (PSS; score 0-15). Differences in scores based on upload source and content were determined by Analysis of Variance (ANOVA) or Kruskal-Wallis tests. Multivariate linear regressions identified any independent predictors of reliability and educational quality. RESULTS: After eliminating duplicates, 153 videos were analyzed. Videos were viewed 28.5 million times in total, averaging 186,160.3 ± 1,012,485.0 views per video. Physicians (54.2%) and medical sources (19.0%) were the most common upload sources, and content was primarily categorized as disease-specific (50.0%) and patient experience (25.5%). Videos uploaded by patients achieved significantly lower JAMA scores (p = 0.004). Conversely, academic or physician-uploaded videos scored higher on PSS (p = 0.003) and demonstrated a trend towards improved GQS (p = 0.051). Multivariate analysis determined longer video duration predicted higher scores on all measures. However, there were no independent associations between upload source or content and assessment scores. CONCLUSION: YouTube contains a large repository of videos concerning pediatric scoliosis; however, the reliability and educational quality of these videos were low. LEVEL OF EVIDENCE: V.

Sex differences in utilization and perioperative outcomes of arthroscopic rotator cuff repair.

Background: As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes. Methods: Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex. Results: Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable. Conclusion: Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide: A One Year Prospective Comparative Study.

STUDY DESIGN: Survey. OBJECTIVE: In March of 2020, an original study by Louie et al investigated the impact of COVID-19 on 902 spine surgeons internationally. Since then, due to varying government responses and public health initiatives to the pandemic, individual countries and regions of the world have been affected differently. Therefore, this follow-up study aimed to assess how the COVID-19 impact on spine surgeons has changed 1 year later. METHODS: A repeat, multi-dimensional, 90-item survey written in English was distributed to spine surgeons worldwide via email to the AO Spine membership who agreed to receive surveys. Questions were categorized into the following domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. RESULTS: Basic respondent demographics, such as gender, age, home demographics, medical comorbidities, practice type, and years since training completion, were similar to those of the original 2020 survey. Significant differences between groups included reasons for COVID testing, opinions of media coverage, hospital unemployment, likelihood to be performing elective surgery, percentage of cases cancelled, percentage of personal income, sick leave, personal time allocation, stress coping mechanisms, and the belief that future guidelines were needed (P<.05). CONCLUSION: Compared to baseline results collected at the beginning of the COVID-19 pandemic in 2020, significant differences in various domains related to COVID-19 perceptions, hospital preparedness, practice impact, personal impact, and future perceptions have developed. Follow-up assessment of spine surgeons has further indicated that telemedicine and virtual education are mainstays. Such findings may help to inform and manage expectations and responses to any future outbreaks.