Reliability of the Walch Classification for Characterization of Primary Glenohumeral Arthritis: A Systematic Review.

INTRODUCTION: The Walch classification has been widely accepted and further developed as a method to characterize glenohumeral arthritis. However, many studies have reported low and inconsistent measures of the reliability of the Walch classification. The purpose of this study was to review the literature on the reliability of the Walch classification and characterize how imaging modality and classification modifications affect reliability. METHODS: A systematic review of publications that included reliability of the Walch classification reported through intraobserver and interobserver kappa values was conducted. A search in January 2021 and repeated in July 2023 used the terms ["Imaging" OR "radiography" OR "CT" OR "MRI"] AND ["Walch classification"] AND ["Glenoid arthritis" OR "Shoulder arthritis"]. All clinical studies from database inception to July 2023 that evaluated the Walch or modified Walch classification's intraobserver and/or interobserver reliability were included. Cadaveric studies and studies that involved subjects with previous arthroplasty, shoulder débridement, glenoid reaming, interposition arthroplasty, and latarjet or bankart procedure were excluded. Articles were categorized by imaging modality and classification modification. RESULTS: Thirteen articles met all inclusion criteria. Three involved the evaluation of plain radiographs, 10 used CT, two used three-dimensional (3D) CT, and four used magnetic resonance imaging. Nine studies involved the original Walch classification system, five involved a simplified version, and four involved the modified Walch. Six studies examined the reliability of raters of varying experience levels with none reporting consistent differences based on experience. Overall intraobserver reliability of the Walch classifications ranged from 0.34 to 0.92, and interobserver reliability ranged from 0.132 to 0.703. No consistent trends were observed in the effect of the imaging modalities or classification modifications on reliability. DISCUSSION: The reliability of the Walch classification remains inconsistent, despite modification and imaging advances. Consideration of the limitations of the classification system is important when using it for treatment or prognostic purposes.

Funding Bias in Shoulder Arthroplasty Research.

BACKGROUND: Prior research has shown that industry funding can impact the outcomes reported in medical literature. Limited data exists on the degree of bias that industry funding may have on shoulder arthroplasty literature outside of the Journal of Shoulder and Elbow Surgery. The purpose of this study is to characterize the type and frequency of funding for recently published shoulder arthroplasty studies and the impact of industry funding on reported outcomes. We hypothesized that studies with industry funding are more likely to report positive outcomes than those without. MATERIALS/METHOD: We performed a retrospective study searching all articles with the term "shoulder arthroplasty," "reverse shoulder arthroplasty," "anatomic total shoulder arthroplasty," or "total shoulder arthroplasty" on PubMed from the years January 2020 to December 2022. The primary outcome of studies was coded as either positive, negative, or neutral. A positive result was defined as one in which the null hypothesis was rejected. A negative result was defined as one in which the result did not favor the group in which the industry-funded implant was used. A neutral result was defined as one in which the null hypothesis was confirmed. Article funding type, subcategorized as National Institute of Health (NIH) funding or industry funding was recorded. Author disclosures were recorded to determine conflicts of interest. Statistical analysis was conducted using the Chi-squared test and Fisher exact test. RESULTS: 750 articles reported on either conflict of interest or funding source and were included in the study. Of the total number of industry funded studies the majority were found to have a positive primary endpoint (58.1%, 104/179), as compared to a negative (7.8%, 14/179), or neutral endpoint (33.5%, 60/179) (p=0.004). 363 articles reported an author conflicts of interest and the majority of these studies had positive primary endpoint (55.6%, 202/363) as compared to negative (9.1%, 33/363) or neutral endpoints (34.4%, 125/363)(p=.002). CONCLUSION: The results of this study suggest that there is a significant relationship between conflicts of interest and the primary outcome of shoulder arthroplasty studies, beyond the overall positive publication bias. Studies with industry funding and author conflicts of interest both report positive outcomes more frequently than negative outcomes. Shoulder surgeons should be aware of this potential bias when choosing to base clinical practice on published data.

Isolated Optic Neuritis: Etiology, Characteristics, and Outcomes in a US Mountain West Cohort.

BACKGROUND: The diagnosis and treatment of autoimmune optic neuritis (ON) has improved with the accessibility and reliability of aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibody testing, yet autoantibody-negative ON remains common. This study describes the demographic, clinical, and outcome data in patients with isolated ON across the pediatric and adult cohort. METHODS: A retrospective chart review of University of Utah Health patients with the International Classification of Diseases (ICD) code of ICD-9 377.30 (ON unspecified), ICD-9 377.39 (other ON), or ICD-10 H46 (ON) and at least 2 ophthalmologic evaluations were conducted between February 2011 and July 2023. Only isolated cases of ON without other brain or spinal demyelinating lesions were evaluated. Differences in demographic and clinical characteristics between AQP4, MOG, and Other-ON were determined. RESULTS: Of the 98 patients (15 children and 83 adults), 9 (9.2%) were positive for AQP4-IgG and 35 (35.7%) tested positive for MOG-IgG. Fifty-four were classified into Other-ON, of which 7 (13.0%) had recurrence or new demyelinating lesions during a median follow-up of 12.5 months-2 were ultimately diagnosed with recurrent isolated ON (RION), 1 with chronic relapsing inflammatory ON (CRION), 2 with multiple sclerosis, 1 with collapsin response-mediator protein (CRMP)-5-ON, and 1 with seronegative neuromyelitis optica spectrum disorder. Four patients were treated with long-term immunosuppressive therapy. No patients with RION or CRION had preceding infections; they had first recurrences of ON within 2 months. At presentation, AQP4-ON (75%) and MOG-ON (48.8%) had more severe vision loss (visual acuity <20/200) than Other-ON (23.2%, P = 0.01). At the 1-month follow-up, 93.0% of patients with MOG-ON and 89.3% of patients with Other-ON demonstrated a visual acuity ≥20/40, compared with only 50% of patients with AQP4-ON (P < 0.01). By the last follow-up, 37.5% of the AQP4-ON still exhibited visual acuity <20/40, including 25% who experienced severe vision loss (visual acuity <20/200). By contrast, over 95% of patients with MOG-ON and Other-ON maintained a visual acuity of ≥20/40. In our cohort, over a quarter of pediatric cases presented with simultaneous bilateral ON, 40% had a preceding infection, and 44.4% initially presented with a visual acuity <20/200. Two pediatric cases had recurrence, and both were MOG-ON. By their last follow-up, all pediatric cases had achieved a visual acuity of 20/40 or better. In addition, pediatric cases were more likely to exhibit disc edema compared with adult cases (100% vs 64%, P < 0.01). CONCLUSIONS: Despite recent advances in identification and availability of testing for AQP4-IgG and MOG-IgG, over half of patients who presented with isolated ON remained with an "idiopathic" diagnostic label. As more than 1 in 10 patients with AQP4-IgG and MOG-IgG negative ON experienced recurrence or develop new demyelinating lesions, clinicians should provide anticipatory guidance and closely monitor for potential long-term outcomes. In addition, it is crucial to re-evaluate the diagnosis in cases of poor recovery, ON recurrence, and the emergence of new neurological symptoms, as ON can often be the initial presentation of other conditions.

Vasculitis in the Central Nervous System: Etiology, Characteristics, and Outcomes in a Large Single-Center Cohort.

Background and Purpose: For the management of central nervous system (CNS) vasculitis, it is crucial to differentiate between primary and secondary CNS vasculitis and to understand the respective etiologies. We assessed the etiology, characteristics, and outcomes of patients with CNS vasculitis. Methods: A single-center retrospective chart review was conducted at the University of Utah, Department of Neurology, between February 2011 and October 2022. Results: The median age of the 44 included patients at diagnosis was 54 years; 25.0% were men. Compared to primary CNS vasculitis, secondary CNS vasculitis exhibits higher fever incidence (observed in infectious and connective tissue disorder [CTD]-associated vasculitis), low glucose levels (mostly in infectious vasculitis) and unique cerebrospinal fluid oligoclonal bands (observed in infectious and CTD-associated vasculitis). Patients with inflammatory cerebral amyloid angiopathy (CAA) were older and more commonly had microhemorrhage than primary angiitis of the CNS (PACNS). All patients with CTD-associated vasculitis had a known history of CTD at presentation. Brain biopsies were performed on 10 of 17 PACNS patients and 4 of 8 inflammatory CAA patients, confirming vasculitis in 7 and 4 patients, respectively. Intravenous methylprednisolone was the predominant induction therapy (63.6%), and cyclophosphamide was the most used adjunctive therapy. Cyclophosphamide, rituximab, azathioprine, and mycophenolate mofetil were utilized as maintenance therapy, often with concurrent prednisone. Patients with inflammatory CAA had a higher tendency for relapse rates than PACNS. Conclusions: This study highlights the variations in patients' characteristics, symptoms, and treatment for CNS vasculitis. Understanding these differences can lead to more efficient diagnostic and management strategies.

Treatment of Shoulder Osteoarthritis With Intact Rotator Cuff and Severe Glenoid Retroversion.

The American Academy of Orthopaedic Surgeons has developed an Appropriate Use Criteria (AUC) for Treatment of Shoulder Osteoarthritis with Intact Rotator Cuff and Severe Glenoid Retroversion. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to determine the appropriateness of various treatments of shoulder osteoarthritis with intact rotator cuff and severe glenoid retroversion. The AUC for Treatment of Shoulder Osteoarthritis with Intact Rotator Cuff and Severe Glenoid Retroversion were derived by identifying scenarios evident during the clinical decision-making process on this topic. These scenarios relied on definitions and general assumptions, mutually agreed upon by the writing panel during scenario development. These definitions and assumptions were necessary to provide consistency in the interpretation of the clinical scenarios among experts rating the scenarios and readers using the final criteria. Writing panel members of this AUC developed patient scenarios using these guiding principles: comprehensive (covers a wide range of patients), mutually exclusive (no overlap between patient scenarios/indications), homogeneous (final ratings should result in equal application in each of the patient scenarios), and manageable (number of total rating items [ie, number of patient scenarios × number of treatments] should be practical for the rating panel). The target number of total rating items was <1,500. This means that not all patient indications and treatments can be assessed using AUC. A total of 240 patient scenarios and five treatments were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, a separate, multidisciplinary, rating panel (made up of specialists and non-specialists) rated the appropriateness of treatment of each patient scenario using a nine-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3).

No difference in torque load to failure between split anconeus fascia transfer and autograft palmaris longus tendon for reconstruction of the lateral ulnar collateral ligament.

Background: The split anconeus fascia transfer (SAFT) is an option for reconstruction of the lateral ulnar collateral ligament (LUCL) in chronic posterolateral rotatory instability (PLRI) of the elbow with potential advantages of using only local tissue within the surgical exposure and not requiring ulnar fixation. This study aimed to assess SAFT strength compared to a traditional free graft reconstruction in a PLRI biomechanical model. Methods: To measure biomechanical strength, eight cadaveric upper extremity pairs were utilized. Within each pair, one specimen was randomly assigned to LUCL reconstruction with autograft palmaris longus and the other to SAFT reconstruction. Torque load to failure was assessed on a load frame with the elbow in 30 degrees of flexion, 5 degrees of valgus, and 25 N axial load as the elbow was brought into external rotation. Torque load to failure was compared between the two reconstruction techniques. Results: No difference was found in the torque load to failure between SAFT specimens compared to palmaris longus autograft specimens (mean 14.6 ± 4.4 Nm vs. mean 11.3 ± 3.9 Nm; P = .16). Discussion: In this biomechanical study, the SAFT LUCL reconstruction provided torque load to failure similar to that of the traditional technique. These findings suggest that the SAFT technique warrants continued study as a biomechanically sound option for LUCL reconstruction in the setting of elbow PLRI.

Exploring critical intervention features and trial processes in the evaluation of sensory integration therapy for autistic children.

BACKGROUND: We evaluated the clinical and cost-effectiveness of manualised sensory integration therapy (SIT) for autistic children with sensory processing difficulties in a two-arm randomised controlled trial. Trial processes and contextual factors which may have affected intervention outcomes were explored within a nested process evaluation. This paper details the process evaluation methods and results. We also discuss implications for evaluation of individual level, tailored interventions in similar populations. METHODS: The process evaluation was conducted in line with Medical Research Council guidance. Recruitment, demographics, retention, adherence, and adverse effects are reported using descriptive statistics. Fidelity of intervention delivery is reported according to the intervention scoring manual. Qualitative interviews with therapists and carers were undertaken to explore the acceptability of the intervention and trial processes. Qualitative interviews with carers explored potential contamination. RESULTS: Recruitment, reach and retention within the trial met expected thresholds. One hundred thirty-eight children and carers were recruited (92% of those screened and 53.5% of those who expressed an interest) with 77.5% retained at 6 months and 69.9% at 12 months post-randomisation. The intervention was delivered with structural and process fidelity with the majority (78.3%) receiving a 'sufficient dose' of intervention. However, there was considerable individual variability in the receipt of sessions. Carers and therapists reported that trial processes were generally acceptable though logistical challenges such as appointment times, travel and COVID restrictions were frequent barriers to receiving the intervention. No adverse effects were reported. CONCLUSIONS: The process evaluation was highly valuable in identifying contextual factors that could impact the effectiveness of this individualised intervention. Rigorous evaluations of interventions for autistic children are important, especially given the limitations such as limited sample sizes and short-term follow-up as faced by previous research. One of the challenges lies in the variability of outcomes considered important by caregivers, as each autistic child faces unique challenges. It is crucial to consider the role of parents or other caregivers in facilitating access to these interventions and how this may impact effectiveness. TRIAL REGISTRATION: This trial is registered as ISRCTN14716440. August 11, 2016.

Digital adaptation of the Standing up for Myself intervention in young people and adults with intellectual disabilities: the STORM feasibility study.

Background: Stigma contributes to the negative social conditions persons with intellectual disabilities are exposed to, and it needs tackling at multiple levels. Standing Up for Myself is a psychosocial group intervention designed to enable individuals with intellectual disabilities to discuss stigmatising encounters in a safe and supportive setting and to increase their self-efficacy in managing and resisting stigma. Objectives: To adapt Standing Up for Myself to make it suitable as a digital intervention; to evaluate the feasibility and acceptability of Digital Standing Up for Myself and online administration of outcome measures in a pilot; to describe usual practice in the context of the coronavirus disease 2019 pandemic to inform future evaluation. Design: Adaptation work followed by a single-arm pilot of intervention delivery. Setting and participants: Four third and education sector organisations. Individuals with mild-to-moderate intellectual disabilities, aged 16+, members of existing groups, with access to digital platforms. Intervention: Digital Standing Up for Myself intervention. Adapted from face-to-face Standing Up for Myself intervention, delivered over four weekly sessions, plus a 1-month follow-up session. Outcomes: Acceptability and feasibility of delivering Digital Standing Up for Myself and of collecting outcome and health economic measures at baseline and 3 months post baseline. Outcomes are mental well-being, self-esteem, self-efficacy in rejecting prejudice, reactions to discrimination and sense of social power. Results: Adaptation to the intervention required changes to session duration, group size and number of videos; otherwise, the content remained largely the same. Guidance was aligned with digital delivery methods and a new group member booklet was produced. Twenty-two participants provided baseline data. The intervention was started by 21 participants (four groups), all of whom were retained at 3 months. Group facilitators reported delivering the intervention as feasible and suggested some refinements. Fidelity of the intervention was good, with over 90% of key components observed as implemented by facilitators. Both facilitators and group members reported the intervention to be acceptable. Group members reported subjective benefits, including increased confidence, pride and knowing how to deal with difficult situations. Digital collection of all outcome measures was feasible and acceptable, with data completeness ≥ 95% for all measures at both time points. Finally, a picture of usual practice has been developed as an intervention comparator for a future trial. Limitations: The pilot sample was small. It remains unclear whether participants would be willing to be randomised to a treatment as usual arm or whether they could be retained for 12 months follow-up. Conclusions: The target number of groups and participants were recruited, and retention was good. It is feasible and acceptable for group facilitators with some training and supervision to deliver Digital Standing Up for Myself. Further optimisation of the intervention is warranted. Future work: To maximise the acceptability and reach of the intervention, a future trial could offer the adapted Digital Standing Up for Myself, potentially alongside the original face-to-face version of the intervention. Study registration: This study was registered as ISRCTN16056848. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/149/03) and is published in full in Public Health Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

People with intellectual disabilities (or 'learning disabilities' in United Kingdom language) are more likely to experience poor physical and mental health than the general population. Stigma (negative stereotypes, prejudice and discrimination) has been linked to lower self-esteem, quality of life, and mental and physical ill health. Efforts to empower people with intellectual disabilities themselves to challenge stigma with a view to improving well-being, health and self-esteem are lacking. In 2017, we developed Standing Up for Myself, a brief group-based programme for people with mild-to-moderate intellectual disabilities aged 16+ to address this gap. As this study got underway, face-to-face meetings were suspended due to the coronavirus disease 2019 pandemic. We used the opportunity to assess whether Standing Up for Myself could be delivered through web-based meetings. We adapted Standing Up for Myself for digital delivery, with close input from advisors with intellectual disabilities and experienced group facilitators. We then tested the digital version in charity and education settings to evaluate if Digital Standing Up for Myself could be delivered as planned and how acceptable it was to group facilitators and participants. Four groups, with a total of 22 members, signed up to try Digital Standing Up for Myself. One participant dropped out before starting Standing Up for Myself, and the other 21 continued until the end of the programme. Retention and attendance were good; participants on average attended four of the five sessions. Ninety per cent of the core programme requirements were fully delivered as detailed in the Digital Standing Up for Myself manual. Problems with technology were manageable, although facilitators found using the Standing Up for Myself Wiki platform (an online platform for storage and sharing of resources) difficult, particularly when sharing video content. Facilitators felt acceptable levels of privacy were achieved and there were no reports of undue distress. All facilitators and many group members said they would recommend Digital Standing Up for Myself to others. Group members shared how the programme benefitted them, noting increased awareness about disabilities, and for some increased confidence, pride and independence. Some had learnt how to stand up for themselves and manage difficult situations and took pride in this. Completing outcome and health cost measures via web-based meetings was acceptable and data were largely fully complete and useable.

Cardiac Involvement in Neurosarcoidosis: A Single-Center Investigation

BACKGROUND AND OBJECTIVES: Sarcoidosis is a multisystem inflammatory granulomatous disease. Among systemic sarcoidosis manifestations, cardiac or nervous system involvement can result in significant morbidity and mortality. We describe the overlapping incidence of cardiac sarcoidosis (CS) within a neurosarcoidosis (NS) cohort and determine the frequency of other nonsarcoid cardiac diseases in these patients. METHODS: We performed a retrospective chart review of patients evaluated at the University of Utah from 2010 to 2022. Patients were included if they had (1) at least one instance of a diagnostic code for sarcoidosis in their medical record-International Classification of Diseases (ICD) 9 code 135 or ICD 10 code D86; (2) at least one outpatient visit in the Neurology Department within the University of Utah electronic health record with a diagnosis of definite, probable, or possible NS based on 2018 consensus criteria; (3) at least one outpatient visit in the Cardiology Department within the University of Utah electronic health record; and (4) ECG available in their medical record for review. Of 64 definite, probable, or possible patients with NS in the University of Utah cohort, 52 met our inclusion criteria and were included in this study. RESULTS: Of 52 patients with NS who met our inclusion criteria, 65.38% were female, with an average age of 60.9 years (range 38-84). More than half (58%) were obese (BMI ≥ 30). CS was diagnosed in 6 patients with NS (12%). Symptoms suggestive of possible cardiac dysfunction included lower extremity edema (50%), palpitations (46%), chest pain (44%), and shortness of breath (27%). ECG abnormalities included nonspecific T-wave change (40%) and right bundle branch block (17%). Three patients experienced ventricular tachycardia: sustained in one patient and nonsustained in 2 patients. Cardiac MRI was performed in 17 patients (32.7%) and in 3 patients (17.6%), which revealed diffuse myocardial enhancement suggesting CS. DISCUSSION: In this cohort, 12% of patients with NS also had confirmed CS. In addition, these patients had a high burden of cardiovascular disease not directly attributed to sarcoidosis. Our data suggest that patients with NS require comprehensive cardiac evaluation. Future studies are needed to clarify the extent of the direct contribution of granulomatous inflammation on the cardiovascular system from the indirect contribution of treatments such as glucocorticoids that lead to increased risk of cardiovascular disease in sarcoidosis.

Gender differences among shoulder arthroplasty surgeons: past, present, and future.

BACKGROUND: Reducing differences in the gender representation of shoulder arthroplasty surgeons may help optimize patient care. This work aimed to determine (1) the current gender distribution of surgeons performing shoulder arthroplasty, (2) how gender relates to practice patterns among shoulder arthroplasty surgeons, and (3) how gender distribution has been changing over time. METHODS: The Medicare Provider Utilization and Payment Data for the years 2012-2020 were used to identify orthopedic surgeons performing anatomic and reverse total shoulder arthroplasty (Current Procedural Terminology code 23472). The data set provides self-reported gender, credentials, National Provider Identifier, annual volume of all procedures (based on Current Procedural Terminology codes) that were performed ≥11 times in the calendar year, and location for all included providers. The data set was linked to the Medicare Physician Compare data set using National Provider Identifiers to determine hospital affiliations, year of medical school graduation, and graduating medical school. All included hospitals were queried to determine academic status (affiliated orthopedic residency or fellowship program). The American Shoulder and Elbow Surgeons (ASES) directory was reviewed to determine the gender breakdown of current members. RESULTS: The number of surgeons performing ≥11 shoulder arthroplasties annually increased from 821 (13 women [1.6%]) in 2012 to 1840 (53 women [2.9%], P = .05) in 2019. One female surgeon ranked in the top 100 surgeons by shoulder arthroplasty volume in 2012 and in 2020. Female surgeons graduated more recently from medical school (mean, 2005) compared with male surgeons (mean, 1997; P < .001). About 10% of female surgeons (10.8%, 12 of 111) and male surgeons (9.1%, 229 of 2528) practiced at hospitals with orthopedic residents (P = .50). Female surgeons performing shoulder arthroplasty were less likely than male surgeons to perform total knee arthroplasty (29.4% vs. 54.1%, P < .001) and total hip arthroplasty (12.6% vs. 34.7%, P < .001). There were 86 female members of ASES (6.7%, 86 of 1275), with a significant difference in the proportion of women in differing membership categories (P = .017). DISCUSSION AND CONCLUSION: A diverse cohort of high-volume shoulder replacement surgeons is integral to delivering high-quality shoulder arthroplasty. Currently, the proportion of women performing high-volume shoulder replacement in the United States is small, with little improvement in recent years. However, women performing shoulder arthroplasty are younger and are often involved in academic practices, and the membership of ASES is increasingly female. Continued efforts to promote orthopedics-and to mentor female residents and medical students interested in shoulder surgery-may bring real change to the gender differences among shoulder replacement surgeons over the coming years.

Standardization of zebrafish drug testing parameters for muscle diseases.

Skeletal muscular diseases predominantly affect skeletal and cardiac muscle, resulting in muscle weakness, impaired respiratory function and decreased lifespan. These harmful outcomes lead to poor health-related quality of life and carry a high healthcare economic burden. The absence of promising treatments and new therapies for muscular disorders requires new methods for candidate drug identification and advancement in animal models. Consequently, the rapid screening of drug compounds in an animal model that mimics features of human muscle disease is warranted. Zebrafish are a versatile model in preclinical studies that support developmental biology and drug discovery programs for novel chemical entities and repurposing of established drugs. Due to several advantages, there is an increasing number of applications of the zebrafish model for high-throughput drug screening for human disorders and developmental studies. Consequently, standardization of key drug screening parameters, such as animal husbandry protocols, drug compound administration and outcome measures, is paramount for the continued advancement of the model and field. Here, we seek to summarize and explore critical drug treatment and drug screening parameters in the zebrafish-based modeling of human muscle diseases. Through improved standardization and harmonization of drug screening parameters and protocols, we aim to promote more effective drug discovery programs.

Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft.

BACKGROUND: Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. METHODS: This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. RESULTS: A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72 years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9 ± 2 vs. 1.8 ± 2), ASES score (44.6 ± 18 vs. 71.2 ± 24), and Patient Reported Outcomes Measurement Information System Physical (46.3 ± 6 vs. 51.3 ± 11) and in external rotation motion (10.5 ± 17° vs. 40.5 ± 13°) and strength (2.8/5 ± 1 vs. 4.7/5 ± 0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. CONCLUSION: In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6 months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Biomechanics of subscapularis V-shaped tenotomy compared to standard tenotomy.

BACKGROUND: Subscapularis function is critical after anatomic total shoulder arthroplasty (aTSA). Recently, however, a technique has been described that features a chevron or V-shaped subscapularis tendon cut (VT). This biomechanical study compared repair of the standard tenotomy (ST), made perpendicular to the subscapularis fibers, to repair of the novel VT using cyclic displacement, creep, construct stiffness, and load to failure. METHODS: This biomechanical study used 6 pairs of fresh frozen paired cadaveric shoulder specimens. One specimen per each pair underwent VT, the other ST. Subscapularis tenotomy was performed 1 cm from the insertion onto the lesser tuberosity. For VT, the apex of the V was 3 cm from the lesser tuberosity. After tenotomy, each humerus underwent humeral head arthroplasty. Eight figure-of-8 sutures were used to repair the tenotomy (Ethibond Excel; Ethicon, US LLC). Specimens were cyclically loaded from 2 to 100 N at 45 degrees abduction at a rate of 1 Hz for 3000 cycles. Cyclic displacement, creep, and stiffness and load to failure were measured. RESULTS: Cyclic displacement did not differ significantly between the ST and VT from 1 to 3000 cycles. The difference in displacement between the V-shaped and standard tenotomy at 3000 cycles was 1.57 mm (3.66 ± 1.55 mm vs. 5.1 ± 2.8 mm, P = .31, respectively). At no point was the V-shape tenotomy (VT) >3 mm of average displacement, whereas the standard tenotomy (ST) averaged 3 mm of displacement after 3 cycles. Creep was significantly lower for VT in cycles 1 through 3. For all cycles, stiffness was not significantly different in the VT group compared with the ST group. Load to failure was not statistically significant in the VT compared to the standard tenotomy throughout all cycles (253.2 ± 27.7 N vs. 213.3 ± 76.04 N; P = .25, respectively). The range of load to failure varied from 100 to 301 N for standard tenotomy compared with 216 to 308 N for VT. CONCLUSION: This study showed that VT and ST demonstrated equivalent stiffness, displacement, and load to failure. VT had the benefit of less creep throughout the first 3 cycles, although there was no difference from cycle 4 to 3000. The VT had equivalent biomechanical properties to the ST at time zero, an important first step in our understanding of the technique. The VT technique warrants further clinical study to determine if the technique has clinical benefits over ST following aTSA.

A mini-review of the evidence for cerebrovascular changes following gender-affirming hormone replacement therapy and a call for increased focus on cerebrovascular transgender health.

Gender-affirming hormone replacement therapy (gaHRT) is an important step for many in the gender diverse community, associated with increased quality-of-life and lower self-reported scores of depression and anxiety. However, considering the interactions that the involved sex hormones have on vasculature (with oestrogen and testosterone demonstrating vasodilatory and vasoconstricting properties, respectively), it is important for transgender healthcare research to examine how the manipulation of these hormones interact with cerebrovascular structure and functioning. There is a stark lack of research in this area. This mini-review outlines the research suggesting a vascular impact of these sex hormones using evidence from a range of cohorts (e.g., menopause, polycystic ovary syndrome) and discusses the work that has been done into cerebrovascular changes following gaHRT. Finally, recommendations for future research into cerebrovascular health in transgender cohorts following gaHRT are outlined.

Home health care is associated with an increased risk of readmission and cost of care without reducing risk of complication following shoulder arthroplasty: a propensity-score analysis.

BACKGROUND: Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services. METHODS: A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes. RESULTS: A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P = .0328) and 90 days (OR 1.215; P = .0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P < .001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P < .001). CONCLUSION: Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation.

The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis.

BACKGROUND: Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. METHODS: A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated. RESULTS: Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. CONCLUSIONS: This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.

Cerebral blood flow and cerebrovascular reactivity are modified by maturational stage and exercise training status during youth.

NEW FINDINGS: What is the central question of this study? Gonadal hormones modulate cerebrovascular function while insulin-like growth factor 1 (IGF-1) facilitates exercise-mediated cerebral angiogenesis; puberty is a critical period of neurodevelopment alongside elevated gonadal hormone and IGF-1 activity: but whether exercise training across puberty enhances cerebrovascular function is unkown. What is the main finding and its importance? Cerebral blood flow is elevated in endurance trained adolescent males when compared to untrained counterparts. However, cerebrovascular reactivity to hypercapnia is faster in trained vs. untrained children, but not adolescents. Exercise-induced improvements in cerebrovascular function are attainable as early as the first decade of life. ABSTRACT: Global cerebral blood flow (gCBF) and cerebrovascular reactivity to hypercapnia ( CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ ) are modulated by gonadal hormone activity, while insulin-like growth factor 1 facilitates exercise-mediated cerebral angiogenesis in adults. Whether critical periods of heightened hormonal and neural development during puberty represent an opportunity to further enhance gCBF and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ is currently unknown. Therefore, we used duplex ultrasound to assess gCBF and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ in n = 128 adolescents characterised as endurance-exercise trained (males: n = 30, females: n = 36) or untrained (males: n = 29, females: n = 33). Participants were further categorised as pre- (males: n = 35, females: n = 33) or post- (males: n = 24, females: n = 36) peak height velocity (PHV) to determine pubertal or 'maturity' status. Three-factor ANOVA was used to identify main and interaction effects of maturity status, biological sex and training status on gCBF and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ . Data are reported as group means (SD). Pre-PHV youth demonstrated elevated gCBF and slower CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ mean response times than post-PHV counterparts (both: P ≤ 0.001). gCBF was only elevated in post-PHV trained males when compared to untrained counterparts (634 (43) vs. 578 (46) ml min-1 ; P = 0.007). However, CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ mean response time was faster in pre- (72 (20) vs. 95 (29) s; P ≤ 0.001), but not post-PHV (P = 0.721) trained youth when compared to untrained counterparts. Cardiorespiratory fitness was associated with gCBF in post-PHV youth (r2  = 0.19; P ≤ 0.001) and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ mean response time in pre-PHV youth (r2  = 0.13; P = 0.014). Higher cardiorespiratory fitness during adolescence can elevate gCBF while exercise training during childhood primes the development of cerebrovascular function, highlighting the importance of exercise training during the early stages of life in shaping the cerebrovascular phenotype.

The utility of an online discussion board for reflective writing in an emergency medicine rotation.

Background: Narrative analysis and reflection have been found to support professional identity formation (PIF) and resilience among medical students. In the emergency department, students have used reflective practice to process challenging clinical experiences, such as ethical dilemmas or moral distress. An online discussion board, however, has not been described as a curricular component of emergency medicine (EM) rotations. The objective of this educational innovation was to support medical students in an EM clinical rotation via an online discussion board for reflecting on and debriefing clinical experiences with faculty and peers. Methods: Fifty-two medical students enrolled in the pass/fail EM elective between May 13, 2019, and October 30, 2020. Each cohort of six students took part in a cohort-specific discussion using the Canvas learning management system. Students were encouraged to post about any observations, reflections, or emotions after their shifts. Faculty course directors responded to each post using concepts of debriefing, coaching, and trauma-informed teaching. Results: Over 18 months, 49 of 52 (94%) students participated in the discussion board. Of 346 total posts, half were by students, and the other half were faculty responses. Students posted 3.27 times each, on average. Students rarely raised questions about scientific knowledge content, fact-based aspects of patient care, or specific skills. Rather, they often posted about intensely affective reactions to experiences that left them with complex emotions. Upon review of posts by the course directors, the majority (54%) of students' posts contained a range of affective responses. Students appreciated faculty responses and supported each other in their written responses to peers. Conclusions: An online discussion board can be used successfully for asynchronous reflective practice to debrief clinical experiences during an EM rotation, if designed incorporating faculty and peer support using trauma-informed teaching principles to bolster well-being and PIF.

Statistical Fragility of Randomized Controlled Trials Evaluating Rehabilitation After Arthroscopic Rotator Cuff Repair.

Background: Clinical decision-making often relies on evidence-based medicine, derived from objective data with conventional and rigorous statistical tests to evaluate significance. The literature surrounding rehabilitation after rotator cuff repair (RCR) is conflicting, with no defined standard of practice. Purpose: To determine the fragility index (FI) and the fragility quotient (FQ) of randomized controlled trials (RCTs) evaluating rehabilitation protocols after RCR. Study Design: Systematic review. Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the PubMed, Cochrane Library, and Embase databases for RCTs evaluating rehabilitation protocols after arthroscopic RCRs from 2000 to June 1, 2022. The FI was determined by manipulating the dichotomous outcome events from each article until a reversal of significance with 2 × 2 contingency tables was achieved. The FQ was determined by dividing the FI by the sample size. Results: Fourteen RCTs with 48 dichotomous outcomes were ultimately included for analysis. The mean FI for the included dichotomous outcomes was 4 (interquartile range, 3-6), suggesting that the reversal of 4 events is required to change study significance. The mean FQ was 0.048. Of the RCTs that reported data regarding loss to follow-up, most studies (58.5%) indicated that >4 patients had been lost to follow-up. Conclusion: The results of RCT studies of RCR rehabilitation protocols are moderately fragile, something clinicians should be aware of when implementing study results into practice. We recommend the inclusion of FI and FQ in addition to standard P values when reporting statistical results in future RCTs with dichotomous outcome variables on this topic.