Musculoskeletal Literacy in Orthopedics: Associated Factors, Effects on Patient-Physician Communication and Intervention Strategies.

Health literacy is defined as the degree to which an individual obtains and processes basic health information and services so as to make appropriate and informed health decisions. Limited health literacy (LHL), as assessed by various validated instruments, remains prevalent amongst older adult patients, non-Caucasian ethnicities, and those of lower socioeconomic backgrounds. Of concern, LHL has been associated with decreased medical knowledge, disuse of preventative medical services, worse chronic disease control and increased use of emergency services. Within orthopedics specifically, LHL has been associated with lower expectations regarding outcomes and ambulation following total hip and knee surgery and fewer questions asked regarding diagnosis and treatment in the outpatient care setting. In some cases, LHL has been independently correlated with worse patient-reported outcome measures (PROMs), though this finding may be due in part to the reading level required of the PROMs. There is growing evidence that active intervention by the orthopedic provider and demonstration of empathy improves patient comprehension of the nature of their musculoskeletal complaints, aids informed decision-making and, ultimately, maximizes patient satisfaction. Recognition of the associated factors for LHL will ensure improved physician-patient communication through the implementation of health literate interventions focused on those most at-risk.

Accuracy and Reliability of Computerized Surgical Planning Software in Anatomic Total Shoulder Arthroplasty.

PURPOSE: The primary purpose of this study was to assess the concordance between preoperatively determined implant parameters using CT-based planning software and surgically implanted prostheses. Secondarily, we sought to evaluate the agreement between preoperative plans performed by surgeons at different levels of training. METHODS: Patients with primary glenohumeral osteoarthritis who underwent anatomic total shoulder arthroplasty (aTSA) and had a preoperative CT scan according to Blueprint (Stryker, Mahwah, NJ) protocol to be used for preoperative planning were included. A cohort of short-stemmed (SS) and stemless cases performed between October 2017 and December 2018 was randomly selected from an institutional database for the study. Planning was performed separately by four observers at different levels of orthopedic training at a minimum of six months following the actual surgery. Concordance between the surgical decisions during planning and the actually utilized implants was calculated. Additionally, inter-rater agreement was analyzed using the intra-class correlation coefficient (ICC). Implant parameters assessed were glenoid size, backside radius of curvature, and the need for posterior augment, in addition to humeral stem/nucleus size, head size, head height, and head eccentricity. RESULTS: Twenty-one patients were included (10 stemmed and 11 stemless) with a cohort comprising 12 (57%) females with a median age of 62 years (IQR 59.5,67). There was a total of 544 decision possibilities based on the above parameters. The total number of decisions that matched surgical data was 333 (61.2%). Prediction of glenoid component augmentation need and size was the variable that matched most with surgical data (83.3%), whereas nucleus/stem size was the worst (42.9%). Interobserver agreement was excellent in one variable, good in three variables, moderate in one, and poor in two. The best interobserver agreement was with regard to head height. CONCLUSION: Preoperative planning using CT-based software may be more accurate for the glenoid component when compared to humeral-sided parameters. Specifically, planning may be most helpful in determining the need and the size of glenoid component augmentation. Utilizing computerized software demonstrates high reliability, even among surgeons early in their orthopedic training.

Clinical and radiological outcomes in lateralized versus nonlateralized and distalized glenospheres in reverse total shoulder arthroplasty: a randomized control trial.

BACKGROUND: Lateralization in reverse total shoulder arthroplasty (RTSA) has been used to theoretically offer the potential benefits of reduced scapular notching rates and improved stability and range of motion (ROM), particularly external rotation. The aim of this study was to compare ROM and clinical and radiographic outcomes between patients who underwent RTSA with a lateralized vs. a nonlateralized and distalized glenosphere. METHODS: A single-surgeon randomized control trial was conducted comparing 27 patients with a lateralized glenosphere and 26 patients with a nonlateralized and distalized glenosphere. A total of 66 patients were enrolled, 2 patients died before 2-year follow-up, 4 patients withdrew from the study, and 7 patients were lost to follow-up. All patients in the lateralized group received 6 mm of lateralization through the glenosphere. Participants represented a population presenting to an orthopedics sports medicine clinic with any indication for RTSA including revision arthroplasty. Patients completed preoperative and routine postoperative functional outcome measures 3, 6, 12, and a minimum of 24 months postoperatively, including American Shoulder and Elbow Surgeons, Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity, and Activities of Daily Living Requiring Active External and Internal Rotation assessments. Patients were also evaluated with ROM and radiographic measurements. The primary outcome of interest in this study was ROM, particularly external rotation. RESULTS: At 2-year follow-up, both groups had significant improvement in their American Shoulder and Elbow Surgeons, Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity, and Activities of Daily Living Requiring Active External and Internal Rotation scores with no significant difference observed between the groups. There were no statistically significant differences in incidence of scapular notching or acromial stress fractures. ROM in both groups improved significantly at their 2-year assessment with the only exception to this being external rotation at 90° of abduction in the nonlateralized and distalized group (39° ± 31° vs. 48° ± 24°, P = .379). CONCLUSIONS: Regardless of glenosphere lateralization status, patients in both groups had significant improvement in functional outcome scores and ROM, and there were no significant differences observed between the groups at 2-year follow-up. Longer follow-up is needed to determine the effect of implant design on late complications, long-term outcomes, and implant retention.

Lateralized versus nonlateralized reverse total shoulder arthroplasty.

Throughout the history of reverse total shoulder arthroplasty, the extent of lateral offset has changed considerably from "too lateral" to "too medial" and has been lately swinging back towards a point somewhere in between. Nonlateralized designs minimize shear forces on the glenoid and decrease force required by the deltoid. Glenoid lateralization decreases impingement and scapular notching and improves range of motion. Humeral lateralization achieves a more anatomic position of the tuberosities while maintaining a nonlateralized center of rotation. Several factors play a role in choosing the extent of lateral offset and method of lateralization.

Novel repair of a quadriceps tendon rupture after a total knee arthroplasty using gracilis and semitendinosus autografts.

BACKGROUND: Multiple techniques have been described for repair of quadriceps tendon rupture after total knee arthroplasty (TKA) with unsatisfactory outcomes. We present a novel technique for repair using hamstring tendon autografts. METHODS: A 54 year-old morbidly obese patient presented five months after quadriceps tendon rupture. Direct repair was performed using two anchors in the patella in addition to augmentation with semitendinosus and gracilis tendon autografts. RESULTS: Satisfactory outcomes were achieved with no residual pain and ability to perform a straight leg raise at three weeks postoperatively. There was no extensor lag at five weeks postoperatively. CONCLUSIONS: Most previous reports of a similar complication were treated using synthetic materials. Using hamstring tendon autografts as described in this report provides an alternative surgical option for reconstruction of quadriceps tendon rupture in the setting of TKA, with potentially favorable outcomes and minimal donor site morbidity. Further studies are needed to evaluate long-term outcome of this procedure and to delineate the gold standard of treatment.

Evaluation of callus formation in distal femur fractures after carbon fiber composite versus stainless steel plate fixation.

INTRODUCTION: Carbon-fiber-reinforced polyetheretherketone (CFR) composite plates have a more favorable stress modulus than stainless steel (SS) plates that may confer an advantage to bridge plating. The purpose of this study was to compare callus formation after CFR and SS plating of distal femur fractures. METHODS: A retrospective review identified distal femoral fractures treated with CFR (n = 10) and SS (n = 21) plate fixation. Callus formation was measured using the modified Radiographic Union Score for Tibia (mRUST) at 3- and 6-month follow-up by three orthopedic trauma surgeons. Loss of alignment, implant failure, and revision surgeries were reviewed. RESULTS: At 3 months, the mRUST in the CFR and SS groups was 9.0 (range, 6.3-12.3) and 6.9 (range, 4.3-11.7), respectively (p = 0.01). At 6 months, the mRUST in the CFR and SS groups was 11.4 (range, 7.7-16.0) and 10.5 (range, 6.0-15.7), respectively (p = 0.3). CFR and SS groups had a loss of fracture alignment in 1 (10%) and 1 (5%) patient, respectively (p = 0.5), and an unplanned revision surgery in 0 (0%) and 3 (15%) patients, respectively (p = 0.2). All three revisions surgeries in the SS group were for nonunion repair. CONCLUSIONS: Treatment of distal femur fractures with CFR versus SS plating resulted in greater callus formation at 3 months. At 6 months, there was no difference in callus formation between groups. A larger series of patients is necessary to determine if the observed early increased callus formation confers a benefit to clinical outcomes. LEVEL OF EVIDENCE: Therapeutic level III.

A decision analysis of treatment strategies for acute periprosthetic joint infection: Early irrigation and debridement versus delayed treatment based on organism.

OBJECTIVE: The purpose of this study was to investigate whether immediate or delayed tailored DAIR treatment based on microbial species is the optimal treatment for acute post-operative periprosthetic joint infection (PJI). METHODS: A multicenter retrospective study was conducted to identify patients who underwent debridement, antibiotics, and implant retention (DAIR) for PJI. Decision analysis modeling was employed to determine the treatment strategy that yielded the greatest patient outcome. RESULTS: 316 patients who underwent DAIR for PJI were identified. CONCLUSION: The decision analysis model determined that the optimal treatment strategy is to perform an immediate DAIR to achieve the greatest QALY outcomes in TKA and THA patients with acute PJI.

Staphylococcus lugdunensis Septic Arthritis following Arthroscopic Anterior Cruciate Ligament Reconstruction.

Summary. We report two cases of Staphylococcus lugdunensis (S. lugdunensis) septic arthritis following arthroscopic anterior cruciate ligament (ACL) reconstruction. Both initial surgical procedures were ACL reconstruction along with simultaneous collateral ligament and meniscus procedures. Patients presented with septic arthritis three and ten weeks following the index procedure. Both patients successfully recovered with early arthroscopic irrigation, debridement, and synovial culture, in addition to long-term parenteral and oral antibiotics.Staphylococcus lugdunensis (S. lugdunensis) septic arthritis following arthroscopic anterior cruciate ligament (ACL) reconstruction. Both initial surgical procedures were ACL reconstruction along with simultaneous collateral ligament and meniscus procedures. Patients presented with septic arthritis three and ten weeks following the index procedure. Both patients successfully recovered with early arthroscopic irrigation, debridement, and synovial culture, in addition to long-term parenteral and oral antibiotics.S. lugdunensis) septic arthritis following arthroscopic anterior cruciate ligament (ACL) reconstruction. Both initial surgical procedures were ACL reconstruction along with simultaneous collateral ligament and meniscus procedures. Patients presented with septic arthritis three and ten weeks following the index procedure. Both patients successfully recovered with early arthroscopic irrigation, debridement, and synovial culture, in addition to long-term parenteral and oral antibiotics.

Outcomes of Reverse Total Shoulder Arthroplasty in Patients 60 Years of Age or Younger: A Systematic Review.

PURPOSE: Reverse total shoulder arthroplasty (RTSA) has been traditionally performed in elderly, low-demand patients. However, indications for RTSA are expanding, and patients who potentially benefit from this procedure are not restricted to those who are elderly. The purpose of this review was to summarize reported outcomes of RTSA in patients aged 60 years or younger. METHODS: We performed a systematic review of the literature to search for outcomes of RTSA in patients aged 60 years or less. Inclusion criteria were studies reporting clinical and/or functional outcomes of RTSA in patients aged 60 years or less with follow-up of greater than 2 years. Cadaveric studies and studies including patients aged greater than 60 years were excluded. Outcomes of interest were range of motion, functional scores (Constant, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale for pain), implant survival, and complications. RESULTS: Four studies with a total of 193 patients met inclusion criteria with mean durations of follow-up of 34 to 140.4 months. At the final follow-up, all studies showed significant improvements in flexion, abduction, and all reported functional scores. Mean postoperative flexion and abduction ranged from 85.7° to 134° and from 79° to 111°, respectively. Implant survival ranged from 87.5% to 94.3% at the latest follow-up. Complication rates ranged from 15% to 39.1%. CONCLUSIONS: Early clinical and functional outcomes of RTSA in patients aged 60 years or less are favorable. Long-term functional results and implant survival rates of RTSA are comparable to previous data from older patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Quantifying the Impact of Patient-Specific Factors and Disease Severity on Clinical Decision Making in Cuff Tear Arthropathy: A Case-Based Survey.

BACKGROUND: Rotator cuff tears are a common cause of disability. Some patients with massive and irreparable tears can develop cuff tear arthropathy (CTA), which makes management more challenging. QUESTIONS/PURPOSES: We sought to examine how orthopedists determine treatment for patients with CTA. Specifically, we investigated (1) the effect of patient age, symptoms, activity level, range of motion, and radiographic findings on the decision making of shoulder specialists and (2) the observer reliability of the Seebauer and Hamada grading systems. METHODS: Five shoulder surgeons were each sent 108 simulated patient cases. Each simulated patient had a different combination of factors, including patient age, symptoms, activity level, range of motion, and radiographs. Responders graded the radiographs and chose a treatment (non-operative, arthroscopic, hemiarthroplasty, or reverse total shoulder arthroplasty). Spearman's correlations and χ 2 tests were used to assess the relationship between factors and treatments. Sub-analysis was performed on surgical cases. An intra-class correlation (ICC) was used to assess observer agreement. RESULTS: The significant Spearman's correlations were symptoms (0.45), Hamada grade (0.38), patient age (0.34), and Seebauer type (0.29). In sub-analysis of operative cases, the significant correlations were Hamada grade (0.56), patient age (0.51), Seebauer type (0.46), activity level (-0.13). The χ 2 analysis was significant for all factors except activity level. The inter- and intraobserver reliabilities were, respectively, Seebauer type (0.59 and 0.63) and Hamada grade (0.58 and 0.65). Interobserver reliability for patient management was 0.44. CONCLUSION: When evaluating CTA, patient symptoms, radiographic grade, and patient age are the factors most strongly associated with the decision making of shoulder specialists. Additionally, the Seebauer and Hamada classifications had similar reliability and clinical utility. However, there was only fair agreement regarding treatment, which indicates that CTA management remains controversial.

Type 2 retear after arthroscopic single-row, double-row and suture bridge rotator cuff repair: a systematic review.

AIM/PURPOSE: To provide a systematic review of the literature on patterns of retear after single-row (SR), double-row (DR) and suture bridge (SB) techniques. METHODS: The PubMed and MEDLINE databases were searched for published articles reporting both repair technique and retear pattern. Studies in languages other than English, those reporting open rotator cuff repair as the index procedure, as well as animal and cadaveric studies and those which did not describe patterns of retear, were excluded. MINORS scoring system was used to quantify potential bias in each study. Retears were classified into type 1 (failure at the tendon-bone interface) and type 2 (medial cuff failure). For all studies included, number and type of retears after different repair techniques were reported and analyzed. RESULTS: Fourteen studies were included yielding a total of 260 rotator cuff retears. Repair technique had a significant impact on the estimated incidence rate of type 2 retear (p = .001). The estimated incidence rate of type 2 retear was 24% with SR (95% CI 14-38%), 43% with DR (95% CI 22-66%), 62% with SB (95% CI 54-70%) and 38% with SB (95% CI 23-57%). CONCLUSION: Despite the lack of high-quality evidence, this study suggests that DR and SB techniques increase the risk of medial cuff failure. Modifications in surgical techniques in both DR and SB repairs can help decrease that risk. LEVEL OF EVIDENCE: Level IV, systematic review of investigations including level IV.

Risk factors associated with ACL registry compliance: can we predict who will follow-up?

PURPOSE: The purpose of this study was to determine patient factors that influence patient compliance to fill out anterior cruciate ligament reconstruction (ACLR) registry forms. METHODS: Patients prospectively enrolled in the ACLR registry at a single institution were retrospectively reviewed. Patients who were followed up for at least 6 months were included. Patients who did not fill out initial registry forms were excluded. Patients were asked to fill out forms preoperatively and at 6, 12 and 24 months postoperatively. The impacts of age, race, employment status, medical insurance, smoking status, driving distance to the hospital and importance to return to the same level of sporting activity were analyzed against patient compliance (yes/no) to complete registry forms at the respective follow-ups. Multivariate analysis was performed to analyze variables at 6 and 12 months postoperatively. The numbers of patients who were followed up for more than 24 months were too low to run a multivariate analysis, so only univariate analysis was performed on this cohort. RESULTS: A total of 221 patients filled out the initial preoperative forms at least 6 months before data gathering was commenced and were included. At 6 months postoperatively, none of the variables significantly influenced patient compliance. At 12 months, younger age and longer driving distance to the hospital had a significant negative impact on compliance [OR per year: 0.92 (0.85-0.99), p = 0.0237; OR per mile: 1.01 (1, 1.01), p = 0.0297]. Patients who filled out registry forms at 6 months were significantly more compliant at 12 months postoperatively (p < 0.0001). At 24 months, the influence of age remained significant (p = 0.0262) and, additionally, patients who initially noted that it was important for them to return to the same level of sports were significantly less compliant (p = 0.0367). CONCLUSION: Younger age and longer driving distance to the hospital were significantly associated with less compliance to fill out ACLR registry forms at 12 months postoperatively. Patient perspectives on the importance to return to the same level of sports were inversely related to compliance at 24 months postoperatively. This information can be utilized to improve compliance in future studies as we have potentially identified patients that can be viewed as "at-risk" for registry noncompliance.

Treatment of infection following intramedullary nailing of tibial shaft fractures-results of the ORS/ISFR expert group survey.

OBJECTIVE: The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally. MATERIALS AND METHODS: A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1-4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts' personal scores and between experts' scores was performed. An agreement mean and correlation degree between experts' scores was calculated. Finally, a success rate report between groups was performed. RESULTS: Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts' scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections. CONCLUSIONS: Experts' and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies. EVIDENCE: Clinical Question.

Patient factors influencing outpatient satisfaction in patients presenting with shoulder pain.

BACKGROUND: Patient-based evaluation of health care has been gaining attention in the past 2 decades. The purpose of this study was to evaluate patient satisfaction in a shoulder outpatient clinic and determine which factors impact satisfaction levels. METHODS: Fifty-nine outpatients with shoulder complaints from December 2017 to January 2018 were included. Patient satisfaction was measured using the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, and 2 methods of calculation were implemented: top-box and average scores. The impacts of age, gender, diagnosis, duration with the provider, Patient-Reported Outcomes Measurement Information System score, Pain Catastrophizing Scale score, pain visual analog scale (VAS) score, and function VAS score on patient satisfaction were analyzed. Patients were divided into more satisfied and less satisfied groups, and logistic regression analysis was performed to determine which factors affect patient satisfaction. RESULTS: The median total average and top-box scores were 95.2% and 90%, respectively. Similarly, in the analysis of all variables, average scores were always higher than top-box scores. The function VAS score and Patient-Reported Outcomes Measurement Information System score significantly influenced satisfaction. When patients were divided into more satisfied and less satisfied groups, the odds of having a less satisfied score among patients with a function VAS score of less than 5 was 5.5 times that of patients with a score of 5 or greater (odds ratio of 5.06 [95% confidence interval, 1.55-16.46] with P = .01 for univariate and adjusted odds ratio of 5.53 [95% confidence interval, 1.14-26.76] with P = .03 for multivariate). CONCLUSION: Despite being calculated from the same question set, using the average-score method for the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey generally yields higher scores than the top-box method. Among patients with shoulder pathology, function of the shoulder, as measured on a VAS, was the most significant factor influencing patient satisfaction in the outpatient setting.

Anatomic Medial Patellofemoral Ligament Reconstruction Without Bone Tunnels or Anchors in the Patella.

Medial patellofemoral ligament reconstruction is an essential component of surgical treatment for recurrent dislocation of the patella. Various techniques have been described, most of which potentially increase the risk of patellar fracture. We present a new technique for anatomic medial patellofemoral ligament reconstruction without using suture anchors or patellar tunnels, therefore, eliminating the risk of iatrogenic patellar fracture and making a revision procedure easier in case of failure.

Recurrent tears of the rotator cuff: Effect of repair technique and management options.

Retears of the rotator cuff, following operative repair, is not an uncommon event. Various factors have been shown to influence recurrence including the technique of repair. Multiple techniques have been performed with varying results and complications. The repair technique significantly affects the rate and pattern of retears. Although risk of retears with double row and suture bridge techniques is relatively low, medial cuff failure is a potential complication which poses significant challenges when revision repair is undertaken. Modifications in surgical techniques in, both, double row and suture bridge repairs can help decrease the risk of medial cuff failure. Thorough analysis of retear rates and patterns reported, and their relation with the repair technique, provides new insights about the pathogenesis of rotator cuff retears, their future prevention and appropriate management.

Arthroscopic Management of SLAP Lesions With Concomitant Spinoglenoid Notch Ganglion Cysts: A Systematic Review Comparing Repair Alone to Repair With Decompression.

PURPOSE: To determine if cyst management is necessary in the setting of SLAP lesions with concomitant paralabral ganglion cysts. METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, including all studies that met inclusion criteria from January 1975 to July 2015. We included patients with a SLAP II-VII lesion and a concomitant paralabral ganglion cyst who underwent arthroscopic labral repair with or without cyst decompression. Patients with follow-up of less than 3 months, a SLAP I lesion, or who underwent concomitant cuff repair were excluded. The Methodological Index for Non-randomized Studies (MINORS) scoring system was used to quantify the potential bias in each study. Outcome measures reported were provided in a table format and a subjective analysis was performed. RESULTS: Nineteen studies were included yielding a total of 160 patients: 66 patients treated with repair alone [R] and 94 patients with additional cyst decompression or excision [R+D]. The VAS, Rowe, and Constant scores were excellent and similar in both groups. The mean VAS was 0.6 in [R] and ranged between 0 and 2 in [R+D] (0.5, 0, 2, 0.2). The mean Rowe scores were 94 and 98 in [R] and 95 in [R+D]. The mean Constant scores were 97 in [R] and ranged between 87 and 98 in [R+D] (98, 87, 92, 94). In total, 5 of 90 patients were unable to return to work and 2 of 45 were unable to return to sport. All 15 patients who had follow-up electromyographies displayed resolution, and in the 115 patients with follow-up MRIs, 12 did not have complete resolution of the cyst. CONCLUSIONS: Despite the lack of high-quality evidence, the studies subjectively analyzed in this review suggest that both groups have excellent results. The results do not show any advantages from performing decompression. LEVEL OF EVIDENCE: Level IV, systematic review of Level II and Level IV studies.

Reverse Segond Fracture Associated with Anteromedial Tibial Rim and Tibial Attachment of Anterior Cruciate Ligament Avulsion Fractures.

Reverse Segond fracture is an uncommon avulsion fracture of the tibial attachment of the deep portion of the medial collateral ligament of the knee. We report a reverse Segond fracture associated with anterior cruciate ligament tibial avulsion fracture and anteromedial tibial rim fracture. Unlike previous reports, the combination of reverse Segond fracture, anteromedial tibial rim fracture, and anterior cruciate ligament avulsion fracture was not associated with posterior cruciate ligament injury, posterolateral corner injury, or tibial plateau fracture. This new combination of injuries provides better understanding of the mechanisms of ligamentous injuries of the knee and highlights the importance of meticulous assessment of these injuries for accurate diagnosis and subsequent management.