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

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

Social Determinants of Health Influence Access to Care and Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To investigate the impact social determinants of health (SDOH) have on accessing orthopaedic treatment after an anterior cruciate ligament injury, as well as patient-reported and surgical outcomes after anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic search of the PubMed, MEDLINE, Epub Ahead of Print, Embase, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported at least 1 SDOH and its effect on patient-reported outcomes or surgical outcomes after anterior cruciate ligament reconstruction. Our search identified 937 studies. After eliminating 273 duplicates, 2 authors screened 664 articles on the basis of title and abstract. After this initial screening, 76 studies were evaluated for data extraction. Studies were categorized based on the social determinant(s) of health reported. RESULTS: Twenty-two articles published between 2002 and 2020 were included in this study, encompassing 15 retrospective cohort studies, 3 prospective cohort studies, 3 cross-sectional studies, and 1 case-control study from 9 journals across 3 countries. Of these articles, 9 investigated race/ethnicity, 8 investigated insurance status, 4 investigated income, 5 investigated education level, 2 investigated employment status, and 5 investigated socioeconomic status. Reported outcomes included time to treatment, concomitant knee injury, patient-reported outcome measurement scores, postoperative complications, need for additional surgery, and postoperative healthcare utilization. CONCLUSIONS: Certain SDOH, including black race, Hispanic ethnicity, public health insurance, and lower socioeconomic status contribute to a delay in access to care, which may result in increased severity of concomitant knee injuries encountered at the time of anterior cruciate ligament reconstruction and inferior outcomes. STUDY DESIGN: Level III, systematic review of level I-III evidence.

Time-Driven Activity-Based Costing Accurately Determines Bundle Cost for Rotator Cuff Repair.

PURPOSE: The purpose of this study was to determine the cost of the episode of care for primary rotator cuff repair (RCR) from day of surgery to 90 days postoperatively using the time-driven activity-based costing (TDABC) method. The secondary purpose of this study was to identify the main drivers of cost for both phases of care. METHODS: This retrospective case series study used the TDABC method to determine the bundled cost of care for an RCR. First, a process map of the RCR episode of care was constructed in order to determine drivers of fixed (i.e., rent, power), direct variable (i.e., healthcare personnel), and indirect costs (i.e., marketing, building maintenance). The study was performed at a Midwestern tertiary care medical system, and patients were included in the study if they underwent an RCR from January 2018 to January 2019 with at least 90 days of postoperative follow-up. In this article, all costs were included, but we did not account for fees to provider and professional groups. RESULTS: The TDABC method calculated a cost of $10,569 for a bundled RCR, with 76% arising from the operative phase and 24% from the postoperative phase. The main driver of cost within the operative phase was the direct fixed costs, which accounted for 35% of the cost in this phase, and the largest contributor to cost within this category was the cost of implants, which accounted for 55%. In the postoperative phase of care, physical therapy visits were the greatest contributor to cost at 59%. CONCLUSION: In a bundled cost of care for RCR, the largest cost driver occurs on the day of surgery for direct fixed costs, in particular, the implant. Physical therapy represents over half of the costs of the episode of care. Better understanding the specific cost of care for RCR will facilitate optimization with appropriately designed payment models and policies that safeguard the interests of the patient, physician, and payer. LEVEL OF EVIDENCE: IV, therapeutic case series.

Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Instruments Compare Favorably With Legacy Patient-Reported Outcome Measures in Upper- and Lower-Extremity Orthopaedic Patients: A Systematic Review of the Literature.

PURPOSE: To compare Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with traditional ("legacy") patient-reported outcome measures (PROMs) in regard to correlations, ease of use, and quality criteria for upper (UE) and lower extremity (LE) orthopaedic conditions. METHODS: A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 857 studies, 85 of which were selected for independent review by 2 authors. Of these, 54 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures. RESULTS: The combined sample size of all included studies yielded 6,074 UE and 9,366 LE patients. Overall, PROMIS PF measures demonstrated strong correlations with legacy PROMs among UE (weighted Pearson correlation, 0.624, standard error [SE] = 0.042; weighted Spearman correlation, 0.566, SE = 0.042) and LE patients (weighted Pearson correlation, 0.645, SE = 0.062; weighted Spearman correlation, 0.631, SE = 0.041). PROMIS PF questionnaires completed by UE patients had fewer questions than legacy PROMs (5.9 vs 17.7, P = .0093) and were completed in less time (90.5 vs 223.8 seconds, P = .084). PROMIS PF questionnaires completed by LE patients had fewer questions than legacy PROMs (4.81 vs 15.33, P < .001) and were completed in less time (63.6 vs 203.2 seconds, P = .0063). The differences for the reliability measures were not significant. CONCLUSIONS: PROMIS PF scores correlate strongly with commonly used legacy PROMs in orthopaedics, particularly in UE and LE patients. PROMIS PF forms can be administered efficiently and to a broad patient population while remaining highly reliable. Therefore, they can be justified for standardized use among orthopaedic patients with UE and LE conditions, improving the ability to aggregate and compare outcomes in orthopaedic research. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV evidence.

Trends in Patient-Reported Outcomes Measurement Information System Scores Exist Between Day of Surgical Scheduling and Day of Surgery.

PURPOSE: To examine trends in Patient-Reported Outcome Measurement Information System (PROMIS) scores among orthopedic sports medicine patients undergoing surgery who completed PROMIS forms both in the ambulatory (preoperative) setting at the time of surgical scheduling, as well as on the day of surgery (perioperative) prior to their procedure. METHODS: Consecutive patients undergoing various sports medicine-related surgeries were recruited. Patients were included if they were scheduled for surgery and completed preoperative PROMIS on the day of surgical scheduling and on the day of surgery. Patients were excluded if they refused the questionnaire or had been administered perioperative anesthesia, which would interfere with questionnaire completion. Paired samples t-tests were run between preoperative and perioperative PROMIS scores to determine statistical significance. RESULTS: 153 patients were included with an average age of 46.5 years. The average (SD) time between completion of PROMIS questionnaires was 46.5 (44.4) days. The absolute value change in scores between preoperative and perioperative visits was 4.09 for PROMIS UE, 3.59 for PROMIS PF, 3.67 for PROMIS PI, and 4.13 for PROMIS D. The overall net change of scores between preoperative and perioperative visits were -.57 for PROMIS UE CAT, .16 points for PROMIS PF CAT, -.85 points for PROMIS PI CAT, and -2.14 points for PROMIS D CAT. Statistically significant differences in preoperative and perioperative PROMIS PI (P =.042) and PROMIS D (P =.004) scores were found. CONCLUSIONS: Health states-as measured by PROMIS CAT forms completed among patients undergoing orthopedic surgery-can either improve or worsen preoperatively between the time of administration in both the ambulatory and perioperative setting. Despite the existence of these preoperative trends, it is important to consider patient and surgery-specific causes, such as the anatomic region, type of surgical intervention, and timing of preoperative PROMIS administration. LEVEL OF EVIDENCE: III, prognostic.

Forearm Flexor Tendon Injury in Adolescent Athletes: Risk Factors, Treatment, and Prevention.

ABSTRACT: Injury to the flexor pronator mass is a common condition that is especially prevalent in overhead throwing athletes. The increasing incidence of these injuries has promoted considerable efforts in research to better understand the pathology, risk factors, and potential mechanisms to prevent injury in these athletes. While there are numerous intrinsic and extrinsic factors associated with injury, a common theme involves chronic overuse and microtrauma with inadequate resting intervals between performances. The purpose of this review is to discuss medial elbow injuries in young athletes with a particular focus on the flexor pronator mass.

Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial.

PURPOSE: To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. METHODS: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer. RESULTS: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P > .05). CONCLUSIONS: This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Patients With Preoperative Clinical Depression Symptomology Experience Significant Improvements in Postoperative Pain, Function, and Depressive Symptoms Following Rotator Cuff Repair.

PURPOSE: To determine the impact of clinical depression on outcomes after rotator cuff repair (RCR), as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) health domains. METHODS: RCR patients were given PROMIS CAT assessments for physical function (PROMIS UE), pain interference (PROMIS PI), and depression (PROMIS D) during preoperative and postoperative clinic visits. PROMIS D scores ≥55 correlate with mild clinical depression; thus patients with PROMIS D scores ≥ 55 were placed in the clinical depression (CD) group, whereas patients with scores <55 were placed in the "no clinical depression" (NCD) group. Categorical variables were compared at preoperative and postoperative (6 months and ≥1 year) timepoints using χ2 tests. Continuous variables were compared using Student's t-tests. RESULTS: Of the 340 RCR patients included in this study, 65 (19.1%) were found to have mild clinical depression preoperatively, with that number being reduced to 23 (6.8%) at 6 months and 19 (5.6%) at ≥1 year after surgery. Compared with preoperative PROMIS scores, CD patients had significant postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (26.7 vs 35.5 vs 38.9; P < .001) and PROMIS PI (67.6 vs 56.7 vs 56.4; P < .001). NCD patients had similar postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (30.8 vs 38.6 vs 46.9; P < .001) and PROMIS PI (61.7 vs 53.0 vs 47.6; P < .001). The improvement in PROMIS scores was similar for the CD and NCD groups in both PROMIS UE (12.2 vs 16.1, respectively) and PROMIS PI (-11.2 vs -14.1, respectively). CONCLUSION: Despite starting with worse PROMIS UE and PROMIS PI scores, patients undergoing RCR with symptoms of CD experienced significant improvement in function, pain, and depressive symptoms. Preoperative depression should not be a contraindication to arthroscopic RCR in patients who are otherwise appropriate operative candidates. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Establishing and comparing reference preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients undergoing shoulder surgery.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular among orthopedic surgeons treating shoulder pathology. Despite this, there have been few studies that have described and compared preoperative reference scores for specific shoulder surgical procedures. The primary purpose of this study was to establish and compare baseline preoperative PROMIS scores for 3 common types of shoulder surgery: rotator cuff repair (RCR), total shoulder arthroplasty (TSA), and labral repair (LR). The secondary goal was to stratify these operative groups by diagnosis and compare preoperative PROMIS scores. METHODS: In this cross-sectional study, adult and pediatric patients who underwent surgery for either RCR, TSA, or LR were included. PROMIS-Upper Extremity (UE), PROMIS-Pain Interference (PI), and PROMIS-Depression (D) scores that were collected at each patient's preoperative visit were reviewed. Continuous and categorical variables were compared between operative groups using analysis of variance and χ2 or Fisher exact tests, respectively. Multivariable general linear models were used to identify significant independent predictors of PROMIS scores when controlling for age, sex, and body mass index. RESULTS: A total of 413 patients were included in the study: 272 in the RCR group, 84 in the TSA group, and 57 in the LR group. The average PROMIS-UE score was 39.8 in the LR group vs. 29.9 in the RCR group (P < .001) and 29.6 in the TSA group (P < .001). There was no difference between the mean RCR and TSA PROMIS-UE scores (P = .93). The average PROMIS-PI score was 56.6 in the LR group vs. 62.8 in the RCR group (P < .001) and 63.9 in the TSA group (P < .001). There was no difference between RCR and TSA PROMIS-PI scores (P = .09). The average PROMIS-D score was 43.5 in the LR group vs. 47.7 in the RCR group (P = .004) and 50.3 in the TSA group (P < .001). The TSA group had a higher mean PROMIS-D score than the RCR group (P = .03). For PROMIS-UE scores, age and body mass index were not found to be significant independent predictors (P = .98 and P = .88, respectively). For PROMIS-PI scores, age, body mass index, and sex were not found to be significant independent predictors (P = .31, P = .81, and P = .48, respectively). CONCLUSION: Patients undergoing shoulder LR had higher preoperative function scores and lower pain interference and depression scores than those undergoing TSA and RCR. These baseline PROMIS scores should be taken into consideration when tracking a patient's outcomes after surgery, as a certain score could mean drastically different functional and pain outcomes depending on the underlying pathology.

ß-Hydroxy ß-methylbutyrate free acid alters cortisol responses, but not myofibrillar proteolysis, during a 24-h fast.

This study was a randomised, double-blind, placebo-controlled cross-over trial examining the effects of ß-hydroxy ß-methylbutyrate free acid (HMB-FA) supplementation on muscle protein breakdown, cortisol, testosterone and resting energy expenditure (REE) during acute fasting. Conditions consisted of supplementation with 3 g/d HMB-FA or placebo during a 3-d meat-free diet followed by a 24-h fast. Urine was collected before and during the 24-h fast for analysis of 3-methylhistidine:creatinine ratio (3MH:CR). Salivary cortisol, testosterone, their ratio (T:C), and the cortisol awakening response were assessed. ANOVA was used to analyse all dependent variables, and linear mixed models were used to confirm the absence of carryover effects. Eleven participants (six females, five males) completed the study. Urinary HMB concentrations confirmed compliance with supplementation. 3MH:CR was unaffected by fasting and supplementation, but the cortisol awakening response differed between conditions. In both conditions, cortisol increased from awakening to 30 min post-awakening (P=0·01). Cortisol was reduced from 30 to 45 min post-awakening with HMB-FA (-32 %, d=-1·0, P=0·04), but not placebo (PL) (-6 %, d=-0·2, P=0·14). In males, T:C increased from 0 to 24 h of fasting with HMB-FA (+162 %, d=3·0, P=0·001), but not placebo (+13 %, d=0·4, P=0·60), due to reductions in cortisol. REE was higher at 24 h of fasting than 16 h of fasting independent of supplementation (+4·0 %, d=0·3, P=0·04). In conclusion, HMB-FA may affect cortisol responses, but not myofibrillar proteolysis, during acute 24-h fasting.

When Do Patients Achieve PROMIS Milestones After Rotator Cuff Repair?

Background: Given the variability of the questions asked, the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive test (CAT) Version 2.0 item bank aids in the evaluation of rotator cuff repair (RCR) rehabilitation by determining when recovery milestones are possible based on the quality of patient responses at certain time points. Purpose: To assess the time point at which patients with RCR were able to achieve specific functional milestones, determined as positive responses to the 5 most frequently asked items on the PROMIS UE CAT Version 2.0. Study Design: Case series; Level of evidence, 4. Methods: The postoperative PROMIS UE CAT Version 2.0 scores of patients who underwent RCR between February 16, 2017, and July 30, 2019, were reviewed with respect to individual PROMIS item, response, and timing of response. A functional milestone was considered achieved if the patient response was "without any difficulty" or "with a little difficulty" to any of the 5 most frequently asked PROMIS items. The percentage of patients in each monthlong postoperative interval who answered with either response was recorded. The logit generalized estimating equations method was used to analyze the association between milestone achievement for each PROMIS item and predictor variables (age, sex, body mass index, smoking status, race, ethnicity, and employment status). Results: A total of 1131 responses from 371 patients were included. The majority of patients attained milestone achievement on 4 of the 5 most frequently asked PROMIS items at time points ranging from 1 to 5 months postoperatively: "Are you able to carry a shopping bag or briefcase?" (by 1 month), "Are you able to put on and take off a coat or jacket?" (by 3 months), "Are you able to pour liquid from a bottle into a glass?" (by 3 months), and "Are you able to carry a heavy object (over 10 pounds/5 kg)?" (by 5 months). For the item "Are you able to put on a shirt or blouse?", the majority of patients did not achieve the milestone by 1 year. Conclusion: These findings support the application of PROMIS UE CAT Version 2.0 milestone achievement in the shared decision-making process and postoperative monitoring, as patients can use this information to determine when they can return to certain activities and providers can apply these standards to identify patients needing additional clinical support.

Reducing Hemoglobin A1C Levels in Type II Diabetes: A Retrospective Analysis of the Renew Procedure.

INTRODUCTION: Periodontal disease and type 2 diabetes are interrelated, with inflammation playing a significant role in the progression of both conditions. Previous research has demonstrated the potential of various treatments, such as diet, exercise, and periodontal therapies, to improve glycemic control in diabetic patients. METHOD: This study proposed a novel surgical approach, the Renew Procedure, as a potential solution to enhance glycemic control in type 2 diabetic patients with periodontal issues. The procedure involves the removal of all teeth, the elimination of oral and maxillofacial infections, the placement of dental implants, and the provision of implant-supported and implant-retained removable dentures. RESULTS: Preliminary findings indicated a significant reduction in HbA1c levels post-surgery, suggesting that this approach may improve overall oral health, reduce inflammation, and consequently lower HbA1c levels. CONCLUSION: Further research is necessary to confirm the efficacy of the proposed solution, but these initial results highlight the importance of addressing oral health through comprehensive strategies for diabetic and periodontitis patients.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique.

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Pre-Visit Digital Messaging Improves Patient-Reported Outcome Measure Participation Prior to the Orthopaedic Ambulatory Visit: Results from a Double-Blinded, Prospective, Randomized Controlled Trial.

BACKGROUND: Patient-reported outcome measures (PROMs) are metrics that assess physical health, mental health, pain, and satisfaction. However, PROM collection in orthopaedic clinics presents numerous logistical and financial challenges. These challenges are reduced when PROMs are completed before clinic encounters, relieving the workflow constraints of in-office PROM collection. The purpose of this study was to determine the efficacy of 3 different methods with respect to pre-visit electronic PROM completion. METHODS: Consecutive adult orthopaedic patients with no previous PROM participation were enrolled. Patients who registered with the electronic medical record (EMR) patient portal (MyChart) and with active e-mail addresses were randomly assigned to 1 of 3 arms: control (no pre-visit messages), MyChart (EMR patient portal pre-visit messages), and e-mail (e-mail pre-visit messages). The primary outcome measure was pre-visit PROM completion rates in orthopaedic patients, and the secondary outcome measures were time to pre-visit PROM form completion and PROM form completion rates according to patient demographic characteristics. By default, the Patient-Reported Outcomes Measurement Information System (PROMIS) forms were available for completion through the portal by 7 days before scheduled visits. Pre-visit messages were sent 7 days prior to the scheduled visit except in the control group, with reminders sent 3 days prior if still not completed. The patients in each arm who completed all assigned forms were labeled as having total PROM completion, and those who completed at least 1 completed form were considered as having partial PROM completion. Multivariable logistic regression models were used to assess differences in PROM completion rates between study arms. Kruskal-Wallis tests were performed to compare the date of the form completion. RESULTS: A total of 291 patients were included. The pre-visit total completion rates for assigned PROMs were higher in the MyChart arm (49% of 97 patients; p = 0.005) and the e-mail arm (52% of 100 patients; p = 0.002) in comparison with the control arm (30% of 94 patients). Male patients were more likely than female patients to have partial pre-visit PROM completion (odds ratio [OR], 1.74; p = 0.03), and Caucasian patients were more likely to have partial pre-visit PROM completion than African American patients (OR, 2.28; p = 0.01). CONCLUSIONS: Orthopaedic patients receiving either e-mail or patient portal messages demonstrated higher pre-visit PROM completion rates. Pre-visit messaging appears to be a useful strategy for increasing PROM completion rates and limiting the clinical workflow strain imposed by in-clinic PROM administration. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Maximum subjective outcome improvement is reported by 3 Months following arthroscopic partial meniscectomy: A systematic review.

Purpose: To review patient outcomes in the literature following arthroscopic partial meniscectomy (APM) in order to identify when patients report reaching subjective maximal improvement postoperatively. Methods: A systematic review of the literature from January 2004 to August 2019 was conducted using PRISMA guidelines to identify articles evaluating patient-reported outcome measures (PROMs) up to a minimum of 6 months after APM in patients >18 years old. Studies were excluded if additional interventions were performed such as repairs, ligamentous reconstruction or repair, cartilaginous manipulation, or revision surgery. PROMs were pooled between studies at preoperative, 3 months, 6 months, 1 year, and 2 year time points. Weighted averages were used within a mixed model method in order to account for the differences in sample size and variance among studies. Significant improvements in PROMs at various time intervals were statistically analyzed using minimal clinically important difference. Results: A total of 12 studies including 1663 patients who underwent APM were selected for the review. The pooled cohort consisted of 1033 (62%) males and 630 (38%) females. Significant improvements were demonstrated from preoperative scores to 3 months postoperatively in Knee Injury and Osteoarthritis Outcome Score subcategories, Lysholm, and visual analog scale scores while no differences were found for Tegner and International Knee Documentation Committee scores. Although statistically significant improvement in PROMs remained at all postoperative time points compared to preoperative scores, no significant differences were observed after 3 months postoperatively. Conclusions: Patients undergoing APM had significant mean changes in legacy PROMs by 3 months postoperatively that exceeded given minimal clinically important difference values, without further clinically important improvement reported up to 2 years postoperatively. Study design: Level III, systematic review.

Athletes Perceive Weighted Baseballs to Carry a Notable Injury Risk, yet Still Use Them Frequently: A Multicenter Survey Study.

INTRODUCTION: Weighted baseball use in throwing programs is widespread; however, their use remains controversial. Prior research shows that weighted baseball programs can increase ball velocity but potentially increase throwing arm injuries. This study aims to ascertain perceptions of weighted baseballs among elite baseball players. METHODS: A created online survey questioned common practices, throwing regimens, injury risk factors, and weighted baseball program use. The questions were modeled to ascertain the perceptions of elite baseball players to understand their experience with weighted baseballs. Descriptive statistical analysis was conducted. RESULTS: Three hundred seventy-six baseball players with a mean age of 20 ± 2 years completed the survey; 64% of the players (239/376) were pitchers. 71% (267/376) reported the use of weighted baseballs. Of those, 75% (199/267) thought it made them a better player. Overall, 73% (275/377) thought weighted baseballs are a risk for injury. 17% (46/267) attributed their injury to using weighted baseballs. Overall, participants reported a mean 72% ± 30% likelihood of future weighted baseball use. CONCLUSION: Most of the participating elite adult baseball players reported prior weighted baseball use with a corresponding improvement in pitching performance despite a perceived increased injury risk. Nearly 20% of the players attributed pain or injury to weighted baseball use. Moreover, the players surveyed intend to continue using weighted baseballs because of the perceived performance benefit.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament Lesion With Capsular Plication in the Lateral Decubitus Position.

Humeral avulsion of the glenohumeral ligament (HAGL) lesions can lead to persistent shoulder instability. While rare, HAGL lesions may present as a concomitant injury following shoulder dislocation events. Traditionally, an open approach has been used to repair the inferior glenohumeral ligament and restore shoulder stability. Modern arthroscopic techniques and instrumentation have permitted a minimally invasive approach for treating HAGL lesions. While technically demanding, arthroscopic repair of HAGL lesions has demonstrated favorable outcomes with less soft-tissue disruption. The following Technical Note describes a safe and effective method for the arthroscopic repair of HAGL lesions. Our technique highlights the use of the lateral decubitus position, a 70° arthroscope, a curved anchor device, and a 90° SutureLasso device.

Can We Eliminate Opioids After Anterior Cruciate Ligament Reconstruction? A Prospective, Randomized Controlled Trial.

BACKGROUND: Multimodal pain protocols have been effective for postsurgical pain control; however, no published protocol has been effective in eliminating opioid consumption. PURPOSE: To compare a multimodal nonopioid pain protocol versus traditional opioid medication for postoperative pain control in patients undergoing anterior cruciate ligament reconstruction (ACLR). STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 90 patients undergoing primary ACLR were assessed for participation. We performed a prospective, randomized controlled trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms were a multimodal nonopioid analgesic protocol (acetaminophen, ketorolac, diazepam, gabapentin, and meloxicam) and a standard opioid regimen (hydrocodone-acetaminophen), and the primary outcome was postoperative visual analog scale (VAS) pain scores for 10 days. Secondary outcomes included patient-reported outcomes, complications, and satisfaction. The observers were blinded, and the patients were not blinded to the intervention. RESULTS: A total of 9 patients did not meet inclusion criteria, and 19 patients declined participation. Thus, 62 patients were analyzed, with 28 patients randomized to the opioid group and 34 to the multimodal nonopioid group. Patients receiving the multimodal nonopioid pain regimen demonstrated significantly lower VAS scores compared with patients who received opioid pain medication (P < .05). Patients were administered the Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form, and no significant difference was found in patients' preoperative scores (opioid group, 58.6 ± 7.9; multimodal nonopioid group, 57.5 ± 7.4; P = .385) and 1-week postoperative scores (opioid group, 66.3 ± 8.2; multimodal nonopioid group, 61.4 ± 8.8; P = .147). When we adjusted for possible confounders (age, sex, body mass index, graft type), no significant differences in pain control were found between the 2 groups. The most common adverse effects for both groups were drowsiness and constipation, with no difference between the groups. All patients in the multimodal nonopioid group reported satisfactory pain management. CONCLUSIONS: A multimodal nonopioid pain protocol provided at least equivalent pain control compared with traditional opioid analgesics in patients undergoing ACLR. Minimal side effects, which did not differ between groups, were noted, and all patients reported satisfaction with their pain management.

Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study.

PURPOSE: We wanted to evaluate opioid prescribing patterns among orthopaedic surgeons and to identify demographics that may be associated with more extensive opioid prescribing habits that could be candidates for targeted education policies. METHODS: Medicare Part D prescriber and prescription information for the most recent available year, 2017, was accessed via a publicly available database offered by the Centers for Medicare and Medicaid. Number of total prescriptions, number of opioid prescriptions, and the total days' supply of opioids prescribed were analyzed for each of 19,219 orthopaedic surgeons. Demographics and board certification status were also recorded. RESULTS: Orthopaedic surgeons who wrote the most opioid prescriptions (>400 per year) also wrote the longest prescription durations (14.1 days/prescription, P < .05 for all comparisons). Surgeons with more than 30 years of experience wrote the longest prescriptions (11.8 days/prescription; P < .001). Male surgeons wrote more opioid prescriptions than female surgeons (151 vs 95, respectively; P < .001). However, female surgeons wrote longer prescriptions than male surgeons (7.5 days/prescription vs 6.1 days/prescription, respectively; P = .01). Surgeons from southern states wrote the most opioid prescriptions (1,386,897) and the longest prescriptions, with an average of 13.0 days per prescription, whereas western states wrote the shortest prescriptions at 10.4 days per prescription (P = .004). CONCLUSION: There are demographic correlations between orthopaedic surgeons and opioid prescribing patterns. In particular, male, older southern surgeons prescribe the highest volumes of opioids. This provides an opportunity for targeted education versus overarching, general policies. Potential directions for future investigation can focus on assessing recent trends in opioid prescriptions among orthopaedic providers. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Presence of Preoperative Depression Symptoms Does Not Hinder Recovery After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The current literature suggests a link between psychosocial factors and poor surgical outcomes in patients with musculoskeletal complaints. However, there remains a limited body of literature examining the effect of depression on outcomes after anterior cruciate ligament reconstruction (ACLR). PURPOSE: The primary purpose of this study was to compare postoperative function patient-reported outcome scores between patients with and patients without preoperative depression symptoms undergoing ACLR. Secondary goals included comparing postoperative pain interference and depression scores between the 2 groups. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In this single-center retrospective cohort study, pediatric and adult patients who underwent ACLR were included. The Physical Function (PF), Pain Interference (PI), and Depression (D) domain scores of the Patient-Reported Outcomes Measurement Information System (PROMIS) were collected preoperatively and at 6 and 12 months postoperatively. Patients were separated into clinical depression (CD) and no clinical depression (NCD) groups based on their preoperative PROMIS-D score. RESULTS: A total of 82 patients undergoing ACLR were included in this study. Of these, 19 (23%) patients met criteria for the CD group. Preoperatively, the CD group reported lower mean PROMIS-PF (33.3 vs 39.7, respectively; P = .001), higher PROMIS-PI (65.7 vs 59.2, respectively; P <.01), and higher PROMIS-D (62.4 vs 45.1, respectively; P < .001) scores than the NCD group. At 12 months postoperatively, the mean PROMIS-PF scores for the CD and NCD groups were 52.1 and 56.7, respectively (P = .12). The mean 12-month postoperative PROMIS-PI scores for the CD and NCD groups were 52.3 and 47.4, respectively (P = .04). At 12 months after ACLR, there was a substantial improvement in PROMIS-PF and PROMIS-PI scores for both the CD (delta = +18.8 and -13.4, respectively) and NCD (delta = +17.0 and -11.8) groups. CONCLUSION: There was a significant improvement, which exceeded currently accepted minimal clinically important difference values, in PROMIS-PF scores at 12 months after ACLR, regardless of the presence of preoperative depression symptoms. These data suggest that having depression symptoms preoperatively does not significantly hinder a patient's recovery after ACLR.