What Factors are Associated With Conversion to Knee Arthroplasty After Subchondroplasty?

BACKGROUND: Subchondral bone marrow lesions identified on knee MRI are believed to play a role in osteoarthritis-associated pain. The subchondroplasty procedure is an arthroscopically assisted procedure for treating such lesions to avoid larger procedures such as knee arthroplasty. However, the survivorship free of conversion to arthroplasty and the factors associated with an increased likelihood of conversion of subchondroplasty to arthroplasty have not been well defined. QUESTIONS/PURPOSES: We performed this study to (1) determine the 5-year survivorship of subchondroplasty free from conversion to knee arthroplasty (unicompartmental or total) and (2) identify variables that were associated with progression to knee arthroplasty after a subchondroplasty procedure. METHODS: In all, 216 patients who underwent a subchondroplasty procedure performed by one surgeon with subchondroplasty experience at a single-center, multilocation facility between September 2014 and August 2017 were retrospectively evaluated to estimate survivorship free from conversion to knee arthroplasty at 5 years. The mean ± SD age and BMI at the time of subchondroplasty procedure were 59 ± 11 years and 33 ± 8 kg/m 2 , respectively; 60% (129 of 216) of the patients were women. Other variables collected were smoking status and grade and location of chondral lesions. The electronic medical record was reviewed to determine whether the patient had a knee arthroplasty after subchondroplasty. Survivorship free from conversion to knee arthroplasty at 5 years was calculated from a Kaplan-Meier survivorship estimator. Factors associated with progression to knee arthroplasty were examined using t-tests and chi-square analyses. Variables showing evidence of an association with knee arthroplasty were explored further using a Kaplan-Meier survivorship estimator (n = 190). RESULTS: Kaplan-Meier survivorship free from conversion to knee arthroplasty was 73% (95% CI 67% to 79%) at 5 years after subchondroplasty. We found that age older than 50 years and Grade 4 chondral lesions were associated with conversion to knee arthroplasty. Patients with a Grade 4 chondral lesion had 5-year survivorship of 62% (95% CI 54% to 71%) and 59% (95% CI 50% to 69%) for those older than 50 years with a Grade 4 chondral lesion. CONCLUSION: Currently, we recommend a detailed, informed discussion of the risks versus benefits with patients who are considering a subchondroplasty procedure, particularly patients aged 50 years and older and those with Grade 4 chondral lesions. Future randomized trials, including those that compare the subchondroplasty procedure with arthroscopy alone or nonoperative management options, are still needed to confirm the efficacy and role of the subchondroplasty procedure in patients with knee osteoarthritis, because only such prospective studies can determine the success of the procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears with and without Augmentation with a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement.

PURPOSE: The study objective was to compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant. METHODS: The study group comprised 24 patients (17 males) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 males) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion (ROM) and patient-reported outcomes (PROs) were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging (MRI) was obtained in 20/24 collagen implant patients and 17/24 control patients at minimum 6 months follow-up to assess tendon healing. RESULTS: American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in ROM and PROs were similar in both groups. MRI revealed intact repairs in 11/20 (55%) patients in the patch group and 9/17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty. CONCLUSIONS: Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Reverse shoulder arthroplasty in patients 85 years and older is safe, effective, and durable.

BACKGROUND: Reverse shoulder arthroplasty (RSA) was originally indicated for older adults, but outcomes in the oldest patients have not been studied. The purpose of this study was to report on patients aged ≥85 years undergoing RSA. We hypothesized that RSA would be safe, effective, and durable. METHODS: Sixty-one RSAs were performed in 58 patients aged ≥85 years (16 patients aged ≥90 years); 40 RSAs were performed for arthritis with cuff deficiency, 14 were performed for proximal humeral fractures, and 7 were performed as revisions. Active range of motion and patient-reported outcomes, comprising the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale pain score, were obtained preoperatively and at final follow-up. Hospital length of stay, discharge disposition, and complications were recorded. Kaplan-Meier survivorship was computed with revision surgery or death as an endpoint. RESULTS: The mean age at RSA was 88.0 years. Mean forward elevation improved from 50.5° to 105.3°; abduction, from 48.7° to 96.1°; and external rotation, from 10.2° to 26.9° (P < .001 for all). Similarly, at a mean follow-up of 2.4 years, the visual analog scale pain score improved from 6.1 to 0.6; Simple Shoulder Test score, from 2.2 to 7.0; and American Shoulder and Elbow Surgeons score, from 33.6 to 78.2 (P < .001 for all). The mean length of stay was 3.6 days, and 15 patients were discharged home. Seven patients received a blood transfusion, and only 2 patients underwent a reoperation, neither of whom required explantation. DISCUSSION AND CONCLUSION: Improvements in active range of motion and patient-reported outcomes in our patients were comparable to those observed in younger cohorts and exceeded published minimal clinically important differences for most patients undergoing RSA for cuff deficiency. Additionally, to date, the patients in our study who died had lived with their RSA for a mean of 3.4 years and living patients had lived with their RSA for a mean of 4.3 years. RSA in patients aged ≥85 years is safe, effective, and durable for their remaining life expectancy. This information may help counsel older patients who are considering RSA, electively or for fractures.

Kinetic and kinematic comparisons in high school pitchers with low and high pitch location consistency.

BACKGROUND: Although ball velocity has often been associated with increased kinetics at the upper extremity and risk of injury in youth and adolescent pitchers, it is unclear if the performance metric pitch location consistency has any positive or negative associations with pitching kinetics. METHODS: High school pitchers (n = 59) pitched 8-12 fastballs using 3D motion capture (480 Hz). Pitchers were divided into high-consistency (HiCon) and low-consistency (LoCon) groups based on the absolute center deviation of each pitcher's pitch to the center of the pitcher's mean pitch location. Ninety-five percent confidence ellipses with major and minor radii were constructed, and kinematics and kinetics were compared between groups. RESULTS: Compared with LoCon pitchers, HiCon pitchers had decreased lead hip flexion at elbow extension (40° ± 12° vs. 52° ± 13°, respectively, P = .008), and at foot contact, decreased back hip extension (-1° ± 10° vs. -10° ± 13°, respectively, P = .038) and increased back hip internal rotation (9° ± 15° vs. -2° ± 15°, respectively, P = .043). LoCon pitchers achieved maximum lead hip flexion earlier in the pitch (61.3% ± 23.2% vs. 75.8% ± 15.1%, respectively, P = .039). A multiregression model predicted 0.49 of variance in pitch location consistency using kinematic inputs. DISCUSSSION AND CONCLUSION: Pitchers who differ in pitch location consistency outcomes do not appear to demonstrate physiologically unsafe kinematics. High school pitchers who strive for improved pitch consistency can consider adjusting parameters of hip kinematics during early portions of the pitch.

Posterior-approach total shoulder arthroplasty: a case series with a minimum of 2-year outcomes.

BACKGROUND: A posterior approach to shoulder arthroplasty has been described that may improve exposure to the retroverted glenoid and spare the rotator cuff. The purpose of this study was to evaluate posterior total shoulder arthroplasty (PTSA) at a minimum of 2 years. METHODS: Between September 2016 and October 2017, 28 patients (30 shoulders) who underwent PTSA were retrospectively identified. Patients were monitored at baseline and at 6 weeks, 3 months, 6 months, 1 year, and a minimum of 2 years after surgery for range of motion, American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores, radiographic outcomes, complications, and patient satisfaction. Radiographs were assessed for head height, neck-shaft angle, humeral head centering, and the presence or absence of glenoid-component cement lines. Repeated-measures analysis-of-variance models were implemented to compare the means for each outcome variable over time. RESULTS: Of the 28 patients (30 shoulders), 24 patients (26 shoulders) (87%) were available for follow-up at a minimum of 2 years (average, 31.2 months; range, 23-40 months). At latest follow-up, the average ASES pain score was 45.2 (standard deviation [SD], 10.9; range, 20-50; 95% confidence interval [CI], 40.8-49.6); average ASES function score, 42.3 (SD, 8.9; range, 21.7-50; 95% CI, 38.7-45.8); average ASES total score, 87.5 (SD, 18.8; range, 31.7-100; 95% CI, 79.8-95.1); and average Simple Shoulder Test score, 10.2 (SD, 2.0; range, 5-12; 95% CI, 9.4-11.0). Average forward flexion was 164° (SD, 13.9°; range, 130°-180°; 95% CI, 158.3°-170.4°); average external rotation, 78° (SD, 9.2°; range, 55°-90°; 95% CI, 74.3°-82.3°); and average internal rotation, T10 (SD, 2; range, L3 to T6; 95% CI, T10 to T8). The average head height was 0.86 mm above the greater tuberosity (range, -6.5 to 6.9 mm), the average neck-shaft angle was 128° (range, 113°-148°), and the average implant placement was 0.12 mm superior to the center of the neck cut (range, -3.3 to 3.5 mm). Six implants were considered malpositioned based on the criterion of >5 mm of head height above or below the tuberosity or >2 mm off-center. Glenoid cement lines were present in 7 shoulders. Two patients experienced complications: 1 patient had symptomatic glenoid loosening 29 months postoperatively that required revision to an anterior reverse total shoulder arthroplasty, and 1 patient had postoperative weakness that resolved by 6 months. CONCLUSION: PTSA is safe and efficacious at 2 years, spares the rotator cuff, and may improve early postoperative function. PTSA is more easily performed with stemless arthroplasty. Challenges with creation of the humeral head osteotomy and identification of the center of the cut humeral head surface can affect the accuracy of implant positioning. Further improvements in technique will likely improve the feasibility of this approach.

Improving Orthopedic Patient Outcomes: A Model to Predict 30-Day and 90-Day Readmission Rates Following Total Joint Arthroplasty.

BACKGROUND: Over the next 10-15 years, there is expected to be an exponential increase in the number of total joint arthroplasties in the American population. This, combined with rising costs of total joint arthroplasty and more recent changes to the reimbursement payment models, increases the demand to perform quality, cost-effective total joint arthroplasties. The purpose of this study is to build models that could be used to estimate the 30-day and 90-day readmission rates for patients undergoing total joint arthroplasty. METHODS: A retrospective review of patients admitted to a single hospital, over the course of 56 months, for total joint arthroplasty was performed. The goal is to identify patients with readmission in a 30-day or 90-day period following discharge from the hospital. Binary logistic regression was used to build predictive models that estimate the likelihood of readmission based on a patient's risk factors. RESULTS: Of 5732 patients identified for this study, 237 were readmitted within 30 days, while 547 were readmitted within 90 days. Age, body mass index, gender, discharge disposition, occurrence of cardiac dysrhythmias and heart failure, emergency department visits, psychiatric diagnoses, and medication counts were all found to be associated with 30-day admission rates. Similar associations were found at 90 days, with the exclusion of age and psychiatric drug use, and the inclusion of intravenous drug abuse, narcotic medications, and total joint arthroplasty within 12 months. CONCLUSION: There are patient variables, or risk factors, that serve to predict the likelihood of readmission following total joint arthroplasty.

Return to Sports in Patients Aged 50 Years or Younger After Robotic-Assisted Patellofemoral Arthroplasty: A 10-Year Experience Reporting High Clinical Benefits and High Patient Satisfaction With Return to an Active Lifestyle.

BACKGROUND: Limited data are available on return to sports and patient psychometric ratings of success after patellofemoral arthroplasty (PFA) in younger patients with high expectations to return to an active lifestyle. PURPOSE/HYPOTHESIS: The purpose of this article was to determine the role of PFA and its success in meeting patient expectations regarding the return to low-impact recreational sports and an active lifestyle in younger, active patients. It was hypothesized that PFA would allow younger patients to return to low-impact sports and an active lifestyle and achieve high patient psychometric ratings. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In this 10-year prospective study (2009-2018), robotic-assisted PFA was performed on 44 patients (32 women and 12 men; n = 51 consecutive knees), with a mean age of 37.2 years (range, 21-50 years). The follow-up rate was 98%, with a mean of 5.3 years (range, 2-9.3 years). Primary clinical outcomes were as follows: the validated Cincinnati Knee Rating System sports activity and symptom rating scales, patient psychometric ratings of the substantial clinical benefit (SCB), and the Patient Acceptable Symptom State (PASS). Secondary outcomes were the Cincinnati Knee Rating System occupational rating, visual analog pain scale, and the 12-Item Short Form Health Survey. Survivorship was defined by conversion to total knee replacement (TKR). RESULTS: Before PFA, 78% of patients (35/45 knees) were symptomatic and unable to perform recreational sports, with only 20% of patients (9/45 knees) performing some low-impact sports. After PFA, 80% of patients (36/45 knees) were able to perform low-impact sports, and 7% (3/45 knees) performed jumping-pivoting sports (P < .001). The SCB scored by the patient showed 87% of knees as good, very good, or normal. On the PASS analysis, 89% of patients (95% CI, 76%-96%) were "pleased," and 93% (95% CI, 82%-99%) would undergo surgery again. There were clinically relevant improvements in symptoms of pain, swelling, and giving way (P = .0001). Preoperatively, 91% of knees had moderate to severe pain with activities of daily living, and only 11% of knees had pain at the follow-up. Five of the 50 knees (10%) underwent TKR conversion with one patient lost to follow-up. CONCLUSION: PFA resulted in a high return of patients to low-impact sports with high SCB and PASS psychometric ratings. The robotic-assisted 3-dimensional preoperative planning allowed precise intraoperative trochlear implant alignment in knees with severe trochlear dysplasia. PFA is recommended as an alternative treatment in younger patients with end-stage symptomatic patellofemoral arthritis. REGISTRATION: NCT02738476 (ClinicalTrials.gov identifier).

Micro-level Factors Associated with Youth Drug Use Among an Urban at-Risk Youth Sample.

BACKGROUND: Youth drug use has reached global epidemic proportions with unequal distribution among communities with low income, immigrants, or ethnic status. PURPOSE: This study seeks to understand the association between micro-level factors and youth drug use behavior among 2693 low-income, ethnic, and immigrant youths in Pomona, CA, USA. The study uneath's unique evidence and intervention elements necessary to resolve youth drug use in Pomona. METHODS: We used social cognitive theory as a conceptual framework, and performed correlation and multiple linear regression analysis in a cross-sectional design. RESULTS AND DISCUSSION: The results reveal that attitudes, perceptions, and behavior related to friends, participants, family, and adults in the participant's life and ease of access to drugs are associated with youth drug use. Variables related to friends and participants show a relatively stronger association with youth drug use in comparison to variables related to parents and adults in participants' lives. Equally, drug and non-drug antisocial behavior of friends and participants show a stronger association with youth drug use relative to prosocial behavior. Also, when a diverse set of predictor variables are combined together, their association to the outcome variable is stronger than that of a single variable. RECOMMENDATIONS: Future interventions in Pomona should prioritize strategies which target participants and friends over activities targeting parents and adults. Interventions targeting antisocial behavior should be prioritized over prosocial behavior. Program implementers should also develop unique evidence and tools which will help parents influence the drug use behavior of youths in Pomona and similar communities.

Functional Interaction of the Cruciate Ligaments, Posteromedial and Posterolateral Capsule, Oblique Popliteal Ligament, and Other Structures in Preventing Abnormal Knee Hyperextension.

BACKGROUND: The ligaments and soft tissue capsular structures of the knee joint that provide a resisting force to prevent abnormal knee hyperextension have not been determined. This knowledge is required for the diagnosis and treatment of knee hyperextension abnormalities. PURPOSE: To determine the resisting moment of knee ligament and capsular structures that resist knee hyperextension. HYPOTHESIS: The combined posteromedial and posterolateral capsular structures function to provide a major restraint to prevent abnormal knee hyperextension. The anterior and posterior cruciate ligaments resist knee hyperextension but function as secondary restraints. STUDY DESIGN: Descriptive laboratory study. METHODS: A 6 degrees of freedom robotic system determined intact laxity limits in 24 cadaveric knees from 0° to 100° of knee flexion for anteroposterior limits at ±135 N, abduction-adduction limits at ±7 N·m, and external-internal limits at ±5 N·m. One loading method (n = 14 knees) used a static loading sequence with knee hyperextension to 27-N·m torque while maintaining all other degrees of freedom at zero load during sequential soft tissue cutting. The second method (n = 10 knees) used a cyclic loading sequence to decrease viscoelastic effects with soft tissue cutting at 0° of extension, followed by knee hyperextension to 27-N·m torque and cycled back to 0°. Selective soft tissue cuttings were performed of the following: oblique popliteal ligament, fabellofibular ligament, posterolateral capsule, posteromedial capsule with posterior oblique ligament, cruciate ligaments, lateral collateral ligament, popliteus, anterolateral ligament and iliotibial band, and superficial plus deep medial collateral ligaments. The sequential loss in the restraining moment with sectioning provides the function of that structure in resisting knee hyperextension. RESULTS: The median resisting force to knee hyperextension, in descending order, was the posteromedial capsule and posterior oblique ligament (21.7%), posterorolateral ligament and fabellofibular ligament (17.1%), anterior and posterior cruciate ligaments (13% and 12.9%, respectively), superior and deep medial collateral ligament (9.6%), oblique popliteal ligament (7.7%), and lateral collateral ligament (5.4%). The combined posterior capsular structures provided 54.7% and the anterior and posterior cruciate ligaments 25.3% of the total resisting moment to prevent knee hyperextension. CONCLUSION: Diagnosis of abnormal knee hyperextension involves a combination of multiple ligament and soft tissue structures without 1 primary restraint. The posteromedial and posterolateral capsular structures provided the major resisting moment to prevent knee hyperextension. The cruciate ligaments produced a lesser resisting moment to knee hyperextension. CLINICAL RELEVANCE: This is the first study to comprehensively measure all of the knee ligaments and capsular structures providing a resisting moment to abnormal knee hyperextension. These data are required for diagnostic and treatment strategies on the pathomechanics of abnormal knee hyperextension in patients after injury or developmental cases.

Overcoming barriers to lung cancer screening using a systemwide approach with additional focus on the non-screened.

BACKGROUND: The lung cancer screening program at St Elizabeth Healthcare (Kentucky, USA) began in 2013. Over 33,000 low-dose computed tomography lung cancer screens have been performed. From 2015 through 2021, 2595 lung cancers were diagnosed systemwide. A Screening Program with Impactful Results from Early Detection, reviews that experience; 342 (13.2%) were diagnosed by screening and 2253 (86.8%) were non-screened. As a secondary objective, the non-screened cohort was queried to determine how many additional individuals could have been screened, identifying barriers and failures to meet eligibility. METHODS: Our QlikSense database extracted the lung cancer patients from the Cancer Patient Data and Management System, and identified and categorized them separately as screened or non-screened populations. Stage distribution was compared in screened and non-screened groups. Those meeting age criteria, with any smoking history, were further queried for screening eligibility, accessing the electronic medical record smoking history and audit trail, and determining if enough information was available to substantiate screening eligibility. The same methodology was applied to CMS 2015 and USPSTF 2021 criteria. RESULTS: The screened and non-screened patients were accounted for in a stage migration chart demonstrating clear shift to early stage among screened lung cancer patients. Additionally, analysis of non-screened individuals is presented. CONCLUSION: Of the St Elizabeth Healthcare eligible patients attributed to primary care providers, 49.6% were screened in 2021. Despite this level of success, this study highlighted a sizeable pool of additional individuals that could have been screened. We are shifting focus to the non-screened pool of patients that meet eligibility, further enhancing the impact on our community.

Social Distancing to Avoid SARS-CoV-2 Infection in Cancer and Noncancer Patients.

BACKGROUND: Social distancing has been recommended by the Centers for Disease Control and Prevention to avoid exposure to SARS-CoV-2 ( Epidemiol Prev 2020;44:353-362).Cancer patients on or after active therapy seem to be more prone to COVID being symptomatic and life-threatening. When evaluating cancer patients' risk of acquiring COVID, it is essential to know the behavior of cancer patients that will affect their risk of exposure. However, it is not known to what degree social distancing is practiced by cancer patients compared with noncancer patients and what factors lead to the decision to distance oneself. METHOD: After a pilot phase using patients' MyChart messaging, links to the electronic questionnaires were texted to patients using Twillio. Responses were stored on REDCap (Vanderbilt University, Nashville, TN). Six questions about their social distancing behavior and mask wearing were posed and responses were compared between cancer and noncancer patients. Demographics, comorbidities, and a questionnaire about anxiety (Generalized Anxiety Disorder 7-item scale) were recorded. To assess differences between cancer and noncancer groups, Bonferroni-corrected χ 2 tests and proportions confidence intervals were used. RESULTS: The pilot survey was sent in mid-2020 and the full survey followed in January 2021 during a high community COVID incidence. Three hundred eighty-seven cancer patients (32.4% responded) and 503 noncancer patients (22.9% responded) completed the survey. Questions about leaving their houses, driving, shopping, friends, and family indicated that patients with cancer are more cautious ( P < 0.001). Cancer patients were up to 20% more likely to distance themselves. No difference was seen in wearing a mask-both groups wore approximately 90% of the time. Most respondents were female (63% versus 71%). Cancer patients were older (>60 y, 69% versus 45%) and less likely to work (52% versus 31%) or less likely to be White collar workers (21% versus 38%). In both groups, 54% marked "not at all anxious." CONCLUSIONS: Cancer patients' responses revealed a distancing behavior that would likely lower the risk exposure to SARS-CoV-2. It is unclear which of the demographic differences would account for this behavior, although remarkably anxiety was not a clear motivating factor. The high acceptance of masks is encouraging. Early publications during the pandemic and patient education suggesting a higher COVID risk for cancer patients may have reduced risk prone behavior. Considering COVID's impact on the vulnerable cancer population and uncertainty in immunosuppressed patients about clearing the virus or adequately responding to a vaccine, further studies about health behavior and health promotion during the pandemic are needed.

Robotic-assisted total knee arthroplasty: Is there a maximum level of efficiency for the operating surgeon?

Aims: Recent studies have attempted to quantify the learning curve associated with integration of robotic technology into surgical practice, but to our knowledge, no study has demonstrated the number of cases needed to reach a steady state of maximum efficiency in operating times using robotic assisted technology. Patients and methods: This was a retrospective analysis of 682 consecutive knees that underwent a robotic-assisted TKA for osteoarthritis by a single surgeon between 2017 and 2020. Procedure times (minutes), length of stay (LOS), and short-term postoperative complications and reoperations were analyzed to define trends. Time series analyses were used to identify the approximate time-point at which a maximum level of surgical operating speed was achieved. Analysis of Variance (ANOVA) and chi-square analyses then followed to compare average procedure duration, LOS, and complications across distinct moving groups of 50 procedures. Results: Time series analyses suggest substantially improved times by the 50th procedure and reached a stable plateau between the 150th and 200th procedure. Average duration for the first 50 procedures was approximately 85 min, dropping to 69 min for procedures 51-100, 66 min for procedures 101-150, and then plateauing at approximately 61 min for procedures 151-682, demonstrating significant improvements in surgical efficiency at each 50-procedure interval (p < 0.05). There was no significant difference in LOS, readmissions, and reoperations with increasing groups of 50 procedures performed. Conclusion: Results from this study will allow surgeons to better understand the implications of integrating robotic arm-assisted technology into their practice. Surgeons can expect significant improvement of their operative time following completion of at least 50 procedures, while likely reaching a maximum level of surgical efficiency between 151 and 200 procedures.

Lower-Intensity Statins Contributing to Gaps in Care for Patients With Primary Severe Hypercholesterolemia.

Background Although severe hypercholesterolemia confers a 5-fold increased long-term risk for coronary artery disease, treatment guidelines may not be fully implemented, leading to underdiagnosis and suboptimal treatment. To further understand the clinical features and gaps in treatment approaches, we analyzed electronic medical record data from a midwestern US multidisciplinary healthcare system, between 2009 and 2020. Methods and Results We retrospectively assessed the prevalence, clinical presentation, and treatment characteristics of individuals currently treated with statin therapy having a low-density lipoprotein cholesterol (LDL-C) value that is either (1) an actual maximum electronic medical record-documented LDL-C ≥190 mg/dL (group 1, n=7542) or (2) an estimated pretreatment LDL-C ≥190 mg/dL (group 2, n=7710). Comorbidities and prescribed lipid-lowering therapies were assessed. Statistical analyses identified differences among individuals within and between groups. Of records analyzed (n=266 282), 7% met the definition for primary severe hypercholesterolemia. Group 1 had more comorbidities than group 2. More individuals in both groups were treated by primary care providers (49.8%-53.0%, 32.6%-36.4%) than by specialty providers (4.1%-5.5%, 2.1%-3.3%). High-intensity lipid-lowering therapy was prescribed less frequently for group 2 than for group 1, but moderate-intensity statins were prescribed more frequently for group 2 (65%) than for group 1 (52%). Conclusions Two percent of patients in our study population being treated with low- or moderate-intensity statins have an estimated LDL-C ≥190 mg/dL (indicating severe hypercholesterolemia), but receive less aggressive treatment than patients with a maximum measured LDL-C ≥190 mg/dL.

Prevalence and Characteristics of Patients With Primary Severe Hypercholesterolemia in a Multidisciplinary Healthcare System.

Severe hypercholesterolemia (SH) includes individuals with LDL-C ≥ 190 mg/dl, regardless of cause. These individuals have a fivefold increased long-term risk for coronary artery disease. Although systematic SH screening can trigger early treatment, current treatment guidelines may not be fully implemented or followed by patients. To further understand this treatment gap, we used electronic health record data to retrospectively assess SH prevalence, characteristics, and treatment in a midwest US healthcare system, between 2009 and 2020. Comorbidities, tobacco exposure, and prescribed lipid-lowering therapies were assessed. Statistical analyses were conducted to identify differences between individuals with primary SH (LDL-C ≥ 190 mg/dl, group 1) and those without primary SH (LDL-C < 190 mg/dl, group 2). Of 265,220 records analyzed, 7.4% met the definition for primary SH. These group 1 cases had more comorbidities than group 2 cases, including premature coronary artery disease (5.8% vs 2.7%). Results showed most individuals in group 1 were treated by primary care providers (43.2% to 45.7%), than by specialty providers (2.5% to 3.3%), and these primary care providers prescribed mainly moderate-intensity statins. Seventy-seven percent of group 1 individuals were treated with a statin, 27% were treated with a high-intensity statin, and 4% were treated with ezetimibe. Fewer young patients (< 40 years) were treated with statins (50% to 58.3%) than older patients (74.0% to 76.3%). Although use of general statins, high-intensity statins, and ezetimibe was higher in individuals with SH than those without SH, treatment remains below guideline recommendations, especially in younger individuals.

Posterior Approach Total Shoulder Arthroplasty: A Retrospective Analysis of Short-term Results.

Subscapularis dysfunction and failure are the leading causes of complications of total shoulder arthroplasty (TSA). An approach to shoulder arthroplasty has been described that may improve exposure to the retroverted glenoid and spare the rotator cuff. This article details the 6-month clinical outcomes of the first 26 patients who underwent TSA using a posterior approach. Thirty-one patients who underwent TSA using a posterior approach between September 2016 and October 2017 were identified retrospectively. Patients were assessed for American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range of motion, complications, radiographic outcomes, and patient satisfaction. Statistical models were used to compare the means for each outcome variable over time. Of the initial 31 patients, 26 patients were available for follow-up at a minimum of 6 months; the remaining 5 patients did not return for follow-up at 6 months. Significant improvement in each outcome variable from baseline was noted by 6 weeks postoperatively. Further improvement was observed at 3 months for SST and external rotation, and at 6 months for ASES function and forward flexion. All outcome variables demonstrated some improvement from one time point to the next. Posterior TSA is a safe and efficacious procedure at 6 months. Compared with traditional TSA, posterior cuff-sparing approaches may improve posterior joint access, posterior soft tissue balancing, and long-term rotator cuff issues. [Orthopedics. 2020; 43(1):e15-e20.].

Trends in aggressivity and driver risk for cars, SUVs, and pickups: Vehicle incompatibility from 1989 to 2016.

Objective: When 2 vehicles of different sizes collide, the occupants of the smaller vehicle are more likely to be injured than the occupants of the larger vehicle. The larger vehicle is both more protective of its own occupants and more aggressive toward occupants of the other vehicle. However, larger, heavier vehicles tend to be designed in ways that amplify their incompatibility with smaller, lighter vehicles (by having a higher ride height, for example). A 2012 study by the Insurance Institute for Highway Safety (IIHS) concluded that fatalities caused by design incompatibility have decreased in recent years. The current study was conducted to update the 2012 IIHS analysis and to explore trends in vehicle incompatibility over time. Methods: Analyses examined deaths in crashes involving 1- to 4-year-old passenger vehicles from 1989 to 2016 collected from the Fatality Analysis Reporting System (FARS). Trends in driver risk were examined by comparing driver death rates per million registered vehicle years across vehicle type and size. Trends in aggressivity were examined by comparing partner driver death rates across vehicle type and size. Results: Cars and SUVs have continued their trend toward reduced incompatibility. In 1989-1992, SUVs were 132% more likely to kill the driver in a partner car compared with when a car crashed with another car. By 2013-2016, this value had dropped to 28%. Pickups and cars remain just as incompatible in 2013-2016 as they were in 1989-1992, however (159% vs. 158%). Remaining pickup incompatibility may be largely due to excess curb weight rather than to shape or design features, because light pickups were just 23% more likely to kill the driver in a partner car compared with when a car crashed with another car. Conclusions: The trend toward reduced fleet incompatibility has continued in the latest crash data, particularly for cars and SUVs. Although pickup-car incompatibility has also decreased over time, pickups remain disproportionately aggressive toward other vehicles, possibly due to their greater average curb weight. Reducing the weight of some of the heaviest vehicles and making crash avoidance technology fitment more widespread may be promising means to reduce remaining fleet incompatibility. Identifying the source of remaining incompatibility will be important for safety improvements going forward.

Crash compatibility between cars and light trucks: benefits of lowering front-end energy-absorbing structure in SUVs and pickups.

Passenger vehicles are designed to absorb crash energy in frontal crashes through deformation or crush of energy-absorbing structures forward of the occupant compartment. In collisions between cars and light trucks (i.e., pickups and SUVs), however, the capacity of energy-absorption structures may not be fully utilized because mismatches often exist between the heights of these structures in the colliding vehicles. In 2003 automakers voluntarily committed to new design standards aimed at reducing the height mismatches between cars and light trucks. By September 2009 all new light trucks will have either the primary front structure (typically the frame rails) or a secondary structure connected to the primary structure low enough to interact with the primary structures in cars, which for most cars is about the height of the front bumper. To estimate the overall benefit of the voluntary commitment, the real-world crash experience of light trucks already meeting the height-matching criteria was compared with that of light trucks not meeting the criteria for 2000-2003 model light trucks in collisions with passenger cars during calendar years 2001-2004. The estimated benefits of lower front energy-absorbing structure were a 19 percent reduction (p<0.05) in fatality risk to belted car drivers in front-to-front crashes with light trucks and a 19 percent reduction (p<0.05) in fatality risk to car drivers in front-to-driver-side crashes with light trucks.

Frequency and extent of media in the internal carotid artery in "endarterectomy" specimens.

Carotid endarterectomy has been performed now for approximately 50 years. No report, however, has described the presence of media in these "endarterectomy" specimens. From January 1997 through May 2003, 147 carotid endarterectomy specimens were examined histologically. Portions of arterial media were present in each of them. The maximal amount of circumferential media in any patient varied from>95% of the cross-sectional circumference in 55 patients (37%) to75% of the arterial circumference of the internal carotid artery contained media. The proper term for this operative procedure might better be "endomediaectomy" rather than "endarterectomy."