Risks of opioid overdose among New York State Medicaid recipients with chronic pain before and during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic contributed to healthcare disruptions for patients with chronic pain. Following initial disruptions, national policies were enacted to expand access to long-term opioid therapy (LTOT) for chronic pain and opioid use disorder (OUD) treatment services, which may have modified risk of opioid overdose. We examined associations between LTOT and/or OUD with fatal and non-fatal opioid overdoses, and whether the pandemic moderated overdose risk in these groups. METHODS: We analyzed New York State Medicaid claims data (3/1/2019-12/31/20) of patients with chronic pain (N = 236,391). We used generalized estimating equations models to assess associations between LTOT and/or OUD (neither LTOT or OUD [ref], LTOT only, OUD only, and LTOT and OUD) and the pandemic (03/2020-12/2020) with opioid overdose. RESULTS: The pandemic did not significantly (ns) affect opioid overdose among patients with LTOT and/or OUD. While patients with LTOT (vs. no LTOT) had a slight increase in opioid overdose during the pandemic (pre-pandemic: aOR:1.65, 95% CI:1.05, 2.57; pandemic: aOR:2.43, CI:1.75,3.37, ns), patients with OUD had a slightly attenuated odds of overdose during the pandemic (pre-pandemic: aOR:5.65, CI:4.73, 6.75; pandemic: aOR:5.16, CI:4.33, 6.14, ns). Patients with both LTOT and OUD also experienced a slightly reduced odds of opioid overdose during the pandemic (pre-pandemic: aOR:5.82, CI:3.58, 9.44; pandemic: aOR:3.70, CI:2.11, 6.50, ns). CONCLUSIONS: Findings demonstrated no significant effect of the pandemic on opioid overdose among people with chronic pain and LTOT and/or OUD, suggesting pandemic policies expanding access to chronic pain and OUD treatment services may have mitigated the risk of opioid overdose.

Evaluating chronic pain as a risk factor for COVID-19 complications among New York State Medicaid beneficiaries: a retrospective claims analysis.

OBJECTIVE: To assess whether chronic pain increases the risk of COVID-19 complications and whether opioid use disorder (OUD) differentiates this risk among New York State Medicaid beneficiaries. DESIGN, SETTING, AND SUBJECTS: This was a retrospective cohort study of New York State Medicaid claims data. We evaluated Medicaid claims from March 2019 through December 2020 to determine whether chronic pain increased the risk of COVID-19 emergency department (ED) visits, hospitalizations, and complications and whether this relationship differed by OUD status. We included beneficiaries 18-64 years of age with 10 months of prior enrollment. Patients with chronic pain were propensity score-matched to those without chronic pain on demographics, utilization, and comorbidities to control for confounders and were stratified by OUD. Complementary log-log regressions estimated hazard ratios (HRs) of COVID-19 ED visits and hospitalizations; logistic regressions estimated odds ratios (ORs) of hospital complications and readmissions within 0-30, 31-60, and 61-90 days. RESULTS: Among 773 880 adults, chronic pain was associated with greater hazards of COVID-related ED visits (HR = 1.22 [95% CI: 1.16-1.29]) and hospitalizations (HR = 1.19 [95% CI: 1.12-1.27]). Patients with chronic pain and OUD had even greater hazards of hospitalization (HR = 1.25 [95% CI: 1.07-1.47]) and increased odds of hepatic- and cardiac-related events (OR = 1.74 [95% CI: 1.10-2.74]). CONCLUSIONS: Chronic pain increased the risk of COVID-19 ED visits and hospitalizations. Presence of OUD further increased the risk of COVID-19 hospitalizations and the odds of hepatic- and cardiac-related events. Results highlight intersecting risks among a vulnerable population and can inform tailored COVID-19 management.

Ultrasound Demonstrates Potential in Identifying Proximal Femoral Morphology Before and After Cam Resection: A Cadaveric Study.

PURPOSE: (1) To compare alpha angles measured on fluoroscopy with those measured on ultrasound pre- and postosteoplasty and (2) to determine whether ultrasound can adequately assess cam deformity correction. METHODS: Twelve full-body specimens (20 hips) were analyzed. Images using fluoroscopy and ultrasound were captured of the operative hip with the hip in 6 consistent positions: 3 views in hip extension (neutral [N], 30° internal rotation [IR], and 30° external rotation [ER]) and 3 views in hip flexion of 50° (neutral [F-N], 40° external rotation [F-ER40], and 60° external rotation [F-ER60]). A curved-array ultrasound transducer probe was used with the transducer placed in line with the femoral neck to evaluate the proximal femoral morphology. An open femoral osteoplasty using an anterior approach was performed. Fluoroscopy and ultrasound were again used to capture images with the hip in the same 6 positions. Bland-Altman plots were used to determine whether fluoroscopic and ultrasound alpha angles agreed at each position. Independent t-tests were used to compare the alpha angles between the 2 modalities at each position, and paired t-tests were used to compare preoperative and postoperative alpha angles at each position. RESULTS: No significant differences between the alpha angle on fluoroscopy and ultrasound at all 6 positions were appreciated preosteoplasty. The mean preoperative alpha angle on ultrasound in each position was as follows: N (55.4° ± 5.9° vs 43.0° ± 2.1°), IR (55.1° ± 5.3° vs 43.9° ± 5.5°), ER (58.6° ± 5.6° vs 42.8° ± 3.0°), F-N (53.9° ± 5.5° vs 41.6° ± 3.3°), F-ER40 (55.5° ± 4.6° vs 41.5° ± 2.7°), and F-ER60 (57.9° ± 6.5° vs 41.2° ± 4.2°). The mean preoperative and postoperative alpha angle on fluoroscopy in each position were as follows: N (56.0 ± 12.8° vs 43.1 ± 2.1°), IR (54.1 ± 13.4° vs 41.9 ± 2.9°), ER (61.2 ± 11.0° vs 44.2 ± 1.9°), F-N (57.9 ± 10.6° vs 44.0 ± 2.3°), F-ER40 (59 ± 8.2° vs 42 ± 2.2°), and F-ER60 (55 ± 7.6° vs 41.1 ± 2.6°). Postosteoplasty, there was no significant difference between the mean alpha angle on fluoroscopy versus ultrasound in any position except F-N (44.0 ± 2.3 vs 41.6 ± 3.3, P = .015). Bland-Altman plots showed a high level of agreement between alpha angle values on fluoroscopy and ultrasound at all positions pre- and postosteoplasty. There was a significant reduction in alpha angle measured on ultrasound and fluoroscopy at each position following osteoplasty. There were no significant differences in the delta of the pre- and postosteoplasty alpha angle measurements between fluoroscopy and ultrasound. CONCLUSIONS: Ultrasound is a useful tool for assessing a cam deformity in patients with femoroacetabular impingement syndrome and for determining adequate resection of a cam deformity intraoperatively. CLINICAL RELEVANCE: Due to the inherent limitations and risks of the fluoroscopy, it is worth evaluating other nonionizing imaging modalities. Ultrasound has potential to be an accessible, cost-effective, and safe imaging modality that lacks radiation and is commonly used for intra-articular hip injections and dynamic examination of the hip.

Lateral meniscus posterior root repair in the setting of anterior cruciate ligament reconstruction restores joint mechanics to the intact state and improves clinical function: a systematic review of biomechanical and clinical outcomes.

PURPOSE: To perform a systematic review of biomechanical and clinical outcomes following lateral meniscus posterior root (LMPR) repair with concomitant anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search was performed systematically using PubMed, Embase, and Medline databases in April 2022. The search included the following terms combined with Boolean operators: 'Meniscus repairs', 'Meniscal Repair', 'Posterior Horn', 'Root', 'Radial'. Inclusion criteria consisted of level I-IV human clinical and biomechanical studies reporting biomechanical data and/or outcomes following LMPR repair in the setting of ACLR. RESULTS: Three biomechanical studies, all utilizing a transtibial pullout technique, were identified, all of which reported significant improvement in joint contact pressures and mechanics and 3/4 of which reported significant improvement in anterior or rotational stability with LMPR repair. Five clinical studies, consisting of 146 patients (mean age 28.5 ± 1.1 years) undergoing LMPR repair, were identified with an average follow-up of 19.1 months (range 6.2-46 months). Across all clinical studies, Lysholm and International Knee Documentation Committee (IKDC) scores were found to improve postoperatively, with 3/4 reporting significant improvement in Lysholm (all, p ≤ 0.001) scores and 3/5 reporting significant improvement in IKDC scores when compared to preoperative values (all, p ≥ 0.004). Meniscal extrusion decreased significantly following repair in 2/4 studies (all, p ≤ 0.001). CONCLUSIONS: Biomechanically, transtibial pullout repair of the LMPR restored joint contact pressures and joint mechanics to intact levels when performed with concomitant ACLR. Clinically, LMPR repair with concurrent ACLR resulted in improved Lysholm and IKDC scores. These findings enable surgeons to determine optimal treatment plans and discuss realistic outcomes with patients when encountering LMPR injuries. LEVEL OF EVIDENCE: IV.

Evaluation of the Latent Tuberculosis Care Cascade Among Public Health Clinics in the United States.

BACKGROUND: Tuberculosis (TB) elimination within the United States will require scaling up TB preventive services. Many public health departments offer care for latent tuberculosis infection (LTBI), although gaps in the LTBI care cascade are not well quantified. An understanding of these gaps will be required to design targeted public health interventions. METHODS: We conducted a cohort study through the Tuberculosis Epidemiologic Studies Consortium (TBESC) within 15 local health department (LHD) TB clinics across the United States. Data were abstracted on individuals receiving LTBI care during 2016-2017 through chart review. Our primary objective was to quantify the LTBI care cascade, beginning with LTBI testing and extending through treatment completion. RESULTS: Among 23 885 participants tested by LHDs, 46% (11 009) were male with a median age of 31 (interquartile range [IQR] 20-46). A median of 35% of participants were US-born at each site (IQR 11-78). Overall, 16 689 (70%) received a tuberculin skin test (TST), 6993 (29%) received a Quantiferon (QFT), and 1934 (8%) received a T-SPOT.TB; 5% (1190) had more than one test. Among those tested, 2877 (12%) had at least one positive test result (3% among US-born, and 23% among non-US-born, P < .01). Of 2515 (11%) of the total participants diagnosed with LTBI, 1073 (42%) initiated therapy, of whom 817 (76%) completed treatment (32% of those with LTBI diagnosis). CONCLUSIONS: Significant gaps were identified along the LTBI care cascade, with less than half of individuals diagnosed with LTBI initiating therapy. Further research is needed to better characterize the factors impeding LTBI diagnosis, treatment initiation, and treatment completion.

Tuberculosis treatment adherence in the era of COVID-19.

BACKGROUND: In-person directly observed therapy (DOT) is commonly used for tuberculosis (TB) treatment monitoring in the US, with increasing usage of video-DOT (vDOT). We evaluated the impact of COVID-19 on TB treatment adherence, and utilization and effectiveness of vDOT. METHODS: We abstracted routinely collected data on individuals treated for TB disease in Baltimore, Maryland between April 2019 and April 2021. Our primary outcomes were to assess vDOT utilization and treatment adherence, defined as the proportion of prescribed doses (7 days/week) verified by observation (in-person versus video-DOT), comparing individuals in the pre-COVID and COVID (April 2020) periods. RESULTS: Among 52 individuals with TB disease, 24 (46%) received treatment during the COVID-19 pandemic. vDOT utilization significantly increased in the COVID period (18/24[75%]) compared to pre-COVID (12/28[43%], p = 0.02). Overall, median verified adherence was similar pre-COVID and COVID periods (65% versus 68%, respectively, p = 0.96). Adherence was significantly higher overall when using vDOT (median 86% [IQR 70-98%]) compared to DOT (median 59% [IQR 55-64%], p < 0.01); this improved adherence with vDOT was evident in both the pre-COVID (median 98% vs. 58%, p < 0.01) and COVID period (median 80% vs. 62%, p = 0.01). CONCLUSION: vDOT utilization increased during the COVID period and was more effective than in-person DOT at verifying ingestion of prescribed treatment.

High Rate of Return to Work by 3 Months Following Latarjet for Anterior Shoulder Instability.

PURPOSE: To evaluate the rate and duration of return to work in patients undergoing Latarjet for failed soft-tissue stabilization or glenoid bone loss. METHODS: Consecutive patients undergoing Latarjet from 2005 to 2015 at our institution were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a standardized and validated work questionnaire, Western Ontario Shoulder Instability Index Survey, and a satisfaction survey. RESULTS: Of 89 eligible patients who had Latarjet, 67 patients (75.3%) responded to the questionnaire, of whom 51 patients (76.1%) were employed within 3 years before surgery (mean age: 29.9 ± 11.8 years; mean follow-up: 54.6 ± 11.9 months) and had an average glenoid bone loss of 14.5 ± 6.1%. Fifty patients (98.0%) returned to work by 2.7 ± 3.0 months postoperatively; 45 patients (88.2%) patients returned to the same level of occupational intensity. Those who held sedentary, light, moderate, or heavy intensity occupations returned to their previous occupation at a rate of 100.0%, 93.3%, 90.0%, and 66.7% (P = .2) at a duration of 1.2 ± 1.6 months, 1.8 ± 1.9 months, 3.1 ± 3.5 months, and 6.5 ± 4.1 months (P = .001), respectively. The average postoperative Western Ontario Shoulder Instability Index score was 70.9 ± 34.2. Fifty patients (98.0%) noted at least "a little improvement" in their quality of life following surgery, with 35 patients (68.6%) noting great improvement. Furthermore, 49 patients (96.1%) reported being satisfied with their procedure, with 25 patients (49.0%) reporting being very satisfied. Four patients (7.8%) returned to the operating room, with 1 patient (2.0%) requiring arthroscopic shoulder stabilization. CONCLUSIONS: Approximately 98% of patients who underwent Latarjet returned to work by 2.7 ± 3.0 months postoperatively. Patients with greater-intensity occupations had a longer duration of absence before returning to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations. LEVEL OF EVIDENCE: IV, case series.

Patients Follow 3 Different Rate-of-Recovery Patterns After Anterior Cruciate Ligament Reconstruction Based on International Knee Documentation Committee Score.

PURPOSE: To determine whether subgroups of patients exist based on the rate-of-recovery pattern of International Knee Documentation Committee (IKDC) scores after anterior cruciate ligament reconstruction (ACLR) and to determine clinical predictors for these subgroups. METHODS: Patients who underwent primary or revision ACLR at a single institution from January 2014 to January 2019 were identified. Latent class growth analyses and growth mixture models (GMMs) with 1 to 6 classes were used to identify subgroups of patients based on functional rate-of-recovery patterns by use of preoperative, 1-year postoperative, and 2-year postoperative IKDC scores. RESULTS: A total of 245 patients who underwent ACLR were included in the analysis. A 3-class GMM was chosen as the final model after 6 different models were run. Class 1, showing improvement from preoperatively to 1-year follow-up, with sustained improvement from 1 to 2 years postoperatively, constituted 77.1% of the study population (n = 189), whereas class 2, showing functional improvement between 1- and 2-year follow-up, was the smallest class, constituting 10.2% of the study population (n = 25), and class 3, showing slight improvement at 1-year follow-up, with a subsequent decline in IKDC scores between 1- and 2-year follow-up, constituted 12.7% of the study population (n = 31). Revision surgery (P = .005), a psychiatric history (P = .025), preoperative chronic knee pain (P = .024), and a subsequent knee injury within the follow-up period (P = .011) were the predictors of class 2 and class 3 rate-of-recovery patterns. Patient demographic characteristics, graft type, and concomitant ligament, meniscus, or cartilage injury at the time of surgery were not associated with the different recovery patterns described in this study. CONCLUSIONS: Patients may follow different rate-of-recovery patterns after ACLR. By use of the GMMs, 3 different rate-of-recovery patterns based on IKDC scores were identified. Although most patients follow a more ideal rate-of-recovery pattern, fewer patients may follow less favorable patterns. Revision surgery, a history of psychiatric illness, preoperative chronic knee pain, and a subsequent knee injury within the follow-up period were predictive of less favorable rate-of-recovery patterns. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Cemented vs. uncemented reverse shoulder arthroplasty for proximal humeral fractures: a systematic review and meta-analysis.

BACKGROUND: The purpose of this systematic review was to compare functional outcomes, complications, and revision rates between cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHFs). METHODS: A systematic search was performed in April 2021 within PubMed, Scopus Web of Science, and Cochrane Library databases for clinical studies reporting outcomes of RSA performed for PHF. Included studies were published in English, had a minimum 1-year follow-up, specified whether the humeral stem was cemented (cRSA) or uncemented (ucRSA), and were evidence level I-IV. Data including range of motion (ROM), functional status, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant-Murley score, visual analog scale (VAS) score, tuberosity healing, complications, and reoperations were extracted. DerSimonian-Laird random effects models with subgroup stratification analyses were applied to investigate differences in outcomes between patients with cRSA and ucRSA. RESULTS: A total of 45 studies comprising 1623 patients were included. The overall pooled age was 75.9 ± 3.4 years. At a mean follow-up of 34.6 (range, 12-108) months, there were no significant differences in ROM, VAS score, Constant-Murley score, rate of tuberosity healing, or reoperation rates between the cRSA and ucRSA cohorts. The mean postoperative ASES score in the cRSA cohort (73.9, 95% CI 71.4-76.5) was significantly lower than the ucRSA cohort (82.9, 95% CI 75.9-90.0, P = .013). The incidence of postoperative all-cause complications was significantly lower in the cRSA cohort (5.5%, 95% CI 4.0%-6.9%) compared with the ucRSA cohort (9.7%, 95% CI 4.5%-14.9%, P = .044). CONCLUSION: The use of uncemented humeral stems in RSA for PHF confers similar functional results to the use of cemented stems in terms of pain, range of motion, functional scores, and tuberosity healing. Although the rate of complications was significantly higher in the uncemented cohort compared with the cemented cohort (9.7% vs. 5.5%, respectively), the rate of reoperations was similar between the groups (1.6% vs. 1.9%, respectively). The uncemented reverse prosthesis seems to be a valid alternative for the management of patients with complex proximal humerus fractures.

Predictors of flare-related inpatient or emergency department stay in systemic lupus erythematosus: A real-world analysis of Medicaid claims in the United States.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation. Medical management of SLE is based on reducing inflammation and tissue damage in the affected organs; however, medications used to treat SLE have been found to contribute to additional organ damage. Therefore, finding new ways to predict and prevent flares that require an inpatient (IP) stay or emergency department (ED) visit is critical for reducing the clinical and economic burden in patients with SLE. OBJECTIVE: To identify risk factors of SLE flares requiring an IP/ED visit among a Medicaid-insured population with SLE. METHODS: This retrospective study included patients from the Merative MarketScan Medicaid database (2013-2019). To capture patients at all stages of their SLE journey, all SLE claims for a patient were captured, and the index date was randomly selected among those claims that were at least 12 months after the first evidence of SLE. Patients were required to be continuously enrolled 1-year pre-index (year 1) and post-index (year 2). Demographics, clinical characteristics, and health care use and costs were measured in year 1, and flares requiring an IP/ED visit were identified in year 2 using the Garris algorithm. Multivariable logistic regression and classification and regression tree (CART) modeling were used to identify year 1 predictors and combination of factors, respectively, associated with flares-related IP/ED visits. RESULTS: Of the 8,083 patients included in the study, 37.6% of patients (n = 3,039) had a flare. Logistic regression identified ED visits in year 1 as one of the strongest predictors of flares-related IP/ED visits in year 2 (odds ratio = 2.19 [95% CI = 1.93-2.49]). SLE treatment progression to biologics (0.54 [0.42-0.70]) was the strongest predictor of decreased odds. Other strong predictors included other neurological disorders (1.63 [1.43-1.87]), Black race (1.49 [1.32-1.68]), chronic kidney disease/renal failure (1.35 [1.10-1.66]), and opioid use (1.30 [1.17-1.45]). CART modeling identified patients with an ED visit, an IP admission, and a diagnosis of Elixhauser Comorbidity Index-defined other neurological disorders in year 1 as having the highest probability of a flare-related IP/ED visit in year 2 (probability = 0.708), whereas patients without an ED visit had the lowest probability (probability = 0.185). CONCLUSIONS: Patients with the highest risk of a flare that required an IP/ED visit were those with a prior ED visit, IP admission, and other neurological disorders. Modeling also identified patients with prior opioid use, Black patients, and patients without SLE medications as subgroups with a high risk of a flare requiring an IP/ED visit.

Clinical and economic characterization of mild, moderate, and severe systemic lupus erythematosus: Real-world observation across payer channels in the United States.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting as many as 322,000 people in the United States. Because of heterogeneity in both disease course and clinical manifestations, it is critical to identify a prevalent SLE population that includes patients with moderate or severe disease. Additionally, differences in the clinical and economic burden of SLE may exist across payer channels, yet to date this has not been reported in any previous studies. OBJECTIVE: To characterize the clinical and economic burden of SLE across disease severity and payer channels. METHODS: This retrospective study included patients from Merative MarketScan Commercial, Medicare Supplemental, and Medicaid databases from 2013 to 2020 (Commercial/Medicare) or 2013 to 2019 (Medicaid), with at least 1 inpatient or at least 2 outpatient SLE claims and no invalid steroid claims. The index date was a random SLE claim with at least 12 months of disease history. Patients were continuously enrolled 1 year pre-index (baseline) and 1 year post-index and classified with mild, moderate, or severe disease using a published algorithm. Baseline demographics, clinical characteristics, flares, and utilization/costs were compared across disease severity. RESULTS: 22,385 Commercial, 2,035 Medicare, and 8,083 Medicaid patients had SLE. Most Medicaid patients (51.1%) had severe disease. Comorbidity scores increased with disease severity (P < 0.001). 30.7% of Commercial, 34.1% Medicare, and 51.3% Medicaid patients had opioids, which increased with disease severity (P < 0.001). All-cause costs ranged from 1.8- to 2.3-fold for moderate vs mild and 4.2- to 6.5-fold for severe vs mild. Outpatient medical costs accounted for the highest proportion of all-cause costs, except Medicaid patients with severe disease, for whom inpatient costs were highest. Mean (SD) SLE-related annual costs were $23,030 (43,304) vs $1,738 (4,427) in severe vs mild for Commercial, $12,264 (31,896) vs $2,024 (4,998) for Medicare, and $7,572 (27,719) vs $787 (3,797) for Medicaid (P < 0.001). For patients with severe disease in Medicaid, 16.5% and 60.1% had inpatient and emergency department (ED) visits, respectively, vs 10.3% and 26.5% Commercial vs 10.6% and 24.6% Medicare. Mean [SD] flares per year in the baseline period increased from 2.5 [1.7] in mild to 4.6 [1.9] in severe for Commercial, 3.2 [1.9] to 5.0 [2.1] for Medicare, and 2.0 [1.6] to 4.5 [2.0] for Medicaid. CONCLUSIONS: Patients with severe SLE experienced more comorbidities, flares, and utilization/costs. Outpatient costs were the largest driver of all-cause costs for Commercial and Medicare (and Medicaid for mild to moderate SLE). Medicaid beneficiaries had the highest rate of severe SLE, highest use of ED and inpatient services, and highest oral corticosteroid and opioid use but the lowest utilization of disease-modifying treatments. Results demonstrate an unmet need in SLE treatment, especially among patients with moderate to severe disease or Medicaid coverage. DISCLOSURES: This study was funded by AstraZeneca. Drs Wu and Bryant are current employees of AstraZeneca and may own stock and/or options. At the time of the study, Ms Perry and Mr Tkacz were employed by IBM Watson Health, which received funding from AstraZeneca to conduct this study.

Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes.

BACKGROUND: Medial meniscus posterior root (MMPR) injuries accelerate the progression of osteoarthritis. While partial meniscectomy was once considered the gold standard for treatment, meniscus root repair has become increasingly utilized with reported improvements in clinical and biomechanical outcomes. PURPOSE: To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical and radiographic outcomes after MMPR repair. STUDY DESIGN: Meta-analysis and systematic review; Level of evidence, 4. METHODS: The PubMed, Embase, and Cochrane databases were queried in August 2021 for studies reporting biomechanical, clinical, and radiographic outcomes after MMPR repair. Biomechanical studies were assessed for main results and conclusions. Data including study characteristics, cohort demographics, and outcomes were extracted. Included clinical studies were analyzed with a random-effects meta-analysis of proportions for binary outcomes or continuous outcomes for mean differences between preoperative and postoperative time points. Subgroup analysis for studies reporting repair outcomes with concomitant high tibial osteotomy (HTO) was performed where appropriate. RESULTS: A total of 13 biomechanical studies were identified and reported an overall improvement in mean and peak contact pressures after MMPR repair. There were 24 clinical studies, consisting of 876 patients (877 knees), identified, with 3 studies (106 knees) reporting outcomes with concomitant HTO. The mean patient age was 57.1 years (range, 23-74 years), with a mean follow-up of 27.7 months (range, 2-64 months). Overall, clinical outcomes (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee injury and Osteoarthritis Outcome Score scores) were noted to improve postoperatively compared with preoperatively, with improved Lysholm scores in patients undergoing concomitant HTO versus MMPR repair alone. Meniscal extrusion was not significantly improved after MMPR repair compared with preoperative measurements. The progression in Kellgren-Lawrence grades from grade 0 to grades 1 to 3 occurred in 5.9% (21/354) of patients after repair, with no patients progressing from grades 1 to 3 to grade 4. CONCLUSION: MMPR repair generally improved biomechanical outcomes and led to improved patient-reported outcomes with greater improvements noted in patients undergoing concomitant HTO. Repair did not significantly improve meniscal extrusion, while only 5.9% of patients were noted to progress to low-grade osteoarthritis. The high level of heterogeneity in the included biomechanical and clinical investigations emphasizes the need for more well-designed studies that evaluate outcomes after MMPR repair.

Utilization and disparities in medication treatment for opioid use disorder among patients with comorbid opioid use disorder and chronic pain during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear. METHODS: We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity. RESULTS: Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (ß=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (ß=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (ß=-0.007 [-0.012, -0.002]) and Hispanic individuals (ß=-0.010 [-0.019, -0.001]). CONCLUSIONS: Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups.

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures.

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.

Treatment Modality of Distal Ulnar Head and Neck Fractures Associated With Operatively Treated Distal Radius Fractures Does Not Affect Outcomes.

Background: This study compares the functional outcomes and complications between operatively and nonoperatively treated distal ulnar head and neck fractures associated with internal fixation of concomitant distal radius fractures. Methods: A 7-year retrospective chart review was performed to identify patients with operatively treated distal radius fractures associated with distal ulnar head and neck fractures. Ulnar styloid fractures were excluded. Fifty-eight patients who had a minimum of 6 months of follow-up were identified. Patients were divided into 3 treatment groups: nonoperative, open reduction internal fixation (ORIF), and distal ulna resection. Reviewed data included demographics, injury and treatment details, complications, and patient-reported outcome measures. Outcomes measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE) surveys. Due to inadequate power, 5 patients treated with distal ulna resection were excluded from statistical analysis. Results: The average patient age was 56 years, with an average follow-up of 27 months. All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF in 28 patients, and with distal ulna resection in 5 patients. There were no statistically significant differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores between ORIF and nonoperative treatment. Conclusion: No differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores were observed between ORIF and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures.

Tuberculosis treatment adherence in the era of COVID-19.

BACKGROUND In-person directly observed therapy (DOT) is commonly used for tuberculosis (TB) treatment monitoring in the US, with increasing usage of video-DOT (vDOT). We evaluated the impact of COVID-19 on TB treatment adherence, and utilization and effectiveness of vDOT. METHODS We abstracted routinely collected data on individuals treated for TB disease in Baltimore, Maryland between April 2019 and April 2021. Our primary outcomes were to assess vDOT utilization and treatment adherence, defined as the proportion of prescribed doses (7 days/week) verified by observation (in-person versus video-DOT), comparing individuals in the pre- and post-COVID (April 2020) periods. RESULTS Among 52 individuals with TB disease, 24 (46%) received treatment during the COVID-19 pandemic. vDOT utilization significantly increased post-COVID (18/24[75%]) compared to pre-COVID (12/28[43%], p=0.02). Overall, median verified adherence was similar pre- and post-COVID (65% versus 68%, respectively, p=0.96). Adherence was significantly higher overall when using vDOT (median 86% [IQR 70-98%]) compared to DOT (median 59% [IQR 55%-64%], p<0.01); this improved adherence with vDOT was evident in both the pre-COVID (median 98% vs 58%, p<0.01) and post-COVID period (median 80% vs 62%, p=0.01). CONCLUSION vDOT utilization increased post-COVID and was more effective than in-person DOT at verifying ingestion of prescribed treatment.

Treatment Patterns for Calcitonin Gene-Related Peptide Monoclonal Antibodies Including Galcanezumab versus Conventional Preventive Treatments for Migraine: A Retrospective US Claims Study.

Background: Most conventional, oral, preventive treatments for migraine are non-specific and ~50% of patients discontinue them within six months. In 2018, the Food and Drug Administration approved three preventive migraine treatments: monoclonal antibodies (mAb) targeting the calcitonin gene-related peptide (CGRP) pathway implicated in migraine; galcanezumab and fremanezumab which target CGRP ligand; and erenumab which targets CGRP receptor. Real-world treatment patterns for CGRP mAb are limited. Purpose: To compare real-world treatment patterns for CGRP mAb, specifically galcanezumab versus standard-of-care (SOC) migraine preventive treatments. Patients and methods: This retrospective, observational study included 12-month baseline and 6- and 12-month follow-up analyses using IBM® MarketScan® databases. Patients identified were aged ≥18 years with ≥1 claim (first claim=index) for CGRP mAb (erenumab, fremanezumab, or galcanezumab) or SOC preventives (eg, antiepileptics, beta-blockers, antidepressants, or onabotulinumtoxinA) as index drugs between May/01/2018 and June/30/2019. Propensity score matching was used to address confounding by observed covariates. Outcomes analyzed included proportion of days covered (PDC), persistence (≤60-day gap), and first non-index drug switch. Descriptive, chi-square (categorical), and t-test (continuous) analyses were conducted. Results: The study included 3082 (CGRP mAb versus SOC) and 421 (galcanezumab versus SOC) matched patient pairs with 12-month follow-up. Mean age across cohorts ranged 43.2-44.4 years (females: 85.7-88.6%). Compared with SOC, the CGRP mAb cohort had higher mean persistence (212.5 vs 131.9 days), adherence (PDC: 55.1% vs 35.2%), and more patients were adherent with PDC ≥80% (32.7% vs 18.7%) (all p <0.001). During 12-month follow-up, fewer patients discontinued CGRP mAb versus SOC (58.8% vs 77.6%, p <0.001). Galcanezumab versus SOC comparisons yielded similar results. In the CGRP mAb cohort, most switchers (28.3%) used galcanezumab as subsequent treatment. Largely similar results were observed for 6-month follow-up cohorts. Conclusion: Patients on CGRP mAb and specifically galcanezumab showed higher adherence and persistence than patients on SOC migraine preventive treatments.

Health care resource utilization and costs associated with treatment among patients initiating calcitonin gene-related peptide inhibitors vs other preventive migraine treatments in the United States.

BACKGROUND: Limited data are available on health care resource utilization (HCRU) and health care costs of calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) for preventive treatment of migraine. OBJECTIVE: To compare all-cause and migraine-related HCRU and direct health care costs in patients with migraine initiating CGRP mAbs, galcanezumab (GMB), vs standard-of-care (SOC) preventive treatments in the United States. METHODS: This retrospective observational study used insurance claims data collected from IBM MarketScan Research Databases. Adults (aged ≥ 18 years) with 1 or more claims for CGRP mAb (GMB, erenumab, or fremanezumab) or SOC preventive treatment between May 1, 2018, and June 30, 2019, were included. The date of earliest migraine treatment claim during this period was the index date. Annual all-cause and migraine-related HCRU included inpatient visits, emergency department visits, and acute and preventive migraine medication fills. After matching, HCRU and costs at 6- and 12-month follow-up in CGRP mAb, specifically GMB, vs SOC cohorts were analyzed using paired t-test and chi-square test. RESULTS: In the 12-month follow-up study, 4,528 patients using CGRP mAb (GMB, n = 426) and 10,897 patients using SOC were included. After matching, 3,082 pairs were identified in the CGRP mAb and SOC cohorts and 421 pairs in the GMB and SOC cohorts. After matching, all variables were well balanced across cohorts. At 12-month follow-up, the percentage decrease in acute and preventive migraine medication fills was significantly greater in the CGRP mAb (acute: -1.5% vs -0.2%, P < 0.001; preventive: -1.1% vs 3.8, P < 0.001) and GMB cohorts (acute: -1.5% vs -0.2%, P = 0.002; preventive: -1.8 vs 3.0, P < 0.001) compared with the SOC cohort. At follow-up, compared with the SOC cohort, the mean change of annual all-cause total costs was significantly higher in both the CGRP mAb ($6,043 vs $1,323, P < 0.001) and GMB cohorts ($8,398 vs $68, P < 0.001), and the mean change of annual migraine-related total costs was significantly higher in both the CGRP mAb ($3,416 vs $976, P < 0.001) and GMB cohorts ($4,334 vs $1,245, P < 0.001). Significant cost savings in mean acute and preventive migraine prescription costs occurred in both the CGRP mAb (acute: -$358 vs -$80, P < 0.001; preventive: -$298 vs $1,376, P < 0.001) and GMB cohorts (acute: -$280 vs -$36, P = 0.034; preventive: -$374 vs $1,537, P < 0.001) compared with the SOC cohort. CONCLUSIONS: Although treatment with CGRP mAbs and GMB increase total costs, they may lead to significantly greater cost savings in outpatient acute and preventive migraine medication costs vs SOC. Further studies assessing indirect health care costs are important to understand additional cost savings with CGRP mAbs. DISCLOSURES: Drs Varnado, Ye, and Schuh are employees and stockholders of Eli Lilly and Company. Dr Wenzel is a former employee of Eli Lilly and Company. Dr Manjelievskaia is an employee of IBM Watson Health. Ms Perry is a former employee of IBM Watson Health. This study was sponsored by Eli Lilly and Company. IBM Watson Health received funding for this study from Eli Lilly and Company. Independent analyses were conducted by IBM Watson Health. Eli Lilly and Company and IBM Watson Health collaborated on designing the study and interpreting results.

Patellar Instability.

➢: Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. ➢: The presence of a preoperative J-sign is predictive of recurrent instability after operative management. ➢: Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. ➢: More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.