Patient Satisfaction with Postoperative Telemedicine Versus In-Office Visits Following Primary Hip Arthroscopy: A Prospective Observational Study Before and During the COVID-19 Pandemic.

Abstract Background: The purpose of this study was to compare satisfaction with postoperative telemedicine visits versus in-office visits among patients undergoing primary hip arthroscopy. Methods: A prospective cohort study was conducted involving subjects ≥18 years old undergoing primary hip arthroscopy at a single center from January 2020 to February 2021. Subjects chose between a telemedicine or in-office visit for 6-week follow-up. Patient satisfaction after the 6-week visit was assessed using an electronic survey. The primary outcome was satisfaction on a scale from 0 to 10. Intergroup comparisons of outcomes were performed using Student's t-test, Mann-Whitney U test, or Fisher's exact test. p-Values <0.05 were considered significant. Results: Seventy-five patients (28M and 47F) were enrolled in the study with mean age 41.2 ± 12.7 years. Forty-four patients (58.7%) attended in-office visits and 31 (41.3%) attended telemedicine visits. There were no significant intergroup differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) classification (p > 0.05). There were no significant intergroup differences in satisfaction with overall care (in-office 9.6 vs. telemedicine 9.3, p = 0.08) or the 6-week visit (in-office 9.0 vs. telemedicine 8.0, p = 0.06). The telemedicine group more frequently reported visits taking <20 min (p = 0.002) and spending >10 min with their surgeon (p = 0.01). However, 51.6% of the telemedicine group and 74.7% of the entire cohort expressed a retrospective preference for in-office visits. Conclusions: There were no significant differences in satisfaction scores between hip arthroscopy patients assigned to telemedicine versus in-office visits for 6-week follow-up, but most patients expressed a preference for in-office visits.

Anterior Shoulder Instability Evolution of Principles and Surgical Treatment.

Anterior shoulder instability has been a common shoulder problem since the earliest of human civilizations. Over the course of thousands of years, our understanding regarding shoulder instability and treatment options have evolved tremendously. Specifically, over the past several decades we have seen a gradual but substantial development in our understanding of the natural history of anterior shoulder instability with and without surgical treatment. There is increasing recognition and improved understanding of the role of bone loss in the pathophysiology of shoulder instability, with ongoing emphasis on restoring native anatomy with minimally invasive techniques. The rich history of successes and failures of past surgical procedures forms the basis of the many innovative surgical techniques currently used, including both bony and soft tissue procedures. The purpose of this review is to highlight some of the most influential and important breakthroughs in the evolution of our understanding and management of anterior shoulder instability.

Outcomes of Endoscopic Treatment for Plantar Fasciitis: A Systematic Review.

BACKGROUND: Endoscopic plantar fascia release (EPFR) is an established operative treatment for recalcitrant plantar fasciitis. The purpose of this systematic review is to provide a comprehensive review on the outcomes of EPFR in the treatment of plantar fasciitis at mid-term and long-term follow-up. METHODS: A systematic review was performed using, MEDLINE, EMBASE, and Cochrane library databases in May 2020 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were evaluated regarding level of evidence (LOE) and quality of evidence (QOE) using the modified Coleman methodological score. Clinical outcomes and complications were also evaluated. RESULTS: Twenty-six studies including 978 feet were included in this systematic review with a weighted mean follow-up of 25.6 ± 21.0 months. Eighteen papers used the American Orthopaedic Foot and Ankle Society (AOFAS) score. The weighted mean preoperative AOFAS score was 55.66 ± 10.3, and the postoperative score was 89.6 ± 5.2 out of 100. The total number of patients who had complications was 88 of 994 (8.9%). The most common complication was recurrence of pain experienced by 41 patients (4.2%). CONCLUSION: Endoscopic plantar fascia release provides good clinical and functional outcomes in patients with refractory plantar fasciitis. However, this procedure is associated with a moderately high complication rate (8.9%) and should only be considered following failure of conservative management. Future prospective studies comparing the various endoscopic and open techniques with nonoperative treatment are required to elucidate the most effective management for recalcitrant plantar fasciitis. LEVELS OF EVIDENCE: Level I: Systematic review of level IV studies.

Return to Work and Sport Following Tibial Tubercle Anteromedialization.

BACKGROUND: Tibial tubercle anteromedialization (AMZ) is a commonly performed procedure for patients with patellofemoral instability or patellofemoral osteochondral disease. While prior studies have demonstrated that this form of osteotomy produces generally good outcomes, the time needed for return to work and return to sport remains unclear. This study aimed to determine the mean length of time before return to work and the rate of return to sport following AMZ. PATIENTS AND METHODS: Patients who had undergone AMZ for either patellofemoral instability or isolated osteochon- dral defect with a minimum follow-up time of 1 year were identified. Patients less than 18 years of age were excluded. Patients were asked to complete a series of patient reported outcomes surveys including specific queries regarding their return to work and return to athletic activity. RESULTS: A total of 109 patients were included in this study. The majority were female (79 patients, 72.3%). The mean age was 30.74 ± 9.90 years at the time of surgery. The mean follow-up duration was 3.40 ± 1.97 years. Of the 109 patients, 104 (95.4%) had returned to work at the time of follow-up. Mean time to return to work was 2.96 ± 3.33 months (range: 0.25 to 24 months). Of the 90 patients who were involved in a sport or physical activity prior to injury, 64 patients (71.1%) had returned to sport at some level at the time of most recent follow-up. Of those who had returned to sport, mean time to return to sport was 9.21 ± 5.46 months (range: 1 to 24 months). CONCLUSIONS: At a minimum follow-up time of 1 year, patients who underwent AMZ were found to have a return to sport rate of 71% with a mean time of 9.21 months to return to athletic activity. Over 95% of AMZ patients had returned to work by 1 year after the procedure. Patients required an average of 3 months to return to work, although those with physically demanding jobs required slightly more time. Data from the current study is useful in setting expectations for patients undergoing tibial tubercle anteromedialization for patellofemoral instability or patellofemoral osteochondral disease.

There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction.

PURPOSE: The purpose of the current study is to systematically review and network meta-analyze the current evidence in the literature to ascertain if there is a superior lateral extra-articular augmentation technique in conjunction with anterior cruciate ligament (ACL) reconstruction (ACL.R) with respect to knee stability, re-rupture rates and functional outcomes. METHODS: The literature search was performed based on the PRISMA guidelines. Cohort studies comparing ACL.R to ACL.R + lateral extra-articular augmentation were included. Lateral extra-articular techniques included were anterolateral ligament reconstruction (ALL.R), Cocker-Arnold, Lemaire, Losee, Maraccaci, and McIntosh. Clinical outcomes were compared between ACL.R alone and the different lateral extra-articular augmentation techniques using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score. RESULTS: Twenty-eight studies with a total of 2990 patients were included. ACL.R + Cocker-Arnold technique had the highest P-Score for ACL re-ruptures and residual pivot-shift. ACL.R + Cocker-Arnold, Lemaire, and ALL.R all significantly reduced the rate of ACL re-rupture, and residual pivot-shift, compared to ACL.R alone. There was no significant difference between any of the lateral extra-articular augmentation techniques and ACL.R alone. ALL.R had the highest P-Score for return to play, and return to play at pre-injury level. CONCLUSION: This study established that ACL.R + Cocker-Arnold, Lemaire and ALL.R resulted in significantly lower ipsilateral ACL re-ruptures, as well as reduced pivot-shift, compared to ACL.R alone. Whereas, the other lateral extra-articular augmentation techniques did not reduce pivot-shift and re-rupture. Additionally, functional outcomes and return to play were comparable between those who underwent ACL.R and lateral extra-articular augmentation and ACL.R alone. LEVEL OF EVIDENCE: III.

Day-of-Surgery Video Calls and Phone Calls Increase Patient Satisfaction with Outpatient Surgery Experience: A Randomized Controlled Trial of Postoperative Communication Modalities.

BACKGROUND: With the increasing utilization of patient satisfaction as a metric for clinical care, there is growing interest in techniques that can be used to improve satisfaction in patients undergoing surgery. The purpose of this trial was to assess the impact of day-of-surgery video and phone calls on patient satisfaction. METHODS: We enrolled 251 patients undergoing outpatient orthopaedic surgery with 3 participating surgeons. Surgeons were randomized to 1 of 3 patient communication modalities: no contact (standard of care), phone call, or video call. Several hours following discharge on the day of surgery, the surgeons contacted patients according to their assigned treatment group. At the initial postoperative office visit, satisfaction outcomes were assessed using the Consumer Assessment of Healthcare Providers and Systems Surgical Care (S-CAHPS) survey and an additional satisfaction questionnaire. RESULTS: Fifty-nine (97%) of 61 patients in the no-contact group, 118 (99%) of 119 patients in the phone group, and 71 (100%) of 71 patients in the video group completed follow-up assessment. The S-CAHPS top-box response rate in both the video group (0.86 ± 0.14, p < 0.001) and the phone group (0.84 ± 0.17, p < 0.001) was greater than in the no-contact group (0.68 ± 0.26). When asked to rate satisfaction with overall care, a greater proportion of patients in the video group (85.9%) gave the top-box response compared with both the phone group (71.8%, p = 0.040) and the no-contact group (60.7%, p = 0.002). Among the patients in the video group, 62.0% indicated that they would prefer a video call in future encounters with their surgeon compared with 1.8% of patients in the no-contact group (p < 0.001) and 1.7% of patients in the phone group (p < 0.001). CONCLUSIONS: Phone and video calls following discharge are an effective way of enhancing patient satisfaction with the clinical care experience as measured by the S-CAHPS survey. In terms of satisfaction with overall care, video calls may be superior to phone calls. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Soothing the heart with music: A feasibility study of a bedside music therapy intervention for critically ill patients in an urban hospital setting.

OBJECTIVES: Music therapy has been shown to be effective for reducing anxiety and pain in people with a serious illness. Few studies have investigated the feasibility of integrating music therapy into general inpatient care of the seriously ill, including the care of diverse, multiethnic patients. This leaves a deficit in knowledge for intervention planning. This study investigated the feasibility and effectiveness of introducing music therapy for patients on 4 inpatient units in a large urban medical center. Capacitated and incapacitated patients on palliative care, transplantation, medical intensive care, and general medicine units received a single bedside session led by a music therapist. METHODS: A mixed-methods, pre-post design was used to assess clinical indicators and the acceptability and feasibility of the intervention. Multiple regression modeling was used to evaluate the effect of music therapy on anxiety, pain, pulse, and respiratory rate. Process evaluation data and qualitative analysis of observational data recorded by the music therapists were used to assess the feasibility of providing music therapy on the units and patients' interest, receptivity, and satisfaction. RESULTS: Music therapy was delivered to 150 patients over a 6-month period. Controlling for gender, age, and session length, regression modeling showed that patients reported reduced anxiety post-session. Music therapy was found to be an accessible and adaptable intervention, with patients expressing high interest, receptivity, and satisfaction. SIGNIFICANCE OF RESULTS: This study found it feasible and effective to introduce bedside music therapy for seriously ill patients in a large urban medical center. Lessons learned and recommendations for future investigation are discussed.

Arthroscopic Anterior Talofibular Ligament Repair with Use of a 2-Portal Technique.

Ankle sprains are common musculoskeletal injuries, with approximately 27,000 occurring every day in the U.S. alone. The anterior talofibular ligament (ATFL) is the most commonly injured ligament. Although most acute lateral ankle sprains can be treated conservatively, up to 20% of these injuries result in chronic lateral ankle instability and may require surgical stabilization. Recently, an arthroscopic lateral ankle ligament repair technique has become increasingly popular. This minimally invasive procedure is expected to reduce postoperative pain and promote faster recovery. The current article presents an ATFL repair using a 2-portal, non-distraction arthroscopic technique. Chronic lateral ankle instability refractory to physical therapy for 3 to 6 months is the main indication for surgical treatment, and sufficient quality of ligament tissue remnant is required for arthroscopic repair. Compared with an open procedure, equivalent clinical results and earlier recovery following arthroscopic ATFL repair have been reported. The major steps of the procedure, demonstrated in this video article, are (1) placement of portals for the arthroscopic procedure, (2) suture anchor insertion into the distal aspect of the fibula, (3) needle insertion into the ATFL remnant, (4) a lasso-loop stitch using a suture relay technique, (5) reattachment of the ATFL remnant, and (6) postoperative protocol. Complications are rare, and earlier return to daily activities compared with a standard open technique can be achieved.

Bone Marrow-Derived Mesenchymal Stromal Cells Enhanced by Platelet-Rich Plasma Maintain Adhesion to Scaffolds in Arthroscopic Simulation.

PURPOSE: To assess the response of bone marrow-derived mesenchymal stromal cells (bMSCs) enhanced by platelet-rich plasma (PRP) in the setting of a normal human tendon (NHT), a demineralized bone matrix (DBM), and a fibrin scaffold (FS) with simulated arthroscopic mechanical washout stress. METHODS: Bone marrow was aspirated from the humeral head and concentrated. BMSCs were counted, plated, and grown to confluence. Cells were seeded onto 3 different scaffolds: (1) NHT, (2) DBM, and (3) FS. Each scaffold was treated with a combination of (+)/(-) PRP and (+)/(-) arthroscopic washout simulation. A period of 60 minutes was allotted before arthroscopic washout. Adhesion, proliferation, and differentiation assays were performed to assess cellular activity in each condition. RESULTS: Significant differences were seen in mesenchymal stromal cell adhesion, proliferation, and differentiation among the scaffolds. DBM and FS showed superior results to NHT for cell adhesion, proliferation, and differentiation. PRP significantly enhanced cellular adhesion, proliferation, and differentiation. Arthroscopic simulation did not significantly decrease bMSC adhesion. CONCLUSIONS: We found that the type of scaffold impacts bMSCs' behavior. Both scaffolds (DBM and FS) were superior to NHT. The use of an arthroscopic simulator did not significantly decrease the adhesion of bMSCs to the scaffolds nor did it decrease their biologic differentiation potential. In addition, PRP enhanced cellular adhesion, proliferation, and differentiation. CLINICAL RELEVANCE: Improved healing after tendon repair can lead to better clinical outcomes. BMSCs are attractive for enhancing healing given their accessibility and regenerative potential. Application of bMSCs using scaffolds as cell carriers relies on arthroscopic feasibility.

The Influence of Trocar Fenestration and Volume on Connective Tissue Progenitor Cells (Stem Cells) in Arthroscopic Bone Marrow Aspiration From the Proximal Humerus.

PURPOSE: To evaluate the number of connective tissue progenitor cells (CTPs) and nucleated cells obtained during bone marrow aspiration (BMA) from the proximal humerus using either a fenestrated or a nonfenestrated trocar and determine differences in varying amounts of aspiration volume. The first hypothesis was that the number of CTPs extracted with the fenestrated trocar would be greater due to its potential to extract more cells through its fenestrations. The second hypothesis was that using consecutive aspirations with either trocar would provide a consistent number of CTPs and nucleated cells throughout the aspiration with no significant decrease of cells at the end. METHODS: Patients were eligible for inclusion if they underwent primary or revision arthroscopic rotator cuff surgery, were between 18 and 75 years of age, and signed the informed consent. Between January 2011 and September 2013, 24 patients underwent BMA from the proximal humerus during arthroscopic surgery. They were grouped according to which of 3 different trocars were used for aspiration: (1) nonfenestrated, (2) fenestrated trocar A, and (3) fenestrated trocar H. Four consecutive 12 mL double syringes were used for each aspiration: 1 (0-12 mL), 2 (12-24 mL), 3 (24-36 mL), and 4 (36-48 mL). One milliliter was removed from each syringe (nonconcentrated BMA). The remainder of the BMA was then spun using a centrifuge. BMA and concentrated BMA were brought to the laboratory, counted for nucleated cells (million cells/mL BMA) and cultured for 7 days to obtain colony-forming units (CTPs/million cells). RESULTS: No significant differences were observed in tubes 1 to 4 in the number of nucleated cells in the nonconcentrated and concentrated BMA using the nonfenestrated trocar compared with the fenestrated trocars A and H (all P > .05), except for concentrated BMA tube 3 (P = .014) and tube 4 (P = .003). Nonconcentrated and concentrated BMA from tubes 1 to 4 had a significantly higher CTP prevalence using the nonfenestrated trocar compared with the fenestrated trocars A and H (all P < .05). Most of the times the first tube of each aspiration showed a significantly greater amount of cells and a greater CTP prevalence compared with tubes 2, 3, and 4. CONCLUSIONS: Aspiration from the proximal humerus with the nonfenestrated trocar during BMA was associated with higher prevalence of CTPs, suggesting that more CTPs can be obtained using a nonfenestrated trocar. Furthermore, CTPs can be obtained through all consecutive aspirations with a greater amount in the first tubes. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Stem cell procedures in arthroscopic surgery.

The stem cell as the building block necessary for tissue reparation and homeostasis plays a major role in regenerative medicine. Their unique property of being pluripotent, able to control immune process and even secrete a whole army of anabolic mediators, draws interest. While new arthroscopic procedures and techniques involving stem cells have been established over the last decade with improved outcomes, failures and dissatisfaction still occur. Therefore, there is increasing interest in ways to improve the healing response. MSCs are particularly promising for this task given their regenerative potential. While methods of isolating those cells are no longer poses a challenge, the best way of application is not clear. Several experiments in the realm of basic science and animal models have recently been published, addressing this issue, yet the application in clinical practice has lagged. This review provides an overview addressing the current standing of MSCs in the field of arthroscopic surgery.

Extracellular Matrix of Current Biological Scaffolds Promotes the Differentiation Potential of Mesenchymal Stem Cells.

PURPOSE: The purpose of this study was to quantitatively assess the ability of bone marrow-derived mesenchymal stem cells (bMSC) to differentiate toward bone, fat, cartilage, and tendon lineages when grown on commercially available scaffolds compared with control and native tendon tissue. METHODS: BMSCs were cultured and analyzed by fluorescent automated cells sorting for surface markers CD73, -90, and -105. BMSCs were grown on rotator cuff tendon (RCT), decellularized human dermis patch (DDP), bilayer collagen matrix, and fibrin matrix (FM) to test their differentiation potential using quantitative polymerase chain reaction and establish markers for osteogenic, adipogenic, chondrogenic, and tenogenic lineages. Immunocytochemical testing was used to determine the specific proteins present on the scaffolds. RESULTS: Alkaline phosphatase and osteocalcin gene expression was significantly higher on RCT (P < .001) and collagen scaffold (CS) (P < .001) compared with DDP and FM scaffolds (P < .001, P < .001). When differentiated toward a cartilage lineage, bMSCs grown on CS had significantly more type II collagen and aggrecan compared with DDP (P < .001, P < .001), FM (P < .001, P < .001), and RCT (P < .001, P < .001). Differentiated bMSCs grown on the CS had a significant increase in PPARγ and FABP4 gene expression compared with bMSCs grown on all other scaffolds (all P < .001). The differentiation of bMSCs into tendon on CSs had significantly more tenacin C, decorin, and type III collagen gene expression when compared with RCT, DDP, and FM (all P < .001). Decorin gene expression in the control undifferentiated CS was also significantly increased, suggesting that the matrix alone may promote a tenogenic lineage (P = .637). CONCLUSIONS: Differences in the extracellular matrix composition of scaffolds significantly impact their potential to promote differentiation of bMSCs. Comparing the native RCT to the tested scaffolds showed that a high content of type I and III collagen significantly increased the potential of bMSCs to differentiate toward bone, tendon, fat, and cartilage lineages. CLINICAL RELEVANCE: This in vitro study shows the differences between commercially available scaffolds for rotator cuff repairs. Therefore, these results support clinical use depending on the surgical intention and the potential of bMSCs to differentiate into bone, tendon, cartilage, and fat tissue.