The Impact of Social Deprivation on Rotator Cuff Repair Outcomes.

BACKGROUND: Rotator cuff tears are a common orthopedic injury and the role of social determinants of health (SDoH) in surgical outcomes remains underexplored. The goal of this study was to investigate the correlation between social deprivation, measured by the Area Deprivation Index (ADI), and outcomes following arthroscopic rotator cuff repair. METHODS: We conducted a retrospective chart review on patients undergoing primary arthroscopic rotator cuff repair at a level one academic center between 2006 and 2019. Patient demographics (age, gender, race), comorbidities, ADI scores, range of motion, visual analog pain scores, and patient-reported outcomes (SST, ASES, and QuickDASH) were collected. Patients were stratified into terciles based on their relative level of deprivation. Statistical analysis was performed using ANOVA, t-tests, chi-square tests, and univariate/multivariate logistic regression. RESULTS: 322 patients were included in this study. The most deprived group had a higher prevalence of diabetes compared to the least and intermediately deprived group (p<0.001). Massive tear occurrence was greater in the least deprived group (p=0.003) compared to the most deprived group. There was no difference in objective outcomes between groups. Patient-reported outcomes (SST, ASES, and QuickDASH) were worse in the most deprived group compared to the least and intermediate deprived groups. CONCLUSION: Social deprivation significantly affects patient-reported outcomes in rotator cuff repair surgery. While clinician-reported outcomes were consistent, patients' perceptions varied based on social determinants. Integrating SDoH considerations in orthopedic care is a promising next step in securing equitable approaches. However, more research is needed to validate and expand these findings.

The Effect of Social Deprivation on Hospital Utilization Following Distal Radius Fracture Treatment.

Purpose: Social determinants of health disparities have been shown to adversely impact outcomes following distal radius fracture (DRF) treatment. Identifying risk factors for increased hospital use following DRF has been historically difficult; however, it is of utmost concern to orthopedic surgeons to improve outcomes and decrease the total cost of care. The effect of social deprivation following DRF has yet to be fully investigated. Methods: This is a retrospective cohort analysis of a single institution's experience in treating DRF with either an operative or nonsurgical modality between 2005 and 2020. Patient demographic information and health care utilization (hospital readmission, emergency department [ED] visitation, office visits, and telephone use) were collected from within 90 days of treatment. Area Deprivation Index (ADI) national percentiles were recorded. Patients were stratified into terciles based on their relative level of deprivation, and their outcomes were compared. Secondary analyses included stratifying patients based on treatment modality, race, and legal sex. Results: In total, 2,149 patients were included. The least, intermediate, and most deprived groups consisted of 552, 1,067, and 530 patients, respectively. Risk factors for hospital readmission included higher levels of relative deprivation. Identifying as Black or African American and nonsurgical management were risk factors for increased ED visitation. No differences in rate of hospital readmission, ED visitation, office visitation, or telephone use were seen based on deprivation level. Conclusions: High levels of social deprivation, treatment modality, race, and legal sex disparities may influence the amount of hospital resource utilization following DRF treatment. Understanding and identifying risk factors for greater resource utilization can help to mitigate inappropriate use and decrease health care costs. We hope to use these findings to guide clinical decision making, educate patient populations, and optimize outcomes following DRF treatment. Type of Study/Level of Evidence: Therapeutic III.

The impact of social deprivation on healthcare utilization patterns following rotator cuff repair.

BACKGROUND: Disparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized. METHODS: This is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012 and 2020. Demographic variables (age, race, gender, American Society of Anesthesiologists (ASA) score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. RESULTS: A total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased emergency department (ED) visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients. CONCLUSIONS: Patients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.

Occupational Therapists in Patient Navigation: A Scoping Review of the Literature.

This review seeks to understand the literature on patient navigator programs (PNPs) that employ occupational therapists (OTs), including the role (conceptualization), functions (operationalization) of OTs who work as patient navigators (PNs) and the settings and populations they serve. This review also mapped the role of PNs to the 2021 Competencies for Occupational Therapists in Canada. Scoping review methodology by Arksey and O'Malley (2005) was employed. Data were analyzed thematically and numerically to identify frequent patterns. Ten articles were included. Within PNPs, OTs worked in hospitals and communities, but their role was rarely well-defined. Five competency domains (i.e., communication and collaboration, culture, equity and justice, excellence in practice, professional responsibility, and engagement with the profession) were evident in existing PNPs that included OTs. This review supports the increasing interest in OTs as PNs by demonstrating the alignment between the OT competencies and roles and functions of OTs working within PNPs.

What is the role of primary care in the COVID-19 vaccine roll-out and the barriers and facilitators to an equitable vaccine roll-out? A rapid scoping review of nine jurisdictions.

OBJECTIVES: This study aimed to: (1) examine the experience of nine global jurisdictions that engaged primary care providers (PCPs) to administer COVID-19 vaccines during the pandemic; (2) describe how vaccine hesitancy and principles of equity were incorporated in the COVID-19 vaccine roll-out strategies and (3) identify the barriers and facilitators to the vaccine roll-out. DESIGN: Rapid scoping review. DATA SOURCES: Searches took place in MEDLINE, CINAHL, Embase, the Cochrane Library, SCOPUS and PsycINFO, Google, and the websites of national health departments. Searches and analyses took place from May 2021 to July 2021. RESULTS: Sixty-two documents met the inclusion criteria (35=grey literature; 56% and 27=peer reviewed; 44%). This review found that the vaccine distribution approach started at hospitals in almost all jurisdictions. In some jurisdictions, PCPs were engaged at the beginning, and the majority included PCPs over time. In many jurisdictions, equity was considered in the prioritisation policies for various marginalised communities. However, vaccine hesitancy was not explicitly considered in the design of vaccine distribution approaches. The barriers to the roll-out of vaccines included personal, organisational and contextual factors. The vaccine roll-out strategy was facilitated by establishing policies and processes for pandemic preparedness, well-established and coordinated information systems, primary care interventions, adequate supply of providers, education and training of providers, and effective communications strategy. CONCLUSIONS: Empirical evidence is lacking on the impact of a primary care-led vaccine distribution approach on vaccine hesitancy, adoption and equity. Future vaccine distribution approaches need to be informed by further research evaluating vaccine distribution approaches and their impact on patient and population outcomes.

A Systematic Review on Navigation Programs for Persons Living With Dementia and Their Caregivers.

BACKGROUND AND OBJECTIVES: System navigation programs are becoming more available to meet the needs of patients with complex care needs. The aim of this review was to systematically assess the outcomes of navigation programs for persons with dementia and their family caregivers. RESEARCH DESIGN AND METHODS: A systematic review methodology was employed. Ten databases were searched for all relevant articles published until October 30, 2021. English-language full-text articles were included if they focused on implemented navigation program(s) that primarily supported persons with dementia who were aged 50 or older. Methodological quality was assessed by 2 independent raters using the Physiotherapy Evidence Database Scale, the STrengthening the Reporting of OBservational studies in Epidemiology checklist, and the Mixed Methods Appraisal Tool. RESULTS: Fourteen articles were included in the review. There was Level 1 evidence for the benefits of system navigation programs on delaying institutionalization, wherein benefits appeared to be specific to interventions that had an in-person component. There was Level 1 (n = 4) and Level 3 (n = 1) evidence on service use from time of diagnosis to continued management of dementia. Finally, Level 1 to Level 5 evidence indicated a number of benefits on caregiver outcomes. DISCUSSION AND IMPLICATIONS: There is strong evidence on the benefits of system navigation for people with dementia on delaying institutionalization and caregiver outcomes, but outcomes across other domains (i.e., functional independence) are less clear, which may be due to the varied approaches within system navigation models of care.

The Management of Missed Median Nerve Laceration After Pediatric Both-Bone Forearm Fracture: A Case Report.

CASE: A 12-year-old girl presented with a both-bone forearm fracture after a fall. Fracture healing occurred, but nerve injury was not addressed until 18 months after injury. Magnetic resonance imaging and electromyography yielded a median nerve injury, and she underwent nerve reconstruction with sural nerve grafting. She improved but continued to have deficits beyond her 1-year follow-up. CONCLUSION: Both-bone forearm fractures are a common fracture pattern with rare complications. Clinicians should have a high index of suspicion with persistent nerve symptoms and consider further investigation, given the importance of early nerve repair.

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature.

Patient navigation is a model of care that aims to improve access to care by reducing the complexity of navigating health, education, and social services across the continuum of care and care settings. Little is known about the processes that facilitate or impede the implementation of patient navigation programs (PNPs). We conducted a scoping review to identify and summarize the current state of knowledge regarding the implementation and outcomes of existing implemented PNPs. We employed a 6-stage scoping review framework to identify and review eligible articles. Sixty-articles met the inclusion criteria (58 peer-reviewed and 2 grey literature). The Consolidated Framework for Implementation Research served as the theoretical framework during analysis to help extract factors relevant to implementation of navigator programs. Results of the scoping review are reported thematically. Influences on implementation were identified: (a) planning to ensure alignment with organizational need (b) funding (c) multidisciplinary engagement (d) establishing workflow (e) mechanisms for communication (f) stakeholders to encourage buy-in (g) appropriate caseload (h) in kind resources. PNPs improve the experiences of patients and families. The findings of this scoping review provides implementation considerations of PNPs across global care settings. Strategies for overcoming pragmatic and logistical issues must be developed for optimal implementation.

Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Rare Post Traumatic Kyphoscoliosis of the Thoracolumbar Spine After Posterior Fusion for Adolescent Idiopathic Scoliosis: A Case Report and Review of the Literature.

Background: Vertebral fracture after posterior arthrodesis and instrumentation for idiopathic scoliosis is a rare occurrence with limited reported cases in the literature. Case Presentation: A 16-year-old female patient surgically treated for adolescent idiopathic scoliosis with T2-L1 posterior spinal fusion was in a low-energy fall resulting in fracture of L1 and new kyphosis and scoliosis of the thoracolumbar spine at the distal aspect of the fusion. The fracture was initially managed conservatively, however pain persisted and thus she was indicated for extension of the fusion and correction of the post-traumatic kyphosis. Conclusions: Fractures after posterior spinal fusion for idiopathic scoliosis are rare and evidence for the appropriate management remains limited in the literature.Level of Evidence: V.

Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting.

BACKGROUND: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting. METHODS: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively. RESULTS: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07). CONCLUSION: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Visual Interpretation of Plain Radiographs in Orthopaedics Using Eye-Tracking Technology.

BACKGROUND: Despite the importance of radiographic interpretation in orthopaedics, there not a clear understanding of the specific visual strategies used while analyzing a plain film. Eyetracking technology allows for the objective study of eye movements while performing a dynamic task, such as reading X-rays. Our study looks to elucidate objective differences in image interpretation between novice and experienced orthopaedic trainees using this novel technology. METHODS: Novice and experienced orthopaedic trainees (N=23) were asked to interpret AP pelvis films, searching for unilateral acetabular fractures while eye-movements were assessed for pattern of gaze, fixation on regions of interest, and time of fixation at regions of interest. Participants were asked to label radiographs as "fractured" or "not fractured." If "fractured", the participant was asked to determine the fracture pattern. A control condition employed Ekman faces and participants judged gender and facial emotion. Data were analyzed for variation in eye movements between participants, accuracy of responses, and response time. RESULTS: Accuracy: There was no significant difference by level of training for accurately identifing fracture images (p=0.3255). There was a significant association between higher level of training and correctly identifying non-fractured images (p=0.0155); greater training was also associated with more success in identifying the correct Judet-Letournel classification (p=0.0029). Response Time: Greater training was associated with faster response times (p=0.0009 for fracture images and 0.0012 for non-fractured images). Fixation Duration: There was no correlation of average fixation duration with experience (p=0.9632). Regions of Interest (ROIs): More experience was associated with an average of two fewer fixated ROIs (p=0.0047). Number of Fixations: Increased experience was associated with fewer fixations overall (p=0.0007). CONCLUSIONS: Experience has a significant impact on both accuracy and efficiency in interpreting plain films. Greater training is associated with a shift toward a more efficient and thorough assessment of plain radiographs. Eyetracking is a useful descriptive tool in the setting of plain film interpretation. CLINICAL RELEVANCE: We propose further assessment of eye movements in larger populations of orthopaedic surgeons, including staff orthopaedists. Describing the differences between novice and expert interpretation may provide insight into ways to accelerate the learning process in young orthopaedists.

Patient-Reported Outcomes After Multiligament Knee Injury: MCL Repair Versus Reconstruction.

BACKGROUND: Management of the medial collateral ligament (MCL) in the setting of a multiligamentous knee injury (MLKI) represents an area of great controversy. PURPOSE: Our study was designed to compare long-term patient-reported outcomes (PROs) after MCL repair versus reconstruction in the setting of a multiligamentous injury of the knee. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: At a single institution, 68 patients were identified over a 10-year period as having MCL intervention in the setting of MLKI. Of these patients, 34 (50%) were successfully contacted via telephone to collect Lysholm and International Knee Documentation Committee (IKDC) scores. A retrospective chart review of these subjects was also conducted to identify patient and surgical factors affecting PROs. RESULTS: At a mean 6-year follow-up (range, 2-11 years), the mean Lysholm score was 77.4 ± 23.1 and mean IKDC score was 72.6 ± 23.6. Univariate analyses identified time to surgery (P = .005) and MCL reconstruction (P = .001) as risk factors for Lysholm score ≤75. Univariate analyses identified patient age (P = .049), time to surgery (P = .018), and MCL reconstruction (P = .004) as risk factors for IKDC score ≤75. On subsequent multivariate analysis, MCL reconstruction was found to be a predictor of Lysholm or IKDC score of ≤75. CONCLUSION: Patients undergoing MCL repair in the setting of MLKI generally had higher PROs than those undergoing reconstructions at a mean 6 years of follow-up. Further work is needed to elucidate patient and surgical factors that may influence subjective outcomes after multiligament knee injuries.

Factors Associated with Knee Stiffness following Surgical Management of Multiligament Knee Injuries.

Postoperative knee stiffness can influence outcomes following operative treatment of multiligament knee injuries (MLKIs). The purpose of this study was to evaluate patient and surgical factors that may potentially contribute to stiffness following surgery for MLKIs. All surgically managed MLKIs involving two or more ligaments over a 10-year period at a single level one trauma center were included in this study. A retrospective review was performed to gather objective data related to the development of knee stiffness after surgery. Patients were classified as "stiff" postoperatively if they (1) had a flexion contracture greater than 10 degrees, (2) failed to reach 120 degrees of flexion at final follow-up, or (3) underwent a manipulation under anesthesia with or without arthroscopic lysis of adhesions to improve range of motion. Patient and surgical factors were evaluated systematically to determine factors associated with stiffness. The mean age of the cohort was 27.6 years at the time of surgery and mean follow-up was 50 weeks. Overall, 26/121 (21.5%) knees were diagnosed with postoperative stiffness. In the acute postoperative phase, 17 patients underwent manipulation under anesthesia. There were no significant differences in age, body mass index, associated injuries, mechanism, external fixation use or surgical timing (acute vs. chronic) between stiff and normal knees. Factors associated with the development of postoperative stiffness included knee dislocation (p = 0.04) and surgical intervention on three or more ligaments (p = 0.04). Careful attention to postoperative rehabilitation regimens should be given to patients with knee dislocations and/or those undergoing reconstruction or repair of three or more injured ligaments. Surgeons may utilize spanning external fixation if necessary without increasing the rate of long-term stiffness. Further, acute surgery does not appear to influence rates of postoperative stiffness or the need for manipulation.

Skill Assessment in the Interpretation of 3D Fracture Patterns from Radiographs.

BACKGROUND: Interpreting two-dimensional radiographs to ascertain the three-dimensional (3D) position and orientation of fracture planes and bone fragments is an important component of orthopedic diagnosis and clinical management. This skill, however, has not been thoroughly explored and measured. Our primary research question is to determine if 3D radiographic image interpretation can be reliably assessed, and whether this assessment varies by level of training. A test designed to measure this skill among orthopedic surgeons would provide a quantitative benchmark for skill assessment and training research. METHODS: Two tests consisting of a series of online exercises were developed to measure this skill. Each exercise displayed a pair of musculoskeletal radiographs. Participants selected one of three CT slices of the same or similar fracture patterns that best matched the radiographs. In experiment 1, 10 orthopedic residents and staff responded to nine questions. In experiment 2, 52 residents from both orthopedics and radiology responded to 12 questions. RESULTS: Experiment 1 yielded a Cronbach alpha of 0.47. Performance correlated with experience; r(8) = 0.87, p<0.01, suggesting that the test could be both valid and reliable with a slight increase in test length. In experiment 2, after removing three non-discriminating items, the Cronbach coefficient alpha was 0.28 and performance correlated with experience; r(50) = 0.25, p<0.10. CONCLUSIONS: Although evidence for reliability and validity was more compelling with the first experiment, the analyses suggest motivation and test duration are important determinants of test efficacy. The interpretation of radiographs to discern 3D information is a promising and a relatively unexplored area for surgical skill education and assessment. The online test was useful and reliable. Further test development is likely to increase test effectiveness. CLINICAL RELEVANCE: Accurately interpreting radiographic images is an essential clinical skill. Quantitative, repeatable techniques to measure this skill can improve resident training and improve patient safety.

Efficiency of a four-item posttraumatic stress disorder screen in trauma patients.

BACKGROUND: One of the most common barriers identified by physicians who fail to screen for posttraumatic stress disorder (PTSD) in trauma patients is time constraint. We hypothesized the four-question Primary Care-PTSD screen (PC-PTSD) was an acceptable alternative to the commonly used 17-question Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C). METHODS: Consecutive trauma patients admitted to a Level I trauma center were given the PCL-C at the time of hospitalization. The four questions of the PC-PTSD are contained within the PCL-C. A positive PC-PTSD screen result was an endorsement of least three of the four questions. An overall score of greater than 44 on the PCL-C indicated a positive screen result. Sensitivity and specificity comparisons were made between the PCL-C and the PC-PTSD. RESULTS: Data were collected from 1,347 patients hospitalized for injury. The PC-PTSD identified 17.22% of patients with PTSD risk, and the PCL-C identified 16.10% at risk. Before discharge, the PC-PTSD has reasonable sensitivity in capturing the population at risk PTSD symptoms. CONCLUSION: In trauma patients before hospital discharge, the PC-PTSD is comparable with the PCL-C. Although some sensitivity is lost,the PC-PTSD is a shorter screen, and the loss of sensitivity may be offset by an increased frequency of administration. LEVEL OF EVIDENCE: Diagnostic test, level III.

Metal ion detection by luminescent 1,3-bis(dimethylaminomethyl) phenyl receptor-modified chromophores and cruciforms.

Chromophores ranging from simple small molecule π-conjugated systems comprised of phenylene ethynylene or fluorenylethynyl units to cross-conjugated Bunz-type cruciforms have been derivatized to include 1,3-bis(dimethylaminomethyl)phenyl moieties. The photophysical responsiveness of these diamino-substituted chromophores to metal ions has been examined. Both emission enhancement (turn-on) and ratiometric fluorescence detection of Cu(2+) and Zn(2+) ions have been achieved in THF.

Interchromophore orientation scaffolding by m-terphenyl oxacyclophanes.

Modular oxacyclophanes featuring m-terphenyl units scaffold inter-pi-system interaction in face-to-face stacked or orthogonal orientations, leading to distinct photophysical properties.