Clinical outcomes of open Latarjet-Patte procedures performed for recurrent anterior shoulder instability with primary bone loss versus failed arthroscopic Bankart repair.

BACKGROUND: This study compares the outcomes of Latarjet-Patte procedures (LPs) performed for primary glenohumeral instability in the setting of critical bone loss (LP-BL) versus salvage surgery performed after a failed arthroscopic Bankart repair (LP-FB). METHODS: LP's performed by senior author from 2017 to 2021 were separated into cohorts by LP indication. Data abstracted from electronic medical records included demographic information, preoperative clinical scores, radiological imaging, and complications. Postoperative clinical outcome scores collected after a 2-year minimum follow-up included: patient-reported outcomes measurement information system (PROMIS) upper extremity (UE), PROMIS pain interference, PROMIS pain intensity, American Shoulder and Elbow Surgeons (ASES), and visual analog scale pain scores. RESULTS: A total of 47 patients (LP-BL: n=29, LP-FB: n=18) with a mean age of 29 years (range, 15-58 years) were included in this study. Both cohorts achieved good upper extremity functionality without significant differences as indicated by mean PROMIS UE (LP-BL: 52.6±10.0 vs. LP-FB: 54.6±7.6, P=0.442) and ASES score (LP-BL: 89.9±15.7 vs. LP-FB: 91.5±14.4, P=0.712). However, the LP-FB cohort reported lower levels of pain (LP-FB: 0.5±1.1 vs. LP-BL: 1.9±2.7, P=0.020) at their latest follow-up. There were no significant differences in complication rates including re-dislocation between cohorts (LP-BL: 2/29 [6.9%] vs. LP-FB: 2/18 [11.1%], P=0.629). CONCLUSIONS: When performed after failed Bankart repair, the LP results in similar postoperative functional outcomes and similar rates of complications and re-dislocations when compared to the primary indication of recurrent glenohumeral instability in the setting of critical bone loss. Level of evidence: III.

Trends in Elbow Ulnar Collateral Ligament Repairs and Reconstructions and an Analysis Between Low- and High-Volume Surgical Centers: A 10-Year Study in New York State.

Background: Elbow ulnar collateral ligament (UCL) reconstruction (UCLR) is the gold standard for operative treatment of UCL tears, with renewed interest in UCL repairs. Purpose: To (1) assess trends in rates of UCLR and UCL repair and (2) identify predictors of complications by demographic, socioeconomic, or surgical center volume factors. Study Design: Descriptive epidemiology study. Methods: Patients who underwent UCLR or UCL repair at New York State health care facilities between 2010 and 2019 were retrospectively identified; concomitant ulnar nerve procedures among the cohort were also identified. Surgical center volumes were classified as low (<99th percentile) or high (≥99th percentile). Patient information, neighborhood socioeconomic status quantified using the Area Deprivation Index, and complications within 90 days were recorded. Poisson regression analysis was used to compare trends in UCLR versus UCL repair. Multivariable regression was used to determine whether center volume, demographic, or socioeconomic variables were independent predictors of complications. Results: A total of 1448 UCL surgeries were performed, with 388 (26.8%) concomitant ulnar nerve procedures. UCLR (1084 procedures; 74.9%) was performed more commonly than UCL repair (364 procedures; 25.1%), with patients undergoing UCL repair more likely to be older, female, and not privately ensured and having undergone a concomitant ulnar nerve procedure (all P < .001). With each year, there was an increased incidence rate ratio for UCL repair versus UCLR (ß = 1.12 [95% CI, 1.02-1.23]; P = .022). The authors identified 2 high-volume centers (720 UCL procedures; 49.7%) and 131 low-volume centers (728 UCL procedures; 50.3%). Patients undergoing UCL procedures at high-volume centers were more likely to be younger and male and receive workers' compensation (all P < .001). UCL repair and ulnar nerve-related procedures were both more commonly performed at low-volume centers (P < .001). There were no significant differences in 3-month infection, ulnar neuritis, instability, arthrofibrosis, heterotopic ossification, or all-cause complication rates between low- and high-volume centers. The only significant predictor for all-cause complication was Medicaid insurance (OR, 2.91 [95% CI, 1.20-6.33]; P = .011). Conclusion: A rising incidence of UCL repair compared with UCLR was found in New York State, especially among female patients, older patients, and nonprivate payers. There were no differences in 3-month complication rates between high- and low-volume centers, and Medicaid insurance status was a predictor for overall complications within 90 days of operation.

Cannabidiol for Postoperative Pain Control After Arthroscopic Rotator Cuff Repair Demonstrates No Deficits in Patient-Reported Outcomes Versus Placebo: 1-Year Follow-up of a Randomized Controlled Trial.

Background: Cannabidiol (CBD) has been shown recently to positively affect patient pain and satisfaction immediately after arthroscopic rotator cuff repair (ARCR). However, it is unclear whether the addition of CBD to a perioperative regimen could affect postoperative outcomes. Purpose: To evaluate patient-reported outcomes among patients who underwent ARCR and received buccally absorbed CBD or an identical placebo for early postoperative pain management at 1-year follow-up. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Eligible patients had previously participated in a multicenter, placebo-controlled, randomized, double-blinded trial that evaluated the analgesic effects of CBD in the immediate postoperative period after ARCR. The experimental group received 25 mg of CBD 3 times/day if <80 kg and 50 mg of CBD 3 times/day if >80 kg for 14 days, with the control group receiving an identical placebo. The following outcomes were assessed at minimum 1-year follow-up: visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and patient satisfaction. The rates of achievement of the Patient Acceptable Symptom State (PASS) were compared based on ASES at latest follow-up. Continuous and categorical variables were compared with the Mann-Whitney U test and Fisher exact test, respectively. Results: Follow-up was obtained from 83 of 99 patients (83.8%) who completed the original trial. There were no significant differences between the CBD and control groups with respect to age, sex, body mass index, rate of concomitant procedures, or number of anchors used intraoperatively. At 1-year follow-up, there were no significant differences between the CBD and control groups in VAS pain (0.8 vs 1.2, P = .38), ASES (93.0 vs 91.1, P = .71), SANE (87.6 vs 90.1, P = .24), or satisfaction (97.4 vs 95.4, P = .41). A majority of patients achieved the PASS (81.0% [CBD] vs 77.5% [control]; P = .79). Conclusion: Perioperative use of CBD for pain control among patients undergoing ARCR did not result in any significant deficits in pain, satisfaction, or patient-reported outcomes at 1-year postoperatively compared with a placebo control group. These findings suggest that CBD can be considered in a postoperative multimodal pain management regimen without detrimental effects on outcome. Registration: NCT04672252 (ClinicalTrials.gov identifier).

Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age: A Systematic Review and Network Meta-analysis.

BACKGROUND: Massive irreparable rotator cuff tears (MIRCTs) remain a challenging treatment paradigm, particularly for nonelderly patients without pseudoparalysis or arthritis. PURPOSE: To use a network meta-analysis to analyze comparative studies of surgical treatment options for MIRCTs in patients <70 years of age for several patient-reported outcomes, range of motion (ROM), and acromiohumeral distance (AHD). STUDY DESIGN: Network meta-analysis of comparative studies; Level of evidence, 3. METHODS: A systematic review of the literature, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the MEDLINE, Embase, and Cochrane Library databases was conducted from 2017 to 2022. Inclusion criteria were (1) clinical comparative studies of MIRCTs (with several study-specific criteria); (2) ≥1 outcome of interest reported on, with standard deviations; (3) minimum 1-year follow-up; and (4) mean age of <70 years for both cohorts, without arthritis or pseudoparalysis. There were 8 treatment arms compared. Outcomes of interest were the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, visual analog scale for pain, AHD, and forward flexion and external rotation ROM. A frequentist approach to network meta-analysis with a random-effects model was performed using the netmeta package Version 0.9-6 in R. RESULTS: A total of 23 studies met the inclusion criteria, with 1178 patients included in the network meta-analysis. There was a mean weighted age of 62.8 years, 568 (48.2%) men, with a mean follow-up of 28.9 months. There were no significant differences between groups in regard to sex (P = .732) or age (P = .469). For the ASES score, InSpace balloon arthroplasty (mean difference [MD], 12.34; 95% CI, 2.18 to 22.50; P = .017), arthroscopic bridging graft (aBG) (MD, 7.07; 95% CI, 0.28 to 13.85; P = .041), and long head of biceps augmented superior capsular reconstruction (BSCR) (MD, 5.16; 95% CI, 1.10 to 9.22; P = .013) resulted in the highest P-scores. For the Constant-Murley score, debridement (MD, 21.03; 95% CI, 8.98 to 33.08; P < .001) and aBG (MD, 6.97; 95% CI, 1.88 to 12.05; P = .007) resulted in the highest P-scores. For AHD, BSCR resulted in the highest P-score (MD, 1.46; 95% CI, 0.45 to 2.48; P = .005). For forward flexion ROM, debridement (MD, 45.77; 95% CI, 25.41 to 66.13; P < .001) resulted in the highest P-score, while RSA resulted in the lowest P-score (MD, -16.70; 95% CI, -31.20 to -2.20; P = .024). CONCLUSION: For patients <70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.

Effect of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers on need for operative intervention for idiopathic adhesive capsulitis.

Background: The exact pathogenesis of idiopathic adhesive capsulitis (IAC) is not fully understood, but an inflammatory profibrotic cascade, largely mediated by transforming growth factor-beta 1 (TGF- ß1) has been implicated. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-Is) both decrease the activity of TGF-ß1. The aim of this study was to determine the impact of ACE-Is or ARBs use on the need for operative intervention in IAC. Methods: This was a retrospective cohort study of patients from a single institutional database with IAC, divided into two cohorts, with and without ACE-I and/or ARB use as the primary exposure and a minimum 2-year follow-up. The primary outcome measured was the incidence of operative intervention including manipulation under anesthesia (MUA) and arthroscopic capsular release (ACR). Additional multivariable logistic regression analysis was performed to evaluate associations between ACE-I/ARB use and likelihood of undergoing an operative procedure. Results: A total of 17,645 patients met inclusion criteria, with 5424 patients in the ACE-I/ARB cohort and 12,221 in the non-ACE-I/ARB cohort. Overall, 422 (2.4%) patients underwent surgical treatment, 378 (2.1%) ACR, and 74 (0.4%) MUA. There was no significant difference between cohorts in the frequency of surgical procedures or time to procedure since diagnosis. There were no significant differences between individual ACE-Is or ARBs, although Losartan was found to have a trend of decreased rate of intervention (31.7% vs. 36.8%, P = .209) when compared to patients not on losartan that did not reach statistical significance. Patient factors predictive of undergoing MUA/ACR were diabetes (P = .013), obesity (P < .001), and male sex (P < .001). Increasing patient age reduces the likelihood of undergoing operative intervention, with patients aged 50-70 years (P = .022) and age >70 years (P < .001) demonstrating reduced odds as compared to patients aged <30 years. Conclusion: Patients with IAC have an overall low (2.4%) rate of requiring surgical intervention. While the antifibrotic mechanism of ACE inhibitors and ARBs did not significantly affect the rate of requiring surgical intervention, male gender, obesity, younger age, and diabetes, all increased the risk for operative intervention. Losartan, specifically, may have a disease modifying effect on IAC that should be investigated with larger controlled trials.

Excellent Correlation of the Patient-Reported Outcomes Measurement Information System Upper Extremity Score With Legacy Outcome Scores Preoperatively and at 1 Year After Arthroscopic Rotator Cuff Repair.

Purpose: To assess the preoperative and postoperative performance of the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE, version 2.0) outcome score in comparison to the American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) instruments in patients undergoing rotator cuff repair. Methods: This prospective longitudinal study included 91 patients undergoing rotator cuff repair. Patients completed the PROMIS-UE, ASES, and WORC instruments preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 12 months. The Pearson correlation coefficient (r) between these tools was calculated at each time point. Correlations were graded as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), or poor (<0.4). Responsiveness to change was assessed using the effect size and the standardized response mean. Floor and ceiling effects for each instrument were also assessed. Results: The PROMIS-UE instrument showed good to excellent correlation with the legacy instruments at all time points. There were variations in the measured effect sizes of the various instruments, with the PROMIS-UE instrument showing responsiveness to change at 3 and 12 months but the ASES and WORC instruments showing responsiveness at 6 weeks, 3 months, and 12 months. Both PROMIS-UE and ASES scores displayed ceiling effects at 12 months. Conclusions: The PROMIS-UE instrument shows excellent correlation with the ASES instrument and a rotator cuff-specific outcome instrument-the WORC instrument-preoperatively and at 1 year after arthroscopic rotator cuff repair. Variations in the measured effect sizes at different postoperative time points and high ceiling effects of the PROMIS-UE instrument at the 1-year time point may limit its utility in the early postoperative phase and at long-term follow-up after rotator cuff repair. Clinical Relevance: The performance of the PROMIS-UE outcome measure after arthroscopic rotator cuff repair was investigated.

Return to Sport after Arthroscopic Rotator Cuff Repair of Full-Thickness Rotator Cuff Tears: A Systematic Review.

OBJECTIVE: Perform a systematic literature review regarding return to sport (RTS) outcomes after arthroscopic rotator cuff repair (aRCR) for full-thickness rotator cuff tears (FTRCTs). DATA SOURCES: Systematic review of all articles in PubMed, Medline, and Excerpta Medica Database (EMBASE) was conducted in April 2022 using a combination of keywords: "rotator cuff repair," "RCR," "complete," "full-thickness," "tear," "RCT," "injury," "shoulder," "arthroscopic," "return to sport," "RTS," "sport," "return to play," and "athlete." Cohorts were included from all articles reporting RTS after aRCR for FTRCTs. Studies that were non-English, failed to distinguish between partial and FTRCT outcomes, or treated FTRCTs by open RCR, mini-open RCR, debridement, or nonsurgical management were excluded. Abstracted data included study design, surgical techniques, concomitant procedures, demographics, FTRCT type and size, patient-reported outcomes, type of sport, competition level, time to return, and reasons for failing to RTS. MAIN RESULTS: 11 studies were reviewed, with inclusion of 463 patients (385 athletes; mean age 47.9). RTS varied considerably in rate and timing, with 50.0% to 100% of patients returning on average between 4.8 to 14 months. In addition, 31 patients returned to a higher level of sport, 107 returned to or near preinjury level, and 36 returned to a lower level of competition or failed to RTS entirely. CONCLUSIONS: The ability for athletes to RTS after aRCR for FTRCTs is likely multifactorial, demonstrating high variability in return rates and time to RTS. Given the paucity of available literature, future studies are warranted to provide a more definitive consensus.

Minimal clinically important difference (MCID) and substantial clinical benefit (SCB) of upper extremity PROMIS scores following arthroscopic rotator cuff repairs.

PURPOSE: To calculate and determine what factors are associated with achieving the Minimal Clinically Important Difference (MCID) and the Substantial Clinical Benefit (SCB) of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Testing v2.0 (UE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity) in patients undergoing arthroscopic rotator cuff repair (aRCR). METHODS: The change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve analysis was used to calculate the anchor-based MCID and SCB. To assess the responsiveness of each PROM, effect sizes and standardized response means (SRM) were calculated. To identify factors associated with attaining the MCID and SCB, univariate and multivariate logistic regression analyses were performed. RESULTS: A total of 323 patients with an average age of 59.9 ± 9.5 were enrolled in this study, of which, 187/323 [57.9%] were male and 136/323 [42.1%] were female. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was: 9.0, 7.5, and 11.2, respectively. The respective SCB was 10.9, 9.3, and 12.7. Effect size and SRM were: PROMIS UE (1.4, 1.3), P-Interference (1.8, 1.5), and P-Intensity (2.3, 2.0). Lower preoperative P-Intensity scores (p = 0.02), dominant arm involvement (p = 0.03), and concomitant biceps tenodesis (p = 0.03) were associated with patients achieving the SCB for PROMIS UE. CONCLUSION: A large responsiveness for each of the PROMIS instruments due to the majority of patients reporting great improvement after aRCR and a small standard deviation across all outcome measures was shown in our study. Lower preoperative P-Intensity scores and concomitant biceps tenodesis were associated with higher odds of achieving the SCB for PROMIS UE. The knowledge of MCID and SCB values for PROMIS instruments will allow the surgeon to determine whether the improvements in the PROMIS scores after aRCR are clinically meaningful. LEVEL OF EVIDENCE: Level III.

Outcomes of arthroscopic tuberoplasty for symptomatic irreparable rotator cuff tendon tear without pseudoparalysis.

Background: The purpose of this study is to report the outcomes in patients undergoing arthroscopic tuberoplasty for symptomatic irreparable rotator cuff tear (RCT). Methods: This is a retrospective cohort study comparing preoperative and postoperative data of patients undergoing arthroscopic tuberoplasty for symptomatic irreparable RCT. Exclusion criteria included open tuberoplasty, concomitant partial RCT repair, glenohumeral arthritis, concomitant ipsilateral extremity fractures, <12 months follow-up, or pseudoparalysis. Demographics, shoulder range of motion (ROM), RCT morphology, re-operation rates, satisfaction and outcome scores were collected from medical records and questionnaires. Outcome scores included Patient Reported Outcome Measurement Information System Upper Extremity (PROMIS), American Shoulder and Elbow Surgeons score (ASES), Subjective Shoulder Value (SSV), and pain Visual Analog Score (VAS). Results: Out of 28 patients identified between 2012 and 2019, 20 (21 shoulders) were available for follow-up at a mean of 43.3 ± 20.9 months. Mean age was 64.6 ± 8.8 years. Mean PROMIS was 37.7 ± 7.3, ASES was 82.9 ± 13.8, and SVV was 67.1 ± 19.4. VAS with activity decreased from 5.0 ± 2.9 preoperatively to 2.3 ± 2.6 (P = .0029). Pre- and post-operative ROM were unchanged. There were 4 failures requiring revision. The remaining 17 patients reported high satisfaction scores (3.4 ± 0.7) and 15 (88.2%) answered "yes" to getting the procedure again, with 3/4 failures stating they would also undergo arthroscopic tuberoplasty again. Conclusion: Arthroscopic tuberoplasty demonstrates high levels of satisfaction and pain reduction in symptomatic irreparable RCT. In appropriately indicated patients, this treatment should be considered prior to other salvage options.

No Differences in 90-Day Complications and Admissions After Latarjet Procedure for Primary Bone Loss Versus Latarjet Procedure for Failed Arthroscopic Instability Repair.

Purpose: To investigate the variance in 90-day complication, emergency department (ED) visit, revision, and readmission rates between the Latarjet procedure (LP) performed as a primary procedure for the treatment of recurrent shoulder instability associated with critical levels of glenohumeral bone loss and the LP performed as a salvage surgical procedure after failed arthroscopic instability repair (FAIR). Methods: Patients who underwent a primary LP from 2016-2021 in a single surgeon's practice were identified and divided into 2 cohorts based on the indication for surgery: primary LP for critical bone loss (unipolar or bipolar) (LP-PBL) or LP as salvage surgery for FAIR (LP-FAIR). Patients without a minimum follow-up period of 90 days were excluded. Chart review was conducted to analyze the prevalence of complications, ED visits and/or admissions, and secondary procedures in the 90-day postoperative period. Radiographic images were reviewed to evaluate for graft and/or hardware failure. An unpaired t test and the Fisher exact test were used to compare the 2 groups regarding continuous and categorical data, respectively, and the significance level was set at P < .05. Results: The final sample sizes consisted of 54 patients in the LP-PBL group and 23 patients in the LP-FAIR group. In the postoperative period, 4 complications were observed in the first 90 days. These included complex regional pain syndrome (n = 1) and superficial wound dehiscence (n = 1) in the LP-PBL cohort. Superficial suture abscess (n = 1) and audible crepitation (n = 1) were observed in the LP-FAIR cohort. There was 1 secondary intervention (arthroscopic debridement) in the LP-FAIR cohort. No statistically significant difference in complication rates, ED visits or admissions, or secondary procedures was found between the LP-PBL and LP-FAIR groups. Conclusions: The results of this study indicate that the 90-day complication, ED visit, revision, and readmission rates after open LP are low irrespective of the extent of glenoid or bipolar bone loss and history of arthroscopic instability repair. Level of Evidence: Level III, retrospective cohort study.

Buccally Absorbed Cannabidiol Shows Significantly Superior Pain Control and Improved Satisfaction Immediately After Arthroscopic Rotator Cuff Repair: A Placebo-Controlled, Double-Blinded, Randomized Trial.

BACKGROUND: Despite the widespread use and sales of cannabidiol (CBD) products in the United States, there is a paucity of literature to evaluate its effectiveness, safety, or ideal route of administration for postoperative pain. PURPOSE: To evaluate the potential analgesic effects of buccally absorbed CBD in patients who have undergone arthroscopic rotator cuff repair (ARCR). STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a US Food and Drug Administration-sanctioned, multicenter, placebo-controlled, randomized, double-blinded trial conducted in patients undergoing ARCR. Patients aged from 18 to 75 years undergoing ARCR were prospectively enrolled and randomized to the control and experimental groups. The experimental group received an oral, buccally absorbed tablet containing 25 mg of CBD 3 times a day if <80 kg, or 50 mg of CBD 3 times a day if >80 kg, for 14 days postoperatively, while the control group received an identical placebo. Patients were followed up on days 1, 2, 7, and 14, and visual analog scale (VAS) for pain scores, opioid consumption, and satisfaction with pain control were recorded. Additionally, liver function tests were conducted on days 7 and 14 to assess safety, and nausea was monitored. P < .05 was considered to be statistically significant. RESULTS: Overall, 100 patients were recruited, with 1 patient being excluded, for a total of 99 patients. There were no significant differences in patient demographics between the 2 groups. On day 1, the VAS pain score was significantly lower in the CBD group than in the control group (4.4 ± 3.1 vs 5.7 ± 3.2, respectively; P = .04), although this difference was no longer present on day 2 (4.7 ± 2.8 vs 5.3 ± 2.6, respectively; P = .32). On both days 1 and 2, patient satisfaction with pain control was significantly higher in the CBD group than in the control group (day 1: 7.0 ± 3.0 vs 5.6 ± 3.7, respectively [P = .04]; day 2: 7.3 ± 2.5 vs 6.0 ± 3.3, respectively [P = .03]). The quantity of opioids consumed was low in both groups, and there were no statistically significant differences in opioid consumption (P > .05). On days 7 and 14, there were no statistically significant differences in VAS scores, opioid consumption, or patient satisfaction with pain control between the CBD and control groups (P > .05 for all). There were no significant differences in liver function test results postoperatively (P > .05). CONCLUSION: Buccally absorbed CBD demonstrated an acceptable safety profile and showed significant promise in the reduction of pain in the immediate perioperative period after ARCR compared with the control. Further studies are currently ongoing to confirm dosing and effectiveness in other orthopaedic conditions. REGISTRATION: NCT04672252 (ClinicalTrials.gov identifier).

The future of health care service in orthopedic practice: telemedicine or in-person visits?

BACKGROUND: The objective of this study was to assess patient satisfaction and preference for telemedicine vs. in-person visits for outpatient shoulder and elbow musculoskeletal consultation during the coronavirus disease 2019 (COVID-19) pandemic and in the future. METHODS: Patients who had telemedicine visits for shoulder and elbow musculoskeletal complaints at a single institution from March through June 2020 were invited to respond to a post-visit survey. The survey included a standardized questionnaire that focused on the patient's satisfaction with the telemedicine visits during the pandemic and preference for using the telemedicine platform in the future, following the pandemic. Additional details regarding their virtual visits (severity of medical condition, as well as previous virtual or emergency department visits) were also obtained. Data regarding patient demographic characteristics and visit details (primary diagnosis, type of visit, length of visit, and treating physician) were extracted from the electronic medical records. RESULTS: In total, 153 patients participated in the study. Overall, high satisfaction scores regarding the telemedicine visits were noted: 91% of patients reported that their concerns were adequately addressed, 89% would recommend telemedicine to a friend, and 94% stated that they would use the telemedicine platform again in the presence of a situation similar to the COVID-19 pandemic. However, the majority of patients (76%) reported a preference for in-person visits for the same musculoskeletal complaint if it were not for COVID-19. A telemedicine visit duration > 10 minutes and a first-time telemedicine visit correlated with higher satisfaction rates (P = .037 and P = .001, respectively). CONCLUSIONS: COVID-19 has provided a boost to the use of our telemedicine platform, with a high satisfaction rate among patients with shoulder and elbow musculoskeletal complaints, largely owing to safety reasons and limited access to in-person doctor visits. However, a considerable number of patients would have preferred in-person visits for similar health complaints if there were no pandemic. Further research on optimizing the selection of patients for telemedicine visits and addressing their expectations and concerns regarding their visits will improve patients' preference for future telemedicine visits.

Locked Anterior-Inferior Sternoclavicular Joint Dislocation: A Case Report.

CASE: We report a rare variant of sternoclavicular joint (SCJ) dislocation, namely locked anterior-inferior dislocation, with unique clinical, radiographic, and intraoperative findings. In this variant, the medial clavicle was displaced anteriorly and inferiorly and locked in the manubrial-intercostal space, with corresponding mechanical dysfunction of the ipsilateral shoulder girdle joints. Symptoms unique to this variant included painful neck spasms and limited glenohumeral elevation. Nonsurgical treatment was not successful, and open reduction and ligament reconstruction resulted in correction of the fixed deformity with resolution of the clinical symptoms. CONCLUSION: Locked anterior-inferior SCJ dislocation is indicated for early open reduction and ligament reconstruction.

Patient and Physician Satisfaction with Telehealth During the COVID-19 Pandemic: Sports Medicine Perspective.

Background:Owing to the COVID-19 pandemic, there has been a large shift in health care toward virtual platforms. This study analyzed patient and physician satisfaction with telehealth during the height of the pandemic within the division of sports medicine.Methods:All sports medicine patients who completed a telemedicine visit from March 30, 2020, through April 30, 2020, were sent a 14-question Likert scale (1-5/5) survey. Sports medicine physicians who used telemedicine were sent a separate 14-question Likert scale (1-5/5) survey at the end of the study period. Factors influencing patient satisfaction were determined using a multivariate linear regression model.Results:A total of 143 patients and 9 sports medicine attendings completed the surveys. Most patients were "satisfied" (4/5) or "very satisfied" (5/5) (88.8%). A multivariate linear regression determined that patients who believed they had a greater ability to adopt new technology and were more effective at communicating questions/concerns to their physicians had greater satisfaction (p = 0.009 and p = 0.015, respectively). Most physicians were either "satisfied" (4/5) or "very satisfied" (5/5) (75.0%). On average, physicians felt that physical examinations conducted through telemedicine were "moderately effective" (2.75/5.00 ± 1.3), that they were "fairly confident" (3.86/5.00 ± 0.83) in their diagnoses, and that most sports medicine attendings plan to use telemedicine in the future (87.5%).Conclusion:Telehealth emerged as a valuable tool for the delivery of health care to sports medicine patients during the COVID-19 pandemic. Patients and physicians reported high levels of satisfactions with its use, and this study further identifies areas that can improve the patient and physician experience.

Correlation of Patient Reported Outcome Measurement Information System (PROMIS) with American Shoulder and Elbow Surgeon (ASES), and Constant (CS) scores in idiopathic adhesive capsulitis.

PURPOSE: To correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with pre-existing validated outcome scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC). METHODS: Patients with a clinical diagnosis of idiopathic AC ("freezing" or "frozen" phases) who agreed to complete the ASES, CS, and PROMIS UE scores during their office visit were included in this study. Trained researchers performed the objective clinical assessments on the included patients. Responses to the 3 outcome scores were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were calculated. RESULTS: The final cohort included 100 patients with AC, of whom there were 72% female and 87% right hand dominant, with a mean age of 55 years. The PROMIS UE required fewer question responses (5.02 ± 1.84) compared with the fixed question burden with ASES (12) and CS (9). The mean outcome scores were 34.6 ± 2.5 (PROMIS UE), 55 ± 22 (ASES), and 51 ± 16 (CS). The PROMIS UE displayed an excellent correlation with both the ASES (r = 0.80, 95% confidence interval [0.72, 0.86], P < .001) and CS (r = 0.76, 95% confidence interval [0.67, 0.83], P < .001). Neither ceiling nor floor effects were present. CONCLUSION: The PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in AC. A lower question burden with the PROMIS UE carries potential for wider acceptability with the researchers and patients with shoulder pathology.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Young age, female gender, Caucasian race, and workers' compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction.

PURPOSE: Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. METHODS: New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2 years to determine incidence and nature of subsequent ipsilateral knee procedures. RESULTS: The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7 years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5 months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10 years, respectively, were found for any ipsilateral reoperation. CONCLUSION: A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. LEVEL OF EVIDENCE: Level III.

Efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis.

HYPOTHESIS: The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. METHODS: A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). RESULTS: A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, -1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, -0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. CONCLUSION: LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis.

PURPOSE: To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear. METHODS: A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness. RESULTS: Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644. CONCLUSIONS: When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. LEVEL OF EVIDENCE: Level III, economic decision analysis.