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Arthroscopic rotator cuff repair (RCR) is a popular treatment for rotator cuff tears. Retear after RCR remains a significant concern even with modern techniques. Augmentation of RCR has been described using multiple different grafts, one option including a cannulated dermal allograft implant (DePuy Mitek). The utilization of this implant avoids significantly increased surgical time, allows for augmentation at the weakest area of repair, and does not lead to any wasted allograft material.

Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection.Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition.A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (β = 0.275, P0.001).Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention.III, diagnostic cohort study.

The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA.Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function.A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up.The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45. From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes. Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24–60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45–66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability. In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up. Therapeutic IV, Case Series.

Acromial (ASF) and scapular spine (SSF) stress fractures are well-recognized complications of reverse shoulder arthroplasty (RSA), but much of the current data are derived from single-center or single-implant studies with limited generalizability. This study from the American Shoulder and Elbow Surgeons (ASES) Complications of Reverse Shoulder Arthroplasty Multicenter Research Group determined the incidence of ASF/SSF after RSA and identified preoperative patient characteristics associated with their occurrence.Fifteen institutions including 21 ASES members across the United States participated in this study. Patients undergoing either primary or revision RSA between January 2013 and June 2019 with a minimum 3-month follow-up were included. All definitions and inclusion criteria were determined using the Delphi method, an iterative survey process involving all primary investigators. Consensus was achieved when at least 75% of investigators agreed on each aspect of the study protocol. Only symptomatic ASF/SSF diagnosed by radiograph or computed tomography were considered. Multivariable logistic regression was performed to identify factors associated with ASF/SSF development.We identified 6755 RSAs with an average follow-up of 19.8 months (range, 3-94). The total stress fracture incidence rate was 3.9% (n = 264), of which 3.0% (n = 200) were ASF and 0.9% (n = 64) were SSF. Fractures occurred at an average 8.2 months (0-64) following RSA with 21.2% (n = 56) following a trauma. Patient-related factors independently predictive of ASF were chronic dislocation (odds ratio [OR] 3.67, P = .04), massive rotator cuff tear without arthritis (OR 2.51, P.01), rotator cuff arthropathy (OR 2.14, P.01), self-reported osteoporosis (OR 2.21, P.01), inflammatory arthritis (OR 2.18, P.01), female sex (OR 1.51, P = .02), and older age (OR 1.02 per 1-year increase, P = .02). Factors independently associated with the development of SSF included osteoporosis (OR 2.63, P.01), female sex (OR 2.34, P = .01), rotator cuff arthropathy (OR 2.12, P = .03), and inflammatory arthritis (OR 2.05, P = .03).About 1 in 26 patients undergoing RSA will develop a symptomatic ASF or SSF, more frequently within the first year of surgery. Our results indicate that severe rotator cuff disease may play an important role in the occurrence of stress fractures following RSA. This information can be used to counsel patients about potential setbacks in recovery, especially among older women with suboptimal bone health. Strategies for prevention of ASF and SSF in these at-risk patients warrant further study. A follow-up study evaluating the impact of prosthetic factors on the incidence rates of ASF and SSF may prove highly valuable in the decision-making process.

BACKGROUND The popularity of both indoor and outdoor rock climbing has dramatically increased over the last decade. The purpose of this study is to evaluate trends in United States climbing injury rates as well as assess specific injury characteristics, especially in the context of indoor and outdoor climbing. METHODS The National Electronic Injury Surveillance System database was queried (2010-2019) to compare national weighted injury estimates and compare various injury characteristics from climbers presenting to US emergency departments. RESULTS The annual national estimates of rock climbing-related injuries presenting to US emergency rooms increased significantly (p=0.030) from 2010 (N=2,381; CI 1,085-3,676) to 2019 (N= 4,596; CI 492-8,699). 58.7% of the injuries in this study that could be classified by location occurred climbing outdoors. Ankle injuries were 2.25 times more likely (CI 1.03-3.08) to occur indoors than outdoors. Outdoor climbers were 2.25 times more likely to sustain an injury via falling and 13.8 times more likely to be injured by being struck by an object than indoor climbers (CI 1.05-2.42, CI 10.67-17.78). CONCLUSIONS Indoor and outdoor rock climbing are associated with different injury characteristics and risks. Therefore proper safety precautions, equipment, and training specific to terrain should be observed by all climbers in order to help decrease the rising trend of rock climbing-related injuries in the United States.

Background: With an increase in the treatment options available for massive rotator cuff tears, understanding the long-term outcomes of the chosen modality is important. Questions/Purpose: The purpose of this study was to systematically review the available literature on repair of massive rotator cuff repairs and learn the longevity of outcomes, the failure rate, outcomes after failure, and any contributing factors to poor outcomes or failure. Methods: We conducted a systematic review of the MEDLINE, Cochrane, and Embase databases to find studies that investigated the long-term results of repair of massive rotator cuff repairs. Studies were excluded if they did not stratify results of massive tears, provide a definition for a massive rotator cuff tear, or report isolate patients with long-term follow-up. Results: Six studies met the inclusion criteria, for a total of 472 shoulders; average patient age was 57.6 years. Follow-up ranged from 119 to 240 months. Outcome scores improved significantly following repair and were maintained throughout follow-up. The repair failure rate across studies was 39.2%. Patients who suffered retear had significantly worse outcome scores than patients with intact tendons at long-term follow-up. Conclusions: The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence. This review found repair of massive rotator cuff tears leads to long-term maintained improvements in outcome measures. Failure of repair is quite common, but results following failure are superior to preoperative outcomes.

Background Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group. Methods Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories. Results Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87). Discussion Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Background It is important to distinguish satisfaction regarding the outcome of care and satisfaction with the delivery of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are modern assessments of hospitals and providers of delivery of care. The purpose of this study was to report inpatient satisfaction according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) scores after shoulder arthroplasty and to determine factors that influence them, as well as their correlation with surgical expectations, pain perception, quality of life, surgical setting, and functional outcomes. Methods All patients scheduled for a shoulder arthroplasty were prospectively asked to complete a demographic and initial shoulder assessment form, a shoulder surgery expectations survey, a pain catastrophizing scale, the SF-12 (12-item Short Form) survey, and a resiliency form (Resilience Scale 11). Patient satisfaction was measured with the CG-CAHPS and HCAHPS surveys. Legacy forms, patient-specific factors, type of surgery performed, location of surgery, length of hospital stay, and discharge disposition were evaluated on their ability to predict these survey scores. Linear regression was used to calculate correlations and predictions of continuous variables, and logistic regression was used to compared the satisfied vs. unsatisfied cohorts. Results The average HCAHPS and CG-CAHPS satisfaction scores for the population were 74.7 ± 20.7 and 82.1 ± 19.4, respectively. Nonsmokers had a mean HCAHPS score of 77.7 ± 22.0, whereas current smokers reported a mean of 59.6 ± 5.2 (P = .03). Patients who were discharged home had a mean HCAHPS score of 77.3 ± 21.9, whereas those discharged to a skilled nursing facility reported a mean of 59.3 ± 6.6 (P = .05). These same groups also had significantly higher odds of being satisfied with the hospital. No significant differences or higher odds were seen for comparisons between overall CG-CAHPS satisfaction and any of the patient-specific factors tested. There was no significant correlation between age, length of stay, pain (pain catastrophizing scale), resiliency (Resilience Scale 11), expectations (shoulder surgery expectations survey), or function (SF-12) and both the HCAHPS and CG-CAHPS satisfaction scores. Conclusion Overall, 37 patients (74%) had CG-CAHPS scores that indicated satisfaction and 34 patients (68%) had HCAHPS scores that indicated satisfaction. Nonsmokers and patients discharged home after surgery report higher levels of inpatient hospital (HCAHPS) satisfaction after shoulder arthroplasty. Patients with high preoperative surgical expectations, pain perception, and resiliency are not generally more satisfied with the hospital or clinician. Preoperative diagnosis, location of surgery, and length of stay do not reliably impact satisfaction with the hospital or clinician. Inpatient HCAHPS and CG-CAHPS satisfaction does not correlate with legacy functional outcome measures and, therefore, may not be predictive of long-term functional outcomes.

Purpose To report the rate of return to sport after surgical treatment for posterior shoulder instability among athletes. Methods A systematic review of the literature regarding rate of return to sport after surgical treatment for posterior shoulder instability was undertaken. The primary outcome measure was return to sport. The secondary outcome measures included rate of return to sport to preinjury level, time to return to sport, injury type, reoperations after primary surgery, and objective patient-reported outcome data. Data is summarized with ranges and tables. Results A total of 23 studies met inclusion criteria. The rate of return to sport ranged from 57.9%-100%. The rate of return to sport to the preinjury level ranged from 47.4%-100%. Time to return to sport ranged from 4.3-7.7 months. Furthermore, 66% of subjects had an acute traumatic injury and 34% were of insidious onset. The most commonly reported outcome measures were American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores and visual analog scale (VAS) pain scores. At a minimum of 1-year follow-up, ASES and VAS pain scores improved. Revision rates ranged from 0%-36.8%. Conclusion The systematic review demonstrated high rates of return to sport and relatively high rates of return to preinjury level of sport among all athletes who underwent surgical treatment for posterior shoulder instability. Objective patient-reported outcome metrics improved postoperatively whereas revision rates remained low.

A 34-year-old female sustained a 1.8 cm full-thickness chondral defect of the right lateral trochlear surface as the result of intramedullary tibial nailing via a suprapatellar portal to treat a displaced right sided open comminuted spiral fracture of the distal tibial shaft. An osteochondral allograft was used to treat the chondral defect. Iatrogenic injury to intraarticular structures is a potential complication when inserting a tibial nail via a suprapatellar portal. Using proper technique with cannula systems and guide pins is essential to lowering the risk of damage to intraarticular structures.

Several techniques for patellar fixation for reconstruction of the medial patellofemoral ligament (MPFL) have been described in the literature. Despite the success of MPFL reconstruction reported in the literature, there is insufficient evidence to recommend a standard method of patellar fixation. A hybrid 2-point fixation technique allows for increased contact area and contact pressure between the insertion of the graft and the patella and offers a broad insertion of the graft onto the width of the patella, thus allowing for a more native attachment site to be re-created. The technique involves 2 suture anchors to increase graft compression onto the patella. This construct increases the primary load to failure of the repair, increases the surface contact area, and increases the stability of the MPFL reconstruction. These mechanical advantages decrease the chance of recurrent patellar instability and the chance of patellar fracture by avoiding transpatellar fixation.

Throughout the history of reverse total shoulder arthroplasty, the extent of lateral offset has changed considerably from “too lateral” to “too medial” and has been lately swinging back towards a point somewhere in between. Nonlateralized designs minimize shear forces on the glenoid and decrease force required by the deltoid. Glenoid lateralization decreases impingement and scapular notching and improves range of motion. Humeral lateralization achieves a more anatomic position of the tuberosities while maintaining a nonlateralized center of rotation. Several factors play a role in choosing the extent of lateral offset and method of lateralization.

OBJECTIVES Low health literacy is both pervasive in the United States and a substantial barrier to satisfactory patient care and the appropriate utilization of healthcare resources. This prospective study aims to evaluate the factors that contribute to limited musculoskeletal literacy in patients who undergo shoulder arthroplasty. METHODS Ninety patients undergoing shoulder replacement surgery completed demographics and Literacy in Musculoskeletal Problems (LiMP) surveys. Scores of less than six were considered indicative of limited musculoskeletal literacy. RESULTS The overall percentage of participants with limited musculoskeletal literacy was 38.8%. Multivariable logistic regression analysis with multiple imputation modeling demonstrated a significant positive relationship between patient income and adequate LiMP scores (p = 0.009) with an odds ratio of 1.15 (CI: 1.04; 1.28) while level of education (p = 0.173) and patient ethnicity (p = 0.830) among other patient characteristics did not have a significant relationship with LiMP scores. CONCLUSION In patients undergoing shoulder replacement surgery, low income was the only variable found to be predictive of limited musculoskeletal health literacy scores. Therefore, when discussing the risks and benefits of shoulder arthroplasty, orthopaedic surgeons should be cognizant of the possibility that any given patient may not meet the threshold of adequate musculoskeletal literacy.

Case Report: A 21-year-old female college athlete presented with continually worsening distal clavicle osteolysis. After conservative management and significant activity modification failed to resolve pain, surgical management was considered. Instability in the sagittal plane was believed to contribute to her persistent pain. Surgical management included acromioclavicular (AC) ligament reconstruction, in addition to the standard distal clavicle excision. Conclusion: Horizontal instability in the AC joint may contribute to the failure of conservative treatment in patients with distal clavicle osteolysis. If surgical management is considered, AC ligament reconstruction, in addition to the standard distal clavicle excision, may provide additional benefit in functional outcomes.

Purpose To report the rate of return to sport following revision anterior cruciate ligament (ACL) reconstruction in athletes. Methods A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for athletes undergoing revision ACL reconstruction at a minimum 1-year follow-up. The primary outcome measure was return to sport following revision ACL reconstruction. Secondary outcomes were International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, Tegner and Lysholm scores, KT-1000 arthrometer measurements, and rates of ACL rerupture. A subjective analysis was performed, and data were summarized using forest plots, ranges, and tables. Results Thirteen studies met the inclusion criteria. The rate of return to sport at any level ranged from 56% to 100%. The rate of return to sport at preinjury level ranged from 13% to 69%. The average time to return to sport ranged from 6.7 to 12 months. The average patient-reported outcome scores ranged from 43% to 86% (International Knee Documentation Committee score), 45% to 95% (Knee Injury and Osteoarthritis Outcome Score), 4.3 to 9 (Tegner), and 84% to 91% (Lysholm). KT-1000 arthrometer measurements ranged from 1.2 to 3.1 mm. Rates of ACL rerupture ranged from 0% to 20%. Conclusions This systematic review demonstrated a relatively high rate of return to sport at any level in patients who underwent revision ACL reconstruction, but a relatively low rate of return to sport at preinjury level of play. Patient-reported outcomes were favorable, showing improvement at follow-up from preoperative scores. Rates of ACL rerupture were high relative to those reported for primary ACL reconstruction. This study suggests that athletes may have difficulty resuming their previous level of sport following revision ACL reconstruction but have a good chance of returning to a lower level of play. Level of Evidence Level IV, systematic review of Level II-IV studies.

Introduction: The purpose of this study was to determine how wait time duration is associated with patient satisfaction and how appointment characteristics relate to wait time duration and patient satisfaction in the orthopedic surgery clinic. Methods: Two hundred sixty-four patients visiting one of 3 ambulatory orthopedic surgery clinics were asked to estimate their wait time and to rate their satisfaction with the visit. The associations between appointment characteristics, wait time, and satisfaction were analyzed using t tests, 1-way analysis of variance, and Pearson correlation coefficients. Results: Wait times were significantly different based on visit type, appointment time, whether an X-ray was required, and whether a trainee was involved ( P < .001). Patients with wait times less than 30 minutes had higher satisfaction scores ( P < .001). Satisfaction ratings were significantly different based on the surgeon’s management recommendation ( P = .0211), but were not significantly different based on sex, age, office location, visit type, appointment time subsection, or time spent with the physician ( P > .05). Conclusion: Wait times negatively correlated with satisfaction. New patient visits, appointment times in the later third of the day, appointments requiring an X-ray, and appointments involving a trainee had significantly longer wait times. Care should be taken to inform patients with visits involving these characteristics that they may experience longer than average wait times.

BACKGROUND: The incidence of elbow injuries and ulnar collateral ligament (UCL) reconstruction in adolescent athletes is increasing. Knowledge and expectations of outcomes following this procedure are necessary for proper counseling and decision-making in this age group. QUESTIONS/PURPOSES: We sought to report patient-reported outcomes, rate of return to sport, and rate of complications and reoperation following UCL reconstruction in adolescent athletes. METHODS: A systematic review was conducted for adolescent athletes undergoing UCL reconstruction. The primary outcome measure was patient-reported outcome scores, specifically the Conway Scale, the Andrews-Timmerman score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) score. Secondary outcome measures included return to sport, rate of subsequent procedures, and complication rate. A descriptive analysis was performed. RESULTS: Seven studies met the inclusion criteria. The average patient-reported outcome scores ranged from 81 to 87% (Conway, “excellent”), 83.6 to 92.7 (Andrews-Timmerman), and 76 to 89.3 (KJOC). The average rates of return to sport were 84% to preinjury level or higher, 93% to any level, and 57% to a higher level. Complication rates ranged from 0.7 to 11%. Rate of subsequent elbow procedures ranged from 0 to 10%. CONCLUSIONS: This systematic review demonstrates favorable outcomes in adolescent athletes following UCL reconstruction. Patient-reported outcome scores and rates of return to sport were comparable with those reported in adult athletes. The procedure is not without risk of complications, and patients and parents should be counseled regarding this risk prior to surgery. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09689-9) contains supplementary material, which is available to authorized users.

Background Patient-based evaluation of health care has been gaining attention in the past 2 decades. The purpose of this study was to evaluate patient satisfaction in a shoulder outpatient clinic and determine which factors impact satisfaction levels. Methods Fifty-nine outpatients with shoulder complaints from December 2017 to January 2018 were included. Patient satisfaction was measured using the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, and 2 methods of calculation were implemented: top-box and average scores. The impacts of age, gender, diagnosis, duration with the provider, Patient-Reported Outcomes Measurement Information System score, Pain Catastrophizing Scale score, pain visual analog scale (VAS) score, and function VAS score on patient satisfaction were analyzed. Patients were divided into more satisfied and less satisfied groups, and logistic regression analysis was performed to determine which factors affect patient satisfaction. Results The median total average and top-box scores were 95.2% and 90%, respectively. Similarly, in the analysis of all variables, average scores were always higher than top-box scores. The function VAS score and Patient-Reported Outcomes Measurement Information System score significantly influenced satisfaction. When patients were divided into more satisfied and less satisfied groups, the odds of having a less satisfied score among patients with a function VAS score of less than 5 was 5.5 times that of patients with a score of 5 or greater (odds ratio of 5.06 [95% confidence interval, 1.55-16.46] with P = .01 for univariate and adjusted odds ratio of 5.53 [95% confidence interval, 1.14-26.76] with P = .03 for multivariate). Conclusion Despite being calculated from the same question set, using the average-score method for the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey generally yields higher scores than the top-box method. Among patients with shoulder pathology, function of the shoulder, as measured on a VAS, was the most significant factor influencing patient satisfaction in the outpatient setting.

American football is one of the most popular sports in the United States (US) among youth and high school athletes; however, participation is decreasing due to concerns about safety. This has led to many new safety initiatives over the last decade, but few studies have sought to evaluate if these interventions have made football safer. The purpose of this study is to investigate national-level data on football-related injuries to compare the injury characteristics and specific injury risks of high school and youth athletes over the last decade.This cross-sectional, retrospective study queried the National Electronic Injury Surveillance System (NEISS) database from 2010-2019 to compare national weighted estimates and injury characteristics of youth (ages 6-12) and high school (ages 14-18) athletes presenting to US emergency departments (EDs) with football-associated injuries.The overall injury risk of football-related injuries presenting to US EDs for high school athletes was 16.17 (C.I. 13.85-18.38) per 1,000 participants/year compared to 11.97 (C.I. 10.34-13.41) per 1,000 participants/year in youth athletes. From 2010 to 2019, the overall injury risk for youth athletes participating in football significantly (p 0.0001) decreased from 13.31 (C.I. 11.23-15.38) per 1,000 participants to 9.93 (C.I. 7.24-12.62) per 1,000 participants. Additionally, the overall injury risk for high school athletes participating in football significantly (p 0.0001) decreased from 2010 (N = 18.63 [C.I. 16.05-21.21] per 1,000 participants) to 2018 (N = 13.19 [C.I. 9.94-16.44] per 1,000 participants). High school athletes were almost twice as likely and 2.37 times more likely to present with knee and shoulder injuries compared to youth athletes per 1,000 participants/year.Our study provides evidence that the overall injury risk for both youth and high school football players has significantly decreased since 2010. Furthermore, our study demonstrates that these athletes sustain unique injury characteristics.

To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45.From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes.Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24-60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45-66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability.In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up.Therapeutic IV, Case Series.

A growing number of studies utilizing wearable technologies are examining the influence of the autonomic nervous system (ANS) on intense training, recovery, and injury risk. Exercise biometric (EB) data were collected on collegiate, female soccer players during a preseason camp. One player sustained an anterior cruciate ligament (ACL) injury. Baseline anthropometric and EB data were compared to non-injured, position-matched teammates. All players had similar baseline testing. The injured athlete had a higher body mass index (BMI) and slower vision reaction time (RT). On the day of her injury (DOI), relative percentage heart rate recovery (tHRR) between intense training sets was calculated. Relative percentage tHRR was much lower for the injured athlete, indicating reduced recovery between training sets immediately prior to the injury. Also on DOI, the injured athlete had a lower glomerular filtration rate (GFR). In addition to BMI and RT differences, the lower relative percentage tHRR and GFR on the DOI observed for the injured athlete may reflect an imbalanced ANS recovery, and potentially to risk factors leading to her ACL injury.

Purpose: To evaluate the impact of either Medicaid or private insurance on securing an appointment in an outpatient orthopaedic clinic and to determine waiting periods until an appointment as well as the relationship between population metrics and access to care. Methods: A total of 88 clinics were called. There were 2 fictitious patients, one with an anterior cruciate ligament (ACL) injury and the other with a medial meniscus injury, with each calling as having Medicaid or private insurance. Clinic responses were recorded for whether an appointment could be made, when it was scheduled, and with what provider. Results: A total of 32 of 88 (36.4%) of the clinics scheduled an appointment for the Medicaid patient reporting an ACL injury versus 71 of 88 (80.6%) of the clinics that scheduled an appointment for the same patient with private insurance. A total of 34 of 88 (38.6%) of the clinics scheduled an appointment for the Medicaid patient reporting a medial meniscus injury versus 71 of 88 (80.6%) of the clinics that scheduled an appointment for the same patient with private insurance. Mean waiting period for ACL patients with Medicaid was 8.6 days and 4.5 days for patients with private insurance, whereas medial meniscus patients with Medicaid was 7.7 days and 5.4 days for patients with private insurance. In total, 60 of the 66 (90.9%) patients with Medicaid who received an appointment were scheduled to see the orthopaedic surgeon (30 in both ACL and medial meniscus groups). In total, 126 (71.6%) patients with Medicaid and 34 (19.3%) patients with private insurance of the 176 encounters faced barriers to scheduling an appointment. Rural communities were associated with appointment acceptance for patients with Medicaid (P < .05), and patients with private insurance had successful appointment scheduling in all community types (P < .05). Conclusions: This study suggests that patients with Medicaid are less likely to receive orthopaedic care for multiple sports medicine injuries, are more likely to encounter barriers, and endure longer waiting periods. There are different patterns of insurance acceptance according to population metrics. Clinical Relevance: Serves as a baseline evaluation of the difference in access to health care that may be impacted by increases in Medicaid coverage and/or changes in government policies.

BACKGROUND: The two most common surgical treatment modalities for anterior cruciate ligament reconstruction (ACL), patellar tendon (PT) and hamstring tendon (HS) autografts, have been shown to have outcomes that are both similar and favorable; however, many of these are short or intermediate-term. The objective of this systematic review is to evaluate randomized controlled trials (RCTs) with a minimum 10-year follow-up data to compare the long-term outcomes of ACL reconstructions performed using PT and HS autografts. METHODS: This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A search of three databases (PubMed, Cochrane and EMBASE) was performed to identify RCTs with a minimum of 10-year follow-up that compared clinical and/or functional outcomes between PT and HS autografts. RESULTS: Four RCTs with a total of 299 patients were included in the study. The mean follow-up ranged from 10.2 to 17 years (mean, 14.79 years). No significant differences in knee laxity or clinical outcome scores were demonstrated in any of the studies. One study found that PT autografts were significantly more likely to have osteoarthritis identified by radiographic findings. Two studies found that patients with PT autografts reported increase kneeling pain, while none of the four studies reported a difference in anterior knee pain. There were no significant differences in graft failure rates. CONCLUSION: This review demonstrates no long-term difference in clinical or functional outcomes between PT and HS autografts. However, radiographic and subjective outcomes indicate that patients with PT autografts may experience greater kneeling pain and osteoarthritis. Therefore, orthopaedic surgeons should consider patient-centric factors when discussing graft options with patients.

Purpose To determine patients’ baseline understanding of overlapping surgery and to evaluate how education changes the perception of the practice in orthopaedic shoulder pain patients at a single institution. Methods All patients who visit the clinic with a chief complaint of shoulder pain were given a 15-question survey. The initial 15-question survey assessed demographics, pre-existing knowledge on the practice of overlapping surgery, and their perception of it. They immediately read a statement on the practice of overlapping surgery. After reading the statement, patients were re-evaluated on their level of concern. Results A total of 100 patients (55 female, 45 male) completed the survey. Mean age was 53.0 (range, 18-85) years. In total, 38 (38%) had no knowledge on the practice of overlapping surgery; 27 (27%) reported their level of concern as a 1, the lowest level of concern. Overall, 84 (84%) patients reported a level of concern of 3 (median) or lower, indicating a low level of concern. A total of 95 (95%) patients reported either a decrease or no change in level of concern after reading an educational statement on overlapping surgery practices, and 60 (60%) believed there would be no impact if an overlapping surgery was performed. If a patient reported a high level of concern, the most common reasons cited were that the attending physician may not be available during the whole case (15%); that a resident, fellow, or physician assistant may jeopardize the patient’s care (24%); or that a critical step would be missed (37%). Conclusions There is a low level of baseline understanding of overlapping surgery in patients with shoulder pain. An educational component added during patient counseling proved to be effective in decreasing the level of concern. This study suggests that counseling and education on overlapping surgery may change patient perception and opinion of the practice. Clinical Relevance Serves as an evaluation of the knowledge of a specific patient population on overlapping surgery and how it changes with counseling and education.

» Orthopaedic surgery reports one of the lowest proportions of female residents among all medical specialties. While the number of female medical students has increased, our field has been particularly slow to respond to the gender gap. » There are several barriers to increased female representation in orthopaedics, including “jock” culture and male dominance, the residency application process, pregnancy and lifestyle concerns, a limited number of mentors and role models, and lack of early exposure to the field. » Organizations such as the American Academy of Orthopaedic Surgeons (AAOS), the Ruth Jackson Orthopaedic Society, The Perry Initiative, Nth Dimensions, and the J. Robert Gladden Society, as well as social media channels, are working to close the gender gap, but there is still more that needs to be done. » By acknowledging and addressing these barriers, both at an individual and institutional level, we can hopefully bring more women into the field. This will ultimately benefit not only ourselves, but our patients as well.