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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.

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

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 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.

The relationship between preoperative hyponatremia and 30-day outcomes following total hip arthroplasty (THA) is currently unknown. The present study used prospectively collected data to quantify the association between preoperative hyponatremia and odds of major morbidity (MM), longer length of stay, readmission, and reoperation within 30 days following THA. Patients who underwent THA between 2012 and 2014 were identified in the National Surgical Quality Improvement Program database using validated Current Procedural Terminology codes. Patients were included if they were either normonatremic or hyponatremic preoperatively. The outcome measures in this study were 30-day MM, hospital length of stay, 30-day readmission, and 30-day reoperation. A unique multivariable logistic regression model was used for each outcome to identify statistically significant associations between hyponatremia and the outcome of interest after adjusting for covariates. From 2012 to 2014, 59,236 THA procedures were recorded in National Surgical Quality Improvement Program, of which 55,611 patients were normonatremic and 3,051 patients were hyponatremic. After adjusting for covariates, preoperative hyponatremia was significantly associated with increased odds of MM (odds ratio [OR] = 1.14; 99% confidence interval [CI]: 1.01–1.30), 30-day reoperation (OR = 1.18; 99% CI: 1.02–1.36), and longer hospital length of stay (OR = 1.20; 99% CI: 1.13–1.27). Hyponatremia was not significantly associated with greater odds of 30-day readmission (OR = 0.91; 99% CI: 0.82–1.01). Preoperative hyponatremia was significantly associated with adverse 30-day outcomes following THA. As the U.S. health care system continues to transition toward value-based reimbursement that emphasizes health care quality, the results of the present study can be used to improve patient selection and preoperative counseling.

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.

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.

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.

Purpose To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care. Methods A systematic review of the available literature on PROMIS scores in shoulder care was performed. This review was accomplished per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Results A total of 11 studies that reported data on 1485 patients met inclusion criteria. There was a strong correlation between general function PROMs and the PROMIS PF for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and proximal humerus fractures. In addition, there was a strong correlation between PROMIS UE and legacy PROMs in patients with rotator cuff injury and shoulder instability. PROMIS instruments asked fewer questions than legacy PROMs (9.46 vs 12.99, respectively), took less time to complete (88.21 vs 96.53 seconds, respectively), had less floor effects in both PROMIS PF and UE (0.17% and 0.62% vs 2.89%, respectively), and had lower ceiling effects for PROMIS PF but not PROMIS UE assessments (0.17% and 6.37% vs 1.89%, respectively). Conclusions This systematic review demonstrated PROMIS instruments have varying correlations with legacy PROMs measures for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and glenohumeral arthritis. PROMIS instruments do measure clinical outcomes faster and with fewer questions. Other than PROMIS UE v1.2 ceiling effects, PROMIS instruments have lower rates of floor and ceiling effects. Level of Evidence Level IV, systematic review of Level II-IV studies.

Alterations in the mechanical properties or "hardness" of tissues allow physicians to detect disease by palpation. Recently, attempts have been made to quantitate and image these tissue properties with the use of magnetic resonance elastography (MRE). This technique has been validated in ex vivo specimens, including kidney, breast, and prostate. In this study, in vivo MRE imaging of rat renal cortex is demonstrated and validated with a disease model that will facilitate further studies. Normal rats and rats with nephrocalcinosis induced with either 2 or 4 weeks of ethylene glycol exposure were studied with MRE. Histology in the diseased rats documented the presence of nephrocalcinosis. MRE measurements and images of shear stiffness were highly reproducible in individual rats. The shear stiffness of the renal cortex in normal rats was 3.87 kPa (95% CI 2.84-4.90 kPa). The shear stiffness increased to 5.02 kPa (95% CI 3.34-6.70 kPa) after 2 weeks of exposure, and to 6.49 kPa (95% CI 4.84-8.14 kPa) after 4 weeks of exposure (P = 0.0302, alpha < 0.05). MRE is capable of detecting alterations in the tissue mechanical properties of kidneys in vivo. It is a promising noninvasive technique that might have pathologic and prognostic significance.