Boddu, Sayi P.

Background: There has been minimal literature evaluating how a prior myocardial infraction (MI) influences outcomes after total knee arthroplasty (TKA). Thus, the purpose of this study was to evaluate how the timing, type, and treatment of MI prior to TKA affect postoperative cardiac complications, general medical complications, and surgical complications. Methods: A retrospective comparative study was conducted using a large insurance database. Patients undergoing primary TKA for osteoarthritis were included. Patients who had experienced MI within 2 years before TKA were identified and were matched 1:4 with patients who had not had such an MI on the basis of demographic variables and comorbidities. Patients who had a prior MI were stratified into 4 groups based on the timing of the MI: 0 to <6 months, 6 to <12 months, 12 to <18 months, and 18 to 24 months before TKA. The rates of postoperative cardiac, general medical, and surgical complications were compared between groups. Subanalyses on the prior MI type, treatment, and location were performed. Results: Prior MI was associated with increased risks of postoperative MI (odds ratio [OR], 3.97 [95% confidence interval (CI), 3.20 to 4.93]), heart failure (OR, 1.45 [95% CI, 1.24 to 1.75]), and 90-day mortality (OR, 2.15 [95% CI, 1.41 to 3.28]). The risk of postoperative MI was highest for those with MI within 6 months before TKA (OR, 6.86 [95% CI, 5.34 to 8.82]). Type-1 MI, ST-elevation MI (STEMI), non-ST-elevation MI (NSTEMI), and anterior and inferior MIs were linked to elevated postoperative MI and/or mortality risks, with timing closer to surgery further amplifying the risk. Percutaneous coronary intervention within 6 months before TKA also increased postoperative risks. Type-2 MI within 6 months before TKA was associated with an increased risk of periprosthetic joint infection compared with controls (OR, 4.23 [95% CI, 1.67 to 10.67]). Conclusions: Patients who had a prior MI, particularly within 6 months before TKA, had significantly elevated risks of postoperative MI, heart failure, and mortality. Outcomes varied by MI type, treatment, and location, with type-1 MIs and STEMIs increasing the postoperative mortality risk. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Purpose To evaluate which patient factors are associated with specific metrics of poor access to care in patients with a rotator cuff tear (RCT). Methods The All of Us Database was utilized to form a cohort of patients with RCT between May 2018 and May 2023. Patients with a diagnosis of RCT using Systematized Nomenclature of Medicine clinical terms were included. The association of RCT diagnosis and patient‐specific factors on self‐reported outcomes of “delayed care,” “could not afford care,” “skipped medication,” and “have not seen provider in more than 1 year” were analyzed. Statistical tests performed were univariate regression and multivariable logistic regression. Results In total, 4,265 patients with RCT who completed the access to care survey were included. In the RCT cohort, 26.7% reported delayed care, 24.9% reported an inability to afford care, 12.1% reported skipped medications, and 1.7% reported not seeing a provider in more than 1 year. Multivariable analysis of patient treatment and demographic features revealed younger age, female sex, lower income, poor physical health, and poor mental health to be strongly associated with higher reported rates of delayed care, inability to afford care, and skipped medications. History of rotator cuff repair, marital status, and sexual orientation were not associated with reported poor access to care. Conclusions A quarter of patients with rotator cuff tears report delays in overall medical care and inability to afford care. Among patients diagnosed with RCT, patients of younger age, female sex, low income, and poor physical and mental health have higher odds of decreased access to health care. Clinical Relevance Health care disparities and access to care are topics that should be investigated to reduce them.

Background: Solid organ transplant (SOT) recipients are living longer and, consequently, more of them require elective total hip arthroplasty (THA) to restore mobility and improve quality of life. Because these patients are chronically immunosuppressed and often burdened by multiple comorbidities, their peri-operative risk profile may differ substantially from that of the general THA population. This study aimed to evaluate risk factors associated with acute medical and surgical complications, implant survivorship, and overall mortality in patients with a history of SOT who underwent THA. Methods: A total of 173 THA procedures were reviewed in patients with previous SOT. Among them, 64 had undergone liver transplantation (LT), 83 had received renal transplants (RT), and 26 had experienced more than one type of organ transplant (MT). Kaplan–Meier survival analysis was employed to estimate median survival. Complications were examined using univariate analysis through mixed-effects logistic regression, while Cox regression was utilized to assess mortality risk. The median follow-up period extended to 99 months. Results: The proportion of patients experiencing at least one acute medical event was 27% in the LT group, 33% in the RT group, and 38% in the MT group, with no statistically significant difference between groups (p = 0.5). American Society of Anesthesiologists Class (ASA) 4 (Odds Ratio (OR) = 28; p = 0.006) and treatment with bisphosphonates (OR = 2.25; p = 0.03) were associated with higher risk of acute medical complications. Increased age at the time of SOT was linked to a reduced likelihood of surgical complications (OR = 0.94, p = 0.008), as was older age at the time of undergoing THA (OR = 0.92, p = 0.001). The observed rates of reoperation and implant revision were 3% and 1%, respectively. The estimated patient survivorship rates at 1, 5, and 10 years were 98.6, 82, and 58.4%, respectively. Older age at SOT (Hazard Ratio (HR) = 1.06, p < 0.001), at THA (HR = 1.08, p < 0.001), ASA 4 at THA (HR = 7.57, p = 0.02), and atrial fibrillation (AFib) (HR = 3.13, p = 0.02) were associated with higher mortality. Conclusions: ASA 4 and bisphosphonates were associated with a higher risk of acute medical complications, whereas older age was associated with lower surgical complications. Additionally, older age, ASA 4, and AFib were associated with higher mortality.

Objective The aim of the study was to assess the interrater reliability between seven individuals assessing quadriceps femoris cross-sectional area, echo intensity, and corrected echo intensity. Design A retrospective subanalysis of data collected in a randomized controlled clinical trial (IRB 19-008473. NCT ID NCT04302558). Patients aged 13–50 yrs with an anterior cruciate ligament tear requiring surgical reconstruction were assessed for cross-sectional area of the rectus femoris, vastus intermedius, vastus lateralis, vastus medialis, and vastus medialis obliquis, and echo intensity of the rectus femoris. Musculoskeletal ultrasound imaging of the quadriceps was performed by one physical therapist, and quantitative assessments were performed by four physicians and three physical therapists. Results Physicians and physical therapists had good reliability for cross-sectional area of the rectus femoris (median interclass correlation 0.86 doctor of medicine (MD) and 0.84 physical therapist), cross-sectional area of the vastus medialis obliquis (0.82 and 0.82), and echo intensity mean (0.92 and 0.92). Rectus femoris cross-sectional area had the smallest coefficient of variation (26.512.7%), whereas subcutaneous fat had the largest coefficient of variation (93.3% left, 86.4% middle, 86.1% right). Conclusions These findings demonstrate reliability between physicians and physical therapists in interpretation of ultrasound images of the quadriceps. The inconsistency demonstrates the need for a consistent training across disciplines to ensure accurate image interpretation.

Purpose To use the All of Us database to investigate barriers to health care access for patients with meniscus tears and to examine how specific demographic, socioeconomic, and health‐related factors independently influence their health care utilization. Methods The National Institutes of Health All of Us database was queried for patient data between March 2017 and March 2023 to form a cohort of patients with meniscal tears. Patients with meniscal tears were identified using Systematized Nomenclature of Medicine clinical terms. All patients with self‐reported meniscus tears were included, with no exclusion criteria to ensure a diverse representation of underrepresented individuals. Patient responses to the “Healthcare Access and Utilization Survey” were analyzed across 4 domains: “delayed care,” “could not afford care,” “skipped medication,” and “have not seen a provider in over one year.” Results In total, 5,671 survey respondents with meniscal tears were included for analysis from a population of 436,000 eligible records. Among them, 27.7% reported delayed care, 23.9% were unable to afford care, 11.8% skipped medication, and 2.0% had not seen a provider in over a year. Patients with annual incomes under $50,000 were more likely to delay care (odds ratio [OR], 1.41; P < .001), be unable to afford care (OR, 1.73; P < .001), or skip medications (OR, 1.79; P < .001). Younger age than the cohort mean of 65.4 years, female sex, and poor physical and mental health were associated with impaired access in at least 1 care domain. Conclusions Over one‐fourth of patients with a diagnosis of meniscus tear who responded to the All of Us “Healthcare Access and Utilization Survey” reported difficulties with access to care across 4 domains, with those of low income, younger age, female sex, and poor mental or physical health experiencing significant barriers to care. Clinical Relevance This research can inform strategies for equitable treatment of meniscal injuries by highlighting disparities in orthopaedic care access and utilization.

Abstract Objective To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit. Background Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders. Methods A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16‐month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age‐ and sex‐matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation. Results In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0–3.2]; p = 0.338). Conclusions In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

Background: Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS. Methods: This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care. Results: In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care. Conclusion: Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Purpose To systematically review the existing literature on the functional performance of athletes at the time of return‐to‐sport (RTS) clearance after anterior cruciate ligament reconstruction (ACLR). Methods A systematic literature search of the MEDLINE, EMBASE, Scopus, and Web of Science databases was performed. The inclusion criteria were original research reports with study populations of athletes who had undergone ACLR and had undergone objective functional testing immediately after clearance to RTS. Functional testing was stratified by hop tests, strength tests, kinetic assessment, and kinematic assessment, and data were extracted from each study using a standardized template. Results Of the 937 unique studies identified, 46 met the inclusion criteria. The average time between ACLR and functional testing was 7.9 months among the included studies. In 10 of 17 studies, patients were found to have an average quadriceps strength limb symmetry index of less than 90%. However, only 2 of 12 studies found the average hop test limb symmetry index to be less than 90%. Kinematics included reduced knee flexion angle and increased trunk flexion on landing in ACLR patients compared with matched controls. On evaluation of kinetics, ACLR patients showed reduced peak vertical ground reaction force, lower peak knee extension and knee flexion moments, and altered energy absorption contribution compared with matched controls. Conclusions This systematic review suggests that athletes show functional deficits at the time of RTS at an average of 7.9 months after ACLR. Traditional functional tests, such as strength and hop tests, are not able to accurately identify patients who continue to show deficits. The most common biomechanical deficits that persist after RTS clearance include diminished peak knee extension moment, decreased knee flexion angle, increased trunk flexion angle, reduced vertical ground reaction force, and increased hamstring central activation ratio during various functional gait and landing tasks. Level of Evidence Level III, systematic review of Level I to III studies.

ABSTRACTBackgroundTreating functional movement disorder (FMD) with motor retraining is effective but resource intensive.ObjectivesIdentify patient, disease, and program variables associated with favorable treatment outcomes.MethodsRetrospective review of the 1 week intensive outpatient FMD program at Mayo Clinic in Minnesota from February 2019 to August 2021. Outcomes included patient‐reported measures (Canadian Occupational Performance Measure‐Performance and Satisfaction subscales [COPM‐P and COPM‐S, range 0–10] and Global Rating of Change [GROC, −7 to +7]) and a retrospective investigator‐rated scale (0–3, worse/not improved to significantly improved/resolved). Linear regression models identified variables predicting favorable outcomes.ResultsParticipants (n = 201, 74% female, mean age = 46) had median FMD duration of 24 months. The commonest FMD subtypes were gait disorder (65%), tremor (41%) and weakness (17%); 53% had ≥2 subtypes. Most patients (88%) completed a therapeutic screening process before program entry. Patient‐reported outcomes at the end of the week improved substantially (COPM‐P average change 3.8 ± 1.9; GROC post‐program average 5.5 ± 1.7). Available investigator‐rated outcomes from short‐term follow‐up were also positive (102/122 [84%] moderately to significantly improved/resolved). Factors predicting greater improvement in COPM‐P were completing therapeutic screening, higher number of non‐motor symptoms, shorter FMD duration, earlier program entry, lower baseline COPM scores, and (among screened patients) higher GROC between therapeutic screening and program start.ConclusionPatients with diverse FMD subtypes improved substantially over a 1 week period. Utilization of therapeutic screening and greater improvement between therapeutic screening and program start were novel predictors of favorable outcomes. Non‐motor symptoms did not preclude positive responses, although patients with predominant non‐motor burden were excluded.