Differences In Objective Outcomes Research Articles

The impact of social deprivation on rotator cuff repair outcomes

BackgroundRotator cuff tears are a common orthopedic injury and the role of social determinants of health (SDoH) in surgical outcomes remains underexplored. The goal of this study was to investigate the correlation between social deprivation, measured by the Area Deprivation Index (ADI), and outcomes following arthroscopic rotator cuff repair. MethodsWe conducted a retrospective chart review on patients undergoing primary arthroscopic rotator cuff repair at a level one academic center between 2006 and 2019. Patient demographics (age, gender, race), comorbidities, ADI scores, range of motion, visual analog pain scores, and patient-reported outcomes (SST, ASES, and QuickDASH) were collected. Patients were stratified into terciles based on their relative level of deprivation. Statistical analysis was performed using ANOVA, t-tests, chi-square tests, and univariate/multivariate logistic regression. Results322 patients were included in this study. The most deprived group had a higher prevalence of diabetes compared to the least and intermediately deprived group (p<0.001). Massive tear occurrence was greater in the least deprived group (p=0.003) compared to the most deprived group. There was no difference in objective outcomes between groups. Patient-reported outcomes (SST, ASES, and QuickDASH) were worse in the most deprived group compared to the least and intermediate deprived groups. ConclusionSocial deprivation significantly affects patient-reported outcomes in rotator cuff repair surgery. While clinician-reported outcomes were consistent, patients' perceptions varied based on social determinants. Integrating SDoH considerations in orthopedic care is a promising next step in securing equitable approaches. However, more research is needed to validate and expand these findings.

Race as a factor in adverse outcomes following unruptured aneurysm surgery

IntroductionStrong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States. MethodsData from the 2012–2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type. Results7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07–1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients. ConclusionOur nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

Paper 85: Superficial MCL Augmented Repair Versus Reconstruction: A Multi-Center Randomized Controlled Trial

Objectives:The purpose of this study was to compare clinical outcomes between randomized groups who underwent MCL augmentation repair versus MCL autograft reconstruction.Methods:Patients were prospectively enrolled from 2013 to 2019 from 3 centers (United States, Norway, Denmark). Grade III superficial (sMCL) injuries were confirmed by stress radiography. Patients were randomized to an anatomic sMCL reconstruction versus an augmented repair with surgical treatment determined after examination under anesthesia confirmed sMCL incompetence. Post-operative visits occurred at 6 weeks and 6 months for repeat evaluation and repeat stress radiography at final follow-up. Patient reported outcome measures (PROMs) were obtained preoperatively and postoperatively at 6 months, 1 year, and at final follow-up. The two one-sided t-test (TOST) procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and Mann-Whitney U-test was used to compare postoperative PROMs between groups.Results:Fifty-four patients were prospectively enrolled from 3 centers. The average overall patient age was 38.0 years (standard deviation (SD = 14.2 years), average body mass index was 25.0 (SD = 3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (SD = 1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (SD = 1.46 mm) in the MCL augmentation group and 3.42 mm (SD = 0.55) in the MCL reconstruction group (p = 0.036). Postoperative valgus stress radiographs at an average of 6 months were 0.21 mm (SD = 0.81 mm) for MCL augmentation and 0.19 mm (SD = 0.67 mm) for MCL reconstruction (p = 0.940). At final follow-up (minimum 1-year), Lysholm scores were significantly higher in the reconstruction group (median 90, inter-quartile range 83–99) compared to the repair group (median 80, IQR 67-92; p=0.031). Final IKDC scores were significantly higher for the reconstruction group (median 85, IQR 68-89) compared to the repair group (median 72, IQR 60-78; p=0.039). Postoperative Tegner scores were not significantly different between the repair group (median 5, IQR 3.5-6) and the reconstruction group (median 5.5, IQR 4-7; p=0.123). Patient satisfaction was not significantly different between the repair (median 7.5, IQR 5.75–9.25) and reconstruction groups (median 9, IQR 7 - 10; p=0.184). There were no reported cases of DVT, infection, or arthrofibrosis in any patient in either group. There were no reported MCL graft ruptures in either the augmentation or reconstruction group as indicated from valgus stress radiographs (≥ 3.2 mm) and physical examination at 12 months postoperatively.Conclusions:There was no difference in objective outcomes between a sMCL augmentation repair versus a complete sMCL reconstruction at one year postoperatively. Patient reported clinical outcomes favored the reconstruction over repair. This randomized controlled trial demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had low risk of graft attenuation and complications.Table 1.Comparison of baseline covariates between MCL Treatment Groups.† Table A2.Comparison of baseline covariates between sites.†

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial

Background: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. Purpose/Hypothesis: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. Results: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group (P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) (P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] (P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) (P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) (P = .184). Conclusion: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

The Role of Specialty Tubes in Preventing Ventilator-Associated Events.

There have been many innovations to the standard endotracheal tube over the years, many of which were intended to reduce the incidence of ventilator-associated pneumonia (VAP). Ventilator-associated events are associated with the objective outcomes of increased duration of mechanical ventilation, length of ICU and hospital stay, and increased risk of mortality. Many specialty tubes have been associated with a reduction in the clinical diagnosis of VAP, but studies have failed to show differences in objective outcomes. This article reviews the evidence related to specialty tubes and discusses their role in improving objective outcomes associated with ventilator-associated events.

Cosmetic aspects in minimally ınvasive parathyroidectomy: Is minimally invasive approach superior?

Aim: The&#x0D; aim of this study was to determine whether minimally invasive parathyroid&#x0D; surgery has any positive impact on cosmesis.&amp;nbsp;Materials and Methods: This case control study included 28 parathyroidectomized patients, who&#x0D; had been operated between January 2006 – December 2008. All patients were&#x0D; called back for at least 8 months after surgery. Demographics were recorded.&#x0D; Minimally invasive parathyroidectomy versus conventional parathyroidectomy were&#x0D; compared by means of skin features (using Fitzpatrick’s classification),&#x0D; results of patient and independent observer scar assessment scales and&#x0D; photographic scar analysis by the blinded plastic surgeon.&amp;nbsp;Results: There&#x0D; were no differences in demographics and Fitzpatrick’s classification between&#x0D; both groups. As expected, incision length of the minimal invasive group was&#x0D; significantly shorter (2.6 ± 0.5cm vs. 4.9±1.0 cm, p=0.02). Meanwhile, no&#x0D; significant difference in objective outcomes of patients between groups was&#x0D; recorded. There was also no significant difference in photographic scar&#x0D; analysis between groups, while independent observer scar assessment scale&#x0D; scores were better in the minimal invasive group (p=0.03).&amp;nbsp;&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Conclusion: Although superior&#x0D; results of an independent observer, assessment of cosmesis by the plastic&#x0D; surgeon and the patient him/herself revealed no superiority of the minimally&#x0D; invasive approach, when compared to conventional parathyroid surgery.

Revision Ligament Reconstruction Tendon Interposition for Trapeziometacarpal Arthritis: A Case-Control Investigation

To test the null hypothesis that there is no difference in patient-reported and objective outcomes of revision ligament reconstruction and tendon interposition (LRTI) compared with primary LRTI. This case-control investigation enrolled 10 patients who had undergone revision LRTI at a tertiary care center. All patients had previously undergone primary trapeziectomy with LRTI. Patients with a minimum of 2 years' follow-up were eligible. All patients completed an in-office study evaluation. Controls (treated only with primary LRTI) were matched from our practice to reach a 1:2 case-control ratio. Outcome measures included Michigan Hand Questionnaire (primary outcome), Quick-Disability of the Arm, Hand, and Shoulder (QuickDASH) questionnaire, visual analog scale (VAS) for pain and improvement, and physical examination. Statistical analyses were conducted to compare patient groups. Patients who underwent revision LRTI reported significantly worse outcomes on all measured standardized questionnaires compared with primary patients. The Michigan Hand Questionnaire indicated worse overall outcomes (54 vs 79) as well as worse pain, appearance, and ability to complete activities of daily living. Compared with those who did not undergo revision LRTI, patients who did also reported more impairment (Quick-Disability of the Arm, Hand, and Shoulder, 47 vs 23), greater pain (VAS pain, 6.3 vs 1), and less improvement after surgery (VAS improvement, 2.7 vs 7.9). There was also a significantly higher rate of patient-reported depression in the revision LRTI group (50% vs 10% of patients treated with primary LRTI). We did not find a significant difference in objective outcomes of pinch strength, grip strength, and thumb palmar abduction between the 2 groups. After revision LRTI, patient-reported outcomes indicate worse perceived function and greater pain than are expected following primary LRTI despite similar motion and strength. Revision surgery can be offered in the setting of persistent or recurrent symptoms, but patients should be counseled that improvement of symptoms is unpredictable. Therapeutic III.

Retropubic Versus Transobturator Slings—Are the Outcomes Changing with Time?

The purpose of this review is to review the most current patient reported (subjective) and physician reported (objective) outcomes and adverse events associated with retropubic (RMUS) and transobturator (TMUS) mid-urethral slings. Since the two landmark meta-analyses published in 2010, four new RCT have been published and five have reported long-term outcomes comparing RMUS versus TMUS. Both RMUS and TMUS are safe and have efficacious longer-term outcomes. There is no difference between these slings' subjective outcomes. There is still debate regarding whether RMUS is slightly superior when assessing objective outcomes. Although three trials showed no difference in objective outcomes, results from the largest trial show that RMUS is superior. Further analysis suggests that women with poor urethral function have less favorable outcomes with TMUS and may do better with RMUS. Adverse events are common, and they differ depending on the surgical approach. These new trials confirm previous reported adverse events.

Increasing Patient Preparedness for Sacral Neuromodulation Improves Patient Reported Outcomes Despite Leaving Objective Measures of Success Unchanged

We assessed how a group shared appointment influenced patient preparedness for sacral nerve stimulation for refractory overactive bladder and/or urge urinary incontinence. We also evaluated subjective and objective outcomes. Patients considering sacral nerve stimulation were prospectively enrolled and invited to attend a group shared appointment. This 75-minute presentation included a question and answer period with an implanting surgeon and an implanted patient. Control patients received standard office counseling. A patient preparedness questionnaire was completed after the group shared appointment or office counseling. Response to treatment was determined using the postoperative satisfaction questionnaire, Patient Global Impression of Improvement (PGI-I) and voiding diaries. In our study 36 women with a mean ± SD age of 61 ± 15 years underwent sacral nerve stimulation. There was no significant difference in patient demographics between the 19 women who attended the group shared appointment and the 17 controls. Overall preparedness was greater in the shared appointment group (p = 0.043) with better understanding of the purpose of (p = 0.003) and alternatives to (p = 0.043) sacral nerve stimulation. Significantly more women in the shared appointment group than controls felt completely prepared (78.9% vs 29.4%, p = 0.003) and completely satisfied (78.9% vs 35.3%, p = 0.003) with sacral nerve stimulation as well as very much better (68.4% vs 17.6%, p = 0.002) according to the PGI-I. There was no difference between the groups in the number of women with a 50% or greater symptom reduction on voiding diary. Participating in a group shared appointment before sacral nerve stimulation improved patient preparedness and perceived outcomes of treatment, although there was no difference in objective outcomes based on voiding diary.

Alternative technique for open reduction and fixation of displaced pediatric medial epicondyle fractures: Author response to letter to the editor

We would like to thank Drs. Raj and Kothari for their comments. We are in agreement that the true position of the arm in this technique is “mid prone,” rather than full pronation. Our experience is that, in this position, even if not fully prone, very little, if any, tension is required to reduce the fragment, and, certainly, the amount of tension is less than that required when trying to reduce the fracture in the supine position. In this position, we postulate that the valgus movement assists in reduction; however, we agree that this is theoretical. We also agree that there is no objective evidence that this is superior, as stated in the final sentence of the discussion: “Finally, there is no difference in objective outcomes regarding this technique and its advantage is in the feel/ease of fracture reduction.” Ultimately, the goal of the manuscript is to offer an alternate surgical option for medial epicondyle fractures, and we believe that, in this case, whether a surgeon chooses to use this technique should be by feel or preference. For the co-authors, we have all found that prone positioning has made the procedure easier for us.

Medical or surgical treatment for chronic gastrooesophageal reflux? A systematic review of published evidence of effectiveness.

To compare the effectiveness of medical (antacids, histamine antagonists and proton pump inhibitors) and surgical (fundoplication) treatment of chronic GORD. Patients with objective (endoscopic or pH) evidence of chronic reflux reported in 6 randomised trials and 3 cohort studies, 1966-1999. Systematic review of comparative studies identified from electronic searches, citations, manual searches of journals, and correspondence with authors and experts. Improvements in prevalence or severity of symptoms, oesophagitis, pH reflux duration, lower oesophageal sphincter pressure, patients' satisfaction, and side-effects. Improved outcomes were more common after surgical than medical treatment with significant differences in objective outcomes in 5/6 randomised trials and in 2/3 cohort studies. Subjective outcomes (symptoms and patients' satisfaction) were also more common among surgical patients in all but one study that assessed them. Odds ratios for improvement with surgical rather than medical treatment ranged from 1.2 to 200, and numbers needed to treat ranged from 1.2 to 58, where these could be calculated. Studies were too heterogeneous for meta-analysis. In trials of chronic severe GORD, surgery is consistently more effective than medical treatment in relieving symptoms and objective oesophagitis, although omeprazole can give similar symptom relief with adjustment of the dose.