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

Bi, Andrew S.; Papalia, Aidan G.; Romeo, Paul V.; Schoof, Lauren H.; Kwon, Young W.; Rokito, Andrew S.; Zuckerman, Joseph D.; Virk, Mandeep S.
Background: The exact pathogenesis of idiopathic adhesive capsulitis (IAC) is not fully understood, but an inflammatory profibrotic cascade, largely mediated by transforming growth factor-beta 1 (TGF- β1) has been implicated. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-Is) both decrease the activity of TGF-β1. The aim of this study was to determine the impact of ACE-Is or ARBs use on the need for operative intervention in IAC. Methods: This was a retrospective cohort study of patients from a single institutional database with IAC, divided into two cohorts, with and without ACE-I and/or ARB use as the primary exposure and a minimum 2-year follow-up. The primary outcome measured was the incidence of operative intervention including manipulation under anesthesia (MUA) and arthroscopic capsular release (ACR). Additional multivariable logistic regression analysis was performed to evaluate associations between ACE-I/ARB use and likelihood of undergoing an operative procedure. Results: A total of 17,645 patients met inclusion criteria, with 5424 patients in the ACE-I/ARB cohort and 12,221 in the non-ACE-I/ARB cohort. Overall, 422 (2.4%) patients underwent surgical treatment, 378 (2.1%) ACR, and 74 (0.4%) MUA. There was no significant difference between cohorts in the frequency of surgical procedures or time to procedure since diagnosis. There were no significant differences between individual ACE-Is or ARBs, although Losartan was found to have a trend of decreased rate of intervention (31.7% vs. 36.8%, P = .209) when compared to patients not on losartan that did not reach statistical significance. Patient factors predictive of undergoing MUA/ACR were diabetes (P = .013), obesity (P < .001), and male sex (P < .001). Increasing patient age reduces the likelihood of undergoing operative intervention, with patients aged 50-70 years (P = .022) and age >70 years (P < .001) demonstrating reduced odds as compared to patients aged <30 years. Conclusion: Patients with IAC have an overall low (2.4%) rate of requiring surgical intervention. While the antifibrotic mechanism of ACE inhibitors and ARBs did not significantly affect the rate of requiring surgical intervention, male gender, obesity, younger age, and diabetes, all increased the risk for operative intervention. Losartan, specifically, may have a disease modifying effect on IAC that should be investigated with larger controlled trials.
ISSN: 2666-6383
CID: 5567702

Effects of increased body mass index on one year outcomes following soft tissue arthroscopic shoulder instability repair

Papalia, Aidan G.; Romeo, Paul V.; Gambhir, Neil; Alben, Matthew G.; Chowdhury, Tas; Simcox, Trevor; Rokito, Andrew; Virk, Mandeep S.
Background: The purpose of this study was to investigate the impact of high body mass index on the 1-year minimal outcome following arthroscopic shoulder stabilization. Methods: Patients who underwent arthroscopic Bankart repair (ABR) between 2017 and 2021 were identified and assigned to 1 of 3 cohorts based on their preoperative body mass index: normal (18-25), overweight (25-30), and obese (>30). The primary outcomes assessed were postoperative shoulder instability and revision rates. The 3 groups were compared using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, pain intensity, Clinical Global Impression scores, visual analog scale pain scores, and shoulder range of motion at 1 year postoperatively. Results: During the study period, 142 patients underwent ABR and had an average age of 35 ± 10 years. Obese patients had a higher percentage of partial rotator cuff tears (60% vs. 27%, odds ratio: 3.2 [1.1, 9.2]; P = .009), longer mean operative time (99.8 ± 40.0 vs. 75.7 ± 28.5 minutes; P < .001), and shorter time to complication (0.5 ± 0 vs. 7.0 ± 0 months; P = .038). After controlling for confounding factors, obesity was associated with a lesser improvement in upper extremity function scores (obese vs. normal: −4.9 [−9.4, −0.5]; P = .029); although this difference exists, found future studies are needed to determine the clinical significance. There were no differences in patient reported outcome measures, recurrence rate, or revision surgery rates between cohorts at any time point (P > .05). Conclusion: Obesity is an independent risk factor for longer operative times but does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores 1 year following ABR.
ISSN: 2666-6383
CID: 5567762

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

Alben, Matthew G; Gordon, Dan; Gambhir, Neil; Kim, Matthew T; Romeo, Paul V; Rokito, Andrew S; Zuckerman, Joseph D; Virk, Mandeep S
PURPOSE/OBJECTIVE:To calculate and determine what factors are associated with achieving the Minimal Clinically Important Difference (MCID) and the Substantial Clinical Benefit (SCB) of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Testing v2.0 (UE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity) in patients undergoing arthroscopic rotator cuff repair (aRCR). METHODS:The change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve analysis was used to calculate the anchor-based MCID and SCB. To assess the responsiveness of each PROM, effect sizes and standardized response means (SRM) were calculated. To identify factors associated with attaining the MCID and SCB, univariate and multivariate logistic regression analyses were performed. RESULTS:A total of 323 patients with an average age of 59.9 ± 9.5 were enrolled in this study, of which, 187/323 [57.9%] were male and 136/323 [42.1%] were female. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was: 9.0, 7.5, and 11.2, respectively. The respective SCB was 10.9, 9.3, and 12.7. Effect size and SRM were: PROMIS UE (1.4, 1.3), P-Interference (1.8, 1.5), and P-Intensity (2.3, 2.0). Lower preoperative P-Intensity scores (p = 0.02), dominant arm involvement (p = 0.03), and concomitant biceps tenodesis (p = 0.03) were associated with patients achieving the SCB for PROMIS UE. CONCLUSION/CONCLUSIONS:A large responsiveness for each of the PROMIS instruments due to the majority of patients reporting great improvement after aRCR and a small standard deviation across all outcome measures was shown in our study. Lower preoperative P-Intensity scores and concomitant biceps tenodesis were associated with higher odds of achieving the SCB for PROMIS UE. The knowledge of MCID and SCB values for PROMIS instruments will allow the surgeon to determine whether the improvements in the PROMIS scores after aRCR are clinically meaningful. LEVEL OF EVIDENCE/METHODS:Level III.
PMID: 36622420
ISSN: 1433-7347
CID: 5399362

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

Gordon, Dan; Pines, Yaniv; Alben, Matthew G; Ben-Ari, Erel; Rokito, Andrew S; Kwon, Young W; Zuckerman, Joseph D; Virk, Mandeep S
PURPOSE/UNASSIGNED:To assess the preoperative and postoperative performance of the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE, version 2.0) outcome score in comparison to the American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) instruments in patients undergoing rotator cuff repair. METHODS/UNASSIGNED:) between these tools was calculated at each time point. Correlations were graded as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), or poor (<0.4). Responsiveness to change was assessed using the effect size and the standardized response mean. Floor and ceiling effects for each instrument were also assessed. RESULTS/UNASSIGNED:The PROMIS-UE instrument showed good to excellent correlation with the legacy instruments at all time points. There were variations in the measured effect sizes of the various instruments, with the PROMIS-UE instrument showing responsiveness to change at 3 and 12 months but the ASES and WORC instruments showing responsiveness at 6 weeks, 3 months, and 12 months. Both PROMIS-UE and ASES scores displayed ceiling effects at 12 months. CONCLUSIONS/UNASSIGNED:The PROMIS-UE instrument shows excellent correlation with the ASES instrument and a rotator cuff-specific outcome instrument-the WORC instrument-preoperatively and at 1 year after arthroscopic rotator cuff repair. Variations in the measured effect sizes at different postoperative time points and high ceiling effects of the PROMIS-UE instrument at the 1-year time point may limit its utility in the early postoperative phase and at long-term follow-up after rotator cuff repair. CLINICAL RELEVANCE/UNASSIGNED:The performance of the PROMIS-UE outcome measure after arthroscopic rotator cuff repair was investigated.
PMID: 37101887
ISSN: 2666-061x
CID: 5465272

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

Pines, Yaniv; Magone, Kevin M; Ben-Ari, Erel; Gordon, Dan; Rokito, Andrew S; Virk, Mandeep S; Kwon, Young W
Background/UNASSIGNED:The purpose of this study is to report the outcomes in patients undergoing arthroscopic tuberoplasty for symptomatic irreparable rotator cuff tear (RCT). Methods/UNASSIGNED:This is a retrospective cohort study comparing preoperative and postoperative data of patients undergoing arthroscopic tuberoplasty for symptomatic irreparable RCT. Exclusion criteria included open tuberoplasty, concomitant partial RCT repair, glenohumeral arthritis, concomitant ipsilateral extremity fractures, <12 months follow-up, or pseudoparalysis. Demographics, shoulder range of motion (ROM), RCT morphology, re-operation rates, satisfaction and outcome scores were collected from medical records and questionnaires. Outcome scores included Patient Reported Outcome Measurement Information System Upper Extremity (PROMIS), American Shoulder and Elbow Surgeons score (ASES), Subjective Shoulder Value (SSV), and pain Visual Analog Score (VAS). Results/UNASSIGNED:= .0029). Pre- and post-operative ROM were unchanged. There were 4 failures requiring revision. The remaining 17 patients reported high satisfaction scores (3.4 ± 0.7) and 15 (88.2%) answered "yes" to getting the procedure again, with 3/4 failures stating they would also undergo arthroscopic tuberoplasty again. Conclusion/UNASSIGNED:Arthroscopic tuberoplasty demonstrates high levels of satisfaction and pain reduction in symptomatic irreparable RCT. In appropriately indicated patients, this treatment should be considered prior to other salvage options.
PMID: 36353410
ISSN: 2666-6383
CID: 5357402

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

Gambhir, Neil; Alben, Matthew G; Kim, Matthew T; Gyftopoulos, Soterios; Rokito, Andrew S; Virk, Mandeep S
Purpose/UNASSIGNED:To investigate the variance in 90-day complication, emergency department (ED) visit, revision, and readmission rates between the Latarjet procedure (LP) performed as a primary procedure for the treatment of recurrent shoulder instability associated with critical levels of glenohumeral bone loss and the LP performed as a salvage surgical procedure after failed arthroscopic instability repair (FAIR). Methods/UNASSIGNED:< .05. Results/UNASSIGNED:The final sample sizes consisted of 54 patients in the LP-PBL group and 23 patients in the LP-FAIR group. In the postoperative period, 4 complications were observed in the first 90 days. These included complex regional pain syndrome (n = 1) and superficial wound dehiscence (n = 1) in the LP-PBL cohort. Superficial suture abscess (n = 1) and audible crepitation (n = 1) were observed in the LP-FAIR cohort. There was 1 secondary intervention (arthroscopic debridement) in the LP-FAIR cohort. No statistically significant difference in complication rates, ED visits or admissions, or secondary procedures was found between the LP-PBL and LP-FAIR groups. Conclusions/UNASSIGNED:The results of this study indicate that the 90-day complication, ED visit, revision, and readmission rates after open LP are low irrespective of the extent of glenoid or bipolar bone loss and history of arthroscopic instability repair. Level of Evidence/UNASSIGNED:Level III, retrospective cohort study.
PMID: 36312717
ISSN: 2666-061x
CID: 5358402

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

Alaia, Michael J; Hurley, Eoghan T; Vasavada, Kinjal; Markus, Danielle H; Britton, Briana; Gonzalez-Lomas, Guillem; Rokito, Andrew S; Jazrawi, Laith M; Kaplan, Kevin
BACKGROUND/UNASSIGNED:Despite the widespread use and sales of cannabidiol (CBD) products in the United States, there is a paucity of literature to evaluate its effectiveness, safety, or ideal route of administration for postoperative pain. PURPOSE/UNASSIGNED:To evaluate the potential analgesic effects of buccally absorbed CBD in patients who have undergone arthroscopic rotator cuff repair (ARCR). STUDY DESIGN/UNASSIGNED:Randomized controlled trial; Level of evidence, 1. METHODS/UNASSIGNED:< .05 was considered to be statistically significant. RESULTS/UNASSIGNED:> .05). CONCLUSION/UNASSIGNED:Buccally absorbed CBD demonstrated an acceptable safety profile and showed significant promise in the reduction of pain in the immediate perioperative period after ARCR compared with the control. Further studies are currently ongoing to confirm dosing and effectiveness in other orthopaedic conditions. REGISTRATION/UNASSIGNED:NCT04672252 ( identifier).
PMID: 35905305
ISSN: 1552-3365
CID: 5277012

The effects of obesity on 1-year functional outcomes after arthroscopic rotator cuff tear repair

Gambhir, Neil; Shankar, Dhruv; Alben, Matthew; Kwon, Young; Rokito, Andrew; Virk, Mandeep S
Background/UNASSIGNED:The purpose of our study was to examine the impact that an increased body mass index (BMI) has on arthroscopic rotator cuff repair (aRCR) outcomes. Methods/UNASSIGNED:We identified a sample of 313 patients who underwent aRCR at our institution from 2017 to 2020. Patients were classified into cohorts by BMI: normal BMI (<25), overweight (25-30), and obese (≥30). Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Pain Interference, Pain Intensity, and Upper Extremity) and Clinical Global Impressions scale rating of pain and functional improvement after surgery were obtained at 1 year postoperatively. The significance of the BMI category as a predictor for outcomes was evaluated using multiple linear and multivariable logistic regressions. Receiver operating characteristic curve analysis with Youden's J-statistic was used to determine optimal BMI cutoff for predicting likelihood of achieving minimum clinically important difference (MCID) and substantial clinical benefit (SCB) on the Clinical Global Impressions scales. Results/UNASSIGNED: > .05). Optimal BMI cutoffs were determined for pain MCID (40.8), pain SCB (26.8), function MCID (27.4), and function SCB (26.8), but all cutoffs had low correct classification rates (≤13%). Discussion and Conclusion/UNASSIGNED:Obesity was not found to be an independent risk factor for increased rotator cuff tear size or tendon involvement but was nonetheless associated with worse upper extremity function and pain after aRCR.
PMID: 35813139
ISSN: 2666-6383
CID: 5279712

The future of healthcare service in orthopedic practice: Telemedicine or in-person visits?

Ben-Ari, Erel; Kirshenbaum, Joshua; Patel, Ruby G; Kwon, Young W; Rokito, Andrew S; Zuckerman, Joseph D; Virk, Mandeep S
BACKGROUND:The objective of this study is to assess patient satisfaction and preference for telemedicine- versus in-person visits for outpatient shoulder and elbow musculoskeletal consultation during the COVID-19 pandemic and in the future. METHODS:Patients who had telemedicine visits for shoulder and elbow musculoskeletal complaints at a single institution from March through June, 2020, were invited to respond to a post-visit survey. The survey included a standardized questionnaire that focused on the patient's satisfaction with the telemedicine visit(s) during the pandemic and preference for using the telemedicine platform in the future following the pandemic. Additional details regarding their virtual visits (severity of their medical condition, previous virtual- or ER visits) were also obtained. Data regarding patient demographics and visit details (primary diagnosis, type of visit, length of visit, treating physician) were extracted from electronic medical records. RESULTS:In total, 153 patients participated in the study. Overall, high satisfaction scores regarding the telemedicine visit were noted: 91% of patients reported that their concerns were adequately addressed, 89% would recommend telemedicine to a friend and 94% stated that they would use this platform again in the presence of a situation like the COVID-19 pandemic. However, the majority of patients (76%) reported a preference for in-person visits for the same musculoskeletal complaint if it were not for COVID-19. A telemedicine visit duration of more than 10 minutes and a first-time telemedicine visit correlated with higher satisfaction rates (P=0.037 and P=0.001, respectively). CONCLUSIONS:COVID-19 has provided a boost to the use of our telemedicine platform, with a high satisfaction rate among patients with shoulder and elbow musculoskeletal complaints, largely due to safety reasons and limited access to in-person doctor visits. However, a considerable number of patients would have preferred in-person visits for similar health complaints if there were no pandemic. Further research on optimizing the selection of patients for telemedicine visits and addressing their expectations and concerns regarding their visits will improve patients' preference for future telemedicine visits.
PMID: 34089879
ISSN: 1532-6500
CID: 4899382

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

Kirby, David J; Fried, Jordan W; Buchalter, Daniel B; Moses, Michael J; Hurly, Eoghan T; Cardone, Dennis A; Yang, S Steven; Virk, Mandeep S; Rokito, Andrew S; Jazrawi, Laith M; Campbell, Kirk A
PMID: 33512302
ISSN: 1556-3669
CID: 4767672