Study Design. Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution.Objective. This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone. Summary of Background Data. One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients.Methods. An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. x 2 and the Wilcoxon Rank-Sum Test were performed to determine significance. Results. Ninety-five percent were ''satisfied'' or ''very satisfied'' with their telemedicine visit, with 62% stating it was ''the same'' or ''better'' than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to inperson visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirtyseven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patientreported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P ¼ 0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone. Conclusion. Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates. K e y w o r d s : C O V I D -1 9 , e v a l u a t i o n , m a n a g e m e n t , neurosurgery, remote medicine, spinal pathology, spine surgery, surgery, telehealth, telemedicine.
Objectives: The management of rotator cuff tears varies based on patient age, function, tear size, and chronicity. Treatment of massive tears results in less favorable or predictable outcome, presenting a challenge in determining the optimal intervention. Classification of a tear as “massive” is often based on MRI and confirmed intraoperatively. However, the use of a functional measure of shoulder motion, such as the scapulohumeral rhythm (SHR), offers an alternate, clinically relevant method to help guide diagnosis and surgical management. Defined as the ratio of glenohumeral (GH) to scapulothoracic (ST) motion, SHR is known to be altered in patients with rotator cuff tears. While previously challenging to measure SHR in a clinical setting, a novel technique known as Dynamic Digital Radiography (DDR) provides a safe and cost-effective method to directly compare changes in motion between patients with rotator cuff tears and correlate these changes to tear severity. The purpose of this study was to evaluate patients with massive and small rotator cuff tears using DDR, assessing for differences in SHR and range of motion between the two groups. Methods: Shoulders were prospectively analyzed using DDR via obtaining a series of pulsed radiographs at up to 15 Hz of the joint in motion. Scapulothoracic motion and glenohumeral motion were quantified based on the DDR images (figure 1). Measurements were taken in humeral abduction at 0-30°, 30-60°, 60-90°, and full abduction using the Grashey view. SHR at different points was calculated by dividing the humeral arc of motion by the scapular arc of motion in each of those motion ranges. Pairwise t-tests were performed on the obtained data to compare differences between groups at an α level of 0.05. Results: 42 patients with a primary diagnosis of rotator cuff tear matched for age and BMI were analyzed (table 1). Based on clinical presentation and MRI, 29 patients were classified as massive rotator cuff tear (MRCT) and 13 patients were classified as small rotator cuff tear (SRCT). The final angle calculations are displayed in table 2. SRCT patients had a significantly higher average overall SHR of 3.04 ± 1.16 compared to the MRCT SHR of 1.91 ± 0.51 (p=0.003). When analyzed across 30-degree intervals of humeral abduction, MRCT patients had a significantly lower SHR compared to SRCT patients at 30-60° (1.83 ± 0.97 vs 3.39 ± 1.62, p=0.005). MRCT also had a lower SHR between 0-30° (2.63 ± 2.08 vs 4.74 ± 3.83, p=0.08) and 60-90° (2.13± 0.80 vs 2.91 ± 1.41 , p=0.13) of humeral abduction compared to SRCT patients, but these differences were not statistically significant. SHR changes across these intervals of humeral abduction are plotted in figure 2. Scapular range of motion during humeral abduction was lower in SRCT compared to MRCT (29.71 ± 12.91 vs 41.57 ± 10.41, p=0.08). No statistically significant difference was found in humeral range of motion between MRCT (76.02 ± 22.66) and SRCT (80.93 ± 20.71). Conclusions: A dynamic measurement of motion demonstrates that scapulohumeral rhythm is significantly different between patients with small vs. massive rotator cuff tears. Based on DDR analysis, patients had a marked difference in the initiation of motion and through the first 60 degrees of humeral abduction, resulting in a nearly 2x lower SHR in MRCT compared to SRCT. Moreover, evaluation of glenohumeral and scapulothoracic motion during humeral abduction demonstrated that patients with larger tears had an increased reliance on scapular contributions to overall humeral elevation. Dynamic measurement of SHR represents a novel method for evaluating rotator cuff tears, with marked differences noted in the earlier phases of shoulder motion. Further study and validation of the dynamic assessment of SHR has the potential to augment the diagnostic algorithm for rotator cuff tears, and ultimately inform prognostic and functional expectations for both the patient and the physician. [Table: see text][Table: see text][Figure: see text][Figure: see text]
Background First carpometacarpal (CMC) osteoarthritis or trapeziometacarpal osteoarthritis is a common debilitating hand condition. No one surgical technique has demonstrated superiority in managing this disease. Purpose This study performed a systematic review of arthroscopic techniques for treating first CMC arthritis to assess the effectiveness of different arthroscopic techniques. Methods Grip strength, pinch strength, visual analog scale, the Disability of Arm, Shoulder, and Hand (DASH) score, range of motion (ROM), and complications were recorded. Two subgroup analyses were performed, comparing outcomes of (1) trapeziectomy of any type versus debridement alone and (2) trapeziectomy alone versus interposition versus suspension techniques. Results Preoperative and postoperative scores significantly improved for DASH scores and pain at rest and with activity with variable improvements in ROM. Complications occurred in 13% of cases in publications that reported complications. When comparing studies that utilized techniques with any type of trapeziectomy to debridement alone, only the trapeziectomy subgroup showed significant improvements in pain. When comparing trapeziectomy alone to interposition and suspension techniques, mean DASH scores and pain levels significantly improved in interposition and suspension subgroups. Conclusions The existing literature describes a predominantly female population with Eaton-Littler stage II and III disease. In the subgroup analysis, arthroscopic techniques involving a trapeziectomy seem to be more effective at lowering pain scores compared to techniques involving debridement alone. Likewise, interposition and suspension techniques may show improved outcomes compared to techniques involving trapeziectomy alone. Level of evidence This is a Level III study.
Objectives: Patients with various shoulder pathologies suffer from diminished range of motion and scapulohumeral rhythm (SHR), defined as the ratio of the respective contributions of glenohumeral and scapulothoracic motion to arm elevation. While previously challenging to measure SHR in a clinical setting, a novel technique known as Dynamic Digital Radiography (DDR) provides a safe and cost-effective method to directly evaluate aberrancies in motion. The purpose of this study was to measure the SHR of pathologic shoulders using Dynamic Digital Radiography (DDR). Methods: Shoulders were prospectively analyzed using DDR via obtaining a series of pulsed radiographs at up to 15 Hz of the joint in motion. Scapulothoracic motion and glenohumeral motion were quantified based on DDR images (figure 1). Measurements were taken in humeral abduction at 0-30°, 30-60°, 60-90°, and full abduction using the Grashey view. SHR at different points was calculated by dividing humeral arc of motion by scapular arc of motion in each of the aforementioned ranges. ANOVA testing was conducted to analyze differences among treatment groups and post-hoc Tukey testing was utilized to identify the specific groups between which differences occurred. Pairwise t-testing was performed to isolate differences between preop and postop radiographs. An alpha of 0.05 was set for determining significance for all outcome measures. Results: 121 shoulders were analyzed, including 40 controls, 13 small rotator cuff tears (SRT), 29 massive rotator cuff tears (MRCT), 16 adhesive capsulitis, and 23 glenohumeral osteoarthritis (table 1). The final angle calculations are displayed in Table 2. SHR for full arc of abduction differed significantly in patients with massive rotator cuff tear (1.91 ± 0.51), adhesive capsulitis (1.55 ± 0.13), and glenohumeral osteoarthritis (2.31 ± 1.03) compared to controls (3.39 ± 0.62). No statistically significant difference was found in overall SHR between small rotator cuff tear (3.04 ± 1.62) and controls (3.39 ± 0.62). When analyzed across 30-degree intervals of humeral abduction, there was a statistically significant lower SHR found at 0-30°, 30-60° and 60-90° of humeral abduction in MRCT, adhesive capsulitis and glenohumeral osteoarthritis patients compared to controls. No significant difference was found in the SHR of patients with SRCT compared to controls across all 30-degree intervals of humeral abduction. SHR changes across these intervals of humeral abduction are plotted in figure 2. Control patients had average overall humeral abduction range of motion of 103.40 ± 31.97° which was significantly larger compared to all included shoulder pathologies (MRCT: 75.75 ± 22.61, SRCT: 80.93 ± 20.71, adhesive capsulitis: 64.49 ± 27.02, osteoarthritis: 71.05 ± 34.88). During humeral abduction, control patients had average overall scapular range of motion of 32.57 ± 13.60 which was significantly smaller compared patients with a MRCT (45.57 ± 10.41) and adhesive capsulitis (64.49 ± 27.02). No statistically significant difference was found when comparing scapular range of motion during humeral abduction in patients with small rotator cuff tears (29.71 ± 12.91) and glenohumeral osteoarthritis (34.77 ± 17.52) compared to normal controls. Conclusions: DDR is sensitive enough to detect a lower SHR in massive rotator cuff tears, adhesive capsulitis, and glenohumeral osteoarthritis compared to normal shoulders. While SHR varies throughout the arc of motion, it remained drastically different these 3 pathologies compared to controls. Moreover, when isolating for humeral and scapular motion on DDR, all 4 pathologic shoulder conditions had decreased humeral abduction compared to normal controls. Patients with adhesive capsulitis and massive rotator cuff tear also had an increased reliance on scapular contribution to overall humeral elevation. Ultimately, further study and validation of this dynamic assessment of SHR has the potential to augment the diagnostic algorithm for various shoulder pathologies. [Figure: see text][Table: see text][Table: see text][Figure: see text]
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