Publications by authors named "Michael Fu"

271 Publications

Arthroscopic distal clavicle excision is associated with fewer postoperative complications than open.

JSES Int 2021 Sep 14;5(5):856-862. Epub 2021 Jul 14.

Hospital for Special Surgery, Shoulder Service, New York, NY, USA.

Background: The rate of complications of open compared to arthroscopic distal clavicle excision remain poorly studied. Therefore, the purpose of this investigation was to (1) Identify most recent national trends in the usage of open vs. arthroscopic approaches for distal clavicle excision (DCE) from 2007 to 2017; (2) to identify and compare the complication rates for both approaches, and to identify patient-specific risk factors for complications; (3) to identify and compare the revision rate for both approaches; and (4) to identify and compare the reimbursement of each approach.

Methods: The PearlDiver database was reviewed for patients undergoing DCE from 2007 to 2017. Patients were stratified into 2 cohorts: those undergoing arthroscopic DCE (n = 8933) and those undergoing open DCE (n = 2295). The rate of postoperative complications within 90 days was calculated and compared. The revision rate and reimbursement of the arthroscopic and open approach were compared. Statistical analysis included chi-square testing to compare the rates of postoperative complications and multivariate logistic regression analysis to identify risk factors for complications within 90 days. Results were considered significant at  < .05.

Results: The percentage of DCEs performed arthroscopically has significantly increased from 53.9% in 2007 to 69.8% in 2016, with a concomitant decrease in the use of open DCE from 46.1% in 2007 to 30.2% in 2016. The open approach was associated with significantly more postoperative complications, including a significantly greater incidence of surgical site infection (1.9% vs. 0.3%;  < .001), wound disruption (0.3% vs. 0.1%;  < .001), hematoma (0.9% vs. 0.2%;  = .001), and transfusion (0.6% vs. 0.1%;  < .001), than arthroscopic DCE. Several risk factors, including open approach, diabetes, heart disease, tobacco use, chronic kidney disease, and female gender, were identified as independent risk factors for complications after DCE. There was no significant difference in revision rate between open and arthroscopic approaches ( = .126). The reimbursement of open and arthroscopic DCE procedures were comparable, with median reimbursements of $5408 and $5,447, respectively ( = .853).

Conclusion: Both arthroscopic and open DCE techniques were found to have similar reimbursement amounts, with a low rate of complications, although the open technique had a higher rate of early complications such as surgical site infection. Over the study period, there was an increase in the utilization of arthroscopic DCE, while the incidence of the open technique remained constant.
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http://dx.doi.org/10.1016/j.jseint.2021.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411067PMC
September 2021

Association of Pitch Timing and Throwing Arm Kinetics in High School and Professional Pitchers.

Am J Sports Med 2021 Aug 18:3635465211031853. Epub 2021 Aug 18.

Sports Medicine Institute Hospital for Special Surgery, New York, New York, USA.

Background: Understanding the relationship between the temporal phases of the baseball pitch and subsequent joint loading may improve our understanding of optimal pitching mechanics and contribute to injury prevention in baseball pitchers.

Purpose: To investigate the temporal phases of the pitching motion and their associations with ball velocity and throwing arm kinetics in high school (HS) and professional (PRO) baseball pitchers.

Study Design: Descriptive laboratory study.

Methods: PRO (n = 317) and HS (n = 54) baseball pitchers were evaluated throwing 8 to 12 fastball pitches using 3-dimensional motion capture (480 Hz). Four distinct phases of the pitching motion were evaluated based on timing of angular velocities: (1) Foot-Pelvis, (2) Pelvis-Torso, (3) Torso-Elbow, and (4) Elbow-Ball. Peak elbow varus torque, shoulder internal rotation torque, and shoulder distraction force were also calculated and compared between playing levels using 2-sample tests. Linear mixed-effect models with compound symmetry covariance structures were used to correlate pitch velocity and throwing arm kinetics with the distinct temporal phases of the pitching motion.

Results: PRO pitchers had greater weight and height, and faster ball velocities than HS pitchers ( < .001). There was no difference in total pitch time between groups ( = .670). PRO pitchers spent less time in the Foot-Pelvis ( = .010) and more time in the Pelvis-Torso ( < .001) phase comparatively. Shorter time spent in the earlier phases of the pitching motion was significantly associated with greater ball velocity for both PRO and HS pitchers (Foot-Pelvis: B = -6.4 and B = -11.06, respectively; Pelvis-Torso: B = -6.4 and B = -11.4, respectively), while also associated with increased shoulder proximal force (Pelvis-Torso: B = -76.4 and B = -77.5, respectively). Decreased time in the Elbow-Ball phase correlated with greater shoulder proximal force for both cohorts (B = -1150 and B = -645, respectively) with no significant correlation found for ball velocity.

Conclusion: Significant differences in temporal phases exist between PRO and HS pitchers. For all pitchers, increased time spent in the final phase of the pitching motion has the potential to decrease shoulder distraction force with no significant loss in ball velocity.

Clinical Relevance: Identifying risk factors for increased shoulder and elbow kinetics, acting as a surrogate for loading at the respective joints, has potential implications in injury prevention.
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http://dx.doi.org/10.1177/03635465211031853DOI Listing
August 2021

The Comparative Effect of Age on Clinical Outcomes Following Anatomic Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty.

Orthopedics 2021 Jul-Aug;44(4):e600-e606. Epub 2021 Jul 1.

At many institutions, the pendulum has swung toward reverse total shoulder arthroplasty (RTSA). Good results have been reported for patients older than 65 years with glenohumeral osteoarthritis with an intact rotator cuff, leading to questioning of the role of anatomic total shoulder arthroplasty (TSA) in the elderly. The purpose of this study was to compare outcome measures between TSA and RTSA patients using minimal clinically important difference (MCID) and substantial clinical benefit (SCB) as a function of age. Primary TSA or RTSA patients with American Shoulder and Elbow Surgeons (ASES) scores at 2-year follow-up were retrospectively identified from a prospective database. Patients with a diagnosis of inflammatory arthritis, infection, proximal humerus fracture, or revision TSA were excluded. Patients were stratified by age as younger than 65 years, 65 to 74 years, and 75 years or older. A total of 659 TSA and 172 RTSA patients were included. Total shoulder arthroplasty had a larger improvement in ASES scores compared with RTSA in patients aged 65 to 74 years and 75 years and older (=.04 and <.01, respectively). In patients aged 75 years or older, the percentages of patients achieving MCID were similar (93.1% TSA and 92.3% RTSA; =.53); however, a higher percentage of TSA patients achieved SCB vs RTSA patients (90.5% vs 76.9%; =.01). This study highlights the importance of indications and a shared decision-making model to ensure patient satisfaction. The results support a trend that primary RTSA is a viable option for low-demand patients aged 75 years or older; however, appropriately indicated TSA offers a potential for greater improvement in ASES scores and is more successful at achieving SCB compared with RTSA at 2-year follow-up. [. 2021;44(4):e600-e606.].
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http://dx.doi.org/10.3928/01477447-20210618-24DOI Listing
July 2021

Arthroscopic Bennett Lesion Resection and Posterior Labral Repair Using All-Suture Anchors.

Arthrosc Tech 2021 Jun 24;10(6):e1603-e1608. Epub 2021 May 24.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.

The Bennett lesion is an extra-articular ossification at the posteroinferior glenoid rim that is common among overhead-throwing athletes. While the majority of these exostoses are asymptomatic, some may cause posterior shoulder pain during throwing motion and frequently have concomitant posterior labral tears. Multiple approaches to Bennett lesion resection have been described, and there is debate regarding the need for capsulotomy, posterior labral repair, and capsular repair. The purpose of this article is to describe our preferred surgical technique for arthroscopic Bennett lesion resection and posterior labral repair using knotless all-suture anchors.
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http://dx.doi.org/10.1016/j.eats.2021.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252819PMC
June 2021

Incremental changes in QRS duration as predictor for cardiovascular disease: a 21-year follow-up of a randomly selected general population.

Sci Rep 2021 Jul 1;11(1):13652. Epub 2021 Jul 1.

Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

The QRS complex has been shown to be a prognostic marker in coronary artery disease. However, the changes in QRS duration over time, and its predictive value for cardiovascular disease in the general population is poorly studied. So we aimed to explore if increased QRS duration from the age of 50-60 is associated with increased risk of major cardiovascular events during a further follow-up to age 71. A random population sample of 798 men born in 1943 were examined in 1993 at 50 years of age, and re-examined in 2003 at age 60 and 2014 at age 71. Participants who developed cardiovascular disease before the re-examination in 2003 (n = 86) or missing value of QRS duration in 2003 (n = 127) were excluded. ΔQRS was defined as increase in QRS duration from age 50 to 60. Participants were divided into three groups: group 1: ΔQRS < 4 ms, group 2: 4 ms ≤ ΔQRS < 8 ms, group 3: ΔQRS ≥ 8 ms. Endpoints were major cardiovascular events. And we found compared with men in group 1 (ΔQRS < 4 ms), men with ΔQRS ≥ 8 ms had a 56% increased risk of MACE during follow-up to 71 years of age after adjusted for BMI, systolic blood pressure, smoking, hyperlipidemia, diabetes and heart rate in a multivariable Cox regression analysis (HR 1.56, 95% CI:1.07-2.27, P = 0.022). In conclusion, in this longitudinal follow-up over a decade QRS duration increased in almost two out of three men between age 50 and 60 and the increased QRS duration in middle age is an independent predictor of major cardiovascular events.
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http://dx.doi.org/10.1038/s41598-021-93024-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8249416PMC
July 2021

Intra-aortic balloon pump on in-hospital outcomes of cardiogenic shock: findings from a nationwide registry, China.

ESC Heart Fail 2021 Aug 21;8(4):3286-3294. Epub 2021 Jun 21.

Peking University First Hospital, Beijing, China.

Aims: The real-world usage of intra-aortic balloon pump (IABP) in various cardiogenic shocks (CS) and the association with outcomes are lacking. We aimed to investigate IABP adoption in CS in a nationwide registry in China.

Methods And Results: We retrospectively retrieved data of 30 106 CS patients (age 67.1 ± 14.6 years, 37.6% female patients) in the Hospital Quality Monitoring System registry from 2013 to 2016. Ischaemic heart disease was the leading cause of CS (73.9%). Hypertension, cardiomyopathy, myocarditis, valvular, and congenital heart disease were seen in 36.0%, 7.5%, 2.6%, 7.3%, and 2.4% of the population. IABP was employed in 2320 (7.7%) subjects. The association between IABP usage and primary outcome of in-hospital mortality and secondary outcomes of expenses and lengths of stay were investigated. The patients with IABP support had similar in-hospital mortality to those without IABP (39.6% vs. 38.3%, P = 0.226), but longer hospital-stay [8.0 (2.0-16.0) vs. 6.0 (2.0-13.0) days, P < 0.001] and higher expenses [7.1(4.4-11.1) vs. 2.3 (0.8-5.5) 10 000RMB, P < 0.001]. IABP support was not associated with reduced mortality in the overall CS population in multivariate regression analysis [odds ratio (OR) 1.05, 95% confidence interval (CI) 0.95-1.17], except for subgroups with myocarditis (OR 0.61, 95% CI 0.39-0.95, P for interaction = 0.010) and those who did not receive the early percutaneous coronary intervention (PCI) (OR 0.86, 95% CI 0.75-0.97, P for interaction < 0.001). Similar results were further confirmed in the propensity-score-matched population.

Conclusions: In this nationwide registry of CS patients, IABP was not noted with improved survival but increased healthcare consumption. However, IABP appears protective in those with myocarditis or who failed to receive early PCI.
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http://dx.doi.org/10.1002/ehf2.13479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8318473PMC
August 2021

Temporal trends in outcome and patient characteristics in dilated cardiomyopathy, data from the Swedish Heart Failure Registry 2003-2015.

BMC Cardiovasc Disord 2021 06 18;21(1):307. Epub 2021 Jun 18.

Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital/Östra Hospital, University of Gothenburg, Smörslottsgatan 1, 416 85, Gothenburg, Sweden.

Background: Temporal trends in clinical composition and outcome in dilated cardiomyopathy (DCM) are largely unknown, despite considerable advances in heart failure management. We set out to study clinical characteristics and prognosis over time in DCM in Sweden during 2003-2015.

Methods: DCM patients (n = 7873) from the Swedish Heart Failure Registry were divided into three calendar periods of inclusion, 2003-2007 (Period 1, n = 2029), 2008-2011 (Period 2, n = 3363), 2012-2015 (Period 3, n = 2481). The primary outcome was the composite of all-cause death, transplantation and hospitalization during 1 year after inclusion into the registry.

Results: Over the three calendar periods patients were older (p = 0.022), the proportion of females increased (mean 22.5%, 26.4%, 27.6%, p = 0.0001), left ventricular ejection fraction was higher (p = 0.0014), and symptoms by New York Heart Association less severe (p < 0.0001). Device (implantable cardioverter defibrillator and/or cardiac resynchronization) therapy increased by 30% over time (mean 11.6%, 12.3%, 15.1%, p < 0.0001). The event rates for mortality, and hospitalization were consistently decreasing over calendar periods (p < 0.0001 for all), whereas transplantation rate was stable. More advanced physical symptoms correlated with an increased risk of a composite outcome over time (p = 0.0043).

Conclusions: From 2003 until 2015, we observed declining mortality and hospitalizations in DCM, paralleled by a continuous change in both demographic profile and therapy in the DCM population in Sweden, towards a less affected phenotype.
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http://dx.doi.org/10.1186/s12872-021-02124-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212489PMC
June 2021

Complication rates and outcomes after outpatient shoulder arthroplasty: a systematic review.

JSES Int 2021 May 16;5(3):413-423. Epub 2021 Jan 16.

Rush University Medical Center, Chicago, IL, USA.

Background: As the number of total shoulder arthroplasties (TSAs) performed annually increases, some surgeons have begun to shift toward performing TSAs in the outpatient setting. However, it is imperative to establish the safety of outpatient TSA. The purpose of this systematic review was to define complication, readmission, and reoperation rates and patient-reported outcomes after outpatient TSA.

Methods: A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, Ovid, and Embase). English-language publications describing results on complication rates in patients who underwent TSA in an outpatient or ambulatory setting were included. All nonclinical and deidentified database studies were excluded. Bias assessment was conducted with the methodologic index for nonrandomized studies criteria.

Results: Seven studies describing outcomes in outpatient TSA were identified for inclusion. The included studies used varying criteria for selecting patients for an outpatient procedure. The total outpatient 90-day complication rate (commonly including hematomas, wound issues, and nerve palsies) ranged from 7.1%-11.5%. Readmission rates ranged from 0%-3.7%, and emergency and urgent care visits ranged from 2.4%-16.1%. Patient-reported outcomes improved significantly after outpatient TSA in all studies. Two studies found a higher complication rate in the comparative inpatient cohort ( = .023-.027). Methodologic index for nonrandomized studies scores ranged from 9 to 11 (of 16) for noncomparative studies (n = 3), while all comparative studies received a score of a 16 (of 24).

Conclusion: Outpatient TSA in properly selected patients results in a similar complication rate to inpatient TSA. Further studies are needed to aid in determining proper risk stratification to direct patients to inpatient or outpatient shoulder arthroplasty.
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http://dx.doi.org/10.1016/j.jseint.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178605PMC
May 2021

Prognosis and outcome determinants after heart failure diagnosis in patients who underwent aortic valvular intervention.

ESC Heart Fail 2021 Aug 31;8(4):3237-3247. Epub 2021 May 31.

Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Aims: To study clinical phenotype, prognosis for all-cause and cardiovascular (CV) mortality and predictive factors in patients with incident heart failure (HF) after aortic valvular intervention (AVI) for aortic stenosis (AS).

Methods And Results: In this retrospective, observational study we included patients from the Swedish Heart Failure Registry (SwedeHF) recorded 2003-2016, with AS diagnosis and AVI before HF diagnosis. The AS diagnosis was established according to International Classification of Diseases 10th revision (ICD-10) codes, thus without information concerning clinical or echocardiographical data on the aortic valve disease. The patients were divided into two subgroups: left ventricular ejection fraction (LVEF) ≥ 50% (AS-HFpEF) and <50% (AS-HFrEF). We individually matched three controls with HF from the SwedeHF without AS (control group) for each patient. Baseline characteristics, co-morbidities, survival status and outcomes were obtained by linking the SwedeHF with two other Swedish registries. We used Kaplan-Meier curves to present time to all-cause mortality, cumulative incidence function for time to CV mortality and Cox proportional hazards model to evaluate the relative difference between AS-HFrEF and AS-HFpEF and AS-HF and controls. The crude all-cause mortality was 49.0%, CV mortality 27.9% in AS-HF patients, respectively 44.7% and 26.6% in matched controls. The adjusted risk for all-cause mortality and CV mortality was similar in HF, regardless of LVEF vs. controls. No significant difference in factors predicting higher all-cause mortality was observed in AS-HFrEF vs. AS-HFpEF, except for diabetes (only in AS-HFrEF), with statistically significant interaction predicting death between the two groups.

Conclusions: In this nationwide SwedeHF study, we characterized incident HF population after AVI. We found no significant differences in all-cause and CV mortality compared with general HF population. They had virtually the same predictors for mortality, regardless of LVEF.
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http://dx.doi.org/10.1002/ehf2.13451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8318512PMC
August 2021

Establishing clinically significant outcomes of the Patient-Reported Outcomes Measurement Information System Upper Extremity questionnaire after primary reverse total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Apr 18. Epub 2021 Apr 18.

Midwest Orthopaedics at Rush, Chicago, IL, USA. Electronic address:

Background And Hypothesis: Since its introduction, the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) assessment has been increasingly used in shoulder arthroplasty outcome measurement. However, determination of clinically significant outcomes using the PROMIS UE has yet to be investigated following reverse total shoulder arthroplasty (RTSA). We hypothesized that we could establish clinically significant outcomes of the PROMIS UE outcome assessment in patients undergoing primary RTSA and identify significant baseline patient factors associated with achievement of these measures.

Methods: Consecutive patients undergoing primary RTSA between 2018 and 2019 who received preoperative baseline and follow-up PROMIS UE assessments at 12 months after surgery were retrospectively reviewed. Domain-specific anchor questions pertaining to pain and function assessed at 12 months after surgery were used to determine minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) values for the PROMIS UE using receiver operating characteristic curve and area-under-the-curve (AUC) analysis. Univariate logistic regression analysis was then performed to identify significant patient factors associated with achieving the MCID, SCB, or PASS.

Results: A total of 95 patients met all inclusion criteria and were included in the analysis. By use of an anchor-based method, the PASS value was 36.68 (sensitivity, 0.795; specificity, 0.765; AUC, 0.793) and the SCB value was 11.62 (sensitivity, 0.597; specificity, 1.00; AUC, 0.806). By use of a distribution-based method, the MCID value was calculated to be 4.27. Higher preoperative PROMIS UE scores were a positive predictor in achievement of the PASS (odds ratio [OR], 1.107; P = .05), whereas lower preoperative PROMIS UE scores were associated with obtaining SCB (OR, 0.787; P < .001). Greater baseline forward flexion was negatively associated with achievement of the PASS (OR, 0.986; P = .033) and MCID (OR, 0.976, P = .013). Of the patients, 83.2%, 69.5%, and 47.4% achieved the MCID, PASS, and SCB, respectively.

Conclusion: This study defines the MCID, SCB, and PASS for the PROMIS UE outcome assessment in patients undergoing primary RTSA, of whom the majority achieved meaningful outcome improvement at 12 months after surgery. These values may be used in assessing the outcomes and extent of functional improvement following RTSA.
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http://dx.doi.org/10.1016/j.jse.2021.03.147DOI Listing
April 2021

Outpatient Surgical Fixation of Proximal Humerus Fractures Can Be Performed Without Increased Rates of Short-Term Complications or Readmissions.

J Orthop Trauma 2021 Oct;35(10):e356-e363

Department of Sports Medicine, Hospital for Special Surgery, New York, NY.

Objective: To delineate differences in short-term complications between outpatient versus inpatient open reduction and internal fixation (ORIF) of proximal humerus fractures.

Design: Retrospective database review.

Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database.

Patients: Patients in the National Surgical Quality Improvement Program database with proximal humerus fractures from 2005 to 2017.

Intervention: Proximal humerus fracture ORIF.

Main Outcome Measurements: Thirty-day readmission, reoperation, thromboembolic events, and other complications.

Results: In total, 920 outpatient and 2490 inpatient ORIF cases were identified. The proportion of outpatient proximal humerus fracture ORIF increased throughout the years from 6.67% in 2007 to 34.89% in 2017. Each outpatient case was propensity-score-matched with one inpatient case by age, sex, functional status, American Society of Anesthesiologists classification, smoking status, diabetes mellitus type, hypertension, chronic obstructive pulmonary disease, and dyspnea on exertion. After matching, there were 920 outpatient and 920 inpatient cases. Statistical analysis revealed no significant difference in complications including reoperation (1.63% vs. 2.50%), thromboembolic events (0.65% vs. 0.65%), and 30-day readmissions (2.93% vs. 2.69%) between outpatient versus matched inpatient procedures (all P > 0.05). The only significant finding was a lower rate of blood transfusion in outpatient procedures (0.54%) compared with inpatient procedures (4.02%) (P < 0.001).

Conclusions: The perioperative outcomes assessed here support the conclusion that ORIF for proximal humerus fractures can be performed in the outpatient setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures. However, it is worth noting that the majority of outpatient cases were younger than the average geriatric proximal humerus fracture patient.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002072DOI Listing
October 2021

Design and Testing of Stimulation and Myoelectric Recording Modules in an Implanted Distributed Neuroprosthetic System.

IEEE Trans Biomed Circuits Syst 2021 04 25;15(2):281-293. Epub 2021 May 25.

Implantable motor neuroprostheses can restore functionality to individuals with neurological disabilities by electrically activating paralyzed muscles in coordinated patterns. The typical design of neuroprosthetic systems relies on a single multi-use device, but this limits the number of stimulus and sensor channels that can be practically implemented. To address this limitation, a modular neuroprosthesis, the "Networked Neuroprosthesis" (NNP), was developed. The NNP system is the first fully implanted modular neuroprosthesis that includes implantation of all power, signal processing, biopotential signal recording, and stimulating components. This paper describes the design of stimulation and recording modules, bench testing to verify stimulus outputs and appropriate filtering and recording, and validation that the components function properly while implemented in persons with spinal cord injury. The results of system testing demonstrated that the NNP was functional and capable of generating stimulus pulses and recording myoelectric, temperature, and accelerometer signals. Based on the successful design, manufacturing, and testing of the NNP System, multiple clinical applications are anticipated.
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http://dx.doi.org/10.1109/TBCAS.2021.3066838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344369PMC
April 2021

Patients undergoing anatomic total shoulder arthroplasty achieve clinically significant outcomes faster than those undergoing reverse shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Mar 9. Epub 2021 Mar 9.

Division of Sports Medicine & Shoulder, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA. Electronic address:

Background: Clinically significant outcome (CSO) benchmarks have been previously established for outcome assessment after total shoulder arthroplasty. However, the time required to achieve CSO improvement is not well understood. The purpose of this study was to (1) determine the time-dependent achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) in patients undergoing either anatomic total shoulder (TSA) or reverse total shoulder arthroplasty (RTSA) and compare the results of the 2 populations and (2) identify variables associated with earlier or delayed achievement of each CSO.

Methods: A prospectively maintained institutional registry was retrospectively queried for all patients receiving a primary TSA or RTSA between September 2, 2016-October 31, 2017. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was administered to all patients preoperatively and at standardized postoperative time periods: 5-7 months (6-month time point), 11-13 months (1-year time point), and 23-25 months (2-year time point). Cumulative percentages of CSO achievement were calculated using Kaplan-Meier survival curve analysis with interval censoring. A Weibull parametric survival regression analysis was used to investigate the influence of demographic and clinical variables on delayed or earlier CSO achievement.

Results: A total of 153 patients (157 shoulders) undergoing TSA (n = 76) and RTSA (n = 81) were included in the study population. The RTSA cohort was older (70.2 ± 7.5 vs. 61.0 ± 8.4, P < .001), had a lower BMI (28.8 ± 5.9 vs. 31.5 ± 6.5, P = .006), and a greater proportion of females (53.1% vs. 32.9%, P = .017) relative to TSA. For SCB, there was a significant difference in the cumulative percentage of TSA and RTSA patients reaching this threshold at both the 6-month (77.3% vs. 59.0%, P = .024) and 2-year (92.0% vs. 79.5%, P = .048) time periods, with similar findings demonstrated for PASS. There was a significant difference in the average time required to achieve the PASS (TSA: 6.1 months vs. rTSA: 11.6 months, P = .009), but not the MCID (P = .407) or SCB (P = .153). Factors significantly associated with earlier achievement of more than 1 of the CSO benchmarks were regular preoperative physical exercise and diagnosis of rotator cuff tear without osteoarthritis.

Conclusion: Patients undergoing RTSA had lower rates of achieving SCB and PASS at both 6 months and 2 years compared to patients undergoing TSA. Patients undergoing RTSA on average required nearly double the time to achieve PASS compared with those undergoing TSA. In both groups, clinically significant improvement continued for the entire 2-year duration of study follow-up.
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http://dx.doi.org/10.1016/j.jse.2021.02.015DOI Listing
March 2021

Correction to: Multi‑modality biomarkers in the early prediction of ischaemic heart disease in middle‑aged men during a 21‑year follow‑up.

BMC Cardiovasc Disord 2021 Feb 23;21(1):111. Epub 2021 Feb 23.

Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital/Östra Hospital, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden.

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http://dx.doi.org/10.1186/s12872-021-01921-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903632PMC
February 2021

Hospital readmissions of patients with heart failure from real world: timing and associated risk factors.

ESC Heart Fail 2021 04 17;8(2):1388-1397. Epub 2021 Feb 17.

Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Aims: This study aims to investigate hospital readmissions and timing, as well as risk factors in a real world heart failure (HF) population.

Methods And Results: All patients discharged alive in 2016 from Sahlgrenska University Hospital/Östra, Gothenburg, Sweden, with a primary diagnosis of HF were consecutively included. Patient characteristics, type of HF, treatment, and follow-up were registered. Time to first all-cause or HF readmission, as well as number of 1 year readmissions from discharge were recorded. In total, 448 patients were included: 273 patients (mean age 78 ± 11.8 years) were readmitted for any cause within 1 year (readmission rate of 60.9%), and 175 patients (mean age 76.6 ± 13.7) were never readmitted. Among readmissions, 60.1% occurred during the first quarter after index hospitalization, giving a 3 month all-cause readmission rate of 36.6%. HF-related 1 year readmission rate was 38.4%. Patients who were readmitted had significantly more renal dysfunction (52.4% vs. 36.6%, P = 0.001), pulmonary disease (25.6% vs. 15.4%, P = 0.010), and psychiatric illness (24.9% vs. 12.0%, P = 0.001). Number of co-morbidities and readmissions were significantly associated (P < 0.001 for all cause readmission rate and P = 0.012 for 1 year HF readmission rate). Worsening HF constituted 63% of all-cause readmissions. Psychiatric disease was an independent risk factor for 1 month and 1 year all-cause readmissions. Poor compliance to medication was an independent risk factor for 1 month and 1 year HF readmission.

Conclusions: In our real world cohort of HF patients, frequent hospital readmissions occurred in the early post-discharge period and were mainly driven by worsening HF. Co-morbidity was one of the most important factors for readmission.
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http://dx.doi.org/10.1002/ehf2.13221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006673PMC
April 2021

High Rate of Full Duty Return to Work After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Workers Who Are Not on Workers' Compensation.

Am J Sports Med 2021 03 3;49(3):729-736. Epub 2021 Feb 3.

Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA.

Background: Femoroacetabular impingement syndrome (FAIS) is an increasingly common diagnosis among working-age adults. Hip arthroscopy provides reliable improvements in pain and may allow patients to return to physical activities. No study to date has evaluated return to work (RTW) among a general population of adults after arthroscopic surgery for FAIS.

Purpose: To evaluate (1) patients' rate of RTW, (2) time required to RTW, and (3) factors correlated with time required to RTW after arthroscopic surgery for symptomatic FAIS.

Study Design: Case series; Level of evidence, 4.

Methods: Consecutive patients aged 25 to 59 years who underwent arthroscopic surgery for FAIS between June 2018 and December 2018 were reviewed. Workers' compensation cases and patients with <1-year follow-up were excluded. The following were collected at a minimum of 1 year postoperatively: demographics, employment characteristics, Hip Outcome Score (HOS; Activities of Daily Living and Sports Specific subscales), modified Harris Hip Score, 12-Item International Hip Outcome Tool (iHOT-12), visual analog scale for pain, and RTW characteristics. Work physical activity level was classified as sedentary, light, moderate, heavy, or very heavy per established criteria.

Results: A total of 97 patients were selected through inclusion and exclusion criteria. RTW surveys were collected for 79 (81.4%), and 61 were employed preoperatively. Time worked per week was 42.8 ± 12.5 hours (mean ± SD). Patients' work level was most commonly classified as sedentary (42.6%), followed by moderate (24.6%). All 61 (100%) patients returned to work at a mean 7.3 weeks (range, <1-88 weeks) postoperatively. Sixty patients (95.2%) returned to full duty. Time required to full duty RTW was strongly correlated with expected time off from work ( = 0.900; < .0001) and moderately correlated with work classification ( = 0.640; = .0001). All patients had significant pre- to postoperative improvements in the HOS-Activities of Daily Living (64.8 ± 15.3 to 87.1 ± 12.2; < .001), HOS-Sports Specific (42.8 ± 18.8 to 76.7 ± 16.5; < .001), iHOT-12 (31.3 ± 18.8 to 69.3 ± 21.1; < .001), modified Harris Hip Score (61.8 ± 12.1 to 80.3 ± 14.1; < .001), and visual analog scale for pain (5.19 ± 2.11 to 2.40 ± 1.96; < .001).

Conclusion: Patients undergoing arthroscopic treatment for FAIS demonstrated a high rate of RTW at a mean of <2 months postoperatively. A patient's expected time off from work and the level of physical demands required for work were highly associated with time required to RTW. These results are valuable for orthopaedic surgeons, patients, and employers when establishing a timeline for expected RTW after surgery.
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http://dx.doi.org/10.1177/0363546520985517DOI Listing
March 2021

Multi-modality biomarkers in the early prediction of ischaemic heart disease in middle-aged men during a 21-year follow-up.

BMC Cardiovasc Disord 2021 02 2;21(1):65. Epub 2021 Feb 2.

Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital/Östra Hospital, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden.

Background: Ischaemic heart disease (IHD) often develops after decades of preceding subclinical coronary atherosclerosis. Biomarkers are useful prognostic predictors of IHD, but their long-term predictive value in a general population has not been adequately studied.

Purpose: To investigate the early predictive value of multi-modality biomarkers in addition to clinical risk factors in incident IHD in a random male general population sample followed from 50 to 71 years of age.

Method: "The Study of Men Born in 1943" is a longitudinal cohort study during follow-up. All the men underwent a baseline examination in 1993, where a panel of biomarkers were analysed and incident IHD was registered during 21-year follow-ups.

Results: Of 739 participants, 97 men (13.1%) developed an IHD event. For time to first occurrence of IHD, univariable analyses showed that elevated levels of high sensitivity troponin T (hs-TNT), high sensitivity-C reactive protein (hs-CRP) and interleukin-6 (IL-6) were significant predictors of IHD. In addition, a high number of biomarkers with elevated levels (hs-TNT > 10 ng/L, hs-CRP > 1 mg/L, IL-6 > 8 ng/L and N-terminal pro b-type natriuretic peptide (NT-proBNP) > 100 pg/mL) increased predictive ability. In univariable and multivariable analysis high-density lipoprotein-cholesterol (HDL-C) had the highest predictive ability. Hs-TNT provided better predictive ability than smoking, body mass index and glucose, and was an independent significant predictor when adjusted for HDL-C, total cholesterol and hypertension. Addition of biomarkers on top of clinical risk factors provided significantly better prediction as tested by likelihood ratio test (p = 0.033), but did not significantly enhance the model's discriminative ability However, it appeared contributing to higher sensitivity in the late phase of follow-up.

Conclusion: In this random, middle-aged male population sample, the addition of biomarker hs-TNT was an independent significant predictor of IHD and significantly improved prediction, indicating the probability of a better prediction of long-term risk of IHD in a low-risk population.

Trial Registration: The study is registered at Clinical Trials.gov Identifier number: NCT03138122.
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http://dx.doi.org/10.1186/s12872-021-01886-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851898PMC
February 2021

Machine-learning model successfully predicts patients at risk for prolonged postoperative opioid use following elective knee arthroscopy.

Knee Surg Sports Traumatol Arthrosc 2021 Jan 9. Epub 2021 Jan 9.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Purpose: Recovery following elective knee arthroscopy can be compromised by prolonged postoperative opioid utilization, yet an effective and validated risk calculator for this outcome remains elusive. The purpose of this study is to develop and validate a machine-learning algorithm that can reliably and effectively predict prolonged opioid consumption in patients following elective knee arthroscopy.

Methods: A retrospective review of an institutional outcome database was performed at a tertiary academic medical centre to identify adult patients who underwent knee arthroscopy between 2016 and 2018. Extended postoperative opioid consumption was defined as opioid consumption at least 150 days following surgery. Five machine-learning algorithms were assessed for the ability to predict this outcome. Performances of the algorithms were assessed through discrimination, calibration, and decision curve analysis.

Results: Overall, of the 381 patients included, 60 (20.3%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were reduced preoperative scores on the following patient-reported outcomes: the IKDC, KOOS ADL, VR12 MCS, KOOS pain, and KOOS Sport and Activities. The ensemble model achieved the best performance based on discrimination (AUC = 0.74), calibration, and decision curve analysis. This model was integrated into a web-based open-access application able to provide both predictions and explanations.

Conclusion: Following appropriate external validation, the algorithm developed presently could augment timely identification of patients who are at risk of extended opioid use. Reduced scores on preoperative patient-reported outcomes, symptom duration and perioperative oral morphine equivalents were identified as novel predictors of prolonged postoperative opioid use. The predictive model can be easily deployed in the clinical setting to identify at risk patients thus allowing providers to optimize modifiable risk factors and appropriately counsel patients preoperatively.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-020-06421-7DOI Listing
January 2021

Return to Work After Primary Rotator Cuff Repair: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 07 4;49(8):2238-2247. Epub 2021 Jan 4.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.

Background: Rotator cuff tears are a prevalent pathology in injured workers, causing significant economic ramifications and time away from work. To date, published articles on work outcomes after rotator cuff repair have not been cumulatively assessed and analyzed.

Purpose: To systematically review reports on return to work after rotator cuff repair and perform a meta-analysis on factors associated with improved work outcomes.

Study Design: Systematic review and meta-analysis; Level of evidence, 4.

Methods: A systematic review of return-to-work investigations was performed using PubMed, Embase, and the Cochrane Database of Systematic Reviews in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Individual studies reporting rates of return to previous work with level of evidence 1 to 4 were independently screened by 2 authors for inclusion, and study quality was assessed using the Methodologic Index for Non-randomized Studies and Newcastle-Ottawa Scale. Work outcome data were synthesized and analyzed using random effects modeling to identify differences in rates of return to previous work as a function of operative technique, work intensity, and workers' compensation status.

Results: Thirteen retrospective investigations comprising 1224 patients who underwent rotator cuff repair met inclusion criteria for this investigation. Across all investigations, a weighted average of 62.3% of patients returned to previous level of work at 8.15 ± 2.7 months (mean ± SD) after surgery. Based on random effects modeling, higher rates of return to previous work were identified with decreasing work intensity ( < .001), while rates were similar between open and arthroscopic repair technique ( = .418) and between workers' compensation and non-workers' compensation cohorts ( = .089). All shoulder pain and functional outcome assessments demonstrated significant improvements at final follow-up when compared with baseline across all investigations.

Conclusion: The majority of injured workers undergoing rotator cuff repair return to previous work at approximately 8 months after surgery. Despite this, >35% of patients are unable to return to their previous work level after their repair procedure. Similar rates of return to work can be anticipated regardless of workers' compensation status and operative technique, while patients in occupations with higher physical intensity experience inferior work outcomes.
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http://dx.doi.org/10.1177/0363546520975426DOI Listing
July 2021

Guideline-directed medical therapy in real-world heart failure patients with low blood pressure and renal dysfunction.

Clin Res Cardiol 2021 Jul 4;110(7):1051-1062. Epub 2021 Jan 4.

Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.

Background: Among patients with heart failure and reduced ejection fraction (HFrEF), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), β-blockers (BB) and mineralocorticoid receptor antagonist (MRA) are known as guideline-directed medical therapy to improve prognosis. However, low blood pressure (BP) and renal dysfunction are often challenges prevent clinical implementation, so we investigated the association of different combinations of GDMT treatments with all-cause mortality in HFrEF population with low BP and renal dysfunction.

Methods: This study initially included 51, 060 HF patients from the Swedish Heart Failure Registry, and finally 1464 HFrEF patients with low BP (systolic BP ≦ 100 mmHg) and renal dysfunction (estimated glomerular filtration rate (eGFR) ≦ 60 ml/min/1.73m) were ultimately enrolled. Patients were receiving oral medication for HF at study enrollment, and divided into four groups (group 1-4: ACEI/ARB + BB + MRA, ACEI/ARB + BB, ACEI/ARB + MRA or ACEI/ARB only, and other). The outcome is time to all-cause mortality.

Results: Among the study patients, 485 (33.1%), 672 (45.9%), 109 (7.4%) and 198 (13.5%) patients were in group 1-4. Patients in group 1 were younger, had highest hemoglobin, and most with EF < 30%. During a median of 1.33 years follow-up, 937 (64%) patients died. After adjustment for age, gender, LVEF, eGFR, hemoglobin when compared with the group 1, the hazard ratio for all-cause mortality in group 2 was 1.04 (0.89-1.21) (p = 0.62), group 3 1.40 (1.09-1.79) (p = 0.009), and group 4 1.71 (1.39-2.09) (p < 0.001).

Conclusions: In real-world HFrEF patients with low BP and renal dysfunction, full medication of guideline-directed medical therapy is associated with improved survival. The benefit was larger close to the index date and decreased with follow-up time.
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http://dx.doi.org/10.1007/s00392-020-01790-yDOI Listing
July 2021

Distal Tibial Allograft Augmentation for Posterior Shoulder Instability Associated With Glenoid Bony Deficiency: A Case Series.

Arthrosc Sports Med Rehabil 2020 Dec 15;2(6):e743-e752. Epub 2020 Dec 15.

Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To report the clinical history and preliminary outcomes of patients who underwent posterior glenoid reconstruction using a distal tibial allograft (DTA) for the management of posterior shoulder instability with glenoid bone loss.

Methods: Patients who underwent posterior shoulder stabilization with a DTA in our institution between 2011 and 2019 were retrospectively reviewed. Demographic characteristics, operative reports, and clinical and functional outcomes were recorded. Outcomes included postoperative range of motion (ROM), recurrent instability, complications, and revision surgery. All patients underwent at least 1 year of follow-up, except 2 patients who underwent revision surgery. Preoperative and postoperative ROM was compared using the 2-tailed Student test for paired samples.

Results: Ten patients who underwent DTA augmentation for posterior instability were included, comprising 2 female and 8 male patients with an average age of 24 years (range, 17-35 years). Five patients had a prior sports-related traumatic event, and 2 patients had a seizure disorder. Seven patients had undergone a prior stabilization procedure. The average reverse bony Bankart lesion was 26% of the glenoid diameter. Concomitant procedures included 4 capsular repairs, 2 labral repairs, 2 capsular plications, and 1 repair for humeral avulsion of the glenohumeral ligament. One patient reported recurrent instability after surgery. Two patients underwent revision surgery, with one removal of symptomatic hardware and one early revision owing to screw penetration into the glenoid. There was no significant difference in preoperative versus postoperative ROM.

Conclusions: Posterior shoulder instability with significant bony deficiency can be managed using DTA augmentation with good outcomes and a reasonable complication rate in these challenging cases.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1016/j.asmr.2020.06.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754527PMC
December 2020

Effect of empagliflozin on exercise ability and symptoms in heart failure patients with reduced and preserved ejection fraction, with and without type 2 diabetes.

Eur Heart J 2021 02;42(6):700-710

Department of Cardiology (CVK), Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Föhrer Str. 15, 13353 Berlin, Germany.

Aims: The EMPERIAL (Effect of EMPagliflozin on ExeRcise ability and HF symptoms In patients with chronic heArt faiLure) trials evaluated the effects of empagliflozin on exercise ability and patient-reported outcomes in heart failure (HF) with reduced and preserved ejection fraction (EF), with and without type 2 diabetes (T2D), reporting, for the first time, the effects of sodium-glucose co-transporter-2 inhibition in HF with preserved EF (HFpEF).

Methods And Results: HF patients with reduced EF (HFrEF) (≤40%, N = 312, EMPERIAL-Reduced) or preserved EF (>40%, N = 315, EMPERIAL-Preserved), with and without T2D, were randomized to empagliflozin 10 mg or placebo for 12 weeks. The primary endpoint was 6-minute walk test distance (6MWTD) change to Week 12. Key secondary endpoints included Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) and Chronic Heart Failure Questionnaire Self-Administered Standardized format (CHQ-SAS) dyspnoea score. 6MWTD median (95% confidence interval) differences, empagliflozin vs. placebo, at Week 12 were -4.0 m (-16.0, 6.0; P = 0.42) and 4.0 m (-5.0, 13.0; P = 0.37) in EMPERIAL-Reduced and EMPERIAL-Preserved, respectively. As the primary endpoint was non-significant, all secondary endpoints were considered exploratory. Changes in KCCQ-TSS and CHQ-SAS dyspnoea score were non-significant. Improvements with empagliflozin in exploratory pre-specified analyses of KCCQ-TSS responder rates, congestion score, and diuretic use in EMPERIAL-Reduced are hypothesis generating. Empagliflozin adverse events were consistent with those previously reported.

Conclusion: The primary outcome for both trials was neutral. Empagliflozin was well tolerated in HF patients, with and without T2D, with a safety profile consistent with that previously reported in T2D. Hypothesis-generating improvements in exploratory analyses of secondary endpoints with empagliflozin in HFrEF were observed.
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http://dx.doi.org/10.1093/eurheartj/ehaa943DOI Listing
February 2021

Plaque morphology in acute symptomatic intracranial atherosclerotic disease.

J Neurol Neurosurg Psychiatry 2020 Nov 25. Epub 2020 Nov 25.

Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China

Background: Intracranial atherosclerotic disease (ICAD) is globally a major ischaemic stroke subtype with high recurrence. Understanding the morphology of symptomatic ICAD plaques, largely unknown by far, may help identify vulnerable lesions prone to relapse.

Methods: We prospectively recruited patients with acute ischaemic stroke or transient ischaemic attack attributed to high-grade ICAD (60%-99% stenosis). Plaque morphological parameters were assessed in three-dimensional rotational angiography, including surface contour, luminal stenosis, plaque length/thickness, upstream shoulder angulation, axial/longitudinal plaque distribution and presence of adjoining branch atheromatous disease (BAD). We compared morphological features of smooth, irregular and ulcerative plaques and correlated them with cerebral ischaemic lesion load downstream in MRI.

Results: Among 180 recruited patients (median age=60 years; 63.3% male; median stenosis=75%), plaque contour was smooth (51 (28.3%)), irregular (101 (56.1%)) or ulcerative (28 (15.6%)). Surface ulcers were mostly at proximal (46.4%) and middle one-third (35.7%) of the lesions. Most (84.4%) plaques were eccentric, and half had their maximum thickness over the distal end. Ulcerative lesions were thicker (medians 1.6 vs 1.3 mm; p=0.003), had steeper upstream shoulder angulation (56.2° vs 31.0; p<0.001) and more adjoining BAD (83.3% vs 57.0%; p=0.033) than non-ulcerative plaques. Ulcerative plaques were significantly associated with coexisting acute and chronic infarcts downstream (35.7% vs 12.5%; adjusted OR 4.29, 95% CI 1.65 to 11.14, p=0.003). Sensitivity analyses in patients with anterior-circulation ICAD lesions showed similar results in the associations between the plaque types and infarct load.

Conclusions: Ulcerative intracranial atherosclerotic plaques were associated with vulnerable morphological features and had a higher cumulative infarct load downstream.
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http://dx.doi.org/10.1136/jnnp-2020-325027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958085PMC
November 2020

Risk of stroke in patients with heart failure and sinus rhythm: data from the Swedish Heart Failure Registry.

ESC Heart Fail 2021 02 9;8(1):85-94. Epub 2020 Nov 9.

Sahlgrenska Academy, Cardiology Unit, Department of Medicine, Östra Hospital, Gothenburg, Sweden.

Aims: We investigated the 2 year rate of ischaemic stroke/transient ischaemic attack (IS) in patients with heart failure (HF) who were in sinus rhythm (HF-SR) and aimed to develop a score for stratifying risk of IS in this population.

Methods And Results: A total of 15 425 patients (mean age 71.5 years, 39% women) with HF-SR enrolled in the Swedish Heart Failure Register were included; 28 815 age-matched and sex-matched controls, without a registered diagnosis of HF, were selected from the Swedish Population Register. The 2 year rate of IS was 3.0% in patients and 1.4% in controls. In the patient group, a risk score including age (1p for 65-74 years; 2p for 75-84 years; 3p for ≥85 years), previous IS (2p), ischaemic heart disease, diabetes, hypertension, kidney dysfunction, and New York Heart Association III/IV class (1p each) was generated. Over a mean follow-up of 20.1 (SD 7.5) months, the cumulative incidences (per 1000 person-years) of IS in patients with score 0 to ≥7 were 2.2, 5.3, 8.9, 13.2, 15.7, 20.4, 26.4, and 33.0, with hazard ratios for score 1 to ≥7 (with 0 as reference): 2.4, 4.1, 6.1, 7.2, 9.4, 12.2, and 15.3. The risk score performed modestly (area under the curve 63.7%; P = 0.4711 for lack of fit with a logistic model; P = 0.7062 with Poisson, scaled by deviance).

Conclusions: In terms of absolute risk, only 27.6% of patients had an annual IS incidence of ≤1%. To which extent this would be amenable to anticoagulant treatment remains conjectural. A score compiling age and specific co-morbidities identified HF-SR patients with increased risk of IS with modest discriminative ability.
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http://dx.doi.org/10.1002/ehf2.13091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835566PMC
February 2021

Outcomes of the Latarjet procedure with minimum 5- and 10-year follow-up: A systematic review.

Shoulder Elbow 2020 Oct 28;12(5):315-329. Epub 2020 Jul 28.

Midwest Orthopaedics, Rush University Medical Center, Chicago, IL, USA.

Background: The purpose of this study was to evaluate mid- and long-term outcomes following the Latarjet procedure for anterior shoulder instability.

Methods: PubMed, MEDLINE, Embase, and Cochrane libraries were systematically searched, in line with PRISMA guidelines, for studies reporting on outcomes following the Latarjet procedure with minimum five-year follow-up. Outcomes of studies with follow-up between 5 and 10 years were compared to those with minimum follow-up of 10 years.

Results: Fifteen studies reporting on 1052 Latarjet procedures were included. Recurrent instability occurred in 127 patients, with an overall random summary estimates in studies with a minimum five-year follow-up of 0-18% (I = 90%) compared to 5-26% (I = 59%) for studies with a minimum 10-year follow-up. Overall rates for return to sports, non-instability related complications, and progression of arthritis estimated at 65-100% (I = 87%), 0-20% (I = 85%), and 8-42% (I = 89%) for the minimum five-year follow-up studies and 62-93% (I = 86%), 0-9% (I = 28%), and 9-71% (I = 91%) for the minimum 10-year follow-up studies, respectively. All studies reported good-to-excellent mean PRO scores at final follow-up.

Conclusions: The Latarjet is a safe and effective procedure for patients with shoulder instability. The majority of patients return to sport, though at long-term follow-up, a trend towards an increased incidence of recurrent instability is appreciated, while a significant number may demonstrate arthritis progression.
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http://dx.doi.org/10.1177/1758573220945318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545530PMC
October 2020

Establishing the Minimal Clinically Important Difference, Patient Acceptable Symptomatic State, and Substantial Clinical Benefit of the PROMIS Upper Extremity Questionnaire After Rotator Cuff Repair.

Am J Sports Med 2020 12 26;48(14):3439-3446. Epub 2020 Oct 26.

Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Background: The Patient-Reported Outcome Measurement Information System Upper Extremity (PROMIS UE) questionnaire has been validated as an effective and efficient outcome measure after rotator cuff repair (RCR). However, definitions of clinically significant outcomes used in interpreting this outcome measure have yet to be defined.

Purpose: To define clinically significant outcomes of the PROMIS UE questionnaire in patients undergoing arthroscopic RCR.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: We reviewed charts of consecutive patients undergoing RCR in our institution between 2017 and 2018 and included patients who were administered the PROMIS UE before surgery and 12 months after surgery. At 12 months postoperatively, patients were asked domain-specific anchor questions regarding their function and satisfaction after surgery, which were then used to determine the minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) using receiver operating characteristic and area under the curve (AUC) analysis. Univariate and multivariate logistic regression analysis was utilized to identify patient factors associated with clinically significant outcomes.

Results: A total of 105 patients with RCR and minimum 12-month postoperative PROMIS UE were included in the analysis. The defined clinically significant outcomes were 4.87 for the MCID using a distribution-based method, 7.95 for the SCB (sensitivity, 0.708; specificity, 0.833; AUC, 0.760), and 39.00 for the PASS (sensitivity, 0.789; specificity, 0.720; AUC, 0.815). Among respondents, 79.0%, 62.9%, and 64.8% achieved the MCID, SCB, and PASS score thresholds, respectively. Workers' compensation was negatively associated with achievement of the PASS. Lower preoperative PROMIS UE scores were associated with obtaining the MCID (odds ratio [OR], 0.871; = .001) and the SCB (OR, 0.900; = .040), whereas higher preoperative scores were predictive of achieving the PASS (OR, 1.111; = .020).

Conclusion: This study defines the clinically significant outcomes for the PROMIS UE after RCR, of which the majority of patients achieved the MCID, PASS, and SCB at 12 months after surgery. These thresholds should be considered in future study design and interpretation of PROMIS UE in patients with RCR.
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http://dx.doi.org/10.1177/0363546520964957DOI Listing
December 2020

Development of supervised machine learning algorithms for prediction of satisfaction at 2 years following total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jun 1;30(6):e290-e299. Epub 2020 Oct 1.

Division of Sports Medicine & Shoulder, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA. Electronic address:

Background: Patient satisfaction after primary anatomic and reverse total shoulder arthroplasty (TSA) represents an important metric for gauging patients' perception of their care and surgical outcomes. Although TSA confers improvement in pain and function for most patients, inevitably some will remain unsatisfied postoperatively. The purpose of this study was to (1) train supervised machine learning (SML) algorithms to predict satisfaction after TSA and (2) develop a clinical tool for individualized assessment of patient-specific risk factors.

Methods: We performed a retrospective review of primary anatomic and reverse TSA patients between January 2014 and February 2018. A total of 16 demographic, clinical, and patient-reported outcomes were evaluated for predictive value. Five SML algorithms underwent 3 iterations of 10-fold cross-validation on a training set (80% of cohort). Assessment by discrimination, calibration, Brier score, and decision-curve analysis was performed on an independent testing set (remaining 20% of cohort). Global and local model behaviors were evaluated with global variable importance plots and local interpretable model-agnostic explanations, respectively.

Results: The study cohort consisted of 413 patients, of whom 331 (82.6%) were satisfied at 2 years postoperatively. The support vector machine model demonstrated the best relative performance on the independent testing set not used for model training (concordance statistic, 0.80; calibration intercept, 0.20; calibration slope, 2.32; Brier score, 0.11). The most important factors for predicting satisfaction were baseline Single Assessment Numeric Evaluation score, exercise and activity, workers' compensation status, diagnosis, symptom duration prior to surgery, body mass index, age, smoking status, anatomic vs. reverse TSA, and diabetes. The support vector machine algorithm was incorporated into an open-access digital application for patient-level explanations of risk and predictions, available at https://orthopedics.shinyapps.io/SatisfactionTSA/.

Conclusion: The best-performing SML model demonstrated excellent discrimination and adequate calibration for predicting satisfaction following TSA and was used to create an open-access, clinical decision-making tool. However, rigorous external validation in different geographic locations and patient populations is essential prior to assessment of clinical utility. Given that this tool is based on partially modifiable risk factors, it may enhance shared decision making and allow for periods of targeted preoperative health-optimization efforts.
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http://dx.doi.org/10.1016/j.jse.2020.09.007DOI Listing
June 2021

Delay to Arthroscopic Rotator Cuff Repair Is Associated With Increased Risk of Revision Rotator Cuff Surgery.

Orthopedics 2020 Nov 1;43(6):340-344. Epub 2020 Oct 1.

The purpose of this study was to determine the association between time from the diagnosis of rotator cuff tear to repair and the rate of subsequent revision surgery for re-tear. A national insurance database was queried from 2007 to 2016 for patients who underwent arthroscopic rotator cuff repair after a diagnosis of rotator cuff tear with minimum 5-year follow-up. On the basis of time from diagnosis to repair, patients were stratified into an early (<6 weeks), a routine (between 6 weeks and 12 months), or a delayed (>12 months) repair cohort. The rates of subsequent revision rotator cuff repair were compared pairwise between cohorts with Pearson's chi-square tests. Multivariate logistic regression was used to adjust for patient demographics and comorbidity burden. A total of 2759 patients were included, with 1510 (54.7%) undergoing early repair, 1104 (40.0%) undergoing routine repair, and 145 (5.3%) having delayed repair. The overall revision rate at 5-year follow-up was 9.6%. The revision rate was higher in the delayed group (15.2%) relative to the early (9.9%) and routine (8.3%) groups (P=.048 and P=.007, respectively). On multivariate analysis, delayed repair was associated with increased odds of revision surgery (odds ratio, 1.97; P=.009) compared with routine repair. Delayed rotator cuff repair beyond 12 months of diagnosis was associated with an increased risk of undergoing subsequent revision rotator cuff repair while controlling for age and comorbidity burden. [Orthopedics. 2020;43(6):340-344.].
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http://dx.doi.org/10.3928/01477447-20200923-02DOI Listing
November 2020

Patient Factors Associated With Clinical Failure Following Arthroscopic Superior Capsular Reconstruction.

Arthroscopy 2021 02 28;37(2):460-467. Epub 2020 Sep 28.

Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, U.S.A.. Electronic address:

Purpose: To identify demographic, clinical, and radiographic factors associated with failure after superior capsular reconstruction (SCR).

Methods: Prospectively collected data were analyzed from patients who underwent SCR using a decellularized dermal allograft for an irreparable rotator cuff tear. Demographic characteristics, radiographic findings, concomitant procedures, and patient-reported outcomes (PROs) were recorded. Failure was defined by ≥1 of the following criteria: (1) conversion to reverse total shoulder arthroplasty (RTSA), (2) a decrease in 1-year postoperative shoulder-specific PROs compared with preoperative scores, or (3) patient reports at final follow-up that the shoulder was in a worse condition than before surgery. Preoperative variables were compared between patients meeting the criteria for clinical failure and those who did not.

Results: Fifty-four patients (mean age 56.3 ± 5.8 years, range 45 to 70) who underwent SCR, with minimum 1-year follow-up, were included in the analysis. Mean follow-up after surgery was 24 months (range 12 to 53). Eleven patients (20.4%) met criteria for clinical failure. Of the 11, 8 reported decreased American Shoulder and Elbow Surgeons (ASES) or Constant scores or indicated that the operative shoulder was in a worse condition than before surgery. Three patients underwent RTSA in the 6 to 12 months after SCR. Female sex and the presence of a subscapularis tear were associated with failure (P = .023 and P = .029, respectively). A trend toward greater body mass index (BMI), lower preoperative forward flexion, and lower preoperative acromiohumeral distance (AHD) was found in patients with clinical failure (P = .075, P = .088, and P = .081, respectively). No other variable included in the analysis was significantly associated with failure.

Conclusion: The proportions of female patients and those with subscapularis tear were greater among patients with clinical failure after SCR. Greater BMI, lower preoperative forward flexion, and lower preoperative AHD trended toward association with clinical failure of SCR.

Level Of Evidence: 4, case series.
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http://dx.doi.org/10.1016/j.arthro.2020.09.038DOI Listing
February 2021

Orthopaedic Randomized Controlled Trials Published in General Medical Journals Are Associated With Higher Altmetric Attention Scores and Social Media Attention Than Nonorthopaedic Randomized Controlled Trials.

Arthroscopy 2021 04 19;37(4):1261-1270. Epub 2020 Sep 19.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address:

Purpose: To (1) compare the Altmetric Attention Score (AAS) and citation rates between orthopaedic and nonorthopaedic randomized controlled trials (RCTs) from 5 high-impact medical journals and (2) identify general characteristics of these articles associated with greater exposure on social media platforms.

Methods: Articles published in The New England Journal of Medicine (NEJM), Lancet, The Journal of the American Medical Association (JAMA), Annals of Internal Medicine, and Archives of Internal Medicine between January 2011 and December 2016 were analyzed. These journals were selected based on retaining high impact factors with rigorous publication standards and availability of the AAS for their publications. The queried time frame was chosen to balance the inception of the AAS with an optimal period for citation accrual. A total of 14 article characteristics, in addition to number of Tweets, Facebook shares, news mentions, and the AAS, were extracted. Inclusion criteria were orthopaedic RCTs reporting on outcomes after surgical intervention. Linear regression was used to assess the relationship between publication characteristics and the AAS and social media attention.

Results: A total of 9 orthopaedic and 59 nonorthopaedic RCTs were included. The mean AASs were significantly different (574 ± 565.7 versus 256.9 ± 222.3, P = .003), whereas citation rate was not (192.2 ± 117.1 versus 382.3 ± 560.3, P = .317). Orthopaedic RCTs had a significantly greater number of mentions on Twitter and Facebook (P < .001). A higher AAS significantly associated with a greater number of citations (β = 0.75, P = .019) for orthopaedic RCTs. The mean AAS of orthopaedic RCTs favoring nonoperative management (809.6 ± 676.3) was greater than those favoring operative treatment (292.0 ± 248.9) but was not statistically significant (P = .361).

Conclusion: Orthopaedic RCTs published in 5 high-impact general medical journals had a significantly greater mean AAS relative to nonorthopaedic RCTs, with no differences in citation rates. Additionally, there was a strong association between the AAS and citation rate of orthopaedic RCTs. Orthopaedic RCTs had greater social media exposure on both Twitter and Facebook.

Clinical Relevance: Orthopaedic surgeons, researchers, and providers who publish RCTs in high-impact medical journals can anticipate extensive social media attention for their articles relative to other nonorthopaedic RCTs in the same journals. Social media attention may be related to operative versus nonoperative management topics. This study provides further evidence for the increasing use of the AAS and its association with citation accrual.
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April 2021
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