During the COVID-19 pandemic, video/phone consultations (VPC) were increasingly utilised as an alternative to face-to-face (F2F) consultations, to minimise nosocomial viral exposure. We previously demonstrated that VPCs were highly rated by both patients and clinicians. This study compared satisfaction between both clinic modalities in contemporaneously delivered outpatient surveys. We also assessed the feasibility and effects of converting F2F orthopaedic consultations to VPC.

Surveys were posted to patients who attended VPCs and F2F consultations at a large tertiary centre from August to October 2020 inclusive, across 51 specialties. F2F and VPC patients ranked their overall satisfaction with their consultation on a 10-point numerical scale (10=highest satisfaction). Simultaneously, a pilot study was undertaken of outpatient fracture clinics to identify patients suitable for VPCs, with X-rays (if needed) taken and transferred from satellite sites to reduce tertiary centre footfall.

For F2F consultations, 1419 of 4465 surveys (31.8%) were returned with similar rates for VPCs (1332 of 4572, 29.1%). While mean satisfaction ratings were high for both clinic modalities, they were significantly higher for F2F: 9.13 (95% CI 9.05-9.22) for F2F clinics, compared to 8.23 (95% CI 8.11-8.35) for VPCs (p<0.001, t-test). F2F patients were almost four times more likely to state a preference for future F2F appointments compared to VPCs, whereas patients who attended VPCs showed an equal preference for either option (p< 0.001, chi2 test). 53% of 111 fracture clinic patients sampled were identified as suitable for VPCs. 1 patient (1.7%) requested their VPC to be converted to F2F due to poor symptom control.

Our study showed patients reported high satisfaction ratings for both F2F clinics and VPCs, with prior experience of VPCs affecting patients’ future preferences. Only 1.7% of F2F patients converted to VPCs declined their virtual appointment. Our results support future use of VPCs.

Objectives

The effects of disease progression and common tendinopathy treatments on the tissue characteristics of human rotator cuff tendons have not previously been evaluated in detail owing to a lack of suitable sampling techniques. This study evaluated the structural characteristics of torn human supraspinatus tendons across the full disease spectrum, and the short-term effects of subacromial corticosteroid injections (SCIs) and subacromial decompression (SAD) surgery on these structural characteristics.

Background

High re-rupture rates following repairs of rotator cuff tears (RCTs) have resulted in the increased use of repair grafts to act as temporary scaffolds to support tendon healing. It has been estimated that thousands of extracellular matrix repair grafts are used annually to augment surgical repair of rotator cuff tears. The only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus. As the shoulder and rotator cuff tendons are exposed to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. We used a novel technique to study material deformation, dynamic shear analysis (DSA).

Improved understanding of the biomechanics and biology of rotator cuff tendons (RCT) may help reduce high re-rupture rates following repairs, particularly amongst larger tears. This study aims to use novel methods for quantitatively determining differences in the mechanical and thermal properties of intact healthy RCTs compared to torn ‘diseased’ tendons. A common problem in the mechanical testing of small tendon samples is that stress risers at the clamp-tendon interface can obscure measurements. As the shoulder is subject to shear, tension and compression, we developed a novel solution using Dynamic Shear Analysis (DSA), a form of rheology which studies material deformation. As collagen is the main component of RCT, the structure and mechanical properties may be affected by collagen conformational changes. Both dermis and rat tail tendon with increased collagen cross-linking exhibit stronger mechanical properties. Thermal changes detected by differential scanning calorimetry (DSC) can help to quantify collagen structural differences in torn RCT, and has been previously used to study muscle, cartilage and vertebral discs.

There were 79 tears (mean age 65.2 years), which were classified according to the size of the tear as small, medium, large and massive. Two separate 3mm-sized biopsy samples were taken and subjected to DSA using oscillatory deformation under compression. The storage modulus (G') was calculated and used as an indicator of mechanical integrity. 18 control tendon specimens were obtained from patients aged between 22-89 years (mean age 58.8 years) during shoulder hemiarthroplasties and stabilisations. Additionally 7 normal, 7 small and 7 massive frozen specimens were thermally characterized. 3 samples per patient were heated between 20-80oC in hermetically sealed vessels. Useful thermal parameters were measured such as the melting temperature (TM) which apparently represents breaking of the amide-amide bonds and protein chains mobility, the denaturation temperature (TD) which supposedly corresponds to proteins falling out of solution and the denaturation enthalpy (ΔH) which reflects the relative amount of triple helical structure.

Healthy tendons had a significantly higher modulus than torn tendons, indicating that torn tendons are mechanically weaker than normal tendons (p = 0.032). Normal tendons had significantly higher mean shear modulus than tendons with small and massive tears (p<0.01). Overall there was a negative correlation between moduli and severity of tendon tear (r = −0.698, p=0.189). The moduli did not significantly correlate with age, sex, hand dominance, or length of preservation in formalin. Massive RCT tears had significantly higher TM and TD when compared to normal RCT (p < 0.05), unlike small RCT tears. No significant difference was detected between the denaturation enthalpy of the different RCT groups. This case control study has demonstrated that normal RCTs have a significantly higher modulus than torn tendons, indicating that torn tendons have less mechanical integrity. Our study further demonstrated a trend between increasing tear size and decreasing mechanical integrity. This study has also demonstrated differences in some of the thermal properties of normal and torn RCTs. These are likely due to collagen structural changes. A decrease in the denaturation temperature of torn tendons, suggests that the material is intrinsically less stable. Torn tendons with reduced storage modulus and collagen integrity may be less able to withstand mechanical loads following repair. This pilot study provides some preliminary insight into the mechanisms that may contribute to, or represent adaptations to high rates of failure of RCT repairs.