Background:
Fear of reinjury and lack of confidence influence return-to-sport outcomes after anterior cruciate ligament (ACL) reconstruction. The physical, psychosocial, and functional recovery of ...patients reporting fear of reinjury or lack of confidence as their primary barrier to resuming sports participation is unknown.
Purpose:
To compare physical impairment, functional, and psychosocial measures between subgroups based on return-to-sport status and fear of reinjury/lack of confidence in the return-to-sport stage and to determine the association of physical impairment and psychosocial measures with function for each subgroup at 6 months and 1 year after surgery.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Physical impairment (quadriceps index QI, quadriceps strength/body weight QSBW, hamstring:quadriceps strength ratio HQ ratio, pain intensity), self-report of function (International Knee Documentation Committee IKDC), and psychosocial (Tampa Scale for Kinesiophobia–shortened form TSK-11) measures were collected at 6 months and 1 year after surgery in 73 patients with ACL reconstruction. At 1 year, subjects were divided into “return-to-sport” (YRTS) or “not return-to-sport” (NRTS) subgroups based on their self-reported return to preinjury sport status. Patients in the NRTS subgroup were subcategorized as NRTS-Fear/Confidence if fear of reinjury/lack of confidence was the primary reason for not returning to sports, and all others were categorized as NRTS-Other.
Results:
A total of 46 subjects were assigned to YRTS, 13 to NRTS-Other, and 14 to NRTS-Fear/Confidence. Compared with the YRTS subgroup, the NRTS-Fear/Confidence subgroup was older and had lower QSBW, lower IKDC score, and higher TSK-11 score at 6 months and 1 year; however, they had similar pain levels. In the NRTS-Fear/Confidence subgroup, the IKDC score was associated with QSBW and pain at 6 months and QSBW, QI, pain, and TSK-11 scores at 1 year.
Conclusion:
Elevated pain-related fear of movement/reinjury, quadriceps weakness, and reduced IKDC score distinguish patients who are unable to return to preinjury sports participation because of fear of reinjury/lack of confidence. Despite low average pain ratings, fear of pain may influence function in this subgroup. Assessment of fear of reinjury, quadriceps strength, and self-reported function at 6 months may help identify patients at risk for not returning to sports at 1 year and should be considered for inclusion in return-to-sport guidelines.
Background Reverse total shoulder arthroplasty (RTSA) has been shown to be an effective treatment for proximal humerus fracture (PHF). This study evaluates outcomes of all patients with PHF treated ...with RTSA as a primary procedure for acute PHF, a delayed primary procedure for symptomatic PHF malunion or nonunion, a revision procedure for failed PHF hemiarthroplasty (HA), or a revision procedure for failed open reduction and internal fixation (ORIF). Methods Patients who underwent RTSA for PHF were evaluated for active range of motion and Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test-12, American Shoulder and Elbow Surgeons (ASES), University of California–Los Angeles (UCLA) shoulder rating scale, Constant, and 12-Item Short Form Health Survey scores. Scaption and external rotation (ER) strength were also assessed. Results RTSA was performed in 49 patients with PHF; 13 patients underwent RTSA for acute PHF, 13 for malunion or nonunion, 12 for failed PHF HA, and 11 for failed PHF ORIF. ER range of motion, SPADI, ASES, UCLA, and Constant scores achieved significance. The acute fracture group significantly outperformed the failed HA group in SPADI, ASES, and UCLA scores. The malunion/nonunion group significantly outperformed the failed HA group in ASES and UCLA scores. The acute fracture and malunion/nonunion groups each had significantly greater ER than the failed HA group. Conclusion RTSA is an effective treatment option for PHF as both a primary and a revision procedure. Primary RTSA outperformed RTSA done as a revision procedure. RTSA for acute PHF is comparable to RTSA for malunions and nonunions. Our outcomes of revision RTSA for failed HA and ORIF are more promising than previously published.
Commercially available preoperative planning software is now widely available for shoulder arthroplasty. However, without the use of patient-specific guides or intraoperative visual guidance, ...surgeons have little in vivo feedback to ensure proper execution of the preoperative plan. The purpose of this study was to assess surgeons' ability to implement a preoperative plan in vivo during shoulder arthroplasty.
Fifty primary shoulder arthroplasties from a single institution were retrospectively reviewed. All surgical procedures were planned using a commercially available software package with both multiplanar 2-dimensional computed tomography and a 3-dimensional implant overlay. Following registration of intraoperative visual navigation trackers, the surgeons (1 attending and 1 fellow) were blinded to the computer navigation screen and attempted to implement the plan by simulating placement of a central-axis guide pin. Malposition was assessed (>4 mm of displacement or >10° error in version or inclination). Data were then blinded, measured, and evaluated.
Mean displacement from the planned starting point was 3.2 ± 2.0 mm. The mean error in version was 6.4° ± 5.6°, and the mean error in inclination was 6.6° ± 4.9°. Malposition was observed in 48% of cases after preoperative planning. Malposition errors were more commonly made by fellow trainees vs. attending surgeons (58% vs. 38%, P = .047).
Despite preoperative planning, surgeons of various training levels were unable to reproducibly replicate the planned component position consistently. Following completion of fellowship training, significantly less malposition resulted. Even in expert hands, the orientation of the glenoid component would have been malpositioned in 38% of cases. This study further supports the benefit of guided surgery for accurate placement of glenoid components, regardless of fellowship training.
Background Reverse total shoulder arthroplasty (RTSA) is now performed at nearly the same rate as anatomic total shoulder arthroplasty in the United States. Repair of the subscapularis is of vital ...importance in total shoulder arthroplasty; however, its utilization in RTSA has recently been questioned. Methods This is a retrospective comparative study from prospectively collected data comparing the outcomes and complications after primary RTSA with or without subscapularis repair. The study includes 202 patients who underwent primary RTSA at a single institution by a single surgeon using the same implant between 2007 and 2012. Average clinical follow-up was greater than 3 years in both groups. Outcome scores, clinical range-of-motion and strength measurements, and complications including dislocations are reported. Results At an average follow-up of greater than 3 years, there were no significant differences in clinical range of motion, strength, and rates of complications including dislocations. External rotation was 24° in the subscapularis repair group and 26° in the no-repair group. There were no differences in the American Shoulder and Elbow Surgeons shoulder score. Subjective measures included the Shoulder Pain and Disability Index; University of California, Los Angeles shoulder rating scale; Simple Shoulder Test; and normalized Constant outcome scores. There were 0 dislocations (0%) in the subscapularis repair group and 3 dislocations in the no-repair group (2.6%), which were not significantly different. Conclusion Primary RTSAs with or without subscapularis repair have similar clinical outcome scores, range of motion, strength, and rates of complications including dislocations at 3 years of follow-up.
Laboratory-based studies on neuromuscular control after concussion and epidemiological studies suggest that concussion may increase the risk of subsequent musculoskeletal injury.
The purpose of this ...study was to determine if athletes have an increased risk of lower extremity musculoskeletal injury after return to play from a concussion.
Injury data were collected from 2006 to 2013 for men's football and for women's basketball, soccer and lacrosse at a National Collegiate Athletic Association Division I university. Ninety cases of in-season concussion in 73 athletes (52 male, 21 female) with return to play at least 30 days prior to the end of the season were identified. A period of up to 90 days of in-season competition following return to play was reviewed for time-loss injury. The same period was studied in up to two control athletes who had no concussion within the prior year and were matched for sport, starting status and position.
Lower extremity musculoskeletal injuries occurred at a higher rate in the concussed athletes (45/90 or 50 %) than in the non-concussed athletes (30/148 or 20 %; P < 0.01). The odds of sustaining a musculoskeletal injury were 3.39 times higher in the concussed athletes (95 % confidence interval 1.90-6.05; P < 0.01). Overall, the number of days lost because of injury was similar between concussed and non-concussed athletes (median 9 versus 15; P = 0.41).
The results of this study demonstrate a relationship between concussion and an increased risk of lower extremity musculoskeletal injury after return to play, and may have implications for current medical practice standards regarding evaluation and management of concussion injuries.
Diabetic peripheral neuropathy (DPN) is a common complication of diabetes that is associated with axonal atrophy, demyelination, blunted regenerative potential, and loss of peripheral nerve fibers. ...The development and progression of DPN is due in large part to hyperglycemia but is also affected by insulin deficiency and dyslipidemia. Although numerous biochemical mechanisms contribute to DPN, increased oxidative/nitrosative stress and mitochondrial dysfunction seem intimately associated with nerve dysfunction and diminished regenerative capacity. Despite advances in understanding the etiology of DPN, few approved therapies exist for the pharmacological management of painful or insensate DPN. Therefore, identifying novel therapeutic strategies remains paramount. Because DPN does not develop with either temporal or biochemical uniformity, its therapeutic management may benefit from a multifaceted approach that inhibits pathogenic mechanisms, manages inflammation, and increases cytoprotective responses. Finally, exercise has long been recognized as a part of the therapeutic management of diabetes, and exercise can delay and/or prevent the development of painful DPN. This review presents an overview of existing therapies that target both causal and symptomatic features of DPN and discusses the role of up-regulating cytoprotective pathways via modulating molecular chaperones. Overall, it may be unrealistic to expect that a single pharmacologic entity will suffice to ameliorate the multiple symptoms of human DPN. Thus, combinatorial therapies that target causal mechanisms and enhance endogenous reparative capacity may enhance nerve function and improve regeneration in DPN if they converge to decrease oxidative stress, improve mitochondrial bioenergetics, and increase response to trophic factors.
The present review classifies and describes the multifactorial causes of anterior cruciate ligament (ACL) surgery failure, concentrating on preventing and resolving such situations. The article ...particularly focuses on those causes that require ACL revision due to recurrent instability, without neglecting those that affect function or produce persistent pain. Although primary ACL reconstruction has satisfactory outcome rates as high as 97%, it is important to identify the causes of failure, because satisfactory outcomes in revision surgery can drop to as much as 76%. It is often possible to identify a primary or secondary cause of ACL surgery failure; even the most meticulous planning can give rise to unexpected findings during the intervention. The adopted protocol should therefore be sufficiently flexible to adapt to the course of surgery. Preoperative patient counseling is essential. The surgeon should limit the patient’s expectations for the outcome by explaining the complexity of this kind of procedure. With adequate preoperative planning, close attention to details and realistic patient expectations, ACL revision surgery may offer beneficial and satisfactory results for the patient.
Periprosthetic proximal humerus fractures (PPHFs) are a detrimental complication of shoulder arthroplasty, yet their characterization and management have been poorly studied. We aimed to determine ...the intra- and inter-observer reliability of four previously described PPHF classification systems to evaluate which classifications are the most consistent.
We retrospectively reviewed 32 patients (34 fractures) that were diagnosed with a PPHF between 1990 and 2017. Patient electronic medical records and research electronic data capture (REDCap) were used for data collection. Post-PPHF radiographs in multiple views for all 34 cases were organized into an encrypted, randomized Qualtrics survey. Four blinded fellowship-trained shoulder and elbow surgeons graded each fracture using previously reported classification systems by (1) Wright & Cofield (1995), (2) Campbell et al (1998), (3) Worland et al (1999), and (4) Groh et al (2008), along with selecting a preferred management strategy for each fracture. Grading was performed twice with at least two weeks between each randomized attempt. Intra-observer reliability was calculated as an unweighted Cohen’s kappa coefficient between attempt 1 and attempt 2 for each surgeon. Inter-observer reliability and agreeability between surgeons’ preferred management strategies were calculated for each classification system using Fleiss’ kappa coefficient. The kappa coefficients were interpreted using the Landis and Koch criteria.
The average intra-observer kappa coefficient for each classification was: Wright and Cofield = 0.703, Campbell = 0.527, Worland = 0.637, Groh = 0.699. The overall Fleiss’ kappa coefficient for inter-observer reliability for each classification was: Wright and Cofield = 0.583, Campbell = 0.488, Worland = 0.496, Groh = 0.483. Inter-observer reliability was significantly greater with the Wright and Cofield classification. Using Landis and Koch criteria, all the classification systems assessed demonstrated only moderate inter-observer agreement. Additionally, the mean inter-observer agreeability kappa coefficient for preferred management strategy was 0.490, indicating only moderate inter-observer agreement.
There is only moderate inter-observer reliability amongst the four PPHF classification systems and the preferred management strategy for the fractures assessed. Of the four PPHF classification systems, Wright and Cofield demonstrated the greatest mean intra-observer reliability and overall inter-observer reliability. Our study highlights a need for the development of a PPHF classification system that can achieve high intra- and inter-observer reliability and that can allow for a standardized treatment algorithm in the management of PPHFs.
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