RESUMEN

BACKGROUND: The time from symptom onset to surgery has been shown to impact functional outcomes after repair of traumatic rotator cuff tears (RCTs), but this temporal relationship has not yet been evaluated in patients with atraumatic, degenerative cuff tears. Furthermore, it has been shown that over time, atraumatic cuff tears tend to enlarge and become more symptomatic, retracted, and atrophic-factors that have been shown to decrease success rates after repair. The aim of this study was to evaluate the relationship between the time from symptom onset to surgery and postoperative outcomes in patients with atraumatic RCTs. METHODS: We performed a retrospective cohort study of patients with degenerative, atraumatic RCTs who underwent surgery performed by 2 fellowship-trained shoulder surgeons and had at least 12 months of postoperative follow-up. These patients were divided into 2 cohorts based on the duration between symptom onset and surgery: early (<12 months) and delayed (≥12 months). The primary outcome measures included reoperation rate and failure of repair. Secondary outcomes included clinical measures of strength and range of motion and patient-reported outcome measures consisting of the Subjective Shoulder Value, visual analog scale for pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment, and Brophy-Marx Activity Scale at last follow-up. RESULTS: Of the 143 patients who met the inclusion criteria, 78 (54.5%) underwent surgery within 1 year of symptom onset whereas 65 (45.5%) underwent surgery after at least 1 year. There were no differences between groups regarding demographic or tear characteristics. At final follow-up, there were no differences between the early- and late-surgery groups regarding retear rate (12% vs. 9%, P = .65), reoperation rate (5% vs. 3%, P = .54), postoperative range of motion in any plane (P > .05), strength in external rotation and internal rotation, visual analog scale pain score, or Subjective Shoulder Value. A greater proportion of the early group (61%) than the late group (46%) experienced improvement in supraspinatus strength of ≥1 grade on manual muscle testing (P = .02) and post hoc analysis. CONCLUSION: Despite our knowledge of the natural history of chronic, atraumatic RCTs, delaying surgical treatment for 1 year or more does not appear to significantly impact postoperative outcomes. Thus, it is reasonable for physicians to recommend either conservative or surgical treatment depending on patient-specific factors and expectations.

Asunto(s)

RESUMEN

The outcome of anterior cruciate ligament (ACL) surgery depends on many factors. Successful ACL surgery includes evaluating patients' characteristics and addressing all the underlying knee pathologies, including the meniscus tears and ramp lesions. In recent years, there has been a growing interest in ramp lesions as well as the role that bony morphology plays in predisposing patients to ACL injury and failed ACL surgery. Not only pathologic but also physiologic variations in bony morphology like tibial slope and lateral femoral condyle ratio have been correlated with clinical outcomes, failure rates, rotatory instability, and even lesions to the contralateral knee. Evaluating each patient's specific anatomy is recommended when customizing ACL surgery. With further research and increased awareness of relevant bony parameters, we will be able to improve our ability to prevent injury, increase the diagnostic accuracy of associated lesions, and tailor surgery to improve the outcomes and reduce failure rates.

Asunto(s)

RESUMEN

PURPOSE: To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization. METHODS: Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal-Wallis rank-sum test. When P < .05, a post-hoc Dunn's test was performed. For categorical variables, the χ2 test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant. RESULTS: A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) (P = .005), active abduction (P = .02), passive IRS (P = .02), and passive external rotation in abduction (P = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant. CONCLUSIONS: In patients undergoing arthroscopic shoulder stabilization for anterior instability, ROM varies with location and extent of labral tear. However, the clinical relevance of such small ROM differences remains undetermined. LEVEL OF EVIDENCE: II, prospective comparative study.

RESUMEN

Management of the subscapularis tendon is a crucial step during the approach for total shoulder arthroplasty. The method of mobilizing the tendon and the technique used to repair it determine the initial integrity of the subscapularis and impact its capacity to heal. Currently, there exist 3 well-described and well-studied approaches to managing and repairing the subscapularis: subscapularis tenotomy, subscapularis peel, and lesser tuberosity osteotomy. More recently, a subscapularis-sparing approach has been proposed as an option. There is debate in the literature regarding which technique provides optimal strength and stability for subscapularis repair following shoulder arthroplasty. In this symposium, we provide an overview of each of the techniques and review the biomechanical studies comparing them.

RESUMEN

PURPOSE: Fat emboli syndrome is a rare but well-described complication of long-bone fractures classically characterised by a triad of respiratory failure, mental status changes and petechial rash. In this paper, we present the case of a patient who sustained bilateral femoral fractures and subsequently developed FES. Our aim was to review and summarise the current literature regarding the pathophysiology and management of fat emboli syndrome (FES) and propose an algorithm for treating patients with bilateral femoral fractures to reduce the risk of FES. METHODS: A literature analysis was performed to determine implications in the clinical setting. RESULTS: Currently, there exists little high-quality evidence to guide the orthopaedic surgeon in identifying patients at highest risk of FES or in preventing FES in patients with multiple long-bone fractures. However, the literature does suggest that the risk is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilisation and the respiratory reserve of the patient. Based on these correlations, we propose an algorithm for treating patients with bilateral femoral fractures, taking into consideration haemodynamic and pulmonary stability. CONCLUSIONS: Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.

Asunto(s)

RESUMEN

To our knowledge, this is the first study to examine the DSM-5-defined conduct disorder (CD) with limited prosocial emotions (LPE) among adolescents in substance use disorder (SUD) treatment, despite the high rates of CD in this population. We tested previously published methods of LPE categorization in a sample of male conduct-disordered patients in SUD treatment (n=196). CD with LPE patients did not demonstrate a distinct pattern in terms of demographics or co-morbidity regardless of the categorization method utilized. In conclusion, LPE, as operationalized here, does not identify a distinct subgroup of patients based on psychiatric comorbidity, SUD diagnoses, or demographics.

RESUMEN

BACKGROUND: Approximately 20% of all geriatric patients who sustain low-energy hip fractures will die within 1 year of the injury, and approximately 3% will die during the initial inpatient hospital stay. Accordingly, the event of a geriatric hip fracture might be an apt prompt for discussing end-of-life care: in light of the risk of death after this injury, the topic of mortality certainly is germane. However, it is not clear to what degree physicians and patients engage in end-of-life planning even when faced with a hospital admission for this potentially life-threatening condition. QUESTIONS/PURPOSES: We assessed the frequency with which end-of-life care discussions were documented among a sample of geriatric patients admitted for hip fracture surgery. METHODS: We studied 150 adult patients, 70 years and older, admitted between September 2008 and July 2012 for the care of an isolated low-energy hip fracture, who did not have documented evidence of end-of-life care planning before the time of admission. For each patient, the medical record was scrutinized to identify documentation of end-of-life care discussions, an order changing "code status," or a progress note memorializing a conversation related to the topic of end-of-life care planning. RESULTS: Of the 150 subjects who had no documented evidence of end-of-life care planning at the time of admission, 17 (11%) had their code status changed during the initial hospitalization for hip fracture, and an additional four patients (3%) had a documented conversation regarding end-of-life care planning without a subsequent change in code status. Accordingly, there were 129 (86%) patients who had no record of any attention to end-of-life care planning during the hospital stay for hip fracture surgery. CONCLUSIONS: Our findings suggest that physicians may be missing a valuable opportunity to help patients and their families be better prepared for potential future health issues. End-of-life care planning respects patient autonomy and enhances the quality of care. Accordingly, we recommend that discussion of goals, expectations, and preferences should be initiated routinely when patients present with a fragility fracture of the hip. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Asunto(s)

RESUMEN

BACKGROUND: Adolescents with substance use disorder (SUD) and conduct problems exhibit high levels of impulsivity and poor self-control. Limited work to date tests for brain cortical thickness differences in these youths. OBJECTIVES: To investigate differences in cortical thickness between adolescents with substance use and conduct problems and controls. METHODS: We recruited 25 male adolescents with SUD, and 19 male adolescent controls, and completed structural 3T magnetic resonance brain imaging. Using the surface-based morphometry software FreeSurfer, we completed region-of-interest (ROI) analyses for group cortical thickness differences in left, and separately right, inferior frontal gyrus (IFG), orbitofrontal cortex (OFC) and insula. Using FreeSurfer, we completed whole-cerebrum analyses of group differences in cortical thickness. RESULTS: Versus controls, the SUD group showed no cortical thickness differences in ROI analyses. Controlling for age and IQ, no regions with cortical thickness differences were found using whole-cerebrum analyses (though secondary analyses co-varying IQ and whole-cerebrum cortical thickness yielded a between-group cortical thickness difference in the left posterior cingulate/precuneus). Secondary findings showed that the SUD group, relative to controls, demonstrated significantly less right > left asymmetry in IFG, had weaker insular-to-whole-cerebrum cortical thickness correlations, and showed a positive association between conduct disorder symptom count and cortical thickness in a superior temporal gyrus cluster. CONCLUSION: Functional group differences may reflect a more nuanced cortical morphometric difference than ROI cortical thickness. Further investigation of morphometric differences is needed. If replicable findings can be established, they may aid in developing improved diagnostic or more targeted treatment approaches.

Asunto(s)