Musculotendinous architecture of pathological supraspinatus: a pilot in vivo ultrasonography study.

Architectural changes associated with tendon tears of the supraspinatus muscle (SP) have not been thoroughly investigated in vivo with the muscle in relaxed and contracted states. The purpose of this study was to quantify the geometric properties within the distinct regions of SP in subjects with full-thickness tendon tears using an ultrasound protocol previously developed in our laboratory, and to compare findings with age/gender matched normal controls. Twelve SP from eight participants (6 male/2 female), mean age 57 ± 6.0 years, were investigated. Muscle geometric properties of the anterior region (middle and deep parts) and posterior region (deep part) were measured using image analysis software. Along with whole muscle thickness, fiber bundle length (FBL) and pennation angle (PA) were computed for architecturally distinct regions and/or parts. Pathologic SP was categorized according to the extent of the tear in the tendon (with or without retraction). In the anterior region, mean FBL of the pathologic SP was similar with normal controls; however, mean PA was significantly smaller in pathologic SP with retraction compared with normal controls, in the contracted state (P < 0.05). Mean FBL in the posterior region in both relaxed and contracted states was significantly shorter in the pathologic SP with retraction compared with normal controls (P < 0.05). Findings suggest FBL changes associated with tendon pathology vary between the distinct regions, and PA changes are related to whether there is retraction of the tendon. The ultrasound protocol may provide important information on architectural changes that may assist in decision making and surgical planning.

Rates of Burnout in Female Orthopaedic Surgeons Correlate with Barriers to Gender Equity.

BACKGROUND: The primary purpose of this study was to investigate the relationships between career burnout and the barriers to gender equity identified by Canadian female orthopaedic surgeons. A secondary purpose was to assess relationships between the demographic characteristics of the female surgeons and career burnout and job satisfaction. METHODS: An electronic survey was distributed to 330 Canadian female orthopaedic surgeons. Demographic variables including age, stage and years in practice, practice setting, and marital status were collated. The survey included the Gender Bias Scale (GBS) questionnaire and 2 questions each about career burnout and job satisfaction. The Pearson r correlation coefficient evaluated the relationships among the higher- and lower-order factors of the GBS, burnout, and job satisfaction. Spearman rank correlation coefficient assessed relationships among burnout, job satisfaction, and demographic variables. RESULTS: Survey responses were received from 218 (66.1%) of the 330 surgeons. A total of 110 surgeons (50.5%) agreed or strongly agreed that they felt career burnout (median score = 4). Burnout was positively correlated with the GBS higher-order factors of Male Privilege (r = 0.215, p < 0.01), Devaluation (r = 0.166, p < 0.05), and Disproportionate Constraints (r = 0.152, p < 0.05). Job satisfaction (median = 4) was reported by 168 surgeons (77.1%), and 66.1% were also satisfied or very satisfied with their role in the workplace (median = 4). Burnout was significantly negatively correlated with surgeon age and job satisfaction. CONCLUSIONS: Half of the female orthopaedic surgeons reported symptoms of career burnout. Significant relationships were evident between burnout and barriers to gender equity. Identification of the relationships between gender-equity barriers and burnout presents an opportunity to modify organizational systems to dismantle barriers and reduce this occupational syndrome. CLINICAL RELEVANCE: Given the relationships between gender inequity and career burnout in this study of female orthopaedic surgeons, actions to dismantle gender barriers and address systemic biases are necessary at all career stages to reduce burnout.

The one-week prevalence of overuse-related shoulder pain and activity limitation in competitive tennis players living in Toronto: a feasibility study.

Objective: We aimed to determine the feasibility of conducting a cross-sectional study to estimate the one-week prevalence of overuse-related shoulder pain and activity limitation in competitive tennis players. Methods: Eligible for the study were competitive adult tennis players who reside in Toronto. Using a convenience sample, the Oslo Sports Trauma Research Centre Overuse Shoulder Injury Questionnaire (OSIQ) was administered online to provide preliminary estimates of the prevalence of shoulder pain and activity limitation, injury severity and pain intensity. Feasibility outcomes included evaluating participation rate and missing data in the questionnaire. Results: Forty-three tennis players were included in the questionnaire (68.3% participation rate, 100% completion rate). There was no missing data. The one-week proportion of those with shoulder pain and activity limitation was 41.9% with a mean injury severity of 33/100. Mean pain intensity was 1.9/10. Conclusion: Our study demonstrates that it is feasible to conduct a cross-sectional study to measure the one-week prevalence of shoulder pain and activity limitation in tennis players.

Objectif: nous avons cherché à déterminer la faisabilité de mener une étude transversale pour estimer la prévalence sur une semaine de la douleur à l'épaule et de la limitation d'activité liée à la surutilisation chez les joueurs de tennis de compétition. Méthodologie: les joueurs de tennis adultes compétitifs qui résident à Toronto sont admissibles pour l'étude. À l'aide d'un simple échantillon, l'Overuse Shoulder Injury Questionnaire, OSIQ (questionnaire sur les blessures à l'épaule), du Centre de recherche sur les traumatismes sportifs d'Oslo a été mis en ligne pour obtenir des estimations préliminaires de la prévalence de la douleur à l'épaule et de la limitation des activités, de la gravité des blessures et de l'intensité de la douleur. Les critères de faisabilité comprenaient l'évaluation du taux de participation et des données manquantes dans le questionnaire. Résultats: quarante-trois joueurs de tennis ont été inclus dans le questionnaire (taux de participation de 68,3 %, taux d'achèvement de 100 %). Il n'y avait pas de données manquantes. La proportion sur une semaine de personnes souffrant de douleur à l'épaule et de limitation d'activité était de 41,9 % avec une gravité moyenne des blessures de 33/100. L'intensité moyenne de la douleur était de 1,9/10. Conclusion: notre étude démontre qu'il est possible de mener une étude transversale pour mesurer la prévalence sur une semaine de la douleur à l'épaule et de la limitation d'activité chez les joueurs de tennis.

Experiences of Canadian Female Orthopaedic Surgeons in the Workplace: Defining the Barriers to Gender Equity.

BACKGROUND: Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery. METHODS: An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons. RESULTS: The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations. CONCLUSIONS: In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all. CLINICAL RELEVANCE: A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care.

Delayed diagnosis of osteodiscitis in an adolescent athlete: a case report.

BACKGROUND: Vertebral osteomyelitis (OM) is an infectious condition of bone caused by an infecting organism, most commonly Staphylococcus aureus (S. aureus). Though rare in adolescents, it is important to remember that this population has vascularized intervertebral discs prior to skeletal maturity and, therefore, is more susceptible to an osteodiscitis infection. PURPOSE: To determine the possible factors that lead to a delayed diagnosis of osteodiscitis compared to an early diagnosis in an adolescent athlete. SUMMARY: This case provides a unique example of osteodiscitis in an adolescent rowing athlete where an infected heel blister was the only indication toward a diagnosis. Early diagnosis and successful management of osteodiscitis are dependent on recognizing constitutional and non-constitutional signs and symptoms of infection. CLINICAL RELEVANCE: In sport, when skin barriers may be compromised more readily, the risk of infection should be considered in the differential diagnosis of unprovoked back pain.

CONTEXTE: L'ostéomyélite vertébrale (OM) est une affection des os causée par un microorganisme infectieux, le plus souvent Staphylococcus aureus (S. aureus). Bien que cette affection soit rare chez les adolescents, il est important de retenir que cette population a des disques intervertébraux vascularisés avant d'atteindre la maturité squelettique et qu'elle est donc plus exposée à l'ostéodiscite. OBJECTIF: déterminer les facteurs possibles qui conduisent à un diagnostic tardif de l'ostéodiscite par rapport à un diagnostic précoce chez un athlète adolescent. RÉSUMÉ: Ce cas fournit un exemple unique d'ostéodiscite chez un athlète adolescent de l'aviron présentant une ampoule infectée au talon qui était l'unique signe permettant de poser un diagnostic. Le diagnostic précoce et la prise en charge réussie de l'ostéodiscite dépendent de la reconnaissance des signes et symptômes constitutionnels et non constitutionnels de l'infection. PERTINENCE CLINIQUE: Chez les sportifs, les barrières cutanées peuvent être compromises plus facilement et le risque d'infection doit être pris en compte dans le diagnostic différentiel des douleurs dorsales non provoquées.

Recurrent symptoms after shoulder instability repair: direct MR arthrographic assessment--correlation with second-look surgical evaluation.

PURPOSE: To retrospectively determine the accuracy of direct magnetic resonance (MR) arthrography of the shoulder in patients with recurrent or residual signs and/or symptoms of instability after prior instability repair, with surgical findings as the reference standard. MATERIALS AND METHODS: After institutional ethics review board approval was obtained and informed consent was waived, 40 patients (31 men, eight women; mean age, 28 years) with recurrent instability after previous instability repair who underwent direct shoulder MR arthrography before repeat surgery were studied. Two musculoskeletal radiologists reviewed direct MR arthrographic studies by using consensus agreement in a blinded fashion. MR assessment included evaluation of the labrum (overall, superior, anterior and anteroinferior, posterior and posteroinferior), rotator cuff, biceps tendon, articular cartilage, and presence or absence of a Hill-Sachs lesion. Mean interval between MR arthrography and repeat surgery was 6.2 months (range, 6 days to 36 months). Surgical reports were compared with MR arthrographic results, and accuracy, sensitivity, and specificity of direct MR arthrography were determined. RESULTS: Accuracy, sensitivity, and specificity, respectively, of direct MR arthrography in diagnosis of overall labral tears (n = 26) were 91.9%, 96.2%, and 81.8%; those of superior labral tears (n = 16) were 89.2%, 93.8%, and 85.7%; and those of anteroinferior tears (n = 17) were 91.9%, 100%, and 85%. Overall accuracy for detecting rotator cuff injury (n = 17) was 87.2% (sensitivity, 94.1%; specificity, 81.8%); accuracy for biceps injury (n = 7) was 95.7% (sensitivity, 85.7%; specificity, 100%); accuracy for glenoid and/or humeral articular cartilage abnormality (n = 15) was 76.2% (sensitivity, 73.3%; specificity, 83.3%); and accuracy for Hill-Sachs lesion (n = 14) was 93.3%. CONCLUSION: Direct MR arthrography is accurate (91.9%) for assessing labral pathologic conditions and other internal derangements of the shoulder in patients with recurrent or residual signs and/or symptoms after prior shoulder instability repair.

Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging.

BACKGROUND: Rotator cuff tears are very common, but little is known about the outcome of nonoperative treatment of symptomatic tears in terms of progression and the need for surgical intervention. METHODS: Fifty-nine shoulders in fifty-four patients (thirty-three women and a mean age of 58.8 years) with rotator cuff tears on initial magnetic resonance imaging who had been managed nonoperatively were studied retrospectively. All had magnetic resonance imaging scans acquired six months or more after the initial study. The progression of the rotator cuff tears was associated with age, anatomical and associated parameters, follow-up time, and structural and other magnetic resonance imaging findings. RESULTS: Baseline magnetic resonance imaging scans demonstrated thirty-three full-thickness tears, twenty-six partial-thickness tears, and four combined full-thickness and partial-thickness tears. Fifty-eight of the fifty-nine tears involved the supraspinatus tendon, and ten involved multiple tendons. Progression in tear size occurred more often among the patients who were followed more than eighteen months (thirteen [48%] of twenty-seven shoulders) compared with those who were followed for less than eighteen months (six [19%] of thirty-two shoulders). Five tears (one partial-thickness tear) decreased in size. More than half (52%; seventeen) of the thirty-three full-thickness tears increased in size compared with 8% (two) of the twenty-six partial-thickness tears (p = 0.0005). Only 17% (six) of the thirty-five tears in patients who were sixty years old or less deteriorated compared with 54% (thirteen) of the twenty-four tears in patients who were more than sixty years old (p = 0.007). No shoulder in a patient with a partial-thickness tear demonstrated supraspinatus atrophy, whereas 24% of those with a full-thickness tear demonstrated atrophy (p = 0.007). The proportion with an increase in tear size was significantly larger for shoulders with fatty infiltration than for those without it (p = 0.0089). CONCLUSIONS: Factors that are associated with progression of a rotator cuff tear are an age of more than sixty years, a full-thickness tear, and fatty infiltration of the rotator cuff muscle(s). In the long-term follow-up of nonoperatively treated rotator cuff tears, magnetic resonance imaging can be used to monitor rotator cuff changes and guide patient management.

Three-dimensional study of the musculotendinous architecture of supraspinatus and its functional correlations.

The supraspinatus is most frequently involved in shoulder pathology. However, the musculotendinous architecture of the supraspinatus has not been well documented. Therefore, the purpose of this study is to investigate the detailed three-dimensional architecture of the supraspinatus throughout its volume. Ten male formalin embalmed cadaveric specimens (mean age 61.9 +/- 16 years) without any evidence of rotator cuff pathology were used. Three-dimensional coordinates (x, y, and z) of the tendon and muscle fiber bundles were collected in situ, using serial dissection and digitization. The data was reconstructed into a three-dimensional model using Maya. Fiber bundle lengths, pennation angles (PA), muscle volumes, and tendon dimensions for each architecturally distinct area were computed and then analyzed using paired t-tests and ANOVA (P < 0.05). The supraspinatus was found to consist of anterior and posterior regions, which were each further subdivided into superficial, middle, and deep parts. Mean PA were found to be significantly different between the distinct parts of the anterior region of the muscle. Medial PA was also found be significantly different between the superficial and middle, and superficial and deep parts of the posterior region. These results provide insight into the normal function of the muscle and its possible contribution to the initiation and progression of supraspinatus tendon tears.

Increased cytokine secretion in patients with failed implants compared with patients with primary implants.

All total joint replacements generate wear debris; yet, some implant prostheses fail while others survive despite the presence of ultrahigh molecular weight polyethylene particulate. It was hypothesized that patients with failed hip implants who have osteolysis will secrete higher inflammatory cytokines than patients receiving total joint replacements. Our study evaluated the peripheral blood monocyte response to varying polyethylene particle volume ratios through cytokine quantification in two patient populations: patients having revision surgery for failed total hip replacements (failed implant group) and patients having primary total hip surgery for osteoarthritis of the hip (primary implant group). We observed elevation of all three proinflammatory cytokines tested (interleukin-6, interleukin-1, and tumor necrosis factor-alpha) in response to polyethylene particulate challenge when compared with the controls in both patient groups. The population with failed implants also had a higher absolute cytokine response to polyethylene exposure compared with the control patients having primary implants. These findings suggest that patients with failed implants have a greater inflammatory cytokine response to polyethylene than seen in patients with primary implants.

Increased subcortical patellar signal intensity at T2-weighted MR imaging: a subacute finding after knee injury.

PURPOSE: To investigate the temporal prevalence of a rim of increased signal intensity in the subcortical part of the patella at T2-weighted magnetic resonance (MR) imaging after arthroscopic knee surgery or knee injury. MATERIALS AND METHODS: The prospective and retrospective components of the study were performed after receiving approval from the institutional research ethics board. Written informed consent was obtained for the prospective component of the study. The need for informed consent was waived for the retrospective component of the study. The authors performed a prospective evaluation of serial MR images of the knee of four patients (three men and one woman; age range, 28-53 years; mean age, 36.8 years) after arthroscopic anterior cruciate ligament (ACL) reconstruction. They also performed a retrospective review of MR images of the knee from 90 consecutive patients (59 male and 31 female patients; age range, 13-66 years; mean age, 34.6 years) referred for the evaluation of an ACL injury. All imaging studies were evaluated in consensus by two musculoskeletal radiologists for the presence of a rim of increased signal intensity in the subcortical part of the patella at T2-weighted imaging. The presence of this signal intensity pattern was correlated with the time to imaging from surgery or joint injury. Logistic regression modeling was performed with increased subcortical signal intensity as the outcome and a second-degree polynomial for elapsed time as the predictor. RESULTS: All four patients who underwent imaging prospectively after ACL surgery showed increased T2-weighted signal intensity in the subcortical part of the patella 12 weeks after surgery. None of the patients showed these signal intensity changes at 6 or 24 weeks. A subcortical rim of increased T2-weighted signal intensity was seen in the patella in 24 (27%) of the 90 consecutive patients who underwent imaging for the assessment of possible ACL injury. Significant independent differences were seen in the prevalence of increased T2-weighted signal intensity in the subcortical part of the patella when related to time between injury and MR imaging (P = .002), with an increase in prevalence as time since injury increased and a decrease in prevalence in patients who underwent MR imaging more than 20 weeks after injury (P = .013). CONCLUSION: Increased T2-weighted signal intensity in the subcortical part of the patella appears to be a subacute transient MR finding seen after knee surgery or injury.