Management of Proximal Hamstring Injuries: Non-operative and Operative Treatment.

PURPOSE OF REVIEW: To evaluate the current evidence and literature on treatment options for proximal hamstring injuries. RECENT FINDINGS: Patients with 3-tendon complete tears with greater than 2 cm of retraction have worse outcomes and higher complication rates compared to those with less severe injuries. Endoscopic and open proximal hamstring repair both have favorable patient reported outcomes at 5-year follow up. Proximal hamstring repair in patients who are male, with isolated semimembranosus injury, and have proximal hamstring free tendon rupture are more likely to have earlier return to sports. The Parisian Hamstring Avulsion Score (PHAS) is a validated patient-reported outcome measure to predict return to sports. Proximal hamstring injuries may occur in both elite and recreational athletes and may present with varying degrees of chronicity and severity. Injuries occur most commonly during forceful eccentric contraction of the hamstrings and often present with ischial tuberosity tenderness, ecchymosis, and hamstring weakness. Treatment decision-making is dictated by the tendons involved and chronicity. Many proximal hamstring injuries can be successfully treated with non-surgical measures. However, operative treatment of appropriately indicated proximal hamstring tendon injuries can result in significantly better functional outcomes and faster and more reliable return to sports compared to nonoperative treatment. Both endoscopic and open surgical repair techniques show high satisfaction levels and excellent patient-reported outcomes at short- and mid-term follow-up. Postoperative rehabilitation protocols vary across the literature and ongoing study is needed to clarify the optimal program, though emphasis on eccentric hamstring strengthening may be beneficial.

Operative and nonoperative treatment of periprosthetic humerus fractures after shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Periprosthetic humerus fracture is a relatively rare complication following shoulder arthroplasty. As shoulder arthroplasty volume increases, more periprosthetic fractures are anticipated. Some surgeons routinely operate on humerus shaft fractures adjacent to a humeral stem, while others recommend first-line nonoperative treatment. The purpose of this study was to identify and describe the prevalence of operative and nonoperative treatment options for periprosthetic humerus fractures, their associated outcomes, and complications. Our goal was to provide clinical insights for surgeons on the outcomes and complications associated with various treatment options. METHODS: We performed a systematic review of studies reporting clinical or radiographic outcomes and complications after operative or nonoperative treatment of postoperative periprosthetic humerus fractures following shoulder arthroplasty. Subgroup analysis was conducted for differences in surgical outcomes between open reduction internal fixation (ORIF) and revision arthroplasty. RESULTS: Twenty studies met the inclusion criteria (196 humeri). The mean clinical follow-up period was 2.6 years. Most fractures were Cofield B (42%), followed by C (27%), and A (12%); 19% were not classified. Forty-two percent of index implants were reverse total shoulders, 27% anatomic total shoulders, 16% hemiarthroplasties, and 1% resurfacing; implant design was not reported for 14%. The average time from index procedure to fracture was 2.9 years. One hundred sixty-seven (85%) fractures were treated operatively, 26 (13%) were treated nonoperatively, and 3 (2%) were missing information. Overall complication rate was 46%. Nonoperatively treated fractures had a higher complication rate (69% vs. 43%, P = .04) and increased risk of malunion (19% vs. 1%, P = < .001). Nonoperative management failed in 57% of Cofield B fractures. Time to union was shorter in the ORIF group than the revision arthroplasty group (24 weeks vs. 30 weeks, P < .001). Among operatively treated fractures, revision arthroplasty was associated with more complications (61% vs. 25%, P = .04) and higher nonunion rates (22% vs. 0%, P = .008) than ORIF. CONCLUSIONS: Complications may be more frequent than previously understood. With a 70% healing rate, nonoperative management is a viable treatment option, but should be weighed against high risk of complications and need for future procedures, especially in Cofield B fractures. Treatment with ORIF is associated with a higher union rate and fewer complications than revision arthroplasty.

Complications and Outcomes After Surgical Intervention in Clavicular Nonunion: A Systematic Review.

BACKGROUND: Surgical repair of clavicle fractures is being employed more frequently, although most fractures are still treated conservatively. Both can result in nonunion. Current treatments for clavicle nonunion include open reduction with internal fixation (ORIF) plating without bone graft, ORIF plating with bone graft, and intramedullary pin fixation. METHODS: We performed a systematic review and meta-analysis of studies reporting outcome, complication, and reoperation rates following surgical treatment for clavicle nonunion. Subgroup analysis was undertaken for outcome and complication rates between single plating and intramedullary pin fixation, bone graft use, and nonunion time length definition. RESULTS: Fifty-three studies met inclusion criteria (1,258 clavicle nonunions). Mean clinical follow-up was 2.6 years. Seventy-two percent of nonunions were of the middle third, 1% were proximal third, 12% were distal third, and 15% were not reported. Forty-eight percent of nonunions were atrophic or oligotrophic and 17% were hypertrophic (35% not reported). Mean time to union was 13.6 weeks. Ninety-five percent of patients achieved union after the primary nonunion surgery. Overall complication rate was 17%. Single-plating fixation had significantly faster union time (15.2 vs. 19.8 weeks), lower reoperation rate (23% vs. 37%), and hardware removal rate (20% vs. 34%) than intramedullary pin fixation. Bone graft had significantly lower rates of delayed union (0.6% vs. 3.6%) but higher complication (15% vs. 8%) and reoperation rates (29% vs. 14%) than the other groups. Studies that defined nonunion after 3 months had significantly faster union times than the 6-month studies (13 vs. 16 weeks). The 3-month group had a significantly lower overall complication rate (12% vs. 25%) and hardware/fixation failure rate (3% vs. 5.5%) than the 6-month group. CONCLUSIONS: This systematic review is the largest report of complications, reoperations, and patient outcomes of clavicle nonunions after surgical intervention in the current literature. Plating showed faster time to union and lower reoperation rates than intramedullary pin fixation. Bone graft use showed lower rates of delayed union but substantially higher rates of complications and reoperations. Reports with a definition of nonunion at 3 months showed faster union times and lower complication rates compared to reports with a definition of nonunion that was 6 months or greater. Surgery could be considered at 3 months post-injury in cases of symptomatic non-united clavicle fracture, and plating results in reliable outcomes. Adjuvant bone grafting requires further study to determine its value and risk/benefit ratio. LEVEL OF EVIDENCE: Level IV, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.

Surgical repair of distal triceps rupture: a systematic review of outcomes and complications.

Background: Triceps tendon injury is rare and accounts for only 2% of all tendinous injuries. It typically occurs after trauma or physical strain with eccentric loading. Treatment involves surgical repair, commonly with either transosseous bone tunnels or suture anchors. Nonsurgical management is typically reserved for low-demand or high-risk patients, as this is associated with deficits in strength and functional disability. Despite several recent high-quality observational studies that have added to our understanding of outcomes after surgical repair, we are not aware of a systematic review that includes literature published after 2015. In addition, prior reviews did not compare outcomes between different surgical repair methods, particularly transosseous bone tunnel and suture anchor techniques. Methods: This systematic review examines published literature between January 1970 and May 2021 in PubMed, Scopus, and Cochrane databases to further examine reported functional outcomes and compare those outcomes between the two surgical repair methods. Results: Our literature search yielded 309 results, of which only 16 met inclusion criteria. At the latest follow-up, the mean Disabilities of Arm, Shoulder, and Hand score was 4, the mean Quick Disabilities of Arm, Shoulder, and Hand score was 8, the mean Mayo Elbow Performance Score was 92, the mean American Shoulder and Elbow Surgeons-Elbow score was 99, the mean modified American Shoulder and Elbow Surgeons score was 94, the mean Oxford Elbow Score was 43, and the mean isokinetic muscle strength testing was 87%. A very high percentage (95%) of patients reported being satisfied with the repair. Preinjury levels of function were achieved in 92% of patients, and 100% regained at least a score of 4 of 5 for gross muscle strength. Complications occurred in 15% of cases, of which retears accounted for 5%. Subanalysis of cases with reported repair types revealed a significantly higher overall complication rate with transosseous repairs than with suture anchor repairs (18% vs. 8%, P = .008) as well as a higher retear rate in the transosseous repair group (7% vs. 2%, P = .03). Conclusion: Patient-reported outcome measures were favorable for both suture anchor and transosseous tunnel repair methods. Suture anchor repair showed significantly better results with regard to isokinetic strength testing, complication rates, and retear rates. Further study is needed to establish superiority of either technique and cost-efficacy. In light of the evidence supporting greater biomechanical strength and lower clinical rates of failure, surgeons may consider use of a suture anchor technique for repair of distal triceps ruptures.

Low mental health scores are associated with worse patient-reported outcomes and difficulty with return to work and sport after distal biceps repair.

BACKGROUND: Most patients have successful outcomes with minimal limitations after distal biceps repair, but a minority continues experiencing functional constraints. We hypothesize that low scores on a validated mental health measure correlate with worse patient-reported outcomes and increased difficulty with return to work and sport. METHODS: We conducted a retrospective review of a consecutive series of patients who underwent distal biceps repair with a single-incision cortical button technique and immediate mobilization. Patient-reported outcome data were available at 1 year or later for 33 (85%) patients. The primary outcomes were American Shoulder and Elbow Surgeons-Elbow (ASES-E) score, Single Assessment Numeric Evaluation score, Visual Analog Scale for pain, Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), and Veterans RAND 12 (VR-12) quality-of-life assessment. RESULTS: All patients were male, with a median age of 49 years (range, 28-65). None had reruptures, and 1 (3%) had superficial wound dehiscence that healed without further surgery. Eleven (33%) had postoperative neuropraxia, 6 of which resolved completely. At latest follow-up, the median Visual Analog Scale was 0 (range, 0-5; mean, 1), and median ASES-E functional score was 36 (range, 24-36; mean, 34). Median Single Assessment Numeric Evaluation score was 92 (range, 41-100). The median QuickDASH was 5 (range, 0-50; mean, 11). More than half of the patients with VR-12 mental component score (MCS) < 50 (5 of 9, 56%) reported difficulty with work activities, compared with 4% (1 of 24) of patients with an MCS ≥ 50 (P = .001). Most patients (8 of 9, 89%) with an MCS < 50 also reported difficulty with return to sporting activities, compared with only 8% (2 of 24) of patients with MCS ≥ 50 (P < .0001). Patients with an MCS < 50 (n = 9) had significantly worse ASES-E functional scores (median, 34; range, 27-36) and QuickDASH scores (median 23, range 0-43), compared with those with an MCS ≥ 50 (ASES-E: median, 36; range, 24-36; P = .033; QuickDASH: median, 2; range, 0-50; P = .026). Most patients (17 of 24, 71%) with MCS ≥ 50 had a perfect score of 36 on the ASES-E functional outcome score, compared with only 22% (2 of 9) among patients with MCS < 50. CONCLUSION: Patients who undergo distal biceps repair show excellent functional patient-reported outcomes at 1-year and later follow-up. Lower scores on the VR-12 MCS are associated with worse patient-reported outcome scores and difficulty with return to work and sporting activities.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis.

BACKGROUND: Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years. METHODS: We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating. RESULTS: Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01). CONCLUSIONS: This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.

An Injury Prevention Program for Professional Ballet: A Randomized Controlled Investigation.

BACKGROUND: Few investigations have examined dance-specific injury prevention programs (IPPs), and no published randomized controlled trials are available that evaluate IPPs for dance. HYPOTHESIS: The implementation of an IPP will significantly reduce the risk of injury in professional ballet dancers. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A randomized controlled trial was designed that entailed a superiority model for the intervention group. All professional dancers from a single ballet company were eligible to participate. Randomization and allocation were performed before the start of the season. The control group practiced and performed without change to preexisting standard operating practice. The IPP group was instructed to perform a 30-minute exercise program 3 times per week over the 52-week study period. Injuries were recorded. Standard continuous and categorical data comparisons and correlations were used. Cox proportional hazards regression models for recurrent failures were used wherein the hazard ratio indicates the relative likelihood of injury in the control versus intervention groups. RESULTS: Of the 52 eligible dancers, 75% (n = 39) participated. Of these 39 dancers, 19 (9 males, 10 females; mean age, 26.6 ± 4.0 years) were randomized to the control group and 20 (11 males, 9 females; mean age, 25.1 ± 5.1 years) to the IPP group. No significant (P > .05) difference was found in baseline demographics between groups. A total of 116 injuries were recorded for the entire study population (49 IPP; 67 control). Traumatic and chronic injuries accounted for 54% and 46% of injuries, respectively. The injury rate was 82% less (IPP hazard ratio, 0.18; z = -2.29; P = .022) in the IPP group after adjustment for confounding variables, and time between injuries was 45% longer (IPP hazard ratio, 0.55; z = -2.20; P = .028) than for controls. CONCLUSION: The present study is the first prospective randomized controlled investigation of an IPP for professional ballet. The results showed an 82% decrease in injury rate for the intervention group and an extended period from previous injury to subsequent injury. REGISTRATION: NCT04110002 (ClinicalTrials.gov identifier).

High Prevalence of Connective Tissue Gene Variants in Professional Ballet.

BACKGROUND: There is a high prevalence of hypermobility spectrum disorder (HSD) in dancers. While there is no known genetic variant for HSD, hypermobile Ehlers-Danlos syndrome is a genetic disorder that exists within HSD. There are many connective tissue disorders (CTDs) with known (and unknown) genes associated with hypermobility. Hypermobility has distinct advantages for participation in flexibility sports, including ballet. PURPOSE: To determine the prevalence of gene variants associated with hypermobility in a large professional ballet company. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: In this cross-sectional investigation, 51 professional male and female dancers from a large metropolitan ballet company were eligible and offered participation after an oral and written informed consent process. Whole blood was obtained from peripheral venipuncture, and DNA was isolated. Isolated DNA was subsequently enriched for the coding exons of 60 genes associated with CTD that included hypermobility as a phenotype, including Ehlers-Danlos syndromes, osteogenesis imperfecta, Marfan syndrome, and others. Genes were targeted with hybrid capture technology. Prepared DNA libraries were then sequenced with next-generation sequencing technology. Genetic database search tools (Human Gene Mutation Database and e!Ensembl, http://useast.ensembl.org/ ) were used to query specific variants. Descriptive statistics were calculated. RESULTS: Of 51 dancers, 32 (63%) agreed to participate in DNA analysis (mean ± SD age, 24.3 ± 4.4 years; 18 men, 14 women). Twenty-eight dancers had at least 1 variant in the 60 genes tested, for an 88% prevalence. A total of 80 variants were found. A variant in 26 of the 60 genes was found in at least 1 dancer. Among the 28 dancers with variants, 16 were found in the TTN gene; 10 in ZNF469; 5 in RYR1; 4 in COL12A1; 3 in ABCC6 and COL6A2; 2 in ADAMTS2, CBS, COL1A2, COL6A3, SLC2A10, TNC, and TNXB; and 1 in ATP6V0A2, B4GALT7, BMP1, COL11A1, COL5A2, COL6A1, DSE, FBN1, FBN2, NOTCH1, PRDM5, SMAD3, and TGFBR1. Nine variants found in this population have never been reported. No identified variant was identical to any other variant. No identified variant was known to be disease causing. In the general population, the prevalence of each variant ranges from never reported to 0.33%. In the study population, the prevalence of each variant was 3.13%. There was no association between hypermobility scores and genetic variants. CONCLUSION: Genetic variants in CTD-associated genes are highly prevalent (88%) in professional ballet dancers. This may significantly account for the high degree of motion in this population.

The Risk of Impingement With Sexual Activity in Femoroacetabular Impingement Syndrome Due to Cam Morphology: Shape Matters.

BACKGROUND: Sexual difficulties and dysfunction are common in patients with femoroacetabular impingement syndrome (FAIS) secondary to hip pain and stiffness. PURPOSE: To determine the risk of impingement in patients with FAIS during common sexual positions using 3-dimensional computer-simulated collision detection before and after cam correction. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten computed tomography scans of the pelvis and femur from patients with FAIS due to isolated cam morphology were retrospectively reviewed. Three-dimensional osseous models were developed using Mimics software. The cam deformity was then completely corrected. Simulations of hip range of motion for the most common sexual positions for men (n = 15) and women (n = 14) were conducted before and after cam resection. Impingement was determined for each sexual position. Position safety was defined as ≤20% of models demonstrating impingement in a position. Descriptive and simple comparative statistics were calculated. RESULTS: There was no sexual position that was impingement free in all models before cam correction. After cam correction, 11 (37.9%) of 29 total positions were impingement free. There was a significant decrease in impingement from before to after cam correction (40.7% vs 11.4%, respectively, of all female positions [P < .0001]; 26.0% vs 6.7%, respectively, of all male positions [P < .0001]). There was a significant increase in the number of "safe" positions from before to after cam correction (4 vs 11, respectively, of all female positions [P = .008]; 7 vs 15, respectively, of all male positions [P = .001]). CONCLUSION: After cam correction, there was a significant reduction in the impingement rate and a significant increase in the number of "safe" sexual positions. CLINICAL RELEVANCE: Impingement in patients with cam morphology is common during sexual activity. Surgical correction of cam morphology significantly reduces the rate of impingement. Although this laboratory imaging-only study did not account for patient symptoms, this likely translates to significant symptomatic improvement during sexual activity after surgical cam correction.

MRI prevalence and characteristics of supraacetabular fossae in patients with hip pain.

BACKGROUND: Supraacetabular fossae (SAF) are normal anatomic variants found at the 12 o'clock position of the acetabulum and can be mistaken for osteochondral defects. PURPOSE: Determine SAF prevalence on MRI of patients with hip pain. Characterise SAF by type, size, and location. Determine sensitivity of radiology reports and sensitivity of radiographs in SAF detection. METHODS: MRIs performed over 1 year in patients with hip/groin pain were analysed for SAF. Measurements of SAF in the coronal and sagittal planes and location using clockface notation were recorded. Radiology reports were reviewed to determine if SAF were identified and radiographs were assessed for presence of SAF. Mean characteristics of type 1 and 2 SAF were compared using Student's t-test. RESULTS: 214 hips (mean age 35.9 ± 14.2 years; 66.8% female) were analysed. Twenty-seven hips (12.6%) had SAF. There were five type 1 SAF (mean age 16.8 ± 2.2 years) and 23 type 2 SAF (mean age 33.0 ± 16.3 years). Mean dimensions of type 1 and 2 SAF (coronal width × sagittal width × depth, in millimetres) were 7.1 × 6.5 × 3.4 and 6.1 × 5.9 × 2.8, respectively. Mean clockwise location in the coronal and sagittal planes (in minutes) was 1236 and 1212 for type 1 SAF and 1213 and 1207 for type 2 SAF. Radiology reports identified 7.1% of SAF identified on MRI. Plain radiographs demonstrated 67.9% of SAF identified on MRI. CONCLUSION: This study found a 12.6% prevalence of SAF in hips. Radiology reports had a 7.1% sensitivity in correctly identifying SAF on MRI. IRB: Pro00016584.