Lumbar disk herniation in pregnancy: its incidence, presentation and management: a systematic review.

Background: Back pain in pregnancy is common, but pain from lumbar disk herniations in pregnancy is rare. This systematic review aims to comprehensively analyse literature on lumbar disk herniation in pregnancy, focusing on risk factors, incidence, clinical presentation, and management. Methods: We conducted a literature review using PubMed and Web of Science databases, including studies from January 1, 1950, to August 1, 2023. The Critical Appraisal Skills Programme (CASP) checklist for cohort studies and the Joanna Briggs Institute Critical Appraisal Checklist for case-control studies were utilised to assess risk of bias. The review protocol was not previously published. Results: A total of 41 studies were reviewed, with 6 addressing incidence and risk factors and 35 focusing on clinical presentation and management. Symptomatic lumbar disk herniation during pregnancy was found to be uncommon, with no significant predisposition noted during pregnancy as per magnetic resonance imaging (MRI) findings. However, patients with MRI-detected herniations were more likely to report back pain. Non-surgical management resulted in higher rates of complete symptom resolution (69% vs. 50%) and lower rates of cesarean section (57% vs. 70%) compared to surgical management. Among surgically treated patients, microdiscectomy showed higher symptom resolution (59%) compared to laminectomy (17%) or a combined approach (33%). Conclusions: While pregnancy does not inherently increase the risk of herniated lumbar disks, the presence of a prolapsed disk can predispose to back pain during pregnancy. There is poor quality evidence that should be interpreted cautiously. Non-surgical management, in the absence of red-flag symptoms including bowel and bladder dysfunction may be trialled and yield comparatively better symptom resolution. Additionally, surgical management if necessitated has no clear link to pregnancy complications within the scope of this study.

Anterior cruciate ligament repair versus reconstruction: A clinical, MRI and patient-reported outcome comparison.

BACKGROUND: There has been a resurgence in anterior cruciate ligament (ACL) repair for proximal tears using modern surgical techniques and technology. This study aims to compare ACL repair with reconstruction using MRI, clinician-measured and patient-reported outcome measures (PROMs). METHODS: A post-hoc analysis was performed on prospectively collected data from 20 consecutive primary ACL repairs by the senior author. This was compared with an age and sex-matched cohort of 20 ACL reconstructions by the same surgeon using PROMs, return-to-sport (RTS) testing, and MRI signal noise quotient (SNQ). RESULTS: Repairs demonstrated equivalent post-operative PROMs to reconstructions as measured by International Knee Documentation Committee subjective score (78.5 ± 17.1 vs. 83.7 ± 13.3, P = 0.333), Tegner Activity Scale (5.9 ± 1.8 vs. 6.1 ± 2.6, P = 0.646) and Lysholm score (89.8 ± 10.0 vs. 89.6 ± 10.4, P = 0.762). There was no difference in repairs and reconstructions passing quadriceps strength criteria (50% vs. 53%, P = 0.097). A greater proportion of repairs passed hamstrings strength criteria (86% vs. 60%, P = 0.023) and hamstrings-to-quadriceps ratio (71% vs. 20%, P = 0.003). There were no differences across hop and Y-balance testing. Repairs had earlier RTS assessment (8.2 ± 2.8 months vs. 10.6 ± 1.4 months, P = 0.020). On 12-month MRI, repairs demonstrated higher femoral (8.8 ± 5.7 vs. 4.6 ± 2.9, P = 0.009) and tibial SNQ (10.0 ± 5.7 vs. 4.3 ± 4.2, P = 0.001), with no mid-substance difference (12.3 ± 8.5 vs. 7.6 ± 5.2, P = 0.074). There were no graft failures. CONCLUSIONS: When patient selection is optimized for proximal tears, ACL repairs demonstrate equivalent PROMs and better objective outcomes to reconstructions at an earlier timepoint. Repair tissue quality on MRI shows higher signal at tibial and femoral attachments.

How does the use of quantified gap-balancing affect component positioning and limb alignment in robotic total knee arthroplasty using functional alignment philosophy? A comparison of two robotic platforms.

PURPOSE: This study aimed to compare the effect of an image-based (MAKO) system using a gap-balancing technique with an imageless (OMNIbot) robotic tool utilising a femur-first measured resection technique. METHODS: A retrospective cohort study was performed on patients undergoing primary TKA with a functional alignment philosophy performed by a single surgeon using either the MAKO or OMNIbot robotic systems. In all cases, the surgeon's goal was to create a balanced knee and correct sagittal deformity (eliminate any fixed flexion deformity). Intra-operative data and patient-reported outcomes (PROMS) were compared. RESULTS: A total of 207 MAKO TKA and 298 OMNIbot TKAs were analysed. MAKO TKA patients were younger (67 vs 69, p=0.002) than OMNIbot patients. There were no other demographic or pre-operative alignment differences. Regarding implant positioning, in MAKO TKAs the femoral component was more externally rotated in relation to the posterior condylar axis (2.3° vs 0.1°, p<0.001), had less valgus femoral cuts (1.6° vs 2.7° valgus, p<0.001) and more varus tibial cuts (2.4° vs 1.9° varus, p<0.001), and had more bone resected compared to OMNIbot TKAs. OMNIbot cases were more likely to require tibial re-cuts than MAKO (15% vs 2%, p<0.001). There were no differences in femur recut rates, soft tissue releases, or rate of achieving target coronal and sagittal leg alignment between robotic systems. A subgroup analysis of 100 MAKO and 100 OMNIbot propensity-matched TKAs with 12-month follow-up showed no significant difference in OKS (42 vs 43, p=0.7) or OKS PASS scores (83% vs 91%, p=0.1). MAKO TKAs reported significantly better symptoms according to their KOOS symptoms score than patients that had OMNIbot TKAs (87 vs 82, p=0.02) with a higher proportion of KOOS PASS rates, at a slightly longer follow-up time (20 months vs 14 months, p<0.001). There were no other differences in PROMS. CONCLUSION: A gap-balanced technique with an image-based robotic system (MAKO) results in different implant positioning and bone resection and reduces tibial recuts compared to a femur-first measured resection technique with an imageless robotic system (OMNIbot). Both systems achieve equal coronal and sagittal deformity correction and good patient outcomes at short-term follow-ups irrespective of these differences.

Superior and Anterior Glenoid Labral Tears Are Associated With Increased Neurofilament Concentration.

BACKGROUND: Pain is a common presentation after glenohumeral labral injuries. However, the source of that pain is undetermined. PURPOSE/HYPOTHESIS: We aimed to determine if there is a differential expression of nerve fibers around the glenoid labrum and if torn labra have increased neuronal expression compared with untorn labra (rotator cuff repair labra). We hypothesized that the superior labrum would have a higher concentration of neurofilament than would the rest of the labrum and that the concentration of neurofilament would increase at the site of a labral tear. STUDY DESIGN: Descriptive laboratory study. METHODS: Seven labra were sampled at the 3-, 5-, 9-, and 12-o'clock positions during total shoulder arthroplasty. Samples were also collected at the 3-, 5-, and 12-o'clock positions during rotator cuff repair (16 labra), anterior labral repair (6 labra), type II superior labral anterior to posterior (SLAP) repair (4 labra), and capsular release for idiopathic capsulitis (5 labra). Sections were immunostained with antibodies to neurofilament, a specific neuronal marker that is used to identify central and peripheral nerve fibers, and the concentration and intensity of immunostained-positive cells assessed. RESULTS: The concentration of neurofilament staining was similar in the superior, anterior, posterior, and inferior glenoid labrum in untorn labra (8 neurofilament expressing cells per square millimeter; P = .3). Torn labra exhibited a 3- to 4-fold increase in neuronal expression, which was isolated to the location of the tear in SLAP (P = .09) and anterior labral tears (P = .02). The concentration of neurofilament expressing cells in torn glenoid labrum samples was comparable that in with the glenoid labrum of adhesive capsulitis samples (P = .7). CONCLUSION: This study supports the hypothesis that after a tear of the anterior or superior labrum the labrum in that region becomes populated with new nerves fibers and that these fibers may be responsible for the pain noted by patients with superior (SLAP) and/or anterior labral (Bankart) tears. CLINICAL RELEVANCE: This study suggests that neural infiltration contributes to the pain experienced by patients with labral tears. It may help with patient education and direct future management of labral lesions.

Sectional Anatomy Quiz-IΧ.

This series lists a pictorial quiz pertaining to identification of normal and abnormal anatomical structures and landmarks at a given level on computed tomography (CT). Readers are expected to identify and appreciate the changes from normal anatomy and variations of a given pathology. The main structures assessed in this quiz are the pons, ventricular system of the brain, and the basal cisterns. Particular emphasis is placed on the presentations of intra-cranial haemorrhages, particularly sub-arachnoid and epidural haemorrhages, and masses around the region of the pons, midbrain and cerebellum. There is also a question pertaining to increased intracranial pressure. Differential diagnoses are also given where necessary to guide clinical practice and further learning. A Points to remember section details key clinical pearls. Furthermore, key resources have been cited as recommendations for further reading. It is anticipated that this series will enhance the understanding of sectional anatomy of the brain to aid in brain CT interpretation.

Is timing of superior labrum anterior to posterior (SLAP) repair important? A cohort study evaluating the effect of the duration of symptoms prior to surgery on the outcomes of patients who underwent type II SLAP repair.

Background: The management of superior labrum anterior to posterior (SLAP) tears is somewhat controversial. It is unclear if the length of time between symptom onset and surgery affects SLAP repair outcomes. Methods: Sixty-one SLAP repairs were retrospectively reviewed pre-operatively and post-operatively at 1, 6, 24 weeks, and > 2 years post-surgery. Patients were allocated to an 'early repair' or 'late repair' group based on time between symptom onset and surgery. Results: Of the 61 patients, 22 patients had surgery within six months of symptom onset. Pre-operatively, 'late repair' patients played a higher level of sport than 'early repair' patients prior to injury. Post-operatively, both groups had similar outcomes up to six months, though at six months 'early repair' patients reported a higher level of work than 'late repair' patients (p = 0.01). At > 2 years after surgery, 'early repair' patients had reduced pain and difficulty with overhead activities (p = 0.002), less stiffness (p = 0.001) and were more satisfied than 'late repair' patients (p = 0.04). Conclusions: Up to six months post-operatively, the time between symptom onset and surgery has limited effect on functional outcomes. However, at > 2 years after surgery, earlier repairs ( < 6 months) are interestingly associated with better functional outcomes. Further studies are required to determine if this is a causal relationship.

Sectional Anatomy Quiz - VIII.

This series lists a pictorial quiz pertaining to identification of normal and abnormal anatomical structures and landmarks at a given level on computed tomography (CT). Readers are expected to identify and appreciate the changes from normal anatomy and variations of a given pathology. It is anticipated that this series will enhance the understanding of sectional anatomy of the brain to aid in brain CT interpretation.

Stiffness: friend or foe? A cohort study evaluating the effect of early postoperative stiffness on the outcomes of patients who underwent superior labral repair.

BACKGROUND AND HYPOTHESIS: Postoperative stiffness is a commonly reported complication after type II superior labrum anterior-posterior (SLAP) repair. It is unclear whether patients with postoperative stiffness, classified as external rotation to the side of ≤20°, ultimately will have greater functional outcomes at ≥2 years after surgery. We hypothesized that postoperative stiffness would result in improved functional outcomes at ≥2 years after surgery. METHODS: Sixty-five consecutive arthroscopic SLAP repair cases performed by a single surgeon were retrospectively reviewed using prospectively collected patient-ranked outcomes and examiner-determined assessments preoperatively and at 1 week, 6 weeks, 24 weeks, and a minimum of 2 years after surgery. Patients were allocated to the stiff group and the non-stiff group based on their external rotation at 6 weeks after repair. RESULTS: Of the patients, 16 (27%) had ≤20° of external rotation at 6 weeks postoperatively. These patients, comprising the stiff group, had more pain and more difficulty with overhead activities early on than patients in the non-stiff group (very severe vs. severe, P < .05), but by 2 years, they had less difficulty and less pain with overhead activities, less patient-reported stiffness, and less severe pain at night than isolated SLAP repair patients with >20° of external rotation at 6 weeks (P < .05). CONCLUSION: This study suggests that in patients who underwent SLAP repair, early postoperative stiffness (at 6 weeks as assessed by ≤20° of external rotation), while problematic early, is associated with improved functional outcomes in the longer term, with patients in the stiff group reporting less pain and difficulty with overhead activities at ≥2 years after surgery.

The glenoid labrum: does labral lesion location matter?

BACKGROUND: The glenoid labrum can be torn in 1 or more locations. It is undetermined if the location of the labral tear alters patient outcomes after repair. METHODS: A total of 252 labral repair cases were retrospectively reviewed using prospectively collected patient-ranked outcomes and examiner-determined assessments preoperatively, at 1 week, 6 weeks, 24 weeks, and at a minimum of 2 years after surgery. RESULTS: Preoperatively, patients who underwent a superior labral repair reported worse pain at night and during activity than patients who subsequently underwent an isolated anterior labral repair or a combined anterior and superior labral repair (P < .05). After surgery, patients who underwent an isolated superior labral repair reported more severe pain at night and during activity, increased stiffness, and less satisfaction with their shoulder than patients who had an isolated anterior (P < .05) or a combined anterior and superior labral repair (P < .05). CONCLUSIONS: Patients with isolated superior labral repairs have more pain both before and after repair than patients who undergo anterior or anterior and superior labral repairs.