Stability Reliability and External Validity of Myrick THIRD Test for Hip Labral Tears.

The purpose of the study is to examine whether the physical examination technique, Myrick The Hip Internal Rotation with Distraction (THIRD), is reliable and valid. The Myrick THIRD test has previously established and documented sensitivity, specificity, positive predictive value, and internal and external validity. The goal of this original research was to demonstrate stability reliability of the Myrick THIRD test when the study is conducted in a clinical setting where the test has not previously been performed, as well as to demonstrate that the Myrick THIRD test has external validity when conducted across multiple examiners in a new setting. The importance of the study reflects current clinical practice and the lack of specific clinical assessment techniques used to determine the source of intra-articular hip pain successfully. Testing included the Myrick THIRD test, magnetic resonance arthrogram (MRA), and arthroscopy. The primary outcomes included the results of the MRA, magnetic resonance imaging (MRI), Myrick THIRD test, and arthroscopy. The inclusion criteria were 18- to 49-year-olds presenting with hip pain. The exclusion criteria included patients younger than 18 and older than 49 years and patients who were willing to undergo MRI arthrogram. A test of paired proportions, correlation, sensitivity, and specificity was performed. The significance level was preset at .05. All 86 patients had a positive Myrick THIRD test, which was confirmed with arthroscopy. Eight of the 11 positive MRI results and 64 of the 74 positive MRA results were confirmed with arthroscopy. The Myrick THIRD test had a statistically significant higher accuracy rate than the MRA (p = .002) but not the MRI (p = .08). Myrick THIRD test showed a significantly higher accuracy rate than MRA.

Impact of Resident Involvement on 30-Day Postoperative Outcomes in Orthopedic Shoulder Surgery.

The literature concerning resident involvement in shoulder surgery is limited. The purpose of this study was to examine whether resident involvement across all orthopedic shoulder surgeries is associated with adverse 30-day outcomes. Utilizing the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent shoulder surgery with or without a resident present were analyzed. Independent t-test and chi-square or Fischer's exact test were used appropriately. A logistic regression model was used to calculate adjusted odds ratios. This study examined 5,648 patients: 3,455 patients in the "Attending alone" group and 2,193 in the "Attending and resident in the operating room" group. Resident presence in the operating room was not associated with increased complications, except for bleeding transfusions (OR 1.71, CI 1.32-2.21, P ≤ 0.001). This study demonstrates that resident involvement in orthopedic shoulder surgery does not present an increased risk for 30-day complications when compared to surgeries performed with the attending surgeon alone.

Resident Involvement in Shoulder-Stabilization Procedures Is Not Associated With an Increased Risk of 30-Day Postoperative Complications.

Purpose: To examine the 30-day postoperative outcomes of resident involvement in shoulder-stabilization surgical procedures using the American College of Surgeons National Surgical Quality Improvement database. Methods: We conducted a retrospective review of the National Surgical Quality Improvement database for all shoulder-stabilization procedures from 2010 to 2018. Procedures included arthroscopic Bankart, arthroscopic Bankart with SLAP repair, arthroscopic Bankart with Remplissage, open Bankart, anterior bone block, posterior bone block, Latarjet coracoid process transfer, and capsular shift/capsulorrhaphy for multidirectional instability. Data included preoperative demographics, comorbidities, and 30-day postoperative outcomes. Cases were categorized into 2 groups: "attending alone" and "attending and resident." Statistical analysis comparing groups on demographics and comorbidities included independent t-test for continuous variables and Pearson χ2 or Fischer exact for categorical variables. A logistic regression model including propensity score was used to calculate adjusted odds ratio for outcomes. Results: A total of 3,954 patients undergoing shoulder-stabilization procedures were included in the study and 28.8% of patients had a resident involved in their procedure. Residents were more likely to be involved in procedure for patients who were of minority ethnicity (P < .001), a lower body mass index (P < .001) and less likely to have a history of chronic obstructive pulmonary disease (P = .029). Resident involvement resulted in statistically significant longer total operation time (91 vs 85 minutes, P < .001). In terms of postsurgical outcomes, complication rates were low for both groups (∼0.8%). Resident involvement was not associated with any significant increase in 30-day postsurgical complications. Conclusions: Our results show that resident involvement in shoulder-stabilization surgery is associated with a significant increase in operative time without any significant increase in 30-day postsurgical complications. Level of Evidence: Level III, retrospective comparative study.

The Missing Link: Defining the Functional Parameters of Pelvic and Acetabular Alignment.

BACKGROUND: This study aimed to define the three-dimensional functional alignment of the pelvis, proximal femur, and acetabulum during postural and physical activities. METHODS: Thirty volunteers aged 40 years or greater were recruited. Reflective markers placed on bony prominences on the pelvis and lower extremities were tracked using a 12-camera motion analysis system. Measurements were obtained for various postures (ie, supine, standing, and sitting) and activities (ie, walking and ascending/descending stairs). RESULTS: Significant pelvic motion occurred only in the sagittal plane. The mean posterior inclinations of the pelvis were 15°, 18°, and 51° in the supine, standing, and sitting positions, respectively. These corresponded to acetabular anteversion/inclination angles of 26°/44°, 28°/45°, and 55°/55°, respectively. For activities, the mean posterior inclinations of the pelvis were 19°, 19°, and 20° during walking and ascending and descending stairs, respectively. These corresponded to acetabular anteversion/inclination angles of 29°/45°, 29°/45°, and 30°/46°, respectively. DISCUSSION: The functional parameters for pelvic and acetabular alignment were defined. Further research is needed to understand the extent to which these normal parameters are altered in the setting of hip and/or spinal degenerative disease to guide acetabular implant placement.

Ulnar stress fracture in a softball player.

Clinicians need to have a high index of suspicion in overhead athlete with persistent pain. MRI and bone scans are more sensitive than X-rays in detecting ulnar stress fractures. Increased awareness will improve diagnosis and patient outcomes.

Kinematics and EMG activity in Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Patients undergoing a Reverse Total Shoulder Arthroplasty (RTSA) often have functional limitations that affect the range of motion of the shoulder. These limitations are not mechanical in nature, but instead linked to a reduced ability to generate muscle force. The specific aims of this study was to offer a comparison between the muscle activity generated by a post-operative RTSA shoulder in a patient to that of their contralateral shoulder during a series of functional activities. MATERIAL & METHODS: A convenience sample of 10 subjects between the ages of 50-75 years of age were recruited. EMG and kinematic data were concomitantly collected while subjects completed tasks that included common activities of daily living. RESULTS: The main findings of this study were that all sub regions of the deltoid functioned as abductors, versus the native shoulder where the middle deltoid primarily works in abduction. For the scapular elevation activity there was a significant difference in flexion between the surgical and contralateral shoulder (p < .001), with the surgical shoulder having nearly 30° less range of motion. CONCLUSION: Anticipating limitations in functional outcomes and range of motion for patients after RTSA may inform patient decision-making and improve clinical evaluations. The finding of increased mid deltoid function during lifting activity has implications for rehabilitation and encouraging protocols that strengthen the deltoid in concentric motions. Additionally, the decreased scapular elevation found in this study may guide rehabilitation focusing on regaining range of motion post-operatively.

The Role of Volume Regulation and Thermoregulation in AKI during Marathon Running.

BACKGROUND AND OBJECTIVES: Marathon runners develop transient AKI with urine sediments and injury biomarkers suggesting nephron damage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: To investigate the etiology, we examined volume and thermoregulatory responses as possible mechanisms in runners' AKI using a prospective cohort of runners in the 2017 Hartford Marathon. Vitals, blood, and urine samples were collected in 23 runners 1 day premarathon and immediately and 1 day postmarathon. We measured copeptin at each time point. Continuous core body temperature, sweat sodium, and volume were assessed during the race. The primary outcome of interest was AKI, defined by AKIN criteria. RESULTS: Runners ranged from 22 to 63 years old; 43% were men. Runners lost a median (range) of 2.34 (0.50-7.21) g of sodium and 2.47 (0.36-6.81) L of volume via sweat. After accounting for intake, they had a net negative sodium and volume balance at the end of the race. The majority of runners had increases in core body temperature to 38.4 (35.8-41)°C during the race from their baseline. Fifty-five percent of runners developed AKI, yet 74% had positive urine microscopy for acute tubular injury. Runners with more running experience and increased participation in prior marathons developed a rise in creatinine as compared with those with lesser experience. Sweat sodium losses were higher in runners with AKI versus non-AKI (median, 3.41 [interquartile range (IQR), 1.7-4.8] versus median, 1.4 [IQR, 0.97-2.8] g; P=0.06, respectively). Sweat volume losses were higher in runners with AKI versus non-AKI (median, 3.89 [IQR, 1.49-5.09] versus median, 1.66 [IQR, 0.72-2.84] L; P=0.03, respectively). Copeptin was significantly higher in runners with AKI versus those without (median, 79.9 [IQR, 25.2-104.4] versus median, 11.3 [IQR, 6.6-43.7]; P=0.02, respectively). Estimated temperature was not significantly different. CONCLUSIONS: All runners experienced a substantial rise in copeptin and body temperature along with salt and water loss due to sweating. Sodium and volume loss via sweat as well as plasma copeptin concentrations were associated with AKI in runners. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_13_CJASNPodcast_19_09_.mp3.

Trunk Muscle Endurance, Flexibility, Stride Foot Balance, and Contralateral Trunk Lean in Collegiate Baseball Pitchers.

Myrick, KM, Pallone, AS, Feinn, RS, Ford, KM, and Garbalosa, JC. Trunk muscle endurance, flexibility, stride foot balance, and contralateral trunk lean in collegiate baseball pitchers. J Strength Cond Res 33(10): 2641-2647, 2019-The incidence of shoulder and elbow injuries in baseball is increasing. The trunk is crucial to transmission of energy from lower limbs, achieving the largest angular momentum and torque during pitching, and controlling acceleration of the arm. Excessive contralateral trunk lean has been correlated with increased ball velocity and forces on the elbow. Underlying biomechanical causes contributing toward excessive lean have not been well described. Previous studies outlined the importance of trunk muscle strength and endurance. Understanding contributing factors associated with contralateral lean and pitch velocity may be helpful in pitching performance, informing strength and conditioning protocols, and preventing injuries. The aim of this study was to examine the correlation between trunk muscle endurance and flexibility, and stride foot balance with contralateral lean during pitching. Level of significance was set at p < 0.05. Pitching motion analysis and functional assessments were obtained. Three-dimensional motion analysis was used. Average degree of contralateral lean was 2.33° (SD = 3.66). No statistically significant relationships were identified between trunk muscle endurance, flexibility, and stride foot balance with contralateral lean; moderate negative association between contralateral lean and pitch speed (B = -0.631, p = 0.175) was identified along with negative association of ipsilateral maximum trunk rotation (r = -0.108, p = 0.208) and ipsilateral side plank (r = -0.095, p = 0.194) with contralateral lean. Contralateral lean does not appear influenced by trunk muscle endurance, flexibility, or stride foot balance, and does not increase pitch velocity in high velocity pitchers. Future study is warranted to determine why contralateral lean exists at lower pitch velocities, and not at higher velocities.

Effects of season long participation on ACL volume in female intercollegiate soccer athletes.

BACKGROUND: The aim of this study was to characterize the volumetric changes of the anterior cruciate ligament over the course of a competitive soccer season in female athletes. METHODS: Seventeen Division-I collegiate soccer players were recruited. Two data collection sessions were conducted. The first data collection occurred prior to the start of the soccer season. Each subject completed a brief questionnaire, had height and weight measured, underwent a clinical assessment of their anterior cruciate ligaments and an eight sequence magnetic resonance imagery of their knees. Contours of the anterior cruciate ligaments were outlined in sagittal T-2 weighted MR images and volumes were calculated using Medical Image Processing, Analysis, and Visualization software. Presence or absence of edema within the ligament was determined in pre and post season scans. All subjects were followed during the season to determine if a lower extremity injury had been sustained. RESULTS: Mean ligament volume significantly increased from preseason to postseason (p=.006). There was a 10% increase in the percentage of knees with edema pre to post season. CONCLUSIONS: The physical demand of a competitive soccer season in female collegiate athletes appears to cause an increase in volume of the anterior cruciate ligament. The increase in volume may be related to the accumulation of microscopic tears over the course of the season which induce inflammation and edema. The volumetric changes in the ligament may have significant clinical implications, however further studies must be done to determine the relationship between anterior cruciate ligament volume and risk of injury.

Morel-Lavallee injury a case study.

Morel-Lavallee lesions are post-traumatic, soft-tissue degloving injuries commonly misdiagnosed as hematomas or ruptured bursa. The clinician needs to be aware of this injury, in order to provide appropriate patient care and treatment. If not treated early, risks include superinfection, continued expansion, overlying tissue necrosis, and suboptimal patient outcomes.

Common electrocardiogram variations pre- and post-marathon.

Electrocardiographic changes can be present in marathon runners. These findings may be misinterpreted as malignant by healthcare providers. For example, incomplete right bundle branch block, early ventricular repolarization, and left ventricular hypertrophy by voltage criteria alone are quite common in athletes, yet considered benign.

Head Injuries in Soccer.

UNLABELLED: Soccer is currently the most popular and fastest growing sport worldwide, with approximately 265 million registered soccer players existing around the world. The popularity of the sport, coupled with the high incidence of 18.8-21.5 head injuries per 1,000 player hours reported, make it essential that clinicians, coaches, and the athletes, have a solid understanding of head injuries. The successful rehabilitation of athletes with head injuries relies upon early and accurate identification strategies and implementation of appropriate return to play measures across all areas in the continuum of care. CLINICAL RELEVANCE: Soccer is a frequently played sport, and head injuries are common. Therefore, it is imperative that clinicians, coaches, and the athletes themselves have a solid understanding of head injury prevention, diagnosis, and treatment options. The purpose of this article was to provide rehabilitation nurses with current information regarding frequently occurring head injuries in the widespread sport of soccer.

Clinical assessment and management of ankle sprains.

Ankle sprains are a common occurrence and are frequently either undertreated or overtreated. With the incidence estimated at more than 3 million a year and at a rate of 2.15/1,000 in the United States alone, this is an orthopaedic injury that providers should be acutely aware of and successfully able to evaluate and treat. This clinical feature will provide a thorough review of the mechanism of injury, the history and physical examination, and the classification and management of these injuries. Clinical red flags are discussed.

Improving follow-up after fragility fractures: an evidence-based initiative.

BACKGROUND: Patients with fragility fractures are at risk for recurrent fractures and are at risk for inadequate follow up. Prevention of future fractures through appropriate follow-up can decrease annual healthcare expenditures and patient morbidity and mortality. PURPOSE: The purpose of this quality improvement project was to delineate an evidence-based practice initiative at a university health center to improve patient follow-up care after fragility fractures. METHODS: A review of the literature revealed significant evidence calling for notification of the patients' primary care provider, ordering a bone density scan within 3 months, and a referral to osteoporosis. A plan for improving patient outcomes was developed utilizing the iowa Model of Evidence-Based Practice to Promote Quality Care. The evidence-based initiative was implemented, and the outcomes were assessed. OUTCOME: The results were that 100% of patients received adequate follow-up after fragility fractures.