Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: Rotator cuff disease is the most common pathology of the shoulder, responsible for approximately 70% of clinic visits for shoulder pain. However, no consensus exists on the optimal treatment. The aim of this study was to analyze level I and II research comparing operative versus nonoperative management of full-thickness rotator cuff tears. METHODS: A literature search was performed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, to identify level I and II studies comparing operative versus nonoperative treatment of rotator cuff tears. Two independent researchers reviewed a total of 1013 articles. Three studies qualified for inclusion. These included 269 patients with 1-year follow-up. The mean age ranged from 59 to 65 years. Clinical outcome measures included the Constant score and visual analog scale (VAS) score for pain. Meta-analysis, using both fixed- and random-effects models, was performed on pooled results to determine overall significance. RESULTS: Statistically significant differences favoring surgery were found in both Constant and VAS scores after 1 year, with mean differences of 5.64 (95% confidence interval, 2.06 to 9.21; P = .002) and -1.08 (95% confidence interval, -1.56 to -0.59; P < .0001), respectively. CONCLUSION: There was a statistically significant improvement in outcomes for patients managed operatively compared with those managed nonoperatively. The differences in both Constant and VAS scores were small and did not meet the minimal difference considered clinically significant. Larger studies with longer follow-up are required to determine whether clinical differences between these treatments become evident over time.

Play Within the Pre-registration Children's Nursing Curriculum Within the United Kingdom: A Content Analysis of Programme Specifications.

PURPOSE: To determine the number of programme specifications which cite play within the curriculum and in what context. Play is an essential part of childhood. Therefore we might expect nurses caring for children to be trained in how to facilitate play within their clinical areas. Programme specifications provide information on course aims, the intended learning outcomes and what the learner is expected to achieve. DESIGN AND METHOD: Inductive qualitative content analysis. RESULTS: Only 13% (seven out of 54) programme specifications published by Higher Education Institutions cite play. Where play is mentioned there is a clear link made to use play as a communication tool. Also distraction figured prominently within the same sentence as play, despite these two terms being quite distinct. The availability of the programme specifications was also noted with 49% (28 out of 57) were easily accessible from the university web sites. A further 16% (9 out of 57) provided web links when access was requested. 35% were not publicly accessible without requesting access. Three Universities declined to be involved. CONCLUSION: It is clear that even if play is embedded within the child field nursing curriculum, it is not clearly stated as a priority within 87% of universities programme specifications which make no mention of it. PRACTICE IMPLICATIONS: If play is not part of programme specifications its importance could be lost to educators already delivering a full curriculum. Nurses could be qualifying with little or no knowledge around their role in facilitating play for their patients.

Similar Biomechanics Between the Double-Cortical Button and Docking Techniques for Ulnar Collateral Ligament Reconstruction: A Cadaveric Evaluation.

Background: The docking technique is widely used to perform ulnar collateral ligament (UCL) reconstructions because of its high failure torque and reliable clinical outcomes. A double-cortical button technique was recently described, with advantages including the ability to tension the graft at the ulnar and humeral attachments and the creation of single bone tunnels. Purpose/Hypothesis: To compare the biomechanics between the docking and double-button UCL reconstruction techniques using cadaveric specimens. We hypothesized that there would be no difference in postoperative stiffness or maximum strength between the techniques. Study Design: Controlled laboratory study. Methods: Eight matched pairs of cadaveric elbow joints underwent controlled humeral valgus torsion cycles in a test frame. Toe region stiffness, elastic region stiffness, and maximum torque were measured during a 4-step protocol: intact, injured, reconstructed (10 and 1000 cycles), and ramp to failure. Graft strains were calculated using 3-dimensional motion capture. Results: After 10 cycles, intact ligaments from the docking and double-button groups exhibited mean ± SD elastic torsional stiffness of 1.60 ± 0.49 and 1.64 ± 0.35 N·m/deg (P = .827), while docking (1.10 ± 0.39 N·m/deg) and double-button (1.05 ± 0.29 N·m/deg) reconstructions were lower (P = .754). There were no significant differences in maximum torque between the docking (3.45 ± 1.35 N·m) and double-button (3.25 ± 1.31 N·m) groups (P = .777). Similarly, differences in maximum graft strains were not significant between the docking (8.1% ± 7.2%) and double-button (5.5% ± 3.1%) groups (P = .645). The groups demonstrated similar decreases in these measures after cyclic loading. Ramp-to-failure testing showed no significant differences in ultimate torque between the docking (8.93 ± 3.9 N·m) and double-button (9.56 ± 3.5 N·m) groups (P = .739). Conclusion: The biomechanical behavior of the double-button technique was not significantly different from that of the docking technique. Both reconstruction techniques restored joint stability, but neither fully recapitulated preinjury joint stiffness. Clinical Relevance: With its procedural advantages, results preliminarily support the use of the double-button reconstruction technique for UCL reconstruction as a reliable single-tunnel technique for primary or revision cases.

Survivorship of Anatomic Total Shoulder Arthroplasty.

Anatomic total shoulder arthroplasty provides pain relief and improved quality of life for patients suffering from glenohumeral arthritis. The 10-year survival rate for these implants has been most recently reported at 96%. As the number of shoulder arthroplasties per year increases, it is important to evaluate factors associated with failure. Patient-specific variables such as age, sex, medical comorbidities, a history of previous shoulder surgery, and rotator cuff integrity can influence implant survival. Both surgeon and hospital volume have been shown to affect perioperative outcomes. Implant design and glenoid pathoanatomy are important structural considerations because both have a causal relationship with survivorship. Modifiable factors, such as smoking, body mass index, and alcohol or opioid consumption, should be addressed preoperatively when possible. Modifiable factors that pertain to surgery are equally as important; it is the responsibility of the surgeon to be aware of the reported outcomes for varying implants and technique-related pearls and pitfalls. For those perioperative factors that are nonmodifiable, it is prudent to counsel patients accordingly because these individuals may be more likely to require an eventual revision procedure.

Management of Subscapularis Insufficiency After Total Shoulder Arthroplasty.

The functional success of anatomic total shoulder arthroplasty (TSA) relies heavily on the healing integrity of the subscapularis tendon. Access to the glenohumeral joint is performed through a deltopectoral approach, and takedown of the subscapularis tendon is necessary in most surgeons' hands. Although initially described as a tenotomy, lesser tuberosity osteotomy and subscapularis peel are two techniques more commonly used today. Both of these options offer good results as long as proper repair is done. A subscapularis-sparing approach has more recently been advocated but is technically demanding. Failure of tendon repair can lead to early failure of anatomic total shoulder arthroplasty with accelerated glenoid loosening, decreased function, and anterior instability. Treatment options for subscapularis insufficiency include nonsurgical management, revision tendon repair, tendon reconstruction or transfer, or conversion to reverse shoulder arthroplasty. As shoulder arthroplasty continues to become increasingly prevalent, subscapularis insufficiency, too, will become more common. Accordingly, a surgeon's knowledge of subscapularis management in an arthroplasty setting must encompass treatment options for postoperative subscapularis insufficiency.

A comparison of narcotic usage and length of post-operative hospital stay in open versus minimally invasive lumbar interbody fusion with percutaneous pedicle screws.

BACKGROUND: Instrumented lumbar fusion can be accomplished through open or minimally invasive techniques. The focus of this study was to compare perioperative narcotic usage and length of hospital stay between patients undergoing open versus minimally invasive spinal surgery (MISS). METHODS: A retrospective chart review was performed on 110 patients who underwent instrumented lumbar fusion over 2 years at our institution. These patients were divided into two groups: those that received open transforaminal interbody fusion (n=69), and those whose surgeries were performed minimally invasively with lateral lumbar transpsoas interbody fusion (LLIF) and percutaneous pedicle screws (n=41). Narcotic usage was recorded for both groups intra-operatively and post-operatively throughout their hospital stay. These values were standardized using an equianalgesia chart. RESULTS: Average narcotic usage post-operatively was significantly lower for the LLIF group relative to those who underwent open lumbar fusion (278.48 vs. 442.06 mg, P=0.03). The average length of post-operative hospital stay was significantly shorter for patients who underwent LLIF compared to those who had an open procedure (4.10 vs. 6.19 days, P=0.02). CONCLUSIONS: Patients who underwent minimally invasive surgery (MIS) LLIF had decreased overall use of opioids in the perioperative period and shorter hospital stays when compared to patients who underwent the open transforaminal interbody fusion approach. These findings support pre-existing literature in favor of LLIF MISS with regards to the above stated outcome measures. The long-term benefits of MISS with regards to narcotic usage in spine patients are not yet known.

Analysis of Cervical Angiograms in Cervical Spine Trauma Patients, Does it Make a Difference?

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate computed tomography angiogram (CTA) use for diagnosing blunt vertebral artery injury (BVAI) at a single institution, to assess the incidence of BVAI in the studied population, and determine if diagnosis affected care. We also wanted to evaluate if testing and treatment resulted in complications. SUMMARY OF BACKGROUND DATA: BVAI is an example of a previously underdiagnosed injury. Ease of CTA has simplified vertebral artery evaluation. Injury to the vertebral or carotid arteries is diagnosed in approximately 0.1% of blunt trauma patients when there is high clinical suspicion, or when symptoms of central nervous system damage are apparent on initial examination. Routine screening of asymptomatic patients increases the incidence to approximately 1%. MATERIALS AND METHODS: After IRB approval, the hospital trauma registry identified patients aged 18-89 presenting with cervical spine fracture from 2006 to 2011. A retrospective review of charts was completed. Data collection included demographic data, fracture pattern, and neurological findings. The indications for and the results of CTA was also reviewed. The type of treatment and any complications were recorded. RESULTS: A total of 637 charts reviewed. A total of 108 subjects underwent CTA/magnetic resonance angiography; 15 diagnosed with VAI injury. Four received treatment. There were no complications from imaging or treatment of BVAI. Eight subjects without CTA evaluation presented with symptoms potentially related to injury on arrival. Three had neurological decline, although none were eligible for treatment. No routine diagnostic/treatment protocol for vertebral arteries was found at our institution. CONCLUSIONS: Although neurological sequelae after VAI can be devastating, routine screening after cervical spine fracture may not be warranted. Beside cost, our study suggests it is rarely associated with symptoms, and the asymptomatic patient rarely receives treatment due to concomitant injuries. Our study reinforces the need for further research to establish protocols so that patient-appropriate, cost-effective evaluation and treatment can be provided.

Outcomes After Percutaneous Reduction and Fixation of Low-Energy Lisfranc Injuries.

BACKGROUND: Lisfranc injuries are often missed initially or not anatomically reduced, leading to midfoot collapse, arthrosis, and pain. Operative management of these injuries is also fraught with complications, particularly with respect to the soft tissues. Wound dehiscence and infection are not uncommon. The goal of this study was to analyze the outcomes of a minimally invasive technique in reduction and percutaneous fixation of low-energy minimally displaced Lisfranc injuries and determine if it is a safe alternative to more traditional, open approaches. METHODS: A retrospective review was performed for all patients who underwent minimally invasive Lisfranc treatment at a single institution over a 6-year period. Thirty-eight patients were identified in this series. All patients were skeletally mature and had a minimum follow-up of 3 years. Patients were assessed clinically and radiographically, in addition to undertaking patient-centric outcome scoring using the Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales at a mean follow-up of 66 months (range, 36-100). Patients were also asked to subjectively rate their percentage return to preinjury functional level at the time of final follow-up. There were 20 males and 18 females. Seventeen patients were injured participating in sports-related activities, 19 during falls, and 2 as a result of motor vehicle accidents. The average age at the time of surgery was 34.2 (range, 16-69) years. At final follow-up, 31 patients were available for assessment (81.6%). RESULTS: The mean FAAM-ADL score was 94.2 (range, 40.5-100), and sports score was 90.4 (range, 0-100). Percentage recovery compared to their preinjury functional level averaged 91.4% (range, 40%-100%). There were no complications in this series. Twenty-two patients underwent screw removal electively at an average of 6.9 months following the index procedure. No patients had undergone any additional operative procedures, or had any objective evidence of midfoot collapse or arthritis at the time of final follow-up. CONCLUSION: Minimally invasive methods of treating low-energy Lisfranc injuries with less soft tissue stripping and disruption, as described in this series, were a valuable tool to optimize outcomes while minimizing the potential morbidity of more traditional, open techniques. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Roscoe Reid Graham (1890 to 1948): a Canadian pioneer in general surgery.

Roscoe Reid Graham, a Canadian surgeon trained at the University of Toronto, was a true pioneer in the field of general surgery. Although he may be best known for his omental patch repair of perforated duodenal ulcers-often referred to as the "Graham patch"-he had a number of other significant accomplishments that decorated his surgical career. Dr. Graham is credited with being the first surgeon to successfully enucleate an insulinoma. He ventured to do an essentially brand new operation based solely on his patient's symptoms and physical findings, a courageous move that even some of the most talented surgeons would shy away from. He also spent a large portion of his career dedicated to the study of rectal prolapse, working tirelessly to rid his patients of this awful affliction. He was recognized by a number of different surgical associations for his operative successes and was awarded membership to those both in Canada and the United States. Despite all of these accolades, Dr. Graham remained grounded and always fervent in his dedication to the patient and their presenting symptom(s), reminding us that to do anything more would be "meddlesome." In an age when medical professionals are often all too eager to make unnecessary interventions, it is imperative that we look back at our predecessors such as Roscoe Reid Graham, for they will continually redirect us toward our one and only obligation: the patient.

Outcome of nonoperative management of displaced oblique spiral fractures of the fifth metatarsal shaft.

BACKGROUND: Nonoperative management has been the preferred treatment for displaced oblique spiral fractures of the fifth metatarsal shaft; yet a paucity of literature supports this claim. The purpose of this investigation was to report the incidence and long-term outcome in the largest cohort of these fractures reported to date. METHODS: From 2006 through 2010, 2990 patients sustaining closed metatarsal fractures were seen and treated. Displaced, oblique, spiral fractures of the distal shaft of the fifth metatarsal were identified and follow-up was conducted. Only patients who were initially treated with nonoperative management were included. Patients were seen at 6 and 12 weeks, and a minimum 2-year follow-up was conducted. In addition, demographic information was obtained, and the Short Form-12 (SF-12) and Foot and Ankle Ability Measure (FAAM) were administered. Average follow-up was 3.5 years. RESULTS: In all, 142 acute fractures were managed for an incidence of 4.8% of all metatarsal fractures. There were 117 females and 25 males, average age was 55. FAAM activities of daily living subscale scores averaged 95.5 (±5.7), while FAAM sports subscales were 92.7 (±9.1). SF-12 physical and mental scores averaged 51.4 (±4.9) and 50.3 (±4.6), respectively. There were 2 delayed unions, 1 asymptomatic nonunion treated nonoperatively, and 2 painful nonunions that required open reduction internal fixation with bone grafting. CONCLUSION: This large cohort described the relative incidence and functional outcomes of displaced oblique fracture of shaft of the fifth metatarsal bone treated nonoperatively. Nonoperative management of these fractures resulted in excellent, long-term functional outcomes. LEVEL OF EVIDENCE: Level II, prospective cohort study.