Aided Cortical Auditory Evoked Potentials in Infants With Frequency-Specific Synthetic Speech Stimuli: Sensitivity, Repeatability, and Feasibility.

OBJECTIVES: The cortical auditory evoked potential (CAEP) test is a candidate for supplementing clinical practice for infant hearing aid users and others who are not developmentally ready for behavioral testing. Sensitivity of the test for given sensation levels (SLs) has been reported to some degree, but further data are needed from large numbers of infants within the target age range, including repeat data where CAEPs were not detected initially. This study aims to assess sensitivity, repeatability, acceptability, and feasibility of CAEPs as a clinical measure of aided audibility in infants. DESIGN: One hundred and three infant hearing aid users were recruited from 53 pediatric audiology centers across the UK. Infants underwent aided CAEP testing at age 3 to 7 months to a mid-frequency (MF) and (mid-)high-frequency (HF) synthetic speech stimulus. CAEP testing was repeated within 7 days. When developmentally ready (aged 7-21 months), the infants underwent aided behavioral hearing testing using the same stimuli, to estimate the decibel (dB) SL (i.e., level above threshold) of those stimuli when presented at the CAEP test sessions. Percentage of CAEP detections for different dB SLs are reported using an objective detection method (Hotellings T 2 ). Acceptability was assessed using caregiver interviews and a questionnaire, and feasibility by recording test duration and completion rate. RESULTS: The overall sensitivity for a single CAEP test when the stimuli were ≥0 dB SL (i.e., audible) was 70% for the MF stimulus and 54% for the HF stimulus. After repeat testing, this increased to 84% and 72%, respectively. For SL >10 dB, the respective MF and HF test sensitivities were 80% and 60% for a single test, increasing to 94% and 79% for the two tests combined. Clinical feasibility was demonstrated by an excellent >99% completion rate, and acceptable median test duration of 24 minutes, including preparation time. Caregivers reported overall positive experiences of the test. CONCLUSIONS: By addressing the clinical need to provide data in the target age group at different SLs, we have demonstrated that aided CAEP testing can supplement existing clinical practice when infants with hearing loss are not developmentally ready for traditional behavioral assessment. Repeat testing is valuable to increase test sensitivity. For clinical application, it is important to be aware of CAEP response variability in this age group.

The role of relaxin in anterior cruciate ligament injuries: a systematic review.

OBJECTIVE: Anterior cruciate ligament (ACL) tears are exceedingly common among the athletic population and are seen with higher incidence in females. Observational studies have noted peak ACL tear rates in the luteal phase of the menstrual cycle, a time in which the hormone relaxin peaks in serum concentration. METHODS: A systematic review of the literature was performed. Inclusion criteria specified all prospective and retrospective studies which included the role of relaxin in the pathogenesis of ACL tears. RESULTS: Six studies met inclusion criteria yielding 189 subjects from clinical studies and 51 in vitro samples. Included studies found that ACL samples exhibit selective relaxin binding. When pre-treated with estrogen prior to relaxin exposure, female ACL tissue samples exhibit increased expression of collagen degrading receptors. CONCLUSION: Relaxin displays binding specificity to the female ACL and increased serum concentrations are correlated with increased ACL tear rates in female athletes. Further research is needed in this area. LEVEL OF EVIDENCE: V.

Threshold Equalizing Noise Test Reveals Suprathreshold Loss of Hearing Function, Even in the "Normal" Audiogram Range.

OBJECTIVES: The threshold equalizing noise (TEN(HL)) is a clinically administered test to detect cochlear "dead regions" (i.e., regions of loss of inner hair cell [IHC] connectivity), using a "pass/fail" criterion based on the degree of elevation of a masked threshold in a tone-detection task. With sensorineural hearing loss, some elevation of the masked threshold is commonly observed but usually insufficient to create a "fail" diagnosis. The experiment reported here investigated whether the gray area between pass and fail contained information that correlated with factors such as age or cumulative high-level noise exposure (>100 dBA sound pressure levels), possibly indicative of damage to cochlear structures other than the more commonly implicated outer hair cells. DESIGN: One hundred and twelve participants (71 female) who underwent audiometric screening for a sensorineural hearing loss, classified as either normal or mild, were recruited. Their age range was 32 to 74 years. They were administered the TEN test at four frequencies, 0.75, 1, 3, and 4 kHz, and at two sensation levels, 12 and 24 dB above their pure-tone absolute threshold at each frequency. The test frequencies were chosen to lie either distinctly away from, or within, the 2 to 6 kHz region where noise-induced hearing loss is first clinically observed as a notch in the audiogram. Cumulative noise exposure was assessed by the Noise Exposure Structured Interview (NESI). Elements of the NESI also permitted participant stratification by music experience. RESULTS: Across all frequencies and testing levels, a strong positive correlation was observed between elevation of TEN threshold and absolute threshold. These correlations were little-changed even after noise exposure and music experience were factored out. The correlations were observed even within the range of "normal" hearing (absolute thresholds ≤15 dB HL). CONCLUSIONS: Using a clinical test, sensorineural hearing deficits were observable even within the range of clinically "normal" hearing. Results from the TEN test residing between "pass" and "fail" are dominated by processes not related to IHCs. The TEN test for IHC-related function should therefore only be considered for its originally designed function, to generate a binary decision, either pass or fail.

Improving the measurement and acoustic performance of transparent face masks and shields.

Opaque face masks harm communication by preventing speech-reading (lip-reading) and attenuating high-frequency sound. Although transparent masks and shields (visors) with clear plastic inserts allow speech-reading, they usually create more sound attenuation than opaque masks. Consequently, an iterative process was undertaken to create a better design, and the instructions to make it are published. The experiments showed that lowering the mass of the plastic inserts decreases the high-frequency sound attenuation. A shield with a clear thermoplastic polyurethane (TPU) panel had an insertion loss of (2.0 ± 1.1) dB for 1.25-8 kHz, which improves on previous designs that had attenuations of 11.9 dB and above. A cloth mask with a TPU insert was designed and had an insertion loss of (4.6 ± 2.3) dB for 2-8 kHz, which is better than the 9-22 dB reported previously in the literature. The speech intelligibility index was also evaluated. Investigations to improve measurement protocols that use either mannikins or human talkers were undertaken. Manufacturing variability and inconsistency of human speaking were greater sources of experimental error than fitting differences. It was shown that measurements from a mannikin could match those from humans if insertion losses from four human talkers were averaged.

Fixed- vs. variable-angle humeral neck cut in anatomic total shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Variable neck-shaft angle (NSA) stemmed humeral components have been incorporated into certain implant designs to better re-create normal anatomy in total shoulder arthroplasty (TSA). The purpose of this study was to determine if premorbid glenohumeral joint anatomy is better restored with a fixed- vs. variable-NSA prosthesis. METHODS: A randomized controlled trial was performed including 50 patients with osteoarthritis indicated for primary anatomic TSA. Patients were randomized preoperatively to receive either a variable- (n = 26) or fixed-NSA (n = 24) prosthesis. Humeral neck cut in the variable-NSA group matched the patient's anatomic neck, with prosthetic NSA of 127.5°, 132.5°, and 137.5° available. Fixed-NSA cuts were made with an intramedullary guide of 132.5°. Preoperative and postoperative radiographs were evaluated for specific radiographic anatomic variables: NSA, head thickness, tuberosity-to-head height, head offset, articular arc, greater tuberosity offset, and center of rotation (COR). Postoperative radiographic criteria were compared between groups. RESULTS: No differences were found between groups in demographics or preoperative radiographic measures. When comparing average difference in preoperative and postoperative measurements in the fixed-NSA group, the humeral head offset from the humeral shaft axis significantly decreased by 1.4 mm (P = .046), and the COR moved superiorly (3.0 mm, P = .002) without significant medialization or lateralization. In the variable angle group, humeral head offset decreased but did not reach significance (1.2 mm, P = .091), and the COR also moved superiorly (2.9 mm, P < .001) without significant medialization or lateralization. All remaining radiographic parameters did not significantly change from pre- to postoperative imaging. In comparing the fixed- and variable-NSA groups' net change from the premorbid measurements, no significant differences were found in tuberosity-to-head height, head offset, or COR position in both the horizontal and vertical planes. CONCLUSIONS: Both fixed- and variable-NSA anatomic TSA humeral components demonstrate adequate restoration of premorbid anatomy radiographically.

Surgical anatomy of the axillary artery: clinical implications for open shoulder surgery.

BACKGROUND: Axillary artery injury is a devastating complication related to anterior shoulder surgery and can result in significant morbidity and/or mortality. The purpose of our study was to evaluate the course of the axillary artery in relation to bony landmarks of the shoulder and identify variations in artery position with humeral external rotation. MATERIALS AND METHODS: Dissection of 18 shoulders (9 fresh whole-body cadavers) with simulated vessel perfusion using radiopaque dye was performed. The axillary artery position was measured from multiple points including 2 points on the coracoid base (C1 and C2), 3 points on the coracoid tip (C3-C5), 4 points on the glenoid: superior, middle, and inferior glenoid (D1-D4), and 2 points on the lesser tuberosity (L1 and L2). Fluoroscopic measurements were taken and compared at 0° and 90° of external rotation (F1 vs. F1' and F2 vs. F2'). Manual and fluoroscopic measurements were compared with one another using Kendall's τb correlation. RESULTS: There were 6 male and 3 female cadavers with an average age of 67.2 ± 9.3 years (range: 49-77 years). The mean distance from the axillary artery to the coracoid base (C1 and C2) measured 21.1 ± 7.3 and 22.3 ± 7.4 mm, respectively, whereas the mean distance to the coracoid tip (C3, C4, and C5) measured 30.7 ± 9.3, 52.1 ± 20.2, and 46.5 ± 14.3 mm, respectively. Measurements relative to the glenoid face (D1, D2, and D3) showed a progressive decrease in mean distance from superior to inferior, measuring 31.6 ± 10.3, 16.5 ± 7.5, and 10.3 ± 7.3 mm, respectively, whereas D4 (inferior glenoid to axillary artery) measured 17.8 ± 10.7 mm. The minimum distance from the axillary artery to any point on the glenoid was as close as 4.1 mm (D3). There was a statistically significant difference in F1 (0° external rotation) vs. F1' (90° external rotation) (18.5 vs. 13.4 mm, P = .03). Kendall's τb correlation showed a strong, positive correlation between manual and fluoroscopic measurements (D4: 16.0 ± 12.5 mm vs. F1: 18.5 ± 10.7 mm) (τb = 0.556, P = .037). CONCLUSION: The axillary artery travels an average of 1-1.8 cm from the inferior glenoid margin, which puts the artery at significant risk. In addition, the artery is significantly closer to the inferior glenoid with humeral external rotation. Surgeons performing anterior shoulder surgery should have a thorough understanding of the axillary artery course and understand changes in the position of the artery with external rotation of the humerus.

Recording Obligatory Cortical Auditory Evoked Potentials in Infants: Quantitative Information on Feasibility and Parent Acceptability.

OBJECTIVES: With the advent of newborn hearing screening and early intervention, there is a growing interest in using supra-threshold obligatory cortical auditory evoked potentials (CAEPs) to complement established pediatric clinical test procedures. The aim of this study was to assess the feasibility, and parent acceptability, of recording infant CAEPs. DESIGN: Typically developing infants (n = 104) who had passed newborn hearing screening and whose parents expressed no hearing concerns were recruited. Testing was not possible in 6 infants, leaving 98, age range 5 to 39 weeks (mean age = 21.9, SD = 9.4). Three short duration speech-like stimuli (/m/, /g/, /t/) were presented at 65 dB SPL via a loudspeaker at 0° azimuth. Three criteria were used to assess clinical feasibility: (i) median test duration <30 min, (ii) >90% completion rate in a single test session, and (iii) >90% response detection for each stimulus. We also recorded response amplitude, latency, and CAEP signal to noise ratio. Response amplitudes and residual noise levels were compared for Fpz (n = 56) and Cz (n = 42) noninverting electrode locations. Parental acceptability was based on an 8-item questionnaire (7-point scale, 1 being best). In addition, we explored the patient experience in semistructured telephone interviews with seven families. RESULTS: The median time taken to complete 2 runs for 3 stimuli, including preparation, was 27 min (range 17 to 59 min). Of the 104 infants, 98 (94%) were in an appropriate behavioral state for testing. A further 7 became restless during testing and their results were classified as "inconclusive." In the remaining 91 infants, CAEPs were detected in every case with normal bilateral tympanograms. Detection of CAEPs in response to /m/, /g/, and /t/ in these individuals was 86%, 100%, and 92%, respectively. Residual noise levels and CAEP amplitudes were higher for Cz electrode recordings. Mean scores on the acceptability questionnaire ranged from 1.1 to 2.6. Analysis of interviews indicated that parents found CAEP testing to be a positive experience and recognized the benefit of having an assessment procedure that uses conversational level speech stimuli. CONCLUSIONS: Test duration, completion rates, and response detection rates met (or were close to) our feasibility targets, and parent acceptability was high. CAEPs have the potential to supplement existing practice in 3- to 9-month olds.

Measuring access to high-modulation-rate envelope speech cues in clinically fitted auditory prostheses.

The signal processing used to increase intelligibility within the hearing-impaired listener introduces distortions in the modulation patterns of a signal. Trade-offs have to be made between improved audibility and the loss of fidelity. Acoustic hearing impairment can cause reduced access to temporal fine structure (TFS), while cochlear implant processing, used to treat profound hearing impairment, has reduced ability to convey TFS, hence forcing greater reliance on modulation cues. Target speech mixed with a competing talker was split into 8-22 frequency channels. From each channel, separate low-rate (EmodL, <16 Hz) and high-rate (EmodH, <300 Hz) versions of the envelope modulation were extracted, which resulted in low or high intelligibility, respectively. The EModL modulations were preserved in channel valleys and cross-faded to EModH in channel peaks. The cross-faded signal modulated a tone carrier in each channel. The modulated carriers were summed across channels and presented to hearing aid (HA) and cochlear implant users. Their ability to access high-rate modulation cues and the dynamic range of this access was assessed. Clinically fitted hearing aids resulted in 10% lower intelligibility than simulated high-quality aids. Encouragingly, cochlear implantees were able to extract high-rate information over a dynamic range similar to that for the HA users.

Improving hearing-aid gains based on automatic speech recognition.

This study provides proof of concept that automatic speech recognition (ASR) can be used to improve hearing aid (HA) fitting. A signal-processing chain consisting of a HA simulator, a hearing-loss simulator, and an ASR system normalizing the intensity of input signals was used to find HA-gain functions yielding the highest ASR intelligibility scores for individual audiometric profiles of 24 listeners with age-related hearing loss. Significantly higher aided speech intelligibility scores and subjective ratings of speech pleasantness were observed when the participants were fitted with ASR-established gains than when fitted with the gains recommended by the CAM2 fitting rule.

Effect of the number of amplitude-compression channels and compression speed on speech recognition by listeners with mild to moderate sensorineural hearing loss.

The use of a large number of amplitude-compression channels in hearing aids has potential advantages, such as the ability to compensate for variations in loudness recruitment across frequency and provide appropriate frequency-response shaping. However, sound quality and speech intelligibility could be adversely affected due to reduction of spectro-temporal contrast and distortion, especially when fast-acting compression is used. This study assessed the effect of the number of channels and compression speed on speech recognition when the multichannel processing was used solely to implement amplitude compression, and not for frequency-response shaping. Computer-simulated hearing aids were used. The frequency-dependent insertion gains for speech with a level of 65 dB sound pressure level were applied using a single filter before the signal was filtered into compression channels. Fast-acting (attack, 10 ms; release, 100 ms) or slow-acting (attack, 50 ms; release, 3000 ms) compression using 3, 6, 12, and 22 channels was applied subsequently. Using a sentence recognition task with speech in two- and eight-talker babble at three different signal-to-babble ratios (SBRs), 20 adults with sensorineural hearing loss were tested. The number of channels and compression speed had no significant effect on speech recognition, regardless of babble type or SBR.

Midterm outcomes of arthroscopic rotator cuff repair in patients aged 75 years and older.

BACKGROUND: Full-thickness rotator cuff tears remain a significant cause of pain and dysfunction in the elderly. Substantial improvement in pain and functional outcomes with arthroscopic cuff repair is possible. Recent data has shown that patients older than 70-75 years still have clinical improvement with operative rotator cuff repair. MATERIALS AND METHODS: This is a retrospective study of patients aged ≥75 years undergoing arthroscopic rotator cuff repair at a minimum of 24 months after surgery. Outcome measurements included range of motion (ROM), visual analog scale (VAS) pain scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, Single Assessment Numeric Evaluation (SANE) scores, and Short Form Health Survey (SF-12) scores. Reoperation and rates of conversion to reverse shoulder arthroplasty (RSA) were determined. RESULTS: Eighty-three patients were included with an average follow-up of 56.9 ± 25.9 months (range 24-127 months). Six (7.2%) patients had additional surgery, including 3 revision rotator cuff repairs for retear, 2 conversion to RSA, and 1 capsular release and loose anchor removal. There were statistically significant improvements in shoulder ROM, ASES, SANE, VAS, and SF-12 scores postoperatively. CONCLUSION: Rotator cuff repair in select patients aged ≥75 years results in reliable improvements in pain and function. There was a low reoperation rate or conversion to RSA (7.2%) at midterm follow-up. This study indicates a role for rotator cuff repair in an elderly population and argues against the routine use of reverse arthroplasty for repairable rotator cuff tears in this population.

Treatment of elbow periprosthetic joint infection: a systematic review of clinical outcomes.

BACKGROUND: Periprosthetic joint infection (PJI) of the elbow is a relatively common complication after total elbow arthroplasty (TEA), and its treatment is frequently variable. Few articles have provided direct comparisons of outcomes, making it difficult to draw conclusions from the available literature. This systematic review synthesizes the English-language literature on elbow PJI to quantify treatment outcomes. METHODS: The PubMed and Scopus databases were searched in December 2018. Our review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Keywords included "elbow replacement infection" and "elbow arthroplasty infection." A total of 1056 titles were identified; after application of the exclusion criteria, 41 studies met the screening criteria and underwent full-text review. Fifteen articles were included for the final analysis regarding demographic characteristics, risk factors, infecting organisms, success of eradication of infection based on surgical method, and functional outcomes of specific treatment regimens. RESULTS: Among the 15 articles selected, there were 309 TEA infections. Staphylococcus aureus was the most frequently isolated organism (42.4%), followed by coagulase-negative staphylococci (32.6%). Risk factors for the development of elbow PJI included rheumatoid arthritis, steroid use, an immunocompromised state, and previous elbow surgery. The rate of successful infection eradication was highest with 2-stage revision (81.2%) and lowest with irrigation and débridement for component retention (55.8%). The level of evidence was IV in 14 studies and III in 1 study. CONCLUSIONS: In this systematic review of TEA infections, Staphylococcus species represent the most common infecting organism. Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection.

Arthroscopic débridement of irreparable rotator cuff tears: predictors of failure and success.

HYPOTHESIS/BACKGROUND: Many techniques have been described to treat irreparable rotator cuff tears (RCT). Arthroscopic débridement for massive, irreparable RCT has been previously described to be a successful operation. The primary objective of our study was to analyze the mid-term outcomes and failure rates of arthroscopic débridement for irreparable RCTs and identify risk factors associated with failure and poor outcomes. METHODS: We retrospectively identified all patients between 2008 and 2013 who underwent arthroscopic débridement for an irreparable RCT. Demographics, operative reports, and preoperative imaging were collected from the medical record and outcome scores (American Shoulder and Elbow Surgeons [ASES] and visual analog scale) were collected at a minimum of 5-year follow-up. RESULTS: Twenty-six patients were included with a median follow-up of 98 months (range, 58-115 months). The average age at the time of surgery was 60 ± 11 years. Six patients (23%) had a reoperation at a median 11 months (range, 1-91 months), with 5 of those being revised to reverse shoulder arthroplasty. Median ASES and visual analog scale pain scores improved significantly from preoperatively to postoperatively (P < .01). Lower preoperative forward elevation was associated with worse postoperative ASES scores (P = .004) and revision to reverse shoulder arthroplasty. We found no associations between preoperative radiographic variables and reoperation or lower outcome scores. DISCUSSION/CONCLUSION: Arthroscopic débridement for irreparable RCT shows good mid-term success with improvements in patient-reported outcome scores and pain. Cost-effectiveness of more expensive procedures should be considered in the context of these successful results. Poor preoperative forward elevation appears to be a negative predictor of outcome and should be considered carefully when indicating patients for this procedure.

Biomechanical analysis of anterior capsule reconstruction and latissimus dorsi transfer for irreparable subscapularis tears.

BACKGROUND: Anterior capsule reconstruction (ACR) and latissimus dorsi transfers (LTs) have been proposed as solutions for irreparable subscapularis tears. The purpose of this study was to biomechanically assess the effects of ACR and LT separately and together for treatment of irreparable subscapularis tears. MATERIALS AND METHOD: Eight cadaveric shoulders underwent 5 testing conditions: (1) intact, (2) irreparable subscapularis tear, (3) ACR, (4) ACR+LT, and (5) LT alone. Anteroinferior translation loads of 20, 30, and 40 N were applied. Range of motion and magnitudes of glenohumeral anterior and inferior translation at 0°, 30°, and 60° of abduction and at 30° and 60° of external rotation were measured for each testing condition. RESULTS: At 30° of abduction and 60° of external rotation, ACR and ACR+LT restored anterior and inferior translation to intact (P > .702) for 30 and 40 N of anteroinferiorly directed force. LT alone did not restore anteroinferior stability at 30 N of distraction force at 30° of glenohumeral abduction and 60° of external rotation (P < .001). However, ACR and ACR+LT led to significant decreases in total range of motion compared to intact at 0° and 30° of abduction (P < .007). CONCLUSIONS: ACR with dermal allograft was able to restore anteroinferior stability in the setting of irreparable subscapularis tears but resulted in decreased total range of motion. LT alone was less effective than ACR in restoring glenohumeral stability. The addition of LT as a dynamic restraint did not increase the efficacy of ACR.

Evaluation of a system for enhancing mobile telephone communication for people with hearing loss.

Objective: To evaluate a system - "the service" - designed to improve mobile telephone communication for people with hearing loss. Design: Each participant registered online and took an online hearing test using their own mobile telephone held in the position of their choice. The test assessed the combined effects of the telephone, the hearing loss of the participant and the hearing aid of the participant (if worn). The results were stored as a "hearing profile" and used to set up frequency-dependent amplification and multichannel amplitude compression. The signal processing was performed in the telephone network and applied to all calls of the participant. Participants completed four questionnaires about their listening experiences using the telephone, one before using the service, two while using the service and one after using the service. Also, the ability to understand speech was measured using challenging sentences. Study sample: Fifty-three participants with varying degrees of hearing loss. Results: The great majority of participants indicated that call clarity was improved and that listening difficulty was reduced when using the service. Speech intelligibility scores were significantly improved when using the service. Conclusions: The service appears to be effective in improving phone communication for people with hearing loss.

Biomechanical analysis of latissimus dorsi tendon transfer with and without superior capsule reconstruction using dermal allograft.

BACKGROUND: Irreparable rotator cuff tears (ICTs) remain a challenging treatment dilemma. Superior capsule reconstruction (SCR) acts as a static stabilizer to decrease superior humeral head migration. Latissimus dorsi tendon transfers (LDTs) dynamically decrease superior humeral head migration and improve external rotation. We hypothesized that the dynamic stabilizing effect of the latissimus transfer plus the static stabilizing effect of SCR would improve shoulder kinematics in shoulders with ICTs. MATERIALS AND METHODS: Eight fresh-frozen cadaveric shoulders were tested in 5 conditions: (1) intact, (2) ICT (supraspinatus plus anterior half of infraspinatus), (3) SCR with dermal allograft, (4) SCR plus LDT, and (5) LDT alone. Rotational range of motion, superior translation, anteroposterior translation, and peak subacromial contact pressure were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Statistical analysis was performed using a repeated-measures analysis of variance test, followed by a Tukey post hoc test for pair-wise comparisons. RESULTS: ICTs increased total shoulder rotation, superior translation, posterior translation, and peak subacromial contact pressure. SCR plus LDT significantly decreased internal rotation only at 60° of abduction. The effect of SCR plus LDT was most evident at lower levels of abduction. At the mid range of abduction (30°), the static stabilizing effect diminished but the dynamic stabilizing effect remained, allowing SCR plus LDT to reduce superior translation more effectively than SCR with dermal allograft alone. CONCLUSIONS: Adding SCR to LDT adds static stabilization to a dynamic stabilizer. Therefore, SCR plus LDT may provide additional stability at the low to mid ranges of abduction.

Outpatient total elbow arthroplasty: 90-day outcomes.

BACKGROUND: Interest in outpatient arthroplasty has grown in response to increasing emphasis on the efficient delivery of safe, high-quality medical care. This study evaluated 90-day episode-of-care complications after outpatient total elbow arthroplasty (TEA). MATERIALS AND METHODS: We retrospectively evaluated 28 patients discharged the same day after primary TEA for 90-day episode-of-care complications, reoperations, and readmissions. Postoperative complications and elbow range of motion measurements were recorded and evaluated at the latest follow-up. All patients were contacted and given a satisfaction survey to assess their outpatient experience. Univariate logistic regression was performed for each risk factor to evaluate the risk for major and minor complications. Statistical significance was set as P < .05. RESULTS: Final follow-up data were available for 28 patients at an average of 14 months. Major complications within 90 days of surgery occurred in 7.1% of patients, ulnar nerve paresthesias occurred in 42.8% of patients, and minor wound problems occurred in 39.2% of patients. Five reoperations occurred after the 90-day postoperative period. All ulnar paresthesias and minor wound complications had resolved by the latest follow-up. Univariate regression analysis revealed a significant correlation between smoking and minor wound complications (P = .038). The satisfaction survey had an 85.7% response rate, with 91.7% of patients stating they were happy they went home the same day, and 95.8% feeling more confident and in control of their lives. CONCLUSIONS: The risk profile of carefully selected patients undergoing same-day discharge after TEA is acceptable when combined with close follow-up.

Vascularized dermal autograft for the treatment of irreparable rotator cuff tears.

BACKGROUND: Irreparable rotator cuff tears (IRCTs) are a challenging problem with diverse treatment modalities. We propose a technique for the treatment of IRCTs in which a vascularized dermal autograft is transferred to the posterosuperior region of the rotator cuff using the supraclavicular artery (SCA) island flap. MATERIALS AND METHODS: Dissection of 11 fresh cadavers (19 shoulders) was performed, and the SCA island flap was harvested in all specimens. A full-thickness posterosuperior rotator cuff defect was created, and the flap was tunneled under the acromion and secured into position over the defect using multiple suture anchors. Simulated flap perfusion was then assessed, and flap measurements were recorded. RESULTS: There were 4 male and 7 female cadavers (19 shoulders). Flap perfusion was assessed in 10 shoulders. On average, the flap thickness was 4.7 mm (range, 3.5-7.1 mm); width, 32.6 mm (range, 25.5-38.0 mm); and length, 169.2 mm (range, 132.0-235.0 mm). The average distance from the flap tip to the Neviaser portal was 76.2 mm (range, 48.0-99.6 mm), and that from the flap tip to the anterolateral acromial edge was 54.1 mm (range, 29.5-75.1 mm). The pedicle-to-footprint distance was 113.7 mm (range, 88.5-147.0 mm). The average flap length exceeded the pedicle-to-footprint distance by 55.5 mm (range, 43.5-88.0 mm), indicating adequate excursion of the flap. All flaps demonstrated adequate simulated perfusion after fixation. CONCLUSION: The SCA island flap may be an option for a vascularized dermal autograft for IRCTs, as shown in this cadaveric study. This illustrates a possible technique with vascular viability.

Operatively Treated Talus Fractures: Complications and Survivorship in a Large Patient Sample.

Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p = .015) and overall complications (56.8%, p < .001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures.

The near non-existence of "pure" energetic masking release for speech: Extension to spectro-temporal modulation and glimpsing.

Stone and Moore [(2014). J. Acoust. Soc Am. 135, 1967-77], showed that the introduction of explicit temporal-only modulations to a speech masker, that otherwise produced a near-constant envelope at the output of each auditory filter, rarely resulted in improved intelligibility, except at a very low modulation rate. This represents a failure in "dip-listening" or "glimpsing" [Cooke (2006). J. Acoust. Soc. Am. 119, 1562-1573], a facility where listeners are presumed to benefit from the temporarily improved signal-to-noise ratio during the masker dips. The dips of Stone and Moore only varied temporally, so Stone and Moore's method was used here to investigate the effect of maskers with both spectral and temporal dips, a pattern more representative of real-world maskers. For sinusoidally shaped modulations, intelligibility improved only at very low modulation rates, below 2 Hz temporally and 0.14 ripples/auditory filter spectrally. Square-wave modulation at a rate of 4 Hz resulted in improved intelligibility when only one cycle of spectral modulation was present across the audio bandwidth. Compared to the spectro-temporal extent of dips present during real-world noisy speech, dips generated by the reported modulation patterns were very large, further supporting the notion that dip-listening reflects a release from modulation masking and not energetic masking.