Return to Sport After Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm: A Systematic Review.

BACKGROUND: Forearm chronic exertional compartment syndrome (CECS) can represent considerable functional impairment in certain active populations, particularly motorcycle racers. Patients with forearm CECS frequently require fasciotomy to relieve symptoms and return to sport (RTS). PURPOSE: To evaluate the rate at which athletes RTS after fasciotomy for forearm CECS and to compare RTS outcomes between fasciotomy techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the PubMed, Scopus, and Cochrane databases was performed from database inception to December 2022 to identify all published reports of forearm CECS managed with fasciotomy. Included studies were analyzed for demographic information, surgical approaches, rehabilitation parameters, RTS rates, time from surgery at which athletes resumed sport, complications, and recurrence. RESULTS: A total of 38 studies (15 level 4 case series, 23 case reports) accounting for 500 patients (831 forearms) who underwent open fasciotomy (112 patients), minimally invasive fasciotomy (166 patients), and endoscopically assisted fasciotomy (222 patients) satisfied inclusion criteria. Most patients (88.0%) were motorcycle racers. The overall RTS rate at any level (RTS-A) was 94.2% (97.3%, 92.2%, and 98.5% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .010), and the overall RTS at preinjury level or higher was 86.8% (95.9%, 85.6%, and 95.2% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .132). There was a significant difference in RTS-A between the minimally invasive fasciotomy and endoscopically assisted fasciotomy groups (P = .004). The overall RTS time was 5.1 ± 2.3 weeks, patient satisfaction was 85.1%, and the recurrence rate was 2.4%, and there were no significant differences between fasciotomy approach groups (P = .456, P = .886, and P = .487, respectively). CONCLUSION: Patients who underwent fasciotomy for forearm CECS had high rates of RTS, quick RTS time, high levels of satisfaction, and low rates of recurrence. Outcomes were largely similar between the 3 fasciotomy approaches.

Rehabilitation and return to activity criteria after operative management of chronic exertional compartment syndrome of the leg: a systematic review.

OBJECTIVES: Endurance athletes with chronic exertional compartment syndrome (CECS) frequently require fasciotomy to return to activity, but there are no existing comprehensive evidence-based rehabilitation guidelines. We aimed to summarize rehabilitation protocols and return to activity criteria after CECS surgery. METHODS: Through a systematic literature review, we identified 27 articles that explicitly defined physician-imposed restrictions or guidelines for patients to resume athletic activities following CECS surgery. RESULTS: Common rehabilitation parameters included running restrictions (51.9%), postoperative leg compression (48.1%), immediate postoperative ambulation (44.4%), and early range of motion exercises (37.0%). Most studies (70.4%) reported return to activity timelines, but few (11.1%) utilized subjective criteria for guiding return to activity. No studies utilized objective functional criteria. CONCLUSIONS: Rehabilitation and return to activity guidelines after CECS surgery remain poorly defined, and further investigation is needed to develop such guidelines that will enable endurance athletes to safely return to activities and minimize recurrence.

Observational study of the effect of ketamine infusions on sedation depth, inflammation, and clinical outcomes in mechanically ventilated patients with SARS-CoV-2.

Severely ill patients with COVID-19 are challenging to sedate and often require high-dose sedation and analgesic regimens. Ketamine can be an effective adjunct to facilitate sedation of critically ill patients but its effects on sedation level and inflammation in COVID-19 patients have not been studied. This retrospective, observational cohort study evaluated the effect of ketamine infusions on inflammatory biomarkers and clinical outcomes in mechanically ventilated patients with SARS-CoV-2 infection. A total of 186 patients were identified (47 received ketamine, 139 did not). Patients who received ketamine were significantly younger than those who did not (mean (standard deviation) 59.2 (14.2) years versus 66.3 (14.4) years; P = 0.004), but there was no statistically significant difference in body mass index (P = 0.25) or sex distribution (P = 0.91) between groups. Mechanically ventilated patients who received ketamine infusions had a statistically significant reduction in Richmond Agitation-Sedation Scale score (-3.0 versus -2.0, P < 0.001). Regarding inflammatory biomarkers, ketamine was associated with a reduction in ferritin (P = 0.02) and lactate (P = 0.01), but no such association was observed for C-reactive protein (P = 0.27), lactate dehydrogenase (P = 0.64) or interleukin-6 (P = 0.87). No significant association was observed between ketamine administration and mortality (odds ratio 0.971; 95% confidence interval 0.501 to 1.882; P = 0.93). Ketamine infusion was associated with improved sedation depth in mechanically ventilated COVID-19 patients and provided a modest anti-inflammatory benefit but did not confer benefit with respect to mortality or intensive care unit length of stay.

In Vivo Effect of Partial Ulnar Collateral Ligament Tear Location on Ulnohumeral Joint Gapping With Stress Ultrasound in Baseball Pitchers.

BACKGROUND: Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results. PURPOSE/HYPOTHESIS: The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)-confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist. RESULTS: Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P = .499). CONCLUSION: No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.

Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review.

BACKGROUND: Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. OBJECTIVE: The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. METHODS: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. RESULTS: Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). CONCLUSIONS: USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.

Comprehensive Review of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease.

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.

Return to Sport Rates and Subjective Outcomes Are Similar After Open or Endoscopically Assisted Compartment Release for Chronic Lower-Extremity Exertional Compartment Syndrome.

Purpose: To retrospectively compare return to sport rates and subjective outcomes of patients who underwent open or endoscopic compartment release for the surgical management of chronic exertional compartment syndrome. Methods: This was a retrospective review of patients who underwent lower-extremity fasciotomy for chronic exertional compartment syndrome from June 2012 to June 2020. Eligibility included patients 15 to 45 years of age who identified as an athlete and had at least 6 months of follow-up. Fasciotomies for trauma or infection were excluded. One surgeon exclusively performed each type of surgery. Postoperative outcome measures included the Lower Extremity Functional Scale, the Marx Activity Scale, and a return to play survey. Results: In total, 24 patients (13 endoscopically assisted fasciotomies, 11 open fasciotomies) had a mean follow-up of 3.8 ± 2.1 years; 19 patients returned to their sporting activity. No significant difference existed between return to play rates (P = .630) or return to play times (P = .351). There were no significant differences between the groups in the Lower Extremity Functional Scale score, Marx Activity Scale score, Single Assessment Numeric Evaluation score, pain score at rest, and during sporting activity. Overall satisfaction rates were found to be significantly greater in the endoscopically assisted fasciotomy group (P = .041). Conclusions: In this small sample of heterogenous groups of patients, we found no significant differences in return to sport rates or subjective results after surgery. Patients experienced a high subjective recurrence rate. The endoscopically assisted fasciotomy group reported greater subjective patient satisfaction compared with the open fasciotomy group. Level of Evidence: Level III, comparative study, retrospective.

Adolescent Quadriceps Tendon Rupture, an Early Complication After ACL Reconstruction: A Case Report.

CASE: A healthy adolescent male patient initially presented with complete rupture of the anterior cruciate ligament (ACL) after a plant-twist injury during a high school football game. Four weeks after ACL reconstruction with autograft bone-patella tendon-bone, the patient slipped and fell, sustaining hyperflexion of the knee, resulting in rupture of the ipsilateral quadriceps tendon. CONCLUSION: Although this rare complication has previously been reported in the adult population, to the best of our knowledge, this is the first known report of an adolescent patient sustaining a quadriceps tendon rupture after ACL reconstruction.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review.

Background: Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation. Methods: A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation. Results: Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal. Conclusion: Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

Delayed Recurrence of Acute Colonic Pseudo-Obstruction in the Setting of Acute Hypoxic Respiratory Failure.

Acute colonic pseudo-obstruction (ACPO) is a rare cause of massive colonic dilation without mechanical obstruction. We report on a 58-year-old gentleman who developed two separate episodes of ACPO following different surgical and medical stressors. The initial episode occurred shortly after lumbar laminectomy and was successfully managed with medical therapy. His second episode occurred several months later in the setting of acute hypoxic respiratory failure secondary to bacterial pneumonia and was refractory to conservative, medical, and endoscopic therapy. Recurrence and the refractory nature of symptoms are presumably multifactorial in etiology, likely due to his episode of acute hypoxic respiratory failure in the setting of chronic immobility following recent spine surgery. The patient was discharged in stable condition to a subacute rehabilitation facility with the expectation that physical therapy would improve his abdominal symptoms.

Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition.

BACKGROUND: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. PURPOSE: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. RESULTS: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. CONCLUSION: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Fluorescence correlation spectroscopy to unravel the interactions between macromolecules in wine.

In this work, the interaction of wine macromolecules with a bovine serum albumin (BSA) was investigated using fluorescence correlation spectroscopy (FCS). FCS offers the opportunity to study molecular and macromolecular aggregation without disturbing the wine by introducing only very small amounts of fluorescently labelled molecules to the system. It was observed that the diffusion coefficient of fluorescently labelled BSA varies with the addition of wine macromolecules, indicating changes in the protein conformation and the formation of complexes and aggregates. The addition of a wine polysaccharide rhamnogalacturonan II-enriched fraction led to aggregation, while addition of a mannoprotein-enriched fraction exhibited a protective effect on protein aggregation. Proteins strongly interacted with tannins, leading to the precipitation of protein-tannin complexes, while the presence of polysaccharides prevented this precipitation. Finally, the application of FCS was demonstrated in real wines, to investigate the problem of protein haze formation through live monitoring of heat-induced aggregation in wine.

The mouthfeel of white wine.

White wine mouthfeel which encompasses the tactile, chemosensory and taste attributes of perceived viscosity, astringency, hotness and bitterness is increasingly being recognized as an important component of overall white wine quality. This review summarizes the physiological basis for the perception of white wine mouthfeel and the direct and interactive effects of white wine composition, specifically those of low molecular weight phenolic compounds, polysaccharides, pH, ethanol, glycerol, dissolved carbon dioxide, and peptides. Ethyl alcohol concentration and pH play a direct role in determining most aspects of mouthfeel perception, and provide an overall framework on which the other minor wine components can interact to influence white wine mouthfeel. Phenolic compounds broadly impact on the mouthfeel by contributing to its viscosity, astringency, hotness and bitterness. Their breadth of influence likely results from their structural diversity which would allow them to activate multiple sensory mechanisms involved in mouthfeel perception. Conversely, polysaccharides have a small modulating effect on astringency and hotness perception, and glycerol does not affect perceived viscosity within the narrow concentration range found in white wine. Many of the major sensory attributes that contribute to the overall impression of mouthfeel are elicited by more than one class compound suggesting that different physiological mechanisms may be involved in the construct of mouthfeel percepts.

White wine taste and mouthfeel as affected by juice extraction and processing.

The juice used to make white wine can be extracted using various physical processes that affect the amount and timing of contact of juice with skins. The influence of juice extraction processes on the mouthfeel and taste of white wine and their relationship to wine composition were determined. The amount and type of interaction of juice with skins affected both wine total phenolic concentration and phenolic composition. Wine pH strongly influenced perceived viscosity, astringency/drying, and acidity. Despite a 5-fold variation in total phenolics among wines, differences in bitter taste were small. Perceived viscosity was associated with higher phenolics but was not associated with either glycerol or polysaccharide concentration. Bitterness may be reduced by using juice extraction and handling processes that minimize phenolic concentration, but lowering phenolic concentration may also result in wines of lower perceived viscosity.

Odor detection thresholds and enantiomeric distributions of several 4-alkyl substituted gamma-lactones in Australian red wine.

The individual enantiomers of gamma-octalactone (1), gamma-nonalactone (2), gamma-decalactone (3) and gamma-dodecalactone (4) have been synthesized. The (R) series of enantiomers was prepared from L-glutamic acid by a strategy involving deamination and reduction to (S)-5-oxo-2-tetrahydrofurancarboxaldehyde (S)-7. The different length side chains were introduced by a series of Wittig reactions, varying in the choice of phosphorane used. Hydrogenation then gave the final gamma-lactones 1-4. The (S) series of enantiomers was prepared in an analogous fashion beginning with d-glutamic acid. Aroma detection thresholds for all eight enantiomers were determined in a "bag in a box" dry red wine by the application of ASTM method E 679, employing a panel of 25 members. The lowest threshold determined was 8 microg/L for (R)-dodecalactone (4) while the highest threshold was 285 microg/L for (R)-nonalactone (2). With the exception of gamma-decalactone (3) there were statistically significant differences (at the 5% level) in aroma detection thresholds between the two enantiomers of the same lactone. A stable isotope method developed for quantification of the lactones 1-4 has been extended for use with chiral phase GC (Rt-betaDEXcst capillary column) allowing quantification of the individual enantiomers. The enantiomeric distribution of gamma-octalactone (1) and gamma-nonalactone (2) in seven botrytized wines and of 2 in a total of 34 red wines were thus determined; with few exceptions, the (R) enantiomer of gamma-nonalactone (2) was found to be more prevalent than its (S) counterpart in the dry red and botrytized white wines analyzed. The same was true for gamma-octalactone (1) in the botrytized white wines.

Statistical correlations between the in-mouth textural characteristics and the chemical composition of Shiraz wines.

The relationships between the levels of polyphenols, acidity, and red pigments in Shiraz wines and their perceived textural profiles as quantified by a trained sensory descriptive analysis panel were explored. A "chamois-like" feeling when the wine was held in the mouth appeared to be related to an absence of polyphenols. The in-mouth "chalk-like" texture was strongly associated with anthocyanin concentration and was negatively associated with alcohol level and acidity. The astringent subqualities of "velvet-like" and "emery-like" roughing were mostly related to polyphenol levels, but these attributes could not be adequately differentiated by the compositional variables under study. Wines that elicited a "puckery" sensation were characterized by relatively low anthocyanin levels, high acidity, and high pigmented polymer and tannin concentrations. The results of the study suggest that the in-mouth textural properties of Shiraz red wine are associated not only with their tannin composition and concentration but also with their acidity and anthocyanin and alcohol concentrations.