Computer navigation of the glenoid component in reverse total shoulder arthroplasty: a clinical trial to evaluate the learning curve.

BACKGROUND: Intraoperative computer navigation has been introduced recently to assist with placement of the glenoid component. The aim of this study was to evaluate the learning curve of a single surgeon performing computer navigation of glenoid implant placement in primary reverse total shoulder arthroplasty (RTSA). METHODS: Following training with the intraoperative computer navigation system, we conducted a prospective case-series study of the first 24 consecutive patients undergoing a primary RTSA with navigation performed by a single surgeon. Surgical times, complications, and accuracy of glenoid positioning compared with the preoperative plan were evaluated. Surgical times were compared with the preceding non-navigated series of 24 consecutive primary RTSA cases. Postoperative 3-dimensional computed tomography scans were performed to evaluate glenoid component version and inclination compared with the preoperative plan. RESULTS: The total surgical time was 77.3 minutes (standard deviation [SD], 11.8 minutes) in the navigated RTSA cohort and 78.5 minutes (SD, 18.1 minutes) in the non-navigated series. A significant downward trend in the total surgical time was observed in the navigated cohort (P = .038), which flattened after 8 cases. No learning curve was observed in deviation of glenoid version or inclination from the preoperative plan. The mean deviation of achieved version from planned version was 3° (SD, 2°), and the mean deviation of achieved inclination from planned inclination was 5° (SD, 3°). CONCLUSION: Findings from this study suggest that intraoperative computer navigation will not require substantially increased operating times compared with standard surgical techniques. With prior surgeon training, approximately 8 operative cases are required to achieve proficiency in intraoperative computer navigation of the glenoid component.

Manganese doping of magnetic iron oxide nanoparticles: tailoring surface reactivity for a regenerable heavy metal sorbent.

A method for tuning the analyte affinity of magnetic, inorganic nanostructured sorbents for heavy metal contaminants is described. The manganese-doped iron oxide nanoparticle sorbents have a remarkably high affinity compared to the precursor material. Sorbent affinity can be tuned toward an analyte of interest simply by adjustment of the dopant quantity. The results show that following the Mn doping process there is a large increase in affinity and capacity for heavy metals (i.e., Co, Ni, Zn, As, Ag, Cd, Hg, and Tl). Capacity measurements were carried out for the removal of cadmium from river water and showed significantly higher loading than the relevant commercial sorbents tested for comparison. The reduction in Cd concentration from 100 ppb spiked river water to 1 ppb (less than the EPA drinking water limit of 5 ppb for Cd) was achieved following treatment with the Mn-doped iron oxide nanoparticles. The Mn-doped iron oxide nanoparticles were able to load ~1 ppm of Cd followed by complete stripping and recovery of the Cd with a mild acid wash. The Cd loading and stripping is shown to be consistent through multiple cycles with no loss of sorbent performance.

Do Sideline Tests of Vestibular and Oculomotor Function Accurately Diagnose Sports-Related Concussion in Adults? A Systematic Review and Meta-analysis.

BACKGROUND: Sports-related concussion (SRC) assessment tools are primarily based on subjective assessments of somatic, cognitive, and psychosocial/emotional symptoms. SRC symptoms remain underreported, and objective measures of SRC impairments would be valuable to assist diagnosis. Measurable impairments to vestibular and oculomotor processing have been shown to occur after SRC and may provide valid objective assessments. PURPOSE: Determine the diagnostic accuracy of sideline tests of vestibular and oculomotor dysfunction to identify SRC in adults. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Electronic databases and gray literature were searched from inception until February 12, 2020. Physically active individuals (>16 years of age) who participated in sports were included. The reference standard for SRC was a combination of clinical signs and symptoms (eg, the Sport Concussion Assessment Tool [SCAT]), and index tests included any oculomotor assessment tool. The QUADAS tool was used to assess risk of bias, with the credibility of the evidence being rated according to GRADE. RESULTS: A total of 8 studies were included in this review. All included studies used the King-Devick test, with no other measures being identified. Meta-analysis was performed on 4 studies with a summary sensitivity and specificity of 0.77 and 0.82, respectively. The overall credibility of the evidence was rated as very low. CONCLUSION: Caution must be taken when interpreting these results given the very low credibility of the evidence, and the true summary sensitivity and specificity may substantially differ from the values calculated within this systematic review. Therefore, we recommend that clinicians using the King-Devick test to diagnose SRC in adults do so in conjunction with other tools such as the SCAT. PROSPERO REGISTRATION: CRD42018106632.

The reliability and validity of magnetic resonance imaging in the assessment of chronic lateral epicondylitis.

PURPOSE: Lateral epicondylitis is a painful condition affecting the proximal enthesis of the extensor carpi radialis brevis tendon. Although magnetic resonance imaging (MRI) has been highlighted as an important diagnostic tool, to our knowledge no previous study has established the observer reliability of MRI for lateral epicondylitis or the relationship between MRI abnormalities of the common extensor origin and the patient's clinical assessment. METHODS: Twenty-one consecutive subjects with a clinical diagnosis of chronic lateral epicondylitis were assessed. An MRI scoring system was used to grade the degree of tendinosis and length of tendon separation of the common extensor origin from the lateral epicondyle. Three independent musculoskeletal radiologists, who were blinded to patient clinical severity, scored images separately. Each scored the images on 3 separate occasions. Clinical symptoms were assessed using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Upper Extremity Functional Scale clinical measures. Maximum pain levels were scored on a visual analog scale, and objective assessment was made with grip strength. RESULTS: Moderate or severe signal changes consistent with tendinosis were observed in 18 of 21 patients. Significant inter-observer reliability and intra-observer agreement were demonstrated for MRI interpretation of grade of tendinosis and length of tendon separation. Significant negative correlation was found between the length of tendon separation and both the QuickDASH and maximum pain levels. CONCLUSIONS: Magnetic resonance imaging is a reliable tool in determining radiological severity of lateral epicondylitis. However, the severity of MRI signal changes does not positively correlate with symptoms. These findings question the validity of MRI in the assessment of lateral epicondylitis.

Cycle Sprint Test for the Evaluation of Lower Limb Muscle Power After Total Knee Arthroplasty: A Proof-of-Concept Study.

BACKGROUND: Lower limb muscle power is emerging as an important determinant of patient function after knee injury or surgery. This study tested proof of concept of a cycle sprint test for the evaluation of lower limb muscle power, as an outcome measure for patients having total knee arthroplasty (TKA). METHODS: Thirty-two patients were enrolled, of which 16 completed all follow-ups (3, 6, and 12 months). All patients completed the Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score questionnaires, a 10-m walk test, and 30-second sit-stand test. A trainer-mounted road cycle fitted with an instrumented crank was used for the cycle sprint test. Maximum muscle power was measured from 3, 10-second maximal efforts. RESULTS: Significant improvements in Oxford Knee Score and Knee Injury and Osteoarthritis Outcome scores relative to baseline were achieved at each follow-up (P < .001), and functional test performance improved significantly at 6 and 12 months (P < .001). Compared with the baseline of 268W, muscle power was significantly lower at 3 months (239W, -13%, P < .05) and significantly higher at 12 months (308W, +12%, P < .05). CONCLUSION: The concept of muscle power measurement using a cycle sprint test before and after TKA has been demonstrated in this study. Identification of individuals with lower limb muscle power deficits after TKA may inform rehabilitation programs and enhance long-term outcomes.

Surfactant mobility in nanoporous glass films.

Polymer molecules when physically confined at nanometer length scales diffuse nonclassically and very differently depending on their molecular weight and the nature of the confinement. Long polymers that exhibit "snakelike" reptation based mobility in melts may diffuse faster in confined nanometer sized cylinders with pore diameter d approximately 15 nm, and short polymers subject to Rouse dynamics have shown signatures of reptation and slower diffusion when confined in nanoporous glass with d approximately 4 nm. However, the mobility of short polymers with radii of gyration similar to a smaller pore diameter (d < or = 2.1 nm) but with extended lengths well larger than the pore diameter has not as yet been studied. In this work, we demonstrate that those short molecules including nonionic surfactants can readily diffuse in strongly hydrophobic nanoporous glasses film with d < or = 2.1 nm. The diffusivity was found sensitive to molecular weight, hydrophilic-lipophilic balance, and molecular structure of surfactants. Remarkably, analysis of the measured diffusion coefficients reveals that short-chain surfactants exhibit signature of reptation based diffusion in the nanoscopic pore confinements. Such reptation mobility in agreement with theoretical predictions is not even observed in reptating polymer melts due to fluctuations of the entanglement pathway. The fixed pathways in the interconnected nanoporous films provide ideal nanoscale environments to explore mobility of confined molecules, and the results have implications for a number of technologies where nanoporous materials are in contact with surfactant molecules.

Feasibility of conducting an early pregnancy diet and lifestyle e-health intervention: the Pregnancy Lifestyle Activity Nutrition (PLAN) project.

BACKGROUND: Childhood obesity is a global issue. Excessive weight gain in early pregnancy is independently associated with obesity in the next generation. Given the uptake of e-health, our primary aim was to pilot the feasibility of an e-health intervention, starting in the first trimester, to promote healthy lifestyle and prevent excess weight gain in early pregnancy. Methods: Women were recruited between 8 and 11 weeks gestation and randomised to the intervention or routine antenatal care. The intervention involved an e-health program providing diet, physical activity and well-being advice over 12 weeks. RESULTS: Women (n = 57, 43.9% overweight/obese) were recruited at 9.38 ± 1.12 (control) and 9.06 ± 1.29 (intervention) weeks' gestation, mainly from obstetric private practices (81.2%). Retention was 73.7% for the 12-week intervention, 64.9% at birth and 55.8% at 3 months after birth.No difference in gestational weight gain or birth size was detected. Overall treatment effect showed a mean increase in score ranking the perceived confidence of dietary change (1.2 ± 0.46, p = 0.009) and score ranking readiness to exercise (1.21 ± 0.51, p = 0.016) over the intervention. At 3 months, infants weighed less in the intervention group (5405 versus 6193 g, p = 0.008) and had a lower ponderal index (25.5 ± 3.0 versus 28.8 ± 4.0 kg/m3) compared with the control group. CONCLUSION AND DISCUSSION: A lifestyle intervention starting in the first-trimester pregnancy utilising e-health mode of delivery is feasible. Future studies need strategies to target recruitment of participants of lower socio-economic status and ensure maximal blinding. Larger trials (using technology and focused on early pregnancy) are needed to confirm if decreased infant adiposity is maintained.

Activity following reverse total shoulder arthroplasty: What should surgeons be advising?

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is now the most frequently performed form of shoulder arthroplasty. There is currently no consensus on recommended levels of activity and sport following RTSA. The aim of this review is to outline the current evidence and provide a guide for surgeons on what to advise their patients regarding activity level following RTSA. METHODS: A systematic review of the literature was performed using the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was performed using the electronic databases PubMed and Medline. Included studies were of level 1 to 4 evidence in the English language evaluating complications and return to sport after RTSA. RESULTS: Eleven studies were selected and included a total of 621 patients (67% female) with a mean age of 73 years (range 22-92). All of the included patients participated in sports prior to RTSA. The rate of return to sport ranged from 60 to 86% and varied with the level of sport activity. Mean time to return to sport after surgery varied greatly between studies. CONCLUSIONS: Return to sport is tolerated following RTSA; however, studies are short to medium term only and although the reported complication rate is low, the studies did not include radiographic evaluation. Longer term studies with subgroup analysis evaluating common recreational activities after RTSA are required, particularly in the younger population, in order to establish clear post-operative guidelines.

Evaluation of Long-term Outcomes Following Plantar Fasciotomy.

BACKGROUND: Plantar fasciitis is a common condition prevalent in both athletic and nonathletic populations. Approximately 10% of patients do not respond to conservative treatment and suffer chronic recalcitrant plantar fasciitis. Outcomes following plantar fasciotomy vary but short-term studies have reported excellent early pain relief and return to activity, and significant improvements in symptoms. Previous study limitations include small patient cohorts, short-term duration of follow-up or lack of validated outcome measures. We therefore aimed to investigate the long-term outcomes following complete plantar fasciotomy. METHODS: Patients who underwent complete plantar fasciotomy surgery from a single surgeon within the past 10 years (minimum 7 months) were invited to participate in this retrospective survey study. To evaluate patient-reported function, participants were asked to complete the Foot and Ankle Outcome Score (FAOS). To assess subjective outcome, the participants were provided a satisfaction survey. The satisfaction survey was designed to include the 3 key factors for assessing postoperative patient satisfaction, which are preoperative expectations, symptom relief, and hospital experience. A total of 74 questionnaires were returned. RESULTS: The median global satisfaction score was 85.4 (IQR=37.5) points out of 100. Significant correlations between the global patient satisfaction score and all FAOS subscale scores were identified. Only 3 participants (4%) reported a complication following surgery; however, 32 participants (44.4%) indicated that they still experienced swelling and/or tenderness in their foot at the time of the survey (mean follow-up time 4.8 ± 2.8 years) but for the majority of patients this was improved from before surgery. CONCLUSION: Long-term patient satisfaction was experienced by the majority of patients following plantar fasciotomy. Although 44% of patients continue to have postoperative complaints, 73% indicated that they were satisfied with their symptoms postoperatively, and 74% would undergo a similar procedure again. LEVEL OF EVIDENCE: Level IV, case series.

Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis: Mean 4.5-Year Clinical Follow-up.

BACKGROUND: Chronic lateral epicondylitis (LE) induces cell apoptosis and autophagy, which lead to the reduction of tendon-derived cells in the torn tendon. Our previous study has shown that ultrasound-guided autologous tenocyte injection (ATI) to the torn tendon in patients with chronic resistant LE significantly improves pain, function, and structural repair at 1 year. This report is the continued assessment of the clinical outcomes of these patients at mean 4.5-year follow-up. HYPOTHESIS: Improvements in LE clinical function and structural repair after ATI will be maintained at mean 4.5-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with severe refractory LE underwent clinical evaluation and MRI before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Autologous tenocytes were injected into the central tendinopathy identified at the common extensor tendon origin under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations for up to 5 years after ATI, including the visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Upper Extremity Functional Scale (UEFS), and grip strength. Post-ATI MRI scanning was performed at 1 year and final follow-up. RESULTS: A total of 16 patients (9 male, 7 female), aged between 37 and 63 years, were included in the study. The mean duration of symptoms before study recruitment was 29.24 months (range, 6-240 months). One patient elected to proceed to surgery 3 months after ATI due to reinjury at work, and 1 patient died of prostate cancer with metastases during the follow-up period. The mean final follow-up time for the remaining 15 patients was 4.51 years (range, 3.08-5.17 years). No complications were observed at the patellar tendon biopsy site for any patient. No adverse events, infection, or excessive fibroblastic reactions were observed in any patient at the injection site. Clinical evaluation revealed significant (P < .001) improvement in mean VAS pain score from 5.73 at initial assessment to 1.21 (78% improvement) at final follow-up. Mean QuickDASH, UEFS, and grip strength scores also significantly (P < .001) improved from initial assessment to final follow-up (from 45.88 to 6.61 [84%], from 31.73 to 9.20 [64%], and from 19.85 to 46.60 [208%], respectively). There was no difference in mean QuickDASH and UEFS scores at 1 year and final follow-up (P > .05); however, grip strength continued to improve (P < .001). A validated MRI scoring system indicated that the mean grade of tendinopathy at the common extensor origin improved significantly (P < .001) from initial assessment (4.31) to 1 year (2.88) and was maintained (P > .05) at final follow-up (2.87). At final follow-up, 93% of patients were either highly satisfied or satisfied with their ATI treatment. CONCLUSION: ATI significantly improved clinical function and MRI tendinopathy scores for up to 5 years in patients with chronic resistant LE who had previously undergone unsuccessful nonsurgical treatment. This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy.

Autologous tenocyte injection for the treatment of severe, chronic resistant lateral epicondylitis: a pilot study.

BACKGROUND: Severe chronic lateral epicondylitis (LE) is associated with degenerative tendon changes, extracellular matrix breakdown, and tendon cell loss. On the basis of positive outcomes from preclinical studies, this study is the first clinical trial of autologous tenocyte injection (ATI) on severe tendinopathy associated with chronic LE. HYPOTHESIS: Autologous tenocyte injection is a safe and effective procedure that enables a reduction in pain and improvement in function in resistant LE. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with severe refractory LE underwent clinical evaluation and magnetic resonance imaging (MRI) before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Tenocytes used for the injection were characterized by flow cytometry and real-time polymerase chain reaction. Autologous tenocytes were injected into the site of tendinopathy identified at the origin of the extensor carpi radialis brevis tendon under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations and repeat MRI at 12 months after intervention. RESULTS: A total of 20 consecutive patients were included in the study. Three patients withdrew consent after enrollment and before ATI. No adverse event was reported at either biopsy or injection sites. Furthermore, no infection or excessive fibroblastic reaction was found in any patient at the injection site. Clinical evaluation revealed an improvement in mean visual analog scale scores, for a maximum pain score from 5.94 at the initial assessment to 0.76 at 12 months (P < .001). Mean quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and grip strength scores also significantly improved over the 12-month follow-up (QuickDASH score, 45.88 [baseline] to 3.84; grip strength, 20.17 kg [baseline] to 37.38 kg; P < .001). With use of a validated MRI scoring system, the grade of tendinopathy at the common extensor origin improved significantly by 12 months (P < .001). One patient elected to proceed to surgery 3 months after ATI following a reinjury at work. CONCLUSION: In this study, patients with chronic LE who had previously undergone an unsuccessful full course of nonoperative treatment showed significantly improved clinical function and structural repair at the origin of the common extensor tendon after ATI. This novel treatment is encouraging for the treatment of tendinopathy and warrants further evaluation.

Histopathology of femoral head donations: a retrospective review of 6161 cases.

BACKGROUND: Although total hip arthroplasty is one of the most common orthopaedic surgical procedures, it remains unclear whether histopathological examination of the excised femoral head adds to the quality of patient care. We propose that assessment of femoral heads resected during total hip arthroplasty and donated for allograft use may provide a profile of femoral head pathology that benefits total hip arthroplasty patients and bone donors. METHODS: We retrospectively analyzed the histological findings reported for 6161 femoral heads donated for allograft use between 1993 and 2006. Specimens obtained during total hip arthroplasty and specimens donated at death were reviewed. Follow-up investigations that resulted from abnormal histopathological findings were also reviewed. The Western Australian Cancer Registry was used to determine whether patients with a suspected neoplasm were subsequently diagnosed with such a disease. A retrospective review of the histopathological findings was conducted to evaluate and reclassify all previous observations of abnormalities. RESULTS: One hundred and five femoral heads demonstrated abnormal or reactive histopathological features not reported prior to surgery and were rejected for allograft use. A reactive lymphocytic infiltrate, most likely due to osteoarthritis, was the most commonly identified feature (forty-five cases). Other features observed in twenty-seven cases were also most likely due to the presence of severe osteoarthritis. Ten femoral heads demonstrated plasmacytosis, which may have been related to osteoarthritis. Two patients were diagnosed with Paget's disease, and two, with rheumatoid arthritis. Nineteen patients had a suspected neoplasm. Of these nineteen, eight cases of non-Hodgkin's lymphoma or chronic lymphocytic leukemia and one case of myelodysplastic syndrome were confirmed on further investigation. One subsequently confirmed malignancy was detected per 770 femoral heads examined. CONCLUSIONS: Our findings indicate that, even with a detailed medical history and careful physical examination, clinically important diseases including neoplasms and Paget's disease are observed in patients diagnosed with osteoarthritis prior to total hip arthroplasty. Histological examination plays an integral role in quality assurance in femoral head banking, and it also represents a possible early diagnostic test for bone and bone-marrow-related diseases in patients undergoing total hip arthroplasty.