Subacromial balloon spacer massive rotator cuff tear treatment systematic review and meta-analysis: Patient selection and physical therapy may be keys to outcome success.

PURPOSE: Subacromial balloon spacer implantation (SBSI) efficacy for massive rotator cuff tear treatment was evaluated based on perceived shoulder function, active shoulder mobility, pain, complications and research study methodological quality. The purpose was to better discern the efficacy of this device from both surgical and rehabilitative perspectives to improve patient outcomes. METHODS: PubMed, EMBASE and Cochrane Library databases were searched (1 January 2010 to 1 June 2024) using 'balloon spacer', 'subacromial spacer', 'subacromial balloon spacer', 'shoulder spacer' and 'inspace' terms. Pre-surgery (baseline), 12-month (12-m) and 24-month (24-m) post-SBSI mean changes were compared using one-way ANOVA and Scheffe post hoc tests, and comparative study effect sizes were calculated (p ≤ 0.05). RESULTS: This review consists of 27 studies with 894 patients (67.8 ± 5 years of age) and 29.4 ± 17-month follow-up. Modified Coleman Methodology Scores (MCMS) revealed fair overall quality (mean = 61.4 ± 11). Constant-Murley scores improved from 34.8 ± 6 (baseline), to 64.2 ± 9 (12-m) and 67.9 ± 8 (24-m) (12-m, 24-m > baseline, p < 0.001). ASES scores improved from 35.1 ± 14 (baseline), to 83.3 ± 7 (12-m) and 81.8 ± 5 (24-m)(12-m, 24-m > baseline, p < 0.001). VAS pain scores improved from 6.6 ± 1 (baseline), to 2.6 ± 1 (12-m) and 2.0 ± 1 (24-m) (12-m, 24-m < baseline, p < 0.001). Flexion increased from 108.5 ± 25° (baseline), to 128.5 ± 30° (12-m) and 151.2 ± 14° (24-m) (24-m > 12-m, baseline, p = 0.01). Abduction increased from 97.7 ± 24° (baseline) to 116.3 ± 23° (12-m) and 142.3 ± 15° (24-m) (24-m > 12-m, baseline, p = 0.02). External rotation (ER) in adduction changed from 33.1 ± 7° (baseline) to 32.5 ± 4° (12-m) and 53.9 ± 9° (24-m)(24-m > 12-m, baseline, p = 0.01). ER at 90° abduction increased from 56.3 ± 3° (baseline) to 83.5 ± 5° (12-m) and 77.1 ± 4° (24-m) (24-m, 12-m > baseline, p = 0.01). Comparison studies, however, displayed insignificant results with small effect sizes. CONCLUSION: Despite overall fair MCMS scores, at 24-m post-SBSI, shoulder function improved and pain decreased. More rigorous comparative studies, however, revealed insignificant findings. Patients with the potential to re-establish the essential glenohumeral joint force couple that depresses the humeral head on the glenoid fossa and who comply with physical therapy may be more likely to achieve success following SBSI. LEVEL OF EVIDENCE: Level IV.

Computerized surgical navigation resection of pelvic region simulated bone tumors using skin fiducial marker registration: an in vitro cadaveric study.

INTRODUCTION: Computerized surgical navigation system guidance can improve bone tumor surgical resection accuracy. This study compared the 10-mm planned resection margin agreement between simulated pelvic-region bone tumors (SPBT) resected using either skin fiducial markers or Kirschner (K)-wires inserted directly into osseous landmarks with navigational system registration under direct observation. We hypothesized that skin fiducial markers would display similar resection margin accuracy. METHODS: Six cadaveric pelvises had one SPBT implanted into each supra-acetabular region. At the left hemi-pelvis, the skin fiducial marker group had guidance from markers placed over the pubic tubercle, the anterior superior iliac spine, the central and more posterior iliac crest, and the greater trochanter (5 markers). At the right hemi-pelvis, the K-wire group had guidance from 1.4-mm-diameter wires inserted into the pubic tubercle, and 3 inserted along the iliac crest (4 K-wires). The senior author, a fellowship-trained surgeon performed "en bloc" SPBT resections. The primary investigator, blinded to group assignment, measured actual resection margins. RESULTS: Twenty of 22 resection margins (91%) in the skin fiducial marker group were within the Bland-Altman plot 95% confidence interval for actual-planned margin mean difference (mean = -0.23 mm; 95% confidence intervals = 2.8 mm, - 3.3 mm). Twenty-one of 22 resection margins (95%) in the K-wire group were within the 95% confidence interval of actual-planned margin mean difference (mean = 0.26 mm; 95% confidence intervals = 1.7 mm, - 1.1 mm). CONCLUSION: Pelvic bone tumor resection with navigational guidance from skin fiducial markers placed over osseous landmarks provided similar accuracy to K-wires inserted into osseous landmarks. Further in vitro studies with different SPBT dimensions/locations and clinical studies will better delineate use efficacy.

A two-year comparison of reverse total shoulder arthroplasty mini-humeral tray and augmented mini-glenoid baseplate implants vs. standard implants.

BACKGROUND: Patients who undergo reverse total shoulder arthroplasty (RTSA) are getting younger with greater function expectations. This retrospective, longitudinal study of prospectively collected data compared perceived shoulder function and strength, active shoulder mobility, radiographic evidence of scapular notching, and implant survival over the initial 2-years post-RTSA among patient groups who received either standard central fixation point liner and glenoid baseplate implants, or lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants. MATERIALS AND METHODS: Patients who underwent primary RTSA using standard central fixation point liner and glenoid baseplate implants (Group 1, n = 180) were compared with patients who underwent primary RTSA using lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants (Group 2, n = 53) for active shoulder mobility, American Shoulder and Elbow Surgeons (ASES) score, perceived ability to lift 10 lbs (4.5 kg) overhead, radiographic evidence of scapular notching, and implant survival. Data was collected pre-surgery, 6-weeks, 6-months, 1-year, and 2-years post-RTSA (p ≤ 0.05). RESULTS: More Group 2 patients had more complex B or C Walch glenoid morphology, while Group 1 had more A1 or A2 types (p ≤ 0.001). Group 2 had greater active shoulder flexion at 6-months, 1-year, and 2-years (p ≤ 0.018) and external rotation (in adduction) at 6-months and 2-years (p ≤ 0.004) compared to Group 1, with higher ASES scores at 6-months and 2-years (p ≤ 0.026) (with small-to-medium effect sizes), and with more patients meeting or exceeding the minimal clinically important difference (MCID) at 2-years (p = 0.045) and patient acceptable symptomatic state (PASS) levels at 6-months, 1-year and 2-years (p ≤ 0.045). Scapular notching was identified in six of 53 (11.3%) Group 2 patients and in 32 of 180 (17.7%) Group 1 patients. Group 1 patients had more grade 2 or greater scapular notching grades compared to Group 2 (p = 0.04). Implant survival was comparable with Group 1 = eight of 180 (4.4%) and Group 2 = 1 of 53 (1.9%) of patients requiring removal for 95.6% and 98.1% implant survival, respectively. CONCLUSION: Limited scapular notching and excellent implant survival was observed in both groups. Despite including individuals with more complex glenoid deficiency, patients receiving the lower size profile implants generally displayed better active shoulder mobility and perceived shoulder function compared to those who received standard implants. These patients also more frequently met or exceeded the MCID by 2-years post-RTSA and PASS levels by 6-months, 1-year, and 2-years post-RTSA, with lower scapular notching grades. LEVEL OF EVIDENCE: Retrospective comparative study.

Global knee function rating more strongly influences adolescent athletes that sustain a sports-related surgical ACL re-injury or contralateral ACL injury.

PURPOSE: This study evaluated differences between adolescent athletes who sustained a surgical anterior cruciate ligament (ACL) re-injury, or contralateral ACL injury following return to sports bridge programme participation (Group 1) compared to those that did not (Group 2). METHODS: At 19.9 ± 7 years of age, 198 athletes participated in this study. Groups were compared for time postsurgery, preprogramme and postprogramme Knee Outcome Survey Sports Activity Scale (KOS-SAS) and global rating of knee function (GRKF) during sports activities, postprogramme lower extremity physical function test performance and perceived sports performance compared to preinjury level. RESULTS: By 6.0 ± 3.2 years postsurgery, 11 (5.6%) sustained another ACL injury. Group 1 was younger (17.3 ± 1.7 years vs. 20.1 ± 6.8 years, p < 0.001). Postprogramme re-evaluation revealed that Group 1 had a greater GRKF compared to their programme initiation GRKF than Group 2 (32.6 ± 38 vs. 20.0 ± 23, p = 0.04). Group 1 also had a greater mean preprogramme to postprogramme GRKF change than Group 2 (51.3 ± 31 vs. 35.5 ± 21, p = 0.02) (effect size = 0.73). More Group 1 subjects also had a GRKF difference that exceeded the overall mean than Group 2 (p = 0.04). Group 1 had moderately strong relationships between preprogramme and postprogramme GRKF score change and the postprogramme GRKF score (r = 0.65, p = 0.04) and between preprogramme and postprogramme KOS-SAS score change and postprogramme GRKF score (r = 0.60, p = 0.04). CONCLUSION: Global rating scores had a stronger influence among adolescent athletes that sustained either surgical ACL re-injury or contralateral ACL injury. Since group physical function and neuromuscular control factors were similar, clinicians need to increase their awareness and understanding of other factors that may influence surgical ACL re-injury or contralateral ACL injury risk. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Mini-augmented glenoid baseplate and mini-humeral tray reverse total shoulder arthroplasty implant comparisons: two-year clinical outcomes.

BACKGROUND: Augmented glenoid baseplate and offset humeral tray reverse total shoulder arthroplasty (RTSA) implants may decrease the mechanical impingement that creates scapular notching and improve shoulder function. This study evaluated the clinical efficacy of three different RTSA glenoid baseplate and offset humeral tray combinations for patient-reported shoulder function, pain and instability, radiographic imaging evidence of glenoid baseplate or humeral stem subsidence and migration, bony changes associated with implant loosening, and scapular notching over the initial 2 years post-RTSA. Primary outcomes included active shoulder mobility, perceived function, pain, instability, scapular notching, and implant survival. METHODS: Sixty-seven patients from 6 research sites received one of three different glenoid baseplate and humeral tray combinations. Group 1 (n = 21) received a mini-augmented glenoid baseplate with a standard humeral tray; Group 2 (n = 23) received a standard glenoid baseplate and a mini-humeral tray with 3 trunnion offset options; Group 3 (n = 23) received both a mini-augmented glenoid baseplate and a mini-humeral tray with 3 trunnion offset options. Subjects underwent radiologic evaluation, completed the ASES scale, the EQ-5D-5L quality of life scale, VAS shoulder pain and instability questions, and active shoulder mobility measurements pre-operatively, and 6-weeks, 6-months, 1-2 years post-RTSA. RESULTS: Improved active shoulder mobility, quality of life, perceived function, decreased shoulder pain and instability, excellent implant survival and minimal scapular notching were observed for all groups. Group 3 had better overall active shoulder mobility than the other groups and better perceived function than Group 1. CONCLUSION: The group that received the mini-augmented glenoid baseplate and mini-humeral tray combination had better overall active shoulder flexion, external rotation at 90° abduction, and internal rotation. This group also had better perceived shoulder function compared to the group that received a mini-augmented glenoid baseplate with a standard humeral tray.

Editorial Commentary: Proper Anterior Cruciate Ligament Graft Choice Mitigates Against the Need for Anterolateral Ligament Reconstruction.

It is not coincidence that fervor surrounding anterolateral ligament (ALL) reconstruction increased as double-bundle anterior cruciate ligament reconstruction (ACLR) enthusiasm cooled. But perhaps we shifted our focus too soon, or perhaps we shifted our focus too much. But we must remember that the ACL is primary. Increases in ACL graft diameter by 1 or 2 mm can significantly increase graft strength and decrease revision rate. Biomechanical and clinical evidence suggests that quadriceps tendon ACLR and patellar tendon ACLR demonstrates less pivot shift phenomena than hamstring ACLR. In addition, As biologically active suture tapes become more mainstream, augmented allografts are an increasingly attractive option. Proper ACL graft choice mitigates against the need for ALL reconstruction. Risk factors for anterolateral rotatory instability may include low body mass index and lateral meniscal pathology, in addition to the well-known risks such as age, gender, activity level, and revision cases. Perhaps lateral extra-articular tenodesis should be reserved for high-risk cases.

Sports activity level after ACL reconstruction is predicted by vastus medialis or vastus medialis obliquus thickness, single leg triple hop distance or 6-m timed hop, and quality of life score.

PURPOSE: Recovery after anterior cruciate ligament reconstruction (ACLR) may take > 2 years, and younger athletes have higher re-injury risk. The purpose of this prospective longitudinal study was to determine how the early to mid-term Tegner Activity Level Scale (TALS) scores of athletically active males ≥ 2 years post-ACLR follow-up was predicted by bilateral isokinetic knee extensor and flexor torque, quadriceps femoris thickness, single leg hop test performance, and self-reported knee function (Knee Injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee (IKDC) Subjective Assessment score). METHODS: After ACLR with a hamstring tendon autograft and safely returning to sports at least twice weekly, 23 men (18.4 ± 3.5 years of age) were evaluated at final follow-up (mean = 4.5, range = 2-7 years). Exploratory forward stepwise multiple regression was used to determine the relationship between independent surgical and non-surgical lower limb variables peak concentric isokinetic knee extensor-flexor torque at 60°/sec and 180°/sec, quadriceps femoris muscle thickness, single leg hop test profile results, KOOS subscale scores, IKDC Subjective Assessment scores, and time post-ACLR on TALS scores at final follow-up. RESULTS: Subject TALS scores were predicted by KOOS quality of life subscale score, surgical limb vastus medialis obliquus (VMO) thickness, and surgical limb single leg triple hop for distance (SLTHD) performance. Subject TALS scores were also predicted by KOOS quality of life subscale score, non-surgical limb vastus medialis (VM) thickness, and non-surgical limb 6 m single leg timed hop (6MSLTH) performance. CONCLUSION: TALS scores were influenced differently by surgical and non-surgical lower extremity factors. At ≥ 2 years post-ACLR, ultrasound VM and VMO thickness measurements, single leg hop tests that challenge knee extensor function, and self-reported quality of life measurements predicted sports activity levels. The SLTHD test may be better than the 6MSLTH for predicting long-term surgical limb function.

Interpositional scaffold anchor rotator cuff footprint tear repair: excellent survival, healing, and early outcomes.

PURPOSE: Shoulder function limitation duration after a full-thickness rotator cuff tendon (RCT) tear may influence post-repair healing and outcomes. A suture anchor was developed to improve footprint repair fixation and healing through biological fluid delivery and scaffold augmentation. The primary multicenter study objective was to evaluate RCT repair failure rate based on 6-month MRI examination, and device survival at 1-year follow-up. The secondary objective was to compare the clinical outcomes of subjects with shorter- and longer-term shoulder function limitation duration. METHODS: Seventy-one subjects (46 men) with moderate-to-large RCT tears (1.5-4 cm), at a median 61 years of age (range = 40-76), participated in this study. Pre-repair RCT tear location/size and 6-month healing status were confirmed by an independent radiologist. Subjects with shorter- (Group 1: 17.8 ± 21 days, n = 37) and longer-term (Group 2: 185.4 ± 89 days, n = 34) shoulder function limitation durations were also compared over 1 year for active mobility, strength, American Shoulder and Elbow Surgeon's Shoulder Score (ASES score), Veterans RAND 12 Item Health Survey (VR-12), and visual analog scale (VAS) pain and instability scores. RESULTS: Three of the 52 subjects [5.8%] who underwent 6-month MRI experienced a re-tear at the original RCT footprint repair site. By the 1-year follow-up, overall anchor survival was 97%. Although Group 2 displayed lower ASES and VR-12 scores pre-repair (ASES = 40.1 ± 17 vs. 47.9 ± 17; VR-12 physical health (PH) = 37.2 ± 9 vs. 41.4 ± 8) (p ≤ 0.048), at 3-month post-RCT repair (ASES = 61.3 ± 19 vs. 71.3 ± 20; VR-12 PH = 40.8 ± 8 vs. 46.8 ± 9) (p ≤ 0.038), and at 6-month post-RCT repair (ASES = 77.4 ± 18 vs. 87.8 ± 13; VR-12 PH = 48.9 ± 11 vs. 54.0 ± 9) (p ≤ 0.045), by 1-year post-RCT repair, groups did not differ (n.s.). Between-groups VR-12 mental health score differences were not evident at any time period (n.s.). Shoulder pain and instability VAS scores also did not differ (n.s.), displaying comparable improvement between groups from pre-RCT repair to 1-year post-RCT repair. Groups had comparable active shoulder mobility and strength recovery at each follow-up (n.s.). CONCLUSION: At 6-month post-RCT repair, only 3/52 of patients [5.8%] had a footprint re-tear, and at 1-year follow-up, overall anchor survival was 97%. Use of this scaffold anchor was associated with excellent early clinical outcomes regardless of shoulder function impairment duration. LEVEL OF EVIDENCE: II.

Liposomal bupivacaine nerve block provides better pain control post-total shoulder arthroplasty than continuous indwelling catheter.

BACKGROUND: Pain control is essential to successful total shoulder arthroplasty (TSA). MATERIALS AND METHODS: This non-blinded, randomized clinical trial compared shoulder pain, narcotic use, interscalene (IS) block application time, and costs in 76 subjects who were randomly assigned to receive either a single injection IS nerve block of 10 cc (133 mg) liposomal bupivacaine mixed with 10 cc of 0.5% bupivacaine (Group 1), or 20 cc of 0.5% ropivacaine direct injection combined with an indwelling IS nerve block catheter delivering 0.2% ropivacaine at a continual 4 cc/h infusion for the initial 3 post-operative days (Group 2). Surgical time, local anesthesia duration, hospital stay length, morphine milligram equivalents (MME) consumed, worst shoulder pain at 24, 48 and 72 h, and complications were recorded. Patient reported function, pain and activity level surveys were completed before, and 6-week post-TSA (P < 0.05). RESULTS: Group 1 had less pain 24-h (0.72 ± 0.8 vs. 3.4 ± 2.9, p < 0.0001) and 48-h (2.5 ± 2.2 vs. 4.8 ± 2.6, p = 0.005) post-TSA. At 24-h post-TSA, MME consumption was similar (Group 1 = 4.5 ± 6.4 vs. Group 2 = 3.7 ± 3.8, p = 0.54), but was lower for Group 1 at 48 h (0.0 ± 0.0 vs. 0.64 ± 0.99, p = 0.001). Group 2 had longer IS block application time (10.00 ± 4.6 min vs. 4.84 ± 2.7 min, p < 0.0001). Only group 2 had a strong relationship between MME consumption over the first 24-h post-TSA and pain 24-h post-TSA (r = 0.76, p < 0.0001), a moderate relationship with pain 48-h post-TSA (r = 0.59, P = 0.001), and a weak relationship with pain 72-h post-TSA (r = 0.44, P = 0.02). Significant relationships for these variables were not observed for Group 1 (r ≤ 0.30, p ≥ 0.23). Group 1 IS block costs were less/patient than Group 2 ($190.17 vs. $357.12 USD). CONCLUSION: A single shot, liposomal bupivacaine interscalene nerve block provided better post-TSA pain control with less narcotic consumption, less time for administration and less healthcare system cost compared to interscalene nerve block using a continuous indwelling catheter. LEVEL OF EVIDENCE: Level I, Prospective, Randomized.

Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL. METHODS: This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups. RESULTS: Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05). CONCLUSION: Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

Early intramedullary nailing of bilateral femur fractures: who might benefit most?

INTRODUCTION: Identifying which patients can receive immediate intramedullary nailing (IMN) after bilateral femoral shaft fracture may improve health-related quality of life outcomes and decrease healthcare costs. This retrospective study evaluated the perioperative factors that guided emergency department transfer of patients to the operating room (OR) where IMN or temporizing external fixation (TEF) was performed, to the intensive care unit (ICU), or to the orthopedic ward. The hypothesis was that patients referred initially to the OR or to the ICU had more serious co-morbidities, complications, or orthopedic polytrauma, increasing the likelihood that they would benefit from "damage control orthopedics" and TEF use. METHODS: A Level I Trauma Center database (2010-2020) review identified the records of 23 patients that met study inclusion and exclusion criteria. Most sustained their injury in a motor vehicle accident (87%) and were not wearing a seatbelt. RESULTS: Patients transferred to the operating room had a greater body mass index and shorter times between admission and surgery. Those transferred to the OR or ICU had higher injury severity scores (ISS), higher arterial blood O2 partial pressure (paO2) values on the first post-surgical day, and had more red blood cell unit (RBCU) transfusions during hospitalization. Patients transferred to the ICU more often underwent TEF and had shorter initial surgical procedure duration. Those with pneumothorax, rib fractures, or with other orthopedic comorbidities were more often transferred to the OR or ICU and those with acute complications requiring exploratory laparotomy were transferred to the OR. CONCLUSIONS: Patients with higher BMI, ISS, greater RBCU transfusion needs, with pneumothorax, rib fractures, or acute complications requiring exploratory laparotomy were more likely to be initially transferred to the OR or ICU. Patients transferred to the orthopedic ward represented a more heterogenous group with greater possibility for benefitting from earlier definitive IMN.

History of Ulnar Collateral Ligament Injury and College Pitcher Fastball Profiles: A Retrospective, Observational, Live Pitching Analysis.

PURPOSE: The aim of this study was to retrospectively compare the fastball profiles of pitchers who had previously sustained grade I or II ulnar collateral ligament (UCL) injuries, were rehabilitated, and released back for competition with those of pitchers with no history of elbow injury. METHODS: Eighteen pitchers from the pitching staff of 1 National Collegiate Athletic Association Division III team participated in this study. Group 1 had a history of grade I or II UCL injury (n = 8), and group 2 (n = 10) did not. A computerized pitch tracking device was used to analyze ball movement and pitching mechanics. The hypothesis was that the pitchers with a history of injury (group 1) would display differing fastball velocity-ball movement relationships compared to those without (group 2). RESULTS: The groups had similar heights, weights, pitching experiences, and arm slot positions at ball release. The pitching coach-determined preinjury arm slot position and the postinjury computerized pitch tracking device measurements after return to competition displayed strong agreement (r = 0.83), suggesting comparable pre and postinjury pitching techniques. The groups had comparable glenohumeral joint range of motion and fastball profiles, except that group 1 released the ball at a 2.5 times lesser horizontal distance away from the pitching rubber center. Group 2 also displayed consistently more robust and more frequent fastball movement relationships with velocity, horizontal break, and vertical break than group 1. CONCLUSIONS: Reduced horizontal ball release distances at comparable vertical ball release heights without changes in the arm slot position suggest that pitchers with a history of grade I or II UCL injury have greater contralateral trunk tilt and elbow flexion at ball release. Increased contralateral trunk tilt may occur to increase pitch velocity at the expense of ball movement while placing the pitching elbow in a potentially injurious position. Computerized fastball profile analysis using a computerized pitch tracking device, in conjunction with coach pitching technique observation, and team medical staff clinical examination may help better identify pitchers with an increased risk of UCL injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Editorial Commentary: Time-Zero Biomechanical Shoulder Instability Studies Are Valuable But Limited Because They Do Not Replicate Clinical Dynamics.

Severe anterior shoulder instability with glenoid bone loss can be very difficult to treat. A recent cadaveric, biomechanical, time-zero study compared the stability of Bankart repair with long head of the biceps brachi transfer versus conjoined tendon transfer in the scenario of 20% anteroinferior glenoid bone loss. The result is long head of the biceps tendon transfer in combination with the Bankart repair provided the best overall condition compared to Bankart repair alone, or with a conjoined tendon transfer. However, a limitation is that this does not confirm that this surgical approach would provide sufficient long-term noncontractile shoulder stability to withstand repetitive soft-tissue loading in a dynamic, clinical situation.

Teaching Disaster Evacuation Management Education to Nursing Students Using Virtual Reality Mobile Game-Based Learning.

The purpose of this study was to explore the effectiveness of a virtual reality mobile game-based application for teaching disaster evacuation management education to nursing students. A pre-test, post-test, and final-test study design was used to compare traditional lecture group and game group instructional knowledge delivery effectiveness and instructional mode satisfaction. The statistical comparison of pre-test and post-test knowledge and decision-making scores did not reveal significant group differences for short-term improvement ( P ≥ .05); however, final test scores revealed that the virtual reality mobile game-based application group had significantly higher knowledge and decision-making retention scores compared with the traditional lecture group ( P = .000). The game group also had significantly higher instructional mode satisfaction scores for course interest and cooperation with others ( P < .05). The virtual reality mobile game-based application was more effective for teaching nursing students about disaster evacuation management educational training than lecture instruction. The greater satisfaction expressed by nursing students when using this instructional mode suggests that it may better facilitate self-initiated lifelong disaster evacuation learning behaviors.

Self-Identity and Adolescent Return to Sports Post-ACL Injury and Rehabilitation: Will Anyone Listen?

Psychological recovery following anterior cruciate ligament (ACL) injury, surgery, and rehabilitation may be influenced by concerns related to self-identity, self-esteem, self-efficacy, health locus of control, fear/avoidance, kinesiophobia, depression, and other emotional or behavioral factors. Through clinical practice guidelines and consensus position articles, knee surgeons, physical therapists, and athletic trainers have greatly improved the process by which physiological musculoskeletal impairment and functional limitation achievement goals translate into evidence-based return to unrestricted sports participation decisions. However, the key psychological indicators or milestones that represent safe return to sports readiness remains poorly understood. The International Classification of Functioning, Disability and Health Model (ICF) provides a helpful framework for generating a more comprehensive decision-making evaluation. The ICF considers patient function as the dynamic interaction between health conditions, environmental factors, and personal factors. Through the use of its common language, the ICF encourages interdisciplinary health care provider communication to more effectively implement team-based, patient-centered care, to better integrate physiological and psychological evaluation and treatment expertise into comprehensive care plans. This article describes the influence of high athletic self-identity on return to sports decision-making among adolescent athletes following ACL injury, surgery, and rehabilitation. Information about adolescence, sports, sports specialization, athletic identity, and more comprehensive return to play decision-making are synthesized into recommendations designed to reduce knee reinjury or new injury risk, and to improve performance among this patient population.

Radial nerve palsy following humeral shaft fracture: a theoretical PNF rehabilitation approach for tendon and nerve transfers.

BACKGROUND: Humerus fracture-induced radial nerve injury can create severe and permanent disabilities. PURPOSE: Surgical management often relies on either tendon or nerve transfer. Regardless of which procedure is selected, physical therapists are challenged to restore functional outcomes without jeopardizing repair healing. Through synergistic, multi planar upper extremity movement patterns, neuromuscular irradiation, or overflow, and neuroplasticity, proprioceptive neuromuscular facilitation (PNF) may improve strength, range of motion and tone. METHODS: After reviewing the literature, a five phase PNF-based treatment approach is proposed with timing differences based on the selected procedure. FINDINGS: Phase I (2 or 4 weeks pre-surgery for tendon or nerve transfer, respectively) consists of comprehensive patient education; Phase II (4-6 or 1-2 weeks post-surgery for tendon or nerve transfer, respectively) explores variable duration peripheral and central nervous system motor learning during isometric activation to enhance central neuroplasticity; Phase III (7-12 or 3-20 weeks post-surgery for tendon or nerve transfer, respectively) incorporates low-intensity motor control including contralateral isotonic upper extremity loading to maximize overflow and neuroplastic effects; Phase IV (13-26 or 21-52 weeks post-surgery for tendon or nerve transfer, respectively) adds high-intensity strength and motor control using ipsilateral isotonic upper extremity loading to maximize overflow and neuroplastic effects. Phase V (27-52 or 53-78 weeks post-surgery for tendon or nerve transfer, respectively) progresses to more activity of daily living, vocational, or sport-specific training with higher intensity strength and motor control tasks. CONCLUSIONS: Through manually guided synergistic, multi planar movement, overflow, and neuroplasticity, a PNF treatment approach may optimize neuromuscular recovery. Validation strategies to confirm clinical treatment efficacy are discussed.

Extended Anterior Approach for Proximal Femur Resection and Hip Reconstruction. Technique Description and Case Report of Three Oncologic Patients.

This retrospective case report describes an extended anterior surgical approach for treating oncologic patients with proximal femur resection and hip reconstruction. Three consecutive women (mean age: 57.3; range: 33 to 81 years) with non-Hodgkins lymphoma (one case) or breast cancer (two cases) that had metastasized to the proximal femur underwent this procedure. Outcome measurements included timed-up-and-go, visual analog scale (VAS) for pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Independent walking distance was also recorded. At a mean of 14 months postoperatively, all three patients had returned to independent flat surface and stair ambulation with minimal hip pain. Normal active hip flexion and extension range of motion were also restored. All patients had ≥ 4/5 involved hip manual muscle test strength. The surgical approach we described enabled effective return to independent flat surface and stair ambulation.

Chance health locus of control beliefs in Hindu Nepali patients following anterior cruciate ligament reconstruction relates to perceived sports knee function and symptoms.

PURPOSE: In western society an internal health locus of control (perception that health outcomes are due to one's own behavior) is related to perceived sports knee function following anterior cruciate ligament reconstruction. This prospective cohort study was performed to determine if similar health beliefs exist among athletically active Hindu patients from Nepal following primary anterior cruciate ligament reconstruction. MATERIALS AND METHODS: Twenty-five consecutive patients (21 men, 4 women) of 26.7 ± 7.7 years of age participated in this study at 4.2 ± 2 months post-surgery. All subjects had undergone primary anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft, with anteromedial portal use for femoral tunnel drilling and interference screw fixation. Subjects completed the Knee Outcome Survey - Sports Activities Scale symptoms and functional limitations during sports subscales and Form C of the Multidimensional Health Locus of Control scales. Descriptive and correlational statistical analysis was performed. An alpha level of p < 0.05 was selected to indicate statistical significance. RESULTS: Knee Outcome Survey - Sports Activity Scale symptoms scores were 71.3 ± 18 (range = 43-97) and functional limitations scores were 42.4 ± 34 (range = 10-95). Multidimensional Health Locus of Control subscale scores were Internal (27.8 ± 4.6), Chance (21.5 ± 6.3), Doctors (16.1 ± 1.9) and other people (14 ± 3.5). Significant relationships were not observed between symptoms or functional limitations subscale scores and Multidimensional Health Locus of Control internal, doctors or powerful others subscale scores. However, strong (r = 0.72) and moderately strong (r = 0.48) relationships were observed between the Multidimensional Health Locus of Control chance subscale score and Knee Outcome Survey - Sports Activities Scale functional limitations and symptoms subscales, respectively. CONCLUSION: Following primary anterior cruciate ligament reconstruction, Hindu patients from Nepal displayed strong relationships between perceived knee function and symptoms and the Multidimensional Health Locus of Control chance subscale. Identification and targeting the beliefs of patients may be clinically important to facilitating positive treatment progression and behavioral changes during post-surgical rehabilitation programs. Further studies are needed to determine how medical and rehabilitation clinicians who provide care to patients from eastern, collectivist cultures can optimize healthcare strategies for patients with sociocultural or religious/spirituality influences that possess strong chance or luck beliefs.Implications for RehabilitationFollowing primary anterior cruciate ligament reconstruction, Hindu patients from Nepal displayed strong relationships between perceived knee function and chance health locus of control beliefs.Identification and targeting the health locus of control beliefs of patients may be clinically important to facilitating positive treatment progression and behavioral changes during post-surgical rehabilitation programs.Medical and rehabilitation professionals need to become more aware of how a patient's religious or spiritual beliefs may conflict with healthcare instructions, or, alternatively, could be better harnessed to facilitate improved program adherence.