Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review.

PURPOSE: To perform a systematic review evaluating clinical outcomes in patients undergoing medial ulnar collateral ligament reconstruction (MUCLR) with soft-tissue allograft. METHODS: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes evaluated were patient-reported outcome scores, return to play (RTP) rates, incidence of postoperative complications, and rates of graft rupture or mechanical failure. RESULTS: The literature search identified 395 articles, and 5 studies met final inclusion criteria after full-text review. A total of 274 patients were analyzed in the included studies and follow-up ranged from 3.0 to 7.6 years. Two studies (number of patients = 141) reported outcomes exclusively of MUCLR with allograft, whereas 3 studies (number of patients = 133) reported outcomes in patients undergoing MUCLR with either allograft or autograft. Allograft sources included gracilis, semitendinosus, plantaris, peroneus longus, and palmaris longus. Level of patient athletic competition ranged from recreational athletes to the professional level; however, nonathletes in the setting of trauma were also included. The RTP rate after MUCLR with soft-tissue allograft was 95.3%, and 89.3% of patients returned to a similar or greater level of play postoperatively. The Timmerman-Andrews score was reported in 2 studies, and the means postoperatively ranged from 94.55 to 97. Postoperative complication rates were low (range, 0% to 20%), and there were no reported incidences of allograft rupture or mechanical failure. CONCLUSIONS: Based on the available data, soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of RTP, and low rates of postoperative complications and graft failure at short-term follow-up. There remains a lack of high-quality evidence directly comparing autograft versus allograft outcomes in elite overhead-throwing athletes to support allograft as an acceptable alternative for MUCLR in this patient population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Cardiometabolic Improvements After Metabolic Surgery and Related Presurgery Factors.

Context: Metabolic surgery remains the most effective and durable treatment for severe obesity and related metabolic diseases. Objective: We examined cardiometabolic improvements after metabolic surgery and associated presurgery demographic and clinical factors in a large multiracial cohort. Methods: Included were 7804 patients (20-79 years) undergoing first-time metabolic surgery at Vanderbilt University Medical Center from 1999 to 2022. Pre- and 1-year postsurgery cardiometabolic profiles were extracted from medical records, including body mass index (BMI), blood pressure, blood lipids, glucose, and hemoglobin A1c. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated per American College of Cardiology/American Heart Association equations. Pre- to postsurgery cardiometabolic profiles were compared by paired t-test, and associated factors were identified by multivariable linear and logistic regression. Results: Among 7804 patients, most were women and White, while 1618 were men and 1271 were Black; median age and BMI were 45 years [interquartile range (IQR): 37-53] and 46.4 kg/m2 (IQR: 42.1-52.4). At 1-year postsurgery, patients showed significant decreases in systolic blood pressure (10.5 [95% confidence interval: 10.1, 10.9] mmHg), total cholesterol (13.5 [10.3, 16.7] mg/dL), glucose (13.6 [12.9, 14.4] mg/dL), hemoglobin A1c (1.13% [1.06, 1.20]), and 10-year ASCVD risk (absolute reduction: 1.58% [1.22, 1.94]; relative reduction: 34.4% [29.4, 39.3]); all P < .0001. Older, male, or Black patients showed less reduction in 10-year ASCVD risk and lower odds of diabetes/hypertension/dyslipidemia remission than younger, female, or White patients. Patients with a history of diabetes, hypertension, dyslipidemia, or cardiovascular disease showed less cardiometabolic improvements than those without. Results were similar with or without further adjusting for weight loss and largely sustained at 2-year postsurgery. Conclusion: Metabolic surgery results in significant cardiometabolic improvements, particularly among younger, female, or White patients and those without comorbidities.

Projected Colorectal Cancer Incidence and Mortality Based on Observed Adherence to Colonoscopy and Sequential Stool-Based Screening.

INTRODUCTION: Modeling supporting recommendations for colonoscopy and stool-based colorectal cancer (CRC) screening tests assumes 100% sequential participant adherence. The impact of observed adherence on the long-term effectiveness of screening is unknown. We evaluated the effectiveness of a program of screening colonoscopy every 10 years vs annual high-sensitivity guaiac-based fecal occult blood testing (HSgFOBT) using observed sequential adherence data. METHODS: The MIcrosimulation SCreening ANalysis (MISCAN) model used observed sequential screening adherence, HSgFOBT positivity, and diagnostic colonoscopy adherence in HSgFOBT-positive individuals from the National Colonoscopy Study (single-screening colonoscopy vs ≥4 HSgFOBT sequential rounds). We compared CRC incidence and mortality over 15 years with no screening or 10 yearly screening colonoscopy vs annual HSgFOBT with 100% and differential observed adherence from the trial. RESULTS: Without screening, simulated incidence and mortality over 15 years were 20.9 (95% probability interval 15.8-26.9) and 6.9 (5.0-9.2) per 1,000 participants, respectively. In the case of 100% adherence, only screening colonoscopy was predicted to result in lower incidence; however, both tests lowered simulated mortality to a similar level (2.1 [1.6-2.9] for screening colonoscopy and 2.5 [1.8-3.4] for HSgFOBT). Observed adherence for screening colonoscopy (83.6%) was higher than observed sequential HSgFOBT adherence (73.1% first round; 49.1% by round 4), resulting in lower simulated incidence and mortality for screening colonoscopy (14.4 [10.8-18.5] and 2.9 [2.1-3.9], respectively) than HSgFOBT (20.8 [15.8-28.1] and 3.9 [2.9-5.4], respectively), despite a 91% adherence to diagnostic colonoscopy with FOBT positivity. The relative risk of CRC mortality for screening colonoscopy vs HSgFOBT was 0.75 (95% probability interval 0.68-0.80). Findings were similar in sensitivity analyses with alternative assumptions for repeat colonoscopy, test performance, risk, age, and projection horizon. DISCUSSION: Where sequential adherence to stool-based screening is suboptimal and colonoscopy is accessible and acceptable-as observed in the national colonoscopy study, microsimulation, comparative effectiveness, screening recommendations.

Pain, function and quality of life are impaired in adults undergoing periacetabular osteotomy (PAO) for hip dysplasia: a systematic review and meta-analysis.

BACKGROUND: Hip dysplasia is a common condition in active adults with hip pain that can lead to joint degeneration. Periacetabular osteotomy (PAO) is a common surgical treatment for hip dysplasia. The effect of this surgery on pain, function and quality of life (QOL) has not been systematically analysed. PURPOSE: In adults with hip dysplasia: (1) evaluate differences in pain, function and QOL in those undergoing PAO and healthy controls; (2) evaluate pre- to post-PAO changes in pain, function and QOL; (3) evaluate differences in pain, function and QOL in those with mild versus severe dysplasia, undergoing PAO; and (4) evaluate differences in pain, function and QOL in those having primary PAO versus those with previous hip arthroscopy. METHODS: A comprehensive, reproducible search strategy was performed on 5 different databases. We included studies that assessed pain, function and QOL in adults undergoing PAO for hip dysplasia, using hip-specific patient reported outcomes measures. RESULTS: From 5017 titles and abstracts screened, 62 studies were included. Meta-analysis showed PAO patients had worse outcomes pre- and post-PAO compared to healthy participants. Specifically, pain (standardised mean difference [SMD] 95% confidence interval [CI]): -4.05; -4.78 to -3.32), function (-2.81; -3.89 to -1.74), and QOL (-4.10; -4.43 to -3.77) were significantly poorer preoperatively.Meta-analysis found patients experienced improvements following PAO. Pain improved from pre-surgery to 1-year (standardised paired difference [SPD] 1.35; 95% CI, 1.02-1.67) and 2 years postoperatively (1.35; 1.16-1.54). For function, the activities of daily living scores at 1 year (1.22; 1.09-1.35) and 2 years (1.06; 0.9-1.22) and QOL at 1 year (1.36; 1.22-1.5) and 2 years (1.3; 1.1-1.5) all improved. No difference was found between patients undergoing PAO with mild versus severe dysplasia. CONCLUSIONS: Before undergoing PAO surgery, adults with hip dysplasia have worse levels of pain, function and QOL compared to healthy participants. These levels improve following PAO, but do not reach the same level as their healthy participants. REGISTRATION: PROSPERO (CRD42020144748).

Medial elbow injuries in the throwing athlete.

There has been an epidemic increase in injuries to the elbow in our youth sports over the past 15 years. Initially, career-ending elbow injuries occurred almost exclusively in the professional population. The landmark procedure developed by Dr. Frank Jobe, colloquially termed "Tommy John surgery" after the initial player in whom he performed the surgical procedure, allowed roughly two-thirds of professional athletes to return to play at or near the same level. As the surgical procedure became more widespread, modifications of the technique by Jobe and many other contributors raised the return-to-play level to 85%-94% of players regaining the ability to return to sport at the preinjury level. Almost simultaneously, the emphasis on velocity in the professional ranks led to an unintentional increase in stress on the throwing elbow. This was magnified in our athletes by the advent of year-round sports, as well as the formation of "showcase" events to demonstrate skills and measure velocity. This, unfortunately, has resulted in an increase in both repetitive stress injuries and acute traumatic injuries in our young athletes. The purpose of this article is to discuss age-related injuries from both a preventative standpoint and a treatment standpoint.

Impact of comorbidities on immediate post-operative complications in oral cavity free flap patients.

PURPOSE: To examine the relationship between comorbidities and the development of immediate post-operative complications in patients undergoing oral cavity composite resection (OCCR) with free flap (FF) reconstruction. MATERIALS AND METHODS: Retrospective analysis was completed on all consecutive OCCRs with FF reconstruction performed at a single quaternary care facility between 1999 and 2020. Comorbidities, immediate post-operative complications, patient demographics, and tumor characteristics were collected. Odds ratios (OR) with 95 % confidence intervals were calculated for associations between comorbidities and immediate post-operative complications. RESULTS: 320 patients who underwent OCCR with FF reconstruction were included. One hundred twenty-one (37.8 %) patients developed a post-operative complication during their initial hospital admission. The most common complications were non-pneumonia cardiopulmonary events (14.1 %), pneumonia (9.4 %), and wound infection (8.4 %). Other complications included flap compromise, bleeding, and fistula. On multivariate analysis, patients without comorbid conditions were less likely to develop a post-operative complication (OR 0.64; 0.41-0.98). Atrial fibrillation (OR 2.94; 1.17-7.39) and cerebrovascular disease (OR 2.28; 1.08-4.84) were associated with increased odds of developing any complications. Furthermore, cerebrovascular disease (OR: 2.33; 1.04-5.39) and peripheral vascular disease (OR: 2.7; 1.2-6.08) were independently associated with pneumonia. CONCLUSION: In this retrospective review of patients undergoing OCCR with FF reconstruction for oral cavity SCC, lack of identifiable comorbidities appeared to be protective for post-operative complications while atrial fibrillation and cerebrovascular disease were associated with increased odds of any complication. Pre-existing vascular disease was also associated with an increased risk of pneumonia.

Football Players With Hip Dysplasia: The Relationship Between Muscle Strength, Functional Performance, Self-reported Sport and Recreation, Cartilage Defects, and Sex. A Cross-sectional Study.

OBJECTIVE: In symptomatic football players with hip dysplasia, we aimed to explore the relationships between self-reported sport and recreation ability and (1) hip muscle strength, (2) functional performance, and investigate if these relationships were modified by sex or cartilage defects. METHODS: In this cross-sectional study, football players (n = 50) with longstanding (>6 months) hip and/or groin pain, a positive flexion/adduction/internal rotation test, and a lateral-center-edge angle <25° were included. Hip muscle strength and functional performance were assessed. Self-reported sport and recreation ability was quantified using the sports and recreational subscales from the International Hip Outcome Tool-33 (iHOT-Sport) and the Copenhagen Hip and Groin Outcome Score (HAGOS-Sport). Relationships were evaluated using regression models with sex and cartilage defects as potential effect modifiers. RESULTS: There was a positive linear relationship between the one-leg-rise test and the iHOT-Sport subscale (ß = 0.61; 95% CI: 0.09, 1.14). A polynomial (concave) relationship was found between peak eccentric adduction strength and the HAGOS-Sport subscale (ß = -30.88; 95% CI: -57.78, -3.99). Cartilage defects modified the relationship between peak isometric adduction strength and HAGOS-Sport, with those with cartilage defects having a polynomial (convex) relationship (ß = 36.59; 95% CI: 12.74, 60.45), and those without cartilage defects having no relationship. CONCLUSION: One-leg-rise performance and adduction strength were associated with self-reported sport and recreation ability, indicating a possible relationship between physical function, hip joint structure, and sport and recreation ability in football players with hip dysplasia. J Orthop Sports Phys Ther 2023;53(10):1-8. Epub: 8 September 2023. doi:10.2519/jospt.2023.12026.

Does hip muscle strength and functional performance differ between football players with and without hip dysplasia?

OBJECTIVE: To compare hip muscle strength and functional performance in football players with and without hip dysplasia and investigate if the relationships were modified by sex. DESIGN: Cross-sectional study. METHODS: This study compared football players with hip dysplasia (HD group) and without hip dysplasia (control group). Hip muscle strength (Nm/kg) and functional task performance were assessed in both groups. Linear regression with generalized estimating equations were used to assess differences between groups. Sex was assessed as a potential effect modifier. RESULTS: 101 football players were included (HD group, n = 50, control group, n = 51). There was no difference in hip muscle strength or functional performance between the HD group and the control group. Results ranged from hip extension strength (Estimate -0.13.95%CI: 0.29 to 0.02, P = 0.087) to hip external rotation strength (Estimate 0.00.95%CI: 0.05 to 0.05, P = 0.918). No relationships were modified by sex or age. CONCLUSIONS: Similar levels of hip muscle strength and functional performance were found in active football players with and without hip dysplasia. These findings differ from other studies. This may be due to our cohort having less advanced hip dysplasia than the surgical populations that have been previously investigated, or due to a beneficial effect of football participation on muscle strength and functional performance in people with hip dysplasia.

Fixation devices for anterior shoulder instability.

PURPOSE: Over the past 40 years, advances in the development of anchors and sutures have contributed to the improvement in surgical outcomes for treatment of shoulder instability. Important choices in surgery when treating instability include the use of knotless versus knotted suture anchors, and bony versus soft tissue reconstruction techniques. METHODS: A literature review was conducted to evaluate the history of instability of the shoulder and the results of specific fixation techniques including bony and soft tissue reconstructions as well as knotted and knotless suture anchors. RESULTS: As knotless suture anchors have continued to grow in popularity since their development in 2001, many studies have compared this newer technique to that of the standard knotted suture anchors. In general, these studies have demonstrated no difference in patient-reported outcome measures between the two options. Additionally, the choice of bony versus soft tissue reconstructions is patient specific as it depends on the specific pathology or combination of injuries. CONCLUSION: In each surgery performed for shoulder instability, it is vitally important that we try to restore normal anatomy. The normal anatomy is best established by knotted mattress sutures. However, loop laxity and tear through by the sutures in the capsule can eliminate this restoration, increasing risk of failure. Knotless anchors may allow better soft tissue fixation of the labrum and capsule to the glenoid, but without complete restoration of normal anatomy.

Randomized Trial of Facilitated Adherence to Screening Colonoscopy vs Sequential Fecal-Based Blood Test.

BACKGROUND & AIMS: Colorectal cancer (CRC) screening guidelines include screening colonoscopy and sequential high-sensitivity fecal occult blood testing (HSgFOBT), with expectation of similar effectiveness based on the assumption of similar high adherence. However, adherence to screening colonoscopy compared with sequential HSgFOBT has not been reported. In this randomized clinical trial, we assessed adherence and pathology findings for a single screening colonoscopy vs sequential and nonsequential HSgFOBTs. METHODS: Participants aged 40-69 years were enrolled at 3 centers representing different clinical settings. Participants were randomized into a single screening colonoscopy arm vs sequential HSgFOBT arm composed of 4-7 rounds. Initial adherence to screening colonoscopy and sequential adherence to HSgFOBT, follow-up colonoscopy for positive HSgFOBT tests, crossover to colonoscopy, and detection of advanced neoplasia or large serrated lesions (ADN-SERs) were measured. RESULTS: There were 3523 participants included in the trial; 1761 and 1762 participants were randomized to the screening colonoscopy and HSgFOBT arms, respectively. Adherence was 1473 (83.6%) for the screening colonoscopy arm vs 1288 (73.1%) for the HSgFOBT arm after 1 round (relative risk [RR], 1.14; 95% CI, 1.10-1.19; P ≤ .001), but only 674 (38.3%) over 4 sequential HSgFOBT rounds (RR, 2.19; 95% CI, 2.05-2.33). Overall adherence to any screening increased to 1558 (88.5%) in the screening colonoscopy arm during the entire study period and 1493 (84.7%) in the HSgFOBT arm (RR, 1.04; 95% CI, 1.02-1.07). Four hundred thirty-six participants (24.7%) crossed over to screening colonoscopy during the first 4 rounds. ADN-SERs were detected in 121 of the 1473 participants (8.2%) in the colonoscopy arm who were adherent to protocol in the first 12 months of the study, whereas detection of ADN-SERs among those who were not sequentially adherent (n = 709) to HSgFOBT was subpar (0.6%) (RR, 14.72; 95% CI, 5.46-39.67) compared with those who were sequentially adherent (3.3%) (n = 647) (RR, 2.52; 95% CI, 1.61-3.98) to HSgFOBT in the first 4 rounds. When including colonoscopies from HSgFOBT patients who were never positive yet crossed over (n = 1483), 5.5% of ADN-SERs were detected (RR, 1.50; 95% CI, 1.15-1.96) in the first 4 rounds. CONCLUSIONS: Observed adherence to sequential rounds of HSgFOBT was suboptimal compared with a single screening colonoscopy. Detection of ADN-SERs was inferior when nonsequential HSgFOBT adherence was compared with sequential adherence. However, the greatest number of ADN-SERs was detected among those who crossed over to colonoscopy and opted to receive a colonoscopy. The effectiveness of an HSgFOBT screening program may be enhanced if crossover to screening colonoscopy is permitted. CLINICALTRIALS: gov, Number: NCT00102011.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit.

Introduction Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Risk of Neurological Decline in Patients With Temporal Lobe Brain Masses.

AIM: The objective of this study was to assess which clinical and radiographic findings may be associated with neurological decline in patients with temporal lobe mass lesions. PATIENTS AND METHODS: This represents a retrospective cohort study. Neurological decline was defined as a decline in Glasgow Coma Scale of 2 or more or new anisocoria. Adult patients aged 18 to 89 years with isolated temporal lobe, intra-axial, contrast-enhancing masses diagnosed between 1/1/2010 and 12/31/2020 were included. Clinical and radiographic findings were collected for each patient. Linear regression analysis was used to identify findings predictive of neurological decline. Patients with neurological decline were compared to stable patients to identify factors that may increase risk for neurological decline. RESULTS: A total of 71 patients met the inclusion criteria. Four out of the 71 patients experienced neurological decline, representing an incidence of 6%. Linear regression analysis identified only radiographic transtentorial herniation as a predictor of neurological decline (ß=0.26, p=0.03). A midline shift greater than 5 mm (100% vs. 40%; odds ratio=1.12, 95% confidence interval=1.00-1.32; p=0.05) and radiographic transtentorial herniation (75% vs. 18%; odds ratio=32.12, 95% confidence interval=3.91-264.18; p=0.03) were significantly more prevalent in patients with neurological decline and were associated with an increased risk of neurological decline. CONCLUSION: Radiographic transtentorial herniation and a midline shift greater than 5 mm may be useful findings to suggest an increased risk of neurological decline in patients with masses of the temporal lobe. This knowledge may be useful to neurosurgeons and physicians in other specialties to best care for this patient population.

How do the top 10 known offending drug classes associated with decreased bone mineral density affect total shoulder arthroplasty outcomes?

BACKGROUND: Many regularly prescribed classes of drugs are known to negatively impact bone health. However, it is unclear if perioperative use of these drugs impacts total shoulder arthroplasty (TSA) outcomes. The purpose of this study was to analyze the impact of perioperative use of 10 drug classes with known negative effects on bone health on prosthesis-related outcomes of TSA. METHODS: Patients who underwent primary TSA were retrospectively identified in the PearlDiver database. Within this population, patients prescribed proton pump inhibitors (PPIs), thiazolidinediones (TZDs), loop diuretics, glucocorticoids, aromatase inhibitors, calcineurin inhibitors, selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs (AEDs), first-generation antipsychotics (FGAs), and second-generation antipsychotics (SGAs) within 6 months before or 6 months after primary TSA were identified (n = 23,748). These patients were propensity score matched 1:1 with controls (n = 23,748) on age, sex, and several comorbidities. After matching, patients with perioperative drug exposure were divided into 10 subgroups (ie, 1 for each drug class). Rates of prosthesis-related complications among patients taking each medication class vs. controls were compared with multivariable logistic regression. RESULTS: Relative to controls, SGA exposure was associated with significantly higher rates of all-cause revision (odds ratio [OR] 1.68) and aseptic revision (OR 1.57). Loop diuretic exposure was associated with significantly higher rates of all-cause revision (OR 1.44) and aseptic revision (OR 1.43). Glucocorticoid exposure was associated with significantly higher rates of all-cause revision (OR 1.32) and aseptic revision (OR 1.30). SSRI exposure was associated with significantly higher rates of all-cause revision (OR 1.27) and aseptic revision (OR 1.24). Periprosthetic fracture, aseptic loosening, and septic revision was comparable for all drug cohorts compared to matched controls (all P > .05). Patients with perioperative exposure to PPIs, TZDs, FGAs, AEDs, aromatase inhibitors, and calcineurin inhibitors displayed comparable rates of all queried complications compared with controls (all P > .05). CONCLUSION: Compared with matched controls, patients with perioperative exposure to SGAs, loop diuretics, glucocorticoids and SSRIs exhibited significantly higher rates of all-cause and aseptic revisions following primary TSA. Several other medications that are risk factors for osteoporosis and fragility fractures did not demonstrate significant associations with any complications, including periprosthetic fracture. These results highlight the need for a thorough review of patients' medical history and current medication usage prior to preoperative risk counseling for patients seeking TSA.

CT pectoralis muscle area is associated with DXA lean mass and correlates with emphysema progression in a tobacco-exposed cohort.

INTRODUCTION: Muscle loss is an important extrapulmonary manifestation of COPD. Dual energy X-ray absorptiometry (DXA) is the method of choice for body composition measurement but is not widely used for muscle mass evaluation. The pectoralis muscle area (PMA) is quantifiable by CT and predicts cross-sectional COPD-related morbidity. There are no studies that compare PMA with DXA measures or that evaluate longitudinal relationships between PMA and lung disease progression. METHODS: Participants from our longitudinal tobacco-exposed cohort had baseline and 6-year chest CT (n=259) and DXA (n=164) data. Emphysema was quantified by CT density histogram parenchymal scoring using the 15th percentile technique. Fat-free mass index (FFMI) and appendicular skeletal mass index (ASMI) were calculated from DXA measurements. Linear regression model relationships were reported using standardised coefficient (ß) with 95% CI. RESULTS: PMA was more strongly associated with DXA measures than with body mass index (BMI) in both cross-sectional (FFMI: ß=0.76 (95% CI 0.65 to 0.86), p<0.001; ASMI: ß=0.76 (95% CI 0.66 to 0.86), p<0.001; BMI: ß=0.36 (95% CI 0.25 to 0.47), p<0.001) and longitudinal (ΔFFMI: ß=0.43 (95% CI 0.28 to 0.57), p<0.001; ΔASMI: ß=0.42 (95% CI 0.27 to 0.57), p<0.001; ΔBMI: ß=0.34 (95% CI 0.22 to 0.46), p<0.001) models. Six-year change in PMA was associated with 6-year change in emphysema (ß=0.39 (95% CI 0.23 to 0.56), p<0.001) but not with 6-year change in airflow obstruction. CONCLUSIONS: PMA is an accessible measure of muscle mass and may serve as a useful clinical surrogate for assessing skeletal muscle loss in smokers. Decreased PMA correlated with emphysema progression but not lung function decline, suggesting a difference in the pathophysiology driving emphysema, airflow obstruction and comorbidity risk.

Periacetabular osteotomy to treat hip dysplasia: a systematic review of harms and benefits.

INTRODUCTION: Periacetabular osteotomy (PAO) is often performed in patients with hip dysplasia. The aim of this systematic review and meta-analysis was to evaluate the harms and benefits of PAO in patients with hip dysplasia in studies reporting both adverse events and patient-reported hip pain and function. MATERIALS AND METHODS: A systematic search combing PAO and patient-reported outcomes was performed in the databases MEDLINE, CINAHL, EMBASE, Sports Discuss and PsychINFO. Studies including both harms and benefits defined as adverse events and patient-reported hip pain and function were included. Risk of bias was assessed using The Cochrane Risk of Bias In Non-Randomized Studies - of Interventions. RESULTS: Twenty-nine cohort studies were included, of which six studies included a comparison group. The majority of studies had serious risk of bias and the certainty of evidence was very low. The proportion of adverse events was 4.3 (95% CI 3.7; 4.9) for major adverse events and 14.0 (95% CI 13.0; 15.1) for minor adverse events. Peroneal nerve dysfunction was the most frequent adverse event among the major adverse events, followed by acetabular necrosis and delayed union or non-union. All patient-reported hip pain and function scores improved and exceeded the minimal clinically important differences after PAO. After 5 years, scores were still higher than the preoperative scores. CONCLUSION: PAO surgery has a 4% risk of major, and 14% risk of minor adverse events and a positive effect on patient-reported hip pain and function among patients with hip dysplasia.

Does pre-arthroplasty antiviral treatment for hepatitis C reduce complication rates after total shoulder arthroplasty? A matched cohort study.

Background: Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA). Methods: A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients. Results: Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P > .05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36). Conclusions: HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications.

Physical impairments in Adults with Developmental Dysplasia of the Hip (DDH) undergoing Periacetabular osteotomy (PAO): A Systematic Review and Meta-Analysis.

Background: Developmental dysplasia of the hip (DDH) is a condition associated with hip pain and impairments. Periacetabular osteotomy (PAO) is a common surgical treatment for DDH. Outcomes following PAO have historically been based on radiology or patient reported outcomes, and not physical impairments. Objective: To investigate differences in physical impairments in adults with DDH undergoing PAO compared with asymptomatic participants, and to investigate pre- to post-PAO changes in physical impairments. Design: Systematic review with meta-analysis. Methods: A literature search was performed in five databases (MEDLINE, CINAHL, EMBASE, Sports Discuss, and PsychINFO), using the PRISMA checklist. Studies were considered eligible if patients were aged 15 years and older, treated with PAO for DDH and if they included a physical impairment outcome measure. Two independent reviewers performed data extraction and assessed methodological quality, using a modified version of the Downs and Black checklist. Results: Of 5,017 studies, 24 studies were included with 2190 patients. The methodological quality scores ranged from 39% to 88%. With low level of evidence, meta-analysis showed 58% of patients had a positive anterior impingement test (95%CI: 39-76%), prior to PAO and one to three years after PAO. Five years after PAO, the proportion fell to 17% (95%CI: 11-24%). Prior to PAO, patients with DDH walked with a lower peak hip extension angle, compared to asymptomatic participants (SMD 0.65 (95%CI 0.21-1.10). Best evidence synthesis of non-pooled data showed limited evidence of increased walking velocity, stride length and improved hip flexion and extension moment 18-months post-PAO compared to pre-op. Cadence, hip abduction and hip flexion strength did not change. Conclusion: Most patients with DDH have a positive hip impingement test, pre-PAO. Compared to asymptomatic participants, patients with DDH demonstrate physical impairments during walking which appear to improve after surgery. Hip abduction and flexion strength did not change pre- to post-PAO. Level of Evidence: 1b.

Uncovering Ankylosing Spondylitis from a Diagnosis of Parsonage-Turner Syndrome: A Case Report of Bilateral Shoulder Pain and Weakness.

Introduction: Parsonage-Turner syndrome is a rare condition that is often misdiagnosed by physicians due to the overlapping symptoms with other conditions such as rotator cuff injury and cervical radiculopathy. The etiology of the Parsonage-Turner syndrome is unknown, but has been associated with an immune-mediated response to rheumatic disease, infection, surgery, and immunizations. Case Presentation: A 18-year-old female former tennis player with a history of complex regional pain syndrome (CRPS), Ehler-Danlos syndrome (EDS), and two prior right shoulder surgeries presented to the orthopaedic clinic with bilateral shoulder pain. After a third surgery on the right shoulder, the patient later developed constant burning and sharp pain around the right shoulder that radiated toward the chest. She also experienced numbness, tingling, and weakness in the right shoulder along with pain and weakness in the left shoulder. The patient was tender over the right musculocutaneous nerve and both shoulders were inflamed on ultrasound. Electromyography (EMG) and nerve conduction studies were performed, which were consistent with a bilateral subacute on chronic brachial plexopathy, suggestive of Parsonage-Turner syndrome. Rheumatology was consulted due to an extensive family history of autoimmune diseases, leading to an additional diagnosis of ankylosing spondylitis. The patient's bilateral shoulder pain slowly improved over the following year with physical therapy and prolotherapy treatments. Conclusion: The case described, herein, represents a unique patient who presents with the rare conditions of ankylosing spondylitis, CRPS, EDS, and Parsonage-Turner syndrome. EMG was critical to differentiate Parsonage-Turner syndrome from the overlapping CRPS symptoms and without this, the diagnosis of ankylosing spondylitis may have been delayed. It is imperative physicians take a thorough history, include uncommon or rare conditions as a potential diagnosis, and undergo thorough testing while evaluating a patient to avoid unnecessary treatment therapies and patient dissatisfaction.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial.

OBJECTIVE: The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery. METHODS: In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression. RESULTS: Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted. CONCLUSIONS: Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning. IMPACT: This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.