The Relationship Between Fear Avoidance Beliefs, Muscle Strength, and Short-Term Disability After Surgical Repair of Shoulder Instability.

CONTEXT: Arthroscopic surgical repair of the shoulder is recommended when conservative treatment for shoulder instability (SI) fails. However, many patients undergoing this procedure do not return to same level of activity. Psychological factors and muscle strength have been shown to be associated with postoperative outcomes in other musculoskeletal conditions. OBJECTIVE: To investigate the association between fear avoidance, muscle strength, and short-term function in patients after surgical SI repair. METHODS: Twenty-five male patients who underwent shoulder surgery following at least one event of SI were included in this study. Evaluations of fear avoidance related to physical activity and disability were performed at baseline (during the first encounter with the physical therapist) and 7 to 8 weeks postsurgery. Fear avoidance beliefs were assessed using the Fear Avoidance Beliefs Questionnaire. Disability was assessed using the Disabilities of Arm, Shoulder, and Hand questionnaire and the Western Ontario SI index. The follow-up evaluation (weeks 7-8) included measurement of maximal isometric strength of the internal and external rotators. Nonparametric Kendall tau was used to determine the correlations between baseline fear avoidance, muscle strength, and disability at follow-up. RESULTS: Disabilities of Arm, Shoulder, and Hand questionnaire at follow-up was significantly correlated with baseline Disabilities of Arm, Shoulder, and Hand questionnaire (τ = .520, P < .001), baseline fear avoidance (τ = .399, P = .008), and both internal rotator (τ = -.400, P = .005) and external rotator strength (τ = -.353, P = .014). Western Ontario SI index at follow-up was moderately correlated with baseline Western Ontario SI index (τ = .387, P = .007), internal rotator (τ = -.427, P = .003), and external rotator (τ = -.307, P = .032), but not with baseline Fear Avoidance Beliefs Questionnaire (τ = .22, P = .145). CONCLUSIONS: The results indicate a possible association between fear avoidance beliefs and short-term disability. Further studies are warranted to better explore and understand these relationships.

Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability.

PURPOSE: The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors. METHODS: Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores. RESULTS: Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship. CONCLUSION: This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.

Knee arthrodesis for a congenital luxation with Larsen syndrome.

A 31-year-old woman with known Larsen syndrome presented with congenital chronic luxation of her right knee with increasing instability symptoms, which limited her daily activities. We refrained from a constrained knee arthroplasty due to her relatively young age and decided to perform a knee arthrodesis. Knee arthrodesis is a viable lifelong-lasting operative treatment alternative for specific instability-related knee disease. The knee arthrodesis was performed by double plating with an additional fixation of the patella. At 1-yearfollow-up, she was able to walk without limitations and did not experience any pain with complete consolidation of the arthrodesis. At 2-year follow-up, she performed all her daily activities without limitations. Both the Knee injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee subjective knee form (IKDC) improved at 2-year follow-up (KOOS: 61.3; IKDC: 56.3) compared with 1-year follow-up (KOOS: 52; IKDC: 40.2).

A systematic review of patient-reported outcome measures used in shoulder instability research.

BACKGROUND: Shoulder instability is extremely common, with various outcome scores used to assess its progression after treatment. This review was performed to identify the scores most commonly used and to evaluate them according to the 4 core domains of shoulder trials (according to the Core Outcome Measures in Effectiveness Trials [COMET] initiative) and their respective psychometric qualities. METHODS: A systematic review of the literature of 3 databases (MEDLINE, Embase, PubMed) was undertaken. Studies were identified using eligibility criteria and critically appraised by 2 authors. Data were extracted using an a priori template. Outcome scores were identified and assessed regarding COMET domain inclusion and their psychometric properties. RESULTS: The most frequently used scores were the Rowe (58%), Constant (33%), Western Ontario Shoulder Instability Index (WOSI; 24%), and American Shoulder and Elbow Surgeons (23%) scores. The majority of outcome scores assessed pain and all assessed physical functioning. Quality of life and a global assessment of treatment success were rarely incorporated. No single outcome score considered all core COMET domains. The WOSI was the most acceptable measure of those assessed with respect to its validity, reliability, and responsiveness. CONCLUSIONS: The WOSI incorporated 3 of the 4 core domains for shoulder trials (pain, physical functioning, and health-related quality of life). It had the most psychometric testing of the identified scores, confirming its reliability, validity, and responsiveness in the setting of shoulder instability. We recommend its use in this setting; however, it should be supplemented with additional outcome scores, such as the University of California-Los Angeles score, to cover all of the core COMET domains.

Decreased perceived ankle and knee joint health in individuals with perceived chronic ankle instability.

PURPOSE: Abnormal movement patterns and neuromuscular impairments at the ankle are thought to contribute to ankle joint degeneration in those with chronic ankle instability. However, these impairments are not confided to the ankle; rather, proximal neuromuscular deficiencies at the knee and aberrant movement patterns, thought to be responsible for reductions in knee joint health, have also been identified. While neuromuscular impairments and self-reported functional limitations have been examined in those with chronic ankle instability, patient-generated symptoms associated with joint health of the ankle and knee have not been investigated. Therefore, the purpose was to compare perceived ankle and knee joint health in individuals with and without chronic ankle instability. METHODS: The Ankle Osteoarthritis Scale and the Knee Injury and Osteoarthritis Outcome Score assessed region-specific ankle and knee joint health. RESULTS: Participants with chronic ankle instability reported more ankle pain (P < 0.001) and disability (P < 0.001) than the control group. Chronic ankle instability individuals also reported worse knee joint health (P < 0.05). CONCLUSIONS: The increased symptomology associated with decreased ankle joint health further supports information demonstrating joint degeneration in young adults with chronic ankle instability. The decreased perceived knee joint health provides preliminary evidence of the negative impact proximal neuromuscular impairments associated with chronic ankle instability that may have on joints other than the ankle. Assessing subjective ankle and knee joint function can guide clinicians in developing individualized rehabilitation by providing them with an understanding if a patient presenting with chronic ankle instability suffers from symptoms arising from more than just the ankle. LEVEL OF EVIDENCE: Case-control, Level III.

Prevalence of Clinical Depression Among Patients After Shoulder Stabilization: A Prospective Study.

BACKGROUND: Depression is a potential risk factor for poor postoperative outcomes. This study aimed to identify the prevalence of clinical depression symptoms before and after shoulder stabilization, as well as the relationship between depression and functional outcomes. METHODS: Patients undergoing arthroscopic primary glenohumeral stabilization for recurrent instability were eligible for enrollment. Participants completed the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) and the Western Ontario Shoulder Instability Index (WOSI) questionnaire preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patients with a preoperative QIDS-SR score of ≥6 were assigned to the clinical depression group. RESULTS: Seventy-six patients were enrolled and were prospectively followed during this study. Thirty-nine patients were stratified into the clinical depression group. Preoperatively, the clinical depression cohort had worse WOSI scores than the cohort without clinical depression (mean difference, 8.3% [95% confidence interval (CI), 0.5% to 16.1%]; p = 0.04). Both the clinical depression cohort and the cohort without clinical depression displayed an improvement in WOSI scores at 1 year postoperatively (p < 0.01 for both cohorts). Both the clinical depression cohort and the cohort without clinical depression displayed an improvement in QIDS-SR scores at 1 year postoperatively (p < 0.01 for both cohorts). At 1 year postoperatively, the clinical depression cohort continued to have worse WOSI scores than the cohort without clinical depression (mean difference, 12.2% [95% CI, 5.9% to 18.5%]; p < 0.01) and worse QIDS-SR scores; the median QIDS-SR score was 5.0 points (interquartile range [IQR], 2.0 to 8.0 points) for the clinical depression group and 0.0 points (IQR, 0.0 to 3.0 points) for the group without clinical depression (p < 0.01). The postoperative prevalence of clinical depression (24%) was lower than the preoperative prevalence (51%) (p < 0.01). Increasing patient age was associated with preoperative depression symptoms (odds ratio, 3.1; p = 0.03). CONCLUSIONS: Fifty-one percent of patients with shoulder instability reported depression symptoms before the surgical procedure. Surgical intervention improved shoulder function and depression symptoms over time; however, the clinical depression cohort had worse postoperative shoulder and depression outcomes. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Translation and validation of a Hebrew version of the Western Ontario Shoulder Instability index.

BACKGROUND: The Western Ontario Shoulder Instability index (WOSI) is a questionnaire designed to measure health-related quality of life in patients with shoulder instability. The aim of the current study was to translate the WOSI into Hebrew and assess its psychometric properties. METHODS: The WOSI was translated into Hebrew according to World Health Organization guidelines. Twenty-five patients completed the WOSI and the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire 2 weeks and 2 months after surgical shoulder stabilization. Internal consistency (Cronbach's α), criterion validity (Pearson's correlation coefficient with DASH), responsiveness, and floor and ceiling effects were assessed. RESULTS: Cronbach's α was 0.88-0.95 for total WOSI (range 0.68-0.95 for different sections). Strong correlation with DASH score (r = 0.76-0.84) indicated good criterion validity. Changes between baseline and follow-up for WOSI and DASH scores were moderately correlated (r = 0.68), suggesting moderate responsiveness. Some items demonstrated floor and ceiling effects, especially at baseline, but no floor or ceiling effects were observed for total WOSI or for the WOSI sections. CONCLUSIONS: The results of the current study demonstrate that the Hebrew version of the WOSI is a valid instrument that can be used to assess disability in patients with shoulder instability. Additional studies are warranted to assess its psychometric properties among various subpopulations. TRIAL REGISTRATION: The study was pre-registered at the ClinicalTrials.gov website, registration number NCT02978365 .

A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift.

Lateral ankle sprains are the most common injuries sustained during physical activity. The epidemiologic trends associated with chronic ankle instability (CAI) suggest that current rehabilitation approaches may be inadequate. We sought to synthesize best-practices evidence for the rehabilitation of patients with acute ankle sprains and CAI through the integration of emerging paradigms in perception, the dynamics of skill acquisition, and the biopsychosocial model of function, disability, and health. From the best available evidence, 4 key factors emerged for effective treatment and rehabilitation strategies: pain reduction, external ankle support for up to 1 year, progressive return to motion, and coordination training. We combined these factors into a meta-theoretical framework that centers on the perceptual interdependence of the cellular, local, and global functioning levels by linking insights from the body-self neuromatrix, the dynamics of skill acquisition, and the biopsychosocial model. Based on the best-practice recommendations from systematic reviews, ankle-sprain rehabilitation represents a multidimensional phenomenon governed by perception. The impairments, activity limitations, and participation restrictions associated with CAI may be linked to perceptual-interdependence alterations. Pain and edema reduction, the use of external ankle support for up to 1 year, progressive return to motion, and coordination training foster enhanced perceptual interdependence from cells to society. Using the perceptual-interdependence framework for ankle-sprain rehabilitation, we offer new insights for charting the course of effective strategies for enhancing function, reducing disability, and preventing the long-term sequelae associated with CAI.

Intraoperative medial joint laxity in flexion decreases patient satisfaction after total knee arthroplasty.

INTRODUCTION: The relationship between postoperative tibiofemoral ligament balance and patient satisfaction in total knee arthroplasty (TKA) has been explored previously. However, the optimal intraoperative medial-lateral ligament balance during knee flexion in terms of postoperative patient satisfaction remains unknown. We evaluated the effect of intraoperative flexion instability on patient satisfaction after TKA. MATERIALS AND METHODS: This study consisted of 46 knees with varus osteoarthritis undergoing TKA. Medial-lateral component gaps at 0° knee extension and 90° flexion were measured intraoperatively using a knee balancer. Differences in postoperative patient outcomes at 3 weeks and 1 year were compared between medially tight knees in 90° flexion with a medial component gap of < 4 mm and medially loose knees in 90° flexion with a gap of ≥ 4 mm. Outcomes were measured using the 2011 Knee Society Scoring System (2011 KS). RESULTS: The median total 2011 KS score at 1 year postoperatively in the medially loose knees [median 97; interquartile range (IQR) 75-117] was significantly lower than that in the medially tight knees (median 128; IQR 104-139, P < 0.01), while preoperative and 3-week postoperative scores were similar. In addition, medial flexion gaps were not significantly associated with total 2011 KS scores before surgery or at 3 weeks postoperatively. However, at 1 year after surgery, medial component flexion gaps were negatively associated with the total 2011 KS score (R = - 0.42; P < 0.01) and the 2011 KS satisfaction subscale score (R = - 0.36; P = 0.01). CONCLUSIONS: Excessive intraoperative medial joint laxity of ≥ 4 mm at 90° flexion progressively decreased patient satisfaction for 1 year. Since intraoperative medial laxity in flexion is likely to interfere with functional recovery after TKA, medial stabilization during TKA is important throughout knee flexion. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Self-reported knee instability associated with pain, activity limitations, and poorer quality of life before and 1 year after total knee arthroplasty in patients with knee osteoarthritis.

Information on the association of self-reported knee instability with clinical outcomes after Total Knee Arthroplasty (TKA) and 1 year follow-up is scarce. The aims were to determine (i) the course and prevalence of self-reported knee instability before and 1 year after TKA and (ii) the associations of preoperative, postoperative, and retained self-reported knee instability with pain, activity limitations, and quality of life (QoL) in patients with knee osteoarthritis. Patients undergoing primary TKA, selected from the Longitudinal Leiden Orthopaedics and Outcomes of OsteoArthritis Study, had their knee instability measured using a questionnaire. The Knee injury and Osteoarthritis Outcome Score pain, activity limitations, and QoL subscales were administered before and 1 year after surgery. Multivariable regression analyses were performed to examine associations between knee instability, pain, activity limitations, and QoL, adjusted for covariates (age, gender, comorbidities, and radiographic severity). Of the 908 included patients, 649 (71%) and 187 (21%) reported knee instability before and following TKA, respectively. Of the patients with preoperative knee instability, this perception was retained in 165 (25%) cases. Knee instability was preoperatively associated with pain (B -9.6; 95%CI: -12.4 to -6.7), activity limitations (B -7.5; 95%CI: -10.2 to -4.8), and QoL (B -4.7; 95%CI: -7.0 to -2.4) and postoperatively with pain (B -15.0; 95%CI: -18.5 to -11.6), activity limitations (B -15.1; 95%CI: -18.4 to -11.8), and QoL (B -18.7; 95%CI: -22.3 to -15.3). Retained knee instability was associated with postoperative pain (B -15.1; 95%CI: -18.9 to -11.2), activity limitations (B -14.1; 95%CI: -17.8 to -10.4), and QoL (B -18.0; 95%CI: -21.7 to -14.3). In conclusion, in clinical care, self-reported knee instability is retained postoperatively in 25% of the patients. Retained knee instability is associated with more pain, activity limitations, and poorer QoL postoperatively. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2671-2678, 2018.

Low- and high-anxious hypermobile Ehlers-Danlos syndrome patients: comparison of psychosocial and health variables.

Despite the frequent co-ocurrence of hypermobile Ehler-Danlos syndrome (hEDS) and pathological anxiety, little is known about the psychosocial and health implications of such comorbidity. Our aim was to explore the association between high levels of anxiety and psychosocial (catastrophizing, kinesiophobia, somatosensory amplification, social support and functioning), health (pain, fatigue, BMI, tobacco/alcohol use, depression, diagnosis delay, general health), and sociodemographic factors in people with hEDS. In this cross-sectional study, 80 hEDS patients were divided into two groups according to self-reported anxiety levels: low and high. Psychosocial, sociodemographic and health variables were compared between the groups. Forty-one participants reported a high level of anxiety (51.2%). No differences were found in the sociodemographic variables between high-anxious and low-anxious patients. The percentage of participants with severe fatigue and high depressive symptomatology was significantly higher in the high-anxious group (80.5 vs 56.4; 26.8 vs 12.8%, respectively). High-anxious hEDS patients also showed significantly higher levels of pain catastrophizing, somatosensory amplification as well as a poorer social functioning and general health. Multivariate analyses showed that somatosensory amplification, pain catastrophizing and poor social functioning are variables that increase the probability of belonging to the high-anxious group. Despite limitations, this first study comparing high-anxious versus low-anxious hEDS patients with respect to health aspects, highlight the importance of considering the psychosocial factors (many susceptible to modification), to improve the adjustment to this chronic condition and provide support to those affected through a biopsychosocial approach.

Assessing the effects of slippery steel beam coatings to ironworkers' gait stability.

Since ironworkers walk and perform their tasks on steel beams, identifying the effects of slippery steel beam surfaces on ironworkers' gait stability-which can be related to safety risk-is critical. However, there is no accepted or validated standard for measuring the slipperiness of coated steel beams, which makes evaluating and controlling for slipperiness a challenge. In this context, this study investigated the effect of the slipperiness of steel beam coatings on ironworkers' gait stability. Accordingly, to identify the relationships between coefficient of friction, perceived slipperiness, and gait stability-represented as the Maximum Lyaponuv exponent (Max LE)-an experiment was conducted with eight different surfaces and sixteen subjects with varying experience as ironworkers. The experiment's results indicate that the slipperiness of the various surfaces greatly affect ironworkers' gait stability while they walk on coated steel beam surfaces. In detail, the Max LE of two subject groups-experienced and inexperienced ironworkers-highly correlated with both the dynamic coefficient of friction values measured by following ANSI B101.3 and with the subjective rating scores of the inexperienced subject group. Unlike subjective rating scores-which were particularly incongruent among experienced workers-the Max LE of inexperienced and experienced subjects has a consistent pattern. This study result highlights an opportunity for using gait stability measurements to quantify and differentiate the safety risks caused by slippery coated steel beams in the future.

Patients' expectations of shoulder instability repair.

PURPOSE: To analyze and compare patient expectations of primary and revision shoulder stabilization and to assess the factors associated with patients' expectations. METHODS: Pre-operative patient expectations after shoulder instability repair were prospectively assessed using a self-designed questionnaire. The survey included questions on the expected level and type of return to sports, instability, pain, risk of osteoarthritis, and overall shoulder condition. RESULTS: One-hundred and forty-five patients (99 primary; 46 revision repair) were included. A return to sport at the same level with slight to no restrictions was expected in 95%, a return to high-risk activities in 34%, to moderate in 58%, and to low-risk activities in 9%. No pain [instability] independent of the activity level was expected by 71% [79%] and occasional pain [instability] during contact and overhead activities by 25% [19%]. 61% expected to have no risk of glenohumeral osteoarthritis, 37% a slight, and 2% a significant risk. The overall expectation for the post-operative shoulder was indicated to be normal or nearly normal in 99% of patients. The revision group did not differ from the primary repair group in any variable. High pre-operative sport performance was positively correlated with post-operative sport expectations. The number of dislocations, the duration of instability, and the subjective instability level were negatively correlated with return to sport expectations. CONCLUSION: Patient expectations for primary and revision shoulder instability repair are high. Realistic patient expectations regarding the surgical procedure are necessary to avoid low patient satisfaction, especially in pre-operatively highly active and demanding athletes. The surgeon must not solely base the treatment on the pathology and possible risk factors for failure but should also take the individual expectation of the patient into account. LEVEL OF EVIDENCE: III.

The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability.

PURPOSE: The main goal of this study was to propose and validate a tool to quantify the psychological readiness of athletes to return to sport following traumatic shoulder instability and conservative or surgical management. METHODS: «Knee¼ was replaced by the term «shoulder¼ in the Anterior Cruciate Ligament-Return to Sport after Injury scale. This pilot test of the Shoulder Instability-Return to Sport after Injury scale (SIRSI) was performed in a group of athletes who underwent surgery for post-traumatic chronic anterior shoulder instability. The final version was then validated according to the international COSMIN methodology. A retrospective study was performed including all rugby players who had reported an episode of instability between 2012 and 2013. The WOSI and the Walch-Duplay scales were used as reference questionnaires. RESULTS: Sixty-two patients were included, mean age 26 ± 5.2 years old, 5 women/57 men. Patients were professional or competitive athletes (70.9%) and followed-up for 4.6 ± 1.6 years after the first episode of shoulder instability. Shoulder surgery was performed in 30/62 (48.4%) patients, a mean 1.6 ± 1.2 years after the first episode of instability. The SIRSI was strongly correlated with the reference questionnaires (r = 0.80, p < 10-5). The mean SIRSI score was significantly higher in patients who returned to play rugby (60.9 ± 26.6% vs 38.1 ± 25.6%, p = 0.001). The internal consistency of the scale was high (α = 0.96). Reproducibility of the test-retest was excellent (ρ = 0.93, 95% CI [0.89-0.96], p < 10-5). No ceiling/floor effects were found. CONCLUSION: The SIRSI is a valid, reproducible scale that identifies patients who are ready to return to the same sport after an episode of shoulder instability, whether they undergo surgery or not. LEVEL OF EVIDENCE: III.

The combination of tibial anterior translation and axial rotation into a single biomechanical factor improves the prediction of patient satisfaction over each factor alone in patients with ACL reconstructed knees.

PURPOSE: The purpose of this study was to identify biomechanical factors, in both reconstructed and healthy knees, that correlate with patient satisfaction after ACL reconstruction. METHODS: Seventeen patients who had undergone unilateral ACL reconstruction were reviewed 9 years post-op. Patients completed subjective questionnaires and underwent manual knee laxity testing (Lachman-Trillat, KT-1000, and pivot shift) and automated laxity testing. During automated testing, both legs were rotated into external rotation and then internal rotation until peak rotational torque reached 5.65 Nm. Load-deformation curves were generated from torque and rotation data. Features of the curves were extracted for analysis. Total leg rotation and anterior laxity during KT-1000 testing were combined into a single factor (Joint Play Envelope or JPE). Patients were divided into groups based on patient satisfaction scores (Group 1: Higher Satisfaction, Group 2: Lower Satisfaction, Group 3: Unsatisfied). Load-deformation curve features and manual laxity testing results were compared between groups 1 and 2 to determine which biomechanical factors could distinguish between the groups. Diagnostic screening values were calculated for KT-1000 testing, the pivot shift test, total leg rotation and JPE. RESULTS: During manual testing, no significant differences in biomechanical factors were found when comparing reconstructed knees in group 1 and group 2. When comparing the reconstructed and healthy knees within group 2, the reconstructed knees had a significantly higher displacement during the KT-1000 manual maximum test (p < 0.002). When considering the reconstructed knees alone, neither the result of the pivot shift test nor KT-1000 testing could distinguish between group 1 and group 2. During automated testing, there were no significant differences between the groups when comparing the reconstructed lower limbs. The healthy lower limbs in group 2 had more maximum external rotation (p < 0.02) and decreased stiffness at maximum external rotation (p < 0.02) when compared to the healthy lower limbs in group 1. Total leg rotation was unable to distinguish between group 1 and group 2. JPE could distinguish between group 1 and group 2 when considering the reconstructed limb alone (p < 0.02). All four diagnostic screening values for JPE were equal or higher than in the other criteria. JPE also showed the most significant correlation with patient satisfaction. CONCLUSIONS: Joint Play Envelope is an objective measure that demonstrated improved predictive value as compared to other tests when used as a measure of satisfaction in patients with ACL reconstructed knees.

Idiopathic Musculoskeletal Pain in Indian children-Prevalence and Impact on Daily Routine / Prevalência e impacto nas atividades diárias da dor musculoesquelética idiopática em crianças da Índia

ABSTRACT Objectives: To study the prevalence of idiopathic musculoskeletal pain (IMSP) in school going children and its impact on daily life. Methods: One thousand eighteen apparently healthy school children aged 5–16 years were assessed and analysed for IMSP and its associated problems. Standard tests for significance were applied. Results: One hundred and sixty-five (16.2%) children mostly males (55.2%) reported IMSP. Lower limbs (52.1%) were the most common location of pain. More than 1 year of pain history was present in 15%. Thirty-seven percent children complained of discomfort during walking, 30.9%, had pain during physical exercise, 29.2% had difficulty attending lessons and 4.2% had interference in pursuing hobbies. The children were also further sub grouped into preadolescents and adolescents. There was significant difference in pain duration and duration of each pain episode in the two groups (p = 0.01). A significant number of children (21.2%) with IMSP reported school absenteeism (p < 0.001). A significant number of adolescents had history positive for contact sports (p = 0.001). Sleep disturbances were also reported to be higher in children with IMSP (29% vs. 5.7%, p = 0.001). Other associated problems in children with IMSP found were day time tiredness (51.1%), headache (47.3%) and abdominal pain (24.8%). Conclusions: Prevalence of IMSP in school children aged 5–16 yrs was found to be 16.2% and a significant percentage of these children experience interference with daily activities including school absenteeism.

RESUMO Objetivos: Estudar a prevalência de dor musculoesquelética idiopática (DMEI) em crianças em idade escolar e seu impacto nas atividades diárias. Métodos: Foram avaliadas e analisadas 1.018 crianças em idade escolar aparentemente saudáveis entre cinco e 16 anos quanto à presença de DMEI e seus problemas associados. Foram aplicados os testes de significância padrão. Resultados: Relataram DMEI 165 (16,2%) crianças, em sua maior parte do sexo masculino (55,2%). Os membros inferiores (52,1%) foram a localização mais comum da dor. A história de dor presente havia mais de um ano foi encontrada em 15% das crianças; 37% delas queixaram-se de desconforto durante a caminhada, 30,9%, tinham dor durante o exercício físico, 29,2% tinham dificuldade de frequentar as aulas e 4,2% sofriam interferência na participação em passatempos. As crianças foram ainda subagrupadas em pré-adolescentes e adolescentes. Houve diferença estatisticamente significativa na duração da dor e na duração de cada episódio de dor nos dois grupos (p = 0,01). Uma quantidade significativa de crianças com DMEI (21,2%) relatou absentismo escolar (p < 0,001). Uma quantidade significativa de adolescentes tinha história positiva de prática de esportes de contato (p = 0,001). Os distúrbios do sono também foram relatados como maiores em crianças com DMEI (29% vs. 5,7%, p = 0,001). Outros problemas associados encontrados em crianças com DMEI foram o cansaço durante o dia (51,1%), a cefaleia (47,3%) e a dor abdominal (24,8%). Conclusões: A prevalência de DMEI encontrada em crianças entre cinco e 16 anos foi de 16,2%. Uma percentagem significativa dessas crianças relata interferência nas atividades diárias, incluindo absentismo escolar.

Evaluation of pivot shift phenomenon while awake and under anaesthesia by different manoeuvres using triaxial accelerometer.

PURPOSE: Evaluating pivot shift phenomenon is difficult due to its subjectivity, wide variation of testing manoeuvres, and difficulty in evaluating patients while awake. The purpose of this study was to evaluate the pivot shift phenomenon using a triaxial accelerometer by two different manoeuvres, the pivot shift test as representative of flexion manoeuvre and N test as a representative of extension manoeuvre, and in two different conditions, awake and under anaesthesia. METHODS: Twenty-nine patients with unilateral anterior cruciate ligament (ACL)-injured knee were included. Pivot shift test and N test were performed for both injured and uninjured legs while awake and under anaesthesia, with the acceleration measurements using a triaxial accelerometer (KiRA). The tests were also subjectively graded on a scale of 0-6 based on the modification of IKDC criteria. RESULTS: Under anaesthesia, acceleration of ACL-injured knees was greater than that of uninjured knees in both pivot shift test (P < 0.001) and N test (P < 0.001) , whereas the acceleration value was greater in the N test. Furthermore, there were significant positive correlations between the acceleration and subjective grading in both tests, whereas the N test was more significant than the pivot shift test. On the other hand, there was no statistical significance in acceleration between ACL-injured and uninjured knees in either test while the patient was awake. CONCLUSION: The triaxial accelerometer was useful to objectively detect and quantitatively evaluate the pivot shift phenomenon by both the pivot shift test and N test under anaesthesia. The acceleration of ACL-injured knees was greater than that of uninjured knees, and the acceleration was correlated with the subjective manual grading, especially in the N test. On the other hand, its use while the patient was awake was likely limited. LEVELS OF EVIDENCE: Diagnostic study of non-consecutive patients without a universally applied gold standard, Level III.

The association between Ehlers-Danlos syndrome-hypermobility type and gastrointestinal symptoms in university students: a cross-sectional study.

BACKGROUND: Patients with Ehlers-Danlos syndrome-hypermobility type (EDS-HT) have increased prevalence of gastrointestinal (GI) symptoms, particularly reflux and dyspepsia. EDS-HT is associated with dysautonomia, psychopathology, and chronic pain which can be associated with GI symptoms. The association between GI symptoms and EDS-HT in a 'non-patient' population and the effect of the above-mentioned factors has never been studied. METHODS: In a cross sectional study, a hypermobility questionnaire was used to screen university students; further clinical examination established the diagnosis of EDS-HT. Validated questionnaires assessed for GI, somatic, pain and autonomic symptoms, psychopathology and quality of life (QOL). These were compared in students with and without EDS-HT; logistic regression analysis examined associations between EDS-HT, GI symptoms and other variables. KEY RESULTS: Of 1998 students screened, 162 were included: 74 EDS-HT (21.0 years, 53% female) vs 88 Non-EDS-HT (21.5 years, 65% female). Compared to non-EDS-HT students, EDS-HT students were more likely to have multiple GI symptoms (41.9% vs 27.3% P=.05), particularly postprandial fullness (34.4% vs 15.9%, P=.01) and early satiety (32% vs 17%, P=.03), greater autonomic (P<.001) and somatic symptoms (P=.04) but not psychopathology (P>.8). The association between EDS-HT and postprandial symptoms was dependent on autonomic factors but independent of pain and psychopathology. Pain-related QOL scores were reduced in the EDS-HT group (80 vs 90, P=.03). CONCLUSIONS AND INFERENCES: The previously described association between EDS-HT, dyspepsia, pain and autonomic symptoms in patients is also present in non-patient groups. Future studies are necessary to explore the etiological role of connective tissue in GI and extra intestinal symptoms.

Mammalian cadherins DCHS1-FAT4 affect functional cerebral architecture.

Cortical development is a complex process where a multitude of factors, including cadherins, plays an important role and where disruptions are known to have far reaching effects in neural development and cortical patterning. Cadherins play a central role in structural left-right differentiation during brain and body development, but their effect on a functional level remains elusive. We addressed this question by examining functional cerebral asymmetries in a patient with Van Maldergem Syndrome (VMS) (MIM#601390), which is caused by mutations in DCHS1-FAT4 cadherins, using a dichotic listening task. Using neurophysiological (EEG) data, we show that when key regulators during mammalian cerebral cortical development are disrupted due to DCHS1-FAT4 mutations, functional cerebral asymmetries are stronger. Basic perceptual processing of biaurally presented auditory stimuli was unaffected. This suggests that the strength and emergence of functional cerebral asymmetries is a direct function of proliferation and differentiation of neuronal stem cells. Moreover, these results support the recent assumption that the molecular mechanisms establishing early left-right differentiation are an important factor in the ontogenesis of functional lateralization.

Emotion processing in joint hypermobility: A potential link to the neural bases of anxiety and related somatic symptoms in collagen anomalies.

BACKGROUND: Joint hypermobility syndrome (JHS) has repeatedly been associated with anxiety and anxiety disorders, fibromyalgia, irritable bowel syndrome and temporomandibular joint disorder. However, the neural underpinnings of these associations still remain unclear. This study explored brain responses to facial visual stimuli with emotional cues using fMRI techniques in general population with different ranges of hypermobility. METHODS: Fifty-one non-clinical volunteers (33 women) completed state and trait anxiety questionnaire measures, were assessed with a clinical examination for hypermobility (Beighton system) and performed an emotional face processing paradigm during functional neuroimaging. RESULTS: Trait anxiety scores did significantly correlate with both state anxiety and hypermobility scores. BOLD signals of the hippocampus did positively correlate with hypermobility scores for the crying faces versus neutral faces contrast in ROI analyses. No results were found for any of the other studied ROIs. Additionally, hypermobility scores were also associated with other key affective processing areas (i.e. the middle and anterior cingulate gyrus, fusiform gyrus, parahippocampal region, orbitofrontal cortex and cerebellum) in the whole brain analysis. CONCLUSIONS: Hypermobility scores are associated with trait anxiety and higher brain responses to emotional faces in emotion processing brain areas (including hippocampus) described to be linked to anxiety and somatic symptoms. These findings increase our understanding of emotion processing in people bearing this heritable variant of collagen and the mechanisms through which vulnerability to anxiety and somatic symptoms arises in this population.