Is There an Association Between Ulnar Nerve Hypermobility and Neuropathy at the Elbow?

OBJECTIVE: To systematically review the association between ulnar nerve hypermobility (UNH) at the elbow and ulnar neuropathy (UNE). DATA SOURCES: Cumulative Index to Nursing and Allied Health, MEDLINE, and Embase databases were searched for English language studies published up to July 4, 2020. STUDY SELECTION: We included case-control, cohort, and randomized controlled studies that established the presence or absence of UNH and UNE. Twenty out of 654 studies identified met the inclusion criteria. DATA EXTRACTION: Two reviewers independently extracted data for analysis. Risk of bias and applicability were assessed with the QUADAS-2 tool. DATA SYNTHESIS: We compared rates of UNH between patients diagnosed with and without UNE and found no significant difference. The meta-analysis pooled rate of UNH was 0.37 (95% confidence interval, 0.20-0.57) for those without UNE and 0.33 (95% confidence interval, 0.23-0.45) for those with UNE. CONCLUSIONS: The clinical finding of UNH is unhelpful when assessing for UNE, as the presence of UNH does not make the diagnosis of UNE more likely.

Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review.

PURPOSE: The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature. METHODS: The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. RESULTS: Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives. CONCLUSIONS: The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Device-assisted tensioning is associated with lower rates of graft failure when compared to manual tensioning in ACL reconstruction.

PURPOSE: To describe (1) the current graft tensioning practices in ACL reconstruction (ACLR) and, (2) the failure rates with the use of manual tensioning, or device-assisted tensioning at the time of graft fixation. METHODS: The electronic databases MEDLINE, EMBASE, and PubMed were searched independently by two reviewers from database inception to search date on January 21, 2017. Inclusion criteria were studies reporting graft tensioning method and rate of graft failure. The definition of graft failure used was: (1) side-to-side instrumented laxity > 5 mm, (2) Lachman 2 +, (3) positive pivot-shift testing, (4) MRI-confirmed graft rupture or, (5) need for revision surgery. RESULTS: A total of 3379 patients and 3380 knees were treated with ACL reconstruction and followed for an average of 41.7 months (range 4-145 months). ACLR with manual tensioning was performed on 1518 (51.9%) patients and device-assisted tensioning was performed on 1802 (48.1%) patients. The average knee position reported was 29.2° in single-bundle ACLR and 22.9° in double-bundle ACLR. The median amount of tension used in manual tensioning was 'maximum manual tension' and 50 N in device-assisted tensioning. Overall, the failure rate in studies reporting manual tensioning was 8.9% compared to 4.3% in device-assisted tensioning. CONCLUSION: Both manual tensioning and device-assisted tensioning are associated with low overall failure rates (< 10%) in ACLR; however, there is a higher rate of reported failure with manual tensioning compared to device-assisted tensioning. These findings highlight the need to investigate variations in graft tensioning practice, such as specific tension devices and their parameters, with high-quality, randomized controlled trials to elucidate details of their clinical impact. LEVEL OF EVIDENCE: Level IV, systematic review of level I-IV studies.

Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy.

PURPOSE: Hip arthroscopy is emerging as the standard of care for conditions involving the hip, and has a unique set of complications. The purpose of this review was to identify (1) the crude rate of pudendal nerve injury following hip arthroscopy and (2) the specific factors leading to pudendal nerve injury. METHODS: MEDLINE, EMBASE, and PubMed were searched from database inception to October 2016. Patient demographics, indications, surgical technique, complication rates, treatment approaches, and rehabilitation strategies were extracted. RESULTS: Twenty-four studies (n = 3405) were included, with the majority (66%) of studies being level IV evidence. The mean age was 33.9 ± 9.7 years (range 12-78) and 48.2% were males. Average follow-up was 30.2 ± 19.1 months. 62 patients were reported to have sustained pudendal nerve injury (1.8%) post-operatively, and all resolved within 6 weeks to 3 months. Of the seven studies that reported using a perineal post, 20 patients were diagnosed with pudendal nerve injury (4.3%), in contrast to two studies (189 patients) reporting only 0.5% pudendal nerve injury without the use of perineal post. Two studies commented on time of traction during surgical intervention with mean times of 98 and 68 min with complication rates of 10% and 6.6%, respectively. CONCLUSIONS: Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction. LEVEL OF EVIDENCE: Level IV, systematic review of level I-IV studies.

Fluid Extravasation in Hip Arthroscopy: A Systematic Review.

PURPOSE: The purpose of this systematic review was to (1) characterize cases of fluid extravasation during hip arthroscopy and explore common factors among them and (2) describe management strategies and outcomes of this complication. METHODS: The databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data regarding patient demographics, fluid management, presentation, management, and outcomes were collected. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies Criteria. RESULTS: Fourteen studies (1,286 patients) were included. Twenty-two occurrences of symptomatic fluid extravasation were reported in 21 patients (1.6% of total patients; one patient had fluid extravasation during 2 separate hip arthroscopies). Two studies of normal fluid extravasation in asymptomatic patients reported 1.13 to 3.06 L of extravasated fluid observed on computed tomography. Nine case studies were included, which provided detailed patient and surgical information. Of these 9 patients (10 cases) with a mean age of 38.2 years old (range, 15 to 55 years), 6 were female. Signs of fluid extravasation included abdominal distension (89%), hypothermia (56%), hypotension. and metabolic acidosis (33% each). Four patients required surgical intervention, while 3 underwent paracentesis. Two patients were managed conservatively. All patients stabilized and were discharged, with one patient reporting abdominal complaints at latest follow-up (length of follow-up unspecified). CONCLUSIONS: Fluid extravasation is a rare but potentially life-threatening complication of hip arthroscopy. It is important for surgeons and anaesthesiologists to be aware of its existence in order to recognize and manage it promptly. Most patients require interventional management by surgery or paracentesis, but some stabilize with conservative management. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review.

PURPOSE: Hip arthroscopy is increasingly used to address hip joint pathology. Iatrogenic instability has been reported as a potential complication, leading to the evaluation of various capsular management strategies. The purpose of this review was to (1) report the techniques used for capsulotomy in hip arthroscopy, (2) understand techniques and indications for capsular closure, and (3) report outcomes based on capsular management strategy. METHODS: MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, indications, surgical technique, rehabilitation strategies, and complication rates were obtained. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) Criteria. RESULTS: Eighty-two studies of primarily level IV evidence (80 %) and of fair quality involving 4504 patients with a mean age of 35 years old (range 1.2-82 years) were included. Fifty percent of patients were male. Mean follow-up was 24.9 months (range 5 days to 13 years). Of 68 studies reporting capsulotomy technique (only 7 % of all otherwise eligible studies), 55 % performed an interportal capsulotomy while 24 % performed a T-capsulotomy. Of 36 studies reporting capsular management strategy post-arthroscopy, 22 % did not repair the capsulotomy, 6 % routinely performed partial repair, and 50 % performed complete repair. Of three studies (206 patients) directly comparing capsular management strategies, only one study found a statistically significant difference between complete and partial repair on the Hip Outcome Score-Sport Specific Subscale, though this difference was less than the minimal clinically important difference (83.6 versus 87.3). The total rate of reported post-operative dislocation, instability, or instability was 0.3 % (5 patients). CONCLUSIONS: Technical details regarding capsulotomy and capsular management post-hip arthroscopy are not consistently reported in the literature. Capsulotomies are most often performed using an interportal technique, and more recent studies report routine closure. Overall, post-operative instability is rare and there is no consistent trend for capsular management strategy. Given current evidence, there is little basis on which to establish the relationship between surgical technique and post-operative instability or long-term consequences (e.g., kinematic changes). Thus, while capsular closure/plication may be suitable for specific populations (i.e., dysplasia or laxity), evidence-based indications for capsular repair remain unclear. LEVEL OF EVIDENCE: Level IV, systematic review of level I-IV Studies.

Assessing muscle architecture with ultrasound: implications for spasticity.

Botulinum Neurotoxin Type A (BoNT-A) injections using Ultrasound (US) guidance have led to research evaluating changes in muscle architecture. Controversy remains as to what constitutes increased Echo-Intensity (EI) in spastic muscles and whether this may affect outcomes. We aim to provide a narrative review of US muscle architecture changes following Central Nervous System (CNS) lesions and explore their relationship to spasticity. Medline, CINAHL, and Embase databases were searched with keywords: ultrasonography, hypertonia, spasticity, fibrosis, and Heckmatt. Three physicians reviewed the results of the search to select relevant papers. Reviews identified in the search were used as a resource to identify additional studies. A total of 68 papers were included. Four themes were identified, including histopathological changes in spastic muscle, effects of BoNT-A on the muscle structure, available US modalities to assess the muscle, and utility of US assessment in clinical spasticity. Histopathological studies revealed atrophic and fibro-fatty changes after CNS lesions. Several papers described BoNT-A injections contributing to those modifications. These changes translated to increased EI. The exact significance of increased muscle EI remains unclear. The Modified Heckmatt Scale (MHS) is a validated tool for grading muscle EI in spasticity. The use of the US may be an important tool to assess muscle architecture changes in spasticity and improve spasticity management. Treatment algorithms may be developed based on the degree of EI. Further research is needed to determine the incidence and impact of these EI changes in spastic muscles.

Evaluation of muscle strength following peripheral nerve surgery: A scoping review.

Peripheral nerve injury (PNI) can result in devastating loss of function, often with poor long-term prognosis. Increased use of peripheral nerve surgical techniques (eg, nerve transfer, nerve grafting, and nerve repair) has resulted in improved muscle strength and other functional outcomes in patients with PNI. Muscle strength has largely been evaluated with the British Medical Research Council (MRC) scale. MRC is convenient to use in clinical settings, but more robust measures of muscle function are necessary to fully elucidate patient recovery. This scoping review aims to examine alternative instruments used to assess muscle function in studies of peripheral nerve surgery for PNI of the upper and lower limbs. A scoping review was conducted using Ovid MEDLINE, CINAHL, EMBASE, and PubMed databases in May and December of 2020, yielding a total of 20 studies pertaining to the review question. Studies pertaining to handheld dynamometry, grip and pinch dynamometry, Rotterdam Intrinsic Hand Myometers, isokinetic dynamometry, ultrasonography, and electromyography were reviewed. We provide a synopsis of each method and current clinical applications and discuss potential benefits, disadvantages, and areas of future research.

A systematic review and meta-analysis of patient-reported outcomes following nerve transfer surgery for brachial plexus injury.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to determine the effect of nerve transfer surgery for brachial plexus injury (BPI) on patient-reported outcomes. LITERATURE SURVEY: MEDLINE, EMBASE, and CINAHL were searched and screened in duplicate for relevant studies on September 25, 2019 and repeated June 24, 2020. METHODOLOGY: The patient population included male and female patients who received nerve transfer surgery for BPI. Further inclusion criteria were: (1) all levels of evidence; (2) published in English; (3) conducted in humans; and (4) report of patient-reported outcome. Two reviewers independently abstracted data regarding injury type, surgical technique, surgical timing, follow-up duration, strength, and patient-reported outcome measures. Quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. SYNTHESIS: Twenty-one studies involving 464 participants were included in analyses. The mean age ± SD was 32.4 ± 1.8 (range: 5-77) and 89.2% of included participants were male. The mean time to surgery was 5.6 ± 0.6 months and the mean follow-up time was 48.1 ± 8.4 months. The most used patient-reported outcome was the Disabilities of Arm, Shoulder and Hand (DASH), where scores variably improved postoperatively, although the degree of disability remained high. Return to work was reported in five studies, with 66.0% of participants returning to work. Patient satisfaction was assessed in four studies with an overall satisfaction proportion of 64.0%. Pain was assessed in 12 studies using various measures. In studies reporting pain intensity postoperatively, 29.3% of patients were "pain-free" or had "no pain." CONCLUSIONS: Patient-reported outcomes following nerve transfer for BPI are infrequently reported in the literature. Although patient-reported outcomes demonstrate variable postoperative improvement, there is evidence of ongoing limitations and postoperative DASH scores report a high degree of ongoing disability. Future studies with greater reporting as well as validation of patient-reported outcomes within BPI are warranted.

Relationship Between Sensibility Tests and Functional Outcomes in Patients With Traumatic Upper Limb Nerve Injuries: A Systematic Review.

OBJECTIVE: To investigate which tests of hand sensibility correlate with functional outcomes in patients with upper limb traumatic nerve injuries and to assess if composite scales of sensibility correlate with functions. DATA SOURCES: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched in May 2020, with a supplementary search in July 2020. Reference lists of the included publications were hand searched. STUDY SELECTION: Database search found 2437 records. Eligible studies reported on inferential association between sensibility tests and functions pertaining to adults after upper limb nerve repair. Two reviewers independently assessed eligibility. Fifteen publications were included. DATA EXTRACTION: Extracted data contain patient characteristics, surgical procedure, follow-up duration, sensibility tests, and functional assessments. Two reviewers independently assessed data quality. DATA SYNTHESIS: Fifteen publications involving 849 patients were reviewed. All publications reported on median and/or ulnar nerve injuries. Monofilament tests correlated with Short-Form Health Survey (r=0.548, P<.05), pick-up test (r=0.45, P<.05), and function domain of Patient-Rated Wrist and Hand Evaluation Questionnaire (PRWHE) (r=0.58, P<.05). The 8 studies of static and moving 2-point discrimination provided conflicting correlations with activities of daily living (ADL) and/or the pick-up test. Data for area localization and object/shape identification were equivocal as well. No data were found for Ten test and vibration tests. Rosén score sensory domain correlated with ADL (r=0.59; 95% confidence interval [CI], 0.41-0.72) and PRWHE function domain (r=-0.56, P<.05). Medical Research Council sensory scale was related to pick-up test; return to work status; and Disabilities of the Arm, Shoulder, and Hand questionnaire. CONCLUSIONS: Monofilament tests allow practitioners to gather sensibility data meaningful to patients' overall recovery of functions after upper limb nerve trauma. For 2-point discrimination and other sensibility tests, practitioners should be aware that improvement in test performance does not necessarily translate to improved hand function. Findings from the composite scales indicate that hand sensibility, in general, is related to functions. Future research on other common sensibility tests is recommended to explore how the test relates to patients' functions.

Exploring the teaching and learning of clinical reasoning, risks, and benefits of cervical spine manipulation.

The aim of this study was to examine how risks and benefits of cervical spine manipulation (CSM) were framed and discussed in the context of mentorship and their impact on the perception of safe practice of CSM in clinical physiotherapy settings. A multi-method qualitative approach was employed, including a document analysis of established educational guidelines, observations of mentoring sessions, and individual face-to-face interviews with five mentees in the process of learning CSM, and four mentors with Orthopedic Manual Physical Therapy (OMPT) certification. Results demonstrated that participants' clinical decision-making processes to perform CSM were primarily oriented to the mitigation of risk. Achieving proficiency in the "science" of clinical reasoning and the "art" of "feel" related to mastering technical skills were viewed as means to mitigating risk and enhancing confidence to use CSM safely in clinical practice. While the "art" of technical skill mastery was of high importance to mentees and considered important to developing competency in performing CSM, it was discussed as distinct from their clinical reasoning processes. Thus, promoting a more balanced and integrated use of the "art" and "science" of safe practice for CSM in OMPT training may result in greater confidence and judicious use of CSM by physiotherapists.

Preoperative physical examination and imaging of femoroacetabular impingement prior to hip arthroscopy-a systematic review.

The purpose of this systematic review is to report current preoperative assessment for femoroacetabular impingement (FAI) including physical examination and imaging modalities prior to hip arthroscopy, and report current imaging measures used in the diagnosis of FAI. The electronic databases MEDLINE, EMBASE and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, non-operative treatment, preoperative assessment including physical examination and imaging prior to hip arthroscopy were abstracted. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. Sixty-eight studies of fair quality evidence that involved a total of 5125 patients (5400 hips) were included. In total, 56% of all patients were male and mean age was 36 years (SD ± 10.0). Within physical examination, FADIR impingement testing was reported in 57% of patients. All included studies reported plain radiographic imaging as a component of preoperative assessment with anterior-posterior pelvis view being the most commonly reported view, followed by the cross-table lateral and Dunn views. Magnetic resonance imaging was obtained for 52% of included patients and computed tomography for 26% of patients. The most commonly reported measure within imaging for the diagnosis of cam type impingement was alpha angle (66%), whereas for pincer type impingement, the cross-over sign (48%) was most reported. Preoperative assessment is underreported in the FAI literature. Improved reporting is warranted to develop a more consistent and validated diagnostic algorithm for FAI to enhance patient selection. Level of evidence: Level IV, Systematic Review of Level I-IV Studies.

Return to Work and Sport Following High Tibial Osteotomy: A Systematic Review.

BACKGROUND: The purpose of this study was to examine (1) timelines for return to sport and work following high tibial osteotomy (HTO), and (2) whether patients return to sport and work at levels similar to preoperative levels. METHODS: A systematic search was conducted across 3 databases (MEDLINE, Embase, and PubMed). Two reviewers independently screened the results for relevant articles. Data regarding patient demographics, indications, surgical technique, return to work and sport, and complication and failure rates were abstracted from eligible studies. RESULTS: Nineteen studies were included, involving 1,189 patients (64% male, 21% female, 15% unspecified) and 1,224 knees. Mean age was 46.2 years (range, 16 to 80 years). Opening-wedge HTO was most commonly used, followed by closing-wedge HTO and hemicallotasis. Mean follow-up was 65.4 months (range, 8 to 253 months). Overall, 87.2% of patients returned to sport postoperatively, and 78.6% returned at an equal or greater level. Among competitive athletes, 54% returned to competition. Overall, 84.5% of patients returned to work postoperatively, and 65.5% returned at an equal or greater level. Approximately 90% of patients who returned to work or sport did so within 1 year. The complication rate was 5.8%, with infection being the most common complication; 7.0% of patients progressed to a total knee arthroplasty at a mean of 6.7 years (range, 0.8 to 15 years) following HTO. CONCLUSIONS: The majority of patients undergoing HTO return to sport and work, and most return within 1 year of the operation. Most patients return to sport at a level equal to or greater than the preoperative level. Approximately two-thirds of patients return to an equal or greater level of physical work. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.