Snapping Hamstring Tendons Case Report: Tenotomy and Tendon Transposition.

CASE: A 14-year-old girl with a hypermobility syndrome presented with bilateral snapping semimembranosus (SM) and semitendinosus (ST) tendons. After failure of conservative treatment, she was treated with tenotomy of SM and later tendon transposition of her ST to her gracilis. CONCLUSIONS: Surgical treatment of snapping hamstring tendons has historically consisted of the release of the tendon insertions (tenotomy) or tendon harvest. This new surgical technique describes an alternative technique for definitive management with tenotomy and tendon transposition where the snapping ST is transposed to the gracilis tendon to maintain hamstring muscle length, strength, and function.

Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair. QUESTIONS/PURPOSES: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function? METHODS: During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures. RESULTS: There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups. CONCLUSION: The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage. LEVEL OF EVIDENCE: Level II, therapeutic study.

The efficacy of docusate sodium and senna glycoside for the treatment of constipation after rotator cuff repair: A randomized controlled study.

BACKGROUND: Although stool softeners and laxatives are commonly prescribed for postoperative constipation, it is unclear if they are effective during the postoperative period. The data gained from this study will be beneficial for advanced practitioners when examining for postoperative constipation concerns. PURPOSE: This study aimed to investigate the efficacy of docusate sodium and senna glycoside in the prevention and treatment of constipation following rotator cuff repair (RCR). METHODS: Patients (n = 107) were randomized to receive docusate sodium, senna glycoside, or nothing (control) in addition to a standardized postoperative protocol. Patients maintained a daily bowel-movement log for postoperative days 0-10. Constipation symptoms and quality of life were assessed preoperatively and at 2 and 6 weeks postoperatively using the Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. RESULTS: Sixty-seven percent of patients experienced constipation. There was no difference in the prevalence of constipation in the docusate, senna, and control groups (71.4%, 66.7%, and 64.3%, respectively; p = .88). Neither PAC-SYM nor PAC-QOL scores significantly differed between the 3 groups at any time point during 6-week follow-up (p > .05). IMPLICATIONS FOR PRACTICE: The majority (67%) of patients experience postoperative constipation following RCR. Although docustate sodium and senna glycoside are common first-line agents for the treatment of constipation, they are ineffective during the postoperative period. Providers need to explore other treatment modalities for postoperative constipation pain.

A Prospective Study of Patient Factors and Decision-making for Surgical Repair of Symptomatic Full-Thickness Rotator Cuff Tears.

Factors motivating patients to undergo rotator cuff repair (RCR) have not been thoroughly investigated. The purpose of this study was to investigate patient and surgeon decision-making factors for RCR, as well as the use of conservative treatment, and their relationship with shoulder function. A total of 144 adult patients undergoing arthroscopic RCR completed a 13-item questionnaire assessing the importance of surgical decision-making factors. Preoperative conservative treatments were also recorded. Surgeons also completed a similar 5-item questionnaire assessing surgeon decision-making factors preoperatively. American Shoulder and Elbow Surgeons (ASES) functional outcome scores were collected preoperatively through 1 year postoperatively. The following factors received the greatest frequency of high-importance scores: limited shoulder function (80.6%), surgeon recommendation (79.2%), and daily chronic pain (76.4%). Among surgeons, patient activity (83.3%) and risk of tear progression (73.6%) received the greatest frequency of high-importance scores. Patients had worse preoperative ASES scores when they reported the following factors as highly important: limited shoulder function, daily chronic pain, concern for tear enlargement, inability to sleep, and failure of conservative management (P<.004). Female gender, corticosteroid injection, and opioid use were also associated with worse preoperative shoulder function (P<.01). Workers' compensation claims, preoperative physical therapy, and multiple corticosteroid injections were associated with worse postoperative ASES scores (P<.05). Limitations in shoulder function and surgeon recommendation were the most common factors influencing patients to undergo RCR. Multiple factors were associated with worse shoulder function. Surgeons should be cognizant of patient decision-making factors and their relationship with shoulder function. [Orthopedics. 2020; 43(2): 85-90.].

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.