Management of Massive Rotator Cuff Tears Without Arthropathy.

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

Observation periods before tooth movement in orthodontic patients who have experienced mild-to-moderate dental trauma: a scoping review of current evidence.

BACKGROUND: Guidelines for orthodontic patients that have experienced mild-to-moderate dental trauma recommend an observation period before beginning or resuming tooth movement, but they appear to be based on limited evidence. OBJECTIVES: This scoping review examines available research on recommended observation periods before beginning or resuming tooth movement for orthodontic patients that have experienced mild-to-moderate dental trauma. The extent of research, methodologies used, outcomes reported, and justification for recommended observation periods were reviewed to identify any gaps in current knowledge. DESIGN: Online databases were searched to identify papers published from 1950 to September 2021. Two publications, one from Sweden and one from Israel, reported dental outcomes of tooth movement with versus without observation periods for orthodontic patients that had experienced trauma. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-1) tool. RESULTS: One article was published in 1982, and the other in 1991. Both were observational retrospective cross-sectional studies of orthodontic patients with a history of mild-to-moderate trauma to permanent teeth (uncomplicated crown fracture, concussion, subluxation, luxation), ranging in age from 7 to 16 years. The studies listed a variety of outcomes, including clinical exams, electric pulp testing, and analysis of periapical or panoramic radiographs for signs of root resorption. CONCLUSIONS: The identified articles lack sufficient evidence to determine an appropriate observation period after mild-to-moderate trauma before beginning or resuming orthodontic treatment. High-quality research is needed to better define appropriate observation periods before beginning or continuing orthodontic treatment for mildly to moderately traumatized teeth.

Efficacy of transdermal 4% lidocaine patches for postoperative pain management after arthroscopic rotator cuff repair: a prospective trial.

BACKGROUND: Postoperative pain management continues to be a challenging aspect of patient care. Lidocaine patches have shown efficacy in reducing pain in other surgical specialties and mixed results in orthopedic trials. We sought to determine the effectiveness of nonprescription lidocaine patches in reducing postoperative pain after arthroscopic rotator cuff repair. METHODS: Patients undergoing primary arthroscopic rotator cuff repair were recruited from 3 surgeons at a single institution. All patients of each surgeon were randomized to a lidocaine patch or control group, with crossover occurring at the midpoint. Experimental group patients received 26 4% lidocaine gel-patches. They were provided written and visual instructions to begin wearing the lidocaine patches during daytime on postoperative day (POD) 2. They were to be switched every 8 hours and removed overnight. Control group patients received normal standard of care but did not receive a placebo control. Exclusion criteria included workmen's compensation claims, age <18 years, history of myocardial infarction, and history of lidocaine or adhesive allergies. The American Shoulder and Elbow Surgeons shoulder survey was completed preoperatively and 2-, 6-weeks, 3-, 4.5-, and 6-months postoperatively. A 14-day visual analog scale pain and medication log was completed three times daily following repair. All patients received interscalene nerve block with bupivacaine and general anesthesia. RESULTS: 80 (40 control, 40 lidocaine) patients were enrolled, with 53 completing follow-up. Groups were demographically similar in age (P = .22), gender (P = .20), and body mass index (P = .77). They were similar in tear pattern (P = .95), concomitant acromioplasty (P = .44), concomitant biceps tenodesis (P = .07), and number of anchors used (P = .25). There was no difference in American Shoulder and Elbow Surgeons scores at any time points (range P = .28-P = .97). Reported 14-day pain logs were not different between study groups at any time points (range P = .07-P = .99). There was no difference in opioid consumption in the first 14 days after surgery (P = .38). The lidocaine group reported less satisfaction with their pain management beginning in the evening of POD 2 (P = .05). This continued until the afternoon of POD 8 (P = .03). CONCLUSION: Transdermal 4% lidocaine patches are not effective in reducing pain or opioid consumption after arthroscopic rotator cuff repair and were associated with reduced patient satisfaction.

Comparison of technical errors in pediatric bitewing radiographs acquired with round vs rectangular collimation.

OBJECTIVE: To compare technical errors in bitewing radiographs acquired with round vs rectangular collimation in a hospital-based pediatric dentistry training program. STUDY DESIGN: A retrospective chart review was conducted of 176 digital bitewing radiographs exposed with round collimation and 106 exposed with rectangular collimation. The number of re-exposures was calculated, and errors in central ray entry (CRE; "cone cuts"), horizontal and vertical positioning, and angulation were measured. RESULTS: There were no greater re-exposures but significantly more CRE errors with rectangular collimation (21.7%; n = 23; 95% confidence interval [CI], 13.9%-30.0%) than with round collimation (3.4%; n = 6; 95% CI, 0.7%-6.1%). CRE error location, horizontal positioning errors, and size of horizontal overlapped contacts were statistically different but not clinically important. CONCLUSIONS: Use of rectangular collimation resulted in increased CRE errors but no other clinically significant problems. This technique should be used to reduce radiation exposure to patients.

The Application of Computerized Adaptive Testing to the International Knee Documentation Committee Subjective Knee Evaluation Form.

BACKGROUND: Patient-reported outcome measures (PROMs) are commonly used to monitor functional outcomes for clinical and research purposes; unfortunately, many PROMs include redundant, burdensome questions for patients. The use of predictive models to implement computerized adaptive testing (CAT) offer a potential solution to reduce question burden in outcomes research. PURPOSE: To validate the usage of an appropriate CAT system to improve the efficiency of the International Knee Documentation Committee (IKDC) Subjective Knee Form. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: Validation was based on electronically collected patient responses from 2 separate orthopaedic sports medicine clinics. Diagnoses included, but were not limited to, meniscal lesions, ligamentous injuries, and chondral defects. The CAT system was previously developed through analysis of an electronic knee PROM database that did not contain any of these cases. RESULTS: A total of 2173 patient responses (1229 patients) were collected. The CAT model was able to reduce the question burden by a mean of 9.33 questions (45.1%). Higher CAT-predicted scores correlated strongly with higher actual scores (r = 0.99; intraclass correlation coefficient = 0.99). The mean difference between the CAT-predicted score and the actual PROM score was 0.48 of a point on a scale of 0 to 100. CONCLUSION: The use of CAT systems, in conjunction with electronic PROMs, can accurately predict outcome scores for IKDC PROMs, while dramatically decreasing the number of questionnaire items needed for any given patient. By decreasing questionnaire burden, clinicians and researchers can potentially increase patient participation and follow-up in both clinical assessments and research trials.

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.

Diagnostic Imaging of Ulnar Collateral Ligament Injury: A Systematic Review.

BACKGROUND: Ulnar collateral ligament (UCL) injuries can be debilitating in overhead athletes. Accurate diagnosis is important; however, several imaging modalities are available for the assessment of UCL injuries. PURPOSE: To provide a comprehensive review of published literature regarding the diagnostic capabilities of different imaging modalities for UCL tears. METHODS: PubMed, Medline, and Embase were queried for peer-reviewed literature published between January 1947 and June 4, 2019, pertaining to diagnostic imaging of UCL tears. Articles assessing static and stress radiography, ultrasound, magnetic resonance imaging (MRI), MRI with arthrography (MRA), and computed tomography arthrography of the UCL were included. Studies were excluded if imaging results were not compared with intraoperative diagnosis, as intraoperative findings are generally considered the gold standard for diagnostic comparison. The articles were assessed per the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines and reviewed with the Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS-2) assessment. RESULTS: The literature search yielded 2478 articles, of which 15 were included in this review. Potential bias was noted in each QUADAS-2 subsection. Multiple studies demonstrate an association between UCL tears and osseous abnormalities identified on static radiographs; however, the use of static or nonstressed radiographs is not recommended for specific evaluation of UCL injuries. Conventional ultrasound was 81% sensitive and 91% specific, as compared with 96% and 81% for stress ultrasound, respectively. The sensitivity and specificity of MRI ranged from 57% to 100% and 89% to 100%. The sensitivity of computed tomography arthrography ranged from 63% to 86%. The sensitivity and specificity of MRA ranged from 81% to 100% and 91% to 100%. CONCLUSION: Of the currently available imaging modalities, MRA provides the best combination of sensitivity and specificity of the evaluation of the UCL. Further research comparing ultrasound with MRA is needed.

A survey on radiation exposure reduction methods including rectangular collimation for intraoral radiography by pediatric dentists in the United States.

BACKGROUND: The authors conducted a survey of the American Academy of Pediatric Dentistry (AAPD) to determine awareness of the Image Gently Campaign in Dentistry (IGCD) and to ascertain radiologic practices, including radiation dose-reduction strategies such as rectangular collimation. METHODS: An institutional review board approved an electronic survey sent to 7,087 AAPD members covering practitioner demographic characteristics, radiographic techniques, and dose-reduction practices, including rectangular collimation. Responses were tabulated and analyzed using binomial tests, χ2 tests, and Fisher exact tests. RESULTS: A total of 1,124 pediatric dentists or residents in pediatric dentistry responded, (response rate 16%, margin of error ± 2.7%). The largest group (23.8%) graduated after 2010. More than 90% indicated that they followed American Dental Association (ADA)-AAPD radiation exposure guidelines, but only 33.5% were aware of IGCD. Almost all respondents used direct digital systems, storage phosphor plates, or both. Only 22.3% (n = 220) used rectangular collimation. Nonusers indicated that they were unfamiliar with collimation (33.3%) or concerned about potential for increased cone cuts (30.2%), 11.6% of respondents were unaware of any regulatory requirements for inspections of radiographic equipment recurring at regular intervals, and 4.1% of respondents considered use of lead aprons optional. CONCLUSIONS: Although the pediatric dentists surveyed believe they are in compliance with ADA-AAPD guidelines, most are unaware of IGCD recommendations. Use of digital radiography is almost ubiquitous, but use of rectangular collimation is limited. PRACTICE IMPLICATIONS: Dentists treating children should be familiar with ADA-AAPD radiation exposure guidelines and should consider using the dose-reduction strategies recommended by IGCD.

Clinical Efficacy of Intra-articular Mesenchymal Stromal Cells for the Treatment of Knee Osteoarthritis: A Double-Blinded Prospective Randomized Controlled Clinical Trial.

BACKGROUND: Currently, there are limited nonoperative treatment options available for knee osteoarthritis (OA). Cell-based therapies have emerged as promising treatments for knee OA. Autologous stromal vascular fraction (SVF) has been identified as an efficient medium for intra-articular administration of progenitor cells and mesenchymal stem cells derived from adipose tissue. HYPOTHESIS: Patients receiving intra-articular SVF would show significantly greater improvement than patients receiving placebo injections, and this improvement would be dose dependent. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a multisite prospective double-blinded randomized placebo-controlled clinical trial. Adult patients with symptomatic knee OA were eligible. Thirty-nine patients were randomized to high-dose SVF, low-dose SVF, or placebo (1:1:1). SVF was obtained via liposuction, processed to create the cellular implant, and injected during the same clinical visit. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and magnetic resonance images were obtained preoperatively and at 6 and 12 months after injection. The Wilcoxon rank sum nonparametric test was utilized to assess statistical significance, and the Hodges-Lehmann location shift was used to assess superiority. RESULTS: The median percentage change in WOMAC score at 6 months after injection for the high-dose, low-dose, and placebo groups was 83.9%, 51.5%, and 25.0%, respectively. The high- and low-dose groups had statistically significant changes in WOMAC scores when compared with the placebo group (high dose, P = .04; low dose, P = .02). The improvements were dose dependent. The median percentage change in WOMAC score from baseline to 1 year after injection for the high-dose, low-dose, and placebo groups was 89.5%, 68.2%, and 0%, respectively. The high- and low-dose groups displayed a greater percentage change at 12 months when compared with the placebo group (high dose, P = .006; low dose, P = .009). Magnetic resonance image review revealed no changes in cartilage thickness after treatment. No serious adverse events were reported. CONCLUSION: Intra-articular SVF injections can significantly decrease knee OA symptoms and pain for at least 12 months. The efficacy and safety demonstrated in this placebo-controlled trial support its implementation as a treatment option for symptomatic knee OA. REGISTRATION: NCT02726945 (ClinicalTrials.gov identifier).

Are Patient and Surgeon Expectations after ACL Reconstruction Realistic?

BACKGROUND: Patient expectations may affect their satisfaction and functional outcomes after treatment of musculoskeletal injuries. Although there is evidence that patient expectations of ACL reconstruction (ACLR) are inflated, there is limited knowledge about the relationship between physician and patient expectations and patient outcomes after they completely recover from ACLR. Furthermore, it is unclear if specific patient factors influence these expectations. QUESTIONS/PURPOSES: (1) Are patient and surgeon expectations of knee function 18 months after ACLR similar? (2) Are patients' and surgeons' expectations of outcomes similar to patients' actual 2-year outcomes? (3) Is there a relationship between preoperative or intraoperative parameters and expectations? (4) Is there a relationship between preoperative or intraoperative parameters and 2-year ACLR outcomes? METHODS: One-hundred twenty-nine patients undergoing primary ACLR were prospectively enrolled in this study, with 98 (76%) completing 2-year follow-up. Patients completed the IKDC Subjective Knee Evaluation preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients also completed the same questionnaires preoperatively to evaluate expected knee function 18 months after surgery. Immediately postoperatively, surgeons completed the same questionnaires regarding the expected postoperative outcome at 18 months postoperative. Preoperative and intraoperative data were collected to determine an association between expectations and outcomes. Nonparametric analysis was performed using the Mann-Whitney U test, the paired Wilcoxon signed ranks tests and Spearman's correlations, as applicable. RESULTS: There was no difference between patient and surgeon expectations (patient, 94.8 [range 47.4-100] versus surgeon, 94.3 [range 46-100]; p = 0.283), and there was no correlation between higher patient expectations and higher surgeon expectations (r = 0.168, p = 0.078). Patient and surgeon expectations were greater than the actual postoperative outcomes (2-year postoperative: 89.7 [range 32.2 to 100]; p < 0.0001); however, the differences are unlikely to be perceived. There was no correlation between higher 2-year postoperative outcomes and higher patient expectations (r = 0.14, p = 0.186) or higher surgeon expectations (r = 0.019, p = 0.86). Arthroscopic evidence of cartilage damage was independently associated with the worst patient and surgeon expectations. The surgeons themselves were also independently associated with surgeon expectation (p < 0.001). No parameters were associated with postoperative outcomes. CONCLUSIONS: There are no clinically significant differences between surgeon expectations, patient expectations, and 2-year actual outcomes. However, there is also no correlation between the patient expectations, surgeon expectations, and actual outcomes. Although expectations are similar to actual outcomes for most patients, surgeons are unable to accurately predict outcomes for specific patients; thus, preventing adequate patient counseling. Surgeons should be cautious when evaluating and counseling patients preoperatively and avoid assuming high expectations. LEVEL OF EVIDENCE: Level II, therapeutic study.

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.].

Comprehensive Wound Risk Stratification of Rib-Based Distraction Instrumentation Procedures.

STUDY DESIGN: Single-center retrospective analysis of a prospectively collected registry. OBJECTIVES: Identify factors predictive of rib-based distraction (RBD) instrumentation wound complication. Create a risk stratification model for RBD instrumentation wound complication. SUMMARY OF BACKGROUND DATA: RBD instrumentation procedures have a high rate of wound complications, often requiring unplanned operative treatment. Currently, there is a relative lack of understanding of RBD complication risk factors compared with the comprehensive understanding of complication risk factors for other spine surgeries. METHODS: Between January 2011 and September 2015, patients treated with RBD instrumentation at a single institution were analyzed for risk factors associated with surgical wound complications that resulted in unplanned operative treatment. Univariate logistic regression determined predictors of wound complication and multivariate regression determined independent predictive factors; α = 0.10. RESULTS: A total of 122 patients aged 0-18 years underwent 140 implant surgeries in which 22 resulted in complications: 18 (82%) infectious and 4 (18%) noninfectious. Mean age at surgery was 5.2 years. Univariate analysis showed a correlation between wound complication rates and the following: male gender (p = .097), diapered patient with lower back incision (p = .004), bilateral procedure (p = .008), more than three incisions (p = .011), left iliac incision (p = .097), right iliac incision (p = .009), patient age ≤4 years (p = .10), and operative time >150 minutes (p = .079). Multivariate analysis identified the following independent predictors: age ≤ 4 years (p = .002), male gender (p = .04), number of skin incisions (p = .001), left iliac incision (p = .018), and nutritionally challenged (p = .044). The multivariate model predicted wound complications with an area under the receiver operating characteristic curve of 0.88. CONCLUSIONS: Knowledge of risk factors for RBD instrumentation wound complications can be used to construct patient risk models. This can identify patients at higher risk for complications and influence clinical decision making. LEVEL OF EVIDENCE: Level II.

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.

A Multidisciplinary Approach to Restore an Unconventional Crown Removal of Traumatized Permanent Central Incisors.

A 13-year-old female presented with traumatized maxillary central incisors that had been endodontically treated. Five years later, at a different dental office, she had the clinical crowns removed, leaving subgingival margins. From the patient's history and our initial assessment, it seemed as if the teeth had been fractured and luxated but not avulsed. Endodontic posts with spot-welded orthodontic brackets were temporarily cemented to enable orthodontic extrusion. Once access to restorable margins was obtained, the temporary posts were removed and conventional fiber posts with interim composite crowns were placed. The restorations were still satisfactory at the one-year follow-up, with a healthy periodontium, intact apical seal, and no signs of external re- sorption observed. Combined specialty treatment provided an esthetically acceptable outcome in a difficult restorative situation for a growing child. The purpose of this case report is to discuss an interim treatment until the child reaches dentofacial maturity, when definitive restorations can be provided.

Active Presurgical Infant Orthopedics for Unilateral Cleft Lip and Palate: Intercenter Outcome Comparison of Latham, Modified McNeil, and Nasoalveolar Molding.

OBJECTIVE: To compare dental arch relationship, craniofacial form, and nasolabial aesthetic outcomes among cleft centers using distinct methods of presurgical infant orthopedics (PSIO). DESIGN: Retrospective cohort study. SETTING: Four cleft centers in North America. PATIENTS: One hundred ninety-one children with repaired complete unilateral cleft lip and palate (CUCLP). MAIN OUTCOME MEASURES: Dental arch relationship was assessed using the GOSLON Yardstick. Craniofacial form was assessed by 12 cephalometric measurements. Nasolabial aesthetics were assessed using the Asher-McDade system. Assessments were performed between 6 and 12 years of age. RESULTS: The center that used no PSIO achieved the most favorable dental arch relationship and maxillomandibular relationship, with a median GOSLON score of 2.3 ( P < .01) and an ANB angle of 5.1° ( P < .05). The proportion of children assigned a GOSLON score of 4 or 5, predictive of the need for orthognathic surgery in adolescence, was 16% at the center that used no PSIO and no secondary surgery, compared to 76% at the centers that used the Latham appliance and early secondary lip and nose surgery ( P < .01). The center that used no PSIO and no secondary surgery achieved significantly less favorable nasolabial aesthetic outcomes than the centers using Latham appliance or nasoalveolar molding (NAM) ( P < .01). CONCLUSIONS: Effects of active PSIO are multifaceted and intertwined with use of revision surgery. In our study, centers using either the Latham appliance combined with early revision surgery or the NAM appliance without revision surgery achieved better nasolabial aesthetic outcomes but worse maxillary growth, compared to a center using no PSIO and secondary surgery.

Prevalence of transposed teeth as seen on panoramic radiographs in children with cleft lip and palate.

OBJECTIVE: To assess the prevalence of complete and incomplete transpositions of teeth in subjects with repaired cleft lip and/or palate. DESIGN: Retrospective review. Panoramic radiographs from 364 subjects with repaired cleft lip and/or palate and with or without syndromes were compared with 364 panoramic radiographs from noncleft controls. The percentages of completely or incompletely transposed teeth, missing teeth, and pegged teeth were recorded for each subject and control. SETTING: Primary care dental clinic in a university affiliated, not-for-profit hospital. MAIN OUTCOME MEASURES: Presence of complete and incomplete transposed teeth, missing teeth, and pegged teeth detected on subjects' panoramic radiographs. RESULTS: This study revealed greater prevalence of tooth transposition in subjects with cleft lip and/or palate (52/364 = 14.3%) as compared with noncleft controls (1/364 = 0.3%; P < .001). CONCLUSIONS: There was a higher prevalence of tooth transpositions in subjects with repaired cleft lip and/or palate with/or without syndromes than in noncleft controls. There was a weak association between transpositions and missing teeth (P = .12) and between transpositions and pegged teeth (.23).

Penultimate effect in ethylene-styrene copolymerization and the discovery of highly active ethylene-styrene catalysts with increased styrene reactivity.

For the first time commercially relevant catalysts for the copolymerization of ethylene and styrene have been identified. The catalysts maintain very high copolymer efficiencies at relatively high reactor temperatures without sacrificing styrene comonomer reactivity. The observations which led to this discovery are based upon the kinetic analysis of ethylene-styrene copolymerization using constrained geometry catalyst (eta5-C5Me4)(SiMe2-N-t-Bu)TiMe2 (1). This analysis revealed a substantial styrene penultimate monomer effect. Inherent reactivity of 1 toward styrene is greatly improved when the penultimate monomer on the growing polymer chain is styrene rather than ethylene. The presence of a penultimate styrene effect led to the hypothesis that catalysts bearing aromatic moieties in close proximity to the active site could lead to enhancement of styrene reactivity for this catalyst family. This hypothesis was born out by two new constrained geometry catalysts, one having two phenyl substituents placed in the 3 and 3' positions of the Cp ring (2) and the other with a 2,2'-biphenyl fragment attached to the Cp ring (3). Both catalysts exhibit higher activity than that of 1 and, more importantly, much higher styrene reactivity leading to copolymers with substantially increased styrene content (21.5% for 2, 30.6% for 3) as compared to 1 (11%) under the same polymerization conditions. Analysis of the X-ray crystal structures of 2 and 3 shows no overriding structural arguments for the increased performance. Outstanding polymerization characteristics achieved with 3 make this catalyst a candidate for commercial production of ethylene-styrene resins in a solution process.

Divalent ansa-zirconocenes: stereoselective synthesis and high activity for propylene polymerization.

The reduction of ZrCl4(PR3)2 with Li powder, in the presence of a stoichiometric amount of trans-1,4-diphenyl-1,3-butadiene, affords the Zr(II) diene complexes (1) in 90-93% yields. This reaction consists of a rate-limiting step for the formation of the chloride-bridged Zr(III) dimer (2) and a fast diene-driven disproportionation of 2 to 1 and ZrCl4(PR3)2 that re-enters the reduction cycle. The reaction of 1 with Li2{Me2Si(2-Me-4-Ph-Ind)2} in toluene produces quantitatively the desired racemic, divalent ansa-zirconocene (3) that is a highly active isospecific propylene polymerization catalyst upon activation with common activators.