Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft.

PURPOSE: To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. METHODS: Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. RESULTS: The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. CONCLUSIONS: Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Influence of Pain Sensitivity on Surgical Outcomes of Arthroscopic Rotator Cuff Repair: A Prospective Cohort Study.

BACKGROUND: The Pain Sensitivity Questionnaire (PSQ) has been found to be a valid tool, and PSQ scores have been shown to be predictive of outcomes after surgery for lumbar stenosis. The effect of pain sensitivity on outcomes of rotator cuff repair (RCR) surgery has not been examined. HYPOTHESIS: PSQ scores would be associated with surgical outcomes after arthroscopic RCR surgery. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients 18 to 80 years old scheduled for RCR were consecutively enrolled. Patients with glenohumeral arthritis grade ≥2 or RCR revision surgery were excluded. PSQ was completed preoperatively. The Disabilities of the Arm, Shoulder and Hand score and American Shoulder and Elbow Surgeons score were used as patient-reported outcome measurements (PROMs), and visual analog scale pain score was documented as well. Active shoulder external rotation (ER), internal rotation, and anterior forward elevation range of motion (ROM) were recorded. PROMs and ROM measurements were recorded preoperatively and at 3 months, 6 months, and 1 year after surgery. Rotator cuff tear size, type of repair, and concomitant procedures were documented. Patients were classified as having high or normal pain sensitivity based on PSQ scores. RESULTS: Of 100 enrolled patients, 38 patients were classified as having high pain sensitivity. Patients with high pain sensitivity had worse American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder and Hand scores preoperatively, 6 months postoperatively, and 1 year postoperatively (P < .01). From the preoperative assessment to 3 months postoperatively, PROMs improved more in patients with high versus normal pain sensitivity. However, for patients with high pain sensitivity, PROMs plateaued after 3 months but continued to improve for patients with normal pain sensitivity (P < .01). Visual analog scale pain scores were higher at all time points for patients with high pain sensitivity (P < .05). Preoperatively, patients with high pain sensitivity had restricted active ROM compared with patients who had normal pain sensitivity for anterior forward elevation, ER, and internal rotation (P = .009, P = .012, and P = .006, respectively). By 1 year after surgery, ER ROM was still restricted in patients with high pain sensitivity. CONCLUSION: Pain sensitivity is an important factor influencing RCR outcomes. Patients with high pain sensitivity undergoing RCR showed less improvement in active ROM and worse PROMs after surgery compared with patients who had normal pain sensitivity. Preoperative PSQ may predict postoperative improvements.

Epidemiology of Primary Shoulder Dislocations. A Cohort Study from a Large Health Maintenance Organization: 2004 to 2019.

BACKGROUND: Previous epidemiological studies on shoulder instability evaluated specific and relatively small subgroups of patients. OBJECTIVES: To determine the incidence rate of primary shoulder dislocations. METHODS: Cohort analysis of electronic health records from 2004 to 2019 was conducted in a urban district of a major health maintenance organization (HMO) in Israel. Patients presented with primary shoulder dislocation that was treated with closed reduction in any medical facility within the district. Overall incidence density rates (IDR) of primary shoulder dislocations and stabilization surgeries were determined. RESULTS: Over a period of 16 years 13,158 patients underwent closed reduction of primary shoulder dislocation. Of those, 712 shoulder stabilization surgeries were performed (5%). The IDR of primary shoulder dislocations were 124 per 100,000 person-years. The IDR of primary shoulder stabilizations were 7 per 100,000 person-years. The peak in the number of dislocations was observed in those 20-29 years old and ≥ 60 years of. In patients under 59 years old, dislocations were more common in men. In those ≥ 60 years of age, dislocations were more common in women. Most shoulder stabilization surgeries were performed on young patients. The annual mean time from the first dislocation to stabilization surgery linearly declined to 6 months in 2019. CONCLUSIONS: The IDR of primary shoulder dislocations calculated from the largest HMO in Israel were 124 per 100,000 person-years. Shoulder dislocations had bimodal age distribution. Overall, 5% of the patients (mainly young) with shoulder dislocations underwent shoulder stabilization surgery during the study period.

Epidemiology of primary shoulder dislocations requiring surgery: A cohort study from a major trauma center during 7 years.

PURPOSE: The epidemiology of shoulder instability in the general population is lacking. The aim of the current study was to determine the incidence rate of primary shoulder dislocations requiring surgical interventions in a major trauma center within a large maintenance organization. METHODS: A retrospective cohort analysis of electronic health records database from 1 January 2014 and 31 December 2020 was conducted in major rural trauma center. This study included all patients aged 10 years or older with a primary shoulder dislocation that were treated with closed reduction in the emergency room department. An overall incidence density rates (IDR) (per 100,000 person-years) of primary shoulder dislocations and stabilization surgeries were determined for the entire cohort. The data was used to evaluate the age-specific and gender-specific epidemiology. RESULTS: During the study period of 7 years there were 1,302 patients who underwent closed reduction after a primary shoulder dislocation (mean age 45 years). Of those, a total of 106 shoulder stabilization surgeries (8%) were performed. The IDR of primary shoulder dislocations was 179 per 100,000 person-years. The IDR of primary shoulder stabilizations was 15 per 100,000 person-years. The peak in number of dislocations was observed in the age groups of 20-29 years and over 60 years. In the age groups under 59 years dislocations were more common in men while in ages over 60 years dislocations were more common in women. The vast majority of shoulder stabilization surgeries were performed in young patients (age under 39 years). CONCLUSION: The IDR of primary shoulder dislocations calculated from a major trauma center of the largest health maintenance organization in Israel was 179 per 100,000 person-years. Shoulder dislocations had bimodal age distribution. Overall, eight percent of the patients (mainly young) with shoulder dislocations underwent shoulder stabilization surgery during the study period.

Efficacy of Anti-inflammatory Treatment Versus Rescue Analgesia After Arthroscopic Partial Meniscectomy in Nonarthritic Knees: A 3-Arm Controlled Study.

BACKGROUND: There is currently no consensus regarding the appropriate treatment for postoperative pain after arthroscopic partial meniscectomy (APM). Prescribing a mild non-anti-inflammatory protocol of rescue analgesia may be sufficient to avoid the side effects of opioids or anti-inflammatories. PURPOSE/HYPOTHESIS: The purpose was to compare the efficacy of pain reduction after APM in nonarthritic knees using betamethasone or celecoxib as anti-inflammatory analgesics versus acetaminophen or tramadol as rescue analgesics. The hypothesis was that there is no advantage for anti-inflammatories in achieving postoperative immediate pain relief after APM in nonarthritic knees compared with a simple nonopioid treatment. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This 3-arm controlled study evaluated postoperative pain levels and analgesic consumption in patients who underwent primary APM (under general anesthesia) at a single institution from December 2018 to December 2019. Patients were prospectively divided into 3 treatment groups: (1) betamethasone injection at the end of the procedure, (2) oral celecoxib prescription, or (3) neither treatment (control). All groups were instructed to take supplementary acetaminophen as needed. Patients were also allowed to take tramadol as needed to evaluate the need for opioids. At postoperative weeks 1, 2, and 3, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, and results were compared between time points and groups. RESULTS: A total of 99 patients were included in the treatment groups: betamethasone group (32 patients), celecoxib group (30 patients), and control group (37 patients). At baseline, there were no statistically significant differences between the groups in age, sex, body mass index, level of activity, comorbidities, or surgical findings. KOOS Pain scores improved at every time point for all 3 groups (P < .001), and no differences in scores were observed among groups. The consumption of acetaminophen or tramadol as rescue analgesia throughout the follow-up period was negligible among groups. CONCLUSION: During the first 3 postoperative weeks after APM in nonarthritic knees, pain was efficiently controlled by betamethasone or celecoxib; however, pain was also efficiently controlled by minimal consumption of acetaminophen with negligible use of tramadol. Therefore, acetaminophen could be prescribed as an effective first-line postoperative analgesic after APM.

Preoperative pain sensitivity questionnaire helps customize pain management after arthroscopic partial meniscectomy.

PURPOSE: To evaluate correlations between preoperative pain sensitivity and postoperative analgesic consumption together with pain perception shortly after arthroscopic partial meniscectomy in non-arthritic knees. METHODS: Ninety-nine patients who underwent primary arthroscopic meniscectomy were prospectively divided into three postoperative treatment groups that were prescribed with betamethasone injection (at the end of surgery), oral celecoxib or rescue analgesia (control). Preoperative pain sensitivity was evaluated by pain sensitivity questionnaires (PSQ). Patients were followed for the first three postoperative weeks to evaluate knee injury and osteoarthritis outcome score (KOOS) pain scores and analgesics consumption. Statistical analysis included correlations among preoperative pain sensitivity, postoperative pain levels and analgesics consumption. A receiver operating characteristic curve was plotted to investigate the cutoff values of the PSQ score to predict insufficient postoperative pain reduction. RESULTS: There were no differences at baseline among all study groups in age, sex, BMI, level of activity, comorbidities and surgical findings. At the final follow-up, KOOS pain scores improved in all groups (p < 0.001). Mean final KOOS pain scores were 76.1 ± 15.2 for the betamethasone group, 70.8 ± 12.6 for the celecoxib group and 78.7 ± 11.6 for the control group. No differences in scores were observed among groups (n.s.). In the control group, a negative correlation was observed between PSQ score and KOOS-pain scores at the end of the follow-up in addition to a positive correlation between PSQ score and rescue analgesia consumption at the first postoperative week. The optimal cutoff value for PSQ score to predict insufficient improvement in KOOS-pain subscale was 5.0 points. CONCLUSIONS: A cutoff value of pain sensitivity questionnaire score above 5.0 points was determined to identify patients with higher sensitivity to pain who underwent arthroscopic partial meniscectomy. These patients reported relatively increased pain and consumed more rescue analgesics postoperatively unless treated with a single intraoperative corticosteroids injection or oral non-steroidal anti-inflammatories. Therefore, surgeons can use pain sensitivity questionnaire score as a preoperative tool to identify patients with high sensitivity to pain and customize their postoperative analgesics protocol to better fit their pain levels. LEVEL OF EVIDENCE: II.

Motorcycle crashes and upper extremity trauma.

OBJECTIVES: Upper extremity injuries following motorcycle crashes (MCC) incur increased healthcare costs and rehabilitation needs. We aim to characterize the epidemiology of MCC upper extremity injuries and identify factors that influence the severity of and cost of care for upper extremity injuries. METHODS: We performed a retrospective cohort analysis of 571 patients with upper extremity injuries after MCC at a level 1 trauma center from 2002 to 2013. We collected data pertaining to demographics, helmet use, toxicology, bony injury, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), hospital length of stay (LOS), and cost. Continuous variables were compared using t-test or Wilcoxon rank test, depending on data distribution, and dichotomous variables were compared using Pearson's chi-squared or Fisher's exact tests. Regression models were used to evaluate the effect of intoxication or helmets on injury location, severity, cost of care, and LOS. RESULTS: The incidence of MCC upper extremity injury was 47.5%, with hand and forearm fractures the most common injuries (25.5% and 24.7% of total injuries). Intoxicated patients were more likely to have a high cost of care (p = 0.012), extended LOS (p = 0.038), plastic surgery involvement in their care (p = 0.038), but fewer upper extremity bony injuries (p = 0.019). Non-helmeted patients sustained less upper extremity bony injuries (p < 0.001) and upper extremity soft tissue injuries (p = 0.001), yet more severe injuries (ISS ≥ 30, p = 0.006 and GCS < 9, p < 0.01) than helmeted patients. CONCLUSION: Upper extremity injuries are common in motorcyclists. Despite vital protection for the brain and maxillofacial injury, helmeted MCC patients have an increased incidence of upper extremity injuries compared to non-helmeted patients, but overall have less severe injuries. Intoxicated patients have fewer upper extremity bony injuries, but the higher cost of care, and extended LOS. Therefore, even with the increased risk of injury helmets may expose to the upper extremity, helmets reduced overall morbidity and mortality. In addition to mandatory helmet laws, we advocate for further development of safety equipment focusing specifically on the prevention of upper extremity injuries.

Morphological and Histological Changes in the Human Anterior Cruciate Ligament after Rupture.

BACKGROUND: Injuries to the anterior cruciate ligament (ACL) are common and complete tears often fail to heal. ACL reconstruction is considered the surgical gold standard of care for ACL injuries in young active patients. OBJECTIVES: To determine the corresponding morphological and histological features of the torn ACL in different time periods after injury. METHODS: The study included 28 remnant specimens of torn ACLs from patients who had ACL reconstruction surgery of the knee. The remnant pathology was evaluated by its morphology during arthroscopy and by histopathologic measurements. RESULTS: At surgery there were three progressive and distinct morphological tear patterns. The first pattern was noticed within the first 3 months from injury and showed no scar tissue. The second pattern appeared later and was characterized by the appearance of scar tissue with adhesion to the femoral wall. The third pattern was characterized by adhesion of the ACL remnant to the posterior cruciate ligament. The histological changes of the first morphological pattern showed abundance of blood vessels and lymphocytes at the torn femoral end with few irregular collagen fibers. The second and third tear patterns showed decrement in the number of blood vessels and lymphocytes with longitudinally oriented collagen fibers. CONCLUSIONS: The morphological features of the ACL remnant in the first 3 months after injury showed no scar tissue and its histological features had the characteristics of a reparative phase. This phase was followed by a prolonged remodeling phase that ended with attachment of the remnant to the posterior cruciate ligament.

Medium-term outcome and classification of traumatic anterior hip dislocations.

INTRODUCTION: Traumatic anterior hip dislocations are subdivided to obturator (inferior) and pubic (superior) dislocations by Epstein's descriptive classification. This rare injury is thought to have favourable clinical outcomes. The incidence of associated femoral head and acetabular injuries has been low in past case series. We sought to revisit this injury and classification in the era of advanced imaging and contemporary surgical techniques. MATERIALS AND METHODS: A retrospective study of 15 patients treated for anterior hip dislocation was performed. Medical records were reviewed for demographic and surgical data. Imaging studies were revisited to determine direction of dislocation and associated fractures. Patients were assessed for pain, hip function using the modified Harris Hip Score (mHHS), hip range of motion and radiographic changes. Mean follow-up time was 3 years. RESULTS: Anterior dislocation occurred in an obturator (inferior), pubic (superior) or central direction. 9 patients had concomitant femoral head impaction and 7 patients suffered from acetabular fractures. 8 patients with an anterior hip dislocation underwent surgical treatment. This therapy, along with early range of motion and weight bearing, produced favourable clinical outcomes with 9 patients reporting no pain and an average mHHS of 83.8. 6 patients had heterotopic ossification at latest follow-up. CONCLUSIONS: Traumatic anterior hip dislocation is commonly associated with femoral head impaction and acetabular injuries which should be addressed operatively when appropriate to produce favourable results. In this paper, we propose a revision to the commonly used descriptive classification system.

Patient outcomes and survival following surgery for spinal metastases.

Context: There is no consensus on the preferred treatment for patients with spinal metastases. Little is known about the outcomes of surgery for this population. The objectives of this paper are to examine the outcomes of surgery among patients with spinal metastases suffering from cord compression (CC) or intractable pain (IP).Design: Retrospective, descriptive (level 4) case series.Setting: Rabin Medical Center, Israel.Participants: 61 patients undergoing surgery for spinal metastasis in a tertiary care hospital. Patients were divided into two groups: those with spinal CC and those with IP only.Interventions: Surgery due to CC or IP among patients with spinal metastases.Outcome measures: Frankel scale to assess neurological status, ambulatory and incontinence status, which were examined before surgery, at discharge and at last follow-up. Endpoints were death or latest follow-up visit. Survival and postoperative complications were documented.Results: There was no significant difference in Frankel score before and after surgery among patients with CC (mean score 3.5 and 3.4 respectively, P = 0.62). Complete incontinence rates significantly increased in patients with CC between preoperative and last follow-up examinations (13.6% vs. 20%, respectively, P = 0.05). Median survival of CC and IP groups was 201 and 402 days, respectively (P = 0.32). Complication rate was 41.4%.Conclusion: In our cohort, Frankel score and walking capability of patients with CC did not change postoperatively, but continence status deteriorated over time. Surgeons should advise patients on expected surgical outcomes, especially in non-ambulatory and incontinent patients.

The Reliability of Classifying the Morphology of Anterior Cruciate Ligament Remnants during Surgery.

Arthroscopic classification of the torn anterior cruciate ligament (ACL) morphology is fundamental for clinical studies on emerging techniques such as repair and preservation. At present, the most acknowledged classification is Crain description of four morphological patterns. The purpose of the study was to analyze the intra- and interobserver reliability of Crain classification in patients undergoing ACL reconstruction surgeries. The study included 101 patients who had ACL reconstruction surgery between the years 2014 and 2017. The morphological pattern of ACL remnant scar formation during surgery was observed and classified according to Crain by three orthopaedic surgeons. Inter- and intraobserver reliabilities were measured using kappa statistics. Intraobserver reliability for the Crain classification ranged from 0.63 to 0.83 (substantial to almost perfect agreement). Interobserver reliability was 0.51 (moderate agreement). In almost a third of the cases, observers reported on additional morphological pattern of scar formation that was not well defined by Crain. A modified classification of four patterns was suggested: (A) without scar tissue, (B) with adhesion to the femoral notch (wall or roof), (C) with adhesion to the notch and posterior cruciate ligament (PCL), and (D) with adhesion to the PCL. Reanalysis of these four morphological configurations resulted in interobserver reliability of 0.82 (almost perfect agreement). In conclusion, the Crain classification of torn ACL remnant morphology has moderate interobserver reliability; however, a suggested classification with modified and additional configurations has almost perfect reliability and may be useful for studies on ACL repair and preservation.

ASSESSMENT OF HUMERAL TORSION BY PALPATION IN BASEBALL PITCHERS: A VALIDATION STUDY.

BACKGROUND/PURPOSE: Greater humeral retroversion has been associated with shoulder and elbow injuries. Methods for measuring torsion include radiography, computed tomography (CT) and sonography (US) which may be costly or unavailable. A palpation method might be a reliable alternative to imaging techniques. The purpose of the current study was to examine the construct validity of the palpation technique for humeral torsion by (1) determining if a side-to-side difference in humeral torsion (HT) could be detected in a cohort of baseball pitchers using the palpation technique and (2) compare the side-to-side difference in HT obtained through the palpation method to the US method. HYPOTHESIS: Clinical assessment of HT by palpation is reliable and is as accurate as sonographic HT measurements among overhead athletes. METHODS: Twenty collegiate and high school pitchers were assessed. Bilateral shoulder passive external rotation (ER) and internal rotation (IR) range of motion were measured. Humeral torsion was indirectly measured using sonographic and palpatory methods. Paired t-tests were used to determine HT side-to-side difference measured by US versus palpation. Pearson's correlation coefficient (r) was used to determine the relationship between HT side-to-side difference detected by palpation and US, and relationships among IR and ER of the shoulder and HT side to-side difference measurements. RESULTS: There was significantly greater HT in dominant versus nondominant arm assessed by both palpation (5°±5, p=0.0004) and ultrasound (9°±11, p=0.0007). There was a positive correlation between both methods of HT measurement (r = 0.522, p=0.018). Palpation significantly underestimated HT as compared to US measurements (difference 4°±9, p=0.048). Difference in IR between shoulders correlated with HT measured by palpation (r=-0.651, p=0.002) and US (r=0.569, p=0.009). Increased ER in the dominant versus nondominant arm correlated with the side-to-side difference in HT measured by both palpation (r = 0.509, p=0.02) and US (r = 0.602, p=0.005). CONCLUSION: Greater HT on the dominant versus nondominant shoulder via palpation indicated this method can be used to assess HT in pitchers. HT assessed by palpation correlated with HT assessed by US. However, the magnitude of side-to-side difference in HT was smaller with palpation compared to US, and the two techniques should not be used interchangeably. Nevertheless, assessment of HT via palpation is a reliable and practical method and its use should be encouraged. LEVEL OF EVIDENCE: Level 3, measurement study.

[PLATELET RICH PLASMA INJECTION AS TREATMENT FOR ROTATOR CUFF TENDINOPATHY AND AS AN AUGMENTATION FOR ROTATOR CUFF REPAIR].

INTRODUCTION: Platelet rich plasma (PRP) intra-articular injections are gaining popularity worldwide. Albeit its vast application, its efficacy has not been proven unequivocally. This position statement was conducted for the Israeli Shoulder and Elbow Society and is intended to guide practitioners on treatment with PRP injections. Platelets secrete growth factors as part of their function which stimulates angiogenesis, cellular proliferation and tissue repair. Four main PRP subtypes exist: activated, non-activated, leucocyte-rich and leukocyte-poor. The function of leukocytes in PRP is not yet clearly understood and may locally cause harm. There are 3 main pathologies involving the shoulder and elbow in which PRP is being used: rotator cuff tendinopathy, rotator cuff tears and epicondylitis. Contraindications to PRP injection are infection, systemic disease presenting at the injection site, bone marrow pathology, thrombocytopenia, systemic steroids use and anticoagulant therapy. Most studies that explored the efficacy of PRP for rotator cuff tendinopathy failed to demonstrate any clinical benefit when compared to other non-operative treatments. Research shows that PRP injection improves rotator cuff tear healing when used as an augmentation to surgical repair, irrespective of tear size. Furthermore, high quality studies reported less pain in the early postoperative period with PRP augmentation in rotator cuff repair surgery but no significant changes to post-operative shoulder function. Larger studies were conducted on PRP injection to various joints which reported no side effects and approved its safety.

Which patients are less likely to improve after arthroscopic rotator cuff repair?

OBJECTIVE: The aim of this study was to evaluate which specific factors influence the improvement in function and to estimate the time to obtain pain relief following arthroscopic rotator cuff repair. METHODS: A total of 97 patients (57 men and 40 women; mean age: 55.5 ± 9.3 years) who had arthroscopic rotator cuff repair between 2013 and 2016 were included into the study. Multivariable stepwise analysis included preoperative variables (age, gender, body mass index, comorbidities, occupation and participation in sports, Oxford shoulder score at baseline, preceding injury and duration of preoperative symptoms) and arthroscopic findings (size of rotator cuff tear, pathology of the long head of the biceps and cartilage lesions). The change in the Oxford shoulder score at the last follow-up was modeled as a function of the above predictor variables. The time to regain a visual analogue scale (VAS) under two points following surgery was considered the time to regain substantial pain relief. RESULTS: The mean follow-up time was 33.2 ± 14.4 months. Twenty three patients had partial thickness and seventy four had full thickness supraspinatus tears. In third of the patients the tears were defined as large full thickness. At the last follow-up the mean Oxford shoulder score improved from 13.8 ± 4.8 to 42.1 ± 7.2 points (P < 0.001). The mean VAS improved from a preoperative score of 6.7 ± 1.3 points to 1.5 ± 0.6 points postoperatively (P < 0.001) and 80 (83%) patients declared they were satisfied to have had the operation. The mean time interval for substantial pain relief was 4.9 ± 3.6 months. Patients with higher preoperative Oxford shoulder score and larger tear size were correlated with lesser improvement in Oxford shoulder score (R = 0.5, P = 0.001). CONCLUSION: Arthroscopic rotator cuff repair improved pain and function at an average follow-up of three years. A substantial pain relief was regained within five months from surgery. Larger rotator cuff tear size and more favorable preoperative function were predictors of worse postoperative function. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury.

PURPOSE: To evaluate the progressive changes in the morphology of traumatic ruptures of the anterior cruciate ligament (ACL) over time. A secondary objective was evaluating their correlation with meniscal tears or chondral lesions. METHODS: The study included one hundred and one patients who underwent ACL reconstruction surgery of the knee after a definite date of injury. The torn ACL remnant morphological pattern was assessed and classified during arthroscopy. A correlation analysis was performed between the pathological features of the remnant and the time length from injury. In addition, correlation between ACL remnant subtypes and meniscal tears or chondral lesions was evaluated. RESULTS: At surgery there were four distinct ACL tear morphological patterns that were correlated to the time span from injury (r = 0.61, p < 0.001) and ended with scarring of the femoral remnant to the posterior cruciate ligament. The early pattern was noticed within median time of 2.6 months from injury and appeared as a separate stump with no scar tissue. The following two patterns appeared within 6 months from injury and were characterized by adhesion of scar tissue to different locations in the femoral notch. The last morphological pattern appeared as adherence of the ACL stump to the posterior cruciate ligament. This pattern was seen in some patients within 6 months from injury but was the dominant pattern later on and was also correlated with meniscal tears. CONCLUSIONS: During the first 3 months from injury the gross morphological features of the torn ACL remnant showed no scar. This phase was followed by scarring of the femoral remnant at first to the femoral notch, and eventually to the posterior cruciate ligament within 6 months from injury and later on. Therefore, further research on the healing potential of the human ACL stump and its biological environment should be focused on the first 3 months from injury. STUDY DESIGN: Case series; Level of evidence, 4.

A Novel Non-Invasive Adjuvant Biomechanical Treatment for Patients with Altered Rehabilitation after Total Knee Arthroplasty: Results of a Pilot Investigation.

BACKGROUND: Many factors contribute to suboptimal results after total knee arthroplasty (TKA) but little is known regarding the value of postsurgical rehabilitation after TKA. We examined the effects of an enhanced closed kinematic chain exercises program (AposTherapy) on gait patterns and clinical outcomes among patients with a lack of progress in their postsurgical rehabilitation. METHODS: Twenty-two patients were prospectively followed during the study. Gait spatiotemporal parameters were measured at the initial evaluation, after 15 minutes of therapy, and after 3 months of therapy. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the short form (SF) 36 health survey were completed by patients before treatment and after 3 months of treatment. RESULTS: The WOMAC and SF-36 scores improved significantly after 3 months of treatment. Gait velocity, single limb support, and step length of the operated leg improved significantly even after a single 15 minutes treatment. Normal gait velocity was observed in 36% of patients after 3 months of treatment. CONCLUSIONS: A physiotherapy program that included enhanced closed kinematic chain biomechanical therapy was beneficial for patients who experienced a suboptimal rehabilitation course after TKA.

Intramedullary nailing without curettage and cement augmentation for the treatment of impending and complete pathological fractures of the proximal or midshaft femur.

Metastases in the proximal femur and in the femoral diaphysis are usually treated with either cephalomedullary or intramedullary nailing. The benefit of curettage and augmentation of the nail with methyl methacrylate remains controversial. The authors retrospectively studied the outcomes with cephalomedullary and intramedullary nailing without curettage and methyl-methacrylate augmentation for lytic metastases of the proximal/diaphyseal femur. Twenty-one complete (11) or impending (10) pathological fractures in 19 consecutive patients were treated between January 2006 and August 2013. There were 11 women and 8 men. Their mean age was 62 years (range, 38 to 87). All patients received adjuvant chemotherapy or radiotherapy.The average postsurgical survival was 9.7 months (range 1-36 months). A single deep infection was debrided. Seventeen out of 19 patients were ambulatory, with or without a walking aid. No implant failure was noted. In other words, patients succumbed to the disease prior to hardware failure. Femoral nail insertion without curettage and cement augmentation provided satisfactory stabilization of proximal and diaphyseal femur fractures, impending or complete, even when there was massive bone destruction.

Low incidence of brain tumors among Ethiopian immigrants in Israel.

Studies comparing brain tumor incidence have consistently shown lower incidence in Africans compared to European populations. We compared the incidence of brain tumors in Ethiopian immigrants and their Israel-born descendants with other Israeli subpopulations. We included all cases of benign or malignant brain tumors from 1992 to 2003, as reported to the Israel Cancer Registry, except individuals known to have been irradiated for tinea capitis. Age standardized incidence rates (ASR) and standardized incidence ratios (SIR) were calculated. Among Ethiopian-born immigrants, 38 brain tumors were diagnosed (an ASR of 6.68 per 10(5) for all brain tumors among Ethiopian immigrants). The incidence of all brain tumors and malignant brain tumors among Ethiopian immigrants was significantly lower than that in Israeli-born Jews [SIR = 0.73, 95% confidence interval (CI) 0.50-0.96, and SIR = 0.65, 95% CI 0.32-0.98, respectively] and in all other Jewish subpopulations. Brain tumor incidence was not significantly different in Israeli-born children of Ethiopian immigrants aged 0-14 compared to Ethiopian immigrants of the same age group (SIR = 0.68, 95% CI 0.14-1.23), and was comparable to incidence among Israeli children of non-Ethiopian parents. We concluded that ethnicity influences brain tumor incidence, and that Ethiopian immigrants to Israel appear to be protected. If an environmental influence on the protective effect of the Ethiopian population in Israel exists, it was not demonstrated in the study in a statistically significant manner. Further investigation is needed to understand the factors involved in the incidence variation among different populations.