Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

Background: Accurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GBL >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as magnetic resonance imaging (MRI) scans, can be used to quantify GBL prior to surgery using the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without using best-fit circle measurements on MRI. Methods: A retrospective review was performed which included 122 patients over an 8-year period that had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured using best-fit circle technique to determine true GBL and compare that to the surgeons' preoperative and intraoperative estimation of GBL. Results: GBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (12/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when using visual inspection of the MRI or intraoperative inspection alone. Conclusion: Simple visual inspection of glenoid images on MRI scan and visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of GBL especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan using the best-fit circle technique is recommended in all cases of instability surgery.

Failed surgical treatment for lateral epicondylitis: literature review and treatment considerations for successful outcomes.

Background: Lateral epicondylitis is a common cause of elbow pain in the general population. It is recognized as a degenerative tendinopathy of the common extensor origin believed to be multifactorial, involving elements of repetitive microtrauma associated with certain physiologic and anatomic risk factors. Methods: Initial treatment typically involves a combination of conservative treatment measures, with up to 90% success at 12-18 months. Surgical treatment is reserved for recalcitrant disease; traditionally involving open surgical débridement of the common extensor origin with reported success rates greater than 90%. Results: Failure of surgical treatment can be multifactorial and present a challenge in determining the optimum management. Residual symptoms may be due to an incorrect initial diagnosis, inadequate surgical débridement, new pathology as a complication of the initial surgery and/or other patient-related and physician- related factors. Even more of a challenge is the possibility that etiology can be due to a combination of listed factors. Discussion: In this review, we review the classification scheme for evaluating failed surgical treatment of LE first proposed by Morrey and expand on this classification system based on the senior author's experience. We present the senior author's preferred systematic approach to evaluation and management of these patients, as well as a salvage surgery technique used by the senior author to address the most common etiologies of surgical failure in these patients.

Isolated Second and Third Carpometacarpal Joint Injuries: A Report of 2 Cases.

CASES: Two high-level male athletes with isolated second and third carpometacarpal (2, 3 CMC) joint injuries presented with mid-dorsal wrist pain, decreased grip strength, and painful wrist motion. Both reported inciting trauma-1 acutely and the other months after the original injury. Both exhibited 2, 3 CMC joint tenderness and positive provocative testing on exam. Advanced imaging confirmed 2, 3 CMC joint injuries. Both patients returned to preinjury level of play 3 months after diagnosis and surgical treatment. CONCLUSION: 2, 3 CMC joint injuries should be considered when evaluating radial/mid-dorsal wrist pain. Surgical treatments range from pin stabilization to fusion depending on chronicity and associated degenerative joint changes.

The selflessness of an 8-year-old.

This short 55-word story highlights an Internal Medicine resident's experience talking to the family of a patient dying while on life support in the ICU, and the family dynamic while the resident discusses end of life care and withdrawal of life support. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Finger Metacarpophalangeal Joint Injuries in Athletes: Evaluation, Diagnosis, Treatment, and Return to Play.

Metacarpophalangeal (MCP) joint injuries of the fingers are frequent among athletes and can markedly affect an athlete's ability to perform at a high level. Despite this, MCP finger injuries in athletes are not frequently discussed, particularly in comparison with MCP joint injuries of the thumb, and remain unrecognized and undertreated injuries in this cohort. Accurate diagnosis and treatment of these injuries begins with an understanding of all the potential diagnoses. The purpose of this study was to review the pertinent anatomy and differential diagnoses for MCP joint injuries in athletes, including the evaluation and management to allow for safe and early return to play.

Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment.

Finger injuries involving the proximal interphalangeal (PIP) joint are common, particularly among athletes. Injury severity is often underappreciated at initial presentation and may be dismissed broadly as a "jammed finger" injury. Delayed diagnosis and treatment of certain injuries can have an important impact on the patient's chance of regaining full function. Central slip and PIP volar plate injuries are frequently encountered injuries that, if left untreated, can lead to the permanent loss of function of the proximal interphalangeal joint. Despite the differing mechanisms of these 2 pathologies, volar plate hyperextension injuries often present with a PIP joint flexion contracture and mild distal interphalangeal joint hyperextension deformity. This is similar to a boutonniere deformity seen after an injury to the central slip, and thus, has been referred to as a "pseudo-boutonnière" deformity. Distinguishing these 2 diagnoses is important, as treatment differs, and highlights the importance of thoroughly understanding the anatomy and relevant clinical applications when evaluating PIP joint injuries.

A Combined Revision Surgical Technique for Failed Operative Lateral Epicondylitis With Concomitant Radial Tunnel Syndrome.

Lateral epicondylitis afflicts a large percentage of the population with most recovering through conservative treatment. The 5% to 10% of patients who undergo operative intervention are met with mixed results. Those that fail to improve often demonstrate a complex presentation of inadequate debridement of the "angiofibroblastic tissue," missed concomitant radial tunnel syndrome, and iatrogenic residual devascularized tissue resulting from the index procedure. To address all 3 of these causes of failure, the authors have developed a revision procedure that includes repeat debridement of residual tendinosis, decompression of the posterior interosseous nerve, and a vascularized anconeus muscle flap to help cushion soft tissue defects and promote a healthier environment for healing. Performed initially in part in 20 patients, this combined procedure has developed into our recommended treatment for these challenging patients.

Middorsal Wrist Pain in the High-Level Athlete: Causes, Treatment, and Early Return to Play.

Wrist injuries in the competitive athlete are a common reason for evaluation related to an acute injury or after symptoms have become chronic. While radius- and ulna-sided wrist pain are common topics covered in the literature, middorsal wrist pain is more common than the available literature would suggest. Missed diagnoses and inadequate treatment can significantly increase athlete morbidity and delay return to play. The goal of this article was to review the differential diagnosis of middorsal wrist pain in the athlete and discuss the diagnosis, treatment, and early return to play for each condition.

Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations.

Odontoid fractures represent the most common fractures involving C2 and the most common cervical spine fractures in patients older than 65 years. Despite their increasing frequency, optimal management of these injuries remain a subject to debate. Although types I and III injuries have relatively good healing potential with nonsurgical treatment, type II fractures carry a higher risk for nonunion. In particular, elderly patients are at risk for nonunion or fibrous malunion after nonsurgical treatment; however, increased medical comorbidities and poor bone quality also increase the risks of surgery in this cohort. The high morbidity and mortality associated with these injuries has made it an area of particular interest among spine surgeons. The purpose of this review was to summarize the pathophysiology, evaluation, and diagnosis of these injuries and to review controversies in management and considerations for treatment based on the most recent available literature.

Percutaneous Spine Biopsy: A Review of the Current Literature.

Spine lesions are often the result of pathologic processes elsewhere in the body; prompt and accurate diagnosis are crucial to optimize treatment. Despite modern advances in imaging modalities, definitive diagnosis ultimately requires biopsy and histologic analysis. Although open surgical biopsy has traditionally been considered the benchmark, percutaneous image-guided needle biopsy of the spine has proven to be a safe and highly effective method in making a diagnosis. Choosing the optimal biopsy approach, instrumentation and modality of image guidance may depend on a number of factors including lesion type, location, and level within the spine. Knowledge of relevant anatomy, indications, contraindications, and potential complications are critical to a successful biopsy procedure.

A Randomized Study Using Telepresence Robots for Behavioral Health in Interprofessional Practice and Education.

Background: The events of the coronavirus disease 2019 (COVID-19) pandemic forced the world to adopt telemedicine frameworks to comply with isolation and stay-at-home regulations. Telemedicine, in various forms, has been used by patients and medical professionals for quite some time, especially telepsychiatry. To examine the efficacy and role of telesimulation as a method to educate health sciences students via telepresence robots. The study recruited students from the above health science disciplines. All participants were trained to administer a contextual interview to a standardized patient (SP) for mental health concerns. Methods: The completion of the contextual interview observation form adult (CIOF-A), National Aeronautics and Space Administration Task Load Index, self-efficacy in patient centeredness questionnaire (SEPCQ), and communication skills attitude scale with or without a telepresence robot. All participants completed baseline metrics and were trained to conduct a contextual interview to an SP. Researchers block-randomized the participants to either the telepresence robot group (TP) or in-person (IP) group. Results: The study recruited n = 43 participants to the IP group (n = 21) or TP group (n = 22). Mean participant demographics of age were 25.3 (±1.9) years in the IP group and 24.3 (±2.1) years for the TP group. Mean and standard deviation scores with effect sizes in CIOF-A scores IP: 0.05 (±1.91) and TP: -0.45 (±1.71), Cohen's d = 0.28; SEPCQ-Patient Domain scores IP: 0.42 (±4.69) and TP: 0.50 (±7.18), Cohen's d = 0.01; change in SEPCQ-Sharing Domain scores IP: 0.53 (±5.10) and TP: 0.91 (±9.98), Cohen's d = 0.05. These effect sizes will inform future studies and appropriate sample sizes. Conclusion: These data indicate that health sciences students utilizing a telepresence robot in an SP scenario to perform a behavioral health screening felt as comfortable and competent as those health sciences students performing the same behavioral health screening in person. ClinicalTrials.gov Identifier: NCT03661372.