Can Repetition-based Training in a High-fidelity Model Enhance Critical Trauma Surgical Skills Among Trainees and Attending Surgeons Equally?

BACKGROUND: The evolution of warfare has resulted in a surge of high-energy blast injuries predominantly involving the lower extremities. Once thought to impact only forward-deployed military, such mechanisms of injury are becoming a harsh reality even in civilian territory. Proficiency in surgical techniques for extremity damage control is vital for surgeons, regardless of specialty. To evaluate and train surgical residents and attending surgeons in critical limb-salvage techniques, Theater Hospital Operations Replication (THOR) has been proposed as a high-fidelity training platform to enhance extremity surgery teaching practices and assess proficiency in fasciotomy, vascular shunting, and knee-spanning external fixation in a simulated, resource-limited environment. QUESTIONS/PURPOSES: Given the importance of proficiency and efficiency in surgeon ability to perform fasciotomies, vascular shunting, and placement of external fixators, in this study, we proposed two research questions: (1) Does repetition-based training within the THOR model improve surgeon knowledge and technical skill? (2) Are there differences in skill outcome when utilizing the THOR model based on surgical specialty (orthopaedic versus general) and/or level in training (attending versus resident)? METHODS: This was an observational learning outcome study performed in the bioskills lab at a single institution, the Naval Medical Center Portsmouth, in which 26 surgeons completed a same-day course consisting of pretraining assessment, cadaver training on three damage-control surgery techniques in a high-fidelity THOR environment, and post-training assessment. The surgeons were either general surgeons or orthopaedic surgeons and consisted of both residents and attending surgeons. Subjects underwent a pretraining knowledge assessment, followed by two rounds of performing simulated surgery. The first round of surgery included guidance and instruction from board-certified orthopaedic surgeons. After a short break for the subjects to review the material, the second round was completed without instruction. To answer our first question of how repetition-based training impacts surgical skill, our metrics included: Objective Structured Assessment of Technical Skills (OSATS) scores (range 1 to 5, scored lowest to highest, where higher scores represent optimal skill performance), procedural accuracy, a 10-question knowledge assessment administered before and after training (scored 0 to 10, where higher scores represent competency of the anatomy and procedure steps), and total procedure time. To address our second question, data on demographic characteristics were collected on all participants, which included surgical specialty, year in training, and gender. RESULTS: The general surgery residents' cohort demonstrated improvement in both mean ± SD OSATS scores (2.4 ± 0.7 before training versus 3.6 ± 0.6 after training, mean difference 1.2 [95% CI 0.4 to 2.0]; p = 0.01) and procedure duration (23 ± 7 minutes before training versus 16 ± 5 minutes after training, mean difference 6 minutes [95% CI 4 to 9]; p = 0.001) for external fixator procedures after THOR. Similar results were seen in fasciotomies after THOR. The orthopaedic surgery residents' cohort showed similar improvements in reducing procedure duration when performing knee-spanning external fixator surgery, as well as exhibited improvements during vascular shunting procedures in both mean ± SD OSATS scores (previously 3.3 ± 0.9 versus 4.0 ± 0.9, mean difference 0.7 [95% CI 0.2 to 1.2]; p = 0.01) and procedure duration (23 ± 5 minutes versus 14 ± 8 minutes, mean difference 10 minutes [95% CI 4 to 15]; p = 0.003) after THOR. When we compared the cohorts, general surgery attending surgeons demonstrated an improvement in vascular shunting procedure duration after instruction with the THOR model (19 ± 3 minutes versus 12 ± 4 minutes, mean difference 7 minutes [95% CI 1 to 13]; p = 0.03) and in overall knowledge scores (4.3 + 0.5 versus 8.0 ± 1.6, mean difference 3.8 [95% CI 0.5 to 7.0]; p = 0.04). The orthopaedic surgery attending surgeons yielded no improvement for any metric, pretraining and post-training. Using the prescores as a covariate, for almost all metrics analyzed, there were no differences between surgeon groups based on specialty after completing the repeated training. CONCLUSION: Use of the high-fidelity THOR training model improved proficiency in the examined sample of extremity damage-control procedures, thus demonstrating its efficacy in enhancing surgical skills and short-interval knowledge retention while simultaneously highlighting the importance of cadaver simulation training in enhancing surgical preparedness for complex trauma. CLINICAL RELEVANCE: The high-fidelity THOR training model represents a promising modality for preparing surgeons for extremity combat trauma management in resource-limited, high-stress environments. Whether in a wartime environment or in the civilian sector, efficient and skilled intervention are crucial in managing patient morbidity. Differences of a few minutes per procedure can mean all the difference in damage control, especially when compounded in situations where vascular shunting, knee-spanning external fixation, and lower leg four-compartment fasciotomy have to be performed together by both orthopaedic and general surgeons. The observational period in this study spanned 1 day and thus does not provide information on retention of long-term skills or knowledge. A follow-on study can assess how time from initial training to final evaluation impacts overall skill competency and knowledge.

Tropical Diseases in Okinawa: Overview and Emerging Infectious Diseases.

Okinawa prefecture is at risk for emerging infectious diseases due to its subtropical climate and its location within the Indo-Pacific region. Understanding the existing vectors and infectious agents contextualizes current threats, guides treatment, and informs prevention, and may be of unique concern in the setting of complex emergencies.

Marine Envenomation in Okinawa: Overview and Treatment Concept.

Okinawa prefecture is a popular tourist destination due to its beaches and reefs. The reefs host a large variety of animals, including a number of venomous species. Because of the popularity of the reefs and marine activities, people are frequently in close contact with dangerous venomous species and, thus, are exposed to potential envenomation. Commonly encountered venomous animals throughout Okinawa include the invertebrate cone snail, sea urchin, crown-of-thorns starfish, blue-ringed octopus, box jellyfish, and fire coral. The vertebrates include the stonefish, lionfish, sea snake, and moray eel. Treatment for marine envenomation can involve first aid, hot water immersion, antivenom, supportive care, regional anesthesia, and pharmaceutical administration. Information on venomous animals, their toxins, and treatment should be well understood by prehospital care providers and physicians practicing in the prefecture.

Effectiveness of Occupational Therapy Interventions to Improve Performance and Participation in Instrumental Activities of Daily Living (IADL) Among Adult Stroke Survivors (2009-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme and/or subthemes, related to a specific topic. This Systematic Review Brief summarizes findings from the systematic review on interventions to improve performance and participation in instrumental activities of daily living among adult stroke survivors. This theme reports on the effectiveness of virtual reality, exercise, vision rehabilitation, and community-based stroke empowerment group interventions.

Effectiveness of Task-Oriented Approaches and Occupation-Based Activities to Improve Performance and Participation in Instrumental Activities of Daily Living (IADL) Among Adult Stroke Survivors (2009-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for task-oriented/occupation-based approaches and augmenting task-oriented training with cognitive strategies to support performance in instrumental activities of daily living among adult stroke survivors.

High-Fidelity Orthopaedic Surgical Skills Models and Resident Performance in the Surgical Treatment of Tibial Plateau Fractures.

The purpose of this study was to quantify the impact of low-fidelity simulation on resident surgical skills education. Fourteen orthopaedic surgery residents (PGY-1 through PGY-5) were separated into two, training-level-matched cohorts - an untrained control cohort (UCC) and a low-fidelity Sawbones training cohort (SAW). Together, both cohorts received didactic instruction on the soft-tissue approach, intra-operative reduction, internal-fixation, and surgical wound closure of Schatzker II tibial plateau fractures. The SAW cohort first rehearsed open-reduction, internal-fixation on radiopaque Sawbones models (Pacific Research Laboratories Inc. Vashon, WA). Both cohorts were then evaluated while performing the same procedure on high-fidelity cadaveric models (Rimasys GmbH Cologne, Germany). Surgical skill and knowledge were assessed using the objective structured assessment of technical skills (OSATS) tool, a written exam, and an after-action survey. There were no significant differences in OSATS scores or written exam scores between the two cohorts. A near-linear positive relationship (R2 = 0.9737) existed between training year and average overall OSATS score. All residents expressed a preference for surgical skills training with high-fidelity cadaveric models. The results of this study fail to demonstrate a training advantage of low-fidelity Sawbones models when surgical skill is measured on high-fidelity cadaveric models. Despite this, residents across both cohorts qualitatively felt the high-fidelity models offered a better educational opportunity for surgical practice than did the low-fidelity Sawbones models. (Journal of Surgical Orthopaedic Advances 31(2):109-112, 2022).

Utility of Ottawa Ankle Rules in an Aging Population: Evidence for Addition of an Age Criterion.

The Ottawa ankle rules (OAR) indicate that any patient with the inability to ambulate up to four steps or with tenderness at either malleoli should receive diagnostic imaging for an acute ankle injury. Current trends indicate that health care providers tend to order more images in practice than necessary according to OAR. The purpose of this study is to analyze OAR in geriatric versus nongeriatric patients. Secondarily, we hope to refine these guidelines for ankle imaging in the hopes that health care providers will be comfortable in adhering to these guidelines more strictly. A retrospective chart review was conducted of 491 adult patients with an average (± standard deviation) age of 54.4 ± 21.6 years (range 18 to 96). Applying the current OAR resulted in a sensitivity of 98.2% and a specificity of 58.6% in this entire cohort. The calculated sensitivities were comparable between the nongeriatric and geriatric cohorts, at 98.60% and 97.99%, respectively. The specificities varied between the nongeriatric and geriatric cohorts, at 60.13% and 33.33%. We propose new guidelines that would mandate imaging studies for any patient ≥65 years of age presenting to the emergency department with ankle pain. When applying these proposed guidelines, the sensitivity of the entire study population was found to be improved to 99.0%, whereas the specificity dropped to 56.7%. The slight decrease in specificity was deemed acceptable because these guidelines are meant to be used as a screening tool and because the risk of OAR not correctly identifying ankle fracture (2% of geriatric fractures) was completely mitigated in the geriatric population.

Surgical Casualty Care in Contested Distributed Maritime Operations: Lessons Learned From the Falklands War.

The Falklands Campaign was fought a significant distance from the home base of the British Fleet. The planning and delivery of medical care during this campaign can provide significant lessons for strategic medical planning in other far spread geographic locations, including the Indo-Pacific region. Consideration of doctrine, including Role 1-4 facilities and the golden hour, may need to be reconsidered in light of changing scenarios. New concepts such as the "90-in-90" and "3-in-3" are also discussed as a framework for future planning in the U.S. Indo-Pacific Command area of responsibility.

Assessing Corpsmen Training Needs: Enhanced Medical Readiness in the Indo-Pacific for Near Peer.

INTRODUCTION: Naval operations rely on Corpsmen to provide combat casualty and primary care services to the fleet, including the Fleet Marine Force. The United States faces new conflict challenges with near-peer adversaries in the modern geo-political climate. Corpsmen will likely require new skills to care for patients in anti-access/area-denial regions and transport patients across expansive maritime environments. To help them adapt to these new challenges, we evaluated the need for Corpsmen curriculum reform at the III Marine Expeditionary Force (MEF). This model begins with a general needs assessment to target gaps between the current and ideal approaches identified by the stakeholders. MATERIALS AND METHODS: We identified 4 primary stakeholders within the Fleet Marine Force community: Marine Commanders (Society), Marines receiving treatment (Patients), Corpsmen providing care (Health Care Workers), and medical providers supervising Corpsmen (Medical Educators). We invited all ranks from III MEF to participate. The participants were interviewed in a mixture of focus groups and individual interviews in conversational and open-ended discussions. Transcripts of these discussions were analyzed and inductively coded using principles of grounded theory to identify prevailing themes that connected across interviews. The study was exempted by the Institutional Review Board at Naval Medical Center San Diego and Headquarters Marine Corps. RESULTS: The study involved 47 participants, including all stakeholders in III MEF and ranks from E1 through general officers. Through interviews and focus groups, 4 key themes emerged regarding Corpsmen's education: "Training," "Tasking," "Performance," and "Impact". "Training" discussions covered formal education, including gaps in basic training and the applicability of skills in civilian settings. "Tasking" examined daily responsibilities and equipment needs, such as teaching roles and first-responder care. "Performance" highlighted the quality of care and challenges in maintaining skills amid non-clinical tasks. Lastly, "Impact" assessed Corpsmen's influence on mission success and job satisfaction, revealing positive and negative perceptions among participants regarding their role and career prospects. CONCLUSION: The discussion emphasizes the importance of contextual factors in developing a Corpsmen-based curriculum, focusing on themes such as Training, Performance, and Impact. Tasking highlights critical areas for curriculum development, especially in educating Corpsmen as Educators, Leaders, and First-responder Caregivers. Gaps in training were identified, particularly in Non-trauma and First-responder Care, impacting Corpsmen's ability to handle diseases and injuries independently. Drawing parallels with Community Health Worker and Physician Extender (PE) education paradigms, we suggest adapting existing models to meet Corpsmen's needs. The discussion also delves into the history of employing PEs and developing training programs within the Naval Service. We propose a combination of Community Health Worker and PE-based education to enhance Corpsmen's competency and job satisfaction while facilitating their transition to civilian health care. Standardized curricula and training programs could improve skill transferability and readiness for Corpsmen in both military and civilian settings.

Distributed Maritime Operations and the Medical Challenge: How a Medical Common Operating Picture Can Help Bridge the Gap.

This work explores the challenges of delivering medical care in the geographically dispersed and resource-constrained environment of Distributed Maritime Operations (DMO) and Expeditionary Advanced Base Operations (EABO). Traditional medical planning approaches may struggle to adapt to the vast operational space, extended evacuation times, and limited medical force present in these scenarios. The concept of a Medical Common Operating Picture (COP) emerges as a potential solution. By providing a shared view of the medical situation across the theater, encompassing logistics, personnel, and patient data, a medical COP has the potential to facilitate medical command and control (MED C2) in DMO/EABO. The implementation of a medical COP has the potential to optimize resource allocation, enhance situational awareness, streamline medical evacuation, and reduce healthcare provider moral injury in large-scale combat operations. A medical COP will allow medical planners to make informed decisions on triage, resupply, and evacuation, ensuring the best use of limited medical resources. This is done by leveraging a comprehensive understanding of the medical landscape, enabling informed clinical and operational decision-making by humanitarian and combat personnel respectively. A fully realized medical COP system will enable a dynamic theater evacuation policy, balancing the conflicting needs of patient care at higher echelons with the operational expediency of returning servicemembers to their operational units, thereby maximizing evacuation effectiveness. It will further enable medical personnel to perform dynamic casualty triage based on operational realities, mitigating potential ethical dilemmas. Implementing such a medical COP system will require overcoming communication limitations to facilitate data exchange and potentially integrating clinical decision support tools for real-time data analysis and recommendations. It will also require the rapid adoption of modernized operational medicine documentation solutions by medical assets within the operational forces. Ultimately, this work suggests that a medical COP has the potential to bridge the gap between traditional medical planning and the unique demands of DMO/EABO, ultimately optimizing casualty care, maximizing resource efficiency, and preserving the fighting force.

Biomechanical Analysis of Combined Medial Calcar and Lateral Locked Plating Versus Isolated Lateral Locked Plating of Proximal Humerus Fractures.

OBJECTIVE: Medial calcar buttress plating combined with lateral locked plating is biomechanically tested against isolated lateral locked plating in synthetic humeri models for the treatment of proximal humerus fractures. METHODS: Proximal humerus fractures (OTA/AO type 11-A2.1) were manufactured in 10 pairs of Sawbones humeri models (Sawbones, Pacific Research Laboratories, Vashon Island, WA). Specimen were randomly assigned and instrumented with either medial calcar buttress plating combined with lateral locked plating (CP) or isolated lateral locked plating (LP). Nondestructive torsional and axial load tests were performed to evaluate construct stiffness. Large-cycle axial tests were conducted followed by destructive ramp-to-failure tests. Cyclic stiffness was compared in both nondestructive and ultimate failure loads. Failure displacement was recorded and compared between groups. RESULTS: The addition of medial calcar buttress plating to lateral locked plating constructs significantly increased the axial ( P < 0.01) and torsional ( P < 0.01) stiffness of the construct compared with isolated lateral locked plating by 95.56% and 37.46%, respectively. All models demonstrated greater axial stiffness ( P < 0.01) after 5000 cycles of axial compression, not dependent on the fixation method. During destructive testing, the CP construct withstood 45.35% larger load ( P < 0.01) and congruently exhibited 58% less humeral head displacement ( P = 0.02) before failure when compared with the LP construct. CONCLUSION: This study demonstrates the biomechanical superiority of medial calcar buttress plating when combined with lateral locked plating as compared with isolated lateral locked plating of OTA/AO type 11-A2.1 proximal humerus in synthetic humeri models.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods.

BACKGROUND: Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods. PURPOSE/HYPOTHESIS: The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation. STUDY DESIGN: Meta-analysis. METHODS: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months' mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05. RESULTS: Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 (P = .004) and satisfaction with cosmesis by 20.50% (P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair. CONCLUSION: Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment.

BACKGROUND: The incidence of pectoralis major tendon tears is increasing, and repair is generally considered; however, a paucity of comparative data are available to demonstrate the superiority of operative treatment. PURPOSE/HYPOTHESIS: The purpose of this study is to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared with nonoperative treatment. METHODS: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed by use of MEDLINE, SPORTDiscus, CINAHL, Cochrane, EMBASE, and Web of Science databases. We included English-language studies that had a minimum of 6 months of average follow-up and 5 cases per study. The MINORS (Methodological Index for Non-Randomized Studies) was used to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect sizes were calculated from random-effects models. Continuous variables were assessed by use of mixed-model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed via the Freeman-Tukey log-linear transformation for variance stabilization and then assessed through use of a mixed model with a study level random effect and subsequently back-transformed. Significance was set at P < .05. RESULTS: A total of 23 articles with 664 injuries met the inclusion criteria for comparison. All patients were male, with an average age of 31.48 years; 63.2% of injuries occurred during weight training, and the average follow-up was 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment, with relative improvements of functional outcome by 23.33% (0.70 improvement by Bak criteria which is scored 1-4; P = .027), full isometric strength 77.07% (P < .001), isokinetic strength 28.86% (P < .001) compared with the uninjured arm, cosmesis satisfaction 13.79% (P = .037), and resting deformity 98.85% (P < .001). The overall complication rate for operative treatment was 14.21%, including a 3.08% rate of rerupture. CONCLUSION: Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. Statistically significant improvements were noted in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity.

Tibial Plateau Fracture Following Anterior Cruciate Ligament Reconstruction with a Bone-Patellar Tendon-Bone Allograft: A Case Report.

CASE: A 36-year-old woman sustained a medial tibial plateau fracture involving a tibial tunnel that had been used 4 years prior for an anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone (BPTB) allograft in the same knee. At 26 months following open reduction and internal fixation of the tibial plateau fracture (6 years following the index ACL reconstruction), the patient returned to full activity. CONCLUSION: To our knowledge, this is the first report of a tibial plateau fracture following ACL reconstruction with a BPTB allograft, which adds to the paucity of literature discussing tibial plateau fractures following ACL reconstruction and discusses the potential predisposing factors to fracture such as ACL graft selection and surgical technique.

Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis.

BACKGROUND: No meta-analysis has compared outcomes of operative and nonoperative proximal hamstring avulsion treatment. PURPOSE: To compare outcomes of operative and nonoperative proximal hamstring avulsion treatment, including acute, chronic, partial, and complete repairs. STUDY DESIGN: Meta-analysis. METHODS: PubMed, CINAHL, SPORTdiscus, Cochrane Library, EMBASE, and Web of Science were searched up to July 2016. Three authors screened the studies and performed quality assessment using criteria from the Methodologic Index for Nonrandomized Studies. A best evidence synthesis was subsequently used. RESULTS: Twenty-four studies (795 proximal hamstring avulsions) were included. Twenty-two studies included proximal hamstring avulsion repairs; 1 study had proximal hamstring avulsion repairs and a control group of nonoperatively treated proximal hamstring avulsions; and 1 study had solely nonoperatively treated proximal hamstring avulsions. The majority of studies were of low methodological quality. Overall, repairs had significantly higher patient satisfaction (90.81% vs 52.94%), hamstring strength (85.01% vs 63.95%), Lower Extremity Functional Scale scores (72.77 vs 69.53), and single-legged hop test results (119.1 vs 56.62 cm) (all P < .001); complications occurred in 23.17% of cases. Compared with chronic repairs, acute avulsion repairs had greater patient satisfaction (95.48% vs 83.79%), less pain (1.07 vs 3.71), and greater strength (85.2% vs 82.8%), as well as better scores for the Lower Extremity Functional Scale (75.64 vs 71.5), UCLA activity scale (University of California, Los Angeles; 8.57 vs 8.10), and Single Assessment Numeric Evaluation (93.36 vs 86.50) (all P < .001). Compared with partial avulsion repairs, complete avulsion repairs had higher patient satisfaction (89.64% vs 81.35%, P < .001), less pain (1.87 vs 4.60, P < .001), and higher return to sport or preinjury activity level, but this was insignificant (81.43% vs 73.83%, P = .082). Partial avulsion repairs had better hamstring strength (86.04% vs 83.71%, P < .001) and endurance (107.13% vs 100.17%, P < .001). Complete repairs had significantly higher complication rates (29.38% vs 11.27%, P = .001). CONCLUSION: Proximal hamstring avulsion repair resulted in superior outcomes as compared with nonoperative treatment, although the complication rate was 23.17%. The nonoperative group was quite small, making a true comparison difficult. Acute repairs have better outcomes than do chronic repairs. Complete avulsion repairs had higher patient satisfaction, less pain, and a higher complication rate than partial avulsion repairs, although partial avulsion repairs had better hamstring strength and endurance. Studies of high methodological quality are lacking in terms of investigating the outcomes of proximal hamstring avulsion repairs.

Outcomes and Predictors of Success for Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty.

A stiff total knee arthroplasty (TKA) can manifest as pain and decreased range of motion (ROM). When conservative management including physical therapy and manipulation under anesthesia fails, arthroscopic lysis of adhesions (LOA) is frequently pursued. The authors examined the efficacy of LOA for the stiff TKA. They retrospectively reviewed the records of 18 patients who underwent LOA for stiff TKA between April 2013 and June 2016 and who failed to meet 90° ROM at 6 weeks postoperatively. They recorded patient demographics, ROM prior to TKA, and incidence of manipulation under anesthesia between initial TKA and LOA as well as pre- and postoperative outcomes of ROM, pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The mean time from TKA to LOA was 117 days, with a mean follow-up of 449 days. Mean improvements in ROM flexion contracture, flexion, and arc were 6.11° (P<.05), 29.45° (P<.001), and 35.56° (P<.001), respectively. Range of motion improved for 17 of 18 patients. The WOMAC was completed by 15 of 18 patients, with a mean improvement in scores of 32.23% (P<.001); all 15 patients with available WOMAC scores improved. Pain score improved by a mean of 2.17 (P<.001), with 14 of 18 patients reporting decreased pain. Improvements in flexion contracture, flexion, ROM arc, WOMAC scores, and pain were all statistically significant (P<.05). Age, weight, body mass index, and time to LOA were found to be statistically significant predictors of outcome. Finally, pre-TKA and pre-LOA ROM parameters were found to be statistically significant predictors of post-LOA ROM outcomes. [Orthopedics. 2017; 40(6):e1062-e1068.].