Shoulder Lesions Do Not Increase Inflammatory Biomarkers in Patients Undergoing Surgery for Glenohumeral Instability: An Exploratory Study

Circulating protein biomarkers have demonstrated utility as a diagnostic tool in predicting musculoskeletal disease severity, but their utility in the evaluation of shoulder lesions associated with shoulder instability is unknown. Thus, the purpose of this exploratory study was to determine whether preoperative biomarkers of cartilage turnover and inflammation are associated with specific shoulder lesions in shoulder instability. Thirty-three patients (29.9 ± 9.4 years of age, 4.5 ± 4.7 dislocations) undergoing surgical treatment for shoulder instability were assessed for the presence or absence of associated shoulder lesions. Biomarkers including cartilage oligomeric matrix protein (COMP), C-reactive protein (HS-CRP), interleukin-8 (IL-8), and macrophage inflammatory protein-1β (MIP-1b) were collected at the time of surgery. Patients with Hill-Sachs lesions had a 31% increase in COMP plasma levels (p=0.046). No other significant differences were observed for COMP, HS-CRP, IL-8, and MIP-1b with any shoulder lesion including Hill-Sachs lesions, capsular injuries, bony Bankart lesions, and SLAP lesions. In conclusion, inflammatory biomarkers including HS-CRP, IL-8, and MIP-1b were not associated with specific shoulder lesions, while biomarkers of cartilage turnover (COMP) were only elevated in Hill-Sachs lesions. These findings suggest that these biomarkers may have limited utility as prognostic indicators in patients with shoulder instability, though large-scale and longitudinal studies are still necessary.

Osteochondral Allograft Transplantation of the Knee in Patients with an Elevated Body Mass Index

OBJECTIVE

To characterize the graft survivorship and clinical outcomes of osteochondral allograft transplantation (OCA) of the knee in patients with an elevated body mass index (BMI).

DESIGN

Prospective data on 38 consecutive patients with a BMI ≥30 kg/m² treated with OCA from 2000 to 2015 were reviewed. Complications, reoperations, and patient responses to validated outcome measures were examined. Failures were defined by any removal/revision of the allograft or conversion to arthroplasty.

RESULTS

Thirty-one knees in 31 patients (mean age, 35.4 years [range, 17-61 years]; 87% male) met the inclusion criteria. Mean BMI was 32.9 kg/m² (range, 30-39 kg/m²). Mean chondral defect size was 6.4 cm² (range, 1.0-15.3 cm²). Prior to OCA, 23 patients (74%) had undergone previous surgery to the ipsilateral knee. Mean duration of follow-up was 4.1 years (range, 2-11 years). After OCA, 5 knees (13%) underwent conversion to unicompartmental (1) or total (4) knee arthroplasty. Two- and 5-year graft survivorship were 87% and 83%, respectively. At final follow-up, clinically significant improvements were noted in the pain (49.3-72.6) and physical functioning (52.9-81.3) subscales of the Short Form-36 ( P ≤ 0.001), International Knee Documentation Committee subjective form (43.5-67.0; P = 0.002), Knee Outcome Survey-Activities of Daily Living (58.2-80.4; P = 0.002), and overall condition subscale of the Cincinnati Knee Rating System (4.7-6.9; P = 0.046).

CONCLUSIONS

OCA can be a successful midterm treatment option for focal cartilage defects of the knee in select patients with a BMI ≥30 kg/m².

The Association of Vitamin D Status in Lower Extremity Muscle Strains and Core Muscle Injuries at the National Football League Combine

PURPOSE

To evaluate the association between serum vitamin D level and the prevalence of lower extremity muscle strains and core muscle injuries in elite level athletes at the National Football League (NFL) combine.

METHODS

During the 2015 NFL combine, all athletes with available serum vitamin D levels were included for study. Baseline data were collected, including age, race, body mass index, position, injury history specific to lower extremity muscle strain or core muscle injury, and Functional Movement Screen scores. Serum 25-hydroxyvitamin D was collected and defined as normal (≥32 ng/mL), insufficient (20-31 ng/mL), and deficient (<20 ng/mL). Univariate regression analysis was used to examine the association of vitamin D level and injury history. Subsequent multivariate regression analysis was used to examine this relation with adjustment for collected baseline data variables.

RESULTS

The study population included 214 athletes, including 78% African American athletes and 51% skilled position players. Inadequate vitamin D was present in 59%, including 10% with deficient levels. Lower extremity muscle strain or core muscle injury was present in 50% of athletes, which was associated with lower vitamin D levels (P = .03). Athletes with a positive injury history also showed significantly lower vitamin D levels as compared with uninjured athletes (P = .03). African American/black race (P < .001) and injury history (P < .001) was associated with lower vitamin D. Vitamin D groups showed no differences in age (P = .9), body mass index (P = .9), or Functional Movement Screen testing (P = .2). Univariate analysis of inadequate vitamin D levels showed a 1.86 higher odds of lower extremity strain or core muscle injury (P = .03), and 3.61 higher odds of hamstring injury (P < .001). Multivariate analysis did not reach an independent association of low vitamin D with injury history (P = .07).

CONCLUSIONS

Inadequate vitamin D levels are a widespread finding in athletes at the NFL combine. Players with a history of lower extremity muscle strain and core muscle injury had a higher prevalence of inadequate vitamin D.

LEVEL OF EVIDENCE

Level IV, retrospective study-case series.

Displaced Proximal Humerus Fractures: is a Sling as Good as a Plate?

The treatment of displaced proximal humerus fractures is challenging and complex, as its success is predicated on multiple factors. While it is clear that a majority of proximal humerus fractures may be treated nonoperatively, it is less clear which patients benefit from surgical management. The PROFHER trial, a randomized controlled study, used patient-reported outcomes to compare surgical to nonsurgical management of displaced proximal humerus fractures. The purpose of this review is to highlight the strengths and weaknesses of the PROFHER trial and to assess the validity of its conclusion in the context of existing literature. The authors found no difference in the Oxford Shoulder Score (OSS) between the surgical and nonsurgical groups. Additionally, no difference was found between groups in any of the secondary outcomes, which included the Short-Form 12 (SF-12) health survey, surgical and fracture-related complications, additional surgery or therapy, inpatient medical complications, and mortality. They concluded that the recent increase in surgical management of proximal humerus fractures is perhaps unwarranted. While the randomization was successful and the pragmatic design may enable greater generalizability, this study possesses numerous flaws inherent in such an ambitious endeavor, including an inability to identify specific factors which explain the lack of superiority of surgical management. Despite its weaknesses, this study is a valuable datapoint which encourages surgeons to reexamine their surgical indications for this injury.

Arthroscopically Assisted Open Reduction-Internal Fixation of Ankle Fractures: Significance of the Arthroscopic Ankle Drive-through Sign

Standalone open reduction-internal fixation (ORIF) of unstable ankle fractures is the current standard of care. Intraoperative stress radiographs are useful for assessing the extent of ligamentous disruption, but arthroscopic visualization has been shown to be more accurate. Concomitant arthroscopy at the time of ankle fracture ORIF is useful for accurately diagnosing and managing syndesmotic and deltoid ligament injuries. The arthroscopic ankle drive-through sign is characterized by the ability to pass a 2.9-mm shaver (Smith & Nephew, Andover, MA) easily through the medial ankle gutter during arthroscopy, which is not usually possible with both an intact deltoid ligament and syndesmosis. This arthroscopic maneuver indicates instability after ankle reduction and fixation and is predictive of the need for further stabilization. Furthermore, when this sign remains positive after fracture fixation, it may guide the surgeon to further evaluate the adequacy of fixation for the possible need for further fixation of the syndesmosis or deltoid. We present the case of an ankle fracture managed with arthroscopy-assisted ORIF and describe the clinical utility of the arthroscopic ankle drive-through sign.

Increased Lateral Tibial Slope Is a Risk Factor for Pediatric Anterior Cruciate Ligament Injury: An MRI-Based Case-Control Study of 152 Patients

BACKGROUND

Increased posterior tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in adults. A similar association has not been rigorously examined in children and adolescents.

PURPOSE

To determine whether alterations in posterior tibial slope are associated with ACL tears in pediatric and adolescent patients and to quantify changes in tibial slope by age.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Magnetic resonance imaging (MRI) studies of the knee were reviewed by 3 raters blinded to each other in a 1:1 sample of cases and age- and sex-matched controls. A total of 76 skeletally immature ACL-injured knees were compared with 76 knees without ACL injury; the mean age of the study population was 14.8 ± 1.3 years. The posterior slope of the articular surface of the medial tibial plateau and lateral tibial plateau was measured by use of a method similar to that used in previous studies in adult populations. The current study technique differed in that the slope was measured on the cartilage surface, not the subchondral bone. Comparisons between knees were made with t tests, and Spearman correlation analysis was used to assess changes in tibial slope with advancing age.

RESULTS

Increased slope of the lateral tibial plateau (LTS) was significantly increased in ACL-injured patients compared with controls (5.7° ± 2.4° vs 3.4° ± 1.7°; P < .001). There was no statistically significant difference in the slope of the medial tibial plateau (MTS) in the ACL-injured and control knees (5.4° ± 2.2° vs 5.1° ± 2.3°; P = .42). There was no difference in LTS between male and female patients (4.46° vs 4.58°; P = .75). Receiver operating characteristic (ROC) analysis of the LTS revealed that a posterior tibial slope cutoff of >4° resulted in a sensitivity of 76% and a specificity of 75% for predicting ACL tears in this cohort. Spearman correlation analysis revealed that MTS and LTS decreased, or flattened, by 0.31° (P = .028, correlation coefficient r = -0.18) and 0.37° (P = .009, correlation coefficient r = -0.21) per year, respectively, as adolescents age.

CONCLUSION

The LTS was significantly associated with an increased risk of ACL injury in pediatric and adolescent patients. The MTS was not associated with risk of injury. Posterior slope was found to decrease, or flatten, with age. A cutoff of >4° for the posterior slope of the lateral compartment is 76% sensitive and 75% specific for predicting ACL injury in this cohort. The LTS did not influence the incidence of ACL injury differently between sexes.

Is deltoid and lateral ligament reconstruction necessary in varus and valgus ankle osteoarthritis, and how should these procedures be performed?

Varus and valgus ankle deformities represent a challenge to the foot and ankle surgeons. The presence of degenerative changes of the tibiotalar joint articular surfaces introduces an additional layer of complexity. Reconstruction of such deformities requires a customized approach to each patient. Surgical intervention often requires joint-sparing realignment, arthroplasty, and/or arthrodesis, depending on the severity of deformity and the joint surface integrity. The ligamentous stability of the ankle plays an essential role in the preservation and optimization of function. This article reviews the role of deltoid and lateral ligament reconstruction in the treatment of varus and valgus ankle osteoarthritis.

A narrative review of surgical resident duty hour limits: where do we go from here?

BACKGROUND

Resident duty hour limits have been a point of debate among educators, administrators, and policymakers alike since the Libby Zion case in 1984. Advocates for duty hour limits in the surgical subspecialties cite improvements in patient safety, whereas opponents claim that limiting resident duty hours jeopardizes resident education and preparedness for independent surgical practice.

METHODS

Using orthopaedic surgery as an example, we describe the historical context of the implementation of the duty hour standards, provide a review of the literature presenting data that both supports and refutes continued restrictions, and outline suggestions for policy going forward that prioritize patient safety while maintaining an enhanced environment for resident education.

RESULTS

Although patient safety markers have improved in some studies since the implementation of duty hour limits, it is unclear whether this is due to changes in residency training or external factors. The literature is mixed regarding academic performance and trainee readiness during and after residency.

CONCLUSION

Although excessive duty hours and resident fatigue may have historically contributed to errors in the delivery of patient care, those are certainly not the only concerns. An overall "culture of safety," which includes pinpointing systematic improvements, identifying potential sources of error, raising performance standards and safety expectations, and implementing multiple layers of protection against medical errors, can continue to augment safety barriers and improve patient care. This can be achieved within a more flexible educational environment that protects resident education and ensures optimal training for the next generation of physicians and surgeons.

Recurrent and metastatic primary cutaneous mucinous carcinoma after excision and Mohs micrographic surgery

Primary cutaneous mucinous carcinoma is a neoplasm of sweat gland origin. Optimal management guidelines have not been established for this rare tumor. It is treated most commonly by traditional excision and more recently by Mohs micrographic surgery in an effort to decrease its recurrence rate. We report a case of primary cutaneous mucinous carcinoma with multiple recurrences and metastases following 3 excisions and 2 Mohs procedures, highlighting the potential difficulty in treating this cancer and suggesting the need for a more effective treatment approach.