Peripheral tear of the triangular fibrocartilage complex: diagnostic accuracy of magnetic resonance imaging and diagnostic performance of the primary and secondary signs

OBJECTIVE

This study is to assess the diagnostic performance of magnetic resonance imaging (MRI) findings for type 1B triangular fibrocartilage complex (TFCC) tear of the wrist.

MATERIALS AND METHODS

This study retrospectively enrolled 78 patients to examine the diagnostic performance of preoperative MRI examinations in patients with type 1B TFCC tears. Thirty-nine participants had confirmed type 1B TFCC tear. The control group included 39 patients who were randomly selected from 1157 patients who underwent MRI for wrist pain. Both groups underwent a review of 19 MRI findings by two independent radiologists, and the correlation between each diagnostic finding and type 1B TFCC tear was assessed using the chi-squared test. The 19 MRI findings comprised eight primary signs of abnormalities in the distal or proximal lamina, in conjunction with 11 secondary signs suggestive of abnormalities in the surrounding structures.

RESULTS

The TFCC tear group demonstrated a significantly higher incidence of two primary MRI signs, i.e., fiber discontinuity and signal alteration in the distal lamina, as observed by both readers (R1, 74.4% vs. 38.5%, p = 0.003, and 87.2% vs. 43.6%, p < 0.001; R2, 74.4% vs. 35.9%, p = 0.001, and 87.2% vs. 53.8%, p < 0.003, respectively). Reader 2 identified a higher prevalence of two additional primary MRI signs: fiber discontinuity and signal alteration in the proximal lamina (all p < 0.05). None of the 11 secondary MRI signs demonstrated statistically significant associations with type 1B TFCC.

CONCLUSION

MRI manifestations of fiber discontinuity and signal alteration in the distal lamina may provide predictive markers for type 1B TFCC wrist tear.

Evaluating Moisture Migration in Schirmer Test Strips: Exploring Brand-Specific Variations and Introducing Calibration and Conversion Methods

PURPOSE

Schirmer test results are widely used for ocular surface disease assessment, but Schirmer strips are not standardized. We compare the characteristics and tear volume with millimeter moisture migration in different brands of Schirmer strips and introduce methods for volume-based, brand-independent calibration.

METHODS

Physical parameters of Haag-Streit, EagleVision, TearFlo, Contacare, and MIPL/A6 Schirmer strip brands were compared. Schirmer strip millimeter moisture migration distances were assessed 5 minutes after application of incremental microliter volumes of human tears. Linear regression analysis of data points from each Schirmer strip brand was performed, and the root-mean-square deviation of data points to the best-fit linear regression was calculated. Calibration correction was performed by converting migration distance to the corresponding tear volume. A reference table and calibration method formulas were created.

RESULTS

Schirmer strips differed in design, shape, and manufacturing precision. Strip width, weight, and length were different between the 5 brands ( P < 0.05). A wide range of Schirmer strip moisture migration values for identical tear volumes was observed among brands. Statistical measurement resulted in a root-mean-square deviation of 2.9 mm for all data points from all brands. Millimeter to volume and weight to volume-based calibration correction methods resulted in a 2.2- and 3.1-fold measurement error reduction, respectively.

CONCLUSIONS

Our findings highlight the lack of standardization among different brands of Schirmer strips, raising concerns about potential sources of unintentional measurement errors. We propose volume-based Schirmer strip calibration methods and conversion of millimeter to microliter results to achieve brand-independent results and improve Schirmer test accuracy.

Traumatic rotator cuff injury: does delayed surgery worsen functional outcomes?

PURPOSE

The optimal timing of surgery after traumatic rotator cuff tears (RCT) is unclear, with its impact on functional outcomes under debate. This study aimed to review functional outcomes after RCT repair in patients who underwent early vs delayed surgery at our unit.

METHODS

This was single-centre retrospective evaluation. Patients with an acute traumatic RCT that underwent repair between 2017 and 2019 and had local follow-up were included and placed into two groups: early surgery (within 6 months from injury) and delayed surgery (more than 6 months from injury). Patient demographics, RCT data and pre- and post-operative (after 12 months) Oxford Shoulder Score (OSS) were extracted from medical records. Data was analysed to compare OSS scores between groups, as well as the effect of cuff tear sizes on OSS scores.

RESULTS

Forty-nine patients were included in the analysis (15 early, 34 delayed). There were no significant differences in age, sex or cuff tear sizes between groups. No difference was identified in the mean post-operative OSS between early vs delayed groups (40.9 ± 6.34 vs 40.5 ± 7.65, p = 0.86). The mean improvement in OSS after surgery was also similar between groups (22.5 ± 7.81 vs 20.97 ± 7.19, p = 0.498). Having a large or massive RCT did not worsen OSS compared to small or medium RCT (p = 0.44), even when stratified by early or delayed surgery.

CONCLUSION

Delayed surgery for traumatic RCT greater than 6 months from injury did not negatively impact long-term functional outcomes at our unit. Patients should be reassured as applicable before surgery in the event of prolonged or unavoidable delays.

Double Trouble: Combined Neurogenic Thoracic Outlet Syndrome and Superior Labrum Anterior Posterior Tear

Neurogenic thoracic outlet syndrome and superior labrum anterior posterior tears are usually treated in a staged manner due to different post-operative therapy needs. This case describes successful combined surgery with expedited physical therapy.

Precision of vacuum cup placement and its association with subgaleal hemorrhage and associated morbidity in term neonates

PURPOSE

To evaluate whether the precision of vacuum cup placement is associated with failed vacuum extraction(VE), neonatal subgaleal hemorrhage(SGH) and other VE-related birth trauma.

METHODS

All women with singleton term cephalic fetuses with attempted VE were recruited over a period of 30 months. Neonates were examined immediately after birth and the position of the chignon documented to decide whether the cup position was flexing median or suboptimal. Vigilant neonatal surveillance was performed to look for VE-related trauma, including subgaleal/subdural hemorrhages, skull fractures, scalp lacerations. CT scans of the brain were ordered liberally as clinically indicated.

RESULTS

The VE rate was 5.89% in the study period. There were 17(4.9%) failures among 345 attempted VEs. Thirty babies suffered from subgaleal/subdural hemorrhages, skull fractures, scalp lacerations or a combination of these, giving an incidence of VE-related birth trauma of 8.7%. Suboptimal cup positions occurred in 31.6%. Logistic regression analysis showed that failed VE was associated with a non-occipital anterior fetal head position (OR 3.5, 95% CI 1.22-10.2), suboptimal vacuum cup placement (OR 4.13, 95% CI 1.38-12.2) and a longer duration of traction (OR 8.79, 95% CI 2.13-36.2); while, VE-related birth trauma was associated with failed VE (OR 3.93, 95% CI 1.08-14.3) and more pulls (OR 4.07, 95% CI 1.98-8.36).

CONCLUSION

Suboptimal vacuum cup positions were related to failed VE but not to SGH and other vacuum-related birth trauma. While optimal flexed median cup positions should be most desirable mechanically to effect delivery, such a position does not guarantee prevention of SGH.

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning

BACKGROUND

Postoperative rotator cuff retear after arthroscopic rotator cuff repair (ARCR) is still a major problem. Various risk factors such as age, gender, and tear size have been reported. Recently, magnetic resonance imaging-based stump classification was reported as an index of rotator cuff fragility. Although stump type 3 is reported to have a high retear rate, there are few reports on the risk of postoperative retear based on this classification. Machine learning (ML), an artificial intelligence technique, allows for more flexible predictive models than conventional statistical methods and has been applied to predict clinical outcomes. In this study, we used ML to predict postoperative retear risk after ARCR.

METHODS

The retrospective case-control study included 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. Patients who initially presented with retears and traumatic tears were excluded. In study participants, after the initial tear repair, rotator cuff retears were diagnosed by magnetic resonance imaging; Sugaya classification types IV and V were defined as re-tears. Age, gender, stump classification, tear size, Goutallier classification, presence of diabetes, and hyperlipidemia were used for ML parameters to predict the risk of retear. Using Python's Scikit-learn as an ML library, five different AI models (logistic regression, random forest, AdaBoost, CatBoost, LightGBM) were trained on the existing data, and the prediction models were applied to the test dataset. The performance of these ML models was measured by the area under the receiver operating characteristic curve. Additionally, key features affecting retear were evaluated.

RESULTS

The area under the receiver operating characteristic curve for logistic regression was 0.78, random forest 0.82, AdaBoost 0.78, CatBoost 0.83, and LightGBM 0.87, respectively for each model. LightGBM showed the highest score. The important factors for model prediction were age, stump classification, and tear size.

CONCLUSIONS

The ML classifier model predicted retears after ARCR with high accuracy, and the AI model showed that the most important characteristics affecting retears were age and imaging findings, including stump classification. This model may be able to predict postoperative rotator cuff retears based on clinical features.

How does vertical laminar fracture impact the decision-making in thoracolumbar fractures? A systematic scoping review and meta-analysis

OBJECTIVE

Although vertical laminar fracture (VLF) is generally considered a severity marker for thoracolumbar fractures (TLFs), its exact role in decision-making has never been established. This scoping review aims to synthesize the research on VLF's role in the decision-making of TLFs.

METHODS

A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, and Web of Science from inception to  June 11, 2023, for studies examining the association of VLF in thoracolumbar fractures with dural lacerations, neurological deficits, radiographic parameters, or treatment outcomes. Additionally, experimental studies that analyze the biomechanics of burst fractures with VLF were included. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the association of VLF with dural laceration and neurological deficit, and ORs were pooled with a 95% confidence interval (CI).

RESULTS

Twenty-eight studies were included in this systematic review, encompassing 2021 patients, and twelve were included in the meta-analysis. According to the main subject of the study, the association of VLF with a dural laceration (n = 14), neurological deficit (n = 4), radiographic parameters (n = 3), thoracolumbar fracture classification (n = 2), and treatment outcome (n = 2). Seven studies with a total of 1010 patients reported a significant association between VLF and neurological deficit (OR = 7.35, 95% CI [3.97, 14.25]; P < 0.001). The pooled OR estimates for VLF predicting dural lacerations were 7.75, 95% CI [2.41, 24.87]; P < 0.001).

CONCLUSION

VLF may have several important diagnostic and therapeutic implications in managing TLFs. VLF may help to distinguish AO type A3 from A4 fractures. VLF may help to predict preoperatively the occurrence of dural laceration, thereby choosing the optimal surgical strategy. Clinical and biomechanical data suggest VLF may be a valuable modifier to guide the decision-making in burst fractures; however, more studies are needed to confirm its prognostic importance regarding treatment outcomes.

Surgical Management of a Torn ACL and Bucket-Handle Meniscal Tear in the Pregnant Patient: A Case Report

CASE

A 36-year-old, 7-month pregnant woman presented to the office with a locked knee and a displaced bucket-handle medial meniscus tear, in the setting of chronic anterior cruciate ligament (ACL) insufficiency. After thorough discussion with the patient and her husband, the obstetrician, and the anesthesiologist, the patient was treated with left knee ACL reconstruction and medial meniscus repair.

CONCLUSION

With sufficient preoperative planning and coordinated multidisciplinary care among orthopaedic, anesthesiologist, and obstetric specialists, elective knee surgery can be performed safely in time-sensitive situations during pregnancy.

Maternal outcomes using delayed pushing versus immediate pushing in the second stage of labour: An umbrella review

INTRODUCTION

Different systematic reviews have been developed in the last decades about maternal risks of immediate pushing and delayed pushing, depending on the duration of the second stage of labour, but they do not provide conclusive evidence.

AIM

The main aim of this overview of systematic reviews was to assess the maternal outcomes using delayed pushing and immediate pushing in the second stage of labour in women receiving epidural analgesia.

METHODS

We searched systematically in PubMed (Medline), EMBASE, CINAHL, and Scopus (October 26th, 2023). Methodological quality was analysed using AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. The outcome measures were the duration of the second stage of labour, duration of active pushing, caesarean section, instrumental vaginal birth, spontaneous vaginal birth, fatigue score, perineal lacerations, postpartum haemorrhage, and rate of episiotomy. Seven systematic reviews with and without meta-analysis were included.

RESULTS

Results showed that delayed pushing increases the total time of the second stage of labour, although delayed pushing decreases the duration of active pushing with moderate quality of evidence. Mixed results were found with respect to the variables instrumental vaginal birth, spontaneous vaginal birth, and fatigue score although the results favour delayed pushing or show no statistically significant differences with respect to immediate pushing. No favourable results were ever found for immediate pushing with respect to delayed pushing, with a limited quality of evidence. Even so, delayed pushing seems to be associated with a significant increase in spontaneous vaginal birth rates. The results found no significant differences between the immediate pushing and delayed pushing groups in the caesarean section rates, perineal lacerations, postpartum haemorrhage, and episiotomy ratio, with a limited quality of evidence.

CONCLUSIONS

This study shows that delayed pushing during the second stage of labour produces at least the same maternal outcomes as immediate pushing, although we note that delayed pushing produces an increase of the duration of the second stage of labour, a shorter duration of the active pushing and a tendency to increase spontaneous vaginal birth and to reduce the instrumental vaginal birth rates and fatigue scores. This should be considered clinically. This review was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42023397616).

The Long Head of the Biceps Has a Stabilizing Effect on the Glenohumeral Joint in Simulated Infraspinatus or Subscapularis but Not Supraspinatus Rotator Cuff Deficiency: A Biomechanical Study

PURPOSE

To investigate the stabilizing role of the long head of the biceps (LHB) for different simulated rotator cuff (RC) tears.

METHODS

Human cadaveric specimens (n = 8) were fixed in a robotic-based experimental setup with a static loading of the RC, deltoid, and the LHB. RC tears were simulated by unloading of the corresponding muscles. A throwing motion and an anterior load-and-shift test were simulated under different RC conditions by unloading the supraspinatus (SS), subscapularis (SSc), infraspinatus (IS), and combinations (SS + SSc, SS + IS, SS + SSc + IS). The LHB was tested in 3 conditions: unloaded, loaded, and tenotomy. Translation of the humeral head and anterior forces depending on loading of the RC and the LHB was captured.

RESULTS

Loading of LHB produced no significant changes in anterior force or glenohumeral translation for the intact RC or a simulated SS tear. However, if SSc or IS were unloaded, LHB loading resulted in a significant increase of anterior force ranging from 3.9 N (P = .013, SSc unloaded) to 5.2 N (P = .001, simulated massive tear) and glenohumeral translation ranging from 2.4 mm (P = .0078, SSc unloaded) to 7.4 mm (P = .0078, simulated massive tear) compared to the unloaded LHB. Tenotomy of the LHB led to a significant increase in glenohumeral translation compared to the unloaded LHB in case of combined SS + SSc (2.6 mm, P = .0391) and simulated massive tears of all SS + SSc + IS (4.6 mm, P = .0078). Highest translation was observed in simulated massive tears between loaded LHB and tenotomy (8.1 mm, P = .0078).

CONCLUSIONS

Once SSc or IS is simulated to be torn, the LHB has a stabilizing effect for the glenohumeral joint and counteracts humeral translation. With a fully loaded RC, LHB loading has no influence.

CLINICAL RELEVANCE

With an intact RC, the condition of the LHB showed no biomechanical effect on the joint stability. Therefore, from a biomechanical point of view, the LHB could be removed from the joint when the RC is intact or reconstructable. However, since there was a positive effect even of the unloaded LHB in this study when SSc or IS is deficient, techniques with preservation of the supraglenoid LHB origin may be of benefit in such cases.

Unusual imaging appearance of cemental tear in the maxillary first molar on cone-beam computed tomography: A case report

A cemental tear (CeT) is a definitive clinical entity and its radiographic appearance is well known in single-rooted teeth. However, the imaging features of CeT in multi-rooted teeth have not been clarified. We report a case of CeT which arose in the maxillary first molar and exhibited an unusual appearance in cone-beam computed tomography images. The torn structure was verified as cementum by micro-computed tomography and histological analysis. The hypercementosis, most likely induced by occlusal force, might have been torn from the root by a stronger occlusal force caused by the mandibular implant. An unusual bridging structure was created between the two buccal roots. These features may occur in multi-rooted teeth with long-standing deep pockets and abscesses that are resistant to treatment.

A Machine Learning Model Demonstrates Excellent Performance in Predicting Subscapularis Tears Based on Pre-Operative Imaging Parameters Alone

PURPOSE

To develop a machine learning model capable of identifying subscapularis tears before surgery based on imaging and physical examination findings.

METHODS

Between 2010 and 2020, 202 consecutive shoulders underwent arthroscopic rotator cuff repair by a single surgeon. Patient demographics, physical examination findings (including range of motion, weakness with internal rotation, lift/push-off test, belly press test, and bear hug test), and imaging (including direct and indirect signs of tearing, biceps status, fatty atrophy, cystic changes, and other similar findings) were included for model creation.

RESULTS

Sixty percent of the shoulders had partial or full thickness tears of the subscapularis verified during surgery (83% of these were upper third). Using only preoperative imaging-related parameters, the XGBoost model demonstrated excellent performance at predicting subscapularis tears (c-statistic, 0.84; accuracy, 0.85; F1 score, 0.87). The top 5 features included direct signs related to the presence of tearing as evidenced on magnetic resonance imaging (MRI) (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology.

CONCLUSIONS

In this study, machine learning was successful in predicting subscapularis tears by MRI alone in 85% of patients, and this accuracy did not decrease by isolating the model to the top features. The top five features included direct signs related to the presence of tearing as evidenced on MRI (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. Last, in advanced modeling, the addition of physical examination or patient characteristics did not make a significant difference in the predictive ability of this model.

LEVEL OF EVIDENCE

Level III, diagnostic case-control study.

Use of a peanut ball, positioning and pelvic mobility in parturient women shortens labour and improves maternal satisfaction with childbirth: a randomised trial

QUESTION

What is the effect of a protocol targeted at the various stages of labour - with a peanut ball, positioning and pelvic mobility - on the duration of labour, pain severity, fatigue, maternal outcomes, neonatal outcomes and satisfaction in parturients without analgesia?

DESIGN

A randomised trial with concealed allocation, blinding of assessors and intention-to-treat analysis.

PARTICIPANTS

One hundred women in active labour.

INTERVENTION

The experimental group received the protocol targeted at the various stages of labour, with a peanut ball, positioning and pelvic mobility, whilst the control group received usual care.

OUTCOME MEASURES

The primary outcomes were the duration of labour and pain severity. The secondary outcomes were maternal fatigue, mode of delivery, risk of perineal laceration, severity of perineal laceration, use of synthetic oxytocin, satisfaction with delivery, Apgar scores, admission of the neonate to an intensive care unit and resuscitation of the neonate in the delivery room. In the active phase of labour, the numerical rating scale and maternal perception of childbirth fatigue questionnaire were applied; they were taken again when the parturient had 8 to 10 cm of dilation. The numerical rating scale was also applied postpartum to evaluate satisfaction with childbirth.

RESULTS

The use of the protocol with a peanut ball reduced the duration of active and expulsive phases and the total duration of labour, with mean differences of 82 minutes (95% CI 41 to 125), 8 minutes (95% CI 0 to 18) and 89 minutes (95% CI 45 to 132), respectively. Maternal satisfaction was better in the experimental group: mean between-group difference on the 10-point scale was 1.1 (95% CI 0.4 to 1.8). The effects on the other outcomes were either similar between groups or unclear.

CONCLUSION

A protocol with a peanut ball, positioning and pelvic mobility reduced the duration of labour and improved maternal satisfaction with childbirth.

REGISTRATION

RBR-74wcnjc.

New Korean Guidelines for the Diagnosis and Management of Dry Eye Disease

New Korean guidelines for the diagnosis and management of dry eye disease were developed based on literature reviews by the Korean Dry Eye Guideline Establishment Committee, a previous dry eye guideline by Korean Corneal Disease Study Group, a survey of Korean Dry Eye Society (KDES) members, and KDES consensus meetings. The new definition of dry eye was also proposed by KDES regular members. The new definition by the regular members of the KDES is as follows: "Dry eye is a disease of the ocular surface characterized by tear film abnormalities and ocular symptoms." The combination of ocular symptoms and an unstable tear film (tear breakup time <7 seconds) was considered as essential components for the diagnosis of dry eye. Schirmer test and ocular surface staining were considered adjunctive diagnostic criteria. The treatment guidelines consisted of a simplified stepwise approach according to aqueous deficiency dominant, evaporation dominant, and altered tear distribution subtypes. New Korean guidelines can be used as a simple, valid, and accessible tool for the diagnosis and management of dry eye disease in clinical practice.

Scratch…Descriptive epidemiologic study of billiards-related injuries

The purpose of this descriptive epidemiological study is to identify billiards-related injuries that presented to the United States emergency departments from 2000 to 2020. This is a study using secondary data from emergency departments from 2000 to 2020 and presented with billiards-related injuries. No applicable intervention, but the main outcome measure was a description of injuries sustained due to participation in billiards. Billiards-related injury was captured by the National Electronic Injury Surveillance System - All Injury Program database. We extracted information on age, gender, injury, and disposition. A collective total of 78,524 (n = 1214) estimated patients, had emergency department visits after incurring billiards-related injuries as a sample. The mean age was 24.9 years. Most injuries occurred in males, 54,915 (n = 851, 69.9%). More injuries appeared to be soft-tissue contusions and abrasions, 19,000 (24.2%, n = 280), followed by lacerations, 17,520 (22.3%, n = 269). The most common cause of injury was being struck by a ball or cue, 39,705 (51.1%, n = 643). While the majority of injured patients were discharged home after evaluation, 2527 (3.2%, n = 45) of them required hospitalization. While a small number of billiards-related injuries presented to the emergency department in comparison to other sports-related injuries, some required more intensive treatment or hospitalization.

Evaluation of therapeutic efficacy of Emustil drops for ocular discomfort and tear film osmolarity using different treatment management modes under dry environmental conditions

BACKGROUND

We aimed to check the efficacy of Emustil (oil in water emulsion) drops on tear film index and ocular surface dynamics in dry environments through protection and relief treatment modalities.

METHODS

The subjects were exposed to a dry environment using a Controlled Environment Chamber (CEC) where the relative humidity (RH) was 5% and the temperature was 21 °C and screened for ocular symptoms, tear osmolarity, ocular surface temperature (OST) and tear production using ocular Surface Disease Index questionnaire (OSDI), OcuSense TearLab Osmometer, FLIR System ThermaCAM P620 and Schirmer strips/phenol red test respectively. Tear production was calculated by the Tear Function Index test (TFI).

RESULTS

The mean tear film osmolarity decreased significantly from 296.8 mOsm/l at 40% RH to 291 mOsm/l at 5%. (p = 0.01). Instillation of Emustil resulted in a significant increase in tear osmolarity in the relief method compared with osmolarity seen at 5% RH when no drop was used. The mean PRT value decreased from 26 ± 9 in normal conditions (40% RH) to 22 ± 4 mm in dry conditions (5% RH). Emustil drops did not induce any significant change in tear production in the PRT test. No significant change was found in OST following exposure to 5% RH. OST did not show a statistically significant change with the emulsion when used for relief (p > 0.05). The mean score of ocular discomfort observed was 70 at 5% RH. Still, the instillation of the oil-in-water emulsion (Emustil) resulted in a noticeable decrease in visual discomfort to 37 (p = 0.00) in protection and 59 in relief (p = 0.05). Emustil drops substantially improved tear film parameters under a desiccating environment, however, tear film parameters respond differently to the management modalities. In the protection method, tear film osmolarity was protected against a dry environment, while in the relief mode, tear production was improved.

CONCLUSION

CEC allows for a thorough evaluation of tear film parameters and dry eye treatment protocols in labs, providing greater confidence when applying them to patients. In addition, our study showed that Emustil not only provides protection and relief for dry eyes but also helps to maintain ocular homeostasis in desiccating environments. This indicates a promising potential for improving dry eye treatment protocols.

Treatment of a fractured humerus and partially torn supraspinatus tendon in a professional boxer with liquid platelet-rich fibrin and heat-coagulated albumin gel: a case report

INTRODUCTION

Fractures with delayed healing can be a serious complication, especially for athletes depending on quick return to sports. To our knowledge, no cases of increased healing of delayed union fractures with autologous biomedical interventions have been reported.

CASE PRESENTATION

A 33-year-old Swedish professional boxer with a fractured humerus with a delayed union and a partially torn supraspinatus tendon was treated with injections of liquid platelet-rich fibrin and heat-coagulated albumin gel. He recovered almost completely from both injuries in only 1 month and could return to professional boxing in 3 months.

CONCLUSION

This case raises the hypothesis that liquid platelet-rich fibrin and heat-coagulated albumin gel may be an effective, minimally invasive intervention in fractures with a delayed union. Further research is required to test this theory.

The association between a rotator cuff tendon tear and a tear of the long head of the biceps tendon: Chart review study

Rotator cuff (RC) and long head of the biceps tendon (LHBT) tears are common shoulder problems presented to the orthopedic clinic. The aim of this study was to assess the association between RC and LHBT tears among a Saudi population sample. A total of 243 patients who were diagnosed with shoulder pain due to RC or LHBT tear between 2016 and 2018 using a magnetic resonance imaging scan were included in this study. Females comprised 66% of the sample, and 59% (n = 143) of the shoulders were on the right side. The mean age of the patients was 58 ± 11 years, ranging from 23 to 88 years. A significant association was detected between the LHBT and RC tears (P < 0.001). Out of 26 cases showing RC and LHBT tears, 81% had a full thickness tear, whereas 19% had a partial tear. The LHBT tears were presented significantly in 48% of cases with at least two completely torn RC compared to 10% in cases with one completely torn RC (P < 0.001). The LHBT tear was significantly observed in shoulders with RC tears including the tendons of subscapularis, supraspinatus, and infraspinatus, but not the teres minor (P < 0.001). Both types of tears were presented significantly in senior patients aged more than 65 years compared to younger patients (P < 0.01). Thus, the LHBT should be assessed carefully in shoulders with more than one RC tear or in chronic cases.

Risk factors for medical adhesive-related skin injury at the site of peripherally inserted central venous catheter placement in patients with cancer: a single-centre prospective study from China

OBJECTIVES

This study aims to explore the incidence of, and risk factors for medical adhesive-related skin injury (MARSI) at peripherally inserted central venous catheter (PICC) sites in patients with cancer.

DESIGN

A prospective observational cohort study was conducted at a tertiary hospital in Shenzhen, China.

SETTING

This was a single-centre study conducted in a tertiary hospital in Shenzhen, China.

PARTICIPANTS

A total of 340 patients with cancer and PICC placement from January 2022 to June 2023 were selected using a convenience sampling method.

METHODS

Factors potentially associated with PICC-related MARSI (PICC-MARSI) were recorded, including patient demographics, and catheter placement and maintenance. Patients were divided into MARSI and non-MARSI groups. Univariate analysis was performed to screen for associated variables, and logistic regression analysis was used to identify independent risk factors for PICC-MARSI.

RESULTS

Of all 340 patients enrolled, 33 (9.7%) developed PICC-MARSI, including skin tear (8, 24.2%), tension injury (5, 15.2%), irritant contact dermatitis (10, 30.3%), allergic dermatitis (7, 21.2%) and maceration (3, 9.1%). Multivariable analysis showed that age (OR=1.058, p=0.001, 95% CI 1.023-1.094), wet skin (OR=4.873, p=0.003, 95% CI 1.728-13.742), dry skin (OR=6.247, p<0.0001, 95% CI 2.239-17.431), oedema (OR=3.302, p=0.008, 95% CI 1.365-7.985), allergy history (OR=6.044, p=0.001, 95% CI 2.040-17.906), dressing type (OR=3.827, p=0.003, 95% CI 1.595-9.185), body mass index (BMI) <18.5 (OR=4.271, p=0.015, 95% CI 1.327-13.742) and BMI 25-30 (OR=2.946, p=0.027, 95% CI 1.131-7.678) were independent risk factors for PICC-MARSI.

CONCLUSIONS

Proper catheter maintenance and appropriate dressing selection are crucial for the prevention of this condition.

Acute patellar dislocation: how skeletal maturity affects patterns of injury

OBJECTIVE

The main objective of this study was to understand the role of skeletal maturity in the different patterns of osteochondral and ligamentous injuries after an acute lateral patellar dislocation.

MATERIALS AND METHODS

Two radiologists independently reviewed MRIs of 212 knees performed after an acute lateral patellar dislocation to evaluate the presence of high-grade patellar osteochondral injury, femoral osteochondral injury, and medial patellofemoral ligament injury. The association of skeletal maturity (indicated by a closed distal femoral physis), age, sex, and first-time versus recurrent dislocation with each of these various lesions was analyzed using Chi-square or T test, and multivariable logistic regression with estimation of odds ratios (OR).

RESULTS

Skeletal maturity was significantly associated with high-grade patellar osteochondral injury [OR=2.72 (95% CI 1.00, 7.36); p=0.049] and femoral-side MPFL tear [OR=2.34 (95% CI 1.05, 5.25); p=0.039]. Skeletal immaturity was significantly associated with patellar-side MPFL tear [OR=0.35 (95% CI 0.14, 0.90); p=0.029].

CONCLUSION

Patterns of injury to the patella and medial patellofemoral ligament vary notably between the skeletally immature and mature, and these variations may be explained by the inherent weakness of the patellar secondary physis.

The effects of warm perineal compress on perineal trauma and postpartum pain: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

In order to reduce the complications of perineal damage and the pain caused by it for the mother, this study was conducted to determine the effect of warm perineal compress on perineal trauma (1st-, 2nd-, 3rd-, and 4th-degree perineal tears), postpartum pain, intact perineum (primary outcomes), episiotomy, length of the second stage, and APGAR score at 1 and 5 min after childbirth (secondary outcome).

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Web of Science, SID, Magiran, and ClinicalTrials.gov were searched to identify the relevant articles from inception to November 1, 2022, with language restriction (only English and Persian). A manual search was also performed. Risk of bias 2 (RoB2) and ROBIN-I were employed to evaluate the quality of the included papers. Meta-analysis was conducted using RevMan 5.3. Heterogeneity was assessed using I2. In cases with high heterogeneity, subgroup analysis was utilized based on the parity and ethnicity, and time of pain measurement after delivery also a random-effects model was used instead of a fixed-effects model. Trial sequential analysis (TSA) was performed for the primary outcomes. The certainty of evidence was assessed using the GRADE approach.

RESULTS

A total number of 228 articles were found in databases. Of these articles, eighty-six were screened by title, 27 by abstract, and 21 by full text. Finally, 14 articles were included, of which ten were RCT and four were non-RCT. Meta-analysis results revealed that warm perineal compress significantly reduced perineal pain (RR 0.23, 95% CI 0.08-0.66; P = 0.0006), average pain (SMD - 0.73, 95% CI 1.23 to - 0.23; P = 0.004), second-degree perineal tear (RR 0.65, 95% CI 0.54-0.79; P˂0.00001), third-degree perineal tear (RR 0.32, 95% CI 0.15-0.67; P = 0.003), fourth-degree perineal tear (RR 0.11, 95% CI 0.01-0.87; P = 0.04), episiotomy (RR 0.63, 95% CI 0.46-0.86; P = 0.004), and intact perineum significantly increased (RR 3.06, 95% CI 1.79-5.22; P < 0.0001) compared to the control group. However, there was no statistically significant difference in terms of first-degree tear (RR 1.04, 95% CI 0.86-1.25; P = 0.72), length of the second stage of labor (MD - 0.60, 95% CI - 2.43 to 1.22; P = 0.52), the first minute (MD - 0.03, 95% CI - 0.07 to 0.02; P = 0.24) and the fifth minute Apgar score (MD - 0.02, 95% CI - 0.07 to 0.03; P = 0.46) between the two groups.

CONCLUSION

Warm perineal compress administered during the second stage of labor reduce postpartum pain, second and third-degree perineal tears, and episiotomy rate while it increases the incidence of intact perineum compared to the control group.

Postoperative results of arthroscopic superior capsule reconstruction using fascia lata: a retrospective cohort study

BACKGROUND

Superior capsule reconstruction (SCR) was developed to improve shoulder function and alleviate pain in patients with primary irreparable rotator cuff tears. Although suitable clinical results of SCR have been reported, only a few studies have investigated the clinical outcomes of arthroscopic superior capsule reconstruction (ASCR) using tensor fascia at a minimum follow-up period of 2 years after surgery.

METHODS

Among 100 consecutive patients who underwent ASCR since April 2010, this retrospective cohort study included 49 patients with a Hamada classification of ≤3 who were available for at least 2-year follow-up after surgery. The mean follow-up period was 34.5 (24-74) months. We analyzed preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, University of California at Los Angeles (UCLA) shoulder scores, preoperative and postoperative active elevation angles, external and internal rotations with the arms in the anatomical position, manual muscle test (MMT) scores, preoperative and postoperative acromiohumeral distance (AHD), and cuff integrity on postoperative magnetic resonance imaging using the Hasegawa classification. We compared 27 pseudoparalyzed (elevation of <90°) shoulders with 22 nonpseudoparalyzed shoulders. We also evaluated the treatment of patients with subscapularis tendon tears and compared the outcomes of patients with good graft repair and those with graft retear.

RESULTS

The JOA score, UCLA score, active elevation angle, internal and external rotation angles, and muscle strength (MMT) significantly improved at the time of investigation preoperatively and 2 years postoperatively. The mean AHD also improved from 5 ± 2.6 mm preoperatively to 9 ± 2.8 mm postoperatively. No significant difference in graft tear rate was observed between pseudoparalyzed shoulder and nonpseudoparalyzed shoulder groups. The subscapularis tendon was torn in 26 of 49 (53%) patients, and all patients underwent repair. The graft repair group showed a significant improvement in JOA scores, UCLA shoulder scores, joint range of motion, MMT, and AHD postoperatively, but not in internal rotation strength. In contrast, the graft tear group did not show any significant improvement. All patients could return to work, except for those performing heavy labor. Complications included graft tear in five patients, postoperative infection in two patients, and progressive postoperative arthropathic changes in one patient.

CONCLUSION

Good clinical results of ASCR were obtained using tensor fascia lata at 2 years after surgery, with few complications and low graft tear rates.

Acute successful management of a chainsaw injury to the roof of the left chest

This case report chronicles the experience of prompt resuscitation, beginning with the patient, and immediate surgery following the fatal malfunction of a chainsaw. The injuries were atypical for chainsaw injuries and involved total transection of the left subclavian artery and vein, total transection of the left brachial plexus and laceration to the apex of the left lung, among other injuries. A coordinated effort allowed for successful repair of the life- and limb-threatening injuries so that the patient could return to his young family in time for his 40th birthday.

Common Peroneal Nerve Injury Caused by a Wild Boar Attack

Wild boar-inflicted nerve injuries have been very rarely reported in the literature. A 62-year-old man was attacked by a wild boar in eastern Turkey and brought to the emergency department. He had 5 lacerations on the lower extremities and 2 on the posterior thoracic region. In addition to soft tissue lacerations, he sustained a complete laceration of the left common peroneal nerve with a foot drop. The common peroneal nerve was repaired primarily the day after the attack. The patient was discharged after a short hospital stay without any immediate complications; however, at the 10-mo follow-up, he still had a left foot drop.

HOW TO PREVENT HAND INJURIES - REVIEW OF EPIDEMIOLOGICAL DATA IS THE FIRST STEP IN HEALTH CARE MANAGEMENT

BACKGROUND

Hand injuries are common affecting all ages, genders, and geographic regions. They can result in long term disability and mortality, while they place a significant financial burden in society. Although, hand injuries can be prevented. Preventive strategies can be designed, but knowledge of injuries' epidemiological characteristics is required beforehand.

METHODS

We performed a review of the current literature related to hand injuries to identify their incidence, patients' demographics, type, mode, and time of the injury.

RESULTS

Hand injuries constitute 6.6% to 28.6% of all injuries presenting to the Emergency Department and 28% of injuries to the musculoskeletal system. They mainly affect young male labourers. Occupational and home accidents are the commonest injury modalities, while traffic road accidents constitute a significant reason for hand injuries as well. Lacerations account for most hand injuries, followed by crush injuries, fractures and amputations. Most occupational injuries occur in the beginning of the week and especially during the morning shift, while there has been identified an increase in the number of hand injuries during the summer months.

CONCLUSIONS

Hand injuries are an important health problem with impact on patient's life and on the society. Although they can be prevented. Preventive strategies need to be addressed towards many directions and people's activities, since prevention will have an important impact on people's quality of life and society's well-being.

Acellular Collagen Matrix Patch Augmentation of Arthroscopic Rotator Cuff Repair Reduces Re-Tear Rates: A Meta-analysis of Randomized Control Trials

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes of arthroscopic rotator cuff repair (ARCR) with and without acellular collagen matrix patch (ACMP) augmentation.

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing ACMP augmentation and a control for ARCR were included. Clinical outcomes were compared using Revman, and a P value < .05 was considered to be statistically significant.

RESULTS

Five RCTs with 307 patients were included. Overall, 11% of patients treated with ACMP augmentation and 34% of patients in the control group had a re-tear (P = .0006). The mean Constant score was 90.1 with ACMP augmentation, and 87.3 in controls (P = .02). Additionally, there was a significant higher American Shoulder and Elbow Surgeons score with ACMP augmentation (87.7 vs 82.1, P = .01).

CONCLUSIONS

The RCTs in the literature support the use of ACMP augment as a modality to reduce re-tear rates and improve outcomes after ARCR.

LEVEL OF EVIDENCE

Level II, Meta-Analysis of Level II Studies meta-analysis of Level II studies.

Editorial Commentary: Acellular Collagen Matrix Patch Augmentation of Large Rotator Cuff Tear Repair Results in Improved Healing

Despite a high retear rate, repair of large rotator cuff tendon tear repairs shows good clinical outcomes. Unfortunately, these results often deteriorate with time, and large tears, not to mention progressively symptomatic retears, especially in compromised rotator cuff tissue, remain a problem. The solution could include augmenting repair with a patch such as an acellular collagen matrix. Proper patient selection is needed to achieve a benefit justifying the added expense and operative time associated with adding a patch. Biomechanically, such patches are strong and increase suture retention, as well as repair construct strength and stiffness. Patches provide a significant healing effect. Recent research and meta-analysis support the use of patches on rotator cuff tendon tears 3 cm or larger, whereas smaller tears (1-2 cm in length) appear to heal without the need for a patch.

Single-Dose Radial Extracorporeal Shock Wave Therapy Modulates Inflammation During Meniscal Tear Healing in the Avascular Zone

BACKGROUND

Extracorporeal shock wave therapy (ESWT) promotes tissue healing by modulating inflammation, which has implications for meniscal tear healing in the avascular zone.

PURPOSE

To evaluate the effects of a single dose of radial ESWT on the healing process and inflammation of the meniscus and knee joints after meniscal tears in the avascular zone.

STUDY DESIGN

Controlled laboratory study.

METHODS

Avascular tears were induced in the medial meniscus (MM) of 72 Sprague-Dawley rats. One week postoperatively, the rats received a single session of radial ESWT with a Power+ handpiece (ESWT group; n = 36) or with a fake handpiece (sham-ESWT group; n = 36). The rats were then euthanized at 2, 4, or 8 weeks postoperatively. The MMs were harvested for analysis of healing (hematoxylin-eosin, safranin O-Fast Green, and collagen type 2 staining) and inflammation (interleukin [IL]-1β and IL-6 staining). Lateral menisci and synovia were obtained to evaluate knee joint inflammation (enzyme-linked immunosorbent assay of IL-1β and IL-6). Cartilage degeneration was assessed in the femurs and tibial plateaus using safranin O-Fast Green staining.

RESULTS

The ESWT group showed significantly better meniscal healing scores than the sham-ESWT group at 4 (P = .0066) and 8 (P = .0050) weeks postoperatively. The IL-1β level was significantly higher in the sham-ESWT group than in the ESWT group at 2 (MM: P = .0009; knee joint: P = .0160) and 8 (MM: P = .0399; knee joint: P = .0001) weeks. The IL-6 level was significantly lower in the sham-ESWT group than in the ESWT group at 2 (knee joint: P = .0184) and 4 (knee joint: P = .0247) weeks but higher at 8 weeks (MM: P = .0169; knee joint: P = .0038). The sham group had significantly higher osteoarthritis scores than the ESWT group at 4 (tibial plateau: P = .0157) and 8 (femur: P = .0048; tibial plateau: P = .0359) weeks.

CONCLUSION

A single dose of radial ESWT promoted meniscal tear healing in the avascular zone, modulated inflammatory factors in the menisci and knee joints in rats, and alleviated cartilage degeneration.

CLINICAL RELEVANCE

Radial ESWT can be considered a potential option for improving meniscal tear healing in the avascular zone because of its ability to modulate inflammation.

Assessment of tear film parameters in females with refractive errors using a single device: An observational study

This observational study aimed to evaluate the use of a single portable device to assess the non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), and lipid layer patterns (LLP) in young females with refractive errors (REs). The study was conducted at the College of Applied Medical Science (Female campus), Riyadh, Saudi Arabia between January 5, 2021 to May 15, 2021. Forty young females, with mean age of 23.0± 4.3 years with REs (-2.53 ± 2.05 D) and 40 females, mean age 23.8± 4.5 years with healthy eyes were recruited. The tests were administered in the following order: Ocular Surface Disease Index (OSDI), followed by NITBUT, TMH, and LLP. Significant differences (via Mann-Whitney U test) were noted in the median ocular surface disease index (OSDI; p˂0.001), NITBUT (p=0.035), TMH (p=0.009), and LLP (p˂0.001) scores between the study and control groups. Females with REs have significantly lower lipid layer, TMH, and NITBUT scores than those with healthy eyes.

Reliability of Magnetic Resonance Imaging Criteria for the Preoperative Assessment of Rotator Cuff Tears: A Systematic Review

BACKGROUND

Magnetic resonance (MR) imaging is the most common modality for assessment of the rotator cuff before and after surgery. Several classifications have been described aiming to define main tear characteristics. However, there is still confusion when it comes to the reliability of those classifications.

PURPOSE

(1) To identify all MR classifications available in the literature for preoperative assessment of rotator cuff tears, (2) to summarize available data on the reliability of identified classifications, and (3) to assess the methodological quality of reliability studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies reporting MR assessment in patients with a superior or posterosuperior rotator cuff tear were included. After identification of the available MR criteria, reliability studies were analyzed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist.

RESULTS

A total of 75 studies were included in this review. Eight categories of outcomes could be identified. Of the total, 62 studies reported interobserver reliability whereas 32 reported intraobserver reliability of some of the identified criteria. Each category reflected a variety of reliability, ranging from poor to excellent agreement. MR proved to be a reliable imaging modality to detect the structural integrity of the posterosuperior cuff, especially in cases of full-thickness tear; it was also reliable in terms of tear width and length and muscle atrophy based on a tangent sign or Thomazeau classification. All other classifications did not prove acceptable reliability. Methodological quality was high for 23 articles and moderate for 14.

CONCLUSION

Preoperative MR is a reliable imaging modality to identify full-thickness tears, measure tear size and morphology, and identify muscle atrophy with tangent sign or Thomazeau classification. All other outcomes and classifications did not show acceptable reliability; therefore, caution is needed when using them for preoperative evaluation of a rotator cuff tear.

Risk Factor for Clinical Failure of Medial Meniscal Allograft Transplant: Early vs Late Graft Tear

BACKGROUND

Graft tears are common postoperative findings in meniscal allograft transplant (MAT). Graft tear in medial MAT may be different from that of lateral MAT, considering the difference between medial meniscal tears and lateral meniscal tears. Moreover, medial MAT is frequently accompanied by ligament reconstruction, which is associated with graft tear. The effect of graft tear on the long-term survivorship of medial MAT has not been investigated.

HYPOTHESIS

Graft tear would adversely affect the survivorship of medial MAT and the effect would be different according to the timing of graft tear.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 55 patients undergoing medial MAT between June 2019 and March 2000 were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) scans were reviewed to identify graft tears, and the timing of their occurrence was investigated. Postoperative MRI was performed routinely during the first postoperative year and every 2 years thereafter. The patients were classified into a no graft tear (NT) group, early graft tear (occurring within 1 year; ET) group, and late graft tear (occurring 1 year after surgery; LT) group. The survival rate of medial MAT was estimated according to graft tear, with a failure being defined as (1) reoperations including arthroplasty, realignment osteotomy, revision MAT, and meniscectomy (>50% of the graft or to the zone of the meniscocapsular junction) or (2) Lysholm score <65. Clinical scores were compared between the groups.

RESULTS

The mean follow-up duration was 8.6 ± 5.3 years. During that period, clinical failures occurred in 6 (10.9%) patients. The overall survival rate at 5 years was 94.0% (95% CI, 90.6%-97.4%). Graft tears were seen in 18 patients: 6 patients in the ET group and 12 patients in the LT group. The median time when the graft tear was noted on MRI scans was 5.5 months (range, 1-11 months) postoperatively in the ET group and 99.5 months (range, 19-264 months) postoperatively in the LT group. Five patients in the ET group had root tears, whereas 9 patients in the LT group had complex or horizontal tears. The 5-year survival rate of the ET group was 62.5% (95% CI, 41.2%-83.8%), which was significantly lower than that of the NT group (96.8%; 95% CI, 93.6%-99.9%) and the LT group (85.7%; 95% CI, 72.5%-98.9%; P = .002). The mean postoperative Lysholm scores were 85.6 ± 17.9 in the NT group, 93.0 ± 2.8 in the ET group, and 79.3 ± 11.6 in the LT group, showing no significant difference between the groups (Kruskal-Wallis test, P = .058).

CONCLUSION

Clinical relevance of graft tear that occurred after medial MAT was dependent upon its timing. ET was a risk factor for clinical failure, whereas LT did not adversely affect graft survivorship. Lysholm scores did not differ according to graft tear.

Functional and Radiologic Outcomes of Degenerative Versus Traumatic Full-Thickness Rotator Cuff Tears Involving the Supraspinatus Tendon

BACKGROUND

Arthroscopic rotator cuff repair (ARCR) is among the most commonly performed orthopaedic procedures. Several factors-including age, sex, and tear severity-have been identified as predictors for outcome after repair. The influence of the tear etiology on functional and structural outcome remains controversial.

PURPOSE

To investigate the influence of tear etiology (degenerative vs traumatic) on functional and structural outcomes in patients with supraspinatus tendon tears.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing ARCR from 19 centers were prospectively enrolled between June 2020 and November 2021. Full-thickness, nonmassive tears involving the supraspinatus tendon were included. Tears were classified as degenerative (chronic shoulder pain, no history of trauma) or traumatic (acute, traumatic onset, no previous shoulder pain). Range of motion, strength, the Subjective Shoulder Value, the Oxford Shoulder Score (OSS), and the Constant-Murley Score (CMS) were assessed before (baseline) and 6 and 12 months after ARCR. The Subjective Shoulder Value and the OSS were also determined at the 24-month follow-up. Repair integrity after 12 months was documented, as well as additional surgeries up to the 24-month follow-up. Tear groups were compared using mixed models adjusted for potential confounding effects.

RESULTS

From a cohort of 973 consecutive patients, 421 patients (degenerative tear, n = 230; traumatic tear, n = 191) met the inclusion criteria. The traumatic tear group had lower mean baseline OSS and CMS scores but significantly greater score changes 12 months after ARCR (OSS, 18 [SD, 8]; CMS, 34 [SD,18] vs degenerative: OSS, 15 [SD, 8]; CMS, 22 [SD, 15]) (P < .001) and significantly higher 12-month overall scores (OSS, 44 [SD, 5]; CMS, 79 [SD, 9] vs degenerative: OSS, 42 [SD, 7]; CMS, 76 [SD, 12]) (P≤ .006). At the 24-month follow-up, neither the OSS (degenerative, 44 [SD, 6]; traumatic, 45 [SD, 6]; P = .346) nor the rates of repair failure (degenerative, 14 [6.1%]; traumatic 12 [6.3%]; P = .934) and additional surgeries (7 [3%]; 7 [3.7%]; P = .723) differed between groups.

CONCLUSION

Patients with degenerative and traumatic full-thickness supraspinatus tendon tears who had ARCR show satisfactory short-term functional results. Although patients with traumatic tears have lower baseline functional scores, they rehabilitate over time and show comparable clinical results 1 year after ARCR. Similarly, degenerative and traumatic rotator cuff tears show comparable structural outcomes, which suggests that degenerated tendons retain healing potential.

MIFEPRISTON IN OBSTETRICS - WHY NOT?

Cervical ripening is a critical component of normal parturition. There are substantial variations in labour induction (IOL) techniques around the world. Mifepristone causes the termination of unwanted pregnancies, but there is a lack of consensus on its use for labour induction. The purpose of our study was to compare the combination of Mifepristone and Misoprostol with the combination of a Foley balloon and Misoprostol for labour induction. The study included 175 pregnant women, with gestational age 37-42 weeks. In the study group - 88 pregnant aged 21-35 (28.56±3.23), a combination of Mifepristone-Misoprostol was used. A combination of Foley catheter and Misoprostol was used in the control group - 87 pregnant aged 21-35 (29.48±3.03). The outcomes were assessed. In the study group the rate of vaginal delivery was higher and the frequency of cesarean section was lower compared to the control group (75 vs. 72, and 13 vs. 15, respectively); The total duration of labour was shorter in the study group (p<0,05); There was no difference between groups in the incidences of neonatal morbidity on the first and the fifth minute of life (p>0,05); The pain level was significantly low in the study group compared to the control group (5±0,75 vs. 8±0,96) and no cervical laceration was revealed in the study group. The Mifepristone - Misoprostol combination has advantages over the Foley balloon - Misoprostol combination for induction of labour regarding reduction in pain intensity, duration of labour, and cervical laceration.

Perineal repair performed by midwives in Australia: A cross-sectional survey study of education and practice

PROBLEM

Perineal repair is generally not a widely practiced skill amongst Australian midwives, the reasons for this are uncertain and may result in technique variations.

BACKGROUND

Many birthing women experience perineal tears that require suturing. As midwives attend the majority of vaginal births, they would be ideally placed to undertake perineal repair.

AIM

To describe the current level of midwifery perineal repair skill acquisition, knowledge, techniques and utilization by Australian midwives.

METHODS

An online survey was distributed to Australian College of Midwives members and shared via social media. Data on demographics, suturing techniques, reasons why midwives did or did not suture and barriers to skill acquisition were collected. Descriptive statistics were calculated for all variables including percentages, mean, standard deviation, median and range as appropriate.

FINDINGS

375 completed surveys were received between April and May 2023. 197 midwives indicated current suturing practice and 178 did not suture. Contributing to continuity of care was the most common motivating factor. The use of a continuous suturing technique for all layers of a perineal injury was reported by the majority of suturing midwives. There was greater variation in the management of labial tears. Low numbers of skilled midwives to support attaining competency and high workloads were the main barriers to attaining suturing skills.

DISCUSSION

Australian midwives view perineal suturing as a valid midwifery skill that can contribute to continuity of care. Largely organisational barriers exist to skill development and greater utilisation.

CONCLUSION

Perineal repair should be prioritised as a fundamental midwifery skill.

Predictors of pain development for contralateral asymptomatic degenerative rotator cuff tears based on features of an ipsilateral painful cuff tear: a prospective longitudinal cohort study

BACKGROUND

Prior rotator cuff disease natural history studies have focused on tear-related factors that predict disease progression within a given shoulder. The purpose of this study was to examine both patient- and tear-related characteristics of a painful rotator cuff tear that predict future pain development and functional impairment in a shoulder with a contralateral asymptomatic cuff tear.

METHODS

This was a prospective longitudinal cohort study of patients aged ≤65 years who underwent surgery for a painful degenerative rotator cuff tear and possessed an asymptomatic contralateral tear. Patients were followed up prospectively by shoulder ultrasound, physical examination, and functional score assessment. The primary outcome was change in the American Shoulder and Elbow Surgeons (ASES) score at 2 years. Secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, Patient-Reported Outcomes Measurement Information System (PROMIS) score, Hospital Anxiety Depression Scale (HADS) depression and anxiety scores, and Veterans RAND-12 (VR-12) mental component score (MCS).

RESULTS

Sixty-five patients were included, with a mean follow-up period of 37 months (range, 24-42 months). In 17 patients (26%), contralateral shoulder pain developed at a median of 15.2 months (interquartile range [IQR], 10.5 months). No difference in age, sex, Charlson Comorbidity Index, or occupational demand was noted between patients in whom pain developed and those in whom pain did not develop. In the presenting painful shoulder, there was no difference in baseline tear size, muscle degeneration, or biceps pathology between groups. The mean baseline tear length (8.6 mm vs. 3.8 mm, P = .0008) and width (8.4 mm vs. 3.2 mm, P = .0004) were larger in asymptomatic shoulders in which pain subsequently developed compared with those in which pain did not develop. However, there was no difference in mean tear enlargement (P = .51 for length and P = .90 for width). There were no differences in baseline ASES, WORC, Patient-Reported Outcomes Measurement Information System (PROMIS), or HADS depression and anxiety scores between shoulders in which pain developed and those in which pain did not develop; however, patients in whom pain developed reported a lower baseline VR-12 MCS (53.3 vs. 57.6, P = .04). Shoulders in which pain developed had higher visual analog scale pain scores (2.9 [standard deviation (SD), 2.5] vs. 0.6 [SD, 1.0]; P = .016), lower ASES scores 75 [SD, 33] vs. 100 [SD, 11.6]; P = .001), and significant changes in all WORC scales with pain onset compared with those that remained asymptomatic. The study showed no significant difference in changes in the HADS anxiety and depression scores but found a significant increase in the VR-12 MCS in patients in whom pain developed (7.1 [interquartile range, 12.6] vs. -1.9 [interquartile range, 8.7]; P = .036).

CONCLUSION

In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. Our analysis showed that only the baseline tear size of the asymptomatic shoulder was predictive of pain development. There were no tear-related features of the presenting painful rotator cuff tear or indices of mental health and physical function or occupational demand that were predictive of future pain development at short-term follow-up.

Complications of flexor tendon repair

This article reviews and highlights complications of flexor tendon repairs. Although the outcomes of flexor tendon repairs have improved over the years, fair or poor functional outcomes are seen, especially in patients whose trauma involves multiple structures of the hand and in zone 5 with multiple tendon lacerations. Rupture of the flexor tendon after repair is no longer a major problem if current repair principles are carefully adhered to. Different degrees of adhesion formations and interphalangeal (IP) joint stiffness still occur in a few patients. Early active postoperative mobilization and use of a shorter splint with sparing of the wrist are effective measures to prevent adhesion formation and IP joint stiffness. Given the overall poor results and high rate of complications with flexor digitorum profundus (FDP) repairs in zone 1, a direct repair of the FDP tendon to any short remnant of the distal insertion with 10-strand or even stronger core suture repair is adopted by many units.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors

BACKGROUND

The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°).

METHODS

This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis.

RESULTS

There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis.

CONCLUSIONS

In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

Manner of death determination in a case of gastric mucosal tears

Gastric tears are rarely described in the forensic pathological literature, although they can lead to a fatal acute exsanguination. Such lesions can arise from several conditions leading to an increased intragastric pressure, such as Mallory Weiss syndrome, cardiopulmonary resuscitation, acute barotrauma and operative procedures, showing peculiar morphological features. We present a case of a 32-year-old drug addicted white woman found dead in a pool of blood in the house of her drug dealer, after taking a dose of intravenous heroin. At autopsy, abundant bloody gastric content and multiple and long gastric tears, extending from the cardias and fundus regions to the gastric corpus were observed; one of them involved the subserous region, resulting in a gastric wall rupture. The victim had no history of recent vomiting and of gastro-intestinal pathologies. Drugs and ethanol levels detected in the specimens of the victim were not consistent with lethal concentrations, thus the death was attributed to acute exsanguination. After reviewing the literature, it turned out that morphological aspects of the gastric tears, such as number, size and topographical distribution, observed at autopsy were atypical compared to those of typical gastric lacerations.

Association Between Proximal Hamstring Tear Characteristics and Achievement of Clinically Significant Outcomes After Endoscopic and Open Repair at Minimum 2-Year Follow-up

BACKGROUND

The effect of preoperative tear characteristics and the relative efficacy of open versus endoscopic surgical techniques have not been elucidated for the surgical treatment of proximal hamstring tendon injuries.

PURPOSE

(1) To report on achievement rates of clinically significant outcomes at a minimum 2-year follow-up for multiple patient-reported outcomes (PROs) after surgical treatment of proximal hamstring injuries, stratified according to severity of proximal hamstring injury, and (2) to compare clinical outcomes associated with endoscopic versus open surgical repair for a subset of similarly classified tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A single-surgeon clinical registry was queried for patients who underwent surgical repair for proximal hamstring ruptures between January 2012 and March 2021. Injuries were classified by magnetic resonance imaging as follows: grade 1, incomplete tear with the involvement of 1 or 2 tendons; grade 2, complete tear with the involvement of 3 tendons and ≤2-cm retraction; and grade 3, complete tear with the involvement of 3 tendons and >2-cm retraction. The Patient Acceptable Symptom State (PASS) for multiple PROs was calculated and compared among injury grades and between surgical techniques.

RESULTS

Among 75 patients with a mean follow-up of 30.5 ± 5.1 months, 20 had grade 1 tears, 24 had grade 2 tears, and 31 had grade 3 tears. Favorable 2-year postoperative PROs were demonstrated by each grade for all measured PROs. Patients with grade 3 tears were noted to have significantly lower rates of 2-year PASS achievement for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Specific (HOS-SS) scales (P≤ .032). Among grade 2 tears, patients treated endoscopically demonstrated significantly greater HOS-SS (endoscopic, 91.7%; open, 58.3%; P = .045) and Patient-Reported Outcomes Measurement Information System for Physical Function (endoscopic, 80.0%; open, 50.0%; P = .033) PASS achievement rates compared with those treated with the open technique. Complication rates were highest in patients with grade 3 tears (45.2%, P = .043).

CONCLUSION

Surgical repair of proximal hamstring tendon tears with varying extents of tendon retraction resulted in high rates of achieving PASS at the 2-year follow-up. Among complete tears with <2 cm of retraction, endoscopic repairs exhibited equal or higher rates of achieving PASS compared with open repairs across multiple PROs at 2 years postoperatively. However, patients with complete tears and retraction >2 cm achieved lower rates of PASS on the HOS-ADL and HOS-SS scales and had a higher rate of complications.

Editorial Commentary: Bridging Graft Techniques Improve Short-Term Outcomes for Irreparable Rotator Cuff Tear Repair

There is a growing need for nonarthroplasty treatment options for irreparable rotator cuff tears. Options include superior capsular reconstruction (SCR), tendon transfers, subacromial balloon spacer, bridge grafting, biological tuberoplasty, and partial rotator cuff repair with or without augmentation. In our experience, repair with marginal convergence techniques is superior to SCR; if there is enough tissue, repair is the preferred strategy. In an effort to improve outcomes after repair, there has been increased interest in the use of interposition or bridging graft (BG) techniques, in which an allograft or autograft is secured on the humerus laterally and to the remnant tendon medially. Interposition or bridging grafts can be used to supplement partial repair in an effort to replace the patient's own missing tissues, and restore the biomechanical force couple of the rotator cuff and create a humeral head-depressing spacer effect in the subacromial space. These techniques show promising results compared to superior capsular reconstruction. Various graft options for BG are available, including human dermal allograft, fascia lata autograft, and tenotomized biceps autograft. Multiple animal studies have demonstrated that interposition grafts can improve the biomechanical properties of the repair construct, and histological studies in animal models have shown evidence of tissue in-growth into the BG, which could lead to increased repair strength over time. Finally, recent studies suggest that a bridging graft may improve short-term outcomes compared to partial repair alone. It remains to be seen whether this difference is clinically meaningful and durable.

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study

PURPOSE

To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up.

METHODS

We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed.

RESULTS

In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105).

CONCLUSIONS

In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Identical clinical outcomes between neutral and classic targeted alignments after high tibial osteotomy in medial meniscus posterior root tear: a prospective randomized study

PURPOSE

This study aimed to compare the clinical and radiographic outcomes and arthroscopic findings after high tibial osteotomy (HTO) between neutral and classic targeted coronal alignments in patients with medial meniscus posterior root tears (MMPRTs).

METHODS

Ninety-eight patients with MMPRT were prospectively enrolled in the final cohort and randomized into two groups. Fifty-two patients with the targeted alignment through the Fujisawa point (60-62.5% of the entire tibial plateau width measured from the medial side) during HTO were included in group A, whereas 46 patients with the targeted alignment through the point at 50-55% of the tibial plateau width were included in group B. The clinical and radiographic outcomes and second-look arthroscopic findings were statistically compared for comprehensive assessments.

RESULTS

After a mean follow-up of 37.1 months, we found no significant differences between the two groups regarding the final Lysholm (p = 0.205) and Hospital for Special Surgery scores (p = 0.084). However, we only observed significant differences between the two groups in terms of the final hip-knee-ankle angle, weight-bearing line ratio, and medial proximal tibial angle (p < 0.001). Second-look arthroscopy did not reveal a significant difference in meniscal healing rate (p = 0.786).

CONCLUSIONS

Performing HTO with the aim to achieve neutral alignment leads to similar clinical outcomes in patients with MMPRT compared to classic alignment. Although subsequent research is required, the current study provides clinical evidence for the safety and efficacy of the new targeted alignment during HTO, which may avoid long-term complications associated with overcorrection when using the traditional technique.

Acetabular Labral Reconstruction Does Not Demonstrate Superior Biomechanical Properties Compared to Labral Repair or Intact Native Labrum but Is Superior to Labral Excision: A Systematic Review of Cadaveric Studies

PURPOSE

To systematically review and compare biomechanical properties of labral reconstruction to labral repair, intact native labrum, and labral excision in cadaveric studies.

METHODS

A search of the PubMed and Embase databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Cadaveric studies focused on hip biomechanics related to intact labrum, labral repair, labral reconstruction, labral augmentation, and labral excision were included. Investigated parameters included biomechanical data measures, such as distraction force, distance to suction seal rupture, peak negative pressure, contact area, and fluid efflux. Review articles, duplicates, technique reports, case reports, opinion articles, articles written in a language other than English, clinical studies focusing on patient-reported outcomes, studies performed in animals, and articles with no abstract available were also excluded.

RESULTS

Fourteen cadaveric biomechanical studies were included that compared labral reconstruction to labral repair (4 studies), labral reconstruction to labral excision (4 studies); and evaluation of distractive force of the labrum (3 studies), the distance to suction seal rupture (3 studies), fluid dynamics (2 studies), displacement at peak force (1 study), and stability ratio (1 study). Data pooling was not performed because of methodological heterogenicity of the studies. Labral reconstruction did not outperform labral repair in restoring the hip suction seal or any other biomechanical property. Labral repair significantly prevented greater fluid efflux when compared to labral reconstruction. Labral repair and reconstruction improved the distractive stability of the hip fluid seal from the labral tear and labral excision stage, respectively. Furthermore, labral reconstruction demonstrated to have better biomechanical properties than labral excision.

CONCLUSIONS

In cadaveric studies, labral repair or intact native labrum was biomechanically more superior than labral reconstruction; however, labral reconstruction can restore acetabular labral biomechanical properties and was biomechanically superior to labral excision.

CLINICAL RELEVANCE

In cadaveric models, labral repair outperforms segmental labral reconstruction in preserving the hip suction seal; nonetheless, segmental labral reconstruction biomechanically outperforms labral excision at time 0.

Preventing and recognising skin tears using a standardised approach

Skin tears, defined as traumatic wounds caused by mechanical forces, can be debilitating for individuals, causing pain and reduced mobility. Although skin tears can develop throughout the lifespan, older age can make the skin increasingly susceptible to this type of injury. Studies have found wide variation in the incidence and prevalence of skin tears, in part because of suboptimal recognition and reporting practices among healthcare professionals. Effective prevention of skin tears requires a standardised approach to risk assessment, prevention, recognition and classification, such as that offered by the International Skin Tear Advisory Panel (ISTAP) best practice recommendations. This article examines the literature on the incidence, prevalence, prevention and recognition of skin tears, and outlines some of the ISTAP best practice recommendations on risk assessment, prevention and recognition. The authors also consider the need for patient and healthcare professional education to optimise the prevention of skin tears.

Comparing automated and manual assessments of tear break-up time using different non-invasive devices and a fluorescein procedure

To evaluate the agreement and repeatability of an automated topography-based method for non-invasive break-up time (NIBUT) analyses in comparison with two other NIBUT procedures, the fluorescein procedure (fBUT), and with the manual assessment with the same device. In the first experiment, a semi-randomised crossover study was performed on forty-three participants (23.1 ± 2.1 years). NIBUT measurements were collected in a randomised order, in both eyes of participants with EasyTear View + (Easytear, Rovereto), Polaris, and Sirius + (CSO, Firenze). Then a fBUT was collected. The overall measurement procedure was repeated in a further session (retest) on the same day. In a second experiment, a retrospective randomised crossover study was performed on eighty-five NIBUT videos previously recorded by the Sirius+. Two observers assessed manually the videos and the NIBUTs were compared with the automatic ones. In the first experiment, ANOVA showed a significant difference between the four measures in both eyes (p < 0.001). Significant differences were found in the paired comparisons between each NIBUT procedure and fBUT (Wicoxon; p < 0.05). Sirius+ resulted in agreement only with Polaris in the left eye. Correlations between all NIBUT procedures resulted in statistical significance in both eyes. All procedures showed very good test-rest reliability. In the second experiment, a significant correlation between automated and manual NIBUT was found, but also a significant statistical difference between the two measurements, although clinically negligible (0.3 s). The investigated NIBUT devices perform differently from each other (and from fBUT), so they cannot be considered interchangeable. The automated measure of NIBUT with Sirius+ has a negligible clinical difference compared to manual assessment on the same device.

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these gaps using quality improvement (QI) methodology. Project champion from a community hospital network identified the use of safe pharmacological and non-pharmacological anxiolysis and analgesia (A&A) as one such gap and partnered with EMSC to address it. Our primary Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) aim was to increase intranasal midazolam (INM) use for common, anxiety-provoking procedures on children <8 years of age from 2% to 25% in a year.EMSC facilitated a QI team with representation from the CED and regional children's hospitals. Following the model for improvement, we initiated a process analysis of this CED A&A practice. Review of all paediatric procedural data identified common anxiety-provoking simple procedures as laceration repairs, abscess drainage and foreign body removal. Our SMART aims were benchmarked to two regional PEDs and tracked through statistical process control. A balancing metric was ED length of stay (ED LOS) for patients <8 years of age requiring a laceration repair. Additionally, we surveyed CED frontline staff and report perceptions of changes in A&A knowledge, attitudes and practice patterns. These data prioritised and informed our key driver diagram which guided the Plan-Do-Study-Act (PDSA) cycles, including guideline development, staff training and cognitive aids.Anxiety-provoking simple procedures occurred on average 10 times per month in children <8 years of age. Through PDSA cycles, the monthly average INM use increased from 2% to 42%. ED LOS was unchanged, and the perceptions of provider's A&A knowledge, attitudes and practice patterns improved.A CED-initiated QI project increased paediatric A&A use in a CED network. An A&A toolkit outlines our approach and may simplify spread from academic children's hospitals to the community.

Efficacy of topical 0.05% cyclosporine A and 0.1% sodium hyaluronate in post-refractive surgery chronic dry eye patients with ocular pain

BACKGROUND

The management of post-refractive surgery dry eye disease (DED) can be challenging in clinical practice, and patients usually show an incomplete response to traditional artificial tears, especially when it is complicated with ocular pain. Therefore, we aim to investigate the efficacy of combined topical 0.05% cyclosporine A and 0.1% sodium hyaluronate treatment in post-refractive surgery DED patients with ocular pain unresponsive to traditional artificial tears.

METHODS

We enrolled 30 patients with post-refractive surgery DED with ocular pain who were unresponsive to traditional artificial tears. Topical 0.05% cyclosporine A and 0.1% sodium hyaluronate were used for 3 months. They were evaluated at baseline and 1 and 3 months for dry eye and ocular pain symptoms and objective parameters, including Numerical Rating Scale (NRS), Neuropathic Pain Symptom Inventory modified for the Eye (NPSI-Eye), tear break-up time (TBUT), Schirmer I test (SIt), corneal fluorescein staining (CFS), corneal sensitivity, and corneal nerve morphology. In addition, tear levels of inflammatory cytokines and neuropeptides were measured using the Luminex assay.

RESULTS

After 3 months of treatment, patients showed a statistically significant improvement in the ocular surface disease index (OSDI), TBUT, SIt, CFS, and corneal sensitivity (all P < 0.01) using linear mixed models. As for ocular pain parameters, the NRS and NPSI-Eye scores were significantly reduced (both P < 0.05) and positively correlated with the OSDI and CFS scores. Additionally, tear IL-1β, IL-6, and TNF-α levels were improved better than pre-treatment (P = 0.01, 0.03, 0.02, respectively).

CONCLUSION

In patients with post-refractive surgery DED with ocular pain, combined topical 0.05% cyclosporine A and 0.1% sodium hyaluronate treatment improved tear film stability, dry eye discomfort, and ocular pain, effectively controlling ocular inflammation.

TRIAL REGISTRATION

Registration number: NCT06043908.

The effect of arthroscopic coracoplasty on subscapularis strength in cases of subcoracoid impingement in the absence of subscapularis tear

Subcoracoid impingement leads to anterior shoulder pain, and arthroscopic subcoracoid decompression (coracoplasty) is the preferred treatment in recalcitrant cases. The purpose of the present study was to evaluate the effect of coracoplasty on the severity of anterior shoulder pain and the strength of the subscapularis muscle and to correlate it with the preoperative and postoperative coracohumeral distance (CHD) (t:transverse, s:sagittal). Sixteen patients without any subscapularis tendon tears who underwent arthroscopic subcoracoid decompression and rotator cuff repair with 2 years follow-up were included. Preoperative and postoperative 2-year assessments of function and pain were performed using the modified Kennedy-Hawkins test, power grading of various subscapularis muscle tests, and ASES scores. Preoperative and postoperative coracohumeral distance (tCHD, sCHD) and coracoid overlap (CO) were measured using MRIs before and after surgery. The Mean Hawkins pain score and coracoid overlap were decreased. The strength scores for subscapularis strength testing, ASES score, maximum degree of internal rotation, and coracohumeral distance increased (P < .05). Changes in belly press strength were negatively correlated with postoperative tCHD (r = -0.6, P = .04) and postoperative sCHD (r = -0.7, P = .008). A significant increase in the internal rotation range of the shoulder, subscapularis strength, and relief of anterior shoulder pain was observed. However, this increase was inversely proportional to the postoperative CHD, indicating the mechanical effect of the coracoid on subscapularis strength.