Extensor Carpi Ulnaris Instability: A Comprehensive Review of Pathology and Operative Techniques

The extensor carpi ulnaris (ECU) is primarily responsible for extension and ulnar deviation at the wrist. Secondary to repetitive loading of, or acute trauma to the flexed, supinated and ulnarly deviated wrist, the ECU tendon can be a common source of ulnar-sided wrist pain. Common pathology includes ECU tendinopathy, tenosynovitis, tendon instability, and tendon rupture. Extensor carpi ulnaris pathology commonly occurs in athletes and patients with inflammatory arthritis. Given the multitude of available methods to treat ECU tendon pathology, the aim of our study was to outline operative management of ECU tendon pathology, with emphasis on reviewing techniques for addressing ECU instability. We acknowledge a continuing debate between anatomical and nonanatomical techniques for ECU subsheath reconstruction. However, use of a portion of the extensor retinaculum for nonanatomical reconstruction is commonly used and demonstrates successful outcomes. Future comparative studies on ECU fixation are required to increase data on patient outcomes, to further define and standardize these techniques.

Grinding, Clicking, and Pivot Pain Resolve in Most Patients After Knee Arthroscopy

PURPOSE

To determine whether knee arthroscopy alleviates the symptom constellation of knee grinding/clicking, catching/locking, and pivot pain.

METHODS

One-year follow-up data from 584 consecutive subjects who underwent knee arthroscopy from August 2012 to December 2019 were collected prospectively. Subjects reported frequency of knee grinding/clicking, catching/locking, and/or pivot pain preoperatively and 1 and 2 years postoperatively. A single surgeon performed each procedure and documented all intraoperative pathology. We measured the postoperative resolution or persistence of these symptoms and used multivariable regression models to identify preoperative demographic and clinical variables that predicted symptom persistence. We also assessed changes in the Pain, Activities of Daily Living, and Quality of Life subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Postoperative symptom resolution was more likely for grinding/clicking (65.6%) and pivot pain (67.8%) than for catching/locking (44.1%). Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predicted persistence of 1 or more patient-reported knee symptoms. KOOS subscale scores consistently improved by at least one standard deviation. Individuals who had resolution of patient-reported knee symptoms exhibited roughly 2-fold improvements in KOOS Pain, ADL and Quality of Life scores compared with those whose symptoms persisted. Persistence of pivot pain was associated with the least improvement of the 3 KOOS subscales.

CONCLUSIONS

Two in three patients with grinding/clicking or pivot pain experience symptom resolution after knee arthroscopy, although catching/locking is more likely to persist. Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predict symptom persistence after knee arthroscopy.

LEVEL OF EVIDENCE

Therapeutic Level IV, retrospective cohort analysis of prospective data.

Identifying Inflammation in Knee Osteoarthritis: Relationship of Synovial Fluid White Blood Cell Count to Effusion-Synovitis on Magnetic Resonance Imaging

OBJECTIVE

Inflammation is a potential pain generator and treatment target in knee osteoarthritis (OA). Inflammation can be detected on magnetic resonance imaging (MRI) and by synovial fluid white blood cell count (WBC). However, the performance characteristics of synovial fluid WBC for the detection of synovitis have not been established. This study was undertaken to determine the sensitivity and specificity of synovial fluid WBC in identifying inflammation in knee OA using MRI effusion-synovitis as the gold standard.

METHODS

We identified records of patients seen at an academic center with a diagnosis code for knee OA, a procedural code for knee aspiration, and a laboratory order for synovial fluid WBC in the same encounter, as well as an MRI within 12 months of the aspiration. MRIs were read for effusion-synovitis using the MRI OA Knee Score (MOAKS). We dichotomized effusion-synovitis as 1) none or small, or 2) medium or large. We calculated the sensitivity and specificity of synovial fluid WBC using MRI effusion-synovitis (medium/large) as the gold standard. We used the Youden index to identify the best cut point.

RESULTS

We included 75 patients. Mean ± SD age was 63 ± 12 years, and 69% were female. The synovial fluid WBC was higher in the medium/large effusion-synovitis group (median 335 [interquartile range (IQR) 312]) than in the none/small group (median 194 [IQR 272]). The optimal cut point was 242, yielding a sensitivity of 71% (95% confidence interval [95% CI] 56-83%) and specificity of 63% (95% CI 41-81%).

CONCLUSION

The sensitivity and specificity of synovial fluid WBC in identifying effusion-synovitis on MRI were limited. Further research is needed to better understand the association between MRI and effusion-synovitis measured by synovial fluid and to determine which measure more strongly relates to synovial histopathology and patient outcomes.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future.

METHODS

We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers.

RESULTS

A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care.

CONCLUSIONS

Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

LEVEL OF EVIDENCE

Level IV-narrative review.

Quantitative sensory testing: identifying pain characteristics in patients with osteoarthritis

OBJECTIVE

This review outlines the most commonly used quantitative sensory tests to identify pain sensitization. We examine cross-sectional associations between quantitative sensory testing (QST) measures and OA symptoms and severity, along with longitudinal associations between QST findings and response to surgical and non-surgical treatments for OA.

DESIGN

We conducted a search in PubMed for English language papers including 'osteoarthritis' and 'quantitative sensory testing' as search terms. Papers that did not pertain specifically to OA or QST were excluded.

RESULTS

Pressure Pain Threshold (PPT), Conditioned Pain Modulation (CPM), and Temporal Summation (TS) are the QST measures used most frequently to identify pain sensitization. Findings indicate that persons with knee OA often exhibit lower PPT thresholds, inefficient CPM, and facilitated TS as compared with controls who do not have OA, supporting the discriminant validity of QST. Pre-treatment QST has shown some success in identifying persons who experience less pain relief from surgical and non-surgical treatments for knee OA. Post-treatment QST has shown that sometimes PPT and CPM can normalize (PPT thresholds increase, and CPM becomes efficient) in patients for whom joint replacement is successful. Recent studies indicate that QST measures are more closely associated with pain severity than OA radiographic severity, suggesting that sensitization may be a trait rather than a state.

CONCLUSIONS

QST may have a role in identifying persons who are susceptible to chronic pain and may offer an opportunity for personalized, more effective treatment of OA.

Satisfactory Pain Management With Minimal Opioid Use After Arthroscopic Rotator Cuff Repair

PURPOSE

To evaluate patient use of opioids following arthroscopic rotator cuff repair, including the number of days and number of pills when used in combination with non-opioid medications and to determine whether patients were satisfied with their pain management and if variables such as age, sex, body mass index, duration of symptoms, anticipation of postoperative pain, preoperative opioid consumption, size of the rotator cuff tear, or anxiety/depression affected pain management.

METHODS

This was a prospective cohort study of 117 prospectively enrolled patients older than the age of 18 years undergoing primary arthroscopic rotator cuff repair. All patients completed preoperative and 2-week postoperative questionnaires to assess their pain and satisfaction with pain management. Univariate and multivariate analyses were performed to evaluate the association of patient characteristics with satisfaction of pain control and amount/duration of opioids postoperatively.

RESULTS

Patients required a median of 18 opioid pain pills or 135 morphine milligram equivalents (interquartiles, 6-35 pills) postoperatively over 6.9 ± 5.1 days. In total, 65% of patients took opioid pain medications for 7 days or fewer. On postoperative day 2, patients reported a VAS pain score of 6.6 ± 2.8 and at the 2-week postoperative visit, mean visual analog scale pain score was 3.5 ± 2.5. Differences in age, sex, body mass index, duration of symptoms, anticipation of postoperative pain, preoperative 2-item Patient Health Questionnaire, 2-item Pain Self-Efficacy Questionnaire, current opioid use, and surgical characteristics had no effect on, or association with, satisfaction with pain management postoperatively.

CONCLUSIONS

Following arthroscopic rotator cuff repair, patients can achieve satisfactory pain control using a multimodal approach with a median of 18 opioid pills (range 6-35 pills) over 6.9 ± 5.1 days when used in combination with non-opioid pain medications. Overall, 74.4% of patients were satisfied with their postoperative pain management.

LEVEL OF EVIDENCE

Level II; Prospective cohort study.

Provider perspectives on the provision of safe, equitable, trauma-informed care for intimate partner violence survivors during the COVID-19 pandemic: a qualitative study

Background

Early research suggests the COVID-19 pandemic worsened intimate partner violence (IPV) in the US. In particular, stay-at-home orders and social distancing kept survivors in close proximity to their abusers and restricted access to resources and care. We aimed to understand and characterize the impact of the pandemic on delivery of IPV care in Boston.

Methods

We conducted individual interviews with providers of IPV care and support in the Greater Boston area, including healthcare workers, social workers, lawyers, advocates, and housing specialists, who continued to work during the COVID-19 pandemic. Using thematic analysis, we identified themes describing the challenges and opportunites providers faced in caring for survivors during the pandemic.

Results

Analysis of 18 interviews yielded four thematic domains, encompassing 18 themes and nine sub-themes. Thematic analysis revealed that the pandemic posed an increased threat to survivors of IPV by exacerbating external stressors and leading to heightened violence. On a system level, the pandemic led to widespread uncertainty, strained resources, amplified inequities, and loss of community. On an individual level, COVID-19 restrictions limited survivors’ abilities to access resources and to be safe, and amplified pre-existing inequities, such as limited technology access. Those who did not speak English or were immigrants experienced even more difficulty accessing resources due to language and/or cultural barriers. To address these challenges, providers utilized video and telephone interactions, and stressed the importance of creativity and cooperation across different sectors of care.

Conclusions

While virtual care was essential in allowing providers to care for survivors, and also allowed for increased flexibility, it was not a panacea. Many survivors faced additional obstacles to care, such as language barriers, unequal access to technology, lack of childcare, and economic insecurity. Providers addressed these barriers by tailoring services and care modalities to an individual’s needs and circumstances. Going forward, some innovations of the pandemic period, such as virtual interactions and cooperation across care sectors, may be utilized in ways that attend to shifting survivor needs and access, thereby improving safe, equitable, and trauma-informed IPV care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01460-9.

Perceptions of Physical Activity and the Use of Activity Monitors to Increase Activity Levels in Patients Undergoing Total Knee Replacement

Objective

Although most total knee replacement (TKR) recipients report less pain and improved function after TKR, many remain sedentary. We aimed to understand TKR recipients’ motivations for undergoing TKR, perceptions of and goals related to physical activity, and the role, if any, that activity monitors might play in their recovery.

Methods

We conducted a qualitative study, individually interviewing 27 participants who had recently undergone or were about to undergo TKR. We conducted a thematic analysis to better understand participants’ views of the benefits and barriers to physical activity after TKR.

Results

We identified nine themes and one subtheme that identify patients’ initial motivations for undergoing TKR and may help TKR recipients achieve increased activity levels and a perceived successful recovery. Some key messages that emerged from our work include the following: exercise is necessary for physical and mental health, pain and functional limitation interfere with daily life, tracking steps motivates individuals to increase activity levels, and different incentives (for engaging in physical exercise and using an activity monitor) are effective for different individuals.

Conclusion

Participants recognized the health benefits of physical activity, and many believed activity monitor use would help them become more active after surgery. Both external and internal factors played a role in motivating individuals to become more active and wear activity monitors.

Meniscal and Mechanical Symptoms Are Associated with Cartilage Damage, Not Meniscal Pathology

BACKGROUND

Traditionally defined "meniscal" and "mechanical" symptoms are thought to arise from meniscal tears. Yet meniscal tears and cartilage damage commonly coexist in symptomatic knees. To better characterize the primary driver of these symptoms, we investigated whether the presence of preoperative patient-reported knee symptoms (PRKS), including knee catching/locking, grinding/clicking/popping, and pain with pivoting, are associated with various intra-articular pathological conditions diagnosed at knee arthroscopy.

METHODS

We collected prospective data from 565 consecutive patients who underwent knee arthroscopy from 2012 to 2019 and had PRKS collected via the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The diagnosis of meniscal pathology and concomitant cartilage damage was confirmed and classified intraoperatively. We used multivariable regression models, adjusting for possible confounders, to examine the association of specific pathological conditions of the knee with the presence of preoperative PRKS.

RESULTS

Tricompartmental cartilage damage was strongly associated with significantly worse PRKS, with an increase of 0.33 point (95% confidence interval [CI] = 0.08 to 0.58; p = 0.01) on a 0 to 4-point scale. We did not observe an association between meniscal pathology and preoperative PRKS.

CONCLUSIONS

Contrary to current dogma, this study demonstrates that traditionally defined "meniscal" and "mechanical" knee symptoms are strongly associated with the burden and severity of underlying cartilage damage rather than with specific meniscal pathology.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review

Importance

Osteoarthritis (OA) is the most common joint disease, affecting an estimated more than 240 million people worldwide, including an estimated more than 32 million in the US. Osteoarthritis is the most frequent reason for activity limitation in adults. This Review focuses on hip and knee OA.

Observations

Osteoarthritis can involve almost any joint but typically affects the hands, knees, hips, and feet. It is characterized by pathologic changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of valued activities, such as walking for exercise and dancing. Risk factors include age (33% of individuals older than 75 years have symptomatic and radiographic knee OA), female sex, obesity, genetics, and major joint injury. Persons with OA have more comorbidities and are more sedentary than those without OA. The reduced physical activity leads to a 20% higher age-adjusted mortality. Several physical examination findings are useful diagnostically, including bony enlargement in knee OA and pain elicited with internal hip rotation in hip OA. Radiographic indicators include marginal osteophytes and joint space narrowing. The cornerstones of OA management include exercises, weight loss if appropriate, and education-complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) in those without contraindications. Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided. Clinical trials have shown promising results for compounds that arrest structural progression (eg, cathepsin K inhibitors, Wnt inhibitors, anabolic growth factors) or reduce OA pain (eg, nerve growth factor inhibitors). Persons with advanced symptoms and structural damage are candidates for total joint replacement. Racial and ethnic disparities persist in the use and outcomes of joint replacement.

Conclusions and Relevance

Hip and knee OA are highly prevalent and disabling. Education, exercise and weight loss are cornerstones of management, complemented by NSAIDs (for patients who are candidates), corticosteroid injections, and several adjunctive medications. For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain.

Clinician Experiences in Treatment Decision-Making for Patients with Spinal Metastases: A Qualitative Study

BACKGROUND

Effective management of metastatic disease requires multidisciplinary input and entails high risk of disease-related and treatment-related morbidity and mortality. The factors that influence clinician decision-making around spinal metastases are not well understood. We conducted a qualitative study that included a multidisciplinary cohort of physicians to evaluate the decision-making process for treatment of spinal metastases from the clinician's perspective.

METHODS

We recruited operative and nonoperative clinicians, including orthopaedic spine surgeons, neurosurgeons, radiation oncologists, and physiatrists, from across North America to participate in either a focus group or a semistructured interview. All interviews were audiorecorded and transcribed verbatim. We then performed a thematic analysis using all of the available transcript data. Investigators sequentially coded transcripts and identified recurring themes that encompass overarching patterns in the data and directly bear on the guiding study question. This was followed by the development of a thematic map that visually portrays the themes, the subthemes, and their interrelatedness, as well as their influence on treatment decision-making.

RESULTS

The thematic analysis revealed that numerous factors influence provider-based decision-making for patients with spinal metastases, including clinical elements of the disease process, treatment guidelines, patient preferences, and the dynamics of the multidisciplinary care team. The most prominent feature that resonated across all of the interviews was the importance of multidisciplinary care and the necessity of cohesion among a team of diverse health-care providers. Respondents emphasized aspects of care-team dynamics, including effective communication and intimate knowledge of team-member preferences, as necessary for the development of appropriate treatment strategies. Participants maintained that the primary role in decision-making should remain with the patient.

CONCLUSIONS

Numerous factors influence provider-based decision-making for patients with spinal metastases, including multidisciplinary team dynamics, business pressure, and clinician experience. Participants maintained a focus on shared decision-making with patients, which contrasts with patient preferences to defer decisions to the physician, as described in prior work.

CLINICAL RELEVANCE

The results of this thematic analysis document the numerous factors that influence provider-based decision-making for patients with spinal metastases. Our results indicate that provider decisions regarding treatment are influenced by a combination of clinical characteristics, perceptions of patient quality of life, and the patient's preferences for care.