Beyond the joint: Exploring the interplay between mental health and shoulder arthroplasty outcomes

Considering the fact that mental health illnesses increase with age, and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient. Employing a holistic approach when managing shoulder arthroplasty patients is necessary for optimizing outcomes and setting up recovery expectations.

Arthroscopic Subscapular Sling Procedure for Anterior Glenohumeral Instability Has Limitations: Dynamic Anterior Stabilization Using Long Head of Biceps Tendon May Represent a More Favorable Alternative

Anterior shoulder instability is a common. Cases of mild glenoid bone loss are typically addressed with conventional arthroscopic Bankart repair procedures, whereas more critical glenoid bone loss often necessitates more invasive, bone blocking procedures. Recently, for cases that fall between the need of arthroscopic repair and open procedures, surgeons have developed methods for using soft tissue grafts in order to create a "sling" effect and augment glenoid labral repair. The subscapular sling procedure aims to restore stability by introducing a semitendinosus autograft into the glenohumeral joint to reconstruct the torn labrum; the graft is wrapped around the subscapularis to create a suspensory sling. Limitations include harvest site morbidity; increased surgical time; subscapularis split which can compromise the tendon integrity resulting in loss of internal rotation; and a persistently positive apprehension test. Finally, the technique is complex, and similar alternatives with fewer limitations may include a dynamic anterior stabilization technique using the long head of the biceps tendon, which creates a stabilizing sling effect without graft harvest from the leg, and has positive reported outcomes.

Top fifty cited articles on humeral fractures

Background

Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature.

Methods

The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables.

Results

Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01).

Conclusion

The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.

Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics

Overhead athletes undergo significant biomechanical adaptations due to repetitive overhead movements, primarily affecting the glenohumeral joint. These adaptations can lead to glenohumeral internal rotation deficit (GIRD), which is characterized by posterior capsule stiffness that results in glenohumeral joint translation and a shift in the center of gravity. The severity of GIRD is dependent upon the presence of asymmetry between gained external and lost internal rotation, which is defined clinically as an asymmetry exceeding 20º; this reduces the total range of motion compared to the unaffected limb or baseline measurements. Diagnosis is challenging, as it can be mistaken for chronic scapular adaptations. To mitigate misdiagnosis, a high clinical suspicion is crucial in overhead athletes, especially those who began performing forceful overhead movements before closure of growth plates. Periodic physical examinations should establish baseline values for glenohumeral rotation and track changes in glenohumeral motion to aid in diagnosis. Symptoms of GIRD include shoulder pain, stiffness, and decreased force exertion. Magnetic resonance imaging is the preferred imaging method for evaluating GIRD and assessing concomitant soft tissue pathologies. Untreated GIRD can lead to rotator cuff strength imbalances. Treatment mainly involves conservative measures, such as physical therapy, to improve internal rotation and alleviate posterior tightness. Surgical interventions are considered when symptoms persist despite conservative treatment with physical therapy or in the presence of concomitant pathologies.

Sleep disturbances in rotator cuff pathology: insights into mechanisms and clinical implications

Rotator cuff disease is highly prevalent and can have a detrimental effect on the quality of life of affected patients. One of the most common complaints from rotator cuff disease is sleep disturbance due to shoulder pain. Numerous studies have attempted to explore the relationship between rotator cuff disease and sleep disturbance, but results are inconsistent and limited. In this setting, the Pittsburgh Sleep Quality Index (PSQI) plays an important role in preoperative assessment and evaluation of sleep in rotator cuff patients. However, despite the current efforts, the literature presents conflicting results regarding the relationships between magnetic resonance imaging characteristics of rotator cuff tear and PSQI score, signifying a gap in understanding. That being said, it has been shown that rotator cuff repair surgery can alleviate sleep disturbances witnessed preoperatively in and can restore quality of life.

The Insertion of a Subacromial Balloon Spacer Can Provide Symptom Relief and Functional Improvement at a Minimum 5-Year Follow-Up in Patients With Massive Irreparable Rotator Cuff Tears

Purpose

To examine long-term patient-reported outcomes and range of motion in patients with massive irreparable rotator cuff tears (MIRCTs) who underwent subacromial balloon spacer implantation.

Methods

A retrospective review of all patients who underwent subacromial balloon placement procedure for MIRCTs at our institution was conducted. Patients with adequate preoperative and postoperative data, with at least 5 years of follow-up, were included in our study. Outcome measures were range of motion (forward elevation), American Shoulder and Elbow Surgeon (ASES) score, and visual analog scale (VAS) score. Independent t test was conducted to check for statistically significant differences between preoperative and postoperative outcome scores, with P < .05 deemed significant.

Results

Ten patients were identified: 4 were lost to follow-up beyond 2 years and were excluded. One was converted to an arthroplasty at the 1-year mark and was then lost to follow-up (conversion rate: 16.6%). Five patients had at least 5 years of follow-up after the balloon procedure and were involved in our case series analysis. Mean age was 63.1 years, and mean follow-up was 5.8 years (range, 5-7 years). Preoperatively, mean forward elevation was 110 degrees, mean ASES score was 40.68, and mean VAS score was 6.2. On follow-up, mean forward elevation was 163 degrees (P = .007), mean ASES score was 90.97 (P = .001), and mean VAS score was 0.9 (P = .004). All patients showed significant improvements in all outcome measures, and none had any significant complications.

Conclusions

In this study, we found that the use of a subacromial balloon spacer can lead to good outcomes at a minimum 5-year follow-up in patients with MIRCTs.

Level of Evidence

Level IV, therapeutic case series.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list

BACKGROUND

In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality.

METHODS

Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics.

RESULTS

Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001).

CONCLUSIONS

There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review

PURPOSE

The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes.

DESCRIPTION

Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons.

ASSESSMENT

Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001).

CONCLUSION

Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

Improving shoulder function and pain in a paraplegic patient with massive irreparable rotator cuff tear using a subacromial balloon spacer

The subacromial balloon spacer is a promising treatment option for alleviating symptoms in patients with massive irreparable rotator cuff tears (MIRCTs). The balloon provides faster pain relief and easier rehabilitation than other options (such as arthroscopic partial rotator cuff repair). For a paraplegic MIRCT patient, the need for speedy recovery and rehabilitation is crucial, as these patients rely on their upper limbs for daily life activities and independence. In this report, we present a 60-year-old male paraplegic patient who presented to the clinic with an MIRCT of the right shoulder. After a holistic investigation and assessment of the patient, a subacromial balloon spacer with an upper border subscapularis repair was chosen as the treatment of choice. The patient had an uneventful recovery, and at the 1-year mark, had forward elevation of 170°, an American Shoulder and Elbow Surgeons score of 95, and a visual analogue scale pain score of 0.

Assessment of therapeutic clinical trials for proximal humeral fractures

Background

Proximal humeral fractures (PHFs) are a common injury among the older population. An ideal therapeutic protocol has yet to be developed, and numerous clinical trials are being conducted to find the best therapeutic approach. The purpose of this study is to evaluate the current body of knowledge available via interventional clinical trials.

Methods

In December 2022, interventional clinical trials relating to PHFs on Clinicaltrials.gov were screened. Trial characteristics included duration, status, intervention, phase, outcomes, location, and study design. Publications associated with each trial were searched on PubMed/Medline using the ClinicalTrials.gov registry number.

Results

The final dataset comprised 64 trials. The majority was completed (36%), did not have an Food and Drug Administration-defined phase (67%), was randomized (81%), involved a single facility (72%), used a parallel assignment intervention model (80%), and used an open-label approach (45%). Eleven trials were associated with a publication, and the publication rate was 17%. Average enrollment was 86 participants, and mean trial duration was 51.4 months. Europe/UK/Russia/Turkey participated in the most trials (70%). Most of the trials were initiated after 2010 (87.5%). Procedure-related interventions (55%) were most common. Disability/function was the most common primary outcome assessed (61%).

Conclusions

The low publication rate and the multitude of trials conducted after 2010 highlight the urgency and need for trial results to be published to establish an ideal therapeutic protocol. Since the majority of the trials involved a single institution and an open-label approach, reinforcing blinding and establishing multi-centered trials can improve the validity of the clinical trial results.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data

INTRODUCTION

Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty.

METHODS

Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes.

RESULTS

A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time (P < 0.001).

DISCUSSION

TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective cohort study.

Midterm outcomes of suture anchor fixation for displaced olecranon fractures

BACKGROUND

Displaced olecranon fractures constitute a challenging problem for elbow surgeons. The purpose of this study is to evaluate the role of suture anchor fixation for treating patients with displaced olecranon fractures.

METHODS

A retrospective review was performed for all consecutive patients with displaced olecranon fractures treated with suture anchor fixation with at least 2 years of clinical follow-up. Surgical repair was performed acutely in all cases with nonmetallic suture anchors in a double-row configuration utilizing suture augmentation via the triceps tendon. Osseous union and perioperative complications were uniformly assessed.

RESULTS

Suture anchor fixation was performed on 17 patients with displaced olecranon fractures. Functional outcome scores were collected from 12 patients (70.6%). The mean age at the time of surgery was 65.6 years, and the mean follow-up was 5.6 years. Sixteen of 17 patients (94%) achieved osseous union in an acceptable position. No hardware-related complications or fixation failure occurred. Mean postoperative shortened disabilities of the arm, shoulder, and hand (QuickDASH) score was 3.8±6.9, and mean Oxford Elbow Score was 47.5±1.0, with nine patients (75%) achieving a perfect score.

CONCLUSIONS

Suture anchor fixation of displaced olecranon fractures resulted in excellent midterm functional outcomes. Additionally, this technique resulted in high rates of osseous union without any hardware-related complications or fixation failures. Level of evidence: IV.

Pyrocarbon hemiarthroplasty and the shoulder: biomechanical and clinical results of an emerging treatment option

While shoulder hemiarthroplasty is still used to treat young patients with shoulder pathology, the use of this procedure has substantially declined in recent years due to its significant complication profile. Glenoid wear with arthrosis is one of the major postoperative complications following shoulder hemiarthroplasty, and efforts to prevent this complication led many scientists to explore alternative weight-bearing surfaces on arthroplasty implants to decrease joint wear and improve patient outcomes. Pyrolytic carbon, or pyrocarbon, is a material that has better biocompatibility, survivorship, strength, and wear resistance compared to the materials used in traditional shoulder hemiarthroplasty. Pyrocarbon implants have been used in orthopedics for over 50 years; recently, their utility in shoulder hemiarthroplasty has garnered much interest. The purpose behind the use of pyrocarbon in shoulder hemiarthroplasty is to decrease the risk of progressive glenoid wear, especially in young active patients in whom joint preservation is important. Promising survivorship and outcomes have been demonstrated by recent studies, including limited glenoid wear following pyrocarbon hemiarthroplasty. Nevertheless, these clinical studies have been limited to relatively small case series with limited long-term follow-up. Accordingly, additional research and comparative studies need to be conducted in order to properly assess the therapeutic efficacy and value of pyrocarbon hemiarthroplasty.

The "Balloon Dip": Insights into a Post-operative Trend in Patients Undergoing Subacromial Balloon Procedure

Introduction

The subacromial balloon is a novel therapeutic device that is used in patients with massive irreparable rotator cuff tears (MIRCTs). The novelty of this device implies that there is still a lot to be known about its mechanism of action and rehabilitation trends. One rehabilitation trend that has been noticed is the "balloon dip", where a patient exhibits exacerbations in pain and function around 3 months following balloon implantation and after having experienced earlier symptomatic relief post-operative. We discuss the clinical, diagnostic, and therapeutic aspects of the patient's management while providing additional insight into this prognostic trend.

Case Report

In this report, we present the case of a 65-year-old male patient who underwent a subacromial balloon procedure for a MIRCT. During his recovery, the patient exhibited a classic "balloon dip" evident by an exacerbation of pain and function around the 3-month mark. After a notable deterioration in pain and function, the patient was examined, reassured, and educated on the importance of adhering to physical therapy. He was able to successfully recover and showed gradual improvement in pain and function along the course of the year.

Conclusion

The "balloon dip" is a rehabilitation pattern that occurs 3-6 months following subacromial balloon spacer implantation. In the majority of cases, careful clinical assessment, watchful monitoring, and education on the importance of following up with physical therapy are sufficient to overcome the dip.

Patient-specific implants in reverse shoulder arthroplasty

Reverse total shoulder arthroplasty (RTSA) is widely popular among shoulder surgeons and patients, and its prevalence has increased dramatically in recent years. With this increased use, the indicated pathologies associated with RTSA are more likely to be encountered, and challenging patient presentations are more likely to be seen. One prominent challenging presentation is RTSA patients with severe glenoid bone loss. Several techniques with varying degrees of invasiveness, including excessive reaming, alternate centerline, bone grafting, and patient-specific implants (PSIs), have been developed to treat patients with this presentation. PSI treatment uses a three-dimensional reconstruction of a computed tomography scan to design a prosthetic implant or component customized to the patient's glenoid morphology, allowing compensation for any significant bone loss. The novelty of this technology implies a paucity of available literature, and although many studies show that PSIs have good potential for solving challenging shoulder problems, some studies have reported questionable and equivocal outcomes. Additional research is needed to explore the indications, outcomes, techniques, and cost-efficiency of this technology to help establish its role in current treatment guidelines and strategies.

International Medical Graduates in US Orthopedic Residency Programs: A Comprehensive Analysis

BACKGROUND

This study aims to provide insight regarding the different qualities of international medical graduates (IMGs) involved in US orthopedic residency programs.

METHODS

Orthopedic residency programs accredited by the ACGME and listed in the AMA database were screened. Data on program size and location, IMG year of training, the geographic region of IMG's medical schools, their research experiences and number of gap years were included.

RESULTS

A total of 167(80.3%) orthopedic residency programs were included. A total of 3838 residents were identified, of which 44 (1.15%) were IMGs. The United Kingdom and Ireland had the highest number of matched IMGs with four (9.1%) each. Massachusetts was the state with the highest number of enrolled IMGs. On average, IMGs had 26.3 publications and joined US orthopedic residency 4.66 years following medical school graduation.

CONCLUSION

Despite the many hurdles experienced by IMGs, a decent number succeeds in matching into US orthopedic residency programs each year.

Surgical management of biconcave glenoids: a scoping review

Biconcave (B2) glenoids, characterized by significant posterior glenoid bone loss and a biconcave wear pattern, are a challenging pathology in shoulder surgery. Significant bone defects present in B2 glenoids increases the risk of complications and rates of failure for operative patients with glenohumeral osteoarthritis. Diagnosing this entity is of pivotal importance, and can be accomplished with imaging and a comprehensive clinical investigation. There are no clear-cut guidelines for management, but options include hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty. In recent years, modern techniques such as corrective reaming, bone grafts, and the use of augmented components have improved patient outcomes. Educating prospective patients is essential for reaching a shared management decision, setting appropriate expectations, and optimizing prognostic outcomes.

Distal Radius Allograft for Glenohumeral Instability: A Novel Osteochondral Allograft Reconstruction Option in the Setting of Glenoid Bone Loss

BACKGROUND

Distal tibial allograft (DTA) reconstruction for glenoid bone loss is nonanatomic, as it does not match the glenoid radius of curvature (ROC) in the anterior-posterior (AP) plane. The dorsal articular portion of the distal radius has not been previously described as an allograft reconstruction option for glenoid bone loss.

PURPOSE

To evaluate distal radius fresh-frozen allograft (DRA) as a potential match for glenoid reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen fresh-frozen human cadaveric specimens-including 6 shoulder, 6 wrist, and 6 tibia specimens-were used. The ROC and the graft length were measured in the superior-inferior (SI) plane. A 30% defect was created in all glenoid specimens, and both DTAs and DRAs were harvested to assess graft fit after fixation. Computed tomography analysis was used to assess bony ROC and bone mineral density (BMD).

RESULTS

The cadaveric specimens had a mean age of 77 years. The mean SI glenoid length was 39.7 mm compared with 36.8 mm for the DRA and 30 mm for the DTA. The ROC in the SI plane was 29 ± 5.3 mm for the glenoid, 37.8 ± 4.9 mm for the DRA, and 24 ± 3.7 mm for the DTA. In the AP plane, the ROC was 39.6 ± 6.6 mm for the glenoid, 30.4 ± 18.6 mm for the DRA, and 126.3 ± 9.5 mm for the DTA. On computed tomography analysis, the ROC in the SI plane was 30.4 ± 1.5 mm for the glenoid, 30.3 ± 5.6 mm for the DRA, and 24.5 ± 9.4 mm for the DTA. In the AP plane, the ROC was 30.8 ± 2 mm for the glenoid, 19.1 ± 2.3 mm for the DRA, and 46.7 ± 21.7 mm for the DTA. The BMD was 226.3 ± 79 Hounsfield units (HU) for the glenoid, 228.5 ± 94.7 HU for the DRA, 235 ± 96.2 HU for the coracoid process, and 235.1 ± 84.6 HU for the DTA.

CONCLUSION

Compared with the DTA, the DRA had a greater mean graft length in the SI plane, providing utilization in cases of larger bony defects; the DRA has a more acute ROC in the AP plane (closer to that of the glenoid), providing a greater potential buttress to anterior humeral translation. Compared with currently utilized grafts, the DRA BMD was not significantly diminished. This study presents the DRA as a novel allograft reconstruction option in the setting of anterior glenoid bone loss; further biomechanical and clinical investigation is indicated.

Bilateral reverse shoulder arthroplasty versus bilateral anatomic shoulder arthroplasty: a meta-analysis and systematic review

As the population is aging and indications are expanding, shoulder arthroplasty is becoming more frequent, especially bilateral staged replacement. However, surgeons are hesitant to use bilateral reverse prostheses due to potential limitations on activities of daily living. This meta-analysis was conducted to compare bilateral anatomic to bilateral reverse shoulder implants. PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until April 2023. The clinical outcomes consisted of postoperative functional scores (American Shoulder and Elbow Surgeons [ASES], Single Assessment Numeric Evaluation [SANE], Physical Component Score [PCS], Mental Component Score, and Simple Shoulder Test), pain, and range of motion (external rotation and forward elevation). Three studies were included in this meta-analysis. Bilateral anatomic implants had better postoperative functional outcomes and range of motion, but no significant difference was seen in postoperative pain when compared to the reverse prosthesis. Better ASES score, SANE score, and PCS as well as better external rotation and forward elevation were seen in the bilateral anatomic shoulder replacement group, but no significant difference in pain levels was seen between the two groups. These results may be explained by the lower baseline seen in the reverse prosthesis group, which may be due to an older population and different indications. Nevertheless, more randomized controlled studies are needed to confirm these findings.

Subacromial Balloon Spacer: When to Use This?

The subacromial balloon spacer is a novel treatment option for the management of massive irreparable rotator cuff tears. This device is introduced into the glenohumeral joint and acts to alleviate the acromiohumeral impingement, caused by the massive irreparable rotator cuff tear. The device also redistributes the tension around the adjacent muscles in the joint, allowing them to compensate for the torn rotator cuff tendons. By doing so, the balloon can act as a "rehabilitation accelerator", ultimately resulting in improved shoulder pain and function. Adherence to balloon indications when selecting the appropriate patient is necessary, and these include an irreparable posterosuperior rotator cuff tear, with preserved subscapularis function, minimal to no osteoarthritis, and the ability to forward flex to 90 degrees. Clinical studies have demonstrated promising potential regarding the benefit of the balloon, with numerous studies demonstrating great outcomes after its implantation. Nevertheless, future research remains necessary to render the evidence behind its utility unequivocal.

Breaking barriers: can ChatGPT compete with a shoulder and elbow specialist in diagnosis and management?

Background

ChatGPT is an artificial intelligence (AI) language processing model that uses deep learning to generate human-like responses to natural language inputs. Its potential use in health care has raised questions and several studies have assessed its effectiveness in writing articles, clinical reasoning, and solving complex questions. This study aims to investigate ChatGPT's capabilities and implications in diagnosing and managing patients with new shoulder and elbow complaints in a private clinical setting to provide insights into its potential use as a diagnostic tool for patients and a first consultation resource for primary physicians.

Methods

In a private clinical setting, patients were assessed by ChatGPT after being seen by a shoulder and elbow specialist for shoulder and elbow symptoms. To be assessed by the AI model, a research fellow filled out a standardized form (including age, gender, major comorbidities, symptoms and the localization, natural history, and duration, any associated symptoms or movement deficit, aggravating/relieving factors, and x-ray/imaging report if present). This form was submitted through the ChatGPT portal and the AI model was asked for a diagnosis and best management modality.

Results

A total of 29 patients with 15 males and 14 females, were included in this study. The AI model was able to correctly choose the diagnosis and management in 93% (27/29) and 83% (24/29) of the patients, respectively. Furthermore, of the remaining 24 patients that were managed correctly, ChatGPT did not specify the appropriate management in 6 patients and chose only one management in 5 patients, where both were applicable and dependent on the patient's choice. Therefore, 55% of ChatGPT's management was poor.

Conclusion

ChatGPT made a worthy opponent; however, it will not be able to replace in its current form a shoulder and elbow specialist in diagnosing and treating patients for many reasons such as misdiagnosis, poor management, lack of empathy and interactions with patients, its dependence on magnetic resonance imaging reports, and its lack of new knowledge.

InSpace Balloon for the Management of Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis

Background

The best course of action for massive irreparable rotator cuff tears (MIRCTs) is not universally agreed upon. Numerous surgical techniques have been discussed. The implantation of a biodegradable spacer into the subacromial area has been documented since 2012 by several authors. The implantation method is touted as being simpler, repeatable, and less invasive than other solutions that are now available. The purpose of this systematic review and meta-analysis, being the first of its kind, was to evaluate the literature to see the efficacy of InSpace balloon (ISB) implantation in the management of MIRCTs.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and with 2 researchers assessing and analyzing each study separately, an extensive electronic search of the literature was conducted in the PubMed database from 1961 until July 27, 2022.

Results

Fourteen studies were included in this systematic review and three in the meta-analysis. Eleven out of fourteen studies favored ISB use for MIRCTs, while only three were against its use. All spacers were arthroscopically implanted in the subacromial space. Three studies were included in the meta-analysis. The differences in the compared outcomes were statistically insignificant.

Conclusions

A controversy about the use of ISB remains in patients with MIRCTs. Both good and bad outcomes were reported. However, the majority of patients had good clinical outcomes across several grading scales, radiographic evidence of improved impingement, and self-report that they would redo the procedure in hindsight. To draw more solid conclusions and have statistically significant results in the meta-analysis, more randomized controlled trials and comparative studies comparing this device to other treatments are needed.

Upper limb injuries in mixed martial arts

OBJECTIVE

Mixed-Martial-Arts(MMA) is a worldwide growing sport that incorporates different fighting styles and disciplines and is often associated with the Ultimate Fighting Championship(UFC) . The aim of this study is to explore the patterns and trends of upper limb injuries in MMA.

METHODS

Ringside physician reports of the UFC fights between 2016 and 2019(inclusive) were extracted and screened from the Nevada State Athletic Commission(NSAC). The following variables were included: sex, weight division, injury mechanism, injury type, injury location, and type of finish. Injury rates were calculated and expressed per 100 athletic exposures (AE). An independent t-test, a one way analysis of variance(ANOVA), and a Joinpoint regression analysis were conducted to explore any significant differences or trends among variables. P-values<0.05 were considered significant(95% CI).

RESULTS

A total of 81 upper limb injuries in 408 fights were recorded between 2016 and 2019. The injury rate was 9.9 injuries per 100 athletic-exposures(AE). Striking opponents was the most common mechanism of injury(p < 0.001). The hand was the most commonly injured location with an injury rate of 6.61 per 100AE(p < 0.001). Females had a higher upper limb injury rate than their male counterparts, but the difference failed to reach significance(p = 0.454). Similarly, no significant differences existed between rates of different types of injures. Matches ending with decision had the highest number of upper limb injuries with a rate of 12.6 per 100AE; however, no significant difference was determined between the rates of different ways of finish(p = 0.115). The strawweight(20.5 per 100AE), female flyweight(19.2 per 100AE), and male flyweight(13.8 per 100AE) divisions had the highest upper limb injury rates.

CONCLUSION

The hand was the most commonly injured upper limb location in MMA, and 'striking opponent' was the most common injury mechanism. Increasing padding in gloves and implementing medical examinations during bouts can help reduce injury rates.

Online resources for information on shoulder arthroplasty: an assessment of quality and readability

BACKGROUND

Many patients use online resources to educate themselves on surgical procedures and make well-informed healthcare decisions. The aim of our study was to evaluate the quality and readability of online resources exploring shoulder arthroplasty.

METHODS

An internet search pertaining to shoulder arthroplasty (partial, anatomic, and reverse) was conducted using the three most popular online search engines. The top 25 results generated from each term in each search engine were included. Webpages were excluded if they were duplicates, advertised by search engines, subpages of other pages, required payments or subscription, or were irrelevant to our scope. Webpages were classified into different source categories. Quality of information was assessed by HONcode certification, Journal of the American Medical Association (JAMA) criteria, and DISCERN benchmark criteria. Webpage readability was assessed using the Flesch reading ease score (FRES).

RESULTS

Our final dataset included 125 web pages. Academic sources were the most common with 45 web pages (36.0%) followed by physician/private practice with 39 web pages (31.2%). The mean JAMA and DISCERN scores for all web pages were 1.96±1.31 and 51.4±10.7, respectively. The total mean FRES score was 44.0±11.0. Only nine web pages (7.2%) were HONcode certified. Websites specified for healthcare professionals had the highest JAMA and DISCERN scores with means of 2.92±0.90 and 57.96±8.91, respectively (P<0.001). HONcode-certified webpages had higher quality and readability scores than other web pages.

CONCLUSIONS

Web-based patient resources for shoulder arthroplasty information did not show high-quality scores and easy readability. When presenting medical information, sources should maintain a balance between readability and quality and should seek HONcode certification as it helps establish the reliability and accessibility of the presented information. Level of evidence: IV.

The long head of the biceps tendon: a valuable tool in shoulder surgery

ANATOMY AND FUNCTION

The long head of the biceps tendon (LHBT) has different properties and characteristics that render it a valuable tool in the hands of shoulder surgeons. Its accessibility, biomechanical strength, regenerative capabilities, and biocompatibility allow it to be a valuable autologous graft for repairing and augmenting ligamentous and muscular structures in the glenohumeral joint.

SHOULDER SURGERY APPLICATIONS

Numerous applications of the LHBT have been described in the shoulder surgery literature, including augmentation of posterior-superior rotator cuff repair, augmentation of subscapularis peel repair, dynamic anterior stabilization, anterior capsule reconstruction, post-stroke stabilization, and superior capsular reconstruction. Some of these applications have been described meticulously in technical notes and case reports, whereas others may require additional research to confirm clinical benefit and efficacy.

CONCLUSION

This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Subacromial Balloon Spacers for Massive Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears are difficult to treat. Several different treatment options have been explored in the orthopedic realm. A 69-year-old male with a massive irreparable rotator cuff tear was originally treated with a subacromial balloon spacer around five years prior to presentation. The patient started having increasing shoulder discomfort. Treatment options were discussed following review of MRI results and the patient decided to move forward with a second balloon spacer. The patient underwent his revision procedure and noted significant improvement in his pain and function on follow-up. Revision subacromial balloon spacers constitute an effective surgical treatment option that may slow the progression of rotator cuff arthropathy and relieve pain and dysfunction in the setting of massive irreparable rotator cuff tears.

Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis

Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between 2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P = 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P < 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P < 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

Clinical and Diagnostic Characteristics of Calcaneal Apophysitis: A Systematic Review and Thematic Analysis

BACKGROUND

Calcaneal apophysitis is an overuse injury in pediatric patients that causes heel pain and reduction in function. The aim of this study is to explore this condition and offer medical insight into its presentation and symptomatology, along with current treatment options.

METHODS

We explored PubMed/Medline for studies involving calcaneal apophysitis in pediatric patients. The search included all articles published from database inception until June 1, 2021. We only included articles published in English. Clinical information and demographics extracted from the reported studies were analyzed and assessed.

RESULTS

Only 28 studies met our criteria, with a total of 1,362 cases. Of the cases reported, 973 affected boys (71.4%). Presentation was bilateral in 589 cases (43.2%) and unilateral in 433 cases (31.8%). Radiographic imaging was used for the diagnosis of 358 cases (26.3%). All reported treatment modalities were conservative, and these included physical therapy and rest, kinesiotherapy and taping, and orthotic devices. A total of 733 cases (53.7%) reported improved outcomes,32 cases (2.3%) reported no improvement, and the remainder of cases did not report prognostic outcomes (44%).

CONCLUSIONS

Calcaneal apophysitis is an overuse disease commonly found in the pediatric population. Educating parents and coaches with regard to its symptomatology, etiology, and treatment is essential to diagnose the condition earlier and provide better outcomes.

Osteoporosis in the Setting of Shoulder Arthroplasty: A Narrative Review

Patients who undergo shoulder surgery are frequently affected by osteoporosis and osteopenia, and the prevalence of this association is expected to increase due to the growing number of elderly individuals undergoing these procedures. It may be advisable to conduct a preoperative DXA scan for orthopedic surgical candidates at high risk, to detect those who could benefit from early intervention and avoid any related adverse events. Some of these complications include periprosthetic fractures, infection, subsequent fragility fractures, and have an all-cause revision arthroplasty at 2 years post-op. Some studies analyzed the beneficence of antiresorptive medications pre-operatively but the latter did not show favorable outcomes. Surgical management may include cementing components of the prosthesis as well as modifying the diameter of the shoulder stem. Nevertheless, more studies are needed to evaluate the efficacy of any intervention, whether medical or surgical, to avoid any shoulder arthroplasty related-complication that may be precipitated by the reduced bone mineral density.

Humeral Fracture in a Female Arm Wrestler: A Patient-Centered Focused Review

Humeral fractures in arm wrestling are rarely reported entities in the orthopedic literature and can present with significant pain and debilitation. These injuries are even more uncommon in female practitioners of the sport. Rotational forces applied to the humerus during competition can result in the transmission of stress into the distal part of the humerus, thereby causing a spiral fracture. Common complications that can arise from such an injury can include radial nerve palsy and butterfly fragments of the humerus. These can occur in arm wrestling and can present with prominent pain, weakness, and functional impairment. Treatment often varies according to the presenting case and are often operative in cases with displaced fractures, and non-operative in those of nondisplaced fractures. Prognostic outcomes are often favorable and uneventful. In this article, we explore a distal humeral fracture in a female arm wrestler and discuss the mechanism, presentation, and management of such an injury, based on a thorough yet concise review of literature.

Effective Management of Bilateral Massive Irreparable Rotator Cuff Tears through Implantation of Subacromial Balloon Spacers

Introduction

Massive irreparable rotator cuff tears are challenging pathologies with many treatment modalities and therapeutic approaches. In patients with certain indications, the subacromial balloon spacer can effectively alleviate pain and improve function, in a manner that may be superior to other management options.

Case Report

We report the case of a 64-year-old active male who had previously underwent a subacromial balloon placement in his right shoulder and an arthroscopic rotator cuff repair procedure on his left shoulder. He later presented with persistent pain and disability in his left shoulder and opted to undergo a second subacromial balloon placement on his left side. To the best of our knowledge, this is the first case of bilateral subacromial balloon placement procedure in the literature.

Conclusion

The subacromial balloon is a safe treatment modality for irreparable rotator cuff tears, and its introduction into bilateral shoulders can provide an easier recovery and rehabilitation when compared to other more invasive procedures.

Evaluation of online video content related to reverse shoulder arthroplasty: a YouTube-based study

BACKGROUND

Reverse shoulder arthroplasty (RSA) has evolved continuously over recent years, with expanded indications and better outcomes. YouTube is one of the most popular sources globally for health-related information available to patients. Evaluating the reliability of YouTube videos concerning RSA is important to ensure proper patient education.

METHODS

YouTube was queried for the term "reverse shoulder replacement." The first 50 videos were evaluated using three different scores: Journal of the American Medical Association (JAMA) benchmark criteria, the global quality score (GQS), and the reverse shoulder arthroplasty-specific score (RSAS). Multivariate linear regression analyses were conducted to determine the presence of a relationship between video characteristics and quality scores.

RESULTS

The average number of views was 64,645.78±264,160.9 per video, and the average number of likes was 414 per video. Mean JAMA, GQS, and RSAS scores were 2.32±0.64, 2.31±0.82, and 5.53±2.43, respectively. Academic centers uploaded the highest number of videos, and surgical techniques/approach videos was the most common video content. Videos with lecture content predicted higher JAMA scores whereas videos uploaded by industry predicted lower RSAS scores.

CONCLUSIONS

Despite its massive popularity, YouTube videos provide a low quality of information on RSA. Introducing a new editorial review process or developing a new platform for patients' medical education may be necessary. Level of evidence: Not applicable.

Subscapular sparing approach for total shoulder arthroplasty: a systematic review and meta-analysis of comparative studies

Background

Total shoulder arthroplasty has been effective in treating primary glenohumeral arthritis surgically. However, the subscapularis (SSC) tendon must be released as part of the surgery's conventional approach, which could lead to postoperative problems and later tendon failure. Using a procedure that spares the tendon, Lafosse et al reported improved postoperative SSC performance. This meta-analysis will compare this approach to the standard one.

Methods

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched till October 2022. The clinical outcomes consisted of the postoperative pain, adverse events, and range of motion.

Results

Only 3 studies were included in this meta-analysis. The subscapularis sparing approach tended to have better postoperative internal rotation (P = .06) and shoulder elevation (P = .1); however, the results were marginally statistically insignificant.

Conclusion

This is the first meta-analysis to compare the subscapularis sparing to the standard approach in total shoulder arthroplasty. Showing better postoperative range of motion (elevation and internal rotation), the SSC approach might be considered as a good substitute to the standard one. However, it is limited by the potentially limited exposure making it harder to use in muscular and obese patients. More randomized clinical trials are needed to reach more significant results and establish clearer indications of this approach.

Intraoperative periprosthetic humeral fracture during reverse shoulder arthroplasty: a sequelae of prior biceps tenodesis

Intraoperative periprosthetic humeral fractures are a rare but debilitating complication of reverse shoulder arthroplasty and can occur during multiple stages of the procedure. Prior biceps tenodesis has been found to reduce cortical humeral strength and predispose the patient to humeral fracture. We present a case of a 68-year-old female with a previous history of biceps tenodesis due to an irreparable rotator cuff tear. Months later, and after symptoms persisted, a reverse shoulder arthroplasty was performed. During the surgery and while performing final reduction, a fracture line was observed involving the hole used for the previous tenodesis procedure. The fracture was repaired, and the patient reported favorable outcomes. We report several factors that might have contributed to sustenance of this intraoperative fracture including prior biceps tenodesis, use of a press fit humeral stem, and the sex of the patient.

Bilateral Divergent Fracture Dislocations in a COVID-19 Patient Following a Hyponatremia-Induced Seizure

Bilateral divergent fracture dislocations of the shoulder are very rare. Caution with regards to seizure development in COVID-19 patients must be taken to avoid such injuries. This is the case of a male COVID-19 patient who sustained hyponatremia-induced seizure that resulted in bilateral divergent shoulder fracture dislocations. The patient suffered a lesser tuberosity fracture on his left shoulder which was posteriorly dislocated, and a greater tuberosity fracture on his right, which was anteriorly dislocated. The patient underwent bilateral open reduction and internal fixation, with suture anchor fixation for the lesser tuberosity fracture on the left side, and a proximal humerus locking plate for the greater tuberosity fracture on the right side. Education on postoperative complications and expectations were provided to the patient.

The impact of the Beirut blast on the COVID-19 situation in Lebanon

Aim

On August 4, 2020, a massive explosion hit Lebanon's capital city, Beirut. The aim of this study was to explore the effect of the Beirut blast on the COVID-19 situation in the country.

Subject and Methods

Data on COVID-19 were retrieved from the Lebanese Ministry of Public Health (LMOPH), where all the COVID-19 positive cases were reported. The study was divided into two periods, considering the incubation period of the COVID-19 virus: (July 27-August 9, 2020) and (August 10-23, 2020). Information obtained included daily number of cases, tests, deaths, hospitalized patients, intensive care unit (ICU) patients, and mode of acquisition (local vs. expat). Daily positivity rates were reported per 100 tests. An independent sample t-test and a Joinpoint regression analysis were used to determine significance. A p value less than 0.05 was considered significant.

Results

A total of 201,010 tests were conducted during our studied period, with 8993 positive cases, constituting a total positivity rate of 4.5 per 100 tests. Case fatality rate over the studied period was 0.8%. The positivity rate of the period prior to August 10, 2020, was 2.7 per 100 tests, significantly less than that of the period following the explosion, which was 6.4 per 100 tests (p < 0.001). During our studied period, daily positivity rates were significantly increasing at a slope of 0.29 (p < 0.001). A significant increase in slope was noted on August 13, 2020 (p < 0.001). The number of hospitalized patients increased from 139 patients on July 27 to 266 on August 23, 2020, and that of ICU patients increased from 36 to 75.

Conclusion

The port of Beirut explosion resulted in a significant increase in the daily number of positive COVID-19 cases. The aftermath of the explosion, the damage to healthcare facilities, and the overcrowding due to emergency efforts were contributing factors to that increase.

Emerging Health Disparities during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has underscored social and racial discrimination in global health, showing that health equity is still a goal to be achieved. Understanding the impact of COVID-19 on public health potential is vital to present a fair opportunity for people of different backgrounds to be as healthy as possible. As such, this communication discusses the emerging health disparities in light of the COVID-19 pandemic and analyzes their implications. Original research, effective health communication, and promotion strategies ought to be leveraged to step closer toward national and international health equity.

Lower limb injuries in an english professional football club: injury analysis and recommendations for prevention

BACKGROUND

Lower limb injuries constitute a problem in the sport of football. Our aim is to explore patterns and trends of lower limb injuries in an English professional football club.

METHODS

This is a descriptive epidemiological study. Reports provided by the club's physical therapy team were screened for injuries among professional football players sustained over four seasons, from 2015/2016 to 2018/2019. Data included setting of injury (in-match or training), anatomical location of injury, type of injury, number of days off and month of injury.

RESULTS

A total of 296 lower limb injuries were recorded in our study, with a rate of 11.14 per 1000 football hours. Injury rate during games was 51.38 per 1000 football hours, significantly greater than that during training at 3.81 per 1000 football hours (p = 0.021). The thigh was significantly the most commonly injured location at 4.67 per 1000 football hours (p < 0.001). Grade I tears were the most common injury type at 1.73 per 1000 football hours, significantly greater than grade III tears (p = 0.027), contusions (p = 0.043), fractures (p = 0.02), and lacerations (p = 0.019). Injury rates were found to be greatest during preseason and declined as season progressed. On average, an injury sidelined the affected footballer for a total of 20 days.

CONCLUSION

Lower limb injuries were more common during matches than training. The thigh is the most common injury location, and grade I muscle tear was the most common type of injury. Injury rates were higher early on in the season. Potential prevention strategies include spacing out competition, adopting training and exercise regimens that cater for recovery, and increasing research regarding injury mechanisms.

Craniofacial and traumatic brain injuries in mixed martial arts

Objective: Mixed-Martial-Arts (MMA) has witnessed a rapid growth over the recent years. This study aims to explore the patterns and trends of head injuries in MMA.Design: Descriptive epidemiological study.Setting: Ringside physician reports of the Ultimate Fighting Championship (UFC) fights between 2016 and 2019 (inclusive) were screened. Data were extracted from the Nevada State Athletic Commission (NSAC) database. Play-by-play video analysis was also conducted.Participants: UFC fighters involved in fights sanctioned by the NSAC, between 2016 and the end of 2019 (N = 816).Independent variables: Sex, location of head injury, type of head injury, injury mechanism, number of significant head strikes, type of finish, and weight division.Main outcome measures: Head injury rates were calculated. A one-way analysis of variance (ANOVA) was used to explore any statistically significant differences between injury rates of different locations, types, and types of finishes. An independent t-test was used to determine whether any significant differences existed between the two sexes, and a Joinpoint regression analysis was used to determine the statistical significance of the trends of head injury rates across different weight divisions. P-values <0.05 were considered significant (95% CI).Results: A total of 288 head injuries in 408 fights were recorded during our study period. Head injury rate constituted 35 injuries per 100 athletic-exposures (AE) in sanctioned fights. Traumatic brain injuries (TBI) were the most common type of injury, with a rate of 16 per 100AE, significantly greater than that of fractures (p = 0.003). Males had a head injury rate of 37 per 100AE, higher than that of females which was 23 per 100AE. Technical Knockout (TKO)/ Knockout(KO) was the type of finish with the highest rate of head injuries, significantly greater than that of decision or submission (p < 0.001). In general, head injury rates were higher as weight divisions increased.Conclusion: Head injuries are prevalent in MMA. Preventive measures need to be implemented to ensure fighter safety and limit injury risk.

Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations

Sever's disease is an underreported prevalent pediatric condition that causes heel pain in children worldwide. It is often described as an overuse injury that can present with either unilateral or bilateral heel pain. Even though the exact mechanism of injury is unknown, it is often thought it involves repetitive stress and pressure on the calcaneal growth plate. Diagnosing Sever's disease mainly relies on a thorough clinical investigation and physical examination, with a positive squeeze test usually sufficient to establish diagnosis. Nevertheless, radiographic imaging can help exclude other differential diagnoses. Therapeutic options of Sever's disease are mostly conservative, and these include rest, physical therapy, kinesiotherapy, and orthoses. Educating parents and coaches on the symptomatology and presentation of Sever's disease is pivotal for the establishment of efficient preventive interventions and earlier diagnoses. This study presents a case of a pediatric patient with Sever's disease and offers medical insight into the diagnostic, clinical, pathologic, and therapeutic characteristics of this condition, in light of the current existing literature.

American college of surgeons NSQIP pancreatic surgery publications: A critical appraisal of the quality of methodological reporting

BACKGROUND

The use of ACS-NSQIP has increased in pancreatic surgery (PS) research. The aim of this study is to critically appraise the methodological reporting of PS publications utilizing the ACS-NSQIP database.

STUDY DESIGN

PubMed was queried for all PS studies employing the ACS-NSQIP database published between 2004 and 2021. Critical appraisal was performed using the JAMA-Surgery Checklist, STROBE Statement, and RECORD Statement.

RESULTS

A total of 86 studies were included. Median scores for number of fulfilled criteria for the JAMA-Surgery Checklist, STROBE Statement, and RECORD Statement were 6, 20, and 6 respectively. The most commonly unfulfilled criteria were those relating to discussion of missed data, compliance with IRB, unadjusted and adjusted outcomes, providing supplementary/raw information, and performing subgroup analyses.

CONCLUSION

An overall satisfactory reporting of methodology is present among PS studies utilizing the ACS-NSQIP database. Areas for improved adherence include discussing missed data, providing supplementary information, and performing subgroup analysis. Due to the increasing role of large-scale databases, enhanced adherence to reporting guidelines may advance PS research.

National trends in cholecystectomies in the US: a 15-year comparison of two surgical approaches

BACKGROUND

The two approaches for performing cholecystectomy are open and laparoscopic ones. This study aims to characterize national trends of cholecystectomies in the United States (US) and determine differences by approach, age group, primary payer, teaching status and location of healthcare center.

METHODS

Retrospective analysis of patients undergoing cholecystectomy was done using the US National Inpatient Sample from 1997 to 2011. Trends in open and laparoscopic cholecystectomy were analyzed, as well as comparison between age groups, primary payer, location and teaching status of hospitals operations were performed at.

RESULTS

Around 6 million cholecystectomies performed from 1997 to 2011. The laparoscopic approach was significantly more common than the open (p-value <0.001). A significant decrease in open cholecystectomies is seen since 1997. Age group of 65-84 had significantly the most cases in the open approach (p-value <0.001), while in laparoscopic the 18-44 age group had the significantly highest amount (p-value <0.001). Medicare covered the most cases for open, while private insurance covered the most in the laparoscopic approach. Most cases were performed in urban, private non-profit, non-teaching hospitals in both groups. In the laparoscopic group the South had a significantly higher (p-value <0.001) number of cases compared to all other U.S. regions.

CONCLUSIONS

Cholecystectomies remained constant from 1997 to 2011. The number of open cholecystectomies decreased over time in favor of laparoscopic ones. More funding should be given to private non-teaching hospitals as they perform the majority of cholecystectomies nationwide. Better management of cholecystectomy risk factors is needed in the South.

COVID-19 Pandemic: An Insult Over Injury for Lebanon

The outbreak of the novel coronavirus disease in 2019 (COVID-19) caused a plethora of challenges worldwide and tested healthcare systems across the six continents. Lebanon had recently faced harsh political and economic crises. We aim to describe the effect of COVID-19 on an already crisis-stricken country. A descriptive analysis of the burden of COVID-19 pandemic on Lebanon was performed. Relevant data on COVID-19 was retrieved from the Lebanese Ministry of Public Health from February 21 till June 13th, 2020. Results obtained were analyzed and a literature review was performed. 1422 confirmed COVID-19 cases were identified and reported in Lebanon by June 13th, 2020, comprising an incidence rate of 208/million persons. There has been a total of 31 deaths thus far, with a reported death rate of 5/million persons. The age group with the highest number of cases was 20–29 years. Beirut was the district with the highest number of cases (18%). The COVID-19 crisis has impacted the country on a multifactorial level. COVID-19 could not have come at a worse time for Lebanon. The country is on brink of bankruptcy, the healthcare system is struggling for survival and the government is striving to regain the trust of the population. 

Landscape of interventional clinical trials involving gastrectomy for gastric cancer

Background

Gastric cancer (GC) is the third most common cause of malignancy associated mortality globally. The cornerstone of curative treatment involves surgical gastrectomy. In this study, we explore clinical trials involving gastrectomy for GC, highlighting inadequacies and underlining promising surgical interventions and strategies.

Materials and methods

On 1 May 2020, ClinicalTrials.gov was explored for interventional trials related to gastrectomy for GC, without adding limitations for location or date. All data pertaining to the trials were collected. Characteristics such as phase, duration, enrolment size, location, treatment allocation, masking and primary endpoint were analysed.

Results

One hundred thirty-eight clinical trials met the search criteria. Clinical trials were performed in only 14 countries; most of them occurring in China. Most trials (33%) were still in the recruiting phase. On average, the length of trials was 3.9 years. Most trials had parallel assignment, were randomised and masked. The primary endpoint which was mostly commonly studied was overall survival (33%). The most common intervention studied is laparoscopic gastrectomy in 43 (31%) trials.

Conclusions

Our study exposed a small number of trials, publication rate, absence of geographic variety in clinical trials involving gastrectomy for GC. Adequate management of trial design can help decrease duration and increase validity of results. More trials comparing different surgical techniques are needed to update the surgical practice of gastrectomy for GC.

Probing the Colorectal Cancer Incidence in Lebanon: an 11-Year Epidemiological Study

BACKGROUND AND OBJECTIVES

Lebanon has witnessed an increase in the rates of several cancer sub-types over the past couple of years. The aim of our study is to investigate the incidence rates of colorectal cancer over 11 years in Lebanon and compare them with other countries.

MATERIALS AND METHODS

Data was collected from the National Cancer Registry (NCR) of Lebanon from the years of 2005 till 2015 inclusive. Data of other countries was retrieved from the online database "Cancer Incidence in Five Continents". The age-specific and age-standardized incidence rates (ASR(w)) were calculated and analyzed using Joinpoint regression.

RESULTS

Colorectal cancer ranked as the 5th most common cancer in Lebanon. The average ASR(w) was 12.6 per 100,00 for males and 10.7 per 100,00 for females. Colorectal cancer ASR (w) showed a significantly increasing trend in both males and females. Lebanon had the second highest incidence of colorectal cancer in the MENA region.

CONCLUSION

Incidence of colorectal cancer has been increasing significantly over the course of our study. It is important to study the risk factors associated with colorectal cancer and develop proper preventive and screening policies in order to decrease exposure and therefore decrease incidence rates in the future.

Achilles tendinopathy: Exploring injury characteristics and current treatment modalities

Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.

Doping in the Ultimate Fighting Championship (UFC): A 4-year epidemiological analysis

BACKGROUND

Doping is a practice that is present in many sports and organizations, including mixed martial arts and the Ultimate Fighting Championship (UFC). The aim of this study is to explore the epidemiological patterns of doping among UFC athletes.

METHODS

We screened the official United-States-Anti-Doping-Agency® (USADA) website, the annual USADA reports and the official UFC website for information on fighters and anti-doping rule violations (ADRVs). Our dataset included gender, age, weight class, testing numbers, date of ADRV, type of ADRV, and duration of suspension. Appropriate statistical tests were conducted to assess for statistical significance.

RESULTS

USADA tested 1070 UFC athletes 2624 times as of late 2015 up till the end of 2019 (N = 1070). A total of 209 adverse findings were recorded; out of which, 102 ADRVs were committed by 93 athletes (8.7%) from all weight divisions. This constituted an adverse finding rate of 16.55 per 1000 test and an ADRV rate of 8.08 per1000 test. Mean age of sanctioned athletes was 32 years. Use of anabolic steroids was significantly the most common ADRV recorded (p = 0.018). The men's heavyweight division had an ADRV rate of 19.3 per 1000 tests, significantly higher than that of women's bantamweight division at 2 per 1000 tests (p = 0.03), women's featherweight division at 0 per 1000 tests (p = 0.009), and men's flyweight division at 3 per 1000 tests (p = 0.035). ADRV rate showed a significantly increasing trend among men's weight divisions (p < 0.001).

CONCLUSION

Doping is present in mixed martial arts. Increasing testing numbers, raising awareness and education on the risks of doping, and conducting further research on the issue is key to help resolve this problem.