Preoperative Depression Negatively Impacts Pain and Functionality Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically investigate the influence of preoperative depression diagnosis and symptom severity on outcomes after anterior cruciate ligament reconstruction (ACLR).

METHODS

A literature search was performed using the PubMed, Scopus, and Embase databases according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies evaluating the impact of depression on clinical outcomes after ACLR were included. Clinical outcomes, changes in depression, and complications were aggregated.

RESULTS

Nine studies comprising 308,531 patients (mean age, 28.1 years; age range, 14-50 years) were included. The depression incidence ranged from 3.8% to 42%. Seven studies showed postoperative improvement in depression scores, with 5 reporting statistical significance. Assessment of depression exhibited substantial variability, with Patient-Reported Outcomes Measurement Information System (PROMIS) scores being the most common method. Patients with depression, despite showing greater improvements in scores, experienced significantly higher PROMIS Pain Interference scores preoperatively (range, 59.1-65.7 vs 56.8-59.2) and postoperatively (range, 46.3-52.3 vs 46.3-47.4) than patients without depression. They also showed significantly lower preoperative (range, 33-38.1 vs 39.7-41.5) and postoperative (range, 51.6-56.7 vs 56.7-57.6) PROMIS Physical Function scores, regardless of greater score improvement. Patients affected by depression had significantly higher rates of minimal clinically important difference achievement for the PROMIS Physical Function score (71%-100% vs 80%) and similar rates for the PROMIS Pain Interference score (71%-81% vs 68%) compared with patients without depression in 3 studies. Depression was associated with reduced adherence to rehabilitation protocols and increased postoperative complications, including infection, graft failure, arthrofibrosis, and readmission.

CONCLUSIONS

ACLR yields favorable outcomes for patients with and without preoperative depression. Individuals with preoperative depression may report inferior outcomes in terms of pain and functionality; nevertheless, despite these challenges, they exhibit significant improvements across all outcome measures after surgery, including reductions in depression levels.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

Understanding Shoulder and Elbow Injuries in the Windmill Softball Pitcher

Although pitching-related injuries in the overhead athlete have been studied extensively, injuries associated with windmill pitching are not as clearly elucidated. Windmill pitching produces high forces and torques in the upper extremity, and studies have shown it creates similar shoulder and elbow joint loads to those reported in baseball pitchers. Studies have shown that the windmill pitching motion generates high levels of biceps activation with an eccentric load, placing the biceps at increased risk for overuse injuries. Although the American Orthopaedic Society for Sports Medicine published prevention guidelines including recommendations for maximum pitch counts in softball, these recommendations have not been adopted by most United States softball governing bodies. The repetitive windmill motion in conjunction with high pitch count demands in competitive softball creates notable challenges for the sports medicine physician. As with overhead throwing athletes, identifying and preventing overuse is crucial in preventing injuries in the windmill pitcher, and prevention and rehabilitation should focus on optimizing mechanics and kinematics, core, hip, and lower body strength, and recognition of muscle fatigue. With more than two million fastpitch softball participants in the United States, it is essential to better understand the etiology, evaluation, and prevention of injuries in the windmill pitching athlete.

Recurrent Instability After Arthroscopic Bankart Repair in Patients With Hyperlaxity and Near-Track Lesions

Background

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success.

Purpose

To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]).

Study Design

Case-control study; Level of evidence, 3.

Methods

The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm.

Results

Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss.

Conclusion

Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Medicaid Payer Status Is a Predictor of Early Postoperative Pain Following Upper Extremity Procedures

Background: The purpose of this study was to investigate the relationship between insurance status and patient-reported pain both before and after upper extremity surgical procedures. We hypothesized that patients with Medicaid payer status would report higher levels of pre- and postoperative pain and report less postoperative pain relief. Methods: In all, 376 patients who underwent upper extremity procedures by a single surgeon at an academic ambulatory surgery center were identified. Patient information, including insurance status and Visual Analog Scale pain score (VAS-pain) at baseline, 2 weeks, and 1, 3, and 6 months, were collected. VAS-pain scores were compared with t-tests and linear regression. Results: Preoperatively and at 2-week, 1-month, and 3-month follow-up, Medicaid patients reported statistically significant higher pain levels than patients with Private insurance, finding a mean adjusted increase of 0.51 preoperatively, 0.39 at 1 month, and 0.79 at 3 months. Preoperatively and at 3-month follow-up, Medicaid patients reported statistically significant higher pain than patients with Medicare, finding increases in VAS-pain of 0.99 preoperatively and 0.94 at 3 months. There was no difference in pain improvement between any insurance types at any time point (all P values > .05). Conclusions: Patients with Medicaid report higher levels of preoperative pain and early postoperative pain, but reported the same improvement in pain as patients with other types of insurance. As healthcare systems are becoming increasingly dependent on patient-reported outcomes, including pain, it is important to consider that differences may exist in subjective pain depending on insurance status.

Revision Anterior Cruciate Ligament Reconstruction with the All-Soft Tissue Quadriceps Tendon Autograft Has Acceptable Early and Intermediate-Term Outcomes

PURPOSE

The purposes were to (1) examine early to intermediate-term clinical outcomes and complications of revision anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (QT) autografts, and (2) compare quadriceps strength between patients who had hamstring versus patella tendon autografts in their previous reconstruction.

METHODS

One hundred patients (52 males/48 females; 22.6 ± 8.0 years) undergoing revision ACLR with all-soft tissue QT autografts were prospectively followed. All revision procedures were performed by a single surgeon, using a minimally invasive graft harvest technique and suspensory fixation. Subjective assessment of knee function was obtained before and after surgery with the International Knee Documentation Committee (IKDC) survey. Postoperative knee laxity and isokinetic quadriceps strength were collected at regular intervals. Strength was reported as limb symmetry index (LSI; surgical side divided by nonsurgical side). Complications including hematomas, postoperative loss of knee extension, and graft failures were recorded. To determine clinical significance (P ≤ .05), outcomes were compared using analysis of variance or paired samples t-tests.

RESULTS

The mean IKDC scores significantly improved (54.3 ± 13.0 vs 82.8 ± 13.8), with an average follow-up of 42.2 ± 21.2 months. There were no significant changes in knee laxity side-to-side differences: 6 weeks (1.2 ± 1.5 mm), 3 months (1.2 ± 1.8 mm), 6 months (1.4 ± 1.6 mm). Quadriceps LSIs significantly improved from 71.6% ± 19.3% at 6 months to 81.5% ± 19.3% at 12 months for 60°/s isokinetic testing and 76.6% ± 16.4% at 6 months to 83.9% ± 16.9% at 12 months for 180°/s testing. Graft harvest site hematomas developed in 2 patients, postoperative loss of knee extension in 4 patients, and graft failure in 11 patients. No significant differences in quadriceps or hamstrings LSIs were noted between patients with previous hamstring versus patella tendon autografts (P > .050).

CONCLUSION

Revision ACLR with all-soft tissue QT autografts has acceptable early and intermediate-term outcomes with reasonable complication rates (11/80 patients with follow-up). Secondary insult to the extensor mechanism via QT autograft harvest does not adversely affect strength after prior patellar tendon versus hamstring autograft.

LEVEL OF EVIDENCE

Level IV, cases series subgroup analysis.

Biomechanical Evaluation of Standard Versus Extended Proximal Fixation Olecranon Plates for Fixation of Olecranon Fractures

Background: Small olecranon fractures present a significant challenge for fixation, which has resulted in development of plates with proximal extension. Olecranon-specific plates with proximal extensions are widely thought to offer superior fixation of small proximal fragments but have distinct disadvantages: larger dissection, increased hardware prominence, and the increased possibility of impingement. Previous biomechanical studies of olecranon fracture fixation have compared methods of fracture fixation, but to date there have been no studies defining olecranon plate fixation strength for standard versus extended olecranon plates. The purpose of this study is to evaluate the biomechanical utility of the extended plate for treatment of olecranon fractures. Methods: Sixteen matched pairs of fresh-frozen human cadaveric elbows were used. Of the 16, 8 matched pairs received a transverse osteotomy including 25% and 8 including 50% of the articular surface on the proximal fragment. One elbow from each pair was randomly assigned to a standard-length plate, and the other elbow in the pair received the extended-length plate, for fixation of the fracture. The ulnae were cyclically loaded and subsequently loaded to failure, with ultimate load, number of cycles, and gap formation recorded. Results: There was no statistically significant difference between the standard and extended fixation plates in simple transverse fractures at either 25% or 50% from the proximal most portion of the articular surface of the olecranon. Conclusion: Standard fixation plates are sufficient for the fixation of small transverse fractures, but caution should be utilized particularly with comminution and nontransverse fracture patterns.

Quadriceps Strength Deficits After a Femoral Nerve Block Versus Adductor Canal Block for Anterior Cruciate Ligament Reconstruction: A Prospective, Single-Blinded, Randomized Trial

Background:

Peripheral nerve blocks, particularly femoral nerve blocks (FNBs), are commonly performed for anterior cruciate ligament (ACL) reconstruction. However, associated quadriceps muscle weakness after FNBs is well described and may occur for up to 6 months postoperatively. The adductor canal block (ACB) has emerged as a viable alternative to the FNB, theoretically causing less quadriceps weakness during the immediate postoperative period, as it bypasses the majority of the motor fibers of the femoral nerve that branch off proximal to the adductor canal.

Purpose/Hypothesis:

This study sought to identify if a difference in quadriceps strength exists after an ACB or FNB for ACL reconstruction beyond the immediate postoperative period. Beyond the immediate postoperative period, we anticipated no difference in quadriceps strength between patients who received ACBs or FNBs for ACL reconstruction.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 102 patients undergoing primary ACL reconstruction using a variety of graft types were enrolled between November 2015 and April 2016. All patients were randomized to receive an ACB or FNB before surgery, and the surgeon was blinded to the block type. All patients underwent aggressive rehabilitation without functional bracing postoperatively. The time to the first straight-leg raise was reported by the patient. Isokinetic strength testing was performed at 3 and 6 months postoperatively.

Results:

Data for 73 patients were analyzed. There was no significant difference in patient demographics of age, body mass index, sex, or tourniquet time between the FNB (n = 35) and ACB (n = 38) groups. The mean time to the first straight-leg raise was similar, at 13.1 ± 1.0 hours for the FNB group and 15.5 ± 1.2 hours for the ACB group (P = .134). The mean extension torque at 60 deg/s increased significantly for both the ACB (53.7% ± 3.4% to 68.3% ± 2.9%; P = .008) and the FNB (53.3% ± 3.3% to 68.5% ± 4.1%; P = .006) groups from 3 to 6 months postoperatively. There was also no significant difference in mean extension torque at 60 deg/s or 180 deg/s between the FNB and ACB groups at 3 and 6 months. There were no significant differences in postoperative complications (infection, arthrofibrosis, retear) between groups.

Conclusion:

Although prior studies have shown immediate postoperative benefits of ACBs compared with FNBs, with a faster return of quadriceps strength, in the current study there was no statistically or clinically significant difference in quadriceps strength at 3 and 6 months postoperatively in patients who received ACBs or FNBs for ACL reconstruction.

Liquifying PLDLLA Anchor Fixation in Achilles Reconstruction for Insertional Tendinopathy

Insertional Achilles tendinopathy (IAT) is a frequent cause of posterior heel pain and is often associated with Haglund's deformity. Surgical correction for refractory cases of IAT has been well studied; however, the method of tendon fixation to bone in these procedures remains controversial, and to date, no standard technique has been identified for tendon fixation in these surgeries. Often, after Haglund's resection, there is large exposed cancellous surface for Achilles reattachment, which may require unique fixation to optimize outcomes. Previous studies have consistently demonstrated improved patient outcomes after Achilles tendon reconstruction with early rehabilitation with protected weight bearing, evidencing the need for a strong and stable anchoring of the Achilles tendon that allows early weight bearing without tendon morbidity. In this report, we highlight the design, biomechanics, and surgical technique of Achilles tendon reconstruction with Haglund's deformity using a novel technique that utilizes ultrasonic energy to liquefy the suture anchor, allowing it to incorporate into surrounding bone. Biomechanical studies have demonstrated superior strength of the suture anchor utilizing this novel technique as compared with prior techniques. However, future research is needed to ensure that outcomes of this technique are favorable when compared with outcomes using traditional suture anchoring methods.

LEVELS OF EVIDENCE

Level V: Operative technique.

Return to Play After Shoulder Instability Surgery in National Collegiate Athletic Association Division I Intercollegiate Football Athletes

BACKGROUND

Recent attention has focused on the optimal surgical treatment for recurrent shoulder instability in young athletes. Collision athletes are at a higher risk for recurrent instability after surgery.

PURPOSE

To evaluate variables affecting return-to-play (RTP) rates in Division I intercollegiate football athletes after shoulder instability surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Invitations to participate were made to select sports medicine programs that care for athletes in Division I football conferences (Pac-12 Conference, Southeastern Conference [SEC], Atlantic Coast Conference [ACC]). After gaining institutional review board approval, 7 programs qualified and participated. Data on direction of instability, type of surgery, time to resume participation, and quality and level of play before and after surgery were collected.

RESULTS

There were 168 of 177 procedures that were arthroscopic surgery, with a mean 3.3-year follow-up. Overall, 85.4% of players who underwent arthroscopic surgery without concomitant procedures returned to play. Moreover, 15.6% of athletes who returned to play sustained subsequent shoulder injuries, and 10.3% sustained recurrent instability, resulting in reduction/revision surgery. No differences were noted in RTP rates in athletes who underwent anterior labral repair (82.4%), posterior labral repair (92.9%), combined anterior-posterior repair (84.8%; P = .2945), or open repair (88.9%; P = .9362). Also, 93.3% of starters, 95.4% of utilized players, and 75.7% of rarely used players returned to play. The percentage of games played before the injury was 49.9% and rose to 71.5% after surgery ( P < .0001). Athletes who played in a higher percentage of games before the injury were more likely to return to play; 91% of athletes who were starters before the injury returned as starters after surgery. Scholarship status significantly correlated with RTP after surgery ( P = .0003).

CONCLUSION

The majority of surgical interventions were isolated arthroscopic stabilization procedures, with no statistically significant difference in RTP rates when concomitant arthroscopic procedures or open stabilization procedures were performed. Athletes who returned to play often played in a higher percentage of games after surgery than before the injury, and many played at the same or a higher level after surgery.

Ptychographic coherent diffractive imaging with orthogonal probe relaxation

Ptychography is a scanning coherent diffractive imaging (CDI) technique that relies upon a high level of stability of the illumination during the course of an experiment. This is particularly an issue for coherent short wavelength sources, where the beam intensity is usually tightly focused on the sample in order to maximize the photon flux density on the illuminated region of the sample and thus a small change in the beam position results in a significant change in illumination of the sample. We present an improved ptychographic method that allows for limited stability of the illumination wavefront and thus significantly improve the reconstruction quality without additional prior knowledge. We have tested our reconstruction method in a proof of concept experiment, where the beam instability of a visible light source was emulated using a piezo driven mirror, and also in a short wavelength microscopy CDI setup using a high harmonic generation source in the extreme ultraviolet range. Our work shows a natural extension of the ptychography method that paves the way to use ptychographic imaging with any limited pointing stability coherent source such as free electron or soft X-ray lasers and improve reconstruction quality of long duration synchrotron experiments.

Helium ion beam milling to create a nano-structured domain wall magnetoresistance spin valve

We have fabricated and measured single domain wall magnetoresistance devices with sub-20 nm gap widths using a novel combination of electron beam lithography and helium ion beam milling. The measurement wires and external profile of the spin valve are fabricated by electron beam lithography and lift-off. The critical bridge structure is created using helium ion beam milling, enabling the formation of a thinner gap (and so a narrower domain wall) than that which is possible with electron beam techniques alone. Four-point probe resistance measurements and scanning electron microscopy are used to characterize the milled structures and optimize the He ion dose. Successful operation of the device as a spin valve is demonstrated, with a 0.2% resistance change as the external magnetic field is cycled. The helium ion beam milling efficiency as extracted from electrical resistance measurements is 0.044 atoms/ion, about half the theoretical value. The gap in the device is limited to a maximum of 20 nm with this technique due to sub-surface swelling caused by injected ions which can induce catastrophic failure in the device. The fine patterning capabilities of the helium ion microscope milling technique indicate that sub-5 nm constriction widths could be possible.

Bone mineral content of the spine and proximal femur in female patients with hip fracture

Measurement of bone density in the spine and hip by quantitative computed tomography (QCT) and dual photon absorptiometry (DPA) was performed in 36 women with hip fracture. Hip density by DPA was determined at three anatomic subregions of the hip. Comparison to normals revealed an average decrease in hip bone density by 15% below controls. Spine density measurements were not significantly different from that of controls. Correlations of hip and spine densities varied by hip subregion. This study demonstrated that bone density measurement methods and measurement at one axial site may not accurately reflect bone density at appendicular subregions.