Scapular motion in the presence of rotator cuff tears: a systematic review.

BACKGROUND: Rotator cuff tears (RCTs) remain a significant source of pain and disability in the shoulder. Although much work has been done in the study of the effects of rotator cuff tears on glenohumeral joint motion, much less has been done in understanding the effect of rotator cuff tearing on scapular motion or activation. It remains unknown whether scapular dyskinesis is causative or adaptive. The purpose of this study was to systematically review the literature to determine the relationship between rotator cuff tear presence and size on scapular motion, and if rotator cuff repair restored normal motion. METHODS: A systematic review using PRISMA guidelines was accomplished to include all studies with biomechanical or clinical outcomes of scapular motion in the presence of RCTs. Studies were excluded if they involved shoulder arthroplasty, rotator cuff tendinopathy, or shoulder impingement without an RCT. From 530 initial references, 42 manuscripts were selected for full review and cross referenced. All studies were evaluated for inclusion and exclusion criteria. RESULTS: Sixteen studies including 335 rotator cuff tears were included in the final review. There were several findings of interest in the literature. First, although all studies demonstrated scapular dyskinesis, they did not report a consistent pattern of motion in the presence of an RCT. In general, scapular posterior tilt was decreased, and scapular upward rotation was increased, especially in large tears, but the literature was unclear as to whether this was a result of the RCT or an adaptive attempt to maintain elevation. Larger RCTs resulted in more pronounced scapular dysfunction, but there was significant variability within studies. Further, dyskinesis was confounded by pain with more abnormal movement in symptomatic vs. asymptomatic RCTs, the latter of which were not different from normal healthy controls. Four studies addressed the effect of RCT on scapular mechanics and found that repair consistently improved it compared to the normal side, but the time to normalization varied between 5 months and 2 years. CONCLUSION: Scapular motion is abnormal in the presence of an RCT, but the literature is inconsistent regarding a universally affected variable or consistent degree of scapular dysfunction in this setting. Furthermore, it remains unknown which changes are adaptive vs. pathologic. Understanding the relationship between rotator cuff tearing and scapular dyskinesis will require better biomechanical models that consider scapular dyskinesis in their design.

The Resilient Athlete: Lessons Learned in the Military.

Resilience, the capacity to recover from a setback or adversity, is a concept that has received considerable recent attention. An individual's resilience predicts their life trajectory following stressful events and this has increasingly been shown in a wide variety of applications. Our understanding of the degree to which we can modify our resilience, and the optimal means to do so, remains in its infancy. The US military has embraced extensive efforts to quantify and build resilience in service members in an effort to preserve the fighting force. We specifically look at the understanding of resilience as it relates to the athletes in terms of competition and return from injury. This article explores the concept of resilience, the efforts to build resilience, lessons learned from the military and applications of the resilience concept to surgical and trauma patients.

Digital Tomography for Detection of Acute Occult Scaphoid Fractures.

Diagnosis of occult scaphoid fractures remains a challenge. Traditional management consisting of 2 weeks of immobilization and repeat radiographs results in unnecessary immobilization of many patients without fracture. Magnetic resonance imaging (MRI) is sensitive but expensive. Digital tomography (DT) is an imaging technique that provides fine-cut visualization with minimal radiation exposure and may be used when there is high clinical suspicion despite negative findings on initial radiographs. The authors compared the ability of DT vs MRI to detect acute occult scaphoid fractures. This was an institutional review board-approved, prospective series. Adults for which clinical suspicion for acute scaphoid fracture (presenting within 96 hours of trauma) and negative findings on initial radiographs existed were included. Both a wrist tomogram and MRI were obtained. Wrists were immobilized and reevaluated at 10 to 14 days with repeat radiographs as a control. Studies were interpreted by a radiologist in a blinded fashion. Forty consecutive extremities in 39 patients met the inclusion criteria. Six (15%) of the 40 scaphoids were determined to be fractured on repeat radiographs. Digital tomogram yielded positive findings in 4 of these. Magnetic resonance imaging yielded positive findings in 8 (20%) of the 40 extremities. Sensitivities were 67% and 100% for digital tomogram and MRI, respectively (P=.0001). The positive predictive value was 100% for DT and MRI. The authors found that DT detects more occult scaphoid fractures than initial standard radiographs but is less sensitive than MRI. This is the first study to compare DT with MRI. Digital tomography can be used to augment radiographs and may increase diagnostic efficiency, minimize unnecessary immobilization, and reduce health care costs. [Orthopedics. 2017; 40(6):e1092-e1095.].

Glenoid bare area: arthroscopic characterization and its implications on measurement of bone loss.

PURPOSE: The purpose of this study was to characterize arthroscopically the frequency and location of the glenoid bare area. METHODS: Three fellowship-trained orthopaedic sports surgeons evaluated and characterized the bare area of the glenoid in 52 consecutive patients undergoing arthroscopic surgery of the shoulder without a diagnosis of instability. Among the patients with a visible bare area, the position was measured, and when eccentrically located, an apparent bone loss or gain was calculated. RESULTS: The bare area of the glenoid was observed in only 48% of patients undergoing arthroscopic surgery, and when observed, it was at the center only 37% of the time. Of the glenoids with visible bare areas, 8% were located anteriorly enough to result in an apparent bone loss calculation of greater than 20%. An additional 25% of visible bare areas were posteriorly located, resulting in an apparent bone gain. CONCLUSIONS: The glenoid bare area is a variably visible and eccentric landmark on the glenoid and thus should not be used as the sole reference point to measure glenoid bone loss.

Meniscus repair: the role of accelerated rehabilitation in return to sport.

With increasing understanding of the detrimental effects of the meniscectomized knee on outcomes and long-term durability, there is an ever increasing emphasis on meniscal preservation through repair. Repair in the young athlete is particularly challenging given the goals of returning to high-level sports. A healed meniscus is only the beginning of successful return to activity, and the understanding of "protection with progression" must be emphasized to ensure optimal return to performance. The principles of progression from low to high loads, single to multiplane activity, slow to high speeds, and stable to unstable platforms are cornerstones to this process. Emphasis on the kinetic chain environment that the knee will function within cannot be overemphasized. Communication between the operating surgeon and rehabilitation specialist is critical to optimizing effective return to sports.

Introducing educational interventions for first year medical students in the area of cancer clinical trials: impact on attitudes and confidence.

BACKGROUND: This study tested the feasibility and efficacy of a multi-faceted educational intervention designed to increase medical students' confidence in discussing cancer clinical trials with patients. METHOD: First year students were provided with written resources, problem-based learning scenarios, and an optional practicum. RESULTS: Pre/Post results indicated significant increases in confidence levels; however, these results were tempered with declines in attitudes related to clinical trials. CONCLUSIONS: Integrating clinical trials education into existing medical school curriculum is both feasible and desirable. This intervention was successful in increasing students' confidence levels in discussing clinical trials with patients and deserves continued study.

Applying Ockham's razor to pancreatitis prognostication: a four-variable predictive model.

OBJECTIVE: We sought to develop a simple yet accurate prognostic scoring system to determine the severity of acute pancreatitis at admission. SUMMARY BACKGROUND DATA: Because acute pancreatitis has a variable and frequently unpredictable course, identifying individuals at greatest risk for significant, life-threatening complications and stratifying their care appropriately remain a concern. Previous prognostic scoring systems predict severity reasonably well but are limited by time constraints, are unwieldy to use, or both. METHODS: Data from the international phase III trial of the platelet-activating factor receptor-antagonist Lexipafant were used to develop a 4-variable prognostic model. We then compared the model's ability to predict the severity of acute pancreatitis with the Ranson, Glasgow, and APACHE II systems. RESULTS: The model (BALI), which included BUN >or=25 mg/dL, Age >or=65 years, LDH >or=300 IU/L, and IL-6 >or=300 pg/mL, measured at admission, was similar to the Ranson, Glasgow, and APACHE II systems in its ability to identify increased mortality from acute pancreatitis. The receiver operating characteristic curve area for the BALI model was >or=0.82 +/- 0.03 (mean +/- SD) versus 0.75 +/- 0.04 (Ranson), 0.80 +/- 0.03 (Glasgow), and 0.79 +/- 0.03 (APACHE II). Furthermore, at a prevalence of 15%, the positive and negative predictive values for increased mortality were similar for all systems. CONCLUSION: The prognostic ability of the BALI 4-variable model was similar to the Ranson, Glasgow, and APACHE II systems but is unique in its simplicity and ability to accurately predict disease severity when used at admission or anytime during the first 48 hours of hospitalization.

Triglyceride-rich lipoproteins as agents of innate immunity.

Bacterial endotoxin (i.e., lipopolysaccharide [LPS]) elicits dramatic responses in the host, including elevated plasma lipid levels due to increased synthesis and secretion of triglyceride-rich lipoproteins by the liver and inhibition of lipoprotein lipase. This cytokine-induced hyperlipoproteinemia, clinically termed the "lipemia of sepsis," was customarily thought to involve the mobilization of lipid stores to fuel the host response to infection. However, because lipoproteins can also bind and neutralize LPS, we have long postulated that triglyceride-rich lipoproteins (very-low-density lipoproteins and chylomicrons) are also components of an innate, nonadaptive host immune response to infection. Recent research demonstrates the capacity of lipoproteins to bind LPS, protect against LPS-induced toxicity, and modulate the overall host response to this bacterial toxin.

Early nonenhanced abdominal computed tomography can predict mortality in severe acute pancreatitis.

We wondered whether nonenhanced computed tomography (CT) within 48 hours of admission could identify individuals at risk for higher mortality from acute pancreatitis. Data from the international phase III study of the platelet-activating factor-inhibitor Lexipafant was used to analyze noncontrast CT versus acute pancreatitis mortality. Nonenhanced CT examinations of the abdomen from the trial were classified by disease severity (Balthazar grades A-E) and then correlated with patient survival. Among the 477 individuals who underwent CT within 48 hours of admission and 220 individuals who did so over the subsequent 6 days, higher CT grades were associated with increased mortality. Each unit increase in Balthazar grade during the initial 48 hours was associated with an estimated increase in the risk of mortality of 33%, and this trend increased to 50% if pancreatic enlargement and peripancreatic stranding (grades B and C) were combined (P<0.05). CT grade correlated minimally with Ranson, Glasgow, or APACHE II score during the initial 48 hours; however, this correlation improved over 3-8 days. Early nonenhanced abdominal CT in patients with acute pancreatitis is a valuable prognostic indicator of mortality in acute pancreatitis, even among patients without clinical features of severe acute pancreatitis.