Disparities in Access to Musculoskeletal Care: Narrowing the Gap: AOA Critical Issues Symposium.

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

Acute Pectoralis Major Tears in Forward Deployed Active Duty U.S. Military Personnel: A Population at Risk?

The purpose of this study is to report on the causes of a series of acute pectoralis major tears in active duty deployed military personnel. Nine cases of acute pectoralis major tears evaluated at one expeditionary military treatment facility over a 4-month deployment cycle were analyzed. Nine male patients were diagnosed with tears: seven complete tears at the tendinous insertion, one complete tear at the musculotendinous junction, and one incomplete tear, with a mean age of 32 years (range, 23-52 years). All injuries occurred during bench press, with the dominant upper extremity involved 56% of the time. Injury occurred an average of 77 days into the tour (range, 3-198 days). Mean time from injury to surgical repair in the cohort was 18 days (range, 10-43 days). Combat-deployed active duty U.S. military personnel likely represent a high-risk population for this injury. Surgical repair is possible, but rarely advisable, in the deployed setting. (Journal of Surgical Orthopaedic Advances 28(2):150-157, 2019).

Acute pectoralis major tears in active duty US military personnel: Midterm outcomes of repairs performed in the forward-deployed setting.

PURPOSE: To report midterm outcomes of a series of acute pectoralis major tears repaired surgically in the deployed setting in active duty military personnel. METHODS: Analysis of acute pectoralis major tears treated at one expeditionary medical treatment facility during a 4-month time frame. RESULTS: Nine male patients with a mean age of 32 years (23-52) were diagnosed with tears; seven underwent operative fixation in the forward deployed setting. All injuries occurred during bench press, with the dominant upper extremity involved 56% of the time. With an average final follow-up of 4.1 years, the mean disabilities of the arm shoulder and hand score was 35.71 (range 31-41) and the mean American shoulder and elbow surgeons score was 90.71 (range 87-95). All personnel returned to their preinjury jobs with an average return to full preinjury function occurring at 7 months (range 4.5-10.5 months) in the operative group. CONCLUSIONS: Combat-deployed active duty US military personnel likely represent a high-risk population for this injury. Our study demonstrates that with at least 4 years of follow-up, surgical repair with a trough and trans-osseous repair technique was technically feasible and clinically successful in the deployed setting. Although this treatment may be considered in rare individual cases moving forward, due to the lengthy postoperative restrictions, inability to return back to duty in a timely manner, and lengthy rehabilitation, we no longer recommend this surgery be performed in theater.

Outcomes of Pectoralis Major Tears in Active Duty US Military Personnel: A Comparison of Surgical Repairs Performed in the Forward Deployed Setting to Those Performed in the Continental United States.

INTRODUCTION: The purpose of our study is to compare pectoralis major tears in active duty military personal repaired surgically in the forward deployed setting to those performed in the Continental United States. MATERIALS AND METHODS: Retrospective comparison of all pectoralis major tendon repairs performed at Madigan Army Medical Center from 2000 to 2007 to a forward deployed series treated by two deployed United States Air Force orthopedic surgeons at one expeditionary medical treatment facility over a 4-month deployment cycle from December 2013 through March 2014. RESULTS: Fourteen patients from the CONUS group and eight patients from deployed group were compared; they had a mean age of 32 years (21-52) all with pectoralis major ruptures that underwent operative fixation. Nineteen of the 22 patients (86%) sustained their injuries during bench press. The average bench press weight was similar with 271.8 lbs in the CONUS group and 273.1 lbs in the deployed group. There were 9 complete tears and 5 partial tears in the CONUS cohort whereas 7 complete tears and 1 partial tear in the deployed cohort, with all tears in both groups occurring at the insertion of the humerus. All 22 patients in both cohorts denied the use of anabolic steroids. The average DASH score at final follow-up was 12.74 in the CONUS group and 36.44 in the deployed group. The CONUS group reported that 7 out of 8 immediate repair patients and 4 out of 6 delayed repair patients returned to functional work level within 6 months with the 2 patients in the delayed repair group taking longer than 9 months to return to work. The deployed members reported return to functional work level at an average of 6.5 months. Both cohorts had early return to weight lifting at 6 and 7 months, respectively. The CONUS group reported a 39% bench press weight reduction and 34% pushup maximum reduction whereas the deployed cohort reported a 20% and 8% reduction respectively. CONCLUSIONS: When comparing deployed to CONUS results, we demonstrated that surgical repairs at one permanent US military in-theater tertiary referral medical center were as successful as repairs performed at one CONUS US Army academic tertiary referral medical center. Although in-theater surgical repair was technically feasible and clinically successful, we believe the lengthy convalescence, stringent post-operative restrictions, demanding environment and impact on operational readiness should preclude deployed surgical repairs from becoming standard practice.

Treatment of Muscle Injuries with Platelet-Rich Plasma: a Review of the Literature.

PURPOSE OF REVIEW: This review discusses the current literature regarding the use of platelet-rich plasma (PRP) in the treatment of muscle strain injuries. Case series as well as experimental trials for both human and animal models are covered. RECENT FINDINGS: Multiple studies have examined outcomes for the use of PRP in the treatment of muscle strain injuries. PRP has been shown to promote muscle recovery via anabolic growth factors released from activated platelets, and in doing so, potentially reduces pain, swelling, and time for return to play. In vitro studies support the regenerative potential of PRP for acute soft tissue injuries. Multiple clinical case series for PRP injections in the setting of muscle strains demonstrate imaging evidence for faster healing, less swelling, which can decrease time for return to play. These studies, however, are retrospective in nature, and few randomized controlled studies exist to demonstrate a clear clinical benefit. Additionally, there is tremendous heterogeneity regarding the injectant preparation, optimum platelet concentration, presence of leukocytes, and volume of PRP which should be administered as well as number of and timing of treatments.

Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review.

BACKGROUND: This systematic review aims to synthesize published data for the most common subscapularis takedown and repair to compare outcomes in the setting of shoulder arthroplasty. METHODS: Searches of MEDLINE and Cochrane Library databases identified studies that reported clinical or radiologic outcomes for subscapularis management in the setting of shoulder arthroplasty. Comparisons included musculotendinous integrity, subscapularis testing and strength, shoulder range of motion, and functional outcome scores. RESULTS: The 14 included studies reported considerable variability in techniques, outcomes, and musculotendinous integrity. Lesser tuberosity osteotomy (LTO) demonstrated better healing rates (93.1%) than subscapularis peel (SP; 84.1%) and midsubstance tenotomy (ST; 75.7%), although not significantly different. A statistically significant increase in fatty infiltration was found after surgery across techniques, and range of motion and strength were similar. Mean rates of normal results for belly-press and lift-off tests were uniformly better for LTO (79.1% and 80.7%) over ST (66.7% and 65.6%), although multiple studies showed poor correlation between subscapularis functional testing and musculotendinous integrity. Mean total Constant and Western Ontario Osteoarthritis of the Shoulder Index outcome scores were slightly better for LTO (77.6, 84.2) than for SP (71.8 and 82.7). Mean American Shoulder and Elbow Surgeons scores favored the ST group (80.8) over the SP (79.1) and LTO (73) groups. CONCLUSIONS: The data suggest no significant differences exist for postoperative musculotendinous integrity or clinical outcomes among the subscapularis management techniques in shoulder arthroplasty. Subscapularis healing and integrity appear to favor the lesser tuberosity takedown method. Additional randomized controlled comparisons with long-term follow-up are needed to more effectively compare these surgical approaches.

Clinical outcomes of suprascapular nerve decompression: a systematic review.

BACKGROUND: Suprascapular neuropathy is an uncommon clinical diagnosis. Although there have been a number of case series reporting on this pathologic process, to date there has been no systematic review of these studies. This study aimed to synthesize the literature on suprascapular neuropathy with regard to clinical outcomes. The secondary objective was to detail the diagnosis and treatment of suprascapular neuropathy and any associated complications. METHODS: A systematic review was performed to identify studies that reported the results or clinical outcomes of suprascapular nerve decompression. The searches were performed using MEDLINE through PubMed and Cochrane Database of Systematic Reviews. RESULTS: Twenty-one studies comprising 275 patients and 276 shoulders met inclusion criteria. The mean age was 41.9 years, and mean follow-up was 32.5 months. The most common symptom was deep, posterior shoulder pain (97.8%), with a mean duration of symptoms before decompression of 19.0 months; 94% of patients underwent electrodiagnostic testing before decompression, and 85% of patients had results consistent with suprascapular neuropathy. The most common outcome reported was the visual analog scale score, followed by the Constant-Murley score. The mean postoperative Constant-Murley score obtained was 89% of ideal maximum. Ninety-two percent of athletes were able to return to sport. Only 2 (0.74%) complications were reported in the included studies. CONCLUSIONS: Surgical decompression in the setting of suprascapular neuropathy leads to satisfactory outcomes as evidenced by the patient-reported outcomes and return to sport rate. Furthermore, the rate of complications appears to be low.

The incidence and effect of fatty atrophy, positive tangent sign, and rotator cuff tears on outcomes after total shoulder arthroplasty.

BACKGROUND: Treatment choices for total shoulder arthroplasty (TSA) in the absence of full-thickness rotator cuff tears (RCTs) are not clearly defined in current literature. This study investigated the prevalence and effect of preoperative partial-thickness RCTs and muscular degenerative changes on postoperative outcomes after TSA. METHODS: Medical records and magnetic resonance imaging studies were reviewed for patients who underwent TSA for primary glenohumeral osteoarthritis with minimum 2-year follow-up to determine preoperative tear classification, Goutallier grade, and supraspinatus tangent sign. Postoperative pain on the visual analog scale, range of motion, and patient outcomes scores were obtained to correlate preoperative RCT status, Goutallier grading, tangent sign, and postoperative outcomes. Patients with full-thickness RCT on preoperative magnetic resonance imaging were excluded. RESULTS: Forty-five patients met all inclusion criteria (average age, 65 ± 10 years; average follow-up, 43 months). Of the patients undergoing TSA, 40% had a significant (>50% thickness) partial RCT. Grade 3 to 4 Goutallier changes were noted in 22% of all patients, and 13% demonstrated grade 3 to 4 changes in the context of no tear. Positive tangent sign was present in 7% of all patients. The preoperative Goutallier grade of the infraspinatus was significantly negatively correlated with postoperative forward elevation (P = .02) and external rotation (P = .05), but rotator cuff pathology, including tear status, Goutallier grade, and the presence of a tangent sign, did not correlate with postoperative functional outcome scores. CONCLUSIONS: Even in the absence of a full-thickness RCT, rotator cuff atrophy, fatty infiltration, and partial thickness tearing are common findings. Although postoperative range of motion is correlated to Goutallier changes of the infraspinatus, rotator cuff pathology is not correlated to outcomes after TSA; therefore, one may proceed with TSA without concern of their effect on postoperative outcomes.

Split Pectoralis Major Transfer for Chronic Medial Scapular Winging.

Scapular winging can be a significant source of chronic pain, weakness, and disability of the shoulder. Isolated serratus anterior palsy from long thoracic nerve injury, which is the most common cause of this condition, produces prominent winging and medial malpositioning of the inferior angle of the scapula. In the case of persistent symptoms despite conservative care, treatment options primarily include scapulothoracic fusion and pectoralis major transfer. Outcomes of scapulothoracic fusion are notable for a high complication rate and limited functional improvements. We describe our technique of indirect, split pectoralis major transfer to the inferolateral scapula with allograft tissue augmentation for the surgical treatment of chronic medial winging. This procedure provides dynamic stabilization of the scapula with secure and tension-free tendon transfer. Advantages over alternative treatments include a relatively low complication rate, acceptable cosmesis, and better range of motion. The rationale and technical aspects of this procedure are discussed. Additional clinical studies are warranted to compare outcomes for the direct and indirect split transfer methods.

Evaluation of the PuriLens contact lens care system: an automatic care system incorporating UV disinfection and hydrodynamic shear cleaning.

PURPOSE: This study evaluates lens care using the PuriLens System, an advanced way to clean and disinfect soft hydrophilic lenses using subsonic agitation and UV radiation, respectively. METHODS: A two-period crossover lens cleaning and safety investigation was conducted using 80 patients. Disinfecting efficacy was tested in accordance with standard FDA protocols. Lens compatibility was studied with Group I and Group IV lenses during the equivalent of a 6-month care regimen by measuring: lens power, base curve, wet diameter, refractive index, clarity, and tint. Safety was evaluated through slit-lamp findings, wearing time, comfort, and visual acuity. RESULTS: The mean wearing time of patients in the study was 13.79 hours. No slit lamp findings greater than grade 2 were noted. Visual acuity was 20/25 or better in 92.5% of examinations. None of the patients lost more than two lines of acuity. Lens surface evaluation showed no deposits (grade 0) to very slight deposits (grade 1) in 94.4% of examinations. Lenses cleaned with the PuriLens System were cleaner by a statistically significant margin (P=0.02) compared to lenses digitally cleaned with a leading multi-purpose solution (ReNu, Bausch & Lomb). Overall, neither the Group I nor Group IV lenses were affected after 180 cleaning cycles. CONCLUSIONS: The PuriLens System provides automatic lens care compliance, superior antimicrobial efficacy, and eliminates the need for daily digital cleaning.