Health-related quality of life does not deteriorate while waiting for anterior cruciate reconstruction.

PURPOSE: The aim of this study was to determine how preoperative health-related quality of life (HRQoL) is affected by the duration of the wait time (WT) for anterior cruciate ligament reconstruction (ACLR) once a decision is made to proceed with surgery. METHODS: This was a multi-centre prospective cohort study. One hundred and twenty-two patients 14 years of age and above waiting for ACLR completed the International Knee Documentation Committee (IKDC) demographic, current health assessment and subjective knee evaluation (SKF) forms on the day of decision to operate and the day of surgery. Changes in scores were analyzed for the entire cohort, adjusted for WTs and a subset was compared for patients with isolated anterior cruciate ligament (ACL) tears and ACL tears with concurrent meniscal involvement. Changes in HRQoL scores from the day of the decision to operate to the 9-month postoperative appointments were also assessed. RESULTS: Energy/Fatigue (p < 0.05), Pain (p < 0.05), General Health (p < 0.05) and the IKDC-SKF Score (p < 0.05) significantly increased between the day of the decision to operate and the day of surgery. Only the change in IKDC-SKF score remained significantly higher after adjusting for WT. Baseline HRQoL scores significantly improved by the 9-month postoperative appointment. CONCLUSION: The length of time waiting for ACLR did not adversely influence HRQoL in this study. However, low preoperative HRQoL and the significant improvement in HRQoL of patients followed postoperatively suggest that timely surgery is beneficial for this patient population. LEVEL OF EVIDENCE: Level II.

Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment.

PURPOSE: The purpose of this study was to determine the clinical success rate of nonoperative treatment of partial-thickness rotator cuff tears (PT-RCTs), to determine baseline clinical factors predictive of outcome of nonoperative treatment of PT-RCTs, and to determine the imaging outcome of nonoperative treatment of PT-RCTs. PATIENTS AND METHODS: All patients with a primary diagnosis of a PT-RCT were eligible for inclusion. Seventy-six patients (48 males, 28 females) with an average age of 52±10 years were included in the study. Patients were evaluated using a standardized format including clinical, imaging, and shoulder specific quality-of-life outcomes. Patients were assessed and treated either successfully nonoperatively or consented to undergo surgical intervention of their PT-RCT. Patients treated nonoperatively underwent follow-up by MRI arthrogram. RESULTS: Thirty-seven patients (49%) underwent nonoperative treatment. Logistic regression analysis indicated that the baseline variables of side (dominant or nondominant side involved), onset (traumatic or atraumatic), and thickness of tendon tear (<50% or >50%) were significant predictors of outcome. At a mean 46±7 months of follow-up, nonoperatively treated patients demonstrated a mean American Shoulder and Elbow Surgeons score of 85.1±16.0, and a Simple Shoulder Test score of 10.0±2.5. Overall, 76% of tears treated nonoperatively did not show a tear progression on anatomic imaging. Nine patients (24%) demonstrated tear progression, of which three patients (8%) demonstrated full-thickness tearing. CONCLUSION: Nonoperative treatment was utilized in ~50% of the patients and resulted in improved clinical outcomes. Onset, shoulder involved, and thickness of the tear were predictive of the success of nonoperative treatment.

Patient perceptions regarding physician reimbursements, wait times, and out-of-pocket payments for anterior cruciate ligament reconstruction in Ontario.

BACKGROUND: Currently, there is a lack of knowledge regarding patient perceptions surrounding physician reimbursements, appropriate wait times, and out-of-pocket payment options for anterior cruciate ligament reconstruction (ACLR). Our objective was to determine the current state of these perceptions in an Ontario setting. METHODS: A survey was developed and pretested to address patient perceptions about physician reimbursements, appropriate wait times, and out-of-pocket payment options for ACLR using a focus group of experts and by reviewing prior surveys. The survey was administered to patients in a waiting room setting. RESULTS: Two hundred and fifty completed surveys were obtained (79.9% response rate). Participants responded that an appropriate physician reimbursement for ACLR was $1000.00 and that the Ontario Health Insurance Plan (OHIP) reimbursed physicians $700.00 for ACLR. Seventy-four percent of participants responded that the OHIP reimbursement of $615.20 for the procedure was either lower or much lower than what they considered to be an appropriate reimbursement for ACLR. Over 90% of participants responded that an ACLR should occur within 90 days of injury. Thirty-five percent of participants were willing to pay $750.00 out-of-pocket to have an ACLR done sooner, while 16.4% of participants were willing to pay $2500.00 out-of-pocket to travel outside of Canada for expedited surgery. CONCLUSION: This survey study demonstrates that patients' estimates of both appropriate and actual physician reimbursements were greater than the current reimbursement for ACLR. Further, the majority of individuals report that the surgical fee for ACLR is lower than what they consider to be an appropriate amount of compensation for the procedure. Additionally, nearly all respondents believe that a ruptured ACL should be reconstructed within 90 days of injury. Consequently, a number of patients are willing to pay out-of-pocket for expedited surgery either in Canada or abroad. However, patients' preferences for shorter wait times must be balanced with the known risk of arthrofibrosis associated with early ACLR.

Surgical indications for long head biceps tenodesis: a systematic review.

PURPOSE: Tenodesis as a treatment for a symptomatic long head of biceps (LHB) tendon is becoming more prevalent and new techniques exist which are purported to make the procedure faster and more effective. The determination of appropriate surgical indications for the procedure will facilitate proper analysis and comparisons of the varied techniques. This review analyses the reported indications in the literature in an attempt to guide future research and treatment. METHODS: The EMBASE and MEDLINE databases were searched to identify surgical studies that report indications for LHB tenodesis. After title, abstract searches, and full-text reviews, 39 studies were included. Study information was extracted including author, publication date, patient numbers, patient age, follow-up period, procedure performed, surgical indications, and study design. RESULTS: Although indications were variable and often non-descriptive, of the 39 included studies, the most common indications for LHB tenodesis were partial tearing (51 %), instability (49 %), or tenosynovitis (44 %), SLAP tear (28 %), and positive clinical exam for LHB pain (26 %). Most studies were of low quality of evidence, such as case series (33.0 %) and retrospective studies (43.5 %), and were of low-to-moderate methodological quality. CONCLUSION: Although indications used for LHB tenodesis are inconsistently reported, the most common indications include LHB tearing, instability, and tenosynovitis. Other indications include clinical exam indicating LHB pathology, SLAP tears and subjective shoulder pain. Rigorous reporting of indications and preoperative/operative findings should be emphasized in future studies, allowing surgeons to appropriately analyse outcomes of LHB tenodesis of different techniques within patient groups with distinct indications. LEVEL OF EVIDENCE: Systematic review, Level IV.

Construct validity testing of the Arthroscopic Knot Trainer (ArK).

PURPOSE: This study introduced a novel simulator called the Arthroscopic Knot Trainer (ArK) and reports preliminary evidence to support its construct validity. To our knowledge, the ArK is the first non-anatomical tissue reduction simulator designed to meet learning objectives specific for developing knot-tying skills. MATERIALS AND METHODS: A step-by-step instructional video was used to teach orthopaedic residents how to tie an arthroscopic SMC knot. Residents were video recorded to assess time of completion, number of knots tied in 10 min and re-assessed 6 months later. Subjects were surveyed for content evidence after using the ArK. Data were analysed by paired t test and independent sample t test in order to compare the mean time to tie knots from test at baseline to retest at 6 months and the between group mean time, respectively. RESULTS: Content evidence supports the ArK trainer as appropriate for teaching and assessing arthroscopic knot-tying skills. Relation to other variables evidence supports the ArK trainer model whether stratified by year of training or by self-reported experience; time required for knot tying was inversely correlated with experience in tying arthroscopic knots. Internal structure evidence was supported with similar findings at retesting. CONCLUSIONS: There are three sources of evidence supporting the construct validity of the ArK as a simulator for arthroscopic knot tying: content, relationship to other variable and internal structure evidence. The ArK is easy to use and has the capacity to distinguish between groups with different skill levels.

Systematic instruction of arthroscopic knot tying with the ArK Trainer: an objective evaluation tool.

PURPOSE: A Proficiency Formula was introduced as an objective self-evaluation method for evaluating basic arthroscopic knot tying in a laboratory setting. The correlation between the Proficiency Formula and gold standard pass/fail dichotomy was demonstrated, as well as with other popular evaluation tools--task-specific checklist (TSC) and global rating scale (GRS). METHOD: A step-by-step video tutorial was used to instruct 35 medical students on how to tie an arthroscopic Samsung Medical Center (SMC) knot secured by three half hitches. Participants were video recorded performing arthroscopic knot tying and assessed on their success tying an SMC knot, pass or fail, and through three outcome tools: the Proficiency Formula, GRS and the TSC. Independent samples t test was used to compare the GRS, TSC and Proficiency Formula scores, between those who were passed or failed by the evaluators. Correlation between the measurement scales was tested using Spearman's rho correlation coefficient. RESULTS: Participants received a mean proficiency score of 195 (140-249). The mean Proficiency score for those that passed was 323 (95 % CI 272-374), for those that failed, 87 (95 % CI 26-148, p < 0.001). We found strong linear correlation between the Proficiency Formula and GRS and TSE (0.83 and 0.78, respectively). CONCLUSION: The Proficiency Formula has high correlation with gold standard GRS and TSC measurements when used to assess arthroscopic knot tying skills on a model. It has the added advantage of being able to be self-assessed.

The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: a randomized-controlled study.

BACKGROUND: Historically, the preoperative consultation has consisted of a discussion between patient and surgeon. There is a growing literature describing efforts to integrate multimedia into surgical patient education. This study aimed to assess the efficacy of an educational video tutorial on early learning of information specific to patients undergoing shoulder arthroscopy when it was used as an adjunct to the standard preoperative consultation. METHODS: This study was a surgeon-blinded, randomized controlled trial involving 40 consecutive patients requiring shoulder arthroscopy. After a preoperative consultation with an orthopaedic surgeon, patients were randomized in a 1:1 ratio to either a control group or a treatment group. The treatment group viewed a 10-minute video, which covered the expected preoperative, intraoperative, and postoperative experience. Immediately afterward, both groups completed a questionnaire measuring satisfaction and recall of information received. All patients completed a second questionnaire at the first postoperative visit that assessed overall satisfaction with their experience. RESULTS: Thirty-four patients were available for follow-up. The video group (N = 15) answered 87% of the knowledge questions correctly, whereas the control group (N = 19) answered only 56% (P = .000). There was stronger agreement in the video group that the preoperative consultation contained an appropriate amount of information (P = .039). Postoperatively, there was agreement that the video was an effective preparation tool for all stages of the surgical experience. However, there was no difference between the groups in satisfaction with their overall surgical experience. CONCLUSIONS: Video can enhance patients' operative experiences and improve their retained knowledge when it is used as an adjunct to the preoperative consultation. LEVEL OF EVIDENCE: Basic science, education methodology study, devices to improve learning.

Biochemical measurement of muscle injury created by lumbar surgery.

PURPOSES: 1. To determine whether lumbar disc surgery (LS) provides a sufficiently detectable rise in serum creatine kinase (CK) concentration to serve as a model to study biochemical measurement of muscle injury, and 2. To use the model to examine the consistency of the time course of CK concentration changes. METHOD: The study used a repeated measures design. Six women and six men scheduled for LS were recruited. Blood samples were taken in the pre-operative waiting areas, immediately after surgery, at 6 hour intervals until discharge, and at 2, 4, and 6 to 7 days following surgery. Total serum CK was quantified using the Roche Modular to detect enzyme concentration. RESULTS: Following LS, mean Total CK increased from a baseline 50 U/L (SD = 53) to a peak 114 U/L (SD = 32) in women (P < 0.001) and from 183 U/L (SD = 69) to a peak 454 U/L (SD = 173) in men (P < 0.05). Baseline to peak changes in CK exceeded subjects' own baseline fluctuations in all 6 women and all 6 men, and amounted to a mean 6 fold (SD = 4) increase in women and 16 fold (SD = 31) increase in men. While CK concentrations returned to baseline over the observation period in all subjects, time to peak ranged between 9 to 47 hours. CONCLUSIONS: The LS model produced a consistently detectable CK response in both genders. Time to peak is variable indicating a need for multiple serial measures to capture this biochemical injury response.

Assessment of stability of the cervical spine in blunt trauma patients: review of the literature, with presentation and preliminary results of a modified traction test protocol.

OBJECTIVE: To review the reported efficacy of various imaging techniques in assessing stability of the neck in blunt trauma patients, and to present the protocol and preliminary results of a modified traction test protocol. DESIGN: This is a prospective cohort study. SETTING: A regional trauma unit in Southern Ontario. PATIENTS: People with blunt-trauma injuries who came to the author's consultant practice with "C-spine not cleared" status, from January 2001 through December 2003. INTERVENTIONS: A fluoroscopically controlled test of axial traction followed by flexion/extension stressing. OUTCOME MEASURES: Radiographic confirmation of the absence of pathological motion under load. RESULTS: In 51 cases studied to date, no instabilities have been found. Four cases of minor ligamentous hypermobility have been detected, with stability confirmed and no surgery required. There have been no failures to depict the neck completely, no missed instabilities and no complications of the procedure. CONCLUSIONS: Cervical stability can be reliably confirmed with this test without any requirement for advanced imaging technology.

Dorsal root entry zone lesioning used to treat central neuropathic pain in patients with traumatic spinal cord injury: a systematic review.

STUDY DESIGN: A systematic review was conducted for studies of any design. OBJECTIVES: To evaluate the effectiveness and safety of dorsal root entry zone lesioning in treating central neuropathic pain of patients with traumatic spinal cord injury. SUMMARY OF BACKGROUND DATA: Central neuropathic pain has a great impact on the quality of life of many patients with traumatic spinal cord injury. Dorsal root entry zone lesioning has become one of several treatment options. No previous systematic reviews were found that address this indication for the procedure. METHODS: Several computerized databases were searched along with reference lists of eligible articles and personal files of advisory panel members. Only primary studies of patients older than 13 years with both traumatic spinal cord injury and central neuropathic pain receiving dorsal root entry zone lesioning were included. Two assessors independently performed data extraction and quality assessment for all the studies. RESULTS: The selection criteria were met by 11 studies. All were case series of 5 to 54 patients. As reported by 10 of the studies, at least 50% of the patients attained more than 50% pain relief or experienced no pain limitation of activity and no need for narcotics. However, all the studies had poorly defined eligibility criteria or none at all, no control groups, and inadequate reporting of adverse effects. Only one study provided adequate patient description. None of the studies reported the validity, reliability, or responsiveness of outcome measures. CONCLUSIONS: Reviewed studies indicate promising results from dorsal root entry zone lesioning for the treatment of central neuropathic pain in selected patients with traumatic spinal cord injury. However, the strength of the evidence provided by the studies was poor in terms of study design, outcome measures, reports on the severity of adverse effects, patient selection criteria, and patient description. For these reasons, the evidence is weak for the use of dorsal root entry zone lesioning to relieve central neuropathic pain in patients with traumatic spinal cord injury.