Rotator cuff outcomes and mental health indices: Correlation or causation?

Background: Psychological factors such as catastrophizing, anxiety, and depression influence clinical outcomes in many conditions. Our purpose was to examine trends and associations between these and outcomes of rotator cuff surgery. Methods: 148 patients (76 W:72 M, 55.1 ± 8.2 years) with unilateral symptomatic rotator cuff syndrome were followed for 1 year after surgery. The Western Ontario Rotator Cuff Score (WORC), the Pain Catastrophizing Score (PCS), and the Hospital Anxiety and Depression Score (HADS) were administered. Evolution and associations of WORC, HADS and PCS scores were examined using uni- and multivariate analyzes. Results: At 1 year, PCS, HADS-A, and HADS-D scores negatively correlated with WORC score (R = -0.6, -0.61, -0.69). The strength of correlation was lower between baseline PCS, HADS-A, and HADS-D scores and 1-year WORC score (R = -0.38, -0.43, -0.42). Prior anxiety diagnosis was associated with higher HADS-A scores at 2- and 6- weeks post-op (p = 0.013, 0.011). 106 participants experienced an improving HADS-D over the year of follow-up. Worse pre-op pain, WORC, PCS, HADS-A, HADS-D, cardiovascular disease and current smoking were associated with non-improving HADS-D. Discussion: Patient-reported outcomes of rotator cuff surgery are associated with patient-reported anxiety, depression, and pain catastrophizing. In many, all outcome scores improved over time suggesting a two-way association between shoulder condition and psychological parameters. Level of evidence: II.

Gene intervention in ligament and tendon: current status, challenges, future directions.

Ligament and tendon injuries are common clinical problems. Healing of these tissues occurs, but their properties do not return to normal. This predisposes to recurrent injuries, instability and arthritis, loss of motion and weakness. Gene therapy offers a novel approach to the repair of ligaments and tendons. Introduction of genes into ligaments and tendons using vectors has been successful. Marker genes and therapeutic genes have been introduced into both tissues with evidence of corresponding functional alterations. In addition, gene transfer has been used to manipulate the healing environment, opening the possibility of gene transfer to investigate ligament and tendon development and homeostasis, in addition to using this technology therapeutically. Several factors modulate the 'success' of gene transfer in these tissues.

Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation.

Twenty-two consecutive patients (23 wrists) underwent open reduction internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches. One of 5 experienced wrist surgeons performed these procedures within an average of 3 days of injury (range, 0-26 days) and intercarpal fixation was kept within the proximal carpal row. Motion was instituted an average of 10 weeks (range, 5-16 weeks) after injury. All patients were males. The average age at the time of injury was 32 years (range, 16-60 years). The average follow-up period was 37 months (range, 13-65 months). Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively, compared with the contralateral wrist. The scapholunate angle increased and the revised carpal height ratio decreased over time, which was statistically significant for both measurements. Three patients (3 wrists) required wrist arthrodesis and a fourth patient had an immediate scaphoid excision and 4-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched US population values; physical summary scores were significantly less. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Seventy-three percent of all patients had returned to full duties in their usual occupations and a total of 82% were employed.

Functional outcome of semiconstrained total elbow arthroplasty.

BACKGROUND: The objective of the present study was to review the results of primary total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. Two hypotheses were tested: (1) the results in patients with inflammatory arthritis would be superior to those in patients with a traumatic or posttraumatic condition, and (2) the isometric extensor torque after total elbow arthroplasty would be significantly less than that of the contralateral elbow. METHODS: Forty-seven consecutive patients (fifty-one elbows) had the operation performed by one of three surgeons between November 1, 1989, and June 30, 1996. Thirty-six surviving patients (thirty-nine elbows) were available for follow-up. The mean duration (and standard deviation) of follow-up was 50 +/- 11 months (range, twenty-four to ninety-seven months). The mean age at the time of the operation was 64 +/- 11 years (range, twenty-seven to eighty-seven years). Eighteen patients (twenty-one elbows) had inflammatory arthritis. Eighteen patients (eighteen elbows) had an acute fracture or posttraumatic condition (posttraumatic osteoarthritis in eight, an acute fracture of the humerus in seven, nonunion of the distal aspect of the humerus in two, and primary osteoarthritis in one). The patients were evaluated with use of questionnaires (the Mayo elbow performance index, the Short Form-36 [SF-36], and the Disabilities of the Arm, Shoulder and Hand [DASH] Questionnaire); clinical examination by an orthopaedic surgeon who was not involved with the pre-operative, operative, postoperative, or follow-up care; radiographs; and elbow strength-testing with an isokinetic dynamometer. RESULTS: The mean score (and standard deviation) on the Mayo elbow performance index for the group that had inflammatory arthritis (90 +/- 11 points) was significantly higher than that for the group with a traumatic or posttraumatic condition (78 +/- 18 points) at the time of the latest follow-up (p < 0.05). In both groups, the mean extensor torque of the involved elbow was significantly less than that of the contralateral elbow (p < 0.05). No significant difference between the groups was found with respect to the flexion-extension arc of motion. Ten elbows (26 percent) had ulnar nerve dysfunction (a transient deficit in six and a permanent deficit in four); nine (23 percent), an intraoperative fracture (of the humeral diaphysis in four, of the ulnar diaphysis in four, and of the olecranon in one); three (8 percent), a periprosthetic infection; three, a triceps disruption; and one (3 percent), a revision because of a fracture of the ulnar component. There were no other revisions. Of the thirty-four elbows with complete radiographic follow-up, twenty-three had no change in the bone-cement interface. Progressive radiolucency was noted around the ulnar prosthesis in eight elbows, around the humeral prosthesis in one elbow, and around both components in two elbows. CONCLUSIONS: Patients who had a total elbow arthroplasty with use of a semiconstrained Coonrad-Morrey prosthesis were generally satisfied; the mean level of patient satisfaction was 9.2 of a possible 10 points for those who had inflammatory arthritis and 8.6 points for those who had a fracture or posttraumatic condition. The rates of complications involving the ulnar nerve, intraoperative fracture, triceps disruption, deep infection, and periprosthetic radiolucency are of concern.

Early expression of marker genes in the rabbit medial collateral and anterior cruciate ligaments: the use of different viral vectors and the effects of injury.

Gene therapy is a technique that may offer advantages over current methods of cytokine delivery to ligaments. To determine if implanted genes could be expressed in normal and injured knee ligaments, the medial collateral ligament and anterior cruciate ligament were studied in 18 rabbits. A retroviral ex vivo technique using allograft medial collateral ligament and anterior cruciate ligament fibroblasts and an adenoviral in vivo technique were compared as methods for delivering the LacZ marker gene to knee ligaments. Bilateral knee surgeries were performed, and the rabbits were equally divided into three groups. Group 1 received the retrovirus and the medial collateral ligament was ruptured, Group 2 received the adenovirus and the medial collateral ligament was ruptured, and Group 3 received the adenovirus and the medial collateral ligament was not injured. The anterior cruciate ligament was not injured in any group. The medial collateral and anterior cruciate ligaments of the right knees received 10(6) allografted, transduced ligament fibroblasts or 10(9) adenovirus particles, whereas the ligaments of the left knee received a similar volume of saline solution only. Equal numbers of rabbits were killed at 10 days, 3 weeks, and 6 weeks following the procedure. Ligament samples were stained with X-gal to detect the expression of the LacZ gene product, beta-galactosidase. LacZ gene expression was evident in ruptured and uninjured medial collateral ligaments as well as in the anterior cruciate ligament. The expression lasted between 10 days and 3 weeks in the medial collateral and anterior cruciate ligaments with use of the retrovirus and between 3 and 6 weeks in the medial collateral ligament and at least 6 weeks in the anterior cruciate ligament with the adenovirus. The length of gene expression in the ruptured and uninjured medial collateral ligaments did not differ. These preliminary studies indicate that gene transfer to normal and injured knee ligaments is possible.

Acute elbow dislocations: simple and complex.

The elbow is the second most common joint dislocated in adults. Up to 20% of dislocations are associated with fractures. Treatment principles are reduction of the joint, stabilization of associated fractures, and early motion. Ligament repairs or reconstruction and hinged external fixators are necessary in some cases to restore stability for early motion. In general, simple dislocations have a better prognosis than complex dislocations (fracture-dislocations).

Scar formation and ligament healing.

Ligaments are highly organized, dense, fibrous connective-tissue structures that provide stability to joints and participate in joint proprioception. Injuries to ligaments induce a healing response that is characterized by the formation of a scar. The scar tissue is weaker, larger and creeps more than normal ligament and is associated with an increased amount of minor collagens (types III, V and VI), decreased collagen cross-links and an increased amount of glycosaminoglycans. Studies have shown that certain surgical variables alter the healing of ligaments. Such factors include the size of gap between the healing ligament, ends, the use of motion in a stable joint and the presence of multiple ligamentous injuries. Research on ligament healing includes studies on low-load and failure-load properties, alterations in the expression of matrix molecules, cytokine modulation of healing and gene therapy as a method to alter matrix protein and cytokine production.

Engineering the healing of the rabbit medial collateral ligament.

A biological approach to improve healing of the medial collateral ligament (MCL) was investigated by exploring the use of therapeutic growth factors based on in vitro and in vivo experiments. The in vitro cell culture studies involved screening a variety of growth factors to select those that exhibit the most positive effects on cell proliferation and extracellular matrix synthesis. The selected growth factors were applied in vivo to a rabbit model where the MCL was ruptured. Biomechanical and histological evaluations are performed to determine whether the selected growth factors can enhance the properties of the healed MCL, whether these improvements are dose dependent, and whether combinations of growth factors can enhance MCL healing to a greater extent than individual growth factors. In vitro studies showed that epidermal growth factor (EGF) and platelet derived growth factor-BB (PDGF-BB) have the greatest effect on ligament fibroblast proliferation, whereas transforming growth factor-beta 1 (TGF-beta 1) superiorly promotes extracellular matrix synthesis. These growth factors were then applied in vivo at different dosages, in isolation and in combination, and the ligaments were evaluated six weeks post-operatively. Tensile testing of the femur-MCL-tibia complexes (FMTCs) revealed that the specimens treated with a high dose of PDGF-BB have ultimate load, ultimate elongation and energy absorbed to failure values that are significantly greater than those from the other groups. The high dose of PDGF-BB was more effective than the low dose, indicating a dose dependency. The addition of TGF-beta 1 to PDGF-BB did not lead to any further increases in the structural properties of the FMTC. These encouraging results suggest that PDGF-BB may be a potential growth factor to enhance the quality of the healing ligament.

The effects of platelet-derived growth factor-BB on healing of the rabbit medial collateral ligament. An in vivo study.

We report a biologic approach to improve medial collateral ligament healing using growth factors normally expressed in healing tissue. Our previous in vitro work demonstrated that platelet-derived growth factor-BB and transforming growth factor-beta 1 promoted fibroblast proliferation and matrix synthesis, respectively. There-fore, these growth factors were used in vivo to determine whether they could improve medial collateral ligament healing, whether this effect was dose-dependent, and if combinations of growth factors could improve healing more than individual growth factors. Thirty-seven rabbits had various doses of growth factors applied to the ruptured right medial collateral ligaments using a fibrin sealant delivery vehicle. The five groups consisted of 1) two groups receiving two doses of platelet-derived growth factor-BB, 2) two groups receiving two doses of this growth factor plus transforming growth factor-beta 1, and 3) one group receiving fibrin sealant only. After sacrifice at 6 weeks, biomechanical and histologic evaluations of the healing ligament were performed. Femur-medial collateral ligament-tibia complexes of the knees given the higher dose of platelet-derived growth factor-BB had ultimate load, energy absorbed to failure, and ultimate elongation values that were 1.6, 2.4, and 1.6 times greater than the same complexes of the control group. Adding transforming growth factor-beta 1 did not lead to any further increase in the structural properties of the complex compared with treatment with platelet-derived growth factor-BB. These encouraging results suggest that use of platelet-derived growth factor-BB may improve the quality of the healing medial collateral ligament, and that it may also have a similar potential for promoting healing of other ligaments.

The effects of age on rabbit MCL fibroblast matrix synthesis in response to TGF-beta 1 or EGF.

In this study, we examined the effects of age on collagen and total protein synthesis by ligament fibroblasts in response to growth factors. Three different doses of transforming growth factor-beta 1 (TGF-beta 1) or epidermal growth factor (EGF) were individually added to in vitro fibroblast cultures from the medial collateral ligament (MCL) of skeletally immature (age 3 months), mature (age 12 months) and senescent (age 48-51 months) rabbits. Analysis of the effects of age revealed that fibroblasts from senescent rabbits produced significantly less collagen in response to TGF-beta 1 or EGF stimulation when compared to fibroblasts from immature rabbits. Furthermore, increased age was found to result in significant reductions in the baseline levels of collagen synthesis but not total protein synthesis. Additionally, collagen and total protein synthesis by MCL fibroblasts were significantly affected by the TFG-beta 1 dose, but not by the EGF dose. When fibroblasts were normalized to their own controls, the increase in collagen and total protein synthesis due to TGF-beta 1 and EGF for the senescent group were found to be greater than those for the skeletally immature rabbits at all doses. This demonstrates that MCL fibroblasts from senescent rabbits are responsive to growth factors.

Functional outcome measures after displaced intra-articular calcaneal fractures.

We have devised a new scoring system using visual analogue scales (VAS) to determine the functional outcome in 15 patients with 20 displaced intra-articular calcaneal fractures, confirmed by CT. The average follow-up was 19 months. A VAS was completed separately by the patient, the surgeon and an independent assessor. It showed satisfactory agreement between observers and strong correlations with a General Health Survey (SF36), a pain scale (McGill Pain Questionnaire) and a disease-specific, historical scale for calcaneal fractures (the Rowe score).

The meiotic segregation of human sperm chromosomes in two men with accessory marker chromosomes.

Accessory marker chromosomes are occasionally discovered in normal individuals and they are presumed "clinically inert" since they do not appear to have any phenotypic effect. However, they do pose a theoretical risk at meiosis since they could disrupt the normal pairing and disjunction of homologous chromosomes. Sperm chromosome complements have been studied in two normal males, each of whom carry a small bisatellited accessory marker chromosome 47,XY, + mar (psps), to determine if these marker chromosomes are associated with an increased frequency of aneuploid gametes. Pronuclear chromosomes were visualized after in vitro fertilization of golden hamster eggs with human sperm. The frequency of sperm complements containing a marker chromosome was not significantly different from 50% as theoretically expected, in either male (17/43 and 13/31 with marker chromosomes). One male had 2/43 (4.7%) aneuploid sperm, which is very close to the average frequency of aneuploid sperm seen in control donors (5%). The other male had 6/31 complements with chromosomal abnormalities. One set of sperm chromosomes had structural abnormalities, and five (16.1%) had numerical abnormalities. This frequency of aneuploidy is significantly elevated over the frequency seen in control donors (P = .0002). It is particularly interesting that all the abnormalities involved small chromosomes, as would be expected if the marker chromosome participated in distributive pairing and thereby disrupted normal disjunction of chromosomes of similar size. These preliminary results suggest that accessory marker chromosomes may increase the risk of aneuploid gametes in some individuals.