Postoperative Rehabilitation of Multidirectional Instability Surgery: A Systematic Review.

Multidirectional instability (MDI) of the shoulder is managed with surgery when conservative rehabilitation fails. The optimal postsurgical management of MDI is not well understood. The purpose of this study is to create a systematic review evaluating postsurgical rehabilitation protocols treating MDI. Articles were included if a postsurgical rehabilitation protocol was described following surgical treatment for MDI. Identified articles underwent 2 phases of screening by blinded team members. Remaining articles had their level of evidence determined by a predefined grading system, ranging from levels I to V. Articles with evidence levels I to IV were included in analysis. Of the 163 articles identified in the literature, 9 were included in this study. Surgical techniques examined in these articles include capsular plication, rotator interval closure, and capsular shift. Rehabilitation protocols were evaluated for duration of treatment and physical therapy modalities. Article results were evaluated for subjective and objective measures of protocol success. Overall, there is a lack of evidence to indicate the optimal rehabilitation protocol post-MDI surgery. Further research is needed to compare rehabilitation protocols following specific surgical procedures to determine their effect on postsurgical patient outcomes.

Role of arthroplasty in the Jehovah's Witness population.

BACKGROUND: Total joint arthroplasties aim to improve quality of life from joint-related pain. Jehovah's Witnesses refuse blood products due to their religious beliefs. Surgeons may be reluctant to perform arthroplasty procedures on these patients for fear of uncontrolled bleeding. However, we hypothesize that through preoperative optimization, arthroplasty can be performed safely. METHODS: We retrospectively reviewed 184 total joint arthroplasties in Jehovah's Witnesses between 2011 and 2019. Each patient was enrolled in the institutions' Bloodless Medicine program. Hemoglobin levels were recorded through standard laboratory testing while in the hospital. Primary outcomes were changes in preoperative and postoperative hemoglobin measures, short-term outcomes measures, and complications. RESULTS: A total of 103 total knee arthroplasties (8 revisions) and 81 total hip arthroplasties (5 revisions) were performed. Hemoglobin drift was 2.5 ± 1.0 for primary TKA and 2.6 ± 1.3 for primary THA (p = 0.570). Hemoglobin drift was 1.9 ± 0.9 for revision TKA and 1.9 ± 0.2 for revision THA (p = 0.990). Only 2.7% of patients met the transfusion requirement of 7 g/dL. The major complication rate for the cohort was 1.6% systemic and 4.9% local, respectively, with no mortalities. The overall readmission rate was 2.7%. CONCLUSION: To our knowledge, this is the largest reported sample of Jehovah's Witness patients undergoing total joint arthroplasty. Postoperative hemoglobin values did not prompt additional intervention in the overwhelming majority of patients, and complication rates were acceptable. Our data suggest that primary arthroplasty is safe in the Jehovah's Witness population. Additionally, we show preliminary evidence that revision arthroplasty is safe in Jehovah's Witness patients.

Opioid Consumption Following Foot and Ankle Surgery.

Background Orthopedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, leftover) are unknown. METHODS: Patients undergoing foot/ankle surgery during a 3-month period who met inclusion criteria were surveyed at their first postoperative visit. Information collected included gender, number of prescribed pills remaining, satisfaction with pain control, and willingness to surrender leftover opioids to a Drug Enforcement Administration (DEA) disposal center. Additional data, including utilization of a perioperative nerve block and type (bony versus nonbony) and anatomic region of procedure, were collected through review of the medical record. All data were analyzed in a retrospective fashion. A total of 171 patients with a mean age of 53.1 ± 15.5 years (range, 18-81 years) were included in the study. RESULTS: The mean number of opioids taken was 27.2 ± 17.5 pills (range, 0-70). The mean number of short-acting opioids and long-acting opioids taken was 21.4 ± 14.8 and 9.2 ± 5.0 pills, respectively. Most (73.5%) patients were satisfied with their pain control. Patients who underwent ankle/hindfoot surgery took more long-acting opioids on average than others ( P = .047). There was not a significant difference in opioid usage between bony and nonbony procedures. Of those with leftover opioids, 63% were willing to surrender them to a DEA disposal center. Patients willing to surrender leftover medications had both more short-acting ( P < .001) and long-acting ( P = .015) opioids leftover than those not willing to surrender them. CONCLUSION: Most patients undergoing foot/ankle surgery had opioids leftover at the first postoperative visit, and most were willing to surrender them. We can adequately treat patients' pain and decrease the number of opioid pills available in the community by decreasing the number of pills prescribed and encouraging disposal of leftovers. LEVEL OF EVIDENCE: Level IV, retrospective case series.

FNDC5 relates to skeletal muscle IGF-I and mitochondrial function and gene expression in obese men with reduced growth hormone.

OBJECTIVE: To investigate the relationship of skeletal muscle FNDC5 mRNA expression and circulating irisin to the GH/IGF-I axis and to skeletal muscle mitochondrial function and mitochondria-related gene expression in obese men. DESIGN: Fifteen abdominally obese men with reduced growth hormone received 12weeks of recombinant human GH (rhGH). Before and after treatment, they underwent (31)P-magnetic resonance spectroscopy to evaluate phosphocreatine (PCr) recovery as a measure of mitochondrial function and skeletal muscle biopsy to assess expression of mitochondrial-related genes. Serum irisin and IGF-I and skeletal muscle FNDC5 and IGF-I mRNA were measured. RESULTS: At baseline, skeletal muscle FNDC5 mRNA was significantly and positively associated with IGF-I mRNA (ρ=0.81, P=0.005) and rate of PCr recovery (ρ=0.79, P=0.006). Similar relationships of circulating irisin to IGF-I mRNA (ρ=0.63, P=0.05) and rate of PCr recovery (ρ=0.48, P=0.08) were demonstrated, but were not as robust as those with muscle FNDC5 expression. Both serum irisin and skeletal muscle FNDC5 mRNA were significantly associated with PPARγ (ρ=0.73, P=0.02 and ρ=0.85, P=0.002), respectively. In addition, FNDC5 mRNA was correlated with skeletal muscle PGC-1α (ρ=0.68, P=0.03), NRF1 (ρ=0.66, P=0.04) and TFAM (ρ=0.79, P=0.007) mRNA. Neither serum irisin nor muscle mRNA expression of FNDC5 changed with rhGH treatment. CONCLUSION: These novel data in skeletal muscle demonstrate that local expression of FNDC5 is associated with mRNA expression of IGF-I and mitochondrial function and mitochondria-related gene expression in obese subjects with reduced growth hormone and suggest a potential role for FNDC5 acting locally in muscle in a low GH state. Further studies are needed to clarify the relationship between the GH/IGF-I axis and irisin.