Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears.

BACKGROUND: Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment. PURPOSE: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the "military press" starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique. RESULTS: Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76). CONCLUSION: The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

Relationship between self-reported shoulder function/quality of life, body mass index, and other contributing factors in patients awaiting rotator cuff repair surgery.

HYPOTHESES: We hypothesized that body mass index (BMI) would be negatively associated with self-reported shoulder function/pain. A second objective was to investigate the significance of other potential contributing factors: age, sex, smoking status, tear size, and workers' compensation (WC) involvement. METHODS: In this retrospective cohort study, consecutive patients who underwent arthroscopic rotator cuff repair surgery between 2002 and 2007 were reviewed. Preoperative American Shoulder and Elbow Society (ASES) and Simple Shoulder Test (SST) scores were compared with regard to age, sex, height, weight, smoking status, WC status, and rotator cuff tear size. RESULTS: Fifty-four patients were enrolled in this study. At a level of significance of P < .05, BMI showed no correlation with preoperative SST or ASES scores. WC status was negatively correlated with ASES scores. Female sex, WC status, and smoking were each negatively correlated with SST scores. The regression model predictive of preoperative SST scores included sex, WC status, and smoking status. WC status was predictive of ASES scores. DISCUSSION: To our knowledge, this is the first study to examine BMI as a contributing factor in the magnitude of pain and level of function in patients with chronic rotator cuff tears. Our data suggest that there is no impact of BMI on function/pain. The inter-relationships between factors such as BMI, sex, age, and others are complex, and further study is needed to fully establish that there is no effect. CONCLUSION: Our hypothesis that BMI is negatively related to magnitude of pain/level of function was not supported. Factors found to be related were sex, WC involvement, and smoking.

The Misericordia Health Centre cataract comfort study.

BACKGROUND: All surgery provokes various degrees of anxiety for patients. The environment leading up to surgery can affect anxiety levels. We performed a prospective randomized study to compare environmental factors around the time of cataract surgery in order to identify interventions that would minimize stress for patients. METHODS: Patients scheduled to undergo cataract surgery at a university-affiliated hospital in Winnipeg were randomly assigned to 1) receive orally administered lorazepam or a placebo before surgery; 2) listen to relaxing music through headphones or routine background noise before surgery; 3) walk (or go by wheelchair if unable to walk) to the operating room or go by stretcher; and 4) listen to relaxing music through headphones or routine background noise during surgery. Randomization for part 1 was double blind; for parts 2 and 3 the surgeon and anesthetist were blinded, but the patient was not. Patients were asked to rate their anxiety, sedation, nausea and pain on arrival at the preoperative area, about 30 minutes after arrival, on arrival in the operating room and on arrival in the postoperative area, on a visual analogue scale graded from 0 ("None" [or "Wide awake" in the case of sedation]) to 10 ("Worst possible" [or "Asleep" in the case of sedation]). Patient satisfaction and willingness to repeat the exact same form of treatment were also rated. RESULTS: Of the 19 surgeons in the department 18 agreed to participate; I withdrew during the study. Data were collected for 144 patients aged 26 to 93 years. Anxiety was highest on arrival at the institution and decreased progressively thereafter. Oral sedation and listening to music before surgery were associated with decreased anxiety and increased levels of sedation (p = 0.002). Walking to the operating room provided no benefit over going by stretcher. Listening to music through headphones during surgery was not accepted by many patients and, when used, negatively affected the surgeon's assessment of the patient's ability to cooperate. Surgeons reported movement more often among patients who received oral sedation than among those who did not (chi2 = 0.01). Levels of pain and nausea were extremely low in all patients, and satisfaction was very high. Patients who received regional local anesthesia had less pain and higher satisfaction than those who received topical anesthesia. Willingness to repeat the same treatment was extremely high. INTERPRETATION: For patients undergoing cataract surgery, efforts should be directed toward reducing anxiety on arrival at the institution, when it is highest, and not just during surgery. Oral sedation and listening to music before surgery appear to be beneficial. Listening to music through headphones during surgery was not found to be advantageous.