The Effect of Graft Harvest and Skin Incision Angle on Sensory Disturbance in ACL Reconstruction With Semitendinosus-Gracilis Tendon Graft: A Randomized Controlled Trial and Cadaveric Study.

BACKGROUND: Injury to the inferior branch of the saphenous nerve (IBSN) and the subsequent loss of skin sensation after anterior cruciate ligament (ACL) reconstruction are common. The literature suggests that the incision angle may affect the incidence and area of loss of skin sensation. PURPOSE: To determine whether there is a difference in the incidence and area of altered sensory loss on the tibia between vertical (VI) and oblique (OI) incisions for semitendinosus-gracilis tendon graft harvest during ACL reconstruction. The cadaveric component was designed to determine whether there is a "safe zone" for incision by identifying the location and number of branches of the IBSN. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Patients (n = 37) were randomized to receive either VI or OI. Incidence and area of altered skin sensation were documented during at least 1 postoperative visit. In addition, 18 cadaveric knees were dissected. RESULTS: The presence or absence of hypoesthesia did not differ between groups postoperatively. Although no statistical differences between groups were seen in the total area of perceived altered skin sensation at 3 (P = .57), 6 (P = .08), 12 (P = .65), and 24 months (P = .27), data demonstrated a trend toward VI participants having a larger area of hypoesthesia at every time point. Among the 18 cadaveric specimens, 4 variations in the distribution of IBSN were noted: 18 (100%) had 1 branch, 14 (78%) had 2 branches, 6 (33%) had 3 branches, and 1 (6%) had 4 branches. No safe zone for incision could be identified. CONCLUSION: No difference was found between a vertical and an oblique incision with respect to incidence or area of sensory loss. Furthermore, it was not possible to identify a safe zone that would prevent transection of all nerves branches of the IBSN based on the cadaveric component of this study.

Effect of Body Weight-Supported Exercise on Symptoms of Knee Osteoarthritis: A Follow-up Investigation.

OBJECTIVE: To examine the long-term effect of participation in a 12-week lower-body positive pressure (LBPP)-supported low-load treadmill exercise regime on knee joint pain, physical function, and thigh muscle strength in patients with knee osteoarthritis (OA). DESIGN: Prospective, observational, repeated measures. SETTING: Clinical orthopedic setting. PATIENTS: Nineteen overweight patients with knee OA. INTERVENTION: Participants exercised under low-load treadmill walking conditions 2×/week for 12 weeks using an amount of LBPP support that minimized knee pain while walking for a period of 30 minutes at a set speed of 3.1 mph at 0-degree incline. MAIN OUTCOME MEASURES: Knee pain, function, thigh muscle strength, and body anthropometry were reassessed a minimum of 6 months after completion of the initial exercise regime and compared with results from baseline and postexercise evaluation. RESULTS: Data suggested that: (1) patients were able to maintain improvements in knee joint pain and symptoms; (2) patients continued to report enhanced joint function and improved quality of life; and (3) patients maintained thigh muscle strength gains. Finally, a majority of patients continued to experience significant reductions in acute knee pain during full weight-bearing treadmill walking. CONCLUSIONS: Data suggest that improvements in knee pain, joint function, and thigh muscle strength associated with participation in a 12-week LBPP-supported low-load exercise regime were maintained well after cessation of the program. These findings have important implications for the development and refinement of exercise strategies and interventions used in the long-term management of joint symptoms associated with knee OA in overweight patients.

Managing Knee Osteoarthritis: The Effects of Body Weight Supported Physical Activity on Joint Pain, Function, and Thigh Muscle Strength.

OBJECTIVE: To determine the effect of a 12-week lower body positive pressure (LBPP)-supported low-load treadmill walking program on knee joint pain, function, and thigh muscle strength in overweight patients with knee osteoarthritis (OA). DESIGN: Prospective, observational, repeated measures investigation. SETTING: Community-based, multidisciplinary sports medicine clinic. PATIENTS: Thirty-one patients aged between 55 and 75 years, with a body mass index ≥25 kg/m and mild-to-moderate knee OA. INTERVENTION: Twelve-week LBPP-supported low-load treadmill walking regimen. MAIN OUTCOME MEASURES: Acute knee joint pain (visual analog scale) during full weight bearing treadmill walking, chronic knee pain, and joint function [Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire] during normal activities of daily living, and thigh muscle strength (isokinetic testing). Appropriate methods of statistical analysis were used to compare data from baseline and follow-up evaluation. RESULTS: Participants reported significant improvements in knee joint pain and function and demonstrated significant increases in thigh muscle strength about the degenerative knee. Participants also experienced significant reductions in acute knee pain during full weight bearing treadmill walking and required dramatically less LBPP support to walk pain free on the treadmill. CONCLUSIONS: Data suggest that an LBPP-supported low-load exercise regimen can be used to significantly diminish knee pain, enhance joint function, and increase thigh muscle strength, while safely promoting pain-free walking exercise in overweight patients with knee OA. These findings have important implications for the development of nonoperative treatment strategies that can be used in the management of joint symptoms associated with progressive knee OA in at-risk patient populations. CLINICAL RELEVANCE: This research suggests that LBPP-supported low-load walking is a safe user-friendly mode of exercise that can be successfully used in the management of day-to-day joint symptoms associated with knee OA, helping to improve the physical health, quality of life, and social well-being of North America's aging population.

Brain MRI CO2 stress testing: a pilot study in patients with concussion.

BACKGROUND: There is a real need for quantifiable neuro-imaging biomarkers in concussion. Here we outline a brain BOLD-MRI CO2 stress test to assess the condition. METHODS: This study was approved by the REB at the University of Manitoba. A group of volunteers without prior concussion were compared to post-concussion syndrome (PCS) patients--both symptomatic and recovered asymptomatic. Five 3-minute periods of BOLD imaging at 3.0 T were studied--baseline 1 (BL1--at basal CO2 tension), hypocapnia (CO2 decreased ∼5 mmHg), BL2, hypercapnia (CO2 increased ∼10 mmHg) and BL3. Data were processed using statistical parametric mapping (SPM) for 1st level analysis to compare each subject's response to the CO2 stress at the p = 0.001 level. A 2nd level analysis compared each PCS patient's response to the mean response of the control subjects at the p = 0.05 level. RESULTS: We report on 5 control subjects, 8 symptomatic and 4 asymptomatic PCS patients. Both increased and decreased response to CO2 was seen in all PCS patients in the 2nd level analysis. The responses were quantified as reactive voxel counts: whole brain voxel counts (2.0±1.6%, p = 0.012 for symptomatic patients for CO2 response < controls and 3.0±5.1%, p = 0.139 for CO2 response > controls: 0.49±0.31%, p = 0.053 for asymptomatic patients for CO2 response < controls and 4.4±6.8%, p = 0.281 for CO2 response > controls). CONCLUSIONS: Quantifiable alterations in regional cerebrovascular responsiveness are present in concussion patients during provocative CO2 challenge and BOLD MRI and not in healthy controls. Future longitudinal studies must aim to clarify the relationship between CO2 responsiveness and individual patient symptoms and outcomes.

Structuring agency: examining healthcare management in the USA and Australia using organizational theory.

PURPOSE: Since the 1970s, the healthcare industry has undergone significant changes. Using neo-institutional and resource dependency theories, the purpose of this paper is to explore how managers perceive constraint and enact agency amidst these historic challenges--perhaps most significantly, declining funding and increasing regulation. DESIGN/METHODOLOGY/APPROACH: The data come from ten interviews with healthcare managers, spanning for-profit, non-profit, and government legal forms and hospital and nursing home sub-industries in both Queensland, Australia and North Carolina, USA. The authors look for patterns across the interviews. FINDINGS: The paper shows that governments and umbrella "parent" organizations force managers to adhere to institutional expectations in exchange for resource investment. Managers navigate these environmental obstacles using a shared business-minded approach and competitive differentiation. Yet various interest groups--including front-line workers, physicians, and patients--challenge this paradigm, as they demand a focus on quality of care. Managers' efforts are likewise curbed by the very resource and institutional pressures they resist. ORIGINALITY/VALUE: The authors understand changes in the healthcare industry as resulting from an increasingly powerful managerial logic, at odds with traditional professional and societal values. Interest groups are best positioned to challenge this logic.

Arthroscopic rotator cuff repair with and without acromioplasty in the treatment of full-thickness rotator cuff tears: a multicenter, randomized controlled trial.

BACKGROUND: The primary objective of this prospective randomized controlled trial was to compare functional and quality-of-life indices and rates of revision surgery in arthroscopic rotator cuff repair with and without acromioplasty. METHODS: Eighty-six patients consented and were randomly assigned intraoperatively to one of two study groups, and sixty-eight of them completed the study. The primary outcome was the Western Ontario Rotator Cuff (WORC) index. Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and a count of revisions required in each group. Outcome measures were completed preoperatively and at three, six, twelve, eighteen, and twenty-four months after surgery. RESULTS: WORC and ASES scores improved significantly in each group over time (p < 0.001). There were no differences in WORC or ASES scores between the groups that had arthroscopic cuff repair with or without acromioplasty at any time point. There were no differences in scores on the basis of acromion type, nor were any interaction effects identified between group and acromion type. Four participants (9%) in the group that had arthroscopic cuff repair alone, one with a Type-2 and three with a Type-3 acromion, required additional surgery by the twenty-four-month time point. The number of patients who required additional surgery was greater (p = 0.05) in the group that had arthroscopic cuff repair alone than in the group that had arthroscopic cuff repair and acromioplasty. CONCLUSIONS: Our findings are consistent with previous research reports in which there was no difference in functional and quality-of-life indices for patients who had rotator cuff repair with or without acromioplasty. The higher reoperation rate was found in the group without acromioplasty. Further study that includes follow-up imaging and patient-reported outcomes over a greater follow-up period is needed.