Outcomes and complications after different surgical techniques for the treatment of chronic distal biceps tendon ruptures: a systematic review and quantitative synthesis.

Hypothesis: The purpose of this study was to perform a systematic review of the available literature evaluating surgical outcomes after chronic distal biceps tendon rupture. Surgical techniques, including primary repair, autograft reconstruction, and allograft reconstruction, were compared, as well as subjective and objective clinical outcomes and complication rates. Methods: A systematic literature search of Level I-IV studies reporting outcomes of surgically treated chronic distal biceps tendon ruptures were performed via PubMed, Cochrane Collaboration, Science Direct, and Google Scholar databases. Twenty-two papers were identified in the review, with 236 patients. A Modified Coleman Methodological Score (CMS) was determined for every article to assess study quality. Patient-reported outcomes, postoperative range of motion, flexion and supination strength, and postoperative complications were recorded. MAYO elbow scores (MEPS) were reported more consistently than the other outcome tools. Results: No Level I or level II studies were identified in our search, and the heterogeneity of outcome measures precluded meta-analysis. Studies demonstrated mean MEPS scores ranging between 86 and 100, regardless of the surgical technique utilized. All studies reported a mean flexion-extension arc equal to or greater than 5-130°. The reported mean postoperative flexion strength was within 10% of the unaffected contralateral side. The most common complication for both direct repair and reconstruction groups was paresthesia of the lateral antebrachial cutaneous nerve [direct repair: 18-16.8%; reconstruction: 8-6.2% (allograft: 4-6%; autograft: 4-7%)]. Rerupture was uncommon and occurred in three patients who had undergone direct repair and in one patient after autograft reconstruction. Conclusions: Surgical treatment of chronic distal biceps injuries yields favorable objective and subjective outcomes. Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes.

Magnetic Resonance Imaging of Pectoralis Major Injuries in an Active Duty Military Cohort: Mechanism Affects Tear Location.

BACKGROUND: Pectoralis major (PM) tendon tears are common injuries in athletic patient populations, where operative repair is largely recommended for maximum functional recovery. The repair varies in difficulty and technique based on the location of the tear within the muscle-tendon unit. Magnetic resonance imagining (MRI) has been reported to be sensitive and specific for identifying the tear location, but the effect of injury mechanism on tear pattern has not been previously investigated. PURPOSE: To examine PM tears in a military patient population and assess the effect of injury mechanism (weightlifting vs high-energy trauma) on the tear pattern and accuracy of MRI interpretation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Active duty military servicemembers undergoing operative repair of PM tendon tears with corresponding preoperative MRIs from 2 medical centers were identified. Two musculoskeletal fellowship-trained radiologists reviewed imaging studies, reporting the location of the tear within the muscle-tendon unit and the severity of the tear (sternal head vs clavicular head vs both). Radiographic findings were compared against intraoperative findings. Mechanism of injury and timing from injury to imaging and surgery were assessed to determine whether they affected the accuracy of MRI interpretations. RESULTS: A total of 72 patients were included (mean ± SD age, 33.7 ± 7.0 years; 100% male). Mechanisms of injury consisted of 46 weightlifting injuries and 26 high-energy injuries. Interrater reliability was poor for tear location (kappa, 0.162; P = .003) but substantial for extent of tear (kappa, 0.637; P < .0001). MRI had a 51.3% sensitivity and 63.6% specificity for identifying complete tears. MRI had a sensitivity of 73.9% and specificity of 72.2% for avulsion injuries and sensitivity of 75% and specificity of 79.3% for musculotendinous injuries. Mechanism of injury had no effect on extent of the tear but did affect the location of the tear, with a higher rate of avulsion injuries in the high-energy mechanism cohort (81% vs 40%; P = .02). CONCLUSION: The mechanism of injury was found to significantly affect the location of tendon tears. A higher rate of avulsion injuries was found in high-energy injuries than weightlifting injuries. MRI appeared to be less sensitive and specific than previous reports for traumatic PM tendon injuries.

Notable Racial and Ethnic Disparities Persist in Lower Extremity Amputations for Critical Limb Ischemia and Infection.

INTRODUCTION: The purpose of this study is to investigate the current disparities for major lower extremity amputation in patients with critical limb ischemia (CLI) and infection. METHODS: A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2011 to 2017 was conducted. Multivariate models were used to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections. RESULTS: For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections (P < 0.001). DISCUSSION: This nationally representative, cohort-based study demonstrates that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection. LEVEL OF EVIDENCE: Level III prognostic.

Orthopedic In-Training Examination: An Analysis of the Sports Medicine Section-An Update.

OBJECTIVE: Previously published studies have evaluated Orthopedic In-Training Examination sports medicine questions, but none have evaluated whether question difficulty has changed over time. DESIGN: Sports medicine subsection questions between 2012 and 2016 were evaluated and compared with previously published data on Orthopedic In-Training Examination from 2004 to 2009. Question categories were classified into 1 of 3 taxonomy levels-basic recall, diagnosis, and advanced problem solving. SETTING: Medical University of South Carolina; Charleston, SC, 29425; Institution. PARTICIPANTS: Two residents evaluated the Sports Subsection questions separately. Then an attending physician evaluated the questions to resolve discrepancies. A statistician was used for analysis. RESULTS: Utilization of imaging modalities averaged 37%, with 28% (11/39) of the questions containing 2 or more imaging modalities. There were increases in utilization of advanced problem-solving questions (45% vs. 27%, p = 0.002) and decreases in basic recall questions (49% vs. 67%, p = 0.008) compared with previously published data. CONCLUSIONS: While the percentage of the Orthopedic In-Training Examination represented by sports medicine has remained relatively unchanged, there were fewer questions requiring residents to demonstrate simple recall and diagnosis, and increased demand to perform advanced problem solving while utilizing multiple imaging modalities.

Stress radiographs for evaluating acromioclavicular joint separations in an active-duty patient population: What have we learned?

INTRODUCTION: Acromioclavicular (AC) joint separation is a common entity in athletic patient populations. The surgical treatment of these injuries varies based upon extent of injury, with numerous imaging modalities recommended to differentiate injury severity and treatment options. The use of weighted stress radiographs is controversial in the diagnostic evaluation of AC separation with previous consensus recommending against their use. No study to date has investigated the clinical utilization of diagnostic studies in the evaluation of AC joint separations in a military surgeon population. METHODS: Thirty-eight shoulder or sports medicine sub-specialty certified orthopaedic surgeons on active service in the Army, Air Force, and Navy were surveyed on their evaluation and treatment protocols for AC joint injuries. Specifically analyzed were imaging choice including the use of weighted stress radiographs as well as treatment recommendations based upon Rockwood grade. Responses were recorded in addition to surgeon descriptive data. Responses were analyzed with descriptive statistics. RESULTS: Thirty-seven of the identified thirty eight surgeons responded to the survey, for a 97% response rate. Of the group, 70% of surgeons were within 10 years of completing fellowship with an estimated average of 15 AC joint separations treated annually. Plain radiographic examination was relied upon by 48% of surgeons for treatment of AC joint separation with 13% using weighted stress radiographs. Overall, 10% of surgeon stated that their treatment plan would vary based upon results from a weighted stress view. 51% of surgeons included magnetic resonance imaging in their diagnostic approach of these injuries. Treatment recommendation varied according to injury severity with 78% preferring nonoperative treatment for acute Grade III injuries with 86% waiting a minimum of 3 months before proceeding with operative treatment. For Grade V injuries, 81% of surgeon preferred operative treatment, with 59% incorporating a soft-tissue graft in their repair or reconstructive procedure. DISCUSSION: This study identified substantial practice variation amongst military surgeons treating a relatively homogenous population with AC joint separations, reflective of a lack of definitive evidence to guide diagnosis and treatment. Overall, nonoperative management is the preferred initial approach for Type III injuries and operative treatment is the preferred initial approach for Type V injuries. The diagnostic evaluation varied across the surgeon cohort, but 87% elected against the use of weighted stress radiographs for the evaluation of AC joint separations, with only 10% relying upon them to dictate their recommended treatment. Future research identifying optimal diagnosis and treatment of AC joint separations is needed.

Genetic sorting of subordinate species in grassland modulated by intraspecific variation in dominant species.

Genetic variation in a single species can have predictable and heritable effects on associated communities and ecosystem processes, however little is known about how genetic variation of a dominant species affects plant community assembly. We characterized the genetic structure of a dominant grass (Sorghastrum nutans) and two subordinate species (Chamaecrista fasciculata, Silphium integrifolium), during the third growing season in grassland communities established with genetically distinct (cultivated varieties or local ecotypes) seed sources of the dominant grasses. There were genetic differences between subordinate species growing in the cultivar versus local ecotype communities, indicating that intraspecific genetic variation in the dominant grasses affected the genetic composition of subordinate species during community assembly. A positive association between genetic diversity of S. nutans, C. fasciculata, and S. integrifolium and species diversity established the role of an intraspecific biotic filter during community assembly. Our results show that intraspecific variation in dominant species can significantly modulate the genetic composition of subordinate species.