Association of Claustrophobia and Anxiety with Cast Intolerance in Patients with Extremity Injuries.

BACKGROUND: Patients undergoing casting for upper or lower extremity injuries may present with recalcitrant pain without an identifiable physiologic etiology, which increases the likelihood of more frequent or unscheduled office visits, insomnia, decreased patient satisfaction, unnecessary investigative procedures or treatments, and-in some cases-cast intolerance. The exact causes of cast intolerance are not well studied, although claustrophobia and associated fears of suffocation and restriction may be underlying causes. QUESTIONS/PURPOSES: We sought to explore the association between claustrophobic tendencies and cast intolerance. We hypothesized that patients with claustrophobia or claustrophobic tendencies would have a higher rate of cast intolerance. METHODS: Patients requiring circumferential casting of an upper or lower extremity were prospectively enrolled at the time of cast application. Data were collected at each office visit until cast removal. Pre- and post-casting anxiety were quantified using the Beck Anxiety Inventory® (BAI®). Pain was assessed at each visit using the visual analog scale (VAS). Claustrophobic tendencies were evaluated after cast removal using the Claustrophobia Questionnaire (CLQ). At the completion of the study, patients were assigned to either the cast-tolerant or the cast-intolerance cohort according to predetermined criteria. CLQ, BAI, and VAS scores were compared between cohorts. RESULTS: Out of 199 patients enrolled, 4% (n = 8) met the criteria for cast intolerance. There was no difference in BAI (anxiety) scores between groups at casting, but cast-intolerant patients had significantly lower post-casting BAI scores than the cast-tolerant controls, indicating a decrease in anxiety after cast removal. Taken together, both groups demonstrated significant reduction in VAS scores from casting to cast removal. The tolerant group had a significant reduction in VAS scores, whereas the intolerant group did not. The intolerant group had a significant negative correlation between initial VAS scores and final BAI scores. The tolerant group had a significant positive correlation between initial VAS scores and final BAI scores, as well as between final VAS scores and final BAI scores. Interestingly, no difference in CLQ scores was seen between groups, although there were positive correlations between CLQ scores and pre- and post-casting anxiety scores and between CLQ and final VAS scores. CONCLUSIONS: Our hypothesis was not supported. Although we did not find a relationship between claustrophobia and cast intolerance, we did find significant correlations between anxiety and pain. The tolerant group's initial and final pain scores had significantly positive correlations to final anxiety, suggesting that pain is likely to cause or increase anxiety; indeed, as pain decreased, so did anxiety. The intolerant group, however, had a significant negative correlation between initial pain and final anxiety scores. It would not be expected that lower pain scores would increase anxiety. This may suggest that cast-intolerant patients experience or report their anxiety as pain. These findings may explain why some patients suffer from pain that cannot be explained by an underlying physiologic process and is resistant to traditional pain management. A multidisciplinary approach, including psychological and psychosocial assessments, may help identify nonphysiologic components to pain. An accurate diagnosis for the cause of pain may lead to nonpharmacological interventions and therefore reduce opioid use and overall costs and improve patient outcomes.

Improved Rotator Cuff Footprint Contact Characteristics With an Augmented Repair Construct Using Lateral Edge Fixation.

BACKGROUND: The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct. HYPOTHESIS: The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct. RESULTS: The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 kPa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures. CONCLUSION: The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort. CLINICAL RELEVANCE: The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.

Biomechanical Evaluation of a Modified Internal Brace Construct for the Treatment of Ulnar Collateral Ligament Injuries.

BACKGROUND: Ulnar collateral ligament (UCL) repair augmented with the "internal brace" construct for the management of acute UCL injuries has recently garnered increasing interest from the sports medicine community. One concern with this technique is excessive bone loss at the sublime tubercle, should revision UCL reconstruction be required. In an effort to preserve the bony architecture of the sublime tubercle, an alternative internal brace construct is proposed and biomechanically compared with the gold standard UCL reconstruction. HYPOTHESIS: The internal brace repair construct will restore valgus laxity and rotation to its native state and demonstrate comparable load-to-failure characteristics with the 3-strand reconstruction technique. STUDY DESIGN: Controlled laboratory study. METHODS: For this study, 8 matched pairs of fresh-frozen cadaveric elbows were randomized to undergo either UCL reconstruction with the 3-ply docking technique or UCL repair with a novel internal brace construct focused on augmenting the posterior band of the anterior bundle of the ligament (modified repair-IB technique). Valgus laxity and rotation measurements were quantified through use of a MicroScribe 3DLX digitizer at various flexion angles of the native ligament, transected ligament, and repaired or reconstructed ligament. Laxity testing was performed from maximum extension to 120° of flexion. Each specimen was then loaded to failure, and the method of failure was recorded. RESULTS: Valgus laxity was restored to the intact state at all degrees of elbow flexion with the modified repair-IB technique, and rotation was restored to the intact state at both full extension and 30°. In the reconstruction group, valgus laxity was not restored to the intact state at either full extension or 30° of flexion (P < .001 and P = .004, respectively). Laxity was restored at 60° of flexion, but the elbow was overconstrained at 90° and 120° of flexion (P = .027 and P = .003, respectively). In load-to-failure testing, the reconstruction group demonstrated significantly greater yield torque (19.1 vs 9.0 N·m; P < .005), yield angle (10.2° vs 5.4°; P = .007), and ultimate torque (23.9 vs 17.6 N·m; P = .039). CONCLUSION: UCL repair with posterior band internal bracing was able to restore valgus laxity and rotation to the native state. The construct exhibited lower load-to-failure characteristics when compared with the reconstruction technique. CLINICAL RELEVANCE: In selected patients with acute, avulsion-type UCL injuries, ligament repair with posterior band internal bracing is a viable alternative surgical option that, by preserving bone at the sublime tubercle, may decrease the complexity of future revision procedures.

Ulnar Collateral Ligament Repair With Suture Bridge Augmentation.

The gold standard for management of elbow ulnar collateral ligament (UCL) injuries in elite athletes is reconstruction of the UCL with a tendon graft. Over the past several years, UCL repair for acute tears, as well as partial tears, in young athletes has gained increasing popularity, with studies reporting good outcomes and high rates of return to sports. Additionally, there is increased interest in ligament augmentation using the InternalBrace concept. A recent technique paper describes a direct repair of the UCL augmented with a spanning suture bridge. Although clinical outcomes for this method are promising, one possible concern when using this technique is bone loss at the ulnar origin of the UCL should revision reconstruction be required. We propose an alternative augmentation method that allows for stress shielding of the healing native ligament while minimizing bone compromise in the face of UCL reconstruction at a later time point.

A Modification of the Active Compression Test for the Shoulder Biceps-Labrum Complex.

The active compression test (O'Brien Sign) is widely used by physicians to aid in the diagnosis of biceps-labrum complex disease. This maneuver has been particularly criticized in the literature, however, with regard to interobserver reliability. Criticisms may in fact stem from inaccurate and inconsistent practice of the examination maneuver, stemming from both patient- and physician-related errors. In this Technical Note, we introduce an easy modification to the O'Brien Sign that limits such errors and improves test uniformity.

Biceps Tenodesis: A Comparison of Tendon-to-Bone and Tendon-to-Tendon Healing in a Rat Model.

In this article, we report on the differences in the healing biology of biceps tenodesis performed on either bone or soft tissue in a rat model. This work provides further insight into what may be the optimal strategy for managing biceps-labrum complex disease.

The Quality of Open-Access Video-Based Orthopaedic Instructional Content for the Shoulder Physical Exam is Inconsistent.

BACKGROUND: The internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information available to patients, no studies have evaluated such parameters for open-access video content designed for provider use. QUESTIONS/PURPOSES: The primary goal of the study was to determine the accuracy of internet-based instructional videos featuring the shoulder physical examination. METHODS: An assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a surrogate for the "best-case scenario" due to its widely accepted components that are stable over time. Three search terms ("shoulder," "examination," and "shoulder exam") were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopaedic surgeons. Quality and accuracy were assessed in accordance with previously published standards. RESULTS: Of the 39 video tutorials reviewed, 61% were rated as fair or poor. Specific maneuvers such as the Hawkins test, O'Brien sign, and Neer impingement test were accurately demonstrated in 50, 36, and 27% of videos, respectively. Inter-rater reliability was excellent (mean kappa 0.80, range 0.79-0.81). CONCLUSION: Our results suggest that information presented in open-access video tutorials featuring the physical examination of the shoulder is inconsistent. Trainee exposure to such potentially inaccurate information may have a significant impact on trainee education.

Emerging Indications for Reverse Shoulder Arthroplasty.

Historically, reverse shoulder arthroplasty was reserved for older, low-demand patients in whom rotator cuff arthropathy was diagnosed. Other common indications included sequelae of previously treated proximal humerus fractures, failed anatomic total shoulder arthroplasty, tumor resection, and rheumatoid arthritis in the elderly population. Unpredictable implant durability and high complication rates have limited the use of reverse shoulder arthroplasty to a narrow group of patients. Over the past decade, however, research has led to an improved understanding of the biomechanics behind reverse shoulder prostheses, which has improved implant design and surgical techniques. Consequently, orthopaedic surgeons have slowly begun to expand the indications for reverse shoulder arthroplasty to include a wider spectrum of shoulder pathologies. Recent studies have shown promising results for patients who undergo reverse shoulder arthroplasty for the treatment of acute proximal humerus fractures, massive rotator cuff tears without arthropathy, primary osteoarthritis, and chronic anterior dislocation, as well as for younger patients who have rheumatoid arthritis. These data suggest that, with judicious patient selection, reverse shoulder arthroplasty can be an excellent treatment option for a growing patient cohort.

Anatomical Study of the Surgical Approaches to the Radial Tunnel.

PURPOSE: To provide a cadaveric analysis of 3 surgical approaches (anterior, anterolateral, posterior) used for decompression of the posterior interosseous nerve within the radial tunnel. The aim of the study was to determine whether the number of compression sites visualized and safely released differed between approaches. We hypothesized that no single approach is adequate for visualization of all key compression sites. METHODS: Thirty fresh-frozen cadaveric specimens were used to perform 10 anterior, 10 anterolateral, and 10 posterior approaches to the radial tunnel. For each approach, key anatomical structures and the 5 documented anatomical sites of nerve compression that were clearly visualized within the surgical exposure were recorded. The portion of the supinator that was directly visualized in each approach was released. A second window was then created to expose the remaining uncut portion of the supinator. Measurements were taken from each specimen. RESULTS: Statistical analysis demonstrated that the anterior and anterolateral approaches were best for visualizing the fibrous bands of the radial head, the leash of Henry, the origin of the extensor carpi radialis brevis, and the arcade of Frohse. The posterior approach was best for visualizing the distal border of the supinator. The relative uncut supinator distance varied with approach. The anterior approach left a larger relative uncut portion than the posterior approach. CONCLUSIONS: No single approach was adequate for complete visualization and release of all compression points of the radial tunnel. In cases of radial tunnel release, complete visualization of the posterior interosseous nerve compression sites is best achieved through multiple windows. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Tension Band Plating for Chronic Anterior Tibial Stress Fractures in High-Performance Athletes.

BACKGROUND: Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. HYPOTHESIS: Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. RESULTS: Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. CONCLUSION: Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal.

Carpal fractures other than scaphoid.

Carpal fractures are uncommon, but if missed, can lead to morbidity and loss of function, especially in an athlete. Early diagnosis through physical examination, plain radiographs, and possibly advanced imaging is paramount. Treatment is specific to each fracture type, and return to play varies with each clinical scenario. This article organizes current knowledge of these potentially difficult fractures with a table of diagnoses and treatment guidelines.