Musculoskeletal Surgery Research Articles

Economic implications of decreased elective orthopaedic and musculoskeletal surgery volume during the coronavirus disease 2019 pandemic.

PurposeIn order to reduce viral spread, elective surgery was cancelled in most US hospitals for an extended period during the COVID-19 pandemic. The purpose of this study was to estimate national hospital reimbursement and net income losses due to elective orthopaedic surgery cancellation during the COVID-19 pandemic.MethodsThe National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) were used to identify all elective orthopaedic and musculoskeletal (MSK) surgery performed in the inpatient setting and in hospital owned outpatient surgery departments throughout the USA. Total cost, reimbursement, and net income were estimated for all elective orthopaedic surgery and were compared with elective operations from other specialties.ResultsElective MSK surgery accounted for $65.6–$71.1 billion in reimbursement and $15.6–$21.1 billion in net income per year to the US hospital system, equivalent to $5.5–$5.9 billion in reimbursement and $1.3–$1.8 billion in net income per month. When compared with elective surgery from all other specialties, elective MSK surgery accounted for 39% of hospital reimbursement and 35% of hospital net income. Compared with all hospital encounters for all specialties, elective MSK surgery accounted for 13% of reimbursement and 23% of net income. Estimated hospital losses from cancellation of elective MSK surgery during 8 weeks of the COVID-19 pandemic were $10.9–$11.9 billion in reimbursement and $2.6–3.5 billion in net income.ConclusionCancellation of elective MSK surgery for 8 weeks during the COVID-19 pandemic has substantial economic implications on the US hospital system.

Nanovibrational Stimulation of Mesenchymal Stem Cells Induces Therapeutic Reactive Oxygen Species and Inflammation for Three-Dimensional Bone Tissue Engineering.

There is a pressing clinical need to develop cell-based bone therapies due to a lack of viable, autologous bone grafts and a growing demand for bone grafts in musculoskeletal surgery. Such therapies can be tissue engineered and cellular, such as osteoblasts, combined with a material scaffold. Because mesenchymal stem cells (MSCs) are both available and fast growing compared to mature osteoblasts, therapies that utilize these progenitor cells are particularly promising. We have developed a nanovibrational bioreactor that can convert MSCs into bone-forming osteoblasts in two- and three-dimensional, but the mechanisms involved in this osteoinduction process remain unclear. Here, to elucidate this mechanism, we use increasing vibrational amplitude, from 30 nm (N30) to 90 nm (N90) amplitudes at 1000 Hz and assess MSC metabolite, gene, and protein changes. These approaches reveal that dose-dependent changes occur in MSCs’ responses to increased vibrational amplitude, particularly in adhesion and mechanosensitive ion channel expression and that energetic metabolic pathways are activated, leading to low-level reactive oxygen species (ROS) production and to low-level inflammation as well as to ROS- and inflammation-balancing pathways. These events are analogous to those that occur in the natural bone-healing processes. We have also developed a tissue engineered MSC-laden scaffold designed using cells’ mechanical memory, driven by the stronger N90 stimulation. These mechanistic insights and cell-scaffold design are underpinned by a process that is free of inductive chemicals.

Effect of pre-game photobiomodulation on muscle recovery in professional soccer players: study protocol for a randomized, cross-over, sham-controlled, triple-blind, clinical trial

Background: Photobiomodulation with low-level laser therapy (LLLT) has been widely used in clinical practice for diverse purposes, such as modulation of the inflammatory process, acceleration of the tissue repair process, pain relief and the enhancement of post-exercise recovery. Studies have demonstrated a beneficial interaction between photobiomodulation and the production of creatine kinase, with a reduction in the release of this marker of muscle damage when laser and/or LEDs is administered prior to high-intensity physical activity. Objective: The aim of the proposed study is to determine the influence of pre-exercise phototherapy on post-exercise muscle recovery. Methods: A randomized, cross-over, sham-controlled, double-blind, clinical trial is proposed. The participants will be healthy professional soccer players aged 15 to 20 years from the same team with a body mass index within the ideal range (20 to 25 kg/m2 ) and no history of lower limb musculoskeletal injuries or surgery or back surgery in the previous six months. The athletes will be allocated to two groups based on the previously calculated sample size and will be blinded to allocation. Creatine kinase will be measured and the subjective perception of fatigue will be determined for each participant. The volunteers will then be randomly allocated to Group A, which will receive active phototherapy, and Group B, which will receive sham phototherapy. The athletes will undergo reevaluations immediately after as well as 48 hours after a football match. The data will be submitted to statistical analysis and the level of significance will be set to 5%. This study is registered with Clinical Trials under protocol number: NCT03416998.

Psychosocial Predictors of Acute and Chronic Pain in Adolescents Undergoing Major Musculoskeletal Surgery

Acute and chronic pain delay recovery and impair outcomes after major pediatric surgery. Understanding unique risk factors for acute and chronic pain is critical to developing effective treatments for youth at risk. We aimed to identify adolescent and family psychosocial predictors of acute and chronic postsurgical pain after major surgery in adolescents. Participants included 119 youth age 10 to 18 years (Mage = 14.9; 78.2% white) undergoing major musculoskeletal surgery and their parents. Participants completed presurgery baseline questionnaires, with youth reporting on baseline pain, anxiety, depression, insomnia and sleep quality, and parents reporting on parental catastrophizing and family functioning. At baseline, 2-week, and 4-month postsurgery, youth completed 7 days of daily pain diaries and reported on health-related quality of life. Sequential logistic regression models examined presurgery predictors of acute and chronic postsurgical pain, defined as significant pain with impairment in health-related quality of life. Acute pain was experienced by 27.2% of youth at 2 weeks, while 19.8% of youth met criteria for chronic pain at 4 months. Baseline pain predicted acute pain (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.32–2.90), while depressive symptoms (OR = 1.22; 95%CI = 1.01–1.47), and sleep quality (OR = 0.26; 95%CI = 0.08–0.83) predicted chronic pain. Tailored interventions need to be developed and incorporated into perioperative care to address risk factors for acute and chronic pain. PerspectiveLongitudinal results demonstrate adolescents’ presurgery pain severity predicts acute postsurgical pain, while depressive symptoms and poor sleep quality predict chronic postsurgical pain. Tailored interventions should address separate risk factors for acute and chronic pain after adolescent surgery.

Direct incorporation of mesenchymal stem cells into a Nanofiber scaffold \u2013 in vitro and in vivo analysis

Bony defects are a common problem in musculoskeletal surgery. Replacement with autologous bone grafts is limited by availability of transplant material. Sterilized cancellous bone, while being osteoconductive, has limited osteoinductivity. Nanofiber scaffolds are currently used for several purposes due to their capability of imitating the extracellular matrix. Furthermore, they allow modification to provide functional properties. Previously we showed that electrospun nanofiber scaffolds can be used for bone tissue regeneration. While aiming to use the osteoinductive capacities of collagen type-I nanofibers we saw reduced scaffold pore sizes that limited cellular migration and thus colonization of the scaffolds. Aim of the present study was the incorporation of mesenchymal stem cells into the electrospinning process of a nanofiber scaffold to produce cell-seeded nanofiber scaffolds for bone replacement. After construction of a suitable spinning apparatus for simultaneous electrospinning and spraying with independently controllable spinning and spraying devices and extensive optimization of the spinning process, in vitro and in vivo evaluation of the resulting scaffolds was conducted. Stem cells isolated from rat femora were incorporated into PLLA (poly-l-lactide acid) and PLLA-collagen type-I nanofiber scaffolds (PLLA Col I Blend) via simultaneous electrospinning and –spraying. Metabolic activity, proliferation and osteoblastic differentiation were assessed in vitro. For in vivo evaluation scaffolds were implanted into critical size defects of the rat scull. After 4 weeks, animals were sacrificed and bone healing was analyzed using CT-scans, histological, immunhistochemical and fluorescence evaluation. Successful integration of mesenchymal stem cells into the scaffolds was achieved by iteration of spinning and spraying conditions regarding polymer solvent, spinning distance, the use of a liquid counter-electrode, electrode voltage and spinning duration. In vivo formation of bone tissue was achieved. Using a PLLA scaffold, comparable results for the cell-free and cell-seeded scaffolds were found, while the cell-seeded PLLA-collagen scaffolds showed significantly better bone formation when compared to the cell-free PLLA-collagen scaffolds. These results provide support for the future use of cell-seeded nanofiber scaffolds for large bony defects.

Bleeding After Musculoskeletal Surgery in Hospitals That Switched From Hydroxyethyl Starch to Albumin Following a Food and Drug Administration Warning.

While US Food and Drug Administration (FDA) black box warnings are common, their impact on perioperative outcomes is unclear. Hydroxyethyl starch (HES) is associated with increased bleeding and kidney injury in patients with sepsis, leading to an FDA black box warning in 2013. Among patients undergoing musculoskeletal surgery in a subset of hospitals where colloid use changed from HES to albumin following the FDA warning, we examined the rate of major perioperative bleeding post- versus pre-FDA warning. The authors of this article used a retrospective, quasi-experimental, repeated cross-sectional, interrupted time series study of patients undergoing musculoskeletal surgery in hospitals within the Premier Healthcare Database, in the year before and year after the 2013 FDA black box warning. We examined patients in 23 "switcher" hospitals (where the percentage of colloid recipients receiving HES exceeded 50% before the FDA warning and decreased by at least 25% in absolute terms after the FDA warning) and patients in 279 "nonswitcher" hospitals. Among patients having surgery in "switcher" and "nonswitcher" hospitals, we determined monthly rates of major perioperative bleeding during the 12 months after the FDA warning, compared to 12 months before the FDA warning. Among patients who received surgery in "switcher" hospitals, we conducted a propensity-weighted segmented regression analysis assessing differences-in-differences (DID), using patients in "nonswitcher" hospitals as a control group. Among 3078 patients treated at "switcher" hospitals (1892 patients treated pre-FDA warning versus 1186 patients treated post-FDA warning), demographic and clinical characteristics were well-balanced. Two hundred fifty-one (13.3%) received albumin pre-FDA warning, and 900 (75.9%) received albumin post-FDA warning. Among patients undergoing surgery in "switcher" hospitals during the pre-FDA warning period, 282 of 1892 (14.9%) experienced major bleeding during the hospitalization, compared to 149 of 1186 (12.6%) following the warning. In segmented regression, the adjusted ratio of slopes for major perioperative bleeding post- versus pre-FDA warning was 0.98 (95% confidence interval [CI], 0.93-1.04). In the DID estimate using "nonswitcher" hospitals as a control group, the ratio of ratios was 0.93 (95% CI, 0.46-1.86), indicating no significant difference. We identified a subset of hospitals where colloid use for musculoskeletal surgery changed following a 2013 FDA black box warning regarding HES use in sepsis. Among patients undergoing musculoskeletal surgery at these "switcher" hospitals, there was no significant decrease in the rate of major perioperative bleeding following the warning, possibly due to incomplete practice change. Evaluation of the impact of systemic changes in health care may contribute to the understanding of patient outcomes in perioperative medicine.

Increased opioid use following rotator cuff repair associated with prior opioid use and surgeon prescription patterns

Prescription opioids are standard of care for postoperative pain management after musculoskeletal surgery, but there is no guidelineor consensus on best practices. Variability in the intensity of opioids prescribed for postoperative recovery has been documented, but it is unclear whether this variability is clinically motivated or associated with provider practice patterns, or how this variation is associated with patient outcomes. This study described variation in the intensity of opioids prescribed for patients undergoing rotator cuff repair (RCR)and examined associations with provider prescribing patterns and patients' long-term opioid use outcomes. Medicare data from 2010 to 2012 were used to identify 16,043 RCRs for patients with new shoulder complaints in 2011. Two measures of perioperative opioid use were created: (1) any opioid fill occurring 3 days before to 7 days after RCR and (2) total morphine milligram equivalents (MMEs) of all opioid fills during that period. Patient outcomes for persistent opioid use after RCR included (1) any opioid fill from 90 to 180 days after RCR and (2) the lack of any 30-day gap in opioid availability during that period. Generalized linear regression models were used to estimate associations between provider characteristics and opioid use for RCR, and between opioid use and outcomes. All models adjusted for patient clinical and demographic characteristics. Separate analyses were done for patients with and without opioid use in the 180 days before RCR. In this sample, 54% of patients undergoing RCR were opioid naive at the time of RCR. Relative to prior users, a greater proportion of opioid naive users had any opioid fill (85.7% vs. 75.4%), but prior users received more MMEs than naive users (565 vs. 451 MMEs). Providers' opioid prescribing for other patients was associated with the intensity of perioperative opioids received for RCR. Total MMEs received for RCR were associated with higher odds of persistent opioid use 90-180 days after RCR. The intensity of opioids received by patients for postoperative pain appears to be partially determined by the prescribing habits of their providers. Greater intensity of opioids received is, in turn, associated with greater odds of patterns of chronic opioid use after surgery. More comprehensive, patient-centered guidance on opioid prescribing is needed to help surgeons provide optimal postoperative pain management plans, balancing needs for short-term symptom relief and risks for long-term outcomes.

Musculoskeletal Injuries in Master Swimmers: A National Survey in Turkey.

BackgroundThis study aimed to determine the frequency of musculoskeletal injuries in master swimmers in Turkey.MethodsA questionnaire was formed and distributed to all master swimmers registered with the Turkish Swimming Federation. The collected data included age, sex, the age to start swimming (SAS), weekly training time (WTT), weekly training distance (WTD), any painful episode that lasted more than 10 days in any of the body regions within last one year, any confirmed diagnosis of musculoskeletal disease by a physician, and history of musculoskeletal surgical operation. The descriptive data were presented, and multiple comparisons were made according to demographic characteristics.ResultsThere were 88 male swimmers with a mean age of 47.1±13.2 years (range, 26-89 years). Of the 88 athletes, 27 (30.7%) had no pain in daily activities, and 61 (69.3%) reported pain in at least one region, with a total of 118 pain zones reported. The shoulder was the most common painful body region (n:37, 42.0%), followed by the lower back (n: 24, 27.3%), neck (n: 19, 21.6%), back (n:12, 13.6%), and knee (n:9, 10.2%). The mean age, SAS, WTT, WTD, and distribution of stroke preference were similar in subjects with or without reported pain and diagnosis (p>0.005). Any painful body region and diagnosis were equally distributed in all swimming styles (p>0.05). The most common surgeries were lumbar disc disease (16.7%) and meniscectomy (16.7%).ConclusionCompared to the findings in the current literature, master swimmers do not have as many musculoskeletal problems as their younger counterparts. The problems seen in master swimmers are lower but similar to those in competitive elite swimmers. From the musculoskeletal health perspective, swimming is safe for the master age group. Swimming can be safely offered to elderly patients who underwent even musculoskeletal surgery.

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey.

The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.

COVID-19 Pandemic and JBJS.

We are collectively in a situation in which we have no experience and for which we have limited preparation. With the Coronavirus pandemic, our worldwide medical community faces its biggest challenge in modern history. Patients and medical colleagues alike generally do not think of those of us who practice musculoskeletal medicine, surgery, and rehabilitation as essential components of the health-care system. However, when 40% of primary-care visits are related to the musculoskeletal system, we definitely play a large role in meeting patient needs. With the cancellation or delay of all elective surgical procedures and the limiting of outpatient visits to orthopaedic, PT, and OT providers, we have been set aside to some degree. The backlog will be enormous when restrictions are lifted, and it is likely that concerns regarding dissemination of the virus will persist for some time. More importantly, emergency/urgent procedures need to be carried out for the benefit of the patient. In order to provide the orthopaedic community with the most up-to-the-day relevant information, we have been accelerating the peer-review process to get important scientific manuscripts posted online within 4 to 5 days after receipt. For this extraordinary effort, I want to thank our authors, reviewers, and, most of all, copy-editing team. We are providing up-to-the-week systematic reviews in collaboration with OrthoEvidence; clinical experiences from Wuhan, China; and well-considered opinion pieces such as “What’s Important” contributions to the JBJS Orthopaedic Forum. We will continue to provide the information as fast as the review and editing processes can be conducted in order to assure our readers that the information is sound and reliable. Articles related to the Coronavirus pandemic will be first posted on the JBJS home page under the heading “COVID-19 and Orthopaedic Surgery” and will appear in print in the earliest possible issue. We invite the community of providers working in the musculoskeletal field to look to JBJS for the most current and reliable information regarding issues related to the COVID-19 pandemic.

Comparison of the Effects of Extracorporeal Irradiation and Liquid Nitrogen on Nerve Recovery in a Rat Model

Aim of the study Biologic reconstruction using tumor-bearing bone autografts devitalized by liquid nitrogen or extracorporeal irradiation (oncological sterilization) is a safe and effective method in musculoskeletal surgery. The purpose of this study was to examine the effects of these two oncological sterilization methods on nerve recovery. Methods A total of 48 rats were randomly divided into 3 groups as autograft, irradiation and liquid nitrogen groups. A nerve defect created in the right sciatic nerve was reconstructed with an autograft obtained from the nerve itself. Group I underwent reconstruction with standard nerve autograft. Group II and Group III underwent reconstruction with devitalized nerve autograft treated through extracorporeal irradiation and liquid nitrogen, respectively. The left sciatic nerves of the rats served as control. Electromyography, motor function test and histomorphological analysis were performed to assess the nerve recovery on the 3rd (early stage) and 4th months (late stage). Results Electrophysiological assessment revealed better results in irradiation group compared with liquid nitrogen group in terms of myelinization and axonal regeneration. Motor performance of the autograft group was slightly better than the other groups. Histologically, autograft group demonstrated better results compared with other groups. Late-stage assessments revealed high rates of myelinization in the graft segment in liquid nitrogen group and in the segment distal to the graft in irradiation group. Conclusions This study has demonstrated that nerve autografts treated by oncological sterilization methods may be used for nerve reconstruction in limb salvage surgery. However, further studies are needed to clarify the applicability of these methods.

Effects of an individually targeted multicomponent counseling and home-based rehabilitation program on physical activity and mobility in community-dwelling older people after discharge from hospital: a randomized controlled trial

Objectives: The aim of this study is to evaluate the effects of multicomponent rehabilitation on physical activity, sedentary behavior, and mobility in older people recently discharged from hospital. Design: Randomized controlled trial. Setting: Home and community. Participants: Community-dwelling people aged ⩾60 years recovering from a lower limb or back musculoskeletal injury, surgery, or disorder were recruited from local health center hospitals and randomly assigned into an intervention (n = 59) or a control (standard care, n = 58) group. Intervention: The six-month intervention consisted of a motivational interview, goal attainment process, guidance for safe walking, a progressive home exercise program, physical activity counseling, and standard care. Measurements: Physical activity and sedentary time were assessed using an accelerometer and a single question. Mobility was evaluated with the Short Physical Performance Battery, self-reported use of a walking aid, and ability to negotiate stairs and walk outdoors. Intervention effects were analyzed with generalized estimating equations. Results: Daily physical activity was 127 ± 78 minutes/day and 121 ± 70 at baseline and 167 ± 81 and 164 ± 72 at six months in the intervention and control group, respectively; mean difference of 3.4 minutes (95% confidence interval (CI) = −20.3 to 27.1). In addition, no significant between-group differences were shown in physical performance. Conclusion: The rehabilitation program was not superior to standard care for increasing physical activity or improving physical performance. Mobility-limited older people who had recently returned home from hospital would have needed a longer and more frequently monitored comprehensive geriatric intervention.

Distraction osteogenesis: A review of the literature

Distraction osteogenesis has been one of the most remarkable achievements in musculoskeletal surgery. It is the sheet anchor for the process of limb lengthening and internal bone transport as well as gradual deformity correction. It has revolutionised the management of limb deficiencies and bone loss. Since its conception over a 100 years ago, it has gone through several stages of evolution brought on by an increasing understanding of the underlying principles that govern the successful application of the concept as well as technological advancements in the field of limb reconstruction surgery. The result of this has been a significantly changing outlook for many musculoskeletal conditions. This review looks at the historical perspectives of this concept, noting the contributions of the pioneers in this field of surgery. Its evolution and the principles governing the various aspects of distraction osteogenesis are discussed in detail. The various methods in use today and its application in modern-day orthopaedics are also critically reviewed.

Incidence and predictors of 30-day postoperative complications following musculoskeletal tumor surgery

Objectives: Surgical intervention remains one of the best curative approaches in musculoskeletal (MSK) tumors. However, postoperative complications remain an issue, especially within the first 30-day postoperatively. Hence, the main objective of this study is to estimate the incidence and to identify the predictive factors of 30-day complications following MSK tumor surgery (MTS). Methods: This is a retrospective, descriptive study of 85 patients who had undergone MTS between 2016 and 2019 in our institution. The included patients were those who had MTS caused by a malignant tumor or giant cell tumor. Results: Twenty-eight patients (33%) had a complication during the first 30 days following surgery. The most common complication was surgical site infection in 64% (n = 18 / 28) followed by venous thromboembolism in 11% (n = 3 / 28) and then death in 7% of the patients (n = 2 / 28). Complications were distributed equally among genders. The complication rate was 36% in bone tumor surgeries (n = 22 / 61) and 21% in soft tissue tumor surgeries (n = 4 / 24). Ewing's sarcoma patients had the highest complication rate among bone tumors (36%, n = 8 / 22). Lower extremities' surgeries had the highest complication rate (35%, n = 18 / 51). Furthermore, 80% of the patients with a cardiovascular condition other than hypertension developed a complication (n = 4 / 5, P = 0.0322). Conclusion: One-third of the patients who underwent MTS developed a complication within a 30-day duration. The diagnosis of Ewing's sarcoma, surgery of lower extremities, and preexisting cardiovascular conditions was linked to a higher complication rate.

Salvage of Failed Osteoarticular Tibia Allografts with Knee Arthroplasties

Background: Limb preservation in musculoskeletal tumor surgery has largely replaced amputation. Biologic reconstructions are now performed as preferred choice; if not feasible options are “megaprostheses”, allografts or composites. Endoprosthetic reconstructions usually provide immediate function, but fail at long term. Osteochondral allografts allow for one-to-one restoration and have potential for incorporation; however degeneration of the cartilage requiring revision almost inevitably will occur. In most cases, revision is then done by endoprosthetic replacement. Aim: In our patients, resurfacing of retained allografts failed. Problems encountered are presented and solutions proposed. Case Presentation: Resurfacing over retained allografts in the 2 index cases has resulted in failures related to fractures and instability. Revision with massive constrained endoprostheses was needed. Based on the experience with these failures, primary endoprosthetic replacement anchored in vital bone in a following case resulted in stable function. Conclusion: Knee replacement for advanced degeneration of the osteochondral allograft apparently needs choosing increased femoro-tibial constraint systems and stem extensions anchored to vital host bone.

Leg Length Discrepancy to Influence on Kinematic Changes of the Pelvis and the Hip during Gait

Purpose: The purpose of this study was to investigate the effects of leg length discrepancy on kinematic changes of the pelvis and hip during gait. Methods: A total of ten healthy women with no history of neurological, musculoskeletal surgery or injuries, or pain in the lower limbs were recruited. They were assigned to two groups; the experimental group (LLD) consisting of five subjects leg length discrepancy of 10mm to 18mm and the control group (CON) consisting of five subjects leg length discrepancy of<10 mm. All participants were in ­structed to perform three walking trials for further analysis by using the Cortex 3.0 software program. Independent T-test and Mann-Whitney test were used to examine the effects of mild LLD on kinematic changes of the pelvis and hip during gait. Results: Angles of hip flexion, hip abduction, pelvic obliquity, and pelvic tilt in the experimental group were not significantly different compared to those of the control group. Conclusion: Mild leg length discrepancy induces kinematic changes in the lower limbs, including decreased hip flexion, increased hip ab­ duction, and increased pelvic obliquity in the shorter limb, and increased hip adduction and increased pelvic obliquity in the longer limb. However, those changes were not significant.

Self-Reported Head Trauma Predicts Poor Dual Task Gait in Retired National Football League Players.

ObjectiveSymptomatic head trauma associated with American‐style football (ASF) has been linked to brain pathology, along with physical and mental distress in later life. However, the longer‐term effects of such trauma on objective metrics of cognitive–motor function remain poorly understood. We hypothesized that ASF‐related symptomatic head trauma would predict worse gait performance, particularly during dual task conditions (ie, walking while performing an additional cognitive task), in later life.MethodsSixty‐six retired professional ASF players aged 29 to 75 years completed a health and wellness questionnaire. They also completed a validated smartphone‐based assessment in their own homes, during which gait was monitored while they walked normally and while they performed a verbalized serial‐subtraction cognitive task.ResultsParticipants who reported more symptomatic head trauma, defined as the total number of impacts to the head or neck followed by concussion‐related symptoms, exhibited greater dual task cost (ie, percentage increase) to stride time variability (ie, the coefficient of variation of mean stride time). Those who reported ≥1 hit followed by loss of consciousness, compared to those who did not, also exhibited greater dual task costs to this metric. Relationships between reported trauma and dual task costs were independent of age, body mass index, National Football League career duration, and history of musculoskeletal surgery. Symptomatic head trauma was not correlated with average stride times in either walking condition.InterpretationRemote, smartphone‐based assessments of dual task walking may be utilized to capture meaningful data sensitive to the long‐term impact of symptomatic head trauma in former professional ASF players and other contact sport athletes. ANN NEUROL 2020;87:75–83

Enhanced Recovery After Surgery: Concepts and Application to Total Shoulder Replacement.

Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement. To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery. Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken. Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management. Future research is now required for ERAS procedure-specific components for TSR surgery.

Sensitivity to Change of the Cerebral Palsy Profile of Health and Function Upper-Extremity (UE) Domain in Children Following Musculoskeletal Surgery

Abstract Date Presented 04/06/19 The psychometric properties examined in this research study will enable evidence-informed decision making for OTs to select robust assessment tools when working with children with cerebral palsy. This study reports on the significantly better ability of the Upper-Extremity Cerebral Palsy Profile of Health and Function Computerized Adaptive Test in detecting a change in UE function of children with cerebral palsy when compared to other measures. Primary Author and Speaker: Namrata Grampurohit Contributing Authors: Mary Slavin, Pengsheng Ni, Alan Jette, MaryJane Mulcahey

The pararectus approach\u2014a versatile option in pelvic musculoskeletal tumor surgery

BackgroundPelvic tumors are usually resected through the utilitarian pelvic incision, an extended ilioinguinal/iliofemoral approach. The pararectus approach, an intrapelvic anatomical approach with extraperitoneal access to the pelvis, has been established previously for the treatment of pelvic and acetabular fractures. However, it has not been used to address pelvic tumors. The study aimed at investigating the feasibility of this approach for pelvic tumor surgery and the possibilities of combining this approach with standard approaches to the hip joint.MethodsThirteen patients that underwent pelvic tumor resections were retrospectively reviewed. Tumor resections were performed through the pararectus (n = 10) or extended pararectus approach (n = 3). In six of those cases, the pararectus approach was combined with extrapelvic approaches including the modified Gibson (n = 4), the Kocher-Langenbeck (n = 1), and the trochanteric flip approach (n = 1). The mean follow-up was 32.6 ± 9.1 months.ResultsIn all cases, the tumor resections were carried out according to the preoperative plan. In seven of 13 cases, wide resections were performed; six of 13 cases were planned close resections. Four cases of major complications were observed (vascular injury, deep infection, iliac vein thrombosis, total hip arthroplasty dislocation). Minor complications were observed in two cases. One tumor recurred locally. At the final follow-up, 10 patients were alive, eight of those without evidence of disease.ConclusionThe study demonstrated the suitability of the pararectus approach for pelvic tumor resections. The possibility to combine the approach with standard approaches to the hip joint allowed for single-stage reconstructions of the pelvis and the hip joint without sacrificing surgical margins and function. The pararectus approach is a versatile option adding to the established approaches for musculoskeletal tumor surgery of the pelvis.