An effective approach to diagnosis and surgical repair of refractory medial epicondylitis

BACKGROUND: Medial epicondylitis of the elbow, an overuse injury characterized by angiofibroblastic tendinosis of the common flexor-pronator origin, generally responds to nonoperative treatment. Refractory cases may require surgical debridement and repair. This study discusses physical examination and imaging findings and an updated surgical technique used in patients with recalcitrant medial epicondylitis. METHODS: The surgical records of 60 patients with refractory medial epicondylitis were reviewed. All received a course of nonoperative care. After 3 to 6 months of failed therapy, imaging was obtained, and surgical intervention was offered when indicated. This open procedure consisted of thorough debridement with repair and restoration of the flexor-pronator origin, using a suture anchor. Accelerated rehabilitation, emphasizing early motion, was used. One-year follow-ups were obtained. The Mayo Elbow Performance Score was calculated preoperatively and postoperatively. RESULTS: Pronation weakness at 90 degrees was a critical physical examination finding. Preoperative magnetic resonance images demonstrated pathologic partial tearing at the flexor-pronator origin. Ulnar neuritis was addressed in 20%. Postoperatively, the Mayo Elbow Performance Score significantly increased (preoperatively, 58 +/- 7.7; postoperatively, 88 +/- 7.8; P = 5.6E-34), and pain significantly decreased (preoperatively, 2.2 +/- 0.3; postoperatively, 0.6 +/- 0.5; P = 3.8E-33). There was one retear in a patient noncompliant with the postoperative protocol. He responded positively to reoperation. CONCLUSION: Identification of weakness on pronation is a reliable physical examination finding for determining clinically significant pathologic changes in patients with medial epicondylitis. Debridement with restoration of the flexor-pronator origin is an efficacious procedure. In this large series of patients, surgical repair with aggressive rehabilitation was shown to be reliable and safe in restoring function and relieving pain in recalcitrant cases of medial epicondylitis

A Common Pain in Pregnancy with an Uncommon Cause

Case Diagnosis: We present a case of a patient with hip pain during pregnancy determined to be pigmented villonodular synovitis (PVNS). Case Description: A 41-year-old woman presented with 9-months of persistent atraumatic left hip pain localized to the groin that had started in her second trimester of pregnancy. Five months after delivery at presentation to clinic, her symptoms had progressively worsened to require a cane for ambulation. On exam, hip range of motion was limited: flexion to 90o, external rotation to 20o, and internal rotation to 10o. She had groin pain with internal and external rotation. She was neurovascularly intact without lymphadenopathy. Radiographs showed significant erosion of the left femoral head and acetabulum with mild protrusio. Apple core erosions were visualized at the femoral neck. MRI showed extensive bone edema on both sides of the joint, with erosion of the femoral head and acetabulum. There was joint effusion, synovial hypertrophy, and excessive synovial tissue. Differential diagnoses included PVNS, avascular necrosis, rapidly progressive osteoarthritis, inflammatory arthritis, septic arthritis, insufficiency fractures, synovial chondromatosis, and transient osteoporosis of the hip. A needle biopsy confirmed the diagnosis of PVNS. She was treated with synovectomy and total hip arthroplasty, and has remained pain free and without evidence of disease for the last 5 years. Discussions: PVNS is a disorder characterized by synovial proliferation. There are only two previous case reports of patients who were diagnosed with PVNS during pregnancy, both of whom had monoarticular involvement of the knee. Conclusions: Synovectomy is the mainstay of surgical treatment of PVNS. Although, in patients with extensive articular involvement, synovectomy and arthroplasty may be required. The current understanding is that cytokines have a trophic influence leading to growth of the tumor. Further studies are needed to establish a definitive connection between PVNS and pregnancy

High-Grade Partial and Retracted (less than 2 cm) Proximal Hamstring Ruptures: Nonsurgical Treatment Revisited

BACKGROUND: High-grade partial proximal hamstring tears and complete tears with retraction less than 2 cm are a subset of proximal hamstring injuries where, historically, treatment has been nonoperative. It is unknown how nonoperative treatment compares with operative treatment. HYPOTHESIS: The clinical and functional outcomes of nonoperative and operative treatment of partial/complete proximal hamstring tears were compared. We hypothesize that operative treatment of these tears leads to better clinical and functional results. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a high-grade partial or complete proximal hamstring rupture with retraction less than 2 cm treated either operatively or nonoperatively from 2007 to 2015. All patients had an initial period of nonoperative treatment. Surgery was offered if patients had continued pain and/or limited function refractory to nonoperative treatment with physical therapy. Outcome measures were each patient\u27s strength perception, ability to return to activity, Lower Extremity Functional Scale (LEFS) score, Short Form-12 (SF-12) physical and mental component outcome scores, distance traversed by a single-leg hop, and Biodex hamstring strength testing. RESULTS: A total of 25 patients were enrolled in the study. The 15 patients who were treated nonoperatively sustained injuries at a mean age of 55.73 +/- 14.83 years and were evaluated 35.47 +/- 30.35 months after injury. The 10 patients who elected to have surgery sustained injuries at 50.40 +/- 6.31 years of age (P = .23) and were evaluated 30.11 +/- 19.43 months after surgery. LEFS scores were significantly greater for the operative group compared with the nonoperative group (77/80 vs 64.3/80; P = .01). SF-12 physical component scores for the operative group were also significantly greater (P = .03). Objectively, operative and nonoperative treatment modalities showed no significant difference in terms of single-leg hop distance compared with each patient\u27s noninjured leg (P = .26) and torque deficit at isokinetic speeds of 60 and 180 deg/s (P = .46 and .70, respectively). CONCLUSION: Patients who undergo operative and nonoperative treatment of high-grade partial and/or complete proximal hamstring tears with \u3c 2 cm retraction demonstrate good clinical and functional outcomes. In our series, 40% of patients treated nonoperatively with physical therapy went on to have surgery. For those patients with persistent pain and/or loss of function despite conservative treatment, surgical repair is a viable treatment option that is met with good results

Defining Success in Perioperative Care Pathways for Hip Fracture Patients

PURPOSE: Hip fracture is an increasingly common cause of morbidity and mortality in the aging U.S. population. Multiple studies have shown that patients who undergo surgical repair within 48 hours of the initial injury have better outcomes. The use of a perioperative care pathway (PCP) for hip fracture patients combines prompt surgical repair with dedicated medical services tailored to patients’ specific comorbidities. METHODS: Our level 1 trauma center implemented a PCP in October 2015, requiring only anesthesia (not hospital medicine) clearance prior to surgery. We identified all hip fracture patients who presented to our level 1 hospital for one year prior to, and one year following, implementation of the pathway. We then performed a comprehensive clinical chart review to collect demographic data, past medical history, and perioperative factors. We performed statistical analyses to evaluate whether using the pathway improved patient outcomes. RESULTS: Preliminary analyses were performed on a series of patients pre- (n=96) and post-pathway (n=100). We summarized patient characteristics and reported these according to participation in the pathway. Distributions were evaluated for normality and to evaluate for outliers. Proportions were reported for categorical variables and assessed for differences using the chi-square test, and continuous data were summarized by means and standard deviations and assessed for differences using the t-test. We found that patients in the pathway worked with physical therapy (PT) an average of 16.8 hours earlier (p=0.013). CONCLUSION: The use of PCPs represents an emerging approach to hip fracture management, but a widely generalizable PCP has yet to be definitively described. Our patients’ decrease in time to PT may be attributable to better postoperative optimization by hospitalist medicine. We anticipate that multivariate analyses will reveal additional gains. Ultimately, our experience may yield implications for the safe, cost- and time-effective surgical care of hip fracture patients nationally

Predictors of Cardiac Mortality in the CCU: A Retrospective Study in a Tertiary Center

Background: Although prior studies have linked troponin I (TnI) elevation, serum sodium (Na) fluctuation, and reduced ejection fraction (EF) with an increased mortality in the medical/surgical critical care units, this has not been validated in the CCU. We aim to identify clinical and laboratory factors to predict cardiac related length of survival (LOS) in the CCU. Methods: We retrospectively analyzed 134 consecutive patients who were admitted to the CCU from December 2012 to March 2015, and who died during that admission. We used student T-test, correlation matrices, and Framingham risk factors adjusted multivariable logistic regression models to examine the role of TnI, serum Na, EF and other clinical covariates on LOS in cardiac death (CD) and non- cardiac death (NCD) group. Results: The average age of the study population was 70.0 ±14.3 (39.0% women). The prevalence of CD and NCD were 63% and 59%. LOS was statistically shorter in the CD vs. NCD group (5.3 days vs. 8.2 days, p=0.012). LOS negatively correlated with initial TnI (p= 0.05). LOS was not statistically affected by EF or Na level. Our regression models identified BMI and diabetes mellitus (DM) as strong predictors of CD (p= 0.04 and p=0.01). Conclusion: Our results validate prior studies showing that TnI, BMI, and DM are predictors of cardiac related mortality in the CCU. Patients with a cardiac etiology had a higher mortality rate and a shorter LOS. Future studies are needed to develop a scoring system specific for predicting mortality in the CCU

Defining Success in Perioperative Care Pathways for Hip Fracture Patients

PURPOSE: Hip fracture is an increasingly common cause of morbidity and mortality in the aging U.S. population. Multiple studies have shown that patients who undergo surgical repair within 48 hours of the initial injury have better outcomes. The use of a perioperative care pathway (PCP) for hip fracture patients combines prompt surgical repair with dedicated medical services tailored to patients’ specific comorbidities. METHODS: Our level 1 trauma center implemented a PCP in October 2015, requiring only anesthesia (not hospital medicine) clearance prior to surgery. We identified all hip fracture patients who presented to our level 1 hospital for one year prior to, and one year following, implementation of the pathway. We then performed a comprehensive clinical chart review to collect demographic data, past medical history, and perioperative factors. We performed statistical analyses to evaluate whether using the pathway improved patient outcomes. RESULTS: Preliminary analyses were performed on a series of patients pre- (n=96) and post-pathway (n=100). We summarized patient characteristics and reported these according to participation in the pathway. Distributions were evaluated for normality and to evaluate for outliers. Proportions were reported for categorical variables and assessed for differences using the chi-square test, and continuous data were summarized by means and standard deviations and assessed for differences using the t-test. We found that patients in the pathway worked with physical therapy (PT) an average of 16.8 hours earlier (p=0.013). CONCLUSION: The use of PCPs represents an emerging approach to hip fracture management, but a widely generalizable PCP has yet to be definitively described. Our patients’ decrease in time to PT may be attributable to better postoperative optimization by hospitalist medicine. We anticipate that multivariate analyses will reveal additional gains. Ultimately, our experience may yield implications for the safe, cost- and time-effective surgical care of hip fracture patients nationally

Estimating global injuries morbidity and mortality : methods and data used in the Global Burden of Disease 2017 study

Background: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future

Estimating global injuries morbidity and mortality : methods and data used in the Global Burden of Disease 2017 study

Background While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.Peer reviewe

Global injury morbidity and mortality from 1990 to 2017 : results from the Global Burden of Disease Study 2017

Correction:Background Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. Methods We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). Findings In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). Interpretation Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.Peer reviewe

Lateral Extra-Articular Tenodesis via an All-Suture Anchor

Background: In young patients, anterior cruciate ligament (ACL) reconstruction often results in graft failure. This may be due, in part, to concomitant injury to anterolateral complex (ALC) of the knee leading to rotatory laxity. The modified Lemaire lateral extra-articular tenodesis (LET) technique is intended to address the anterolateral rotatory instability due to injury to the ALC and to protect the ACL graft and meniscus. Indications: The International Anterolateral Complex Consensus Group Meeting identified 4 appropriate indications for the modified Lemaire LET procedure: revision ACL, high-grade pivot shift, generalized ligamentous laxity/genu recurvatum, and young patients returning to pivoting activities. Technique Description: The technique consists of harvesting an 8-cm long by 1-cm wide graft from the iliotibial band. The graft is released proximally and remains attached distally to Gerdy’s tubercle. The graft is then passed deep to the lateral collateral ligament (LCL) from distal to proximal. The graft is then affixed to a point proximal and posterior to the lateral femoral epicondyle with an all-suture button. The graft is then tensioned with knee at 30° of flexion and neutral rotation, and then secured in place. Results: With the modified Lemaire LET, there was previously concern for overconstraint and lateral compartment degeneration. However, recent studies have shown that there is no increased risk for these complications with the LET procedure. The STABILITY trial found that the addition of LET to ACL reconstruction significantly reduces re-rupture and residual laxity when compared with ACL reconstruction alone. Moreover, the addition of LET to ACL reconstruction can restore native knee kinematics. Conclusion: The addition of the modified Lemaire LET technique to traditional ACL reconstruction is a safe and effective adjunct that reduces the occurrence of graft rupture, addresses residual rotational laxity, and can restore native knee kinematics in appropriately indicated patient populations. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.</p