Search

Background: Sleep disturbance is a significant symptom associated with both rotator cuff tears and arthroscopic rotator cuff repair. Melatonin has been shown to be safe and effective in managing multiple sleep disorders, including secondary sleep disorders, with relatively minor adverse effects and lack of addictive potential. Purpose: To investigate the effects of oral melatonin on postoperative sleep quality after arthroscopic rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective randomized clinical trial evaluating patients undergoing arthroscopic rotator cuff repair. Exclusion criteria included history of alcohol abuse, current antidepressant or sedative use, revision rotator cuff repair, severe glenohumeral arthritis, and concurrent adhesive capsulitis. Patients were randomly assigned in a 1:1 ratio to 1 of 2 groups: 5-mg dose of melatonin 1 hour before bedtime or standard sleep hygiene (≥6 hours per night, avoiding caffeine and naps in the evening). Patients in the melatonin group took their assigned melatonin dose for 6 weeks beginning the day of surgery. Patient-reported outcome assessments, including the Pittsburgh Sleep Quality Index (PSQI), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the Single Assessment Numeric Evaluation (SANE), and pain medication charts were collected preoperatively as well as at 2 weeks, 6 weeks, 3 months, 4 months, and 6 months postoperatively. Numeric variables were analyzed using paired and unpaired t tests, with significance set at P <.05. Results: Eighty patients were included for final analysis (40 in the control group, 40 in the melatonin group). Patient characteristics such as age, sex, race, body mass index, and laterality did not differ significantly (P ≥.05). Preoperative ASES, SANE, and PSQI scores did not differ between groups (P ≥.055). PSQI scores were significantly lower (better quality sleep) in the melatonin group at the 6-week postoperative period (P =.036). There was a positive correlation between how patients rated the intensity of their pain and the PSQI at the 6-week postoperative period (0.566). The PSQI question regarding sleep quality was found to be significantly lower in the melatonin group at the 3-month, 4-month, and 6-month postoperative periods (P =.015, P =.041, and P ≤.05, respectively). SANE scores were significantly lower in the melatonin group (P =.011) at 6 weeks and then higher in the melatonin group (P =.017) at 6 months. ASES scores were significantly higher in the melatonin group at 4 and 6 months (P =.022 and P =.020, respectively). Lastly, patients who were randomized into the melatonin group were found to use significantly less narcotic medication at the 4-month postoperative period (P =.046). Conclusion: Melatonin use after arthroscopic rotator cuff repair led to improved sleep quality (PSQI) in the early postoperative period as well as improved functional outcomes (ASES and SANE scores) and decreased narcotic use in the later postoperative period. Patients with significant sleep disturbances associated with rotator cuff repairs may benefit from the use of melatonin. Registration: NCT04278677 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1–e12.] [ABSTRACT FROM AUTHOR]

Background: Although stool softeners and laxatives are commonly prescribed for postoperative constipation, it is unclear if they are effective during the postoperative period. The data gained from this study will be beneficial for advanced practitioners when examining for postoperative constipation concerns. Purpose: This study aimed to investigate the efficacy of docusate sodium and senna glycoside in the prevention and treatment of constipation following rotator cuff repair (RCR). Methods: Patients (n = 107) were randomized to receive docusate sodium, senna glycoside, or nothing (control) in addition to a standardized postoperative protocol. Patients maintained a daily bowel-movement log for postoperative days 0–10. Constipation symptoms and quality of life were assessed preoperatively and at 2 and 6 weeks postoperatively using the Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. Results: Sixty-seven percent of patients experienced constipation. There was no difference in the prevalence of constipation in the docusate, senna, and control groups (71.4%, 66.7%, and 64.3%, respectively; p =.88). Neither PAC-SYM nor PAC-QOL scores significantly differed between the 3 groups at any time point during 6-week follow-up (p >.05). Implications for practice: The majority (67%) of patients experience postoperative constipation following RCR. Although docustate sodium and senna glycoside are common first-line agents for the treatment of constipation, they are ineffective during the postoperative period. Providers need to explore other treatment modalities for postoperative constipation pain. [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcome measures (PROMs) are commonly used to monitor functional outcomes for clinical and research purposes; unfortunately, many PROMs include redundant, burdensome questions for patients. The use of predictive models to implement computerized adaptive testing (CAT) offer a potential solution to reduce question burden in outcomes research. Purpose: To validate the usage of an appropriate CAT system to improve the efficiency of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Validation was based on electronically collected patient responses from 2 separate orthopaedic sports medicine clinics. Diagnoses included, but were not limited to, meniscal lesions, ligamentous injuries, and chondral defects. The CAT system was previously developed through analysis of an electronic knee PROM database that did not contain any of these cases. Results: A total of 2173 patient responses (1229 patients) were collected. The CAT model was able to reduce the question burden by a mean of 9.33 questions (45.1%). Higher CAT-predicted scores correlated strongly with higher actual scores (r = 0.99; intraclass correlation coefficient = 0.99). The mean difference between the CAT-predicted score and the actual PROM score was 0.48 of a point on a scale of 0 to 100. Conclusion: The use of CAT systems, in conjunction with electronic PROMs, can accurately predict outcome scores for IKDC PROMs, while dramatically decreasing the number of questionnaire items needed for any given patient. By decreasing questionnaire burden, clinicians and researchers can potentially increase patient participation and follow-up in both clinical assessments and research trials. [ABSTRACT FROM AUTHOR]

Background: Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair.Questions/purposes: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function?Methods: During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures.Results: There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups.Conclusion: The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage.Level Of Evidence: Level II, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Ulnar collateral ligament (UCL) injuries can be debilitating in overhead athletes. Accurate diagnosis is important; however, several imaging modalities are available for the assessment of UCL injuries. Purpose: To provide a comprehensive review of published literature regarding the diagnostic capabilities of different imaging modalities for UCL tears. Methods: PubMed, Medline, and Embase were queried for peer-reviewed literature published between January 1947 and June 4, 2019, pertaining to diagnostic imaging of UCL tears. Articles assessing static and stress radiography, ultrasound, magnetic resonance imaging (MRI), MRI with arthrography (MRA), and computed tomography arthrography of the UCL were included. Studies were excluded if imaging results were not compared with intraoperative diagnosis, as intraoperative findings are generally considered the gold standard for diagnostic comparison. The articles were assessed per the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines and reviewed with the Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS-2) assessment. Results: The literature search yielded 2478 articles, of which 15 were included in this review. Potential bias was noted in each QUADAS-2 subsection. Multiple studies demonstrate an association between UCL tears and osseous abnormalities identified on static radiographs; however, the use of static or nonstressed radiographs is not recommended for specific evaluation of UCL injuries. Conventional ultrasound was 81% sensitive and 91% specific, as compared with 96% and 81% for stress ultrasound, respectively. The sensitivity and specificity of MRI ranged from 57% to 100% and 89% to 100%. The sensitivity of computed tomography arthrography ranged from 63% to 86%. The sensitivity and specificity of MRA ranged from 81% to 100% and 91% to 100%. Conclusion: Of the currently available imaging modalities, MRA provides the best combination of sensitivity and specificity of the evaluation of the UCL. Further research comparing ultrasound with MRA is needed. [ABSTRACT FROM AUTHOR]

Commercially relevant catalysts are identified for the copolymerization of ethylene and styrene and these catalysts have maintained very high copolymer efficiencies at relatively high reactor temperatures without sacrificing styrene comonomer reactivity. Excellent polymerization characteristics achieved with a 2,2'-biphenyl fragment attached to the Cp ring has made this catalyst a candidate for commercial production of ethylene-styrene resins in a solution process.

A highly efficient, stereoselective synthesis of racemic, divalent ansa-ziroconocene catalysts using the Zr(II) diene synthon is developed. The configurational interplay between the diene and ansa-bis ligands accounts for the high stereoselectivity in the synthesis is introduced.

Background: Currently, there are limited nonoperative treatment options available for knee osteoarthritis (OA). Cell-based therapies have emerged as promising treatments for knee OA. Autologous stromal vascular fraction (SVF) has been identified as an efficient medium for intra-articular administration of progenitor cells and mesenchymal stem cells derived from adipose tissue. Hypothesis: Patients receiving intra-articular SVF would show significantly greater improvement than patients receiving placebo injections, and this improvement would be dose dependent. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a multisite prospective double-blinded randomized placebo-controlled clinical trial. Adult patients with symptomatic knee OA were eligible. Thirty-nine patients were randomized to high-dose SVF, low-dose SVF, or placebo (1:1:1). SVF was obtained via liposuction, processed to create the cellular implant, and injected during the same clinical visit. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and magnetic resonance images were obtained preoperatively and at 6 and 12 months after injection. The Wilcoxon rank sum nonparametric test was utilized to assess statistical significance, and the Hodges-Lehmann location shift was used to assess superiority. Results: The median percentage change in WOMAC score at 6 months after injection for the high-dose, low-dose, and placebo groups was 83.9%, 51.5%, and 25.0%, respectively. The high- and low-dose groups had statistically significant changes in WOMAC scores when compared with the placebo group (high dose, P =.04; low dose, P =.02). The improvements were dose dependent. The median percentage change in WOMAC score from baseline to 1 year after injection for the high-dose, low-dose, and placebo groups was 89.5%, 68.2%, and 0%, respectively. The high- and low-dose groups displayed a greater percentage change at 12 months when compared with the placebo group (high dose, P =.006; low dose, P =.009). Magnetic resonance image review revealed no changes in cartilage thickness after treatment. No serious adverse events were reported. Conclusion: Intra-articular SVF injections can significantly decrease knee OA symptoms and pain for at least 12 months. The efficacy and safety demonstrated in this placebo-controlled trial support its implementation as a treatment option for symptomatic knee OA. Registration: NCT02726945 (ClinicalTrials.gov identifier) [ABSTRACT FROM AUTHOR]

Factors motivating patients to undergo rotator cuff repair (RCR) have not been thoroughly investigated. The purpose of this study was to investigate patient and surgeon decision-making factors for RCR, as well as the use of conservative treatment, and their relationship with shoulder function. A total of 144 adult patients undergoing arthroscopic RCR completed a 13-item questionnaire assessing the importance of surgical decision-making factors. Preoperative conservative treatments were also recorded. Surgeons also completed a similar 5-item questionnaire assessing surgeon decision-making factors preoperatively. American Shoulder and Elbow Surgeons (ASES) functional outcome scores were collected preoperatively through 1 year postoperatively. The following factors received the greatest frequency of high-importance scores: limited shoulder function (80.6%), surgeon recommendation (79.2%), and daily chronic pain (76.4%). Among surgeons, patient activity (83.3%) and risk of tear progression (73.6%) received the greatest frequency of high-importance scores. Patients had worse preoperative ASES scores when they reported the following factors as highly important: limited shoulder function, daily chronic pain, concern for tear enlargement, inability to sleep, and failure of conservative management (P<.004). Female gender, corticosteroid injection, and opioid use were also associated with worse preoperative shoulder function (P<.01). Workers' compensation claims, preoperative physical therapy, and multiple corticosteroid injections were associated with worse postoperative ASES scores (P<.05). Limitations in shoulder function and surgeon recommendation were the most common factors influencing patients to undergo RCR. Multiple factors were associated with worse shoulder function. Surgeons should be cognizant of patient decision-making factors and their relationship with shoulder function. [Orthopedics. 2020; 43(2): 85-90.]. [ABSTRACT FROM AUTHOR]

Objective: To compare dental arch relationship, craniofacial form, and nasolabial aesthetic outcomes among cleft centers using distinct methods of presurgical infant orthopedics (PSIO). Design: Retrospective cohort study. Setting: Four cleft centers in North America. Patients: One hundred ninety-one children with repaired complete unilateral cleft lip and palate (CUCLP). Main Outcome Measures: Dental arch relationship was assessed using the GOSLON Yardstick. Craniofacial form was assessed by 12 cephalometric measurements. Nasolabial aesthetics were assessed using the Asher-McDade system. Assessments were performed between 6 and 12 years of age. Results: The center that used no PSIO achieved the most favorable dental arch relationship and maxillomandibular relationship, with a median GOSLON score of 2.3 (P < .01) and an ANB angle of 5.1° (P < .05). The proportion of children assigned a GOSLON score of 4 or 5, predictive of the need for orthognathic surgery in adolescence, was 16% at the center that used no PSIO and no secondary surgery, compared to 76% at the centers that used the Latham appliance and early secondary lip and nose surgery (P < .01). The center that used no PSIO and no secondary surgery achieved significantly less favorable nasolabial aesthetic outcomes than the centers using Latham appliance or nasoalveolar molding (NAM) (P < .01). Conclusions: Effects of active PSIO are multifaceted and intertwined with use of revision surgery. In our study, centers using either the Latham appliance combined with early revision surgery or the NAM appliance without revision surgery achieved better nasolabial aesthetic outcomes but worse maxillary growth, compared to a center using no PSIO and secondary surgery. [ABSTRACT FROM AUTHOR]

A 13-year-old female presented with traumatized maxillary central incisors that had been endodontically treated. Five years later, at a different dental office, she had the clinical crowns removed, leaving subgingival margins. From the patient's history and our initial assessment, it seemed as if the teeth had been fractured and luxated but not avulsed. Endodontic posts with spot-welded orthodontic brackets were temporarily cemented to enable orthodontic extrusion. Once access to restorable margins was obtained, the temporary posts were removed and conventional fiber posts with interim composite crowns were placed. The restorations were still satisfactory at the one-year follow-up, with a healthy periodontium, intact apical seal, and no signs of external resorption observed. Combined specialty treatment provided an esthetically acceptable outcome in a difficult restorative situation for a growing child. The purpose of this case report is to discuss an interim treatment until the child reaches dentofacial maturity, when definitive restorations can be provided. [ABSTRACT FROM AUTHOR]

Objective: To compare dental arch relationship, craniofacial form, and nasolabial aesthetic outcomes among cleft centers using distinct methods of presurgical infant orthopedics (PSIO)., Design: Retrospective cohort study., Setting: Four cleft centers in North America., Patients: One hundred ninety-one children with repaired complete unilateral cleft lip and palate (CUCLP)., Main Outcome Measures: Dental arch relationship was assessed using the GOSLON Yardstick. Craniofacial form was assessed by 12 cephalometric measurements. Nasolabial aesthetics were assessed using the Asher-McDade system. Assessments were performed between 6 and 12 years of age., Results: The center that used no PSIO achieved the most favorable dental arch relationship and maxillomandibular relationship, with a median GOSLON score of 2.3 ( P < .01) and an ANB angle of 5.1° ( P < .05). The proportion of children assigned a GOSLON score of 4 or 5, predictive of the need for orthognathic surgery in adolescence, was 16% at the center that used no PSIO and no secondary surgery, compared to 76% at the centers that used the Latham appliance and early secondary lip and nose surgery ( P < .01). The center that used no PSIO and no secondary surgery achieved significantly less favorable nasolabial aesthetic outcomes than the centers using Latham appliance or nasoalveolar molding (NAM) ( P < .01)., Conclusions: Effects of active PSIO are multifaceted and intertwined with use of revision surgery. In our study, centers using either the Latham appliance combined with early revision surgery or the NAM appliance without revision surgery achieved better nasolabial aesthetic outcomes but worse maxillary growth, compared to a center using no PSIO and secondary surgery.

A 13-year-old female presented with traumatized maxillary central incisors that had been endodontically treated. Five years later, at a different dental office, she had the clinical crowns removed, leaving subgingival margins. From the patient's history and our initial assessment, it seemed as if the teeth had been fractured and luxated but not avulsed. Endodontic posts with spot-welded orthodontic brackets were temporarily cemented to enable orthodontic extrusion. Once access to restorable margins was obtained, the temporary posts were removed and conventional fiber posts with interim composite crowns were placed. The restorations were still satisfactory at the one-year follow-up, with a healthy periodontium, intact apical seal, and no signs of external re- sorption observed. Combined specialty treatment provided an esthetically acceptable outcome in a difficult restorative situation for a growing child. The purpose of this case report is to discuss an interim treatment until the child reaches dentofacial maturity, when definitive restorations can be provided.

Objective: To assess the prevalence of complete and incomplete transpositions of teeth in subjects with repaired cleft lip and/or palate., Design: Retrospective review. Panoramic radiographs from 364 subjects with repaired cleft lip and/or palate and with or without syndromes were compared with 364 panoramic radiographs from noncleft controls. The percentages of completely or incompletely transposed teeth, missing teeth, and pegged teeth were recorded for each subject and control., Setting: Primary care dental clinic in a university affiliated, not-for-profit hospital., Main Outcome Measures: Presence of complete and incomplete transposed teeth, missing teeth, and pegged teeth detected on subjects' panoramic radiographs., Results: This study revealed greater prevalence of tooth transposition in subjects with cleft lip and/or palate (52/364 = 14.3%) as compared with noncleft controls (1/364 = 0.3%; P < .001)., Conclusions: There was a higher prevalence of tooth transpositions in subjects with repaired cleft lip and/or palate with/or without syndromes than in noncleft controls. There was a weak association between transpositions and missing teeth (P = .12) and between transpositions and pegged teeth (.23).