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Background Patient-reported outcomes (PROs) are clinical tools that measure patients' goals of care and assess patient-reported physical, mental, and social well-being. Despite their value in advancing patient-centered care, routine use of PROs in stroke management has lagged. As part of the pragmatic COMPASS (Comprehensive Post-Acute Stroke Services) trial, we developed COMPASS-Care Plan (CP), a clinician-facing application that captures and analyzes PROs for stroke and transient ischemic attack patients discharged home and immediately generates individualized electronic CP. In this report, we (1) present our methods for developing and implementing COMPASS-CP PROs, (2) provide examples of CP generated from COMPASS-CP, (3) describe key functional, social, and behavioral determinants of health captured by COMPASS-CP, and (4) report on clinician experience with using COMPASS-CP in routine clinical practice for care planning and engagement of stroke and transient ischemic attack patients discharged home. Methods and Results We report on the first 871 patients enrolled in 20 North Carolina hospitals randomized to the intervention arm of COMPASS between July 2016 and February 2018; these patients completed a COMPASS follow-up visit within 14 days of hospital discharge. We also report user satisfaction results from 56 clinicians who used COMPASS-CP during these visits. COMPASS-CP identified more cognitive and depression deficits than physical deficits. Within 14-day posthospitalization, less than half of patients could list the major risk factors for stroke, 36% did not recognize blood pressure as a stroke risk factor, and 19% of patients were nonadherent with prescribed medications. Three-fourths of clinicians reported that COMPASS-CP identifies important factors impacting patients' recovery that they otherwise may have missed, and two-thirds were highly satisfied with COMPASS-CP. Conclusions The COMPASS-CP application meets an immediate need to incorporate PROs into the clinical workflow to develop patient-centered CP for stroke patients and has high user satisfaction. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02588664.

For the repair of acromioclavicular separations, we describe a new method of securing the clavicle to the coracoid process using suture anchors. We have repaired 11 consecutive complete acromioclavicular separations in this manner with very good results. We find this to be an easy and reproducible method of anatomical fixation.

Anterior cruciate ligament injury rates are reported to be two to eight times higher in women than in men within the same sport. Because the menstrual cycle with its monthly hormonal fluctuations is one of the most basic differences between men and women, we investigated the association between the distribution of confirmed anterior cruciate ligament tears and menstrual cycle phase. Sixty-nine female athletes who sustained an acute anterior cruciate ligament injury were studied within 24 hours of injury at four centers. The mechanism of injury, menstrual cycle details, use of oral contraceptives, and history of previous injury were recorded. Urine samples were collected to validate menstrual cycle phase by measurement of estrogen, progesterone, and luteinizing hormone metabolites and creatinine levels at the time of the anterior cruciate ligament tear. Results from the hormone assays indicate that the women had a significantly greater than expected percentage of anterior cruciate ligament injuries during midcycle (ovulatory phase) and a less than expected percentage of those injuries during the luteal phase of the menstrual cycle. Oral contraceptive use diminished the significant association between anterior cruciate ligament tear distribution and the ovulatory phase.

Changes in legislation, availability of passive or active restraint systems, or both, together with increased public awareness for safety and the need for use of restraint, have shifted the spectrum of trauma in motor vehicle crashes from the head and torso to other regions. Lower extremity trauma in motor vehicle crashes continues to be a significant problem. The objective of this study was to investigate the biomechanics of the human foot and ankle complex under impact loading and replicate calcaneal fractures routinely seen in motor vehicle crashes. Twenty-two unembalmed cadaver lower extremity specimens were subjected to dynamic loads using a minisled pendulum device. Input and output forces and results of pathologic analysis were obtained using load cell data, radiographs obtained before and after testing, and gross dissection. The intraarticular fracture patterns produced were similar to those seen clinically and described in the literature. Maximum forces ranged from 3.6 to 11.4 kN for the fracture, and 0.5 to 7.3 kN for the nonfracture groups. Logistic regression analysis revealed a 50% probability of calcaneal fracture at 5.5 kN and a 25% probability at 4.0 kN. These studies will lead to an understanding of the tolerance of the lower extremity in sustaining calcaneal fractures under impact. Implications of the work are in the design of crash test dummies, data acquisition, and modifications in motor vehicle design and safety.

Heterotopic ossification is a well-recognized complication of spinal cord injury, closed head injury, total hip arthroplasty, burns, and other trauma and has been observed in various tissues such as muscles, tendons, ligaments, and menisci. Complications of arthroscopic acromioplasty are relatively uncommon and include hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and instrument breakage. However, little has been reported on heterotopic ossification of the shoulder, particularly after arthroscopic surgery. Recurrent rotator cuff impingement symptoms caused by small amounts of heterotopic ossification after arthroscopic acromioplasty have been described. We report a case of severe heterotopic ossification about the shoulder after arthroscopic acromioplasty.

Magnetic resonance (MR) and ultrasound (US) imaging are currently touted for assessment of rotator cuff disease. Optimum clinical imaging techniques include use of (a) a 1.5-T MR imaging unit with small planar coils, proton-density-weighted and T2-weighted fast spin-echo sequences, and 10-12-cm fields of view (yielding 400-470 x 500-625-microm in-plane spatial resolution) and (b) a state-of-the-art commercial US unit with insonation frequencies of 9-13 MHz (yielding 200-400-microm axial and lateral resolution). Proper diagnosis requires familiarity with normal anatomic characteristics and imaging pitfalls. Care must be taken to avoid sonographic tendon anisotropy and MR imaging magic angle effects, which can be misinterpreted as rotator cuff tear. At MR imaging, a complete cuff tear typically appears as either a hyperintense defect or a tendinous avulsion that extends from the bursal to the articular side of the cuff; a partial cuff tear typically appears as a focal hyperintense region that contacts only one surface of the cuff. Complete and partial tears manifest with a wide spectrum of findings at US. MR imaging and US are effective for evaluating rotator cuff injuries, with high reported accuracies for detection of complete tears but more disparate results for detection of partial tears.

A case of fracture of the proximal tibia at the site of graft harvest for an anterior cruciate ligament reconstruction is reported. This fracture, at the distal edge of the harvest site on the tibial tubercle, was the result of stress concentration at this location. The patient's tibia fracture was treated with a long leg cast and healed without complication. Fracture of the patella at the graft harvest site has been reported as a complication of anterior cruciate ligament reconstruction. This is the first report of a fracture of the tibia at the site of graft harvest.

A survey of 100 professionally supervised bungee jumpers who used an ankle harness in a single leap from a platform reveals that 42 jumpers had a total of 59 minor medical complaints or symptoms after their jumps. Immediate symptoms included musculoskeletal pain in the ankle, neck, back, and chest, neurologic complaints such as dizziness and headache, and blurred vision. Dizziness was the most common symptom, and neurologic complaints outnumbered musculoskeletal symptoms. All complaints resolved within 1 week of the jump except for lacerations sustained by one person who tried to grab the platform as he was jumping.

Hyaline cartilage plays an essential role in the maintenance of normal synovial joint function by reducing friction and distributing loads. Histologic analysis of hyaline cartilage reveals zonal variation in cellular morphology, proteoglycan concentration, and collagen fiber size and orientation. High-resolution magnetic resonance (MR) imaging reveals an analogous laminar anatomy that is often visible on clinical images obtained with proper attention to technique. In vitro and in vivo pulse sequences show three distinct laminae: a hypointense superficial lamina, a hyperintense intermediate lamina, and a heterogeneous deep lamina that consists of alternating hyperintense and hypointense bands perpendicular to the subchondral bone. Imaging pitfalls include magic angle effects, truncation artifact, partial volume effect, regional anatomic variation, chemical shift, and magnetic susceptibility effects. Pathologic conditions that affect articular cartilage include chondromalacia patellae, osteoarthritis, and localized traumatic lesions. Although detection of early cartilage disease remains elusive, MR imaging can demonstrate intermediate and advanced lesions.

This article discusses the normal, clinically relevant MR imaging anatomy of the elbow. A compartmental approach is utilized to help simplify this anatomically complex region. Imaging techniques, common anatomic variants, and imaging pitfalls are also briefly discussed.

Knee injuries are an all too common occurrence in athletes. Prompt diagnosis, aggressive treatment and rehabilitation is necessary to minimize time away from athletic activity and to maximize function at a competitive level. This article reviews the latest trends in diagnosing and treating common knee injuries in athletes, including ligamentous and meniscal injuries.

We evaluated 38 subjects with isolated posterior cruciate ligament-deficient knees at a mean of 13.4 years (range, 5 to 38) after injury to study the occurrence of symptoms, disabilities, and articular degeneration. Each subject completed a standardized questionnaire, physical examination, and had radiographs taken of both knees. Eight (21%) patients had surgeries for meniscal injuries after their posterior cruciate ligament injuries. The mean questionnaire score for function (50-point maximum) was 34.4 +/- 6.5 (SD) for the patients who did have meniscal surgeries versus 40.0 +/- 8.7 for the 30 patients who did not (P = 0.05). Among the 30 patients with isolated posterior cruciate ligament-deficient knees with normal menisci, 24 (81%) had at least occasional pain and 17 (56%) had at least occasional swelling. As time from injury increased, increased articular degeneration on radiographs was seen (P = 0.037). Our study suggests that the prognosis for the isolated posterior cruciate ligament-deficient knee varies. Some patients experience significant symptoms and articular deterioration, while others are essentially asymptomatic and maintain their usual knee function.

Acute repair of disruptions of the knee extensor mechanism is indicated to reestablish extensor continuity and allow for early motion. This study reviews the results of acute primary repair of patellar tendon ruptures augmented by a nonabsorbable polyester tape (Mersilene; Ethicon, Inc.) followed by immediate mobilization. Twenty-four patients with disruptions of their patellar tendons were treated using the described technique. The ruptured tendon was initially approximated using an end-to-end suture repair with no. 5 Ticron suture in a whipstitch manner. An O Vicryl suture was used to approximate the free tendon edges. A 5-mm Mersilene tape was then used in a cerclage manner to augment and protect the repair. Postsurgery, passive range of motion (ROM) was begun immediately in the knees with isolated injury or in those patients whose concomitant injuries would allow for early motion. Using clinical and radiographic criteria, follow-up evaluations of 19 patients were performed at an average of 22.4 months. In patients with isolated injuries, active ROM was from 0 degrees extension to 132 degrees flexion (contralateral knee 0-135 degrees). Two patients had prominent knots: in one, the knots were painful and were removed surgically. Six patients developed patellofemoral chondrosis. Five patients had the Mersilene tape tied with the knee in full extension, and all developed patellofemoral pain. The other repairs were done with the knee flexed to 90 degrees before tying; one patient in this group developed patellofemoral symptoms. All patients with isolated injuries have returned to employment. There were no reruptures or infections.(ABSTRACT TRUNCATED AT 250 WORDS)

The development of small-diameter interlocking intramedullary nails that can be inserted without reaming provides a fixation option for open tibial-shaft fractures. Nonreamed intramedullary nailing of these injuries facilitates soft-tissue management without an increase in infection or nonunion rates relative to external fixation. Reaming is not required, which means less injury to the tibial endosteal blood supply. Proximal and distal interlocking maintains better bone alignment than is possible with semirigid or noninterlocking intramedullary nails. The technique of using these devices with static interlocking is described, as are some suggested techniques for avoiding complications.

Surgery for ligamentous injuries of the knee continues to be one of the most common procedures performed by orthopaedists. Anterior cruciate ligament (ACL) reconstructions are addressed specifically. Basic science and laboratory research have had a dramatic effect on our understanding of the underlying pathology of the injury, and this information has been used in the development of the clinical procedures most commonly used today. The classic stages of ligament healing are contrasted with the limited potential of the ACL. Surgical options using autografts, allografts, augmentation devices, and primary repair are discussed. Present research is examined for possible future directions in the treatment of ligament injuries.