Bart Lubberts

A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age.

UNLABELLED Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation. METHODS We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older). RESULTS Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation. DISCUSSION AND CONCLUSION The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.

What is the effect of venous thromboembolism and related complications on patient reported health-related quality of life? A meta-analysis.

UNLABELLED We conducted a meta-analysis of the literature to 1) assess the health-related quality of life for patients with a minimum follow-up of one year after an episode of pulmonary embolism (PE) or deep-vein thrombosis (DVT), and 2) to assess the HRQOL for patients who develop chronic thromboembolic pulmonary hypertension (CTEPH) and post thrombotic syndrome (PTS). PubMed, EMBASE, and the Cochrane Library were searched from inception to March 30, 2016. Data were pooled using random-effects meta-analysis, and heterogeneity was assessed with I² and Tau² tests. SF-12, SF-36, and VEINES-QOL were evaluated with pooled standardised mean difference (SMD) and 95 % confidence intervals (CI). Fourteen studies were included for meta-analysis. In patients who sustain a PE, physical health becomes impaired (p<0.001, 2 studies) but mental health appears to remain similar to population norms (p=0.069, 2 studies) after at least one year. Patients who develop CTEPH report worse physical (p<0.001, 1 study) and mental health (p=0.009, 1 study). In patients who suffer from a DVT, physical health (p=0.19, 9 studies), mental health (p=0.67, 9 studies), and disease specific quality of life (p=0.61, 8 studies) remain similar to population norms after at least one year. Patients who develop PTS, however, report worse physical health (p<0.001, 7 studies), mental health (p<0.001, 7 studies), and disease specific quality of life (p<0.001, 10 studies). These data can be used to educate patients during the shared decision making process that increasingly governs medical care today. LEVEL OF EVIDENCE II.

Current trends in the diagnosis and management of syndesmotic injury

Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today’s body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.

Influence of Priming on Patient-Reported Outcome Measures: A Randomized Controlled Trial

BACKGROUND Patient-reported outcome measures (PROMs) are influenced by psychosocial factors, but it is unknown whether we can influence PROM scores by modifying the mindset of the patient. PURPOSE We assessed whether priming affects scores on PROMs. METHODS In all, 168 patients with musculoskeletal illness participated in this double-blinded, randomized, controlled, parallel study between July 2014 and October 2014 in a level I trauma center. Inclusion criteria were patients aged 18 years or older with English fluency and literacy and the ability to provide informed consent. Priming was performed by means of the Pain Catastrophizing Scale (PCS). The patients were randomized (1:1:1) into 3 groups: intervention group I was negatively primed with the original PCS; intervention group II was positively primed with a positively phrased PCS group; and control group III was not primed. Assessments were performed using PROMs on the domain of physical function, depression, and pain. Bivariate and multivariable regression analyses were conducted. RESULTS The intervention and control groups were well balanced in demographic and condition-specific characteristics. The positive PCS was independently associated with higher PROM scores in the physical function domain (Patient-Reported Outcome Measurement Information System Upper Extremity Function: coefficient = 4.7, partial R(2) = 0.042; CI: 1.2-8.2; p < 0.010). CONCLUSIONS Patients primed with a positively phrased version of the PCS reported less functional disability as compared with patients who were either negatively primed or not primed at all. This suggests that by influencing the mindset, PROMs can be influenced, resulting in better outcome if positively primed. LEVEL OF EVIDENCE Level 1 therapeutic study. TRIAL REGISTRATION NCT02209259.

Quantitative 3-dimensional computed tomography analysis of olecranon fractures

HYPOTHESIS/BACKGROUND Olecranon fractures have variable size of the proximal fragment, patterns of fragmentation, and subluxation of the ulnohumeral joint that might be better understood and categorized on the basis of quantitative 3-dimensional computed tomography analysis. Mayo type I fractures are undisplaced, Mayo type II are displaced and stable, and Mayo type III are displaced and unstable. The last is categorized into anterior and posterior dislocations. The purpose of this study was to further clarify fracture morphology between Mayo type I, II, and III fractures. METHODS Three-dimensional models were created for a consecutive series of 78 patients with olecranon fractures that were evaluated with computed tomography. We determined the total number of fracture fragments, the volume and articular surface area of each fracture fragment, and the degree of displacement of the most proximal olecranon fracture fragment. RESULTS Displaced olecranon fractures were more comminuted than nondisplaced fractures (P = .02). Displaced fractures without ulnohumeral subluxation were smallest in terms of both volume (P < .001) and articular surface involvement (P < .001) of the most proximal olecranon fracture fragment. There was no difference in average displacement of the proximal fragment between displaced fractures with and without ulnohumeral subluxation (P = .74). Anterior olecranon fracture-dislocations created more displaced (P = .04) and smaller proximal fragments than posterior fracture-dislocations (P = .005), with comparable fragmentation on average (P = .60). DISCUSSION/CONCLUSION The ability to quantify volume, articular surface area, displacement, and fragmentation using quantitative 3-dimensional computed tomography should be considered when increased knowledge of fracture morphology and fracture patterns might be useful.

Effect of Sequential Sectioning of Ligaments on Syndesmotic Instability in the Coronal Plane Evaluated Arthroscopically

Background: Arthroscopic evaluation of the syndesmosis allows direct visualization of syndesmotic instability. The purpose of this study was to determine the minimum degree of ligamentous injury necessary to destabilize the syndesmosis in the coronal plane when assessed arthroscopically and pinpoint where such instability should be measured within the incisura. Methods: Fourteen cadaveric specimens were divided into 2 groups and arthroscopically assessed first with the syndesmosis intact and then following serial differential ligamentous transection. Group 1 (n = 7): anterior-inferior tibiofibular (AITFL), interosseous (IOL), posterior-inferior tibiofibular (PITFL), and deltoid (DL) ligament. Group 2 (n = 7): PITFL-IOL-AITFL-DL. At each step, a standard 100-N lateral hook test was applied and tibiofibular coronal plane diastasis measured arthroscopically at both the anterior and posterior third of the incisura. These measurements were in turn compared with those of the stressed intact ligamentous state. Results: There was no significant syndesmotic instability measured at either the anterior or posterior margin of the incisura after transection of a singular ligament (AITFL or PITFL) or after the IOL was additionally transected. Diastasis at the posterior margin was significantly increased when all syndesmotic ligaments were sectioned (group 1: P = .018; group 2: P = .008), but this was not noted along the anterior margin. Diastasis at the anterior margin reached significance only with complete transection of syndesmosis and DL (group 1: P < .001; group 2: P = .044). Conclusion: Under arthroscopic evaluation, the syndesmosis becomes unstable in the coronal plane only when all syndesmotic ligaments are transected, which should preferentially be measured at the posterior margin of the incisura. Anteriorly, diastasis becomes apparent only with addition of DL disruption, although this added finding may aid in diagnosis of occult deltoid injury. Clinical Relevance: AITFL, IOL, and PITFL need to be injured to produce coronal plane syndesmotic instability. Arthroscopic assessment of such instability should occur along the posterior margin of the incisura. When they exist, similar findings anteriorly suggest concomitant deltoid injury.

There is no best surgical treatment for chronic isolated syndesmotic instability: a systematic review

Importance Appropriate management of chronic isolated ankle syndesmotic injuries is needed to prevent the development of concomitant pathology. Previous studies have evaluated treatment and outcomes of chronic syndesmotic injuries. However, these studies did not distinguish between isolated—an injury without associated fibula fracture—and non-isolated syndesmotic injuries. Objective We conducted a systematic review to assess the functional outcomes and determine evidence for optimal management of chronic isolated syndesmotic injuries. Evidence review A review of the literature was performed according to the PRISMA guidelines. PubMed, EMBASE and the Cochrane Library were searched on 2 May 2016. Studies were identified by using synonyms for ‘ankle syndesmosis’, ‘injury’, ‘delayed’, ‘chronic’ and ‘treatment’. Findings The search resulted in 216 reports on PubMed, 86 on EMBASE and 3 on the Cochrane Library. After reading the remaining full-text articles, we included 11 studies describing outcomes after surgical management of chronic unstable isolated injuries. Conclusions and relevance Currently, there is no evidence to support or refute any of the surgical interventions performed for chronic unstable isolated syndesmotic injuries. High level of evidence research is warranted if we want to establish optimal treatment.

Arthroscopically measured syndesmotic stability after screw vs. suture button fixation in a cadaveric model

BACKGROUND Appropriate management of ankle syndesmotic instability is needed to prevent the development of complications. Previous biomechanical studies have evaluated movement of the fibula after screw or suture button fixations with different results, most likely being caused by variations in experimental setups that did not mirror the in vivo clinical setting. This study aimed to arthroscopically compare in a cadaveric model the stability of syndesmotic fixation with either a suture button or syndesmotic screw. METHODS Eight fresh matched pairs of human ankle cadaver specimens (above knee) underwent arthroscopic assessment with (1) intact ligaments, (2) after complete disruption, and (3) after repair with either a quadracortical syndesmotic screw or suture button construct. In every stage, four loading conditions were considered under 100N of direct force: 1) unstressed, 2) lateral hook test, 3) anterior to posterior (AP) translation test, and 4) posterior to anterior (PA) translation test. Coronal plane tibiofibular diastasis, as well as sagittal plane tibiofibular translation, were arthroscopically measured. RESULTS Coronal plane anterior and posterior tibiofibular diastasis and sagittal plane tibiofibular translation were measured using probes of increasing diameters. Following screw fixation, syndesmotic stability was similar to the uninjured syndesmosis in the coronal plane (anterior, median 0.0mm [IQR 0.0-0.3] vs. 0.3mm [IQR 0.2-0.3]; p=0.57; posterior, median 0.1mm [IQR 0.0-0.4] vs. 0.2mm [IQR 0.1-0.3]; p=1.0) but more rigid in the sagittal plane (median 0.0mm [IQR 0.0-0.1] vs. 1.0mm [IQR 0.4-1.5]; p=0.012). Repairing the unstable syndesmosis with a suture button construct resulted in coronal plane stability similar to the uninjured syndesmosis (anterior, median 0.2mm [IQR 0.1-0.3] vs. 0.2mm [IQR 0.1-0.3]; p=0.48; posterior, median 0.2mm [IQR 0.1-0.3] vs. 0.3mm [IQR 0.1-0.5]; p=0.44). However, sagittal plane fibular motion remained unstable as compared to the uninjured syndesmosis (median 2.2mm [IQR 1.6-2.6] vs. 0.8mm [IQR 0.4-1.3]; p=0.012). CONCLUSION Current fixation methods for syndesmotic disruption maintain coronal plane fibular stability. Screw and suture button constructs, however, respectively resulted in greater or insufficient constraint to fibular motion in the sagittal plane as compared to the intact syndesmotic ligament. These findings suggest that neither traditional screw nor suture button fixations optimally stabilize the syndesmosis, which may have implications for postoperative care and clinical outcomes.

The effect of ankle distraction on arthroscopic evaluation of syndesmotic instability: A cadaveric study

Background: To assist with visualization, orthopaedic surgeons often apply ankle distraction during arthroscopic procedures. The study aimed to investigate whether ankle distraction suppresses fibular motion in cadaveric specimens with an unstable syndesmotic injury. Methods: Fourteen fresh‐frozen above knee specimens underwent arthroscopic assessment with 1) intact ligaments, 2) after sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, and the posterior inferior tibiofibular ligament, and 3) after sectioning of the deep and superficial deltoid ligament. In all scenarios, the lateral hook test, anterior‐posterior hook test, and posterior‐anterior hook test were applied. Each test was performed with and without ankle distraction. Coronal plane anterior and posterior tibiofibular diastasis as well as sagittal plane tibiofibular translation due to the applied load were arthroscopically measured. Findings: Tibiofibular diastasis in the coronal plane, as measured at both the anterior and posterior third of the incisura, was found to be significantly less when ankle distraction was applied, as compared to arthroscopic evaluation in the absence of distraction. In contrast, measurement of sagittal plane tibiofibular translation was not affected by ankle distraction. Interpretation: Since arthroscopic findings of syndesmotic instability are subtle the differential values of the syndesmotic measurements taken on and off distraction are clinically relevant. To optimally assess syndesmotic instability one should evaluate the syndesmosis without distraction or focus on fibular motion in the sagittal plane when distraction is required. HighlightsAnkle distraction decreases coronal plane diastasis of the unstable syndesmosis.Ankle distraction does not appear to affect fibular motion in the sagittal plane.Syndesmotic instability should be evaluated without ankle distraction.Assessment of syndesmotic stability is best identified in the sagittal plane.

Stable and unstable grade II syndesmotic injuries require different treatment strategies and vary in functional outcomes: a systematic review

Importance Appropriate management of syndesmotic injuries enables athletes to return earlier to play. Currently, there is no best evidence-based management of grade II syndesmotic injuries available. Objective We conducted a systematic review to identify the current available evidence if either conservative or surgical treatment of grade II ankle syndesmotic injuries leads to improved functional outcomes. Evidence review A review of the literature was performed according to the PRISMA guidelines. PubMed, EMBASE and the Cochrane Library were searched from January 1962 to 11 May 2016. Studies were identified by using synonyms for ‘ankle syndesmosis’, ‘injury’, ‘return to activity’ and ‘patient-reported outcomes’. Findings The search yielded 106 reports on PubMed, 74 on EMBASE and 5 on the Cochrane Library. After reading the remaining full-text articles, we included two studies describing conservative treatment and one study evaluating both conservative and surgical treatment of grade II syndesmotic injuries. Conclusions and relevance Currently, we are unable to adequately differentiate between stable grade II and unstable grade II injuries, and therefore it is unknown which grade II syndesmotic injuries should be treated conservatively and which surgically. Developing arthroscopically assessed validated measurements to define the stable syndesmosis may form part of the evaluation and grading of these injuries, and would be an important first step.