Shari R. Liberman

Prevalence of Scapular Dyskinesis in Overhead and Nonoverhead Athletes: A Systematic Review

Background: Scapular dyskinesis, or abnormal dynamic scapular control, is a condition that is commonly associated with shoulder pathology but is also present in asymptomatic individuals. Literature varies on whether it represents a cause or symptom of shoulder pathology, but it is believed to be a risk factor for further injury. Clinical identification focuses on visual observation and examination maneuvers. Treatment of altered scapular motion has been shown to improve shoulder symptoms. It is thought to be more common in overhead athletes due to their reliance on unilateral upper extremity function but the incidence within nonoverhead athletes is unknown. Hypothesis: Overhead athletes will have a greater prevalence of scapular dyskinesis when compared with nonoverhead athletes. Study Design: Systematic review; Level of evidence, 3. Methods: After PROSPERO registration, a systematic review was performed using PRISMA guidelines through the PubMed database looking for studies published before October 2014. All studies containing the search terms scapular, scapulothoracic, dyskinesis, dyskinesia, shoulder athlete, or overhead athlete were included. Studies that did not include prevalence data for scapular dyskinesis were excluded. Study methodological quality was evaluated using the modified Coleman methodology score. Descriptive statistics and 2-proportion 2-tailed z-tests were used to compare the reported prevalence of scapular dyskinesis between overhead and nonoverhead athletes. Results: Twelve studies were analyzed including 1401 athletes (1257 overhead and 144 nonoverhead; mean age, 24.4 ± 7.1 years; 78% men). All the studies were evidence level 2 (33%) or level 3 (67%). The reported prevalence of scapular dyskinesis was significantly (P < .0001) higher in overhead athletes (61%) compared with nonoverhead athletes (33%). Conclusion: Scapular dyskinesis was found to have a greater reported prevalence (61%) in overhead athletes compared with nonoverhead athletes (33%). Clinical Relevance: Prevalence data for scapular dyskinesis are scarce within the literature. Information on the reported prevalence, laterality, and association with the dominant extremity will allow for better allocation of diagnostic and therapeutic interventions. Recognition and treatment will help athletes to optimize functional performance and decrease the risk of further shoulder injury.

Performance and Return to Sport After Forearm Fracture Open Reduction and Internal Fixation in National Football League Players

Background: Forearm fractures are one of the most common upper extremity injuries requiring surgery in professional football. Surgical fixation of forearm fractures may speed recovery and decrease games missed in football. Methods: National Football League (NFL) players who underwent forearm fracture open reduction and internal fixation (ORIF) were identified. Matched controls (position, age, experience, performance) were identified. Control and case performance scores were calculated using a standardized scoring system. Return to sport (RTS) in the NFL was defined as playing in a single NFL game after surgery. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Thirty-six surgeries were analyzed following ORIF. Thirty-three were able to RTS in the NFL at an average of 152.1 + 129.8 days. Controls had a significantly longer NFL career (P < .001) and played in significantly more games per season (P = .026) than players who underwent surgery. There was a significant (P = .013) decrease in games/season for DBs following surgery. No significant difference was seen in postoperative performance scores compared with preoperative scores among any positions, nor in postoperative and postindex performance scores compared with matched controls. Conclusion: There is a high rate of RTS in the NFL following forearm fracture ORIF. Following surgery, players’ careers were 1 year shorter and played nearly 2 fewer games per season than matched controls. Games per season following surgery was significantly lower among DBs when compared with presurgery. Postoperative performance scores were not significantly different compared with preoperative and when compared with matched controls.

Case Report: Angiosarcoma in the Upper Extremity Related to a Nonfunctioning Arteriovenous Fistula

Background: Angiosarcoma is a rare but aggressive malignancy with a high predilection for the head and neck. There have been few case reports of the development of angiosarcoma in a nonfunctional arteriovenous fistula in a hemodialysis patient. Methods: After institutional review board approval, a retrospective chart analysis is conducted to present the case of a patient who received plastic surgical treatment at our hospital. Results: We present the case of a 44-year-old male who presented with ischemic changes and paresthesias of the upper extremity associated with the development of angiosarcoma in an arteriovenous fistula. Conclusions: Angiosarcoma remains a rare but important diagnosis to include in the differential diagnosis for upper extremity pain and paresthesias in chronic renal failure and nonfunctioning arteriovenous fistula.

Physician Rating Scales Do Not Accurately Rate Physicians

The purpose of this study was to determine the proportion of questions used by online physician rating scales to directly rate physicians themselves. A systematic review was performed of online, patient-reported physician rating scales. Fourteen websites were identified containing patient-reported physician rating scales, with the most common questions pertaining to office staff courtesy, wait time, overall rating (entered, not calculated), trust/confidence in physician, and time spent with patient. Overall, 28% directly rated the physician, 48% rated both the physician and the office, and 24% rated the office alone. There is great variation in the questions used, and most fail to directly rate physicians themselves. [Orthopedics. 2018; 41(4):e445-e456.].

Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome

Background: Thoracic outlet syndrome (TOS) is a complex entity resulting in neurogenic or vascular manifestations. A wide array of procedures has evolved, each with its own benefits and drawbacks. The authors hypothesized that treatment of TOS with first rib resection (FRR) may lead to increased complication rates. Methods: A retrospective case control study was performed on the basis of the National Surgical Quality Improvement Program database from 2005 to 2014. All cases involving the operative treatment of TOS were extracted. Primary outcomes included surgical and medical complications. Analyses were primarily stratified by FRR and secondarily by other procedure types. Results: A total of 1853 patients met inclusion criteria. The most common procedures were FRR (64.0%), anterior scalenectomy with cervical rib resection (32.9%), brachial plexus decompression (27.2%), and anterior scalenectomy without cervical rib resection (AS, 8.9%). Factors associated with increased medical complications included American Society of Anesthesiologists (ASA) classification of 3 or greater and increased operative time. The presence or absence of FRR did not influence complication rates. Conclusions: FRR is not associated with an increased risk of medical or surgical complications. Medical complications are associated with increased ASA scores and longer operative time.

Open, Arthroscopic, and Percutaneous Surgical Treatment of Lateral Epicondylitis: A Systematic Review

Background: Approximately 10% of patients with lateral epicondylitis go on to have surgical treatment; however, multiple surgical treatment options exist. The purpose of this study was to review the literature for the clinical outcomes of open, arthroscopic, and percutaneous treatment of lateral epicondylitis. The authors hypothesized that the clinical outcome of all 3 analyzed surgical treatments would be equivalent. Methods: A systematic review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar in July 2016 to compare the functional outcome, pain, grip strength, patient satisfaction, and return to work at 1-year follow-up for open, arthroscopic, and percutaneous treatment of lateral epicondylitis. Results: Six studies (2 Level I and 4 Level II) including 179 elbows (83 treated open, 14 arthroscopic, 82 percutaneous) were analyzed. Three outcome measures (Disabilities of the Arm, Shoulder, and Hand [DASH] score, visual analog scale [VAS], and patient satisfaction) were reported for more than one category of surgical technique. Of these, the authors noted no clinically significant differences between the techniques. Conclusions: This is the first systematic review looking at high-level evidence to compare open, percutaneous, and arthroscopic techniques for treating lateral epicondylitis. There are no clinically significant differences between the 3 surgical techniques (open, arthroscopic, and percutaneous) in terms of functional outcome (DASH), pain intensity (VAS), and patient satisfaction at 1-year follow-up.

Performance and Return to Sport After Thumb Ulnar Collateral Ligament Surgery in National Football League Players

Background: Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair of complete tears has yielded excellent results in elite athletes. Methods: National Football League (NFL) players who underwent thumb UCL surgery and matched controls were identified. Demographic and performance data were collected. Performance scores were calculated using a standardized scoring system. Return to sport (RTS) in the NFL was defined as playing in at least 1 NFL game after thumb UCL surgery. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Twenty-three players were identified (mean age: 28.8 ± 3.4 years and mean experience in the NFL: 5.9 ± 3.4 years). Twenty-two players (95.7%) were able to return to sport in the NFL at an average of 132.2 ± 126.1 days. The overall 1-year NFL career survival rate of players undergoing thumb UCL surgery was 87.0%. There was not a statistically significant decrease in games per season and career length for any position following surgery. No positions had a significant difference in postoperative performance when compared with preoperative performance, and there was no significant performance difference postoperatively when compared with matched controls. Conclusions: There is a high rate of RTS in the NFL following thumb UCL surgery. Players who underwent thumb UCL surgery played in a similar number of games per season and had similar career lengths in the NFL as controls. No position group had any significant postoperative performance score differences when compared with postindex matched controls.

Endoscopic decompression of the ulnar nerve in the cubital tunnel yields similar outcomes but a lower complication rate than open decompression: a systematic review and meta-analysis

Importance Cubital tunnel syndrome is the second most common peripheral nerve compression syndrome in the USA. There is controversy in the literature regarding the best surgical option. Objective The purpose of this investigation was to perform a systematic review to determine if there is a difference in clinical outcomes or complications between open and endoscopic cubital tunnel release in patients with compression of the ulnar nerve in the cubital tunnel. Evidence review A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS and Cochrane Central Register of Controlled Trials databases were searched for level I–IV therapeutic comparative studies of open versus endoscopic cubital tunnel decompression in adult human patients. The levels of evidence were then assigned based on the Oxford Centre for Evidence-Based Medicine. Study methodological quality was analysed using the Modified Coleman Methodology Score. Only the outcome measurements that 3 or more studies used were included in our data synthesis. Postoperative patient satisfaction, Bishop score, recurrence and complication rates were compared between the endoscopic and open groups using the χ2 test using p<0.05. Findings Six articles (507 patients, mean age of 48.2 years, with 28.8 months average follow-up) were analysed. 76.1% of patients were satisfied in the endoscopic group, and 73.8% were satisfied in the open group (p=0.7023). 87.4% of endoscopic patients and 81.2% of open patients had a Bishop score of excellent or good (p=0.236). The endoscopic group had a recurrence rate of 1.1%, and the open group had a 3.5% recurrence rate (p=0.0872). There were significantly fewer complications in the endoscopic group (7.9%) compared to the open group (12.9%) (p<0.01). Conclusions and relevance Equivalent clinical outcomes, patient satisfaction and recurrence rates were observed between open and endoscopic techniques. However, a significantly lower complication rate was observed with the endoscopic technique. Level of evidence Level IV, systematic review of level I–IV studies.