Rehabilitation and return to sport criteria following surgical treatment of osteochondritis dissecans of the capitellum: a systematic review

Background

Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum.

Hypothesis/Purpose

The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS.

Methods

Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment.

Results

All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months).

Conclusion

The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

The hidden impact of orthopedic surgeries: Examining the psychological consequences

Orthopedic surgery is commonly considered "quality of life care," as most orthopedic procedures have been shown to provide excellent pain relief and successful surgical outcomes for patients. Although orthopedic surgeries continue to improve patients' functional outcomes through modern surgical techniques and preoperative psychological screening, variation in patient function persists in current studies. Sub-optimal function in patients has been shown to be associated with emotional health burdens, such as anxiety and depression. Previous research has found that preoperative psychological conditions could negatively affect patients' functional outcomes. However, these studies were limited in that they did not examine novel psychological repercussions in emotionally healthy patients following surgery. To address this gap in knowledge, a narrative review was conducted to differentiate specific orthopedic surgeries that have psychological consequences on patients and to determine the current psychological support available for these patients. Data was collected from the Medical Humanities sector of the Texas Medical Center Library and the National Library of Medicine. Studies were included that examined novel psychological effects on patients after undergoing orthopedic surgery. A total of 38 articles were identified, and the majority focused on orthopedic trauma surgery while the rest examined total joint arthroplasty and orthopedic sports procedures. A key finding was that orthopedic trauma surgeries, alone and compared to total joint arthroplasty, result in a greater risk of negative psychological effects, while there was limited data on the psychological effects of orthopedic sports procedures. This narrative review suggests a need to integrate psychosocial support for patients with traumatic orthopedic intervention, regardless of the patient's preoperative psychological state. Furthermore, more research examining the mental well-being of patients following elective orthopedic surgeries is necessary to determine if these operations would benefit from postoperative psychological support as well.

Pharmacokinetics of isoniazid: The good, the bad, and the alternatives

Although isoniazid (INH) has been successful in treating Tuberculosis (TB) since its introduction in 1952, there has been continual reports of drug-associated hepatotoxicity in TB patients. These toxic side effects may reveal more about the recipient of the drug, than the drug itself. A combination of pharmacogenetic and pharmacokinetic studies have identified polymorphisms within enzymes involved in INH metabolism and detoxification. These essential metabolic enzymes include N-acetyltransferase 2, Cytochrome P450 2E1, and glutathione S transferases. Different phenotypes of these enzymes can affect the rate of INH metabolism, resulting in production of hepatotoxic metabolites. This review is intended to elucidate the pharmacokinetics of INH by examining its Administration, Distribution, Metabolism, and Elimination, while suggesting potential alternatives within INH personalized treatment to help reduce hepatotoxicity.