A High Rate of Return to Running Is Seen After Both Arthroscopic and Open Shoulder Surgery

PURPOSE

To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery.

METHODS

We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively.

RESULTS

A total of 126 patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively (P = .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability.

CONCLUSIONS

Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Autograft-Only and Allograft-Augmented Hamstring Autograft Have Similar Failure Rates After Anterior Cruciate Ligament Reconstruction

Purpose

To compare failure rates and clinical outcomes after hamstring autograft anterior cruciate ligament (ACL) reconstruction with and without allograft augmentation by a single surgeon otherwise using the same surgical technique.

Methods

This was a retrospective analysis with prospectively collected patient-reported outcomes of primary hamstring autograft ACL reconstruction with and without allograft augmentation performed in a military population by a single surgeon. The primary outcome measure was graft failure, defined as graft rupture confirmed by use of magnetic resonance imaging scans and/or revision ACL reconstruction. The secondary outcome measure was the postoperative Knee Injury and Osteoarthritis Outcome Score.

Results

This study included 112 patients with a mean follow-up period of 65.3 months. In patients with a graft diameter of 8 mm or greater, there was no difference in failure rates (9.4% for autograft only vs 6.3% for hybrid, P = .59). There was a higher failure rate in patients in the autograft-only group with a graft diameter of less than 8 mm (29.4%) when compared with the hybrid graft group (6.3%, P = .008). There were no hybrid grafts less than 8 mm in diameter. There were no differences in the Knee Injury and Osteoarthritis Outcome Score between groups as long as the graft diameter was 8 mm or greater.

Conclusions

In patients undergoing hamstring ACL reconstruction, there was no significant difference in graft failure rates or outcome scores between autograft only and autograft with allograft augmentation as long as grafts were 8 mm or greater. High failure rates were seen when the graft diameter was less than 8 mm.

Level of Evidence

Level III, retrospective cohort study.

Is Self-reported Return to Duty an Adequate Indicator of Return to Sport and/or Return to Function in Military Patients?

BACKGROUND

In the military, return-to-duty status has commonly been used as a functional outcome measure after orthopaedic surgery. This is sometimes regarded similarly to return to sports or as an indicator of return to full function. However, there is variability in how return-to-duty data are reported in clinical research studies, and it is unclear whether return-to-duty status alone can be used as a surrogate for return to sport or whether it is a useful marker for return to full function.

QUESTIONS/PURPOSES

(1) What proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity? (2) What proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type or level, or medical evaluation board)?

METHODS

Preoperative and postoperative self-reported physical profile status (mandated physical limitation), physical activity status, work status, deployment status, military occupation specialty changes, and medical evaluation board status were retrospectively reviewed for all active-duty soldiers who underwent orthopaedic surgery at Madigan Army Medical Center, Joint Base Lewis-McChord from February 2017 to October 2018. Survey data were collected on patients preoperatively and 6, 12, and 24 months postoperatively in all subspecialty and general orthopaedic clinics. Patients were considered potentially eligible if they were on active-duty status at the time of their surgery and consented to the survey (1319 patients). A total of 89% (1175) were excluded since they did not have survey data at the 1 year mark. Of the remaining 144 patients, 9% (13) were excluded due to the same patient having undergone multiple procedures, and 2% (3) were excluded for incomplete data. This left 10% (128) of the original group available for analysis. Ninety-eight patients reported not having a physical profile at their latest postoperative visit; however, 14 of these patients also stated they were retired from the military, leaving 84 patients in the return-to-duty group. Self-reported "full-time duty with no restrictions" was originally used as the indicator for return to duty; however, the authors felt this to be too vague and instead used soldiers' self-reported profile status as a more specific indicator of return to duty. Mean length of follow-up was 13 ± 3 months. Eighty-three percent (70 of 84) of patients were men. Mean age at the preoperative visit was 35 ± 8 years. The most common surgery types were sports shoulder (n = 22) and sports knee (n = 14). The subgroups were too small to analyze by orthopaedic procedure. Based on active-duty status and requirements of the military profession, all patients were considered physically active before their injury or surgery. Return to sport was determined by asking patients how their level of physical activity compared with their level before their injury (higher, same, or lower). We identified the number of other indicators that may suggest decreased function by investigating change in work type/level, self-reported nondeployability, or medical evaluation board. This was performed with a simple survey.

RESULTS

Of the 84 patients reporting return to duty at the final follow-up, 67% (56) reported an overall lower level of physical activity. Twenty-seven percent (23) reported not returning to the same work level, 32% (27) reported being nondeployable, 23% (19) reported undergoing a medical evaluation board (evaluation for medical separation from the military), and 11% (9) reported a change in military occupation specialty (change of job description).

CONCLUSION

Return to duty is commonly reported in military orthopaedics to describe postoperative functional outcome. Although self-reported return to duty may have value for military study populations, based on the findings of this investigation, surgeons should not consider return to duty a marker of return to sport or return to full function. However, further investigation is required to see to what degree this general conclusion applies to the various orthopaedic subspecialties and to ascertain how self-reported return to duty compares with specific outcome measures used for particular procedures and subspecialties.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Synovial Inclusion Cyst Mimicking a Femoral Neck Stress Fracture in an Active Duty Servicemember: A Case Report

CASE

A 19-year-old female servicemember with history of ischiopubic rami stress fractures was referred to orthopaedic surgery for magnetic resonance imaging findings concerning for a tension-sided femoral neck stress fracture. However, her history and symptoms were discordant with the diagnosis of stress fracture. The patient was managed with protected weight-bearing for 6 weeks with gradual return to physical activity.

CONCLUSION

Prophylactic surgical fixation is advocated for the management of tension-sided femoral neck stress fractures. However, surgeons should consider a broader differential diagnosis, to include a synovial inclusion cyst, when the clinical presentation is not consistent with a stress fracture.

['I'll serve my time…' II. A replication study of recidivism in patients with a one-year hospital order]

BACKGROUND

In the Netherlands a one-year hospital order is often imposed on forensic patients with a psychotic disorder. The purpose of the order is to reduce the patient's violence behaviour by forcing him/her to receive medical treatment for a year. A pilot study showed that the recidivism rate for this group, following discharge, was relatively high. Patients who re-offended had relatively high HCR-20 scores and were more often involved in incidents during treatment than patients who had not re-offended.

AIM

To replicate the findings of the pilot study and to compare the recidivism rate of this group to the recidivism rate of patients who had been given a detention order for a longer time with possibilties for prolongation ('tbs').

METHOD

The study involved 95 patients with a psychotic disorder who had been treated in an FPA (Forensic Psychiatric Clinic) by reason of a one-year hospital order or a detention order for an unspecified time. Hospital records were consulted in order to complete the HKT-30 and the PCL-R and to check how many incidents had occurred during each patient's treatment. The HKT-30 is a dutch version of the HCR-20. The results were counted at a later date by persons not informed about the outcome. After the hospital records had been checked, the recidivism figures were obtained from the Information Service of the Ministry of Justice.

RESULTS

Of the patients subject to the one-year hospital order 43.5% reoffended following discharge. Recidivism by patients who had been given the longer-term detention order was significantly lower, namely 23.1%. The seriousness of the offences committed following discharge differed significantly from the offence for which they were originally charged/convicted. The HKT-30 and factor 2 of the PCL-R predicted the possibility of recidivism, but the number of violent incidents that occurred on the ward did not.

CONCLUSION

Our findings indicate that the recidivism among patients subject to a one-year hospital order is relatively high compared to the rate among patients who had received a longer-term detention order. The most likely explanation for this difference is that the hospital order was imposed for a shorter period.

UV-induced generation of rare tautomers of allopurinol and 9-methylhypoxanthine — A matrix isolation FTIR study

Monomers of allopurinol and 9-methylhypoxanthine were studied using the matrix isolation technique combined with Fourier transform infrared spectroscopy. The oxo tautomeric forms of both compounds were found to dominate in freshly deposited low-temperature argon matrices. For 9-methylhypoxanthine, a small amount of the hydroxy tautomer was also detected in an Ar matrix before any irradiation. Upon exposure of the matrices to the UV (lambda>230 nm or lambda>270 nm) light, a proton transfer photoreaction converting the oxo forms of both compounds into the corresponding hydroxy tautomers occurred. Generation of conjugated ketenes as minor photoproducts was also observed. For 4(3H)-pyrimidinone (a model compound for both allopurinol and 9-methylhypoxanthine), photoreversibility of the UV-induced oxo --> hydroxy transformation was experimentally proven by direct observation of the back hydroxy --> oxo photoreaction. The substrates (oxo tautomers) and products (hydroxy tautomers) of the observed phototransformations were identified by comparison of their IR spectra with the spectra theoretically predicted at the DFT(B3LYP)/6-31++G(d,p) level. The IR bands in the experimental spectra were assigned to the calculated normal modes.

Preferred Conformers and Photochemical (λ > 200 nm) Reactivity of Serine and 3,3-Dideutero-Serine In the Neutral Form

A systematic investigation of the conformational potential energy surface of neutral serine [HOCH2CHNH2COOH] and 3,3-dideutero-serine [HOCD2CHNH2COOH] was undertaken, revealing the existence of 61 different minima. The structures and vibrational spectra of the most stable conformers, which were estimated to have relative energies within 7 kJ mol(-1) and account for ca. 93% of the total conformational population at room temperature, were calculated at both the MP2 and DFT/BLYP levels of theory with the 6-311++G(d,p) basis-set and used to interpret the spectroscopic data obtained for the compounds isolated in low-temperature inert matrixes. The assignment of the main spectral infrared features observed in the range 4000-400 cm(-1) to the most stable conformers of serine was undertaken. In addition, UV irradiation (lambda > 200 nm) of the matrix-isolated compounds was also performed, leading to decarboxylation, which was found to be strongly dependent on the conformation assumed by the reactant molecule.

Photochemical syn-anti isomerization reaction in N4-hydroxycytosine. An experimental matrix isolation and theoretical study

Infrared spectra of N4-hydroxycytosine isolated in argon and nitrogen low-temperature matrixes are reported. The compound was found to adopt the syn structure of the imino-oxo tautomeric form exclusively. A photoreaction (lambda > 250 nm) converting this form into the anti isomer was observed. The reaction is reversible and leads to a photostationary point. The initial infrared spectrum and the spectrum of the photoproduct were assigned to the syn and anti isomers, respectively. This assignment is based on a close agreement between the experimental spectra and the spectra theoretically simulated at the DFT(B3LYP)/6-31++G** level of theory.

The Payment Error Prevention Program (PEPP): reducing Medicare payment errors in prospective payment system hospitals

Peer Review Organizations (PROs) are charged by the Health Care Financing Administration (HCFA) to assist in protecting the integrity and solvency of the Medicare program. Recent audits of the Medicare program from the Office of Inspector General (OIG) revealed that more than $12 billion Medicare dollars in 1998 were spent in improper payments, with more than 25% attributed to prospective payment system (PPS) hospitals. The Payment Error Prevention Program (PEPP) is an initiative designed by HCFA in 1999 to assist PROs in meeting the goal of reducing payment errors in PPS hospitals. PEPP is implemented through the development of quality improvement (QI) methodologies. These projects are designed to achieve measurable improvements in processes and outcomes of payment errors. PEPP works to reduce payment errors at PPS hospitals through cooperative efforts with Ohio agencies and licensing boards, federal law enforcement organizations, HCFA contractors, hospital medical staffs, and medical and osteopathic associations.

Tautomerism and infrared spectra of 2-thiopurine: an experimental matrix isolation and theoretical ab initio and density functional theory study

Infrared spectra of 2-thiopurine (2-mercaptopurine, 2-purinethiol ) isolated in low-temperature Ar and N2 matrixes are reported. These spectra indicate that the compound adopts exclusively the thiol N9H tautomeric form. The theoretical calculations of relative energies of 2-thiopurine tautomers have been carried out at the MP4(SDTQ)//HF level using the 6-31G(d,p) basis set. The thiol N9H tautomer was predicted to be the most stable of all isomers of 2-thiopurine. The infrared spectra of the tautomers of 2-thiopurine have been calculated at the DFT(B3LYP)/6-31G(d,p) level. Good agreement between the experimental spectra and the spectra calculated for thiol N9H tautomer supported the identification of the dominant tautomer. It has also allowed for the reliable assignment of the bands observed in the experimental IR spectrum.

Polyelectrolyte-Induced Aggregation of Microcrystalline Cellulose: Reversibility and Shear Effects

The polyelectrolyte-induced aggregation of microcrystalline cellulose (MCC) was studied by focused beam reflectance measurement (FBRM) to determine the reversibility of MCC aggregation under high-shear conditions. A correlation was established between the mean chord length output of FBRM probing a high-shear zone with the mean particle size (laser diffraction) of an aliquot extracted from the low-shear bulk mixing zone. Flocs formed by addition of a cationic polyelectrolyte were ruptured by shear forces of mixing and did not reaggregate at low mixing intensities. Flocs formed by addition of both polyelectrolyte and colloidal silica sols were found to reaggregate at low shear quite reversibly following high-shear degradation. The Kolmolgoroff microscale, eta, was determined using a three-compartment mixing model for the FBRM experiments, and the minimum aggregate adhesion forces were calculated to be approximately 3 nN under the experimental mixing conditions. Shear-dependent FBRM studies are also used to estimate the radial dependence of particle adhesion forces within an aggregate. AFM-based surface force measurements between model anionic surfaces (mica and glass beads) showed more reversible adhesion forces in the presence of colloidal silica than with cationic polyelectrolyte only. A descriptive model of the interfaces giving rise to the observed MCC aggregation and adhesion behavior is proposed. Copyright 2000 Academic Press.

Spectroscopic identification of 2,4-pyrimidinedithiol; an experimental matrix isolation and ab initio Hartree-Fock and density functional theory study

2,4-Pyrimidinedithiol (the dithiol form of 2,4-dithiouracil) was generated by UV (lambda > 335 nm) irradiation of the dithione form of 2,4-dithiouracil isolated in low-temperature argon or nitrogen matrices. The IR and UV spectra of the photoproduct are reported. The dithiol form of 2,4-dithiouracil was identified by comparison of the experimental spectrum with the spectrum theoretically predicted for this form at the HF/6-31 (d,p) and DFT(B-3LYP)/6-31 (d,p) levels. This comparison resulted also in assignment of the bands observed in the IR spectrum of 2,4-pyrimidinedithiol to the theoretically predicted normal modes.

Theoretical and matrix-isolation experimental studies on 2-thiocytosine and 5-fluoro-2-thiocytosine

2-Thiocytosine (s2Cyt) and 5-fluoro-2-thiocytosine (f5s2Cyt) were studied by means of IR spectroscopy under different environmental conditions: isolated in low-temperature inert gas matrices, associated in thin amorphous and polycrystalline films. The compounds isolated in matrices were only very slightly influenced by the environment. From the analysis of the IR spectra of both compounds it appears that they exist in inert gas matrices only in the amino-thiol tautomeric form. Strong environmental effects were observed for s2Cyt and f5s2Cyt deposited in the form of thin polycrystalline films. Contrary to matrices, in polycrystalline films the amino-thione form dominates for both s2Cyt and f5s2Cyt. The experimental findings are in agreement with the ab initio quantum mechanical calculations of the relative total energies of the tautomeric forms. Those energies were calculated using the Self Consistent Field method corrected for electron correlation effects with the use of the second-order many-body perturbation theory (SCF+MBPT(2)). The theoretical calculations show that the amino-thiol tautomeric form is more stable than the amino-thione form by 38 kJ mol-1 and 48 kJ mol-1 for s2Cyt and f5s2Cyt, respectively. Both molecules, s2Cyt and f5s2Cyt, may also appear in the uracil-like imino-thione tautomeric form, which is predicted to be only 8 kJ mol-1 less stable than the amino-thione form. A new method of the preparation of f5s2Cyt is reported.

Nonrandom chromosomal aberrations and clonal chromosomal evolution in acute leukemia associated with Down's syndrome

Nine Down's syndrome (DS) children, four with acute leukemia, one with acute leukemia as well as rhabdomyosarcoma, and four with other hematologic disorders, were analyzed for constitutional and acquired chromosomal aberrations. Acquired clonal chromosomal aberrations were identified only in the acute leukemia cases, and four of the five acute leukemia demonstrated numerical and/or structural aberrations involving chromosomes #8, #19, and #21. Of the 11 aneuploid stem cell lines identified in the five acute leukemia cases, trisomy 21, trisomy 8, trisomy 19, and tetrasomy or pentasomy 21 was found in 11, seven, four, and two lines, respectively. The frequent appearance of multiple stem cell lines with common and/or overlapping chromosomal aberrations in acute leukemia cases demonstrates the existence of genomic instability and heterogeneity of the neoplastic cell population, which results from clonal chromosomal evolution. Furthermore, trisomy 19 was identified only with the concurrent presence of trisomy 8, suggesting that the nondisjunction of chromosome #19 probably occurred after that of #8. Trisomy 21 was observed in every aneuploid stem cell line and, in one case, trisomy 21 was maintained in the bone marrow leukemic cells but not in the orbital rhabdomyosarcoma cells, indicating that this constitutional chromosomal aberration is probably crucial for and predisposed to the development of acute leukemia in DS patients. The association of acquired clonal chromosomal aberrations, especially those involving chromosomes #8, #19, and #21, with DS acute leukemia strongly suggests the clinical implication of cytogenetic analysis in the diagnosis of acute leukemia development in DS patients.

Personality Matched Across Media In A Large High-School Sample

Forms A and B of the High-School Personality Questionnaire and the complete Objective-Analytic Test Kit were administered to 840 boys aged 12-18. At issue was the alignment of second-stratum factors from the questionnaire data with the first-stratum factors from the O-A data. A salient relationship in the expected direction was found only for Anxiety (Q11, U124). Among other such relationships were that of Exvia (Q1) with U121 (Exuberance) and Tough Poise (Q111, Cortertia) with U125 (Realism).

Morphine dependence in rats assessed in a shock discrimination task

The effects of chronic morphine sulfate (5 mg/kg/day for 14 days) on shock discrimination performance of rats was assessed in Experiment 1. Significant tolerance developed to the disruptive effects of morphine on performance. A significant increase in discrimination performance was found 48 h after the last injection in tests conducted without the injection environment cues present. Ten days after the chronic drug regimen, tests conducted 30 min after exposure to the injection-environment cues revealed no differences between animals previously administered morphine and control animals administered saline. In Experiment II, shock discrimination performance was assessed in a separate group of rats after exposure to a single injection of morphine sulfate (30 mg/kg), which eliminated associative processes, e.g., Pavlovian or instrumental conditioning, as factors in the subsequent behavioral tests for hyperalgesia. Significant changes in discrimination performance (primarily enhanced percent correct to the high shock stimulus) indicative of increased pain sensitivity were obtained in tests conducted 1, 2, and 3, but not 9 days after the injection. These experiments indicate that increased pain sensitivity, as opposed to hyperresponsivity operationally measured in traditional analgesia tests (e.g., hot plate, jump-flinch, and tail flick), is a component of morphine withdrawal of a nonassociative origin.

Effects of morphine, d-amphetamine, and pentobarbital on shock and light discrimination performance in rats

The effects of 2 and 4 mg/kg morphine sulfate, 0.5 and 1 mg/kg d-amphetamine sulfate, and 6 and 12 mg/kg pentobaribital sodium were tested in rats in two different discrete-trial two-choice discrimination tasks. The discriminative stimuli for one task were high and low intensity shocks. In the other, correct choices were signaled by the position of a brief light flash. Morphine (4 mg/kg) significantly disrupted performance of both tasks, with more reliable disturbance occurring in the shock discrimination animals. Pentobarbital (12 mg/kg), while exerting noticeable effects on gross motor behavior, had little effect on discrimination performance; d-amphetamine (1 mg/kg) was disruptive of discrimination performance in only some animals. The results indicate that much of the effect of relatively low doses of morphine on the shock discrimination performance of rats may be due not to its putative specific antinociceptive properties, but to alterations in conceptual-judgmental processes or decreases in motivation (e.g., hunger) unrelated to pain.