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Background Although rotator cuff syndrome is common and extensively studied from the perspective of producing healed tendons, influence of gender on patient-reported outcomes is less well examined. As activity and role demands may vary widely between men and women, clarity on whether gender is an important factor in outcome would enhance patient education and expectation management. Our purpose was to determine if differences exist in patient-reported outcomes between men and women undergoing rotator cuff surgery. Methods One hundred forty-eight participants (76 W:72 M) aged 35–75 undergoing surgery for unilateral symptomatic rotator cuff syndrome were followed for 12 months after surgery. Demographics, surgical data, and the Western Ontario Rotator Cuff (WORC) scores were collected. Surgery was performed by two fellowship-trained shoulder surgeons at a single site. Results There were no gender-based differences in overall WORC score or subcategory scores by 12 months post-op. Pain scores were similar at all time points in men and women. Women were more likely to have dominant-arm surgery and had smaller rotator cuff tears than men. Complication rates were low, and satisfaction was high in both groups. Conclusion Patient gender doesn’t appear to exert an important effect on patient-reported rotator cuff outcomes in this prospective cohort. Further work examining other covariates as well as the qualitative experience of going through rotator cuff repair should provide greater insight into factors that influence patient-reported outcomes.

This trial compared a restrictive hemoglobin threshold with a liberal threshold for blood transfusion among hip-surgery patients with risk factors for CVD. The liberal strategy resulted in more transfusions and did not reduce death or inability to walk independently. In the United States, more than 17 million red-cell units are collected annually, and 15 million units are transfused. 1 Blood transfusions are frequently given to surgical patients and to the elderly. 2 , 3 Yet, the indications for postoperative transfusion have not been adequately evaluated and remain controversial. Most clinical trials have been small. 4 One adequately powered trial involving adults in intensive care units showed a nonsignificant decrease in 30-day mortality with a restrictive transfusion strategy, as compared with a liberal strategy (18.7% vs. 23.3%). 5 However, the effect of a restrictive approach on functional recovery or risk of myocardial infarction in patients . . .

Strategies to address inequities, bias, and discrimination that disadvantage Canadian physicians from marginalized groups are urgently needed. We describe a multilevel needs assessment of equity, diversity, and inclusion (EDI) in 2 departments of surgery that focused on identifying evidence-based interventions. We invited members of the departments of surgery at the University of Calgary and the University of Saskatchewan to complete the Diversity Engagement Survey (DES), a 22-item instrument designed to understand workplace engagement and inclusion among physicians, with higher scores indicating greater engagement and inclusion. Leaders completed a Leadership EDI Readiness Assessment to understand their own barriers to EDI work and an Organizational EDI Readiness Assessment to understand structures for EDI in their division. Leaders were provided resources and interventions to address the identified gaps in these assessments. The most common organizational gaps in structures for EDI work in surgical divisions and training programs (n = 34, 37.4%) were in community outreach and measurement and reporting. Surgeons who identified as cisgender men (n = 101) felt more engaged and included than those who identified as cisgender women (n = 43; 3.81 [standard deviation (SD) 0.73] v. 3.51 [SD 0.78]; p = 0.04). White cisgender men (n = 66) had the highest feelings of engagement and inclusion (mean 3.95 [SD 0.62]). Participating surgical sections and training programs were directed to evidence-informed initiatives to improve community outreach and measurement and reporting to address EDI in their settings. Our findings support that gender and racial or ethnic identities influence the workplace experiences of surgeons in Canada. A multilevel approach to EDI work in surgical departments can direct leaders to areas for intervention. Il est urgent de se doter de stratégies de lutte contre les inégalités, les biais et la discrimination que subissent les médecins canadiens appartenant à des groupes marginalisés. Nous décrivons ici une évaluation multiniveau des besoins en matière d’équité, de diversité et d’inclusion (EDI) dans 2 départements de chirurgie afin d’identifier des correctifs reposant sur des données probantes. Nous avons invité les membres des départements de chirurgie de la University of Calgary et de la University of Saskatchewan à répondre à un sondage en 22 points sur la diversité conçu pour mesurer et comprendre les sentiments d’engagement et d’inclusion chez les médecins dans leurs milieux de travail, les scores obtenus étant directement proportionnels au degré d’engagement et d’inclusion. Les chefs de département ont répondu à un questionnaire portant sur leur état de préparation en matière d’EDI afin de mettre au jour leurs propres réticences à l’endroit des correctifs proposés, et sur l’état de préparation des organisations afin de cerner les structures d’EDI en place dans leurs divisions. On a proposé aux chefs de département des ressources et des exemples de correctifs visant à combler les lacunes révélées par les évaluations. Les lacunes organisationnelles les plus communes au plan des structures d’EDI dans les divisions et les programmes de formation en chirurgie (n = 34 [37,4 %]) étaient les mécanismes de sensibilisation, d’évaluation et de reddition de comptes. En chirurgie, les personnes s’identifiant comme hommes cisgenres (n = 101) ont dit se sentir plus engagées et incluses que celles qui s’identifiaient comme femmes cisgenres (n = 43; 3,81 [écart type (ET) 0,73] c. 3,51 [ET 0,78]; p = 0,04). Ce sont les hommes cisgenres de race blanche (n = 66) qui ont exprimé le plus grand sentiment d’engagement et d’inclusion (score moyen 3,95 [ET 0,62]). Les divisions et les programmes de formation en chirurgie participants ont été orientés vers des stratégies fondées sur des données probantes pour améliorer leurs mécanismes de sensibilisation, d’évaluation et de reddition de comptes pour mieux intégrer les principes d’EDI dans leurs milieux. Nos observations confirment que les identités de genre et de race ou d’ethnie influent sur les expériences en milieu de travail dans les départements de chirurgie au Canada. Une approche multiniveau aux stratégies d’EDI peut orienter les chefs de département vers les secteurs d’intervention.

Posttraumatic elbow stiffness remains a common and challenging clinical problem. In the setting of a congruent articular surface, the joint capsule is regarded as the major motion-limiting anatomic structure. The affected joint capsule is characterized by irreversible biomechanical and biochemical fibrogenic changes strikingly similar to those observed in many other fibroproliferative human conditions. Studies in humans and preclinical animal models are providing emergent evidence that neuroinflammatory mechanisms are critical upstream events in the pathogenesis of posttraumatic connective tissue fibrogenesis. Maladaptive recruitment and activation of mast cell infiltrates coupled with the aberrant expression of growth factors such as transforming growth factor-beta, nerve growth factor, and neuropeptides such as substance P are common observations in posttraumatic joint contractures and many other fibroproliferative disorders. Blockade of these factors is providing promising evidence that if treatment is timed correctly, the fibrogenic process can be interrupted or impeded. This review serves to highlight opportunities derived from these recent discoveries across many aberrant fibrogenic disorders as we strive to develop novel, targeted antifibrotic prevention and treatment strategies for posttraumatic elbow stiffness.

Background Injuries and resulting stiffness around joints, especially the elbow, have huge psychological effects by reducing quality of life through interference with normal daily activities such as feeding, dressing, grooming, and reaching for objects. Over the last several years and through numerous research results, the myofibroblast-mast cell-neuropeptide axis of fibrosis had been implicated in post-traumatic joint contractures. Pre-clinical models and a pilot randomized clinical trial (RCT) demonstrated the feasibility and safety of using Ketotifen Fumarate (KF), a mast cell stabilizer to prevent elbow joint contractures. This study aims to evaluate the efficacy of KF in reducing joint contracture severity in adult participants with operately treated elbow fractures and/or dislocations. Methods/design A Phase III randomized, controlled, double-blinded multicentre trial with 3 parallel groups (KF 2 mg or 5 mg or lactose placebo twice daily orally for 6 weeks). The study population consist of adults who are at least 18 years old and within 7 days of injury. The types of injuries are distal humerus (AO/OTA type 13) and/or proximal ulna and/or proximal radius fractures (AO/OTA type 2 U1 and/or 2R1) and/or elbow dislocations (open fractures with or without nerve injury may be included). A stratified randomization scheme by hospital site will be used to assign eligible participants to the groups in a 1:1:1 ratio. The primary outcome is change in elbow flexion-extension range of motion (ROM) arc from baseline to 12 weeks post-randomization. The secondary outcomes are changes in ROM from baseline to 6, 24 & 52 weeks, PROMs at 2, 6, 12, 24 & 52 weeks and impact of KF on safety including serious adverse events and fracture healing. Descriptive analysis for all outcomes will be reported and ANCOVA be used to evaluate the efficacy KF over lactose placebo with respect to the improvement in ROM. Discussion The results of this study will provide evidence for the use of KF in reducing post-traumatic joint contractures and improving quality of life after joint injuries. Trial registration This study was prospectively registered (July 10, 2018) with ClinicalTrials.gov reference: NCT03582176 .

Objectives Using a rabbit model of post-traumatic joint contractures, we investigated whether treatment with a mast cell stabilizer after joint injury would lessen the molecular manifestations of joint capsule fibrosis. Methods Surgical joint injury was used to create stable post-traumatic contractures of the knee in skeletally mature New Zealand white rabbits. Four groups of animals were studied: a non-operated control group ( n  = 8), an operated contracture group ( n  = 13) and two operated groups treated with the mast cell stabilizer, ketotifen, at doses of 0.5 mg/kg ( n  = 9) and 1.0 mg/kg ( n  = 9) twice daily. Joint capsule fibrosis was assessed by quantifying the mRNA and protein levels of α-SMA, tryptase, TGF-β1, collagen I and collagen III. Significance was tested using an ANOVA analysis of variance. Results The protein and mRNA levels of α-SMA, TGF-β1, tryptase and collagen I and III were significantly elevated in the operated contracture group compared to control ( p  < 0.01). In both ketotifen-treated groups , protein and mRNA levels of α-SMA, TGF-β1 and collagen I were significantly reduced compared to the operated contracture group ( p  < 0.01). Conclusions These data suggest an inflammatory pathway mediated by mast cell activation is involved in joint capsule fibrosis after traumatic injury.

Background With the exception of normal anatomic changes in the medial collateral ligament and radial head, other factors related to carrying angle changes have not been systematically studied. We reviewed patients who underwent open arthrolysis of the elbow, and evaluated if open arthrolysis could change carrying angle. We then identified factors associated with carrying angle changes. Methods Fifty patients with a minimum of 24 months of follow-up after open arthrolysis were evaluated retrospectively. Preoperative and postoperative carrying angles were compared. Results The carrying angles of 36 elbows in 36 patients were unchanged after surgery (Group A), while the carrying angles of 14 elbows in 14 patients increased postoperatively (Group B). In Group A, mean postoperative extension and flexion were 7° (range 0–24°) and 125° (range 10–135°) respectively, while mean postoperative pronation and supination were 60° (range 50–80°) and 65° (range 30–85°), respectively. In Group B, mean postoperative extension and flexion were 25° (range 0–40°) and 128° (range 60–138°), while mean postoperative pronation and supination were 65° (range 45–85°) and 60° (range 45–75°), respectively. No significant difference in range of motion and Mayo Elbow Performance Score was observed between the two groups. Conclusions During open arthrolysis, humeral trochlea debridement and techniques for improving forearm rotation could increase carrying angle. However, this had no impact on elbow functional recovery.

Our objective is to describe the natural history of motion loss with time and myofibroblast numbers in a rabbit knee model of post-traumatic joint contractures. Twenty-eight skeletally mature New Zealand White female rabbits had five-mm-squares of cortical bone removed from the medial and lateral femoral condyles of the right knee. A Kirschner wire (K-wire) was used to immobilize the knee joint in maximum flexion. A second operation was performed 8 weeks later to remove the K-wire. The rabbits were divided into four groups depending on the time of remobilization; 0, 8, 16 or 32 weeks. The average flexion contracture of the experimental knees in the 0-week and 8-week remobilization groups (38° and 33°, respectively) were significantly greater when compared with the values of the unoperated contralateral knees (8°). The average flexion contractures of the experimental knees in the 16-week and 32-week remobilization groups were also greater than the unoperated contralateral knees, although they were not statistically significant. The average flexion contractures of the 16-week and 32-week groups were 19° and 18°, respectively, indicating a stabilization of the motion loss. Myofibroblast numbers in the posterior joint capsules were elevated 4–5× in the knees with contractures when compared to the contralateral knees. The initial decrease in severity followed by stabilization of motion loss and the association of motion loss with myofibroblasts mimics the human scenario of permanent post-traumatic joint contractures.

Background International guidelines recommend education, exercise, and dietary weight management as core treatments to manage osteoarthritis (OA) regardless of disease severity or co-morbidity. Evidence supports the clinical effectiveness of OA management programs, but the cost-effectiveness of core treatments remains unclear. We will systematically review, synthesize, and assess the literature in economic evaluations of core treatments (education, exercise, and dietary weight management) for the management of hip and/or knee OA. Methods We will search the following elecftronic databases (from inception onwards): MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), National Health Services Economic Evaluation Database, and EconLit. Economic evaluations alongside randomized or nonrandomized clinical trials investigating OA education, exercise, and dietary weight management interventions will be included. Title, abstract, and full text of relevant publications will be screened independently by two reviewers. A content matter expert will resolve any conflicts between two reviewers. Key information from relevant papers will be extracted and tabulated to provide an overview of the published literature. Methodological quality will be evaluated using the Consensus on Health Economic Criteria list. A narrative synthesis without meta-analysis will be conducted. Subgroup analysis will attempt to find trends between research methods, intervention characteristics, and results. Discussion The findings of this review will evaluate the breadth and quality of economic evaluations conducted alongside clinical trials for core treatments in OA management. Systematic review registration PROSPERO CRD42020155964

Background With improving surgical techniques for total elbow arthroplasty clinical outcomes have improved and its utilization continues to increase. Despite these advances, complication rates remain as high as 24%. Of these complications periprosthetic joint infection is one of the most common and morbid. The rheumatoid elbow remains a leading indication for total elbow arthroplasty. Patients with this condition frequently require immunosuppressive therapy, which places them at higher risk of both typical and atypical infections. Case presentation We present the case of a persistent, late-onset periprosthetic joint infection in a total elbow arthroplasty of a 64-year-old Caucasian woman with severe refractory rheumatoid arthritis. The offending pathogen, Aspergillus terreus , is previously unreported in the arthroplasty literature and grew concurrently with coagulase-negative staphylococcus. Eradication of the fungal and bacterial agents involved resection arthroplasty, serial debridement, and multiple courses of intravenous and oral antimicrobial therapy. Two attempts at reimplantation arthroplasty failed to eliminate the infection and our patient ultimately required definitive resection arthroplasty. Conclusions Arthroplasty in the rheumatoid elbow confers with it a high complication rate. Inflammatory disease and immunosuppressive drugs combined with the subcutaneous anatomy of the elbow contribute to the risk of infection. Fungal periprosthetic joint infection in the rheumatoid patient presents both diagnostic and therapeutic challenges. Fungal growth should always be treated and requires organism-specific antimicrobials in conjunction with surgical debridement. More literature is needed to determine the optimal treatment regimen for this devastating complication.