Ong J, Godfrey R, Nazarian A, Tam J, Isaacson B, Pasquina P, Williams D

Bacterial biofilms readily develop on all medical implants, including percutaneous osseointegrated (OI) implants. With the growing rate of antibiotic resistance, exploring alternative options for managing biofilm-related infections is necessary. Antimicrobial blue light (aBL) is a unique therapy that can potentially manage biofilm-related infections at the skin-implant interface of OI implants. Antibiotics are known to have antimicrobial efficacy disparities between the planktonic and biofilm bacterial phenotypes, but it is unknown if this characteristic also pertains to aBL. In response, we developed experiments to explore this aspect of aBL therapy.

aBL had the most significant efficacy disparity between the planktonic and biofilm phenotypes (a 2.5 log10 unit difference). However, further testing against biofilms revealed that aBL had a positive correlation between increasing efficacy and exposure time, while levofloxacin encountered a plateau. While aBL efficacy was affected the most by the biofilm phenotype, its antimicrobial efficacy did not reach a maximum.

We determined that phenotype is an important characteristic to consider when determining aBL parameters for treating OI implant infections. Future research would benefit from expanding these findings against clinical S. aureus isolates and other bacterial strains, as well as the safety of long aBL exposures on human cells.

Ong J, Godfrey R, Nazarian A, Tam J, Isaacson BM, Pasquina PF and Williams DL (2023) Comparison of Staphylococcus aureus tolerance between antimicrobial blue light, levofloxacin, and rifampin. Front. Microbiol. 14:1158558. doi: 10.3389/fmicb.2023.1158558

Nowak A, Kennelley G, Hager N, Metzger E, Isaacson B, hoenig T, Hollander K, Tenforde A

We enjoyed reading the articles by Abbott, et al. that cover the important topic of stress fractures in female military personnel “Part I: Background and Clinical Considerations for Stress Fractures in Female Military Recruits” and “Part II: Risk Factors for Stress Fractures in Female Military Recruits.” Both reviews identify that female military personnel are at a greater risk for stress fractures during training than their male counterparts and detail unique risk factors that are a necessary consideration in optimizing management. While we congratulate the authors for this detailed work, it is important to highlight additional research that adds to our understanding of this injury and the approach for management and prevention of these injuries.

Andrew S Nowak, Gabrielle E Kennelley, Nelson Hager, Elizabeth C Metzger, Brad Isaacson, Tim Hoenig, Karsten Hollander, Adam S Tenforde, Stress Fractures in the Military: Opportunities to Advance Recognition, Treatment, and Prevention, Military Medicine, Volume 188, Issue 9-10, September/October 2023, Pages 244–245, https://doi.org/10.1093/milmed/usad067

Negri LB, mannaa y, Korupolu S, farinelli w, anderson r, Gelfand J

Cutaneous bacterial wound infections typically involve gram-positive cocci such as Staphylococcus aureus (SA) and usually become biofilm infections. Bacteria in biofilms may be 100–1000-fold more resistant to an antibiotic than the clinical laboratory minimal inhibitory concentration (MIC) for that antibiotic, contributing to antimicrobial resistance (AMR). AMR is a growing global threat to humanity. One pathogen–antibiotic resistant combination, methicillin–resistant SA (MRSA) caused more deaths globally than any other such combination in a recent worldwide statistical review. Many wound infections are accessible to light. Antimicrobial phototherapy, and particularly antimicrobial blue light therapy (aBL) is an innovative non-antibiotic approach often overlooked as a possible alternative or adjunctive therapy to reduce antibiotic use. We therefore focused on aBL treatment of biofilm infections, especially MRSA, focusing on in vitro and ex vivo porcine skin models of bacterial biofilm infections. Since aBL is microbicidal through the generation of reactive oxygen species (ROS), we hypothesized that menadione (Vitamin K3), a multifunctional ROS generator, might enhance aBL. Our studies suggest that menadione can synergize with aBL to increase both ROS and microbicidal effects, acting as a photosensitizer as well as an ROS recycler in the treatment of biofilm infections. Vitamin K3/menadione has been given orally and intravenously worldwide to thousands of patients. We conclude that menadione/Vitamin K3 can be used as an adjunct to antimicrobial blue light therapy, increasing the effectiveness of this modality in the treatment of biofilm infections, thereby presenting a potential alternative to antibiotic therapy, to which biofilm infections are so resistant.

Yan M, Wu M

Exercise, especially anaerobic one, can gradually increase muscle mass over time as a result of adaptive responses of muscle cells to ensure metabolic homeostasis in the tissue. Low-level light therapy (LLLT) or photobiomodulation exhibits beneficial effects on promoting muscular functions, regeneration, and recovery from exhausting exercise, although the underlying cellular mechanisms remain poorly understood. We found that hypoxia, a condition following anaerobic exercise, significantly impeded myotube differentiation from myoblasts. However, this adverse effect was blunted greatly by pre-exposure of myoblast cells to a 980 nm laser at 0.1 J/cm2 , resulting in almost nearly normal myotube differentiation. LLL pre-treatment enhanced myotube formation by 80%, with a tubular diameter of 4.28 ± 0.11 μm on average, representative of a 53.4% increase over sham light treatment. The normalized myoblast differentiation concurred with 68% more mitochondrial mass and myogenin expression over controls. Moreover, LLL pre-treatment appeared to enhance glucose uptake, prevent energy metabolic switch from oxidative phosphorylation to glycolysis, and diminish lactate production under hypoxic conditions. The observation provides valuable guidance with respect to the timing of LLLT and its potential effects on muscle strengths in concert with anaerobic exercise.

Yan, M., & Wu, M. X. (2023). Low-Level Light Pre-Conditioning Promotes C2C12 Myoblast Differentiation Under Hypoxic Conditions. Journal of Biophotonics. https://doi.org/10.1002/jbio.202100246

Ong J, Godfrey R, Nazarian A, Tam J, Drake L, Isaacson B, Pasquina P, Williams D

Biofilm contamination is often present at the skin-implant interface of transfemoral osseointegrated implants leading to frequent infection, irritation, and discomfort. New biofilm management regimens are needed as the current standard of washing the site with soap and water is inadequate to manage infection rates. We have investigated the potential of antimicrobial blue light which has reduced risk of resistance development and broad antimicrobial mechanisms. Our lab has developed an aBL device uniquely designed for an ex vivo system based on an established ovine OI implant model with Staphylococcus aureus ATCC 6538 biofilms as initial inocula. Samples were irradiated with aBL or washed for three consecutive days after which they were quantified. Colony forming unit (CFU) counts were compared to a control group (bacterial inocula without treatment). After one day, aBL administered as a single 6 h dose or two 1 h doses spaced 6 h apart both reduced the CFU count by 1.63 log10 ± .02 CFU. Over three days of treatment, a positive aBL trend was observed with a maximum reduction of ~2.7 log10 CFU following 6 h of treatment, indicating a relation between multiple days of irradiation and greater CFU reductions. aBL was more effective at reducing the biofilm burden at the skin-implant interface compared to the wash group, demonstrating the potential of aBL as a biofilm management option.

Ong, J., Godfrey, R., Nazarian, A., Tam, J., Drake, L., Isaacson, B., Pasquina, P., & Williams, D. (2023). Antimicrobial Blue Light as a Biofilm Management Therapy at the Skin-Implant Interface in an Ex Vivo Percutaneous Osseointegrated Implant Model. Journal of Orthopaedic Research. https://doi.org/10.1002/jor.25535

Yuan X, Pav V, Colahan C, Miller M, Nelson H, Pasquina P, Cohen S, Isaacson B

Low back pain (LBP) has accounted for the most medical encounters every year for the past decade among Active-Duty Service Members (ADSMs) of the U.S. Armed Forces. The objectives of this retrospective, descriptive study was to classify LBP by clinical category (Axial, Radicular, and Other) and duration (Acute, Subacute, and Chronic) and examine the LBP-related health care utilization, access to care, and private sector costs for ADSMs over a 2-year follow-up period. The Military Health System Data Repository was queried in fiscal year 2017 for all ADSMs (ages 18-62) with outpatient encounters documented with any of 67 ICD-10 diagnosis codes indicative of LBP. A 1-year clean period before the first (index) outpatient LBP encounter date was used to ensure no recent history of LBP care. Patients were eligible if continuously enrolled and on active duty for 1 year before and 2 years following the index visit. Patients were excluded for non-musculoskeletal causes for LBP, red flags, or acute trauma within 4 weeks of the index visit and/or systemic illness or pregnancy anytime during the clean or follow-up period.

Yuan, X., Pav, V., Colahan, C., Miller, M. E., Hager, N. A., Pasquina, P. F., Cohen, S. P., & Isaacson, B. M. (2022). Active-Duty Service Members Newly Presenting with Low Back Pain in Fiscal Year 2017: Health Care Utilization, Access to Care, and Private Sector Costs Over 2-year Follow-up. Military Medicine. https://doi.org/10.1093/milmed/usac363

Cohen S, Khunsriraksakul c, Yoo y, Parker E, Samen-Akinsiku c, Patel n, Cohen s, Yuan x, Cheng j, Moon j

Ketamine infusions are frequently employed for refractory complex regional pain syndrome (CRPS), but there are limited data on factors associated with treatment response. Sympathetic blocks are also commonly employed in CRPS for diagnostic and therapeutic purposes and generally precede ketamine infusions.

Factors associated with a positive response to ketamine in univariable analysis were the presence of SMP (61.0% success rate vs 26.7% in those with sympathetically independent pain; P = .009) and post-block temperature increase (5.66 ± 4.20 in ketamine responders vs 3.68 ± 3.85 in non-responders; P = .043). No psychiatric factor was associated with ketamine response. In multivariable analysis, SMP (OR 6.54 [95% CI 1.83, 23.44]) and obesity (OR 8.75 [95% 1.45, 52.73]) were associated with a positive ketamine infusion outcome.

The response to sympathetic blocks may predict response to ketamine infusion in CRPS patients, with alleviation of the affective component of pain and predilection to a positive placebo effect being possible explanations.

Pain Medicine, Volume 24, Issue 3, March 2023, Pages 316–324, https://doi.org/10.1093/pm/pnac153

Rhon D, Yuan X, Barlow B, Konitzer L, Cook C

Within a large government health system, to assess the practice of using non-specific diagnoses for knee disorders and determine how often they appear as the only diagnosis without more specificity. The secondary purpose was to identify the incidence of obscure knee disorders diagnosed: pes anserine bursitis, prepatellar bursitis, pigmented villonodular synovitis, and plica syndrome.

Rhon, Daniel & Yuan, Xiaoning & Barlow, Brian & Konitzer, Lisa & Cook, Chad. (2022). Use of Non-Specific Knee Diagnoses and Incidence of Obscure Knee Injuries in a Large Government Health System. Clinical Epidemiology. Volume 14. 1123-1133. https://doi.org/10.2147/CLEP.S375040

Tenforde A, Vogel K, Tam J, Grävare Silbernagel K

Achilles tendinopathy (AT) is a common overuse injury in runners. While the mainstay of treatment for AT is tendon loading exercises (physical therapy and exercise programme (EXER)), some patients have refractory symptoms. Extracorporeal shockwave therapy (ESWT) and photobiomodulation therapy (PBMT) have each been evaluated to facilitate tendon healing; the influence of combining treatments is unknown and limited studies have been completed in runners. This randomized control study, with an elective cross-over at 3 months, will evaluate the efficacy of three forms of treatment of non-insertional AT: (1) EXER (loading programme specific to Achilles tendon combined with physical therapy); (2) EXER and ESWT; (3) EXER, ESWT and PBMT. Sixty runners will be assigned using block randomization into one of three treatment groups (n=20). After 3 months, each participant may elect a different treatment than previously assigned and will be followed for an additional 3 months. The EXER Achilles loading programme will be standardized using the Silbernagel at-home programme. The primary outcome of interest is treatment group responses using the Victorian Institute of Sports Assessment—Achilles (VISA-A) Score. Secondary outcomes include the Patient-Reported Outcomes Measurement Information System—29 questions, the University of Wisconsin Running Injury and Recovery Index, heel raise to fatigue test, hopping test and ultrasound measurements. We will also capture patient preference and satisfaction with treatment. We hypothesize that the cohorts assigned EXER+ESWT+PBMT and EXER+ESWT will see greater improvements in VISA-A than the EXER cohort, and the largest gains are anticipated in combining ESWT+PBMT. The elective cross-over phase will be an exploratory study and will inform us whether patient preference for treatment will impact the treatment response.

Tenforde, A. S., Vogel, K. E. L., Tam, J., & Grävare Silbernagel, K. (2022). Research protocol to evaluate the effectiveness of shockwave therapy, photobiomodulation and physical therapy in the management of non-insertional Achilles tendinopathy in runners: a randomized control trial with elective cross-over design. BMJ Open Sport & Exercise Medicine. https://doi.org/http://dx.doi.org/10.1136/bmjsem-2022-001397

Rhon D, Teyhen D, Collins G, Bullock G

Abstract submitted to The World Congress of Sports Physical Therapy 2022

Using the same data, compare performance between an injury prediction model categorizing predictors and one that did not, and compare selection of predictors based on univariate significance versus assessing non-linear relationships. Validation and replication of a previously developed injury prediction model in a cohort of 1466 healthy military service members followed for one year after physical performance, medical history, and sociodemographic variables were collected. The original model dichotomized 8 predictors. The second model (M2) kept predictors continuous but assumed linearity, the third model (M3) conducted non-linear transformations. The fourth model (M4) chose predictors the proper way (clinical reasoning and supporting evidence) which led to an addition of 7 additional predictors (15 predictors total), but still kept predictors dichotomized. Model performance was assessed with R2, calibration in the large, calibration slope, and discrimination. Decision curve analyses were performed with risk thresholds from 0.25 to 0.50.

Rhon, D. I., Teyhen, D. S., Collins, G. S., & Bullock, G. S. (2022). Predictive Models for Musculoskeletal Injury Risk: Why statistical Approach Makes All the Difference. BMJ Open Sport & Exercise Medicine. https://doi.org/10.1136/bmjsem-2022-001388

Foster K, Greenlee T, Fraser J, Young J, Rhon D

Investigate the burden of knee, hip, and lumbar spine disorders occurring in the year following an ankle sprain and the influence therapeutic exercise (TE) has on this burden. 33,361 individuals diagnosed with ankle sprain in the Military Health System between 2010 and 2011 were followed for 1 year. Prevalence of knee, hip, and lumbar care-seeking injuries sustained after sprain was identified. Relationships between demographic groups, ankle sprain type, and use of TE with rate of proximal injuries were evaluated using Cox Proportional Hazard Models to determine Hazard Rate effect modification by attribute. Observed impact of TE for ankle sprain on rate of injury to proximal joints was evaluated using Kaplan-Meier survival analyses.

Foster, K. S., Greenlee, T. A., Fraser, J. J., Young, J. L., & Rhon, D. I. (2022). The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury. Medicine & Science in Sports & Exercise. https://doi.org/10.1249/MSS.0000000000003035

Foster K, Greenlee T, Young J, Janney C, Rhon D

Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70-2.79), increasing age (OR 1.03, 95% CI 1.02-1.04), female sex (OR 1.58, 95% CI 1.28-1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03-1.09), female sex (OR 2.73, 95% CI 1.74-4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03-2.89), and active-duty status (OR 2.28, 95% CI 1.38-3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28-0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries

Foster, K. S., Greenlee, T. A., Young, J. L., Janney, C. F., & Rhon, D. I. (2022). How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury? The Journal of Knee Surgery. https://doi.org/10.1055/s-0042-1751246

Powell J, Sparling T, Yuan X

Globally, 57.7 million people lived with traumatic limb loss in 2017, with the prevalence of amputation in the United States alone expected to reach 3.6 million by 2050. Pain is a common complication after limb loss, with up to 59% of patients experiencing residual limb pain (RLP). Although RLP is often due to a structural etiology, it is difficult to treat, as the exact structure involved is frequently not apparent on history and physical exam alone. This narrative review aims to summarize the available literature on diagnostic ultrasound (US) of the residual limb and examine the utility of US in identifying specific pathology. A total of 31 peer-reviewed manuscripts published between 1989 and 2021 were included, grouped by pathology. While US presents a promising and cost-effective approach to identifying pathology within the residual limb, many gaps remain in the current knowledge, and no specific protocol for a sonographic assessment of the residual limb has ever been proposed. Future studies of diagnostic US of the residual limb should focus on replicable sonographic techniques and standardized exam protocols.

Powell, J. E., Sparling, T. L., & Yuan, X. (2022). Diagnostic Ultrasound of the Residual Limb: A Narrative Review. PM&R. https://doi.org/10.1002/pmrj.12896

Pendlebury G, Rimmert B, Yuan X

Ischiofemoral impingement (IFI) is an uncommon etiology of hip pain, first reported in three patients after total hip arthroplasty and proximal femoral osteotomy. IFI is defined as a narrowing of the ischiofemoral space (IFS) between the lesser trochanter and ischium, leading to edema of the quadratus femoris (QF) muscle and sciatic nerve compression. Abnormalities of the QF may lead to hip, buttock, and groin pain radiating distally from the posterior thigh, likely due to irritation of the sciatic nerve adjacent to the QF.² Existing literature on this condition is limited, including case reports of congenital variants in women and children.³ We report the case of a 50-year-old woman with chronic right hip pain who was diagnosed with ischiofemoral impingement syndrome (IFIS) by physical examination findings and magnetic resonance imaging (MRI) results.

Pendlebury, G., Rimmert, B., & Yuan, X. (2022). Ischiofemoral Impingement Syndrome: Case Report and Treatment Review. Practical Pain Management

Yuan X, Lowder R, Avilles- Wetherell K, Skroce C, Yao K, Soo Hoo J

Rehabilitation is the key to management of patients with subacromial impingement syndrome to prevent disability and loss of function. While point-of-care musculoskeletal ultrasound aids clinical diagnosis of subacromial impingement syndrome, many patients do not demonstrate the classic findings of dynamic supraspinatus tendon impingement beneath the acromion on ultrasound. The objective of this study was to establish the most reliable shoulder ultrasound measurements for subacromial impingement, by evaluating the intra-rater and inter-rater reliability of measurements in asymptomatic participants.

Yuan, X., Lowder, R., Aviles-Wetherell, K., Skroce, C., Yao, K. V., & Soo Hoo, J. (2022). Reliability of point-of-care shoulder ultrasound measurements for subacromial impingement in asymptomatic participants. Frontiers in Rehabilitation Science. https://doi.org/10.3389/fresc.2022.964613

Persinger J and Hager N

The Physical Medicine and Rehabilitation Clinic (PM&R) at Walter Reed National Military Medical Center (WRNMMC) augmented their high frequency ultra-sound systems with an ultra-high frequency ultrasound(UHFUS) system for use in the diagnosing and treatment of musculoskeletal (MSK) and nerve injury warfighters. The Visualsonics VevoMD is an UHFUS system with operating frequencies in the 24–70 MHz range as compared to the typical POC and tertiary care ultrasound systems operating in the15–22 MHz range. Access to this system afforded a unique opportunity to explore the usefulness of this cutting-edge technology in the unique settings of limb loss and multi-trauma in the military.

Persinger, J. E., & Hager, N. (2022). Unique Diagnostic Capabilities and Impact of Ultra-High Frequency Ultrasound in the Musculoskeletal Clinical Setting. Journal of Ultrasound in Medicine. https://doi.org/https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.16028

Cook C, Zhou L, Bolognesi M, Sheean A, Barlow B, Rhon D

Concomitant cruciate and meniscus injuries of the knee are generally associated with acute trauma and commonly treated with surgical intervention. Comorbidities (simultaneous presence of two or more medical conditions) may be acquired from changes in activity levels and lifestyle after an injury and/or treatment. This study aimed to compare differences in comorbidity proportions between surgical and nonsurgical approaches in Military Health System beneficiaries who had concurrent cruciate and meniscus injuries. The retrospective case control design included 36-month data that were analyzed to reflect 12 months prior to injury/surgery and 24 months after injury/surgery. A comparison of differences within and between groups in surgical and nonsurgical approaches was calculated and logistic regression was used to determine if surgery increased or decreased the odds of comorbidities at 24 months. In our sample of 2,438 individuals with concurrent meniscus and cruciate injury, 79.1% (n¼1,927) received surgical intervention and 20.9% (n¼511) elected for nonoperative management. All comorbidities demonstrated significant within-group differences from pre- to post surgery for those with a surgical intervention; approximately, half the comorbidities increased (i.e., concussion or traumatic brain injury, insomnia, other sleep disorders, anxiety, posttraumatic stress disorder, and tobacco abuse disorder), whereas the other half decreased (i.e., chronic pain, apnea, cardiovascular disease, metabolic syndrome, mental health other, depression, and substance abuse disorders). The odds of acquiring a comorbid diagnosis after surgery reflected the bivariate comparisons with half increasing and half decreasing in odds. To our knowledge, this is the first study to explore comorbidity changes with a control group for individuals with concurrent meniscus and cruciate injuries.

Cook, C. E., Liang, Z., Bolognesi, M., Sheean, A. J., Barlow, B. T., & Rhon, D. I. (2022). Does Surgery for Concomitant Cruciate and Meniscus Injuries Increase or Decrease Subsequent Comorbidities at 2 Years? The Journal of Knee Surgey. https://doi.org/10.1055/s-0042-1750046

Rhon D, Greenlee T, Carreño P, Patzkowski J, and Highland K

Most individuals undergoing elective surgery expect to discontinue opioid use after surgery, but many do not. Modifiable risk factors including psychosocial factors are associated with poor postsurgical outcomes. We wanted to know whether pain catastrophizing is specifically associated with postsurgical opioid and health-care use.

Rhon, D. I., Greenlee, T. A., Carreño, P. K., Patzkowski, J. C., & Highland, K. B. (2022). Pain Catastrophizing Predicts Opioid and Health-Care Utilization After Orthopaedic Surgery A Secondary Analysis of Trial Participants with Spine and Lower-Extremity Disorders. The Journal of Bone and Joint Surgery. https://doi.org/10.2106/JBJS.22.00177

Rhon D and Tucker C

Orthopaedic surgery has revolutionized the expectations for restoration of physical function after musculoskeletal injury and, along with physical therapy, has transformed the limits of recovery. Many orthopaedic procedures have a high success rate for improving quality of life and patient-reported outcomes, yet these procedures carry some level of risk, including postoperative complications. The stepped-care model of health care delivery, when applied to musculoskeletal care, recommends implementing less-intense and lower-risk treatments with known efficacy, such as promotion and education of self-management strategies and physical therapy, before more-invasive and higher-risk treatments such as surgery. This model of managing musculoskeletal disability can improve efficiency of care delivery and reduce medical costs at the health system level. Unfortunately, there is a documented lack of implementing an appropriate course of conservative care, especially physical therapy, prior to surgery across multiple orthopaedic disciplines including sports, spine, and trauma medicine and joint arthroplasty. Failure to respond to nonsurgical treatment has been suggested as a requisite component of the surgical appropriateness criteria, yet practical application can be elusive. Multiple barriers to adequate utilization of conservative treatment exist, including U.S. payment models that increase out-of-pocket expense for patients, negative patient perception of therapy, unreasonable patient expectations from therapy versus surgery, and communication barriers between patient, surgeon, and therapist. Surgeons should ensure that high-quality guidelineappropriate care is delivered early and adequately to their patients. Rehabilitation professionals have a responsibility to deliver high-value care, properly documenting the type and extent of treatment to improve surgical decision-making between surgeons and patients. Criteria to determine appropriateness for surgery should include a standardized and extensive assessment of failed therapies prior to certain elective surgeries. Improved collaboration between surgeons and rehabilitation professionals can result in improved outcomes for patients with musculoskeletal disorders.

Rhon, D. I., & Tucker, C. J. (2022). Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes. Arthroscopy, Sports Medicine, and Rehabilitation. https://doi.org/10.1016/j.asmr.2021.09.038

Tropf J, Colantonio D, Tucker C, Rhon D

Meniscus injuries occur at a higher rate in the military than the general population. Appropriate management and rehabilitation of meniscus injuries is important for maintaining readiness. The purpose of this study was to describe the health burden of meniscus injuries in the Military Health System (MHS) to identify the surgical intervention rate for meniscus injuries, and to determine which injury characteristics and demographic variables were associated with the likelihood of surgery after injury. The U.S. Department of Defense Management Analysis and Reporting Tool, a database of health care encounters by military personnel and dependents, was queried for encounters associated with a meniscal injury diagnosis between January 1, 2010, and December 31, 2011. Meniscus injuries were categorized into (1) isolated medial, (2) isolated lateral, (3) combined medial and lateral, and (4) unspecified cohorts. Patients under 18 and over 51 years were excluded, as well as patients without records at least 1 year prior to diagnosis or 2 years after. Relevant surgical procedures were identified with the Current Procedural Terminology (CPT) codes for arthroscopic surgery of the knee, meniscus repair, meniscectomy, and anterior cruciate ligament (ACL) reconstruction. There were 2,969 meniscus injuries meeting inclusion criteria during the study period. There were 1,547 (52.1%) isolated medial meniscus injuries, 530 (17.9%) isolated lateral meniscus injuries, 452 (15.3%) involved both menisci, and 435 (14.7%) were unspecified. The mean age was 35.5 years (standard deviation [SD] ¼ 9.3). An adjacent ligamentous injury occurred in 901 patients (30.3%). The treatment course led to arthroscopic surgery in 52.8% (n ¼ 1,568) of all meniscus injuries. Eighty-five percent (n ¼ 385) of combined medial and lateral tears, 54.9% of medial tears, and 51.6% of lateral tears underwent surgery. Partial meniscectomy was the most common procedure performed while 47.2% (n ¼ 1,401) of tears were not treated surgically. Bilateral meniscus injuries had 4.57 greater odds of undergoing knee arthroscopy (95% confidence interval [CI]: 3.46, 6.04), 2.42 times odds of undergoing a meniscus repair, and 4.59 times odds for undergoing a meniscus debridement (95% CI: 3.62, 5.82). The closed nature of the MHS allows reliable capture of surgical rates for meniscus injuries within the military population. Meniscus injuries are common in the military and impose a significant burden on the MHS. Appropriate management and rehabilitation of this injury is important for maintaining readiness.

Tropf, J. G., Colantonio, D. F., Tucker, C. J., & Rhon, D. I. (2022). Epidemiology of Meniscus Injuries in the Military Health System and Predictive Factors for Arthroscopic Surgery. The Journal of Knee Surgery. https://doi.org/10.1055/s-0042-1744189