Victorian Order of Nurses

Meniscus injuries often accompany ACL tears, and can lead to many future concerns including an earlier onset of knee osteoarthritis. Meniscus injuries can impact joint load absorption, potentially leading to different landing strategies. In the adult population it has been shown that ten months after surgery there are no differences in jump performance between patients with concomitant meniscus and ACL injury and isolated ACL injury. However, the impact of concomitant injury on landing strategies and whether it is replicated in adolescent patients is still unclear. Considering that young females are among the highest risk for poor landing mechanics and associated ACL injury, we aimed to identify if jump outcomes differ between female patients who had a concomitant meniscus injury versus an isolated ACL injury after they were cleared post-operatively to return to activity (RTA). We conducted a cross-sectional analysis of 30 female adolescent patients who underwent to ACL reconstruction surgery (ACLR). Patients were classified as a concomitant group (meniscus and ACL injury) or an isolated group (only ACL injury). All participants were released by the attending surgeon to return to activity, and performed five trials of countermovement jump on two force plates (Bertec Corp., USA, 1000 Hz). The outcomes measured were the peak of ground reaction force (GRFp) and impulse during the propulsion phase, GRFp and absorption rate (GRFp/time to peak) during the landing phase, and jump height. Data were normalized to the participant's body weight or height. Mann-Whitney U, Independent t-tests, or chi-square tests were used to compare groups for demographic characteristics. A MANOVA was used to identify the difference between groups (isolated vs. concomitant injury). Seventy-seven percent of the patients presented a concomitant meniscus and ACL injury. There was no difference between groups for demographic characteristics, autograft type, or time since surgery (Table 1). The concomitant injury group presented lower GRFp and higher time to GRFp in the injured leg than the isolated injury group (Figure 1A-B). The absorption rate was lower in both legs for the concomitant injury group (Figure 1C-D). Female adolescent patients with a concomitant meniscus and ACL injury present a worse strategy in jump landing than those with isolated ACL injury 9 months post-ACLR. Concomitant meniscus and ACL injury lead to longer landing compensations, which suggests a protective mechanism in favour of the injured leg after ACLR. Therefore, the rehabilitation process and RTA clearance may take longer and require special attention to the landing strategy for those patients who have had surgery for concomitant injury. For any figures or tables, please contact the authors directly.

Prosthetic shoulder infection is the most common reason for revision arthroplasty within two years of the index procedure. Due to the preponderance of indolent and slow-growing infection in shoulder arthroplasty, establishing a diagnosis of infection prior to revision shoulder arthroplasty can be extremely difficult. The aim of this study was to determine the association between specific clinical symptoms and signs as well as nuclear imaging results with culture positive status in revision shoulder arthroplasty. This study is a secondary analysis of a multicenter prospective cohort study involving four sites and 69 patients who underwent revision shoulder arthroplasty. The cohort was 60% female with a mean age of 64 years (range 36–83 years). Outcomes of interest included pre-operative specific clinical symptoms (pain at rest, fevers, chills and sweats); and white blood cell (WBC) nuclear scan results. At least five synovial tissue biopsies from separate regions in the shoulder were obtained intra-operatively during revision surgery. Twenty-three percent of patients (n=16) had confirmed culture positive infections based on the open biopsies. Sixty-four percent of patients presented with pain at rest. Pain at rest (p=0.37), chills (p=0.42), and sweats (p=0.11) were not associated with infection status. Fever was not reported by any patients in the cohort. There was no association between infection status and ESR (p=0.52), CRP (0.11), or WBC (p=0.34). No patients in the cohort had a positive WBC nuclear scan. This study suggests that specific clinical symptoms including pain at rest, systemic symptoms including fevers, chills, or sweats, and WBC bone scan are poorly associated with the presence of infection in revision shoulder arthroplasty. These findings point to the need for novel testing methods to establish the presence of infection in this patient population.

Canadian spine care delivery is in a crisis, largely due to inordinate patient wait times. Relying on the current method of a simple count of patients awaiting surgery leads to disproportionate wait time estimations depending on pathology; for example, patients with scoliosis wait disproportionately longer than those for simple discectomies. Using the The Spinal Invasiveness Score (SIS) to categorize surgeries for organization purposes is a comprehensive solution; it is a validated scoring system that assigns points based on surgical invasiveness across six surgical parameters. These surgical parameters include: Anterior decompression, anterior fusion, anterior instrumentation, posterior decompression, posterior fusion and posterior instrumentation. Waitlists can then be calculated based on SIS score, with additional benefits such as subcategorization of wait times and subsequent initiatives to target certain subcategories of procedures. This study evaluates the perceptions of spine surgeons and hospital administrators regarding the adoption of SIS for spine surgery waitlist management in Canada, focusing on benefits, limitations, and barriers to implementation. A qualitative descriptive study was conducted surveying spine surgeons and hospital administrators across Canada. Participants reviewed a case study comparing the current waitlist model with the SIS-based approach and were surveyed on their preferred method for wait time calculation and asked for insights on the potential advantages and barriers of adopting SIS. Responses were analyzed using thematic analysis to identify recurring themes around SIS's perceived benefits, limitations, and barriers to adoption. Among 21 respondents, 17 (81%) favored the SIS approach over the current system. This group included 9 of 11 surgeons and 8 of 10 administrators, showing robust support across disciplines. Respondents identified several benefits of the SIS approach: Enhanced Prioritization: The SIS model's ability to quantify procedural complexity allows for the subcategorization of waitlists (e.g., multi-level vs. single-level surgeries), facilitating more precise case prioritization. Improved Case Triaging: The SIS system enables more efficient triaging of surgeries based on their complexity, allowing healthcare providers to allocate resources more effectively. Better Waitlist Management: By distinguishing between different types of procedures (e.g., instrumented vs. non-instrumented), the SIS approach supports optimal scheduling and resource distribution. However, barriers identified included difficulty for the health system to capture SIS score for each surgery, cost of implementation and SIS not capturing full complexity of cases such as elevated BMI or revision status. The SIS method received strong support from stakeholders, demonstrating its potential to improve spine surgery waitlist management in Canada. The method allows for more accurate, standardized wait time calculations and better resource allocation. While barriers such as data capture challenges, implementation costs, and limited representation of complex cases remain, the positive feedback suggests that SIS is a viable tool for enhancing current practices. A pilot study in a provincial spine program has shown early success in advocating for more tailored OR scheduling, such as longer OR days to accommodate complex surgeries. With careful implementation and adaptation, SIS could become a key part of nationwide waitlist management strategies.

Femoroacetabular Impingement (FAI) occurs secondary to morphologic abnormalities of the hip joint resulting in abnormal bony contact during functional hip range of motion. It is hypothesized this predisposes the hip joint surface to experience increased stress, load, and increased risk of early osteoarthritis. Longitudinal studies have observed that a significant number of patients with radiographic signs of FAI went on to develop end-stage osteoarthritis or require total hip arthroplasty. There are studies investigating the presence of radiographic features of FAI in asymptomatic patients. However, there is less published literature investigating the presence of radiographic features of FAI in symptomatic patients. The primary objective of this retrospective review is to evaluate the presence of radiographic features of FAI in symptomatic patients and its relationship with global acetabular retroversion (AR) measured on Computed Topography (CT) scan Institutional research ethics board approval was obtained prior to study commencement. A retrospective cohort study was conducted using clinical practice data of a single academic surgeon. Patients who underwent hip arthroscopy for symptomatic FAI between August 2017- August 2024 were screened. Patients with AR, defined as >/= 5 degrees relative to normal published parameters at the 1 o'clock, 2 o'clock and 3 o'clock positions were included. Standard pelvic radiographs were analyzed for radiographic signs of FAI: crossover sign (including crossover percentage), ischial spine sign and empty posterior wall sign. Statistical analysis was performed to determine the sensitivity and specificity of each sign and if there is a relationship between the number of radiographic signs observed on standard pelvic radiographs and acetabular retroversion (AR) measured on CT. Continuous variables were compared using univariate analysis of variance (ANOVA) and linear regression analyses. A total of 200 patients were reviewed and 156 patients were included for analysis. Patients were categorized into globally retroverted (n=48), regionally retroverted (n=64) and normal version (n=44). The presence of 2 radiographic signs in globally retroverted patients were significant for greater acetabular retroversion at the 1- and 2 o'clock positions (p > 0.05), but not at the 3 o'clock position (p = 0.059). A positive crossover sign in isolation was most sensitive at detecting acetabular retroversion at 91.6%. A positive crossover sign percentage greater than 30% was most specific at 86.7%. The presence of three radiographic signs with a crossover percentage greater than 30% increased specificity to 93.3%. Linear regression analysis observed a correlation between crossover percentage and degree of acetabular retroversion at the 1 and 3 o'clock positions (p < 0.05). In this limited retrospective review of patients with symptomatic FAI, radiographic signs of FAI can detect global AR with significant sensitivity and specificity. Our results are comparable to previously described studies investigating their utility in detecting focal retroversion at the 3 o'clock position. Crossover percentage was observed to have a positive association with the extent of AR and may be valuable as a predictive tool. The results of this retrospective review may provide guidance in when to pursue CT imaging in select cases where AR is suspected to inform operative management.

The prevalence of obesity has been steadily increasing over the last two decades1. Total knee arthroplasty (TKA) in the setting of obesity demonstrates increased risk of medical perioperative complications, however there is no conclusive evidence on the impact obesity has on TKA outcomes2,3. The purpose of this study was to investigate the effects of obesity on functional outcomes after TKA in a prospective cohort analysis. Patients undergoing unilateral TKA due to osteoarthritic changes were recruited. Functionality was measured at pre-op, 6 and 12 months post-op using the Forgotten Joint Score-12 (FJS-12) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Two linear-fixed effects models with contrasts were performed examining the impact of obesity (pre-op BMI, treated as a continuous variable) on return to function (FJS-12; WOMAC). Contrasts of estimated marginal means (EMMs) were used to examine functional change over time between various BMI levels (18, 21.75, 27.5, 32.5, 37.5, 42.5) representative of the World Health Organization's BMI classifications (underweight, normal, pre-obesity, obesity class I, II, and III) with pre-obesity serving as the comparison level. Both models controlled for potential effects of age, sex, and two comorbid conditions (diabetes, cardiovascular) that were associated with elevated pre-op BMI. Of the 351 enrolled patients, 296 completed one year follow-up and were included in the analysis. Approximately 61% (n=180) of participants were female, the mean (SD) age was 66.04 (7.64) years, and mean BMI (SD; range) at pre-op was 34.04 (6.93; 18.3, 53.0). Overall mean (SD) FJS-12 scores at pre-op, 6, and 12 months were 11.9 (11.8), 62.7 (27.5), 64.9 (27.9) respectively. Overall mean (SD) WOMAC scores at pre-op, 6, and 12 months were 51 (15.8), 14.1 (15.0), 12.3 (13.9) respectively. No differences were found in length of stay (LOS), readmissions, and ED visits among BMI categories. Compared to the pre-operative score, significant differences by BMI categories were observed for the 6-month FJS-12 (β = −0.66, p = .007) and 12-month WOMAC (β = −0.34, p = .021) scores. For example, at 6 months a greater change in FJS-12 score was observed for those with lower levels of BMI compared to those with higher levels of BMI. However, by 12 months, all patients appeared to return to functional levels regardless of BMI level. Despite a slower return to function, patients with elevated BMI are able to return to similar levels of function to those with a lower BMI by 12 months. We did not find any significant differences in readmission, ED visits, or LOS. This similar return to function justifies candidacy for surgery.

Prior studies assessing performance in National Hockey League (NHL) players following hip arthroscopy have relied on traditional statistics (goals, assists, points) which are influenced by randomness, coaching strategy, usage, teammate performance, game script, and other factors that can lead to systematic misjudgement. Our objective was to assess performance in NHL players following hip arthroscopy using advanced statistics that do not have the shortcomings of traditional statistics. NHL players who underwent hip arthroscopy between 2008 and 2022 were identified through a publicly available injury database. Demographic and outcome data were collected for the one-year period preceding and the two-year period following surgery. Our primary outcome measure was wins above replacement per 60 minutes played (WAR/60), with secondary outcomes including offensive and defensive goals above replacement per 60 minutes played. A matched cohort was created based on position, draft year, and index season performance. Pre- and post-injury outcomes were compared using a paired T-test. Thirty-three players underwent 38 eligible procedures. Preinjury, postinjury year one, and postinjury year two WAR/60 were 0.055, 0.016, 0.02 in cases (p=0.007, p=0.019 compared to preinjury) and 0.061, 0.049, and 0.037 in controls (p=0.60, p=0.046, p=0.468) compared to cases). Offensive goals above replacement per 60 minutes played was decreased compared to presurgery one- and two-years post-surgery but only performance two years post-surgery met statistical significance (p=0.46, p=0.01). Defensive goals above replacement per 60 minutes played was decreased compared to presurgery at postsurgery year one and two, but only performance in year one was statistically significant (p=0.00, p=.19). Postinjury defensive goals above replacement per 60 minutes played was significantly decreased compared to controls at postinjury year one (p=0.004) National Hockey League performance declines one year following hip arthroscopy. This is driven by decreased defensive performance. Performance recovers by postinjury year two.

Patellofemoral instability (PFI) is a common musculoskeletal disorder involving lateral patellar subluxation or dislocation. This condition occurs most commonly during adolescence, with over 50% of this demographic experiencing recurrent dislocations, which can lead to longstanding issues [1]. Morphologic features in the knee have been associated with increased risk of injury or pathology [2], however, the ability to measure PF joint function in vivo is challenging. Therefore, this research seeks to use patient-specific knee models to investigate variability in knee mechanics between adolescents with and without a history of PFI during dynamic tasks. Six adolescents (three controls and three with a history of PFI) were enrolled in this study. An MRI of the dominant or symptomatic knee was obtained, and the patients subsequently underwent gait and lunge trials at the human movement biomechanics laboratory. The MRIs were segmented to produce a patient-specific model of the bone and cartilage of the femur, tibia and patella. These models were then integrated into a validated musculoskeletal model. The participant's gait and lunge trials were then simulated through inverse kinematics. The cartilage contact pressure and knee kinematics were calculated using the Concurrent Optimization of Muscle Activations and Kinematics (COMAK) routine [3]. The resulting knee kinematics and contact mechanics in both the tibiofemoral (TF) and PF joints were compared throughout the tasks to assess the variability of functional knee mechanics between individuals with and without PFI. The findings from this research emphasized changes in joint kinematics and cartilage contact pressure during dynamic tasks between the two groups. At the PF joint, the PFI participants displayed higher instances of lateral patellar translation compared to the control participants during stance phase (U = 491, P-value = < 0 .001), lunge descent (U = 1273, P-value = < 0 .001), and lunge ascent (U = 0, P-value = < 0 .001; Fig. 1). Furthermore, they displayed lower cartilage contact pressure compared to the control participants during stance phase (U = 6474, P-value = < 0 .001), and lunge ascent (U = 7356, P-value = < 0 .001), as well as a much lower contact area that is more medially located for all three movements (Fig. 2). These findings agree with previous studies regarding biomechanical variations in PFI populations [4]. In summary, there were noticeable differences in PF biomechanics in terms of both kinematic and kinetic measures between the two models. In these preliminary results from an ongoing study, there were noticeable differences in PF biomechanics in terms of both kinematic and kinetic measures between the two groups. Due to the difficulties of analysing PF biomechanics in vivo, this study demonstrates how these models can be used to improve our understanding of PF (dys)function to help guide injury prevention and surgical intervention strategies. For any figures or tables, please contact the authors directly.

Abstract Background Neuropsychiatric symptoms (NPS) constitute a major challenge for patients with Alzheimer's disease (AD). We explored NPS clusters in AD and longitudinally evaluated their association with function and structural neuroimaging markers. Method Participants with AD ( N = 111) were included from the Ontario Neurodegenerative Disease Research Initiative. NPS were assessed using the Neuropsychiatric Inventory Questionnaire (NPI‐Q). NPS clusters were identified through exploratory factor analysis at baseline. We evaluated 34 bilateral cortical regions of interest (ROIs) and 9 bilateral subcortical ROIs using volumetric information from MRI data evaluated annually over 3 years. We examined longitudinal associations between NPS clusters with basic (ADLs) and instrumental (iADLs) activities of daily living, as well as with subcortical and cortical volumes, using mixed linear regression models controlling for age, sex, MoCA, education level, and visit number. Result Factor analysis identified four symptom clusters explaining 62% of the variance. These were labeled “behavioral” (disinhibition, irritability, motor disturbance, and agitation), “psychotic” (hallucinations, delusions, and euphoria), “neurovegetative” (apathy and appetite), and “affective” (depression, anxiety, nighttime behavior) clusters. The “behavior” cluster was longitudinally associated with left middle temporal (β = ‐382.6, p = .006), right lingual (β = ‐456.0, p = .01), right nucleus accumbens (β = ‐5656.6, p = .004), and right thalamic (β = ‐700.7, p = .008) volumes. The “neurovegetative” cluster was longitudinally associated with left fusiform (β = ‐195.4, p = .03), left middle temporal (β = ‐282.3, p = .001), and right nucleus accumbens (β = ‐3176.7, p = .01). The “affective” cluster was associated with left rostral anterior cingulate (β = ‐1423.4, p = .0003), right entorhinal (β = ‐804.3, p = .03), right medial orbitofrontal (β = ‐830.6, p = .001), right pars opercularis (β = ‐911.6, p = .001), and left putamen (β = ‐729.5, p = .004) volumes. Longitudinally, all clusters predicted iADL outcomes and clusters 1, 3, and 4 predicted ADL outcomes. Greater NPS burden, male sex, visit number, older age, and lower MoCA predicted worse function. Conclusion NPS clusters in AD separate into behavioral, psychotic, neurovegetative, and affective dimensions. These clusters demonstrate unique associations with function and neuroimaging markers.

BackgroundSingle doses of mivelsiran, an investigational RNA interference (RNAi) therapeutic, have demonstrated robust amyloid‐beta precursor protein (APP) lowering in the CNS. We report additional interim safety and pharmacodynamic data in patients with early‐onset Alzheimer’s disease (EOAD) who received single ascending doses (SAD) and, for the first time, multiple doses of mivelsiran in the ongoing Phase 1 study (NCT05231785).MethodsPatients with EOAD (symptom onset <65 years of age, Clinical Dementia Rating global score 0.5 or 1.0, Mini‐Mental State Examination score >20) were randomized to a single intrathecal dose of mivelsiran 25–100mg or placebo for 6 months (plus up to 6 months follow‐up if needed for washout). After washout, patients could enter a separate multiple ascending dose (MAD) portion and receive open‐label mivelsiran. Presented here are data from a SAD cohort of mivelsiran 100mg and a MAD cohort of mivelsiran 50mg every 6 months (Q6M). Frequency of adverse events (AEs) and pharmacodynamics were primary and secondary endpoints, respectively.ResultsForty‐five patients were enrolled in SAD cohorts (as of 11/20/2024). Of those, 9 patients were randomized to mivelsiran 100mg or placebo (mean [SD] age, 64.1 [3.7] years; 33.3% male; 100% white). Most AEs were mild or moderate. Peak mean (SE) change from baseline in cerebrospinal fluid (CSF) soluble APP beta (sAPPβ) at Month 1 (─84.5% [1.3]) was largely sustained through Month 10 (─61.1% [2.8]).After meeting washout criteria, 10 patients from SAD cohorts received mivelsiran 50mg Q6M (mean [SD] age, 59.9 [4.4] years; 70.0% male; 70.0% white). No serious or severe AEs were reported. At Day 15 after the first dose, mean (SE) change from baseline in CSF sAPPβ was ─63.7% (5.0); at Month 1 after the second dose, change was ─83.8% (2.3). Additional data will be presented.ConclusionsIn this first report of multiple‐dose clinical data for a CNS‐targeting RNAi therapeutic, single and multiple doses of mivelsiran were generally well tolerated and continued to demonstrate robust, durable, dose‐dependent CSF sAPPβ reductions. Further sAPPβ lowering was observed after a second dose of mivelsiran 50mg. These results support further evaluation of mivelsiran in patients with Alzheimer’s disease or cerebral amyloid angiopathy.