The aim of the study was to investigate the relationship between a fatigue-induced increase of perceived exertion in the neck with a decrease of mean power frequency (MPF) in the surface electromyography (sEMG) signal during repeated shoulder elevation endurance tasks. About Thirty-two healthy women (age range 20-62) performed two maximum 6-min shoulder elevation endurance tasks at 30% of their maximal voluntary contraction (MVC) level, separated by a rest of 6 min. During these exercises, perceived exertion was estimated using the Borg scale (range 0-10), whereas the MPF of the sEMG signal from the upper trapezius was simultaneously detected. Linear regression analysis was applied over time for each trial and subject for both MPF and Borg scale rating values. The MPF was normalized by the intercept of the linear regression analysis. The resulting slopes of normalized mean power frequency (nMPF) and Borg scale rating were correlated with each other by linear regression for both trials. In order to investigate the individual behavior of fatigue effects between trials, Delta (trial 2-trial 1) slopes of nMPF and Borg scale ratings were calculated for each subject. These slopes of nMPF and Borg scale ratings were correlated with each other as well by linear regression. The increase of Borg scale ratings, as well as the decrease of nMPF, were significantly higher in trial 2 than trial 1 (P<0.01). The results show a linear correlation between slopes of nMPF and Borg scale ratings for both trials 1 and 2 (r=0.76, P<0.01). Trial-to-trial slopes (Delta (trial 2-trial 1)) of nMPF and Borg scale rating, were also significantly correlated (r=0.68, P<0.05). Thus, the individually sensed increase of perceived exertion in the neck during trial 2 was accompanied by a simultaneously higher detected decrease of nMPF. These findings indicate a close relationship between subjective perception of exertion in the neck and objectively assessed muscle fatigue of the upper trapezius.

Background: To date, no study has assessed fulfillment of patients’ expectations after foot and ankle surgery. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. Methods: Preoperatively, patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled), to between 0 and 1 (expectations partially fulfilled), to 1 (expectations met), to greater than 1 (expectations surpassed). Receiver operating characteristic (ROC) curves and areas under the curve (AUCs) with 95% confidence intervals (CIs) were used to compare the expectations survey to other outcome surveys, including Foot and Ankle Outcome Score, improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. Results: Of the 271 patients (mean age 55.4 years, mean BMI 27.5, 65% female), 34% had expectations surpassed (FP >1), 4% had expectations met, 58% had expectations partially fulfilled (FP between 0 and 1), and 5% had no expectations met. The mean FP was 0.84 ± 0.41 (range 0-3.13), indicating partially fulfilled expectations. FP correlated significantly with all outcome measures ( P ≤ .007). FP was associated most closely with satisfaction ( r = 0.66 [95% CI 0.57-0.75]; AUC = 0.92 [95% CI 0.88-0.96]; P < .001) and improvement ( r = 0.73 [95% CI 0.64-0.81]; AUC = 0.94 [95% CI 0.91-0.96]; P < .001). Based on the associations with satisfaction and improvement outcomes, a clinically important proportion of expectations fulfilled is 0.68, with sensitivity 0.85-0.90 and specificity 0.84-0.86. Conclusion: The proportion of expectations fulfilled is a novel patient-centered outcome that correlated with validated outcome measures. The expectations survey may be used by surgeons to counsel patients preoperatively and also to assess patients’ results postoperatively. Level of Evidence: Level II, prospective comparative series.

Background: Restoring the joint line is an important principle in total knee arthroplasty. However, the effect of joint line level on patient outcomes after total ankle arthroplasty (TAA) remains unclear, as there is no established method for measuring ankle joint level in TAA. The objective of this study was to develop a reliable radiographic ankle joint line measurement method and to compare ankle joint line level measured pre-TAA, post-TAA, and in nonarthritic ankles. Methods: A total of 112 radiographic sets were analyzed. Each set included weightbearing anteroposterior radiographs of the operative ankle taken preoperatively, 1-year postoperatively, and of the contralateral ankle. Measurements of vertical intermalleolar distance (VIMD) and vertical joint line distance (VJLD) at pre-TAA, post-TAA, and of the contralateral ankle were recorded by 2 authors on 2 separate occasions. The ratio of VJLD to VIMD was defined as the joint line height ratio (JLHR). Reliability of measurements and correlation between VIMD and VJLD were assessed. Pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHR were compared and considered significantly different if P <.05. Results: The inter- and intrarater reliability of radiographic measurements was excellent ( r > 0.9). There were strong positive correlations of VIMD and VJLD, r = 0.809 (pre-TAA)/0.756 (post-TAA), P < .001. Mean (SD) pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHRs were 1.54 (0.31), 1.39 (0.26), and 1.62 (0.49), respectively. Pre- and post-TAA JLHRs were significantly higher compared to the nonarthritic contralateral ankle ( P < .05). JHLR was not significantly different between pre- and post-TAA ( P = .15). Conclusion: The JLHR was reliable and could be a clinically applicable method for assessing ankle joint line level in patients undergoing TAA. End-stage ankle arthritis demonstrated elevated joint line level compared with nonarthritic ankles, and the joint line level post-TAA remained elevated compared with nonarthritic ankles. Further studies are needed to understand the effect of joint line elevation on clinical outcomes after TAA. Level of Evidence: Level III, retrospective comparative study.

Introduction: Mental health diagnoses involving depression or anxiety are common and can have a dramatic effect on patients with musculoskeletal pathologies. In orthopaedics, depression/anxiety (D/A) is associated with worse postoperative patient-reported outcomes. However, few studies have assessed the effect of D/A on expectations and satisfaction in foot and ankle patients. Methods: Adult patients undergoing elective foot and ankle surgery were prospectively enrolled. Preoperatively, patients completed the eight-item Patient Health Questionnaire Depression Scale, Generalized Anxiety Disorder Screener-7, Foot and Ankle Outcome Score (FAOS), and Expectations Survey. At 2 years postoperatively, surveys including satisfaction, improvement, and fulfillment of expectations were administered. Fulfillment of expectations (fulfillment proportion) and FAOS scores were compared between patients with D/A and non-D/A patients. Results: Of 340 patients initially surveyed, 271 (80%) completed 2-year postoperative expectations surveys. One in five patients had D/A symptoms. Preoperatively, D/A patients had greater expectations of surgery (P = 0.015). After adjusting for measured confounders, the average 2-year postoperative fulfillment proportion was not significantly lower among D/A compared with non-D/A (0.86 versus 0.78, P = 0.2284). Although FAOS scores improved postoperatively for both groups, D/A patients had significantly lower preoperative and postoperative FAOS scores for domains of symptoms, activity, and quality of life (P < 0.05 for all). D/A patients reported less improvement (P = 0.036) and less satisfaction (P = 0.005) and were less likely willing to recommend surgery to others (P = 0.011). Discussion: Patients with D/A symptoms had higher preoperative expectations of surgery. Although D/A patients had statistically similar rates of fulfillment of expectations compared with non-D/A patients, they had markedly lower FAOS scores for domains of symptoms, activity, and quality of life. D/A patients also perceived less improvement and were more often dissatisfied with their outcomes. These findings should not dissuade providers from treating these patients surgically but rather emphasize the importance of careful patient selection and preoperative expectation management. Level of Evidence: Level III; retrospective review of prospective cohort study