Physeal fusion status and lesion size are more important than patient age for healing of juvenile osteochodritis dessicans lesions of the distal femur.

PURPOSE: The purpose of the study was to evaluate the effect of skeletal age and lesion size, location, and grade on the success of nonoperative treatment for juvenile osteochondritis dissecans (OCD). It is hypothesized that skeletal maturity, including a combination of maturation phenotypes, correlates with nonoperative lesion healing. METHODS: The clinical and radiographic data on 52 patients aged 7-20 years treated for OCD of the distal femur between 2010 and 2019 were retrospectively reviewed. Knee radiographs were assessed for number of lesions present and lesion location, size, and stage. Assessments of skeletal maturation were performed on all antero-posterior knee radiographs using the Roche, Wainer, and Thissen (RWT) method. Patients were categorized as healed if they demonstrated no pain on clinical examination. The relationship between skeletal maturity and nonoperative lesion healing was determined using Spearman rank correlations on available variables. RESULTS: Neither chronological nor skeletal age was associated with surgical status (Rho = 0.03, n.s., and Rho = 0.13, n.s., respectively) or the healing status of nonoperatively treated OCD lesions (Rho = 0.44, n.s., and Rho = 0.03, n.s., respectively). Epiphyseal fusion status of the distal femoral physis was moderately correlated with nonoperative healing, but was not statistically significant (lateral femoral physis: Rho = 0.43, p = 0.05; medial femoral physis: Rho = 0.43, n.s.). Lesion length correlated with surgical status (Rho = - 0.38, p = 0.009). CONCLUSION: The extent of fusion of the distal femoral physis (multi-stage grading) may be more strongly correlated with nonoperative healing than other markers of skeletal maturity or chronological age. Clinicians can use this as an additional radiographic sign when considering nonoperative treatment for juvenile OCD lesions in the distal femur. OCD lesion length and physeal fusion status appear to be more important for healing than patient age.

Common and Consequential Fractures That Should Not Be Missed in Children.

Missed or delayed diagnosis of fractures in children is not uncommon owing to their immature skeletons, unique fracture patterns, and distinctive radiologic findings. The term occult is used to describe radiographically subtle fractures. Some of these fractures can be associated with excellent outcomes despite the pitfalls of delayed diagnosis. However, a subset of these injuries have more guarded prognoses when missed, despite their harmless radiographic appearance. A high index of suspicion should be maintained when treating pediatric extremity injuries with clinical findings disproportionate to a benign-appearing radiograph. Moreover, overreliance on radiology reports can perpetuate diagnostic error. In cases of discrepancy, timely follow-up for repeat examination or immediate advanced imaging can help avoid missed diagnoses. Most critically, the one diagnosis not to miss is nonaccidental trauma, as continued exposure to abuse puts the child at risk of further injury and death. [Pediatr Ann. 2022;51(9):e357-e363.].

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury.

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.

Computed tomography guided radio-frequency ablation of osteoid osteomas in atypical locations.

PURPOSE: Percutaneous radio-frequency ablation is a minimally invasive treatment option for osteoid osteomas. The ablation process is straightforward in the more common locations like the femur/tibia. Surgery has historically been the gold standard, but is currently used in lesions, that may not be effectively and safely ablated, i.e. close to skin/nerve. Radio-frequency ablation can still be used in such cases along with additional techniques/strategies to protect the sensitive structures and hence improve the outcomes. The authors describe their experience with four challenging osteoid osteoma ablation cases. METHODS: We retrospectively reviewed radio-frequency ablations of four osteoid osteomas in rather atypical locations, the protective techniques/strategies employed, the adequacy and safety of the radio-frequency ablation with the use of these techniques. RESULTS: All patients had complete resolution of pain with no recurrence in the follow-up period. No complications were reported. CONCLUSION: RFA has been proven to be an effective and safe option for treatment of OOs in the common locations. It is generally recommended to have a 1 cm safety margin between the RF probe and any critical structures in the vicinity. However, with OOs in atypical locations this may not be always possible and hence additional techniques may be needed to ensure protection of the surrounding sensitive structures and also allow for effective ablation.

MRI findings of Stener-like lesion of the knee: A case series with surgical correlation.

PURPOSE: To describe the MRI findings of the "Stener-like" lesion of the knee and its distinction from simple medial collateral ligament (MCL) tear. A "Stener-like" lesion of the superficial medial collateral ligament is a tear involving the distal fibers, where the torn fibers become displaced superficial to the pes anserinus fibers, a displacement which can prevent healing. METHODS: Nine cases of Stener-like lesion were prospectively diagnosed on MRI. Retrospective, IRB-approved, HIPAA-compliant chart review was performed to determine correlation of surgical and MRI findings. Seven cases were surgically confirmed and are included in the series. RESULTS: MRI is useful in making the diagnosis of Stener-like lesions and prompting the surgeon to explore the distal MCL. Coronal MRI shows variable proximal retraction of the torn ligament. It has a lax contour and abuts the pes anserinus. The proximity of the torn ligament end to the pes can result in misdiagnosis of a partial tear. Axial images are useful to confirm position of the ligament superficial to the pes. All cases had associated tear of the deep MCL fibers, as well as sprains of the proximal superficial MCL. CONCLUSIONS: It is important to recognize the Stener-like lesion because this lesion is usually managed surgically, while most MCL tears are managed conservatively. The presence of injury to the proximal MCL is usually present, and may be a distractor from the distal injury. Care must be taken to include the distal attachment of the sMCL on coronal MRI images.

Incidence of Concurrent Peroneal Nerve Injury in Multiligament Knee Injuries and Outcomes after Knee Reconstruction.

The purpose of this study was to determine incidence of concurrent peroneal nerve injury and to compare outcomes in patients with and without peroneal nerve injury after surgical treatment for multiligament knee injuries (MLKIs). A retrospective study of 357 MLKIs was conducted. Patients with two or more knee ligaments requiring surgical reconstruction were included. Mean follow-up was 35 months (0-117). Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full duty (p = 0.06). In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity (p = 0.41). At final follow-up, there were no significant differences in level of pain (mean visual analog scale 1.6 vs. 2; p = 0.17), Lysholm score (mean 88.6 vs. 88.8; p = 0.94), or International Knee Documentation Committee score (mean 46.2 vs. 47.8; p = 0.67) for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121 degrees) was significantly lower (p = 0.02) for patients with nerve injury compared with patients without nerve injury (mean 127 degrees). Concurrent peroneal nerve injury occurred in 19% of patients in this large cohort suffering MLKIs. After knee reconstruction surgery, patients with concurrent peroneal nerve injuries had significantly lower knee ROM and trended toward a lower rate of return to work. However, outcomes with respect to activity level, pain, and function were not significantly different between the two groups. This study contributes to our understanding of patient outcomes in patients with concurrent MLKI and peroneal nerve injury, with a focus on the patient's ability to return to work and sporting activity.

Subchondroplasty for the treatment of post-traumatic bone marrow lesions of the medial femoral condyle in a pre-clinical canine model.

This study characterizes long-term outcomes associated with subchondroplasty (SCP) treatment for impact-induced subchondral bone marrow lesions (BML) using a validated pre-clinical canine model. With IACUC approval, purpose-bred research hounds (n = 16) underwent arthroscopic impact injury (40N) to both medial femoral condyles. At 3 months, functional assessments, arthroscopy, and MRI were performed and knees (n = 32) were randomly assigned to SCP (3 ml fluoroscopically guided percutaneous injection of AccuFill BSM into BML bone defects) or sham injection (Control). Dogs were assessed at 3, 6, 12, and 24 months after treatment using functional assessments, radiographic evaluation, arthroscopy, and MRI. Dogs were humanely euthanatized at 3, 6, 12, or 24 months after treatment for gross, microCT, and histologic assessments. All knees had focal articular cartilage defects with associated subchondral BMLs, as well as clinical dysfunction, 3 months after injury. At the 3 and 6 months, SCP knees showed more functional impairment than Control knees, however, these differences were not statistically significant. At 1- and 2-year post-treatment, function in SCP knees was better than in Control knees with range of motion being significantly (p < 0.05) better for SCP. Radiographic, arthroscopic, MRI, gross, microCT, and histologic findings matched the functional assessments well with Control being associated with better results at the two early time points and SCP being associated with better results at 1 and 2 years. Clinical significance: SCP treatment using calcium phosphate bone void filler was associated with an initial increase in pain and dysfunction followed by symptomatic benefits for up to 2 years after treatment for post-traumatic femoral condyle BMLs in a preclinical canine model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2709-2717, 2018.

Current Concepts in Rehabilitation for Traumatic Anterior Shoulder Instability.

PURPOSE OF REVIEW: The objectives of this review are to evaluate the current evidence-based literature and concepts surrounding rehabilitation in patients with anterior shoulder instability injuries and surgical repair. RECENT FINDINGS: The current literature evidence for shoulder rehabilitation for anterior shoulder instability and labral repair is limited. As a result, there are variations among surgeons and physical therapists in rehabilitation protocols after anterior shoulder instability injuries and repair. While general consensus on certain rehabilitation parameters exists, the evidence for the importance of rehabilitation and functional performance test for return to sport in future injury prevention is still lacking in literature. Rehabilitation after anterior shoulder instability injury and anterior labral repair is paramount in the injured or post-operative shoulder. Restoration of soft tissue mobility, dynamic glenohumeral joint stability, and balance and strength around the shoulder not only protect healing of injured or repaired soft tissues but also potentially minimizes future re-injury or recurrence risk.

Rivaroxaban Use for Thrombosis Prophylaxis Is Associated With Early Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection is a disastrous complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of certain agents to prevent deep vein thrombosis after arthroplasty has been linked to an increased risk of adverse effects including wound drainage and infection. Adverse effects of one alternative, rivaroxaban, was studied in a single community hospital. METHODS: International Classification of Diseases, Clinical Modification 9 codes were used to identify primary THAs and TKAs in an administrative database at one large-volume community hospital performed in 2012. Patients were divided into 2 groups: the study group received rivaroxaban, whereas the control group received another form of chemical thromboprophylaxis for at least 2 weeks postoperative. Demographics, risk factors, and illness severity scores were collected for each group. The primary measured outcome was the incidence of deep surgical site infection (SSI) within 30 days postoperative. RESULTS: A total of 639 TKA or THA patients were included, with 159 patients who received rivaroxaban and 480 who received another form of chemical thromboprophylaxis. There were no significant differences between groups regarding demographics, risk factors, or illness severity scores. Incidence of early deep SSI in the rivaroxaban group was higher than in the control group (2.5% vs 0.2%; P < .015). CONCLUSION: The use of rivaroxaban for thromboprophylaxis led to a significantly increased incidence of deep SSI in a continuous series of patients undergoing primary THA and TKA in a single institution.

Irrigation and Debridement Before a 2-Stage Revision Total Knee Arthroplasty Does Not Increase Risk of Failure.

BACKGROUND: Studies have suggested that the success of 2-stage revision total knee arthroplasty (rTKA) may be compromised by a prior failed irrigation and debridement (I&D). The purpose of this study was to use 2 large state inpatient databases to compare the 2-stage rTKA failure rates for those patients with and without a prior I&D. METHODS: This retrospective, longitudinal study used inpatient discharge data from the State Inpatient Database of 2 states (California and New York) from 2005 to 2011. A combination of International Classification of Diseases, Ninth Revision, diagnosis and procedure codes was used to identify rTKA patients and compare failure rates for rTKA patients with and without prior I&D. The primary outcome was failure of the staged revision, which was defined as subsequent surgery due to infection within 4 years of the 2-stage rTKA. RESULTS: Of the 750 patients who underwent 2-stage rTKA, 57 had undergone a prior I&D. In all, 126 patients failed rTKA. After 4 years, the estimated failure rate was 8.7% (95% confidence interval [CI], 1.9%-16.9%) in the group with prior I&D and 17.5% (95% CI, 14.7%-20.4%) in the group without prior I&D. After adjusting for sex, race, insurance, median household income, and comorbidities, the hazard ratio for the group with a failed I&D was 0.49 (P = .122; 95% CI, 0.20-1.20), which indicated a lower risk of failure compared to the group without prior I&D. CONCLUSION: These findings indicate that the failure rate of 2-stage rTKA is not increased by prior failed I&D.

Development of a Novel Canine Model for Posttraumatic Osteoarthritis of the Knee.

Translational models of posttraumatic osteoarthritis (PTOA) that accurately represent clinical pathology need to be developed. This study assessed a novel canine model for PTOA using impact injury. Impacts were delivered to the medial femoral condyle of dogs using a custom-designed impactor at 20, 40, or 60 MPa. Functional assessments and magnetic resonance imaging (MRI) were performed at 2 and 12 weeks, and arthroscopic and histologic assessments were performed at 12 weeks after injury. At 2 and 12 weeks, dogs had observable lameness, knee pain, effusion, loss in range of motion (ROM) and dysfunction in both hindlimbs with severity correlated strongly (r > 0.77) to impact level. At 12 weeks, function, pain, effusion, and ROM were significantly (p < 0.049) worse in knees impacted at 40 and 60 MPa compared with 20 MPa. MRI showed consistent cartilage and subchondral bone marrow lesions, and arthroscopy revealed synovitis and cartilage destruction in impacted knees, with increased severity for 40 and 60 MPa impacts. Histopathology was significantly (p = 0.049) more severe in 40 and 60 MPa and strongly correlated (r = 0.93) to impact level. This novel translational model appears to be valid for investigation of PTOA, including determination of temporal mechanisms of disease and preclinical testing for preventative and therapeutic strategies.

Dynamic Locked Plating of Distal Femur Fractures.

OBJECTIVES: Nonunion after locked bridge plating of comminuted distal femur fractures is not uncommon. "Dynamic" locked plating may create an improved mechanical environment, thereby achieving higher union rates than standard locked plating constructs. SETTING: Academic Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Twenty-eight patients with comminuted supracondylar femur fractures treated with either dynamic or standard locked plating. INTERVENTION: Dynamic plating was achieved using an overdrilling technique of the near cortex to allow for a 0.5-mm "halo" around the screw shaft at the near cortex. Standard locked plating was done based on manufacturer's suggested technique. The patients treated with dynamic plating were matched 1:1 with those treated with standard locked plating based on OTA classification and working length. MAIN OUTCOME MEASUREMENTS: Three blinded observers made callus measurements on 6-week radiographs using a 4-point ordinal scale. The results were analyzed using a 2-tailed t test and 2-way intraclass correlations. RESULTS: The dynamic plating group had significantly greater callus (2.0; SD, 0.7) compared with the control group (1.3: SD, 0.8, P = 0.048) with substantial agreement amongst observers in both consistency (0.724) and absolute score (0.734). With dynamic plating group, 1 patient failed to unite, versus three in the control group (P = 0.59). The dynamic group had a mean change in coronal plane alignment of 0.5 degrees (SD, 2.6) compared with 0.6 (SD, 3.0) for the control group (P = 0.9) without fixation failure in either group. CONCLUSIONS: Overdrilling the near cortex in metaphyseal bridge plating can be adapted to standard implants to create a dynamic construct and increase axial motion. This technique seems to be safe and leads to increased callus formation, which may decrease nonunion rates seen with standard locked plating. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Definitive plates overlapping provisional external fixator pin sites: is the infection risk increased?

OBJECTIVES: The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a 2-staged protocol of acute spanning external fixation and later definitive internal fixation. DESIGN: Retrospective comparison study. SETTING: Two level I trauma centers. PATIENTS/PARTICIPANTS: A total of 85 OTA 41C bicondylar tibial plateau fractures and 97 OTA 43C pilon fractures treated between 2005 and 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an "overlapping" group and a "nonoverlapping" group. INTERVENTION: Fifty patients had overlapping pin sites and 132 did not. MAIN OUTCOME MEASURE: Presence of a deep wound infection. RESULTS: Overall, 25 patients developed a deep wound infection. Of the 50 patients in the "overlapping" group, 12 (24%) developed a deep infection compared with 13 (10%) of the 132 patients in the "nonoverlapping" group (P = 0.033). CONCLUSIONS: Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the 2-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence of wrong-site surgery among foot and ankle surgeons.

In 1998, the American Academy of Orthopaedic Surgeons initiated the "sign your site" campaign to address the issue of wrong-site surgery (WSS). Using a confidential online survey sent to 1094 active members of the American Academy of Foot and Ankle Surgeons, the authors assessed participation in the "sign your site" campaign and the occurrence of WSS encountered during their careers. A total of 319 responses were received (response rate = 29.2%). In all, 41 of 310 respondents (13%) reported performing WSS at least once, with 4 surgeons (1%) reporting the occurrence twice in their careers; 70 of 310 (23%) surgeons reported that they had prepped the wrong surgical site, but the error was recognized prior to making an incision. In all, 302 of 309 respondents (97.7%) reported that they were aware of the "sign your site" initiative. Since the introduction of the campaign, significantly more (89.2% vs 49.2%) foot and ankle surgeons routinely mark the surgical site (P < .001). The Joint Commission revised the universal protocol for surgical site verification requiring an individual directly involved in a surgical procedure to mark the site as of January 1, 2009. The authors believe this revision will lower the incidence of WSS further.

Rat tibial osteotomy model providing a range of normal to impaired healing.

The purpose of this study was to develop an inexpensive and easily implemented rat tibial osteotomy model capable of producing a range of healing outcomes. A saw blade was used to create a transverse osteotomy of the tibia in 89 Sprague-Dawley rats. A 0.89 mm diameter stainless steel wire was then inserted as an intramedullary nail to stabilize the fracture. To impair healing, 1, 2, or 3 mm cylindrical polyetheretherketone (PEEK) spacer beads were threaded onto the wires, between the bone ends. Fracture healing was evaluated radiographically, biomechanically, and histologically at 5 weeks. Means were compared for statistical differences by one-way ANOVA and Holm-Sidak multiple comparison testing. The mean number of "cortices bridged" for the no spacer group was 3.4 (SD ± 0.8), which was significantly greater than in the 1 mm (2.3 ± 1.4), 2 mm (0.8 ± 0.7), and 3 mm (0.3 ± 0.4) groups (p < 0.003). Biomechanical results correlated with radiographic findings, with an ultimate torque of 172 ± 53, 137 ± 41, 90 ± 38, and 24 ± 23 N/mm with a 0, 1, 2, or 3 mm defect, respectively. In conclusion, we have demonstrated that this inexpensive, technically straightforward model can be used to create a range of outcomes from normal healing to impaired healing, to nonunions. This model may be useful for testing new therapeutic strategies to promote fracture healing, materials thought to be able to heal critical-sized defects, or evaluating agents suspected of impairing healing.

Pseudoaneurysm as a complication of ankle arthroscopy.

We present a case of a pseudoaneurysm of the anterior tibial artery following ankle arthroscopy with synovectomy, an extremely rare complication when standard anteromedial and anterolateral portals are used. The patient was diagnosed and treated with appropriate interventions which led to an uneventful recovery. Nevertheless, the potential sequelae of delayed diagnosis or misdiagnosis of the complication are dangerous; therefore, a high index of suspicion for a pseudoaneurysm must be maintained in the postoperative period.

Epidemiology and outcomes of Achilles tendon ruptures in the National Football League.

The purpose of this study is to document the epidemiology of Achilles tendon ruptures in the National Football League (NFL) and to quantify the impact of these injuries on player performance. A retrospective review of several online NFL player registries identified 31 Achilles tendon ruptures in NFL players between 1997 and 2002. Nineteen percent of injuries occurred during preseason play, while another 18% occurred during the first month of the official season. There was a postinjury reduction of 88%, 83%, and 78% in power ratings for wide receivers, running backs, and tight ends, respectively, over a 3-year period. There was a 95%, 87%, and 64% postinjury reduction in power ratings for linebackers, cornerbacks, and defensive tackles over a 3-year period. On average, players experienced a greater than 50% reduction in their power ratings following such an injury. Thirty-two percent (n = 10) of NFL players who sustained an Achilles tendon rupture did not return to play in the NFL.