Patellar Tendon Reconstruction Using Tibialis Posterior Allograft for Treatment of Patellar Tendon Rupture After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction.

Background: Bone-patellar tendon-bone (BPTB) autografts are often used to treat anterior cruciate ligament (ACL) tears in young, highly active patients. These grafts are robust and provide adequate stability, allowing for return to sport and optimal functional outcomes in athletes. Patellar tendon rupture following BPTB ACL reconstruction is rare and can be difficult to treat. Case Report: A 19-year-old collegiate wrestler injured his left knee during a match. On evaluation 7 days after the injury, he was found to have increased anterior translation of the tibia on Lachman testing and an abnormal pivot shift. Magnetic resonance imaging demonstrated a complete tear of the ACL, and he successfully underwent a BPTB ACL reconstruction without complication. He progressed appropriately in the acute postoperative period. Six weeks after his index surgery, the patient reinjured his left knee and was diagnosed with a patellar tendon rupture. The previously reconstructed ACL was intact. A posterior tibialis tendon graft was used to repair the patellar tendon via a transosseous tunnel in the tibial tuberosity. The patient's recovery was complicated by a superficial wound that resolved with treatment. He achieved full range of motion and was able to return to sport. Conclusion: No technique for treating patellar tendon rupture following BPTB ACL reconstruction has been widely accepted. The treatment of this injury is left to the preference of the surgeon. This case demonstrates that tibialis posterior allografts are a viable option for the treatment of such injuries.

Vague Presentation of Cat Scratch Disease in a Child.

Background: Prolonged fever for more than a week or fever of unknown origin in pediatric patients with or without soft tissue infection should raise suspicion for Bartonella henselae infection. Case Report: A 10-year-old female presented to urgent care with a "bug bite" on the left ring finger, cough, and 2 to 3 days of low-grade fever. Ten days later, her symptoms progressed to soft tissue swelling of the left elbow without fracture on radiograph. Magnetic resonance imaging revealed multiple reniform masses with avid contrast enhancement consistent with suppurative adenitis. She was admitted for irrigation and debridement. The patient underwent surgical debridement with removal of infected lymph nodes. Histology revealed necrotizing granulomatous lymphadenitis. Polymerase chain reaction was positive for B henselae. Antibody titer revealed B henselae immunoglobulin G titer of 1:512 (reference, 1:64), and negative immunoglobulin M titers were indicative of mature immune response. The patient was treated with azithromycin 250 mg tablets twice daily for 3 days followed by 3 days of the 250 mg tablet once daily. Follow-up showed resolution of infection without symptoms concerning for visceral organ infection. Conclusion: While the patient's initial presentation was vague, a complete history, quick follow-up, and decisive intervention prevented significant sequelae such as visceral organ involvement.

Viable cartilage allograft outperforms existing treatments for focal knee cartilage defects.

PURPOSE: Viable cartilage allograft (VCA) is a cartilage tissue matrix that contains cryopreserved viable allogeneic cartilage fibres. This study aimed to assess safety and benefits in treating focal knee cartilage defects with VCA. We hypothesized that VCA is a safe single-stage procedure in isolated chondral defects. METHOD: In vitro analysis, in vivo studies and a prospective case series were performed. VCA was evaluated in a goat cartilage repair model. Symptomatic International Cartilage Repair Society grade 3/4A lesions of the femoral condyle or patella were implanted with VCA. International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome (KOOS) subscales, Lysholm, Short Form-12, Visual Analog Scale and pain frequency levels were assessed. Radiographic and magnetic resonance imaging (MRI) was performed at regular intervals postoperatively. Data were analysed by statisticians to determine the power and significance of the results. RESULTS: The goat study confirmed that VCA is effective for cartilage repair. Twenty patients were implanted; the mean age was 28.1 (16-56), the mean body mass index (BMI) was 27.9 ± 5.6 and the mean follow-up was 24.1 months (range = 12.0-36.0 months). Lesions were in either the femoral condyle (7) or patella (13). Lesion sizes ranged from 1.5 to 6.0 cm2 (mean = 4.58 cm2 ). Outcome scores improved from preoperative baseline (POB): IKDC (78.2), Lysholm (89.0), KOOS: Pain (95.8), Symptoms (86.3), ADL (87.8), Sports (85.0) and QOL (75.0). MRI imaging demonstrated excellent osteochondral allograft assimilation. Second-look arthroscopy (two patients) demonstrated complete fill and incorporation (Brittberg scores 11/12). Functional scores were maintained at 24 (M): IKDC (86.24 ± 17.2), Lysholm (87.23 ± 15.0), KOOS: Pain (91.72 ± 17.3), Symptoms (84.92 ± 16.1), ADLs (93.80 ± 16.1), Sports (84.45 ± 27.7), QOL (81.30 ± 20.8). CONCLUSION: VCA is an off-the-shelf, single-stage, conformable allogeneic graft that treats chondral defects with no additional fixation. Preclinical and short-term prospective clinical studies show that VCA can safely treat chondral defects with potential advantages to existing options. LEVEL OF EVIDENCE: Level IV study.

Long-term Follow-up on Revisions of a Recalled Large Head Metal-on-metal Hip Prosthesis: A Single Surgeon Series.

Background: In 2010, a recall was issued for a specific monoblock large head metal-on-metal (MoM) hip prosthesis due to short-term revision rates of 12%-13% (articular surface replacement, DePuy Orthopaedics, Inc., Warsaw, IN). High complication, infection, and rerevision rates for revised MoM implants have been reported. The purpose of the study is to report long-term outcomes and trend metal ion levels of this recalled MoM prosthesis from a single surgeon series. Methods: Retrospective chart review was performed on all patients that underwent revision of large MoM hip replacements between 2010 and 2015. Pre- and post-revision Harris Hip Score (HHS), cup abduction angles, anteversion angles, and cup sizes were compared. Survivorship and HHS were the primary outcomes measured; serum cobalt and chromium levels were secondary outcomes. Multivariate linear regression was used to examine the correlation between prerevision serum metal ion levels and HHS. Results: A total of 24 hips (21 patients) met inclusion criteria. Mean time to revision was 4.12 years ± 1.1. Mean follow-up was 10.0 years (7-11.9 years). Mean HHS increased significantly after revision from 48.5 to 89.5 (P < .001). Higher prerevision cobalt levels were correlated with lower prerevision HHS (cobalt R = 0.25; chromium R = 0.3160). There was no correlation with prerevision cobalt (P = .2671) or chromium (P = .3160) with postrevision HHS. Most recent metal ion testing revealed a significant decrease in both cobalt (P = .0084) and chromium (P = .0115). Survival rate is 100%. Conclusions: Our study showed excellent survivorship and outcomes at 10 years. There were no failures for any reason including infection. This differs from previous studies and confirms excellent long-term results are possible with revision of this recalled MoM implant.

Revision Carpal Tunnel Release With Umbilical Cord Allograft: A Four-Year Retrospective Cohort Study.

Background: Refractory symptoms of carpal tunnel syndrome can persist or reoccur after carpal tunnel release (CTR) surgery in 1% to 25% of patients, with up to 12% of patients requiring secondary surgery. If revision surgery is required, the results are much less successful compared to primary surgery. In this study, we investigated whether cryopreserved human umbilical cord allograft placement during CTR revision surgery improved short- and long-term surgical outcomes. Methods: We conducted a single-center cohort analysis of patients between January 2015 and July 2018 who underwent secondary open revision CTR with umbilical cord allograft for recurrent or persistent compression neuropathy of the median nerve. Surgical outcomes of patients in the study group-reduction of pain, paresthesia, and weakness; complications; and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores-were compared to the outcomes of controls without umbilical cord allograft use who were operated on by the same surgeon between December 2011 and September 2015. Results: A total of 37 patients underwent CTR with (n=26) and without (n=11) umbilical cord allograft (mean follow-up of 4 years). Following surgery, preoperative symptoms of pain (96% vs 73%, P=0.048) and paresthesia (100% vs 73%, P=0.014) were significantly improved in the patients who received umbilical cord allograft. Mean QuickDASH scores (19.0 vs 23.7, P=0.58) and preoperative weakness (90% vs 67%, P=0.14) were improved in the patients who received umbilical cord allograft but were nonsignificant. Short- and long-term complications were similar between groups (P=0.56, P=0.51, respectively). Conclusion: This study suggests that human umbilical cord allograft placement during open revision CTR is safe and effective for improving long-term symptoms of compressive neuropathy in patients with recurrent carpal tunnel syndrome.

MACI "Sandwich" Technique for a Large Osteochondritis Dissecans Lesion: A Case Report.

There is widespread use of matrix-induced autologous chondrocyte implantation. Initial use of autologous bone grafting in combination with the matrix-induced autologous chondrocyte implantation procedure has shown efficacy in small- to medium-sized osteochondral lesions. This case report demonstrates use of the "Sandwich" technique in a large, deep osteochondritis dissecans lesion of the medial femoral condyle. Technical considerations that are key to containment of the lesion and outcomes are reported.

Drain options after vertebral body tethering.

PURPOSE: Since the introduction of vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS), a variety of post-operative chest drainage systems have been utilized. Most surgeons use formal chest tubes with a Pleur-evac, while others use smaller bulb suction drains (e.g., Blake drain). In addition, some centers utilize pleural closure. This multicenter study evaluates whether drain type or pleural closure impact perioperative and 90 day complication rates. METHODS: A retrospective review was conducted from three institutions with established VBT programs. All preoperative, perioperative and 90 day postoperative data were analyzed to determine differences in outcomes between three cohorts: standard chest tube (SCT), standard chest tube with pleural closure (SCTPC) and 10 French Bulb drain (BD). RESULTS: 104 patients were identified for the study. 57 SCT, 25 SCTPC and 22 BD. All data are listed in order: SCT, SCTPC, BD. Length of stay (3.7, 4.3, 3.0 days) was less in the BD group (p = 0.009); post-operative drainage (460, 761, 485 cc) was less in the SCT and BD groups (p < 0.001); intra-operative estimated blood loss (EBL) 146, 382, 64 cc was less in the BD group (p < 0.001). No significant difference in number of days (3.2, 3.2, and 2.8 days) drainage was in place, groups (p = 0.311). Complication profile was similar with 2 chest tube reinsertions in the SCT and one hemothorax that resolved spontaneously in BD group. CONCLUSIONS: In this series of 104 patients, SCT, SCTPC and BD all had a similar safety profile. All three methods were safe and effective in managing post-operative chest drainage after thoracic VBT. In the series, BD group had significantly shorter LOS than both groups that used chest tubes. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Closed Traumatic A2 Through A4 Pulley Rupture and Flexor Digitorum Superficialis Avulsion Treated With Reconstruction.

Background: Multiple closed spontaneous pulley ruptures are rare injuries and require surgical reconstruction to prevent functional deficits. Pulley rupture combined with avulsion of the flexor digitorum superficialis (FDS) tendon is an even more uncommon occurrence. Case Report: We describe a closed traumatic annular 2 (A2) through annular 4 (A4) pulley rupture with avulsion of the FDS tendon. This uniquely associated pathology was treated with a complex surgical reconstruction that corrected flexion contracture and tendon bowstringing in the left long finger. The desired outcome was achieved through A2 and A4 pulley reconstruction using an autologous palmaris longus tendon graft with FDS tendon excision and proximal interphalangeal joint capsulotomy. Conclusion: Multiple pulley rupture is not commonly combined with FDS avulsion, and treatment of this injury requires careful surgical planning based on pulley biomechanics to maximize postoperative function.

Arthroscopic Saucerization of a Symptomatic Posterior Horn Tear in a Discoid Medial Meniscus.

Background: Discoid medial meniscus is an extremely rare congenital anatomic variant with an estimated incidence of 0.12%. Arthroscopic meniscal saucerization and repair are reserved for symptomatic tears only. We present a case of discoid medial meniscus tear, outline the surgical arthroscopic technique used for treatment, and compare several surgical approaches. Case Report: An 18-year-old male presented with left knee pain and mechanical symptoms present for 2 years. Physical examination showed stability to both varus and valgus stresses with absence of locking or catching on McMurray testing. Magnetic resonance imaging confirmed discoid medial meniscus with a horizontal oblique tear of the posterior horn. The patient underwent saucerization of the left discoid medial meniscus and medial meniscus repair. Conclusion: Discoid medial meniscus predisposes individuals to meniscal tears that often require operative management. Careful consideration of surgical approach can help to optimize patient outcomes while minimizing the risk of iatrogenic injury.

Anterior Interosseous Nerve Palsy After Shoulder Arthroscopy Treated With Surgical Decompression: A Case Series and Systematic Review of the Literature.

Background: Anterior interosseous nerve (AIN) palsy is a very uncommon cause of upper extremity pain and weakness that comprises less than 1% of all upper extremity nerve palsies. Rarely reported but also mentioned in the literature is AIN palsy after shoulder arthroscopy. Methods: A systematic review of the literature to date using PubMed was conducted to identify patients who suffered AIN palsy after shoulder arthroscopy procedures. Articles included met the following criteria: (1) published in English; (2) primary presentation of the data; (3) patients had undergone shoulder arthroscopy before developing symptoms of AIN palsy; and (4) diagnosis was confirmed with clinical symptoms of AIN palsy. Measured outcomes included patient demographics, specific shoulder procedure, anesthesia procedure, intra-operative patient positioning, intra-operative compressive dressing, intra-operative traction, surgical versus conservative treatment, abnormal findings during decompression procedure, proposed mechanism of injury, and follow-up. Results: The search yielded 6 articles, of which 4 (13 cases) met inclusion criteria. An additional 2 cases were included in this report totaling 15 cases. The average patient age was 49 years (range: 31-64) with 73% males. At average follow-up of 24 months, 67% of patients experienced complete resolution of symptoms-more than half of which underwent surgical decompression. Patients who failed to progress experienced weakness of the flexor digitorum profundus and flexor pollicis longus muscles. Conclusions: Proposed injury mechanisms for AIN palsy after shoulder arthroscopy range from mechanical trauma, compressive hematoma, and direct anesthetic neurotoxicity. Management should be directed by clinical symptoms, imaging, and patient factors with majority of patients expected to have excellent clinical outcomes.

Isolated Volar Dislocation of the Fifth Carpometacarpal Joint.

Background: Isolated dislocation of the carpometacarpal (CMC) joints is a rare injury that accounts for less than 1% of hand injuries. Few cases of isolated volar dislocations of the fifth CMC joint have been reported, making such injuries worthy of reporting. Given the rarity of these injuries, they are easily overlooked in the emergency setting and thus require a high index of clinical suspicion. Case Report: A 57-year-old female sustained an isolated volar dislocation of the fifth CMC joint when she fell onto her outstretched right hand. Physical examination revealed an inability to move the fifth digit, and the patient reported severe pain over the ulnar aspect of her right hand. X-rays of the right wrist revealed the dislocation. The patient was managed with closed reduction and application of an ulnar gutter splint. Conclusion: Solitary dislocations of any CMC joint are less common than simultaneous dislocation of multiple CMC joints, especially at the fifth CMC joint with volar dislocation. Because of the potential long-term adverse effects of untreated dislocations, these injuries must not be overlooked. Thus, patients presenting to the emergency department after traumatic injury involving an axial loading force to the hand should be carefully evaluated.

Pseudotumor recurrence in a post-revision total hip arthroplasty with stem neck modularity: A case report.

BACKGROUND: This unique presentation of hip swelling is only the seventh reported case of pseudotumor recurrence in a non-metal-on-metal total hip arthroplasty (THA) construct. The constellation of patient symptoms and laboratory findings contradict the expected elevated serum metal ion levels associated with the formation of pseudotumor. The presentation, lab trends, and imaging findings contribute to the growing base of knowledge surrounding the effects of corrosion in arthroplasty constructs with stem-neck modularity. CASE SUMMARY: A 74-year-old man status post primary THA presented with left hip swelling and elevated serum metal ions five years after implantation of a modular stem-neck prosthesis. The swelling was diagnosed as pseudotumor based on laboratory trends and imaging findings and was treated with revision arthroplasty that completely resolved the initial hip swelling. The patient presented with recurrent hip swelling and recurrent pseudotumor findings on imaging in the same hip four months later. Non-operative management with ultrasound-guided hip aspiration resulted in symptom relief and resolution of the recurrent swelling. After one year of follow-up, the patient had no further recurrences of hip swelling. CONCLUSION: This case of post-revision pseudotumor recurrence elucidates attributable patient, surgical, and implant factors with a discussion of diagnostics, management, and prognosis for patients with pseudotumor in non-metal-on-metal arthroplasty constructs.

Approach to Isolated Trapezoid Fractures.

Background: The trapezoid is the least commonly fractured carpal bone, comprising 4% of all carpal fractures. To date, few articles have been published on isolated trapezoid fractures. Mechanisms of injury have typically been reported as an axial load, with or without forced wrist flexion/extension, that is transmitted from the second metacarpal indirectly to the trapezoid. Case Reports: Two patients presenting with symptoms of nonspecific wrist pain after acute trauma were initially worked up with plain film x-rays. Physical examinations identified nonspecific wrist pain in both patients. Mechanisms of injury involved direct trauma and an axial force transmitted through the scaphoid region of an extended wrist in each patient. Plain x-rays were negative for trapezoid fracture in both patients. Computed tomography and magnetic resonance imaging revealed the diagnoses. Conservative management consisted of splinting and immobilization, with full recovery reported at 2.5- and 3-month follow-up. Conclusion: Isolated fractures of the trapezoid require a high index of suspicion as they are rare, and localizing signs and symptoms are typically vague and may mimic those of scaphoid fractures. When athletes present with dorsal wrist pain, swelling, and snuffbox tenderness in the setting of negative plain x-rays, the most likely mechanisms of injury are associated with athletic activity. Treatment depends on the degree of displacement and other associated injuries and ranges from activity modification or immobilization to open reduction with internal fixation.

YouTube is a poor source of patient information for knee arthroplasty and knee osteoarthritis.

BACKGROUND: The objective of this study was to assess the educational quality of YouTube videos pertaining to total knee arthroplasty and knee osteoarthritis. METHODS: A systematic search for the terms "knee replacement" and "knee arthritis" was performed using YouTube's search function. Data from the 60 most relevant videos were collected for each search term. Quality assessment checklists with a scale of 0 to 10 points were developed to evaluate the video content. Videos were grouped into poor quality (grade 0-3), acceptable quality (grade 4-7), and excellent quality (grade 8-10), respectively. RESULTS: Overall, 106 videos were categorized. For videos regarding total knee arthroplasty (n = 50), 64% of videos were of poor educational quality (32/50), 28% were of acceptable quality (14/50), and 8% were of good educational quality (4/50). Common missing information included discussion of surgical complications and implant duration. For videos regarding knee arthritis (n = 56), 66% of videos were of poor educational quality (37/56), 32% were of acceptable quality (18/56), and 2% were of good educational quality. Common missing information were causes and risk factors for knee arthritis and long-term prognosis. CONCLUSIONS: The present study suggests that YouTube is a poor educational source for patients regarding knee arthroplasty and knee arthritis. Recognizing the limitations of YouTube as well as which topics are not commonly presented may better guide physicians to educate their patients.