4-in-1 Quadricepsplasty for Fixed and Habitual Dislocation of Patella.

Fixed and habitual dislocations of patella represent the most severe forms of patellar instability and frequently require surgical intervention. Isolated medial patellofemoral ligament (MPFL) reconstruction, which has been the cornerstone of treatment for episodic patellar dislocation, is inadequate to address such complex instability patterns. The purpose of this report is to describe the 4-in-1 quadricepsplasty technique for stabilization of fixed and habitual dislocation of patella. The 4 components of quadricepsplasty are lateral retinacular releases and lengthening, Roux-Goldthwait patellar tendon hemi-transfer, modified Insall's proximal "tube" realignment, and quadriceps slide-lengthening.

Salvage Treatment Options for Painful Hip Dislocations in Nonambulatory Cerebral Palsy Patients.

Hip dislocation is a common occurrence in nonambulatory patients with cerebral palsy, occurring in up to 70% of patients. However, only 15% to 57% of chronic dislocations progress to become painful. In these patients, several salvage treatment options are available, including proximal femoral resection, subtrochanteric valgus osteotomy, hip arthrodesis, and prosthetic arthroplasty. Of the options, proximal femoral resection, subtrochanteric osteotomy, and prosthetic arthroplasty have been shown to provide reliable pain relief with improved sitting balance, with no evidence of one technique being superior to another. However, each technique has unique aspects to its postoperative care and potential complication profile that requires thorough understanding and communication with parents/caregivers when considering surgical intervention.

Magnetically controlled growing instrumentation for early onset scoliosis: Caution needed when interpreting the literature.

BACKGROUND: Magnetically controlled growing rods (MCGR) are a novel treatment option for early onset scoliosis (EOS). Although the complication profile with MCGR use has been reviewed, these reviews do not take into account important implants modifications, termed iterations, that were made due to early on postoperative complications is not well reported or understood. AIM: To assess the effect of MCGR implant iterations on post-operative complications in EOS. METHODS: A systematic review was performed to identify studies investigating MCGR specifically for the treatment of EOS, refined to those reporting the implant iteration, specifically the incorporation of the keeper plate to the implant design. Articles with mixed implant iteration usage were excluded. Complications following surgery were recorded as well as potential risk factors and compared between implant cohorts. RESULTS: Although 20 articles were identified for inclusion, 5 included mixed implant iteration leaving a total of 271 patients identified through 15 clinical studies that met inclusion criteria. The average follow-up was 25.4-mo. Pre-keeper plate implants were utilized in 3 studies with a total of 49 patients. Overall, 115 (42.4%) post-operative complications were identified, with 87% defined as major. The addition of the keeper plate significantly decreased the rate of post-operative complications per study (35.7% vs 80.6%, P = 0.036), and the rate of distraction failure (8.1% vs 40.8%, P = 0.02). Unplanned reoperation occurred in 69 (26.7%) patients but was not different between implant iteration cohorts (25.5% without keeper plate vs 27.1% with keeper plate, P = 0.92). CONCLUSION: MCGR for EOS has a cumulative complication rate of 42.4% but this is significantly reduced to 35.7% when reviewing only keeper-plate enabled implants. However, 25% of published articles included mixed implant iterations. Future studies should discern between implants iterations when reporting on the usage of MCGR for EOS.

Volumetric Considerations for Valving Long-Arm Casts: The Utility of the Cast Spacer.

Fiberglass casts are frequently valved to accommodate swelling following injury or surgery. The use of cast spacers has been recommended to bridge this gap between pressure reduction and cast strength, but no studies have assessed their effect on cast pressure. We applied 30 long-arm fiberglass casts to adult volunteers, divided between a univalve group and a bivalve group. A pediatric blood pressure bladder was applied under the cast to simulate soft tissue swelling. Valved casts were secured using an elastic wrap, 10-mm cast spacer, or 15-mm cast spacer. Measurements of cast pressure and circumference were performed at each stage and compared on the basis of type of valve and securement. Our results indicated that cast univalving resulted in an approximately 60% reduction in cast pressures, with a 75% reduction seen in the bivalve group. The addition of cast spacers resulted in significant pressure reductions for both valving groups. The univalve group secured with a 10-mm cast spacer produced reductions in cast pressure similar to those of the elastic-wrapped bivalve cast, both with the cast padding intact and with it released. The use of cast spacers results in significant cast pressure reductions, regardless of valving technique. A univalved cast secured with a cast spacer can produce decreases in cast pressures similar to those seen with an elastic-wrapped bivalved cast, and it is a viable option for reducing cast pressure without compromising cast structural integrity with a bivalve technique.

Improved Chondrotoxic Profile of Liposomal Bupivacaine Compared With Standard Bupivacaine After Intra-articular Infiltration in a Porcine Model.

BACKGROUND: Increasingly, liposomal bupivacaine is being used with multimodal pain management strategies. In vitro investigations have shown decreased chondrotoxicity profiles for liposomal bupivacaine; however, there is no evidence regarding its in vivo effects. Hypothesis/Purpose: This study sought to investigate the in vivo chondrotoxicity of liposomal bupivacaine, hypothesizing that there would be increased chondrocyte viability after exposure to liposomal bupivacaine when compared with standard bupivacaine. STUDY DESIGN: Controlled laboratory study. METHODS: Eight juvenile, female Yorkshire cross piglets underwent a lateral stifle joint injection with either 1.3% liposomal bupivacaine or 0.5% bupivacaine. Injections were performed on one joint per animal with no injection to the contralateral knee, which served as the control. Chondrocyte viability was assessed 1 week after injection with a live-dead staining protocol and histologic examination. RESULTS: Significant chondrocyte death was seen with the live-dead staining in the bupivacaine group (33% nonviable cells) in comparison with liposomal bupivacaine (6.2%) and control (5.8%) groups ( P < .01). However, histologic examination showed no differences in chondral surface integrity, fibrillation, and chondrocyte viability. CONCLUSION: Liposomal bupivacaine was found to be safe for intra-articular injection in this animal model. Although bupivacaine demonstrated decreased chondrocyte viability on a cellular level, histologically there were no changes. This study highlights the dichotomy between fluorescent staining and histologic appearance of articular chondrocytes in short-term analyses of viability. CLINICAL RELEVANCE: This study supports the peri-articular application of liposomal bupivacaine in the setting of preserved articular cartilage. A single injection of standard bupivacaine did not produce histologic changes in the articular cartilage.

Treatment and Complications of Patients With Ipsilateral Acetabular and Femur Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: The purpose of this study was to review the treatment of patients with ipsilateral acetabular and femur fractures to provide descriptive demographic data, injury pattern classification, treatment, and evaluate the complication profile reflective of current practices. STUDY DESIGN: Multicenter retrospective cohort. SETTING: Eight Level 1 Trauma Centers. PATIENTS/PARTICIPANTS: One hundred one patients met inclusion criteria. INTERVENTION: Surgical treatment of both the acetabular and femur fractures. MAIN OUTCOME MEASUREMENTS: The complications evaluated include avascular necrosis, heterotopic ossification, posttraumatic arthritis, deep venous thrombosis, pulmonary embolism and superficial/deep infection, fracture union, and secondary surgeries. RESULTS: Forty-three patients had 31 type fractures (29A; 11B, and 3C), 60 had 32 type (37A, 8B; 15C), and 8 had 33 type (1A, 4B, 3C) femur fractures; 10 patients had combinations involving more than 1 femur fracture pattern. There were 35 62A type fractures, 47 62B, and 19 62C acetabular fractures. Age of 45 or older was associated with marginal impaction (P = 0.001). The aggregate infection rate was 17%. More than 30% of patients required secondary surgeries. The rate of avascular necrosis was higher in acetabular fractures combined with proximal femur fractures (P < 0.05). The rate of deep venous thrombosis was associated with increased age and time to surgical fixation (P < 0.05). CONCLUSIONS: We report the largest review of the surgical treatment and complications of ipsilateral acetabular and femoral fractures. This study provides useful information regarding the complications and provides some treatment recommendations regarding these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Instrumentation on Suture Tensile Strength and Knot Pullout Strength of Common Suture Materials.

OBJECTIVE: To determine the effect of instrumentation of suture material on knot security and tensile strength. STUDY DESIGN: In all, 5 types of suture material were used; 10 knots were tied without any instrumentation and 10 knots were tied with a hemostat holding tension on the first throw while the second throw was made for each suture type. Each group was tested to failure with the maximum load and mode of failure recorded. The maximum load between groups of each suture type was compared; frequency of failure through knot slippage vs material fracture was also compared between groups. RESULTS: There was no significant difference observed in the maximum load to failure for any suture type between instrumented and noninstrumented groups. Additionally, there was no difference between any instrumented and noninstrumented groups for material failure vs failure due to knot slippage. CONCLUSIONS: Instrumentation of suture material during two-hand tying does not affect the strength of suture material or knot security.

Heterotopic Ossification Causing Radiculopathy after Lumbar Total Disc Arthroplasty.

To date, no reports have presented radiculopathy secondary to heterotopic ossification following lumbar total disc arthroplasty. The authors present a previously unpublished complication of lumbar total disk arthroplasty (TDA) secondary to heterotopic ossification (HO) in the spinal canal, and they propose a modification to the McAfee classification of HO. The patient had undergone an L5/S1 lumbar TDA two years prior due to discogenic back pain. His preoperative back pain was significantly relieved, but he developed new, atraumatic onset radiculopathy. Radiographs and a computed tomography myelogram revealed an implant malposition posteriorly with heterotopic bone formation in the canal, causing an impingement of the traversing nerve root. Revision surgery was performed with implant extraction, L5/S1 anterior lumbar interbody fusion, supplemental posterior decompression, and pedicle screw fixation. The patient tolerated the procedure well, with complete resolution of the radicular leg pain. At a two-year follow up, the patient had a solid fusion without subsidence or recurrence of heterotopic bone. This case represents a novel pattern of heterotopic ossification, and it describes a previously unreported cause for implant failure in lumbar disc replacement surgery-reinforcing the importance of proper intraoperative component positioning. We propose a modification to the existing McAfee classification of HO after TDA with the addition of Class V and VI HO.

A modified Bohlman technique using a novel implant for treatment of high-grade spondylolisthesis.

Several surgical options for managing high-grade spondylolisthesis have been described in the literature and range from posterior-only in situ fusion to circumferential fusion with complete reduction of the dislocation. The level of evidence supporting any one technique is weak, and to date there is no Level I or II evidence supporting any current surgical treatment option. Techniques have evolved as implant technology has advanced and surgeons have gained experience with deformity correction. Still, the paucity of cases at any one institution limits the ability to perform clinical studies in a prospective and randomized fashion. To the authors' knowledge, the use of the AxiaLif bolt in a modified Bohlman technique has not been described. In the setting of a case of symptomatic high-grade spondylolisthesis refractory to nonoperative management, the authors describe a modified Bohlman technique in which they used the AxiaLif bolt rather than the fibula graft that was originally described. They then supplemented this with pedicle screw instrumentation and an iliac crest autograft. At the 2-year follow-up exam, the patient exhibited relief of his preoperative back and leg pain and he had returned to all activities. The latest radiographs demonstrated successful fusion. A single-stage, posterior instrumented fusion in which the AxiaLif bolt is used in lieu of fibula autograft or allograft in a modified Bohlman technique is technically less demanding, does not have the morbidity associated with harvesting a fibula autograft, and carries no risk of disease transmission associated with the use of allograft.

Magnetic resonance imaging of the cervical, thoracic, and lumbar spine in children: spinal incidental findings in pediatric patients.

Study Design Retrospective case series. Objective To determine the rate of spinal incidental findings on magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine in the pediatric population. Methods We reviewed MRI imaging of the neuraxial spine in patients less than 18 years of age and documented abnormal spinal findings. We then reviewed the charts of these patients to determine the reason for ordering the study. Those who presented with pain were considered symptomatic. Those who had no presenting complaint were considered asymptomatic. The data were analyzed to break down the rate of spinal incidental findings in the cervical, thoracic, and lumbar spine, respectively. Results Thirty-one of the 99 MRIs had positive findings, with the most common being disk protrusion (51.6%). Spinal incidental findings were most common in the lumbar spine (9.4%) versus the cervical spine (8%) or thoracic spine (4.7%). In this group, Schmorl nodes and disk protrusion were the two most common findings (37.5% each). Other spinal incidental findings included a vertebral hemangioma and a Tarlov cyst. In the thoracic spine, the only spinal incidental finding was a central disk protrusion without spinal cord or nerve root compression. Conclusion MRI is a useful modality in the pediatric patient with scoliosis or complaints of pain, but the provider should remain cognizant of the potential for spinal incidental findings.

Snapping knee caused by symptomatic fabella in a native knee.

We report a case of a 31-year-old man with a 5-year history of snapping knee syndrome secondary to a single, large symptomatic fabella of the knee. On physical examination, the patient was able to reproduce an audible and palpable snapping with active range of motion. His condition was refractory to physical therapy. He had undergone a prior iliotibial band release at an outside facility. After excision of the fabella, measuring 15 × 8 × 9 mm, the patient's snapping and pain with activity were resolved.

Gender and age differences in growth factor concentrations from platelet-rich plasma in adults.

The use of platelet-rich plasma (PRP) to facilitate healing of orthopedic-related injuries has gained popularity; however, the clinical benefits are not consistent. Differences may result from variations in growth factor (GF) levels in normal populations. The purpose of this study was to determine if GF levels present in activated PRP preparations differed by gender and age (≤ 25 versus >25 years) in a healthy population (N = 102). All GFs analyzed (epidermal growth factor [EGF], hepatocyte growth factor [HGF], insulin growth factor-1 [IGF-1], platelet-derived growth factor-AB [PDGF-AB], platelet-derived growth factor-BB [PDGF-BB], transforming growth factor beta-1 [TGFß-1], and vascular endothelial growth factor) had higher levels for females and for those ≤ 25 years old. Of the GFs tested, four of seven were significantly higher (p < 0.05) for females (EGF, HGF, IGF-1, PDGF-BB), the most significant being IGF-1 (female, 85.0; male, 69.3 ng/mL; p < 0.01). Five of seven GFs achieved significance (p < 0.05) for people ≤ 25 years old (EGF, IGF-1, PDGP-AB, PDGF-BB, and TGFß-1), with IGF and PDGF-AB achieving p < 0.001 (≤ 25 years, 85.1; >25 years, 56.8, and ≤ 25 years, 7.66; >25 years, 5.77 ng/mL, respectively). Finally, for both genders, most of the GFs were positively correlated with all GFs. This study demonstrated that both age and gender account for variations in specific GFs present in PRP, and this may partially explain some of the inconsistent results of PRP clinical trials.

A criterion based sling weaning progression (sweap) and outcomes following shoulder arthroscopic surgery in an active duty military population.

INTRODUCTION: Little objective evidence is available to guide rehabilitation protocols in regard to the sling weaning process following arthroscopy surgery of the shoulder. The purpose of this study was to establish an objective, criterion based protocol for accelerated sling weaning following shoulder arthroscopy. METHODS: 82 active duty service members (ADSM) underwent elective shoulder arthroscopic surgery by three orthopaedic staff surgeons. One physical therapist progressed patients through the criterion based sling weaning progression (SWEAP) protocol for each surgery and documented pain levels, sleep habits, and decrease in sling use. Preoperative and six month postoperative Quick Disability of the Arm, Shoulder, and Hand (qDASH) and Shoulder Pain and Disability Index (SPADI) scores were obtained. The ability to perform an Army Physical Fitness Test (APFT) was recorded at six months postoperative. RESULTS: Patients completed sling weaning at an overall mean of 16.6 ± 5.0 days with continued use in unprotected military settings only beyond this timeframe. As patients steadily progressed out of the sling for 1 hour, 2-3 hours, and half-day periods, average pain scores decreased during these time periods at 5.0±1.2, 3.7±1.2, and 2.1±1.3 (0-10 pain scale), respectively. Patients obtained 6-7 hours of sleep or normal sleep habits at an average of 10.9±4.4 days postoperative. Overall, preoperative qDASH and SPADI scores improved from 39.8±13.0 to 2.4±2.0 and 46.4±16.1 to 3.3±3.2, respectively, at 6 months follow up. All 82 patients were able to return to deployable status. 30 (36.6%) patients required formal restrictions for the push-up portion of the APFT at six months postoperative. 7 of these 30 patients required running restrictions. CONCLUSIONS: Early improvement in quality of life indicators can be obtained in the initial postoperative period with a progressive, criterion based SWEAP protocol. Patients demonstrated favorable outcomes with return to occupational and physical fitness activities. This study will guide orthopedic surgeons and physical therapists to enhance the sling weaning process during rehabilitation protocols and improve preoperative counseling sessions for accurate postoperative expectations. STUDY DESIGN: Retrospective Case Series; Level of evidence 4.

Variance of matrix metalloproteinase (MMP) and tissue inhibitor of metalloproteinase (TIMP) concentrations in activated, concentrated platelets from healthy male donors.

BACKGROUND: The use of autologous blood concentrates, such as activated, concentrated platelets, in orthopaedic clinical applications has had mixed results. Research on this topic has focused on growth factors and cytokines, with little directed towards matrix metalloproteinases (MMPs) which are involved in post-wound tissue remodeling. METHODS: In this study, the authors measured the levels of MMP-2, MMP-9 and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), in activated platelets derived from blood of healthy, male volunteers (n = 92), 19 to 60 years old. The levels of the natural inhibitors of these proteases, tissue inhibitor of metalloproteinase 1 (TIMP-1), TIMP-2 and TIMP-4 were also assessed. RESULTS: Notably, there was no significant change in concentration with age in four of six targets tested. However, TIMP-2 and TIMP-4 demonstrated a statistically significant increase in concentration for subjects older than 30 years of age compared to those 30 years and younger (P = 0.04 and P = 0.04, respectively). CONCLUSION: TIMP-2 and TIMP-4 are global inhibitors of MMPs, including MMP-2 (Gelatinase A). MMP-2 targets native collagens, gelatin and elastin to remodel the extracellular matrix during wound healing. A decreased availability of pharmacologically active MMP-2 may diminish the effectiveness of the use of activated, concentrated platelets from older patients, and may also contribute to longer healing times in this population.

Intravenous angiocatheters as a novel alternative to Semmes-Weinstein monofilament evaluation in testing protective sensation.

Semmes-Weinstein monofilament (SWM) evaluation for protective sensation in diabetic feet is a widely used tool to guide patient care. Little evidence is available for alternative testing modalities for use when monofilament is not available or is deformed. Multiple varieties of intravenous angiocatheter tubing were subjected to biomechanical testing on a digital scale to assess the force generated once bending was observed by five independently tested raters. A 5.07 SWM (10 g) was tested in similar manner to establish a baseline and validate testing methodology. The 24 gauge × 0.75 in angiocatheter measured the closest to the 5.07 SWM (10 g) at an average force of 22 ± 0.91 g compared with 10.2 ± 0.13 g. Large-gauge angiocatheters measured greater forces. High intra-rater and inter-rater reliability was observed with all values greater than 0.98 (p < 0.001). A 24 gauge × 0.75 in angiocatheter tubing can be used as an alternative to the standard 5.07 SWM (10 g) for testing protective sensation in diabetic feet. Reviewing previously published receiver operating characteristics, this modality would yield estimated sensitivity and specificity values greater than 0.8 and 0.7, respectively, for detecting insensate feet tested at the bilateral metatarsal heads.