Consensus and Equipose in the Management of Military Trainee Femoral Neck Stress Fractures: A Survey of Military Surgeons.

BACKGROUND: Femoral neck stress fractures (FNSFs) are a unique injury pattern not commonly treated in the civilian trauma population; however, it is particularly high with military trainees engaged in basic combat training. To date, no study has surveyed a population of military orthopedic surgeons on treatment preferences for military service members (SMs) with FNSF. QUESTIONS: We aim to evaluate the extent of clinical equipoise that exists in the management of these injuries, hypothesizing that there would be consensus in the factors dictating surgical and non-surgical intervention for FNSF. PATIENTS AND METHODS: A 27-question survey was created and sent to U.S. military orthopedic surgeon members of the Society of Military Orthopaedic Surgeons. The survey was designed in order to gather the experience among surgeons in treating FNSF and identifying variables that play a role in the treatment algorithm for these patients. In addition, seven detailed, clinical vignettes were presented to further inquire on surgeon treatment preferences. Binomial distribution analysis was used to evaluate for common trends within the surgeon's treatment preferences. RESULTS: Seventy orthopedic surgeons completed the survey, the majority of whom were on active duty status in the U.S. Military (82.86%) and having under 5 years of experience (61.43%). Majority of surgeons elected for a multiple screw construct (92.86%), however the orientation of the multiple screws was dependent on whether the fracture was open or closed. Management for compression-sided FNSF involving ≥50% of the femoral neck width, tension-sided FNSF, and stress fractures demonstrating fracture line progression had consensus for operative management. Respondents agreed upon prophylactic fixation of the contralateral hip if the following factors were involved: Complete fracture (98.57%), compression-sided fracture line >75% (88.57%), compression-sided fracture line >50-75% with hip effusion (88.57%), contralateral tension-sided fracture (87.14%), and compression-sided fracture line >50-75% (84.29%). An FNSF < 50% on the contralateral femoral neck or a hip effusion was indeterminate in surgeons indicating need for prophylactic fixation. Majority of surgeons (77.1%) utilized restricted toe-touch weight-bearing for postoperative mobility restrictions. CONCLUSIONS: Consensus exists for surgical and non-surgical management of FNSF by U.S. military orthopedic surgeons, despite the preponderance of surgeons reporting a low annual volume of FNSF cases treated. However, there are certain aspects in the operative and non-operative management of FNSF that are unanimously adhered to. Specifically, our results demonstrate that there is no clear indication on the management of FNSF when an associated hip effusion is involved. Additionally, the indications for surgically treating contralateral FNSF are unclear. LEVEL OF EVIDENCE: IV.

Bulk Osteochondral Allograft for a Firearm Injury to the Medial Femoral Condyle in a Military Service Member: A Case Report.

A 27-year-old U.S. military active duty male sustained an accidental, self-inflicted left knee gunshot injury with an unsalvageable medial femoral condyle injury. The patient underwent bulk osteochondral allograft transplantation. Nine months post-operation, the patient was fit for full military duties with no reported functional limitations and remained on active duty. Severe knee medial femoral condyle bone loss after accidental firearm injury is uncommon. Bulk knee osteochondral allograft transplantation to the medial femoral condyle provided a successful treatment option for an active duty U.S. military member with multicompartment osteochondral defects and severe medial femoral condyle bone loss due to a gunshot injury.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Aseptic Revision and Reoperation Risks After Meniscectomy at the Time of Anterior Cruciate Ligament Reconstruction.

BACKGROUND: An intact meniscus is considered a secondary stabilizer of the knee after anterior cruciate ligament reconstruction (ACLR). While loss of the meniscus can increase forces on the anterior cruciate ligament graft after reconstruction, it is unclear whether this increased loading affects the success of the graft after ACLR. PURPOSE: To identify the risk of subsequent knee surgery when meniscectomy, either partial or total, is performed at the time of index ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We conducted a matched cohort study using data from the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Patients were identified who had a primary ACLR performed between January 1, 2005 and December 31, 2016, with up to 12 years of follow-up. The study sample comprised patients with ACLR who had a lateral meniscectomy (n = 2581), medial meniscectomy (n = 1802), or lateral and medial meniscectomies (n = 666). For each meniscectomy subgroup, patients with ACLR alone were matched to patients with a meniscectomy on a number of patient and procedure characteristics. After the application of matching, Cox proportional hazards regression was used to evaluate the risk of aseptic revision, while competing risks regression was used to evaluate the risk of cause-specific ipsilateral reoperation between meniscectomy and ACLR alone. Analysis was performed for each meniscectomy subgroup. RESULTS: After the application of matching, we failed to observe a difference in aseptic revision risk for patients with ACLR and a meniscectomy-lateral (hazard ratio [HR], 0.80; 95% CI, 0.63-1.02), medial (HR, 0.95; 95% CI, 0.70-1.29), or both (HR, 1.25; 95% CI, 0.77-2.04)-as compared with ACLR alone. When compared with patients who had ACLR alone, patients with a lateral meniscectomy had a higher risk for subsequent lateral meniscectomy (HR, 1.89; 95% CI, 1.18-3.02; P = .008), and those with a medial meniscectomy had a lower risk for manipulation under anesthesia (HR, 0.13; 95% CI, 0.02-0.92; P = .041). CONCLUSION: No difference in aseptic revision risk was observed for patients undergoing primary ACLR between groups with and without meniscectomy at the time of index surgery. Partial lateral meniscectomy at the time of index ACLR did associate with a higher risk of subsequent lateral meniscectomy.

Aspirin for Deep-Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction.

AIM: To evaluate whether a daily full-dose aspirin regimen after anterior cruciate ligament (ACL) reconstruction reduces the risk of postoperative symptomatic deep-venous thrombosis (DVT). MATERIALS AND METHODS: Single-center retrospective cohort study of patients who underwent ACL reconstruction from 2007 to 2016. One thousand two hundred thirty-three patients met inclusion criteria: 821 patients received no chemoprophylaxis and 412 patients received daily full-dose aspirin. RESULTS: A total of 10 patients, seven receiving no chemoprophylaxis and three using aspirin, sustained a postoperative symptomatic DVT. Calculated adjusted odds ratio for symptomatic postoperative DVT for aspirin versus no chemoprophylaxis was 0.928 (95% CI 0.237-3.629, P value = 0.91). Odds ratio for symptomatic postoperative DVT occurrence among tobacco users versus non-tobacco users was 3.76 (95% CI 1.077-13.124, P = 0.04). CONCLUSIONS: No statistically significant difference was observed in postoperative symptomatic DVT after ACL reconstruction in those who received full-dose aspirin chemoprophylaxis versus those with no chemoprophylaxis. Additionally, there was a significantly increased risk of postoperative symptomatic DVT with tobacco use.

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden.

BACKGROUND: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. PURPOSE: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. RESULTS: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. CONCLUSION: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Screw and Sheath Tibial Fixation Associated With a Higher Likelihood of Deep Infection After Hamstring Graft Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone-patellar tendon-bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation. PURPOSE: To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated. RESULTS: Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Staphylococcus aureus for the BPTB group and Staphylococcus epidermidis in both hamstring groups were the most common infecting organisms. HS with screw and sheath had a higher likelihood of 90-day deep infection compared with BPTB ACLR (odds ratio [OR], 2.87; 95% CI, 1.29-6.38). We failed to observe a difference for HS without screw and sheath compared with BPTB ACLR (OR, 1.23; 95% CI, 0.54-2.77). The NNE was 330 and 2701 for HS with and HS without screw and sheath, respectively. CONCLUSION: Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed.

Wide Decompression May Render the Ulnar Nerve Unstable: A Cadaveric Study.

The purpose of this study was to evaluate for ulnar nerve instability following incrementally widened in situ decompression. A standard release of the ulnar nerve was performed in 16 cadaveric elbows, extending from 7cm distal to the medial epicondyle, and then released proximally for a total of 10 cm in 2-cm increments. Eight of the 16 elbows (50%) displayed subluxation of the ulnar nerve following complete in situ decompression. The rate of subluxation was found to increase with increasing length of proximal decompression. The greatest increase in rate of subluxation was seen beyond 4 cm proximal to the medial epicondyle. Cubital tunnel release should be limited to decompression of only the cubital tunnel if clinical and electrodiagnostic studies indicate that the cubital tunnel is the source of compression.

Central serous chorioretinopathy resulting in altered vision and color perception after glenohumeral corticosteroid injection.

Complications from shoulder corticosteroid injections are uncommon. This article presents a case of altered color perception and visual disturbances in a 29-year-old male active duty Navy SEAL following an intra-articular glenohumeral corticosteroid injection, previously unreported in the orthopedic literature. The corticosteroid injection was administered for the treatment of right-shoulder stiffness occurring approximately 3 months following an arthroscopic superior labrum anterior-posterior (SLAP) repair and subacromial decompression of the ipsilateral shoulder. The patient experienced immediate relief after the injection. Seven days later, however, he began to notice visual disturbances with color and image distortion of his right eye. He also developed a papular, nonpruritic rash on his upper trunk that eventually extended down his legs. He was diagnosed by an ophthalmologist as having central serous chorioretinopathy, a condition in which serous fluid accumulates in the subretinal space of the eye, causing detachment of the retina from the underlying retinal pigment epithelium. The reaction spontaneously resolved within approximately 10 to 12 weeks without treatment. Although intra-articular corticosteroid injections are frequently performed with a low rate of complication, clinicians should be familiar with this rare yet distressing condition. Furthermore, patients with increased production of endogenous corticosteroids (eg, those with Cushing's syndrome, type A personality, hypertension, or obstructive sleep apnea) should be warned of the potential of chorioretinopathy after an intra-articular corticosteroid injection.