Potential for Bias and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scoring System.

BACKGROUND: The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scoring System (AOFAS-AH) has not been validated and has significant risk for researcher bias, given that 40 out of 100 points are assessed by study staff subjectively. The purpose of this study is to evaluate its recent use in the orthopaedic literature to determine the percentage of previously published studies for which study conclusions would be changed if the AOFAS-AH scores were artificially altered, representing the effect of a systematic researcher bias. MATERIALS AND METHODS: Articles from January 2012 and February 2015 in three orthopaedic journals were queried for use of the AOFAS-AH. Quantities of 4, 8, or 12 points were added to or subtracted from mean AOFAS-AH scores for each study while otherwise maintaining the reported standard deviation to simulate a researcher bias when scoring the subjective sections. Statistical analysis was performed with the adjusted AOFAS-AH mean scores in order to elucidate a potential "reversal" in statistical significance and conclusion. RESULTS: A 1582 original research articles were published during this time period. 128 articles utilized the AOFAS-AH score. 30 articles (23.4%) reported the required statistical data to permit manipulation of AOFAS-AH scores. Nine of the 30 articles (30%) had a reversal following a manipulation of 12 or fewer points. Seven (5.5%) reported the blinding status of the researchers. CONCLUSION: The potential for bias is high with the AOFAS-AH and its continued is questionable. Researchers utilizing the AOFAS-AH should at a minimum appropriately blind study staff and consider pre-study clarification of subjective terminology. LEVELS OF EVIDENCE: Level IV.

Gravity Reduction View: A Radiographic Technique for the Evaluation and Management of Weber B Fibula Fractures.

BACKGROUND: While various radiographic parameters and application of manual/gravity stress have been proposed to elucidate instability for Weber B fibula fractures, the prognostic capability of these modalities remains unclear. Determination of anatomic positioning of the mortise is paramount. We propose a radiographic technique, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise. METHODS: The patient is positioned lateral decubitus with the injured leg elevated on a holder with the fibula directed superiorly. The x-ray cassette is placed posterior to the heel, with the beam angled at 15° of internal rotation to obtain a mortise view. Our proposed treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view (and in comparison to the superior clear space (SCS)) and is based on reducibility of the MCS. A retrospective review of patients evaluated utilizing the GRV was performed. RESULTS: 26 patients with Weber B fibula fractures were managed according to this treatment algorithm. Mean age was 50.57 years old (range:18-81, SD=19). 17 patients underwent operative treatment and 9 patients were initially treated nonoperatively. 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, at a mean follow-up of 26 weeks, all patients had a final MCS that was less than the SCS (final mean MCS 2.86 mm vs. mean SCS of 3.32) indicating effectiveness of the treatment algorithm. CONCLUSIONS: The GRV is a radiographic view in which deltoid competency, reducibility and initial positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the GRV. We have proposed a treatment algorithm based on the GRV that we found it useful in our patients in guiding treatment and achieving anatomic mortise alignment.

Patient Compliance with Postoperative Lower-Extremity Non-Weight-Bearing Restrictions.

BACKGROUND: A period of non-weight-bearing is prescribed following many orthopaedic injuries and procedures. It is believed that a period of non-weight-bearing is important for proper healing and recovery. The degree to which patients are compliant with non-weight-bearing instructions is unknown. The purpose of this study was to measure patient compliance with a period of prescribed non-weight-bearing. METHODS: In this single-blinded study, pressure-sensitive film was embedded into short leg casts of 51 consecutive adult orthopaedic patients with unilateral lower-extremity abnormality who had been instructed to be strictly non-weight-bearing. Sensors were retrieved at the time of cast removal (mean, 24.3 days [range, 7 to 48 days]) and then were analyzed for force distribution and magnitude. Noncompliance was defined as maximum detectable pressure exerted on ≥50% of the film. Patient characteristics and the time of year that the casts were worn were also examined to determine if they correlated with weight-bearing. RESULTS: Fourteen (27.5%) of 51 patients were noncompliant with the non-weight-bearing restriction. Six (42.9%) of the 14 noncompliant patients compared with 11 (29.7%) of the 37 compliant patients experienced an adverse event (p = 0.51). Sex, age, language spoken, body mass index, time in the cast, and the treating surgeon did not have a significant influence on weight-bearing performance (p > 0.05). Significantly greater weight-bearing was found (p = 0.04) in warmer months (June to October) than in colder months (November to March) in the United States. CONCLUSIONS: The noncompliance rate with the postoperative non-weight-bearing restriction was 27.5% (95% confidence interval, 15.2% to 39.8%) in this patient group, despite explicit instructions and education about possible complications associated with weight-bearing. The only factor found to have a significant effect on weight-bearing compliance was the time of year that the cast was worn. No significant difference was found between the complication rate of the compliant patients and that of the noncompliant patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Determining Measurement Error for Bohler's Angle and the Effect of X-Ray Obliquity on Accuracy.

BACKGROUND: Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA. METHODS: A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement. RESULTS: A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity. CONCLUSIONS: Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph. LEVELS OF EVIDENCE: Level V: Cadaver bench study.

Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for the Acute Ankle Fracture.

BACKGROUND: Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures. METHODS: A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications. RESULTS: A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement in patient outcome over historical techniques. There is also insufficient (grade I) evidence from 2 prospective randomized studies and 1 case-control study to provide any direct comparative data on functional outcomes, complication rates or total operative time between AAORIF and ORIF for the treatment of acute ankle fractures. CONCLUSIONS: Ankle arthroscopy is a valuable tool in identifying and treating intra-articular lesions associated with ankle fractures. The presence of such intra-articular pathology may lead to the unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions therefore has the potential to improve patient outcomes. To date, however, currently available literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF, and few prospective randomized controlled studies have been performed comparing these 2 operative techniques-rendering any suggestion that AAORIF improves clinical outcomes over traditional ORIF difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct before we can advocate its routine use in these patients. LEVEL OF EVIDENCE: Level II, systematic review.

Sport and activity restrictions following total ankle replacement: A survey of orthopaedic foot and ankle specialists.

BACKGROUND: Despite an increasing utilization of total ankle replacement, surgeons have little guidance with regards to physical activity and sport participation recommendations following the procedure. METHODS: Orthopaedic foot and ankle specialists were surveyed as to the activity and sports restrictions they place on their patients following ankle replacement. Fifty sports and activities were included and the results were used to derive a set of consensus recommendations. Of the 1063 surgeons that were sent the survey, 173 responded, yielding a response rate of 16.3%. RESULTS: In general, surgeons were comfortable with aerobic or low impact sports and activities. Boot immobilized sports represented a grey area with the determination of whether or not to allow them based largely on the prior experience of the patient. High impact, cutting and jumping sports and activities were largely discouraged. Young age, high BMI and poor bone quality led surgeons to be more restrictive. CONCLUSIONS: These consensus recommendations serve as a useful guideline for surgeons and help patients set appropriate expectations for the procedure.

Superior labrum anterior-to-posterior repair incidence: a longitudinal investigation of community and academic databases.

BACKGROUND: Superior labrum anterior-to-posterior (SLAP) lesion repair is controversial regarding indications and potential complications. METHODS: Databases were used to determine the SLAP repair incidence compared with all orthopaedic procedures over a period of 10 years. In part A, the New York Statewide Planning and Research Cooperative System ambulatory surgery database was investigated from 2002 to 2009. In part B, the California Office of Statewide Health Planning and Development ambulatory surgery database was investigated from 2005 to 2009. In part C, the American Board of Orthopaedic Surgery (ABOS) database was investigated from 2003 to 2010. RESULTS: In part A, from 2002 to 2009, there was a 238% increase in SLAP repair volume compared with a 125% increase in all orthopaedic procedures. In part B, from 2005 to 2009, there was a 20.17% increase in SLAP repair volume compared with a decrease of 13.64% in all orthopaedic procedures. In part C, among candidates performing at least 1 SLAP repair, there was no statistically significant difference in likelihood of performing a SLAP repair (95% confidence interval, 0.973-1.003) in 2010 as compared with 2003 (P > .10). CONCLUSIONS: There has been a significant increase in the incidence of SLAP repairs in the past 10 years in statewide databases. This pattern was not seen in the ABOS database, in which the annual volume of SLAP repairs remained stable over the same period. This suggests that SLAP lesions have been over-treated with surgical repair but that part II ABOS candidates are becoming more aware of the need to narrow indications. LEVEL OF EVIDENCE: Epidemiology study, database analysis.

Anterior cruciate ligament graft choices.

CONTEXT: Reconstruction of the anterior cruciate ligament (ACL) is a common surgical procedure; however, there is no consensus to what the best graft option is to replace the injured ACL. The main options available consist of allografts and autografts, which include patellar tendon, hamstring tendon, and quadriceps tendon autografts. EVIDENCE ACQUISITION: The PubMed database was searched in August 2010 for English-language articles pertaining to ACL grafts. RESULTS: Postoperative outcome variables were analyzed to determine similarities and differences among the different graft options. These variables include stability, strength, function, return to sports, patient satisfaction, complications, and cost. CONCLUSIONS: Both allografts and the 3 main options for autografts can provide excellent results in ACL reconstruction and lead to a high percentage of satisfied patients. However, differences exist among the graft choices. Both the similarities and the differences are important to discuss with a patient who will be undergoing ACL reconstruction so that he or she has the best information available when making a choice of graft.

Posterior cruciate ligament resection for ganglion cyst and associated ligament degeneration.

With increased use of magnetic resonance imaging (MRI) and arthroscopy, intra-articular ganglion cysts of the posterior cruciate ligament (PCL) have received more recognition as a possible cause of knee discomfort. Reported treatment options have ranged from ultrasound-guided cyst aspiration to arthroscopic cyst resection. In this report, we present the case of a patient who, on MRI, was diagnosed with a symptomatic intrasubstance PCL ganglion that later, during surgery, demonstrated mucinous degeneration of the entire ligament. Treatment was complete resection of the PCL. Five years after surgery, the patient demonstrated excellent, asymptomatic knee function. Although the best treatment for an intrasubstance PCL ganglion cyst that has caused degeneration of the entire ligament is unknown, PCL resection without reconstruction should be considered a viable option. It can result in a large increase in range of motion and function.

Rotator cuff deficient arthritis of the glenohumeral joint.

Rotator cuff deficient arthritis of the glenohumeral joint, especially cuff tear arthropathy, has proved a challenging clinical entity for orthopaedic surgeons ever since Charles Neer originally detailed the problem in 1983. Understanding has improved regarding the pathophysiology and pathomechanics underlying cuff tear arthropathy. Surgical reconstruction options can lead to excellent outcomes for patients afflicted with these painful and functionally limited shoulders. Humeral hemiarthroplasty and reverse total shoulder arthroplasty have jumped to the forefront in the treatment of cuff tear arthropathy. As studies continue to look at the results of these procedures in cuff tear arthropathy, existing indications and treatment algorithms will be further refined. In this article the history and pathophysiology of cuff tear arthropathy are reviewed. Additionally, the clinical findings and results of surgical reconstruction are discussed.