Adjustable Cortical Fixation Repair Is a Safe and Effective Technique for Quadriceps Tendon Rupture.

Purpose: To report the clinical outcomes of quadriceps tendon repair using adjustable cortical fixation devices at a minimum 2-year follow-up. Methods: A retrospective chart review identified patients who underwent quadriceps tendon repair using adjustable cortical fixation devices between January 2017 and March 2020. Patients with a partial tendon rupture were excluded. Demographic and injury-specific variables were gathered preoperatively and postoperatively from the electronic medical record and patient-reported outcomes (Lysholm Knee Questionnaire, Lower Extremity Functional Scale, and SF-12) were collected via telephone at a minimum of 2 years postoperatively. Results: Fourteen quadriceps tendon repairs were included in a total of 13 patients. The average time to follow-up was 3.5 ± 1.2 years with a range of 1.9 to 5.7 years. The mean age of this cohort was 55.7 ± 11.6 years, and the mean body mass index was 32.9 ± 6.0. Ten injuries (71.4%) were sustained by mechanical fall, 2 patients (14.3%) suffered a direct blow to the knee, and 2 patients (14.3%) reported a noncontact injury mechanism. Thirteen quadriceps ruptures (13/14, 92.9%) underwent surgery within 10 days of their injury. One knee (7.1%) had a postoperative extensor lag of 5°, whereas another knee (7.1%) required a reoperation for manipulation under anesthesia and arthroscopic lysis of adhesions at 3 months' postoperatively. None of the included patients (0.0%) developed a tendon re-rupture, venous thromboembolism, delayed wound healing, surgical-site infection, neuropraxia or nerve injury, hardware irritation, patella fracture, or heterotopic ossification. Conclusions: In this study, adjustable cortical fixation was a safe and effective surgical technique for quadriceps tendon repair, with adequate restoration of quadriceps function and a low rate of adverse events at 2 years postoperatively. Level of Evidence: Level IV, therapeutic case series.

Role of diabetes type in perioperative outcomes after hip and knee arthroplasty in the United States.

The objective of this study was to determine whether the type of diabetes mellitus (DM) affected the incidence of immediate perioperative complications following joint replacement. From 1988 to 2003, the Nationwide Inpatient Sample recognized 65,769 patients with DM who underwent total hip and knee arthroplasty in the United States. Bivariate and multivariate analyses compared patients with type 1 (n = 8728) and type 2 (n = 57,041) DM regarding common perioperative complications, mortality, and hospital course alterations. Type 1 DM patients had increased length of stays and inflation-adjusted costs after surgery (p < .001). Type 1 patients also had significant increases in the incidence of myocardial infarction, pneumonia, urinary tract infection, postoperative hemorrhage, wound infection, and death (p < .02). Perhaps because of the differences in the duration of disease and their underlying pathologies, patients with type 1 diabetes carry more significant overall perioperative risks and require more health care resources compared with patients with type 2 diabetes following hip and knee arthroplasty.

Management of medial-sided knee injuries, part 2: posteromedial corner.

Injury to the posteromedial corner (PMC) of the knee differs anatomically and biomechanically from isolated injury to the medial collateral ligament. Newer anatomic and biomechanical studies are refining the field's understanding of the medial side of the knee, as well as its role in multiple ligament injuries. Valgus instability places additional strain on a reconstructed anterior or posterior cruciate ligament, which can contribute to late graft failure. Injuries to the PMC may not heal without surgical repair or reconstruction, particularly when part of a multiple-ligament injury. Identification of PMC injury before cruciate reconstruction is important so that appropriate repair or reconstruction of the PMC and medial collateral ligament can be undertaken at the same time. This article reviews the relevant literature on the PMC, discusses reasons for selective operative management, and illustrates reconstructive strategies for PMC injuries occurring as part of a medial-sided or multiligament injury to the knee.

Management of medial-sided knee injuries, part 1: medial collateral ligament.

The medial collateral ligament complex is a primary stabilizer that combines static and dynamic resistance to direct valgus stress while contributing significant restraints to rotatory motion and anterior-posterior translation. Varying opinions exist among investigators regarding injury classification and treatment algorithms. Whereas most agree that the majority of isolated medial collateral ligament complex injuries can be treated nonoperatively, isolated injuries with chronic instability and multiligament injuries may require operative intervention. Substantial confounding factors are present within published reports, making comparative analyses and systematic review challenging. This review focuses on the anatomy and biomechanics of the medial structures of the knee; it discusses the clinical evaluation of complex injuries; and it reviews nonoperative and operative treatment methods.

Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction.

Bone tunnel widening poses a problem for graft fixation during revision anterior cruciate ligament (ACL) reconstruction. Large variability exists in the utilization of imaging modalities for evaluating bone tunnels in pre-operative planning for revision ACL reconstruction. The purpose of this study was to identify the most reliable imaging modality for identifying bone tunnels and assessing tunnel widening, and specifically, to validate the reliability of radiographs, MRI, and CT using intra- and inter-observer testing. Data was retrospectively collected from twelve patients presenting for revision ACL surgery. Five observers twice measured femoral and tibial tunnels at their widest point using digital calipers in coronal and sagittal planes. Measurements were corrected for magnification. Tunnel identification, diameter measurements, and cross-sectional area (CSA) calculations were recorded. A categorical classification of tunnel measurements was created to apply clinical significance to the measurements. Using kappa statistics, intra- and inter-observer reliability testing was performed. CT demonstrated excellent intra- and inter-observer reliability for tunnel identification. Intra- and inter-observer reliability was significantly less for MRI and radiographs. CT revealed superior reliability versus either radiographs or MRI for CSA analysis. Intra-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.66, 0.5, and 0.37, respectively. Inter-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.65, 0.39, and 0.32, respectively. Our results demonstrate CT is the most reliable imaging modality for evaluation of ACL bone tunnels as proven by superior intra- and inter-observer testing results when compared to MRI and radiographs. Radiographs and MRI were not reliable, even for simply identifying the presence of a bone tunnel.

The cortical ring sign: a reliable radiographic landmark for percutaneous coracoclavicular fixation.

BACKGROUND: For treatment of acute acromioclavicular separations, we have been using a reproducible radiographic view of the coracoid-the cortical ring sign-that we believe allows for placement of percutaneous coracoclavicular fixation safely and reliably in the center of the coracoid base, while avoiding the coracoid tip. This study evaluates the coracoid anatomy that the cortical ring sign represents, its utility for guiding fixation trajectory, and the proximity of neurovascular structures to this proposed trajectory. MATERIALS AND METHODS: Kirschner wires were used to measure the orientation of the fluoroscopic beam in relation to the scapula and the proposed fixation trajectory using this radiographic view. RESULTS: The cortical ring sign is achieved by first directing the x-ray beam perpendicular to the medial border of the scapula in the parasagittal plane and 49 degrees off the axis of the scapular spine in the axial plane, then fine-tuning until the coracoid cortical ring becomes evident. The nearest neurovascular structures to the fixation trajectory are the suprascapular artery and nerve (< 2 cm). CONCLUSION: The cortical ring sign view targets the coracoid base and, as such, allows reliable, safe, percutaneous fixation in the center of the coracoid base. LEVEL OF EVIDENCE: Basic Science.

The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty.

BACKGROUND: As the prevalence of diabetes mellitus in people over the age of sixty years is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should be expected to increase accordingly. In general, patients with diabetes are at increased risk for adverse events following arthroplasty. The goal of the present study was to determine whether the quality of preoperative glycemic control affected the prevalence of in-hospital peri-operative complications following lower extremity total joint arthroplasty. METHODS: From 1988 to 2005, the Nationwide Inpatient Sample recorded over 1 million patients who underwent joint replacement surgery. The present retrospective study compared patients with uncontrolled diabetes mellitus (n = 3973), those with controlled diabetes mellitus (n = 105,485), and those without diabetes mellitus (n = 920,555) with regard to common surgical and systemic complications, mortality, and hospital course alterations. Additional stratification compared the effects of glucose control among patients with Type-I and Type-II diabetes. Glycemic control was determined by physician assessments on the basis of the American Diabetes Association guidelines with use of a combination of patient self-monitoring of blood-glucose levels, the hemoglobin A1c level, and related comorbidities. RESULTS: Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had a significantly increased odds of stroke (adjusted odds ratio = 3.42; 95% confidence interval = 1.87 to 6.25; p < 0.001), urinary tract infection (adjusted odds ratio = 1.97; 95% confidence interval = 1.61 to 2.42; p < 0.001), ileus (adjusted odds ratio = 2.47; 95% confidence interval = 1.67 to 3.64; p < 0.001), postoperative hemorrhage (adjusted odds ratio = 1.99; 95% confidence interval = 1.38 to 2.87; p < 0.001), transfusion (adjusted odds ratio = 1.19; 95% confidence interval = 1.04 to 1.36; p = 0.011), wound infection (adjusted odds ratio = 2.28; 95% confidence interval = 1.36 to 3.81; p = 0.002), and death (adjusted odds ratio = 3.23; 95% confidence interval = 1.87 to 5.57; p < 0.001). Patients with uncontrolled diabetes mellitus had a significantly increased length of stay (almost a full day) as compared with patients with controlled diabetes (p < 0.0001). All patients with diabetes had significantly increased inflation-adjusted postoperative charges when compared with nondiabetic patients (p < 0.0001). CONCLUSIONS: Regardless of diabetes type, patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty.

The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States.

The purpose of this study was to determine whether patients with diabetes mellitus (DM) have a higher likelihood of immediate, inpatient complications following primary and revision total hip (THA) and total knee arthroplasty (TKA) than patients without DM. From 1988 to 2003, the Nationwide Inpatient Sample identified 751340 primary or revision THA or TKA patients. 64262 (8.55%) had DM. Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed using bivariate and multivariate analyses with logistic regression modeling. Diabetic patients had fewer routine discharges and higher inflation-adjusted hospital charges for all procedures. Although complications were not uniformly increased, diabetic patients had significantly increased odds of pneumonia, stroke, and transfusion (P < .001) after primary arthroplasty. This analysis of a large patient database indicates clinically relevant information for patients and surgeons, suggesting that patients undergoing THA and TKA demonstrate more complications and utilize more resources if they have the comorbidity of DM level II evidence.

Hip incision planning for free vascularized fibular grafting of the proximal femur: a handy tip.

Free vascularized fibula graft surgery has been shown to be successful in the treatment of osteonecrosis of the femoral head. Refinements in the surgical technique have greatly decreased patient morbidity and overall surgical time. Careful placement of the hip incision is one such refinement. Specific bony landmarks to map out the location of the incision and a simple technique for incision placement are described. An accurately placed 10- to 15-cm incision will allow access to both the proximal femur and the ascending branch of the lateral femoral circumflex artery and veins.