Biomechanical Comparison of Adjustable-Loop Femoral Cortical Suspension Devices for Soft Tissue ACL Reconstruction.

Background: Several new adjustable-loop devices (ALDs) for anterior cruciate ligament reconstruction (ACLR) have not been tested in vitro. Purpose: To compare the biomechanical performances of 5 ALDs under a high cyclic load and forces representative of the return-to-play conditions seen in the recovering athlete. Study Design: Controlled laboratory study. Methods: A total of 10 devices for each of 5 chosen ALDs (UltraButton [Smith & Nephew], RigidLoop [DePuy Mitek], ProCinch [Stryker], TightRope [Arthrex], and ToggleLoc [Biomet]) were tested in a device-only model. The devices were secured to a servohydraulic test machine and preconditioned from 10 to 75 N at a rate of 0.5 Hz for 20 cycles. They were then subjected to high cyclic forces (100-500 N for 4000 cycles) and subsequently pulled to failure at 50 mm/min. The preconditioning displacement, permanent deformation, cumulative peak displacement, stiffness coefficient, and load to failure data were collected. Results: The UltraButton displayed the greatest preconditioning displacement (0.22 ± 0.20 mm), followed by the RigidLoop (0.11 ± 0.03 mm), ProCinch (0.07 ± 0.04 mm), TightRope (0.07 ± 0.02 mm), and ToggleLoc (0.02 ± 0.03 mm). The TightRope displayed the greatest permanent deformation (3.19 ± 1.03 mm) followed by the UltraButton (2.14 ± 0.92 mm), ToggleLoc (2.02 ± 1.09 mm), RigidLoop (1.67 ± 0.1 mm), and ProCinch (1.38 ± 0.18 mm). The TightRope displayed the greatest cumulative peak displacement (3.69 ± 1.03 mm) followed by the UltraButton (2.46 ± 0.92 mm), ToggleLoc (2.37 ± 1.08 mm), RigidLoop (2.01 ± 0.1 mm), and ProCinch (1.75 ± 0.19 mm). The UltraButton displayed the largest stiffness coefficient (1347.22 ± 136.33 N/mm) followed by the RigidLoop (1325.4 ± 116.37 N/mm), ToggleLoc (1216.62 ± 131.32 N/mm), ProCinch (1155.56 ± 88.04), and TightRope (848.48 ± 31.94). The ToggleLoc displayed the largest load to failure (1874.42 ± 101.08 N) followed by the RigidLoop (1614.12 ± 129.11 N), UltraButton (1391.69 ± 142.04 N), ProCinch (1384.85 ± 58.62 N), and TightRope (991.8 ± 51.1 N.). Conclusion: The 5 ALDs exhibited different biomechanical properties. None of them had peak cumulative displacements for which the confidence interval lay above 3 mm, thus no single device was determined to have a higher rate of clinical failure compared with the others. Clinical Relevance: ALD choice may affect biomechanics after ACLR.

Pediatric On-Call Challenges for the General Orthopaedic Surgeon.

Taking call as an orthopaedic surgeon is commonplace and expected at many institutions. Taking general orthopaedic call without specialized backup physicians can be challenging and daunting. Pediatric patients commonly present to emergency departments around the country with a host of pathologies, many of which are different from those of adults. It is imperative to recognize injuries and scenarios that require emergent or urgent intervention, those that can potentially become difficult, and how to triage nonurgent ones. Just as important is identifying one's ability to treat these patients (as a surgeon or an institution) and the capacity and mechanism to transfer these patients to specialized care centers. The general orthopaedic surgeon will be required to assess on-call challenges with pediatric patients.

Modified Langenskiöld procedure for chronic, recurrent, and congenital patellar dislocation.

PURPOSE: Langenskiöld described a reconstructive soft-tissue procedure for irreducible lateral congenital patellar dislocations. Paley further detailed the technique in the surgical management of congenital femoral deficiency. The aim of this study was to evaluate the outcomes of patients with congenital, chronic and recurrent patellar dislocations treated with the modified Langenskiöld procedure. METHODS: This is a retrospective case series. Between 2011 and 2018, 18 knees in 13 patients (mean age 15.8 years (sd 4.4; 12 to 29.9), nine female) with diagnoses of recurrent (six patients, eight knees), chronic (four patients, six knees) and congenital (three patients, four knees) patellar dislocations were treated with the modified Langenskiöld procedure. RESULTS: There were no recurrent lateral dislocations in the congenital or recurrent groups. One of the patients in the congenital group had an overcorrection with some medial patellar maltracking but until this time has not required any further surgery. In the chronic group two of the six knees developed further dislocations; these were both on the same patient, who had no dislocations until one year after surgery. Mean Kujala score was 83.7 (sd 17; 47 to 100) for all groups. In spite of preoperative knee flexion contractures of up to 30° in three patients (six knees), all patients had full extension postoperatively. Eight patients reported being satisfied with their outcome, one was somewhat satisfied, two were very dissatisfied, and two did not respond. CONCLUSION: The modified Langenskiöld reconstruction provides a powerful correction for challenging cases of congenital and recurrent patellar dislocations. Re-dislocation as well as overcorrection can occasionally occur. LEVEL OF EVIDENCE: Level IV.

External fixator-augmented flexible intramedullary nailing of an unstable pediatric femoral shaft fracture model: a biomechanical study.

The objective of this study was to test the compressive strength and torsional stiffness provided by the addition of a two-pin external fixator to an unstable pediatric femoral shaft fracture model after being instrumented with flexible intramedullary nailing (FIMN), and to compare this to bridge plating and FIMN alone. A length-unstable oblique diaphyseal fracture was created in 15 pediatric sized small femur models. Fracture stabilization was achieved by three constructs: standard retrograde FIMN with two 3.5-mm titanium (Ti) nails (Group 1), FIMN augmented with a two-pin external fixator (Group 2), and a 4.5-mm bridge plate (Group 3). Groups I and II were tested in 10 cycles of axial rotation to 10° in both directions at 0.1 Hz under 36 kg of compression. Torsional stiffness was calculated. Compressive strength was calculated by applying an axial load of 5 mm/min until failure was encountered. Failure was defined as the force required to achieve 10° varus at the fracture site or shortening of 2 cm. Group II demonstrated a greater compressive strength compared to Group I (1067.32 N vs 453.49 N, P < 0.001). No significant difference in torsional stiffness was found between Groups I and II (0.45 vs 0.38 Nm/deg, P = 0.18). Group III showed superior compressive strength and rotational stiffness compared to Groups I and II. In an unstable pediatric femoral shaft fracture model, augmenting FIMN with a two-pin external fixator increased the compressive strength by 147%, but did not increase torsional stiffness. Bridge plating with a 4.5-mm plate provided superior compressive strength and torsional stiffness.

Intramedullary Fixation of Both Bone Forearm Fractures in Children and Adolescents: Healing Correlates With Development of the Olecranon Apophysis.

BACKGROUND: The purpose of this study was to determine whether healing of both bone forearm (BBFA) fractures in children and adolescents is associated with the stage of the olecranon apophysis development as described by the Diméglio modification of the Sauvegrain method. METHODS: Records were reviewed from 2 children's hospitals from 1997 to 2008 to identify all patients younger than 18 years of age who had BBFA fractures treated with intramedullary nail fixation. Sixty-three patients were identified meeting inclusion and exclusion criteria. The stage of the olecranon apophysis was noted on the lateral radiograph at the time of the injury. Data were statistically analyzed to assess the olecranon stage at which the increased rate of delayed union becomes more prevalent using the receiver operating characteristic curve. Time to union, complications, and need for reoperation were recorded for each group. RESULTS: One thousand three hundred ninety-eight patient records were reviewed with 63 patients meeting the inclusion criteria. Using a receiver operating characteristic curve, a cutoff of olecranon stage > 3 (stages 4 to 7) was a significant predictor of the increased rate of delayed union time compared with olecranon stages 0 to 3 (P=0.004). Non-healing-related complication rates for each group were 2/28 (7.1%) for olecranon stages and 0 to 3 and 6/35 (17.1%) for olecranon stages 4 to 7. CONCLUSIONS: The rate of delayed union for BBFA fractures that have been treated with intramedullary nail fixation is increased in children with more mature olecranon apophyses as compared with those with younger olecranon stages. We propose the use of the stage of olecranon apophysis development when choosing the surgical approach and implant for when treating operative BBFA fractures in children. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

COVID-19 pandemic and the implications for orthopaedic and neurosurgery residents and fellows on spine rotations.

Background: The COVID-19 global pandemic has caused unprecedented levels of strain on the United States healthcare and its workforce. Orthopaedic and neurosurgery residents and fellows, as part of this workforce have also experienced some of the uncertainty and stress caused by this pandemic. Concerns exist regarding the effects of the pandemic on spine surgery education due to the cancellation of all elective surgeries. Current Context: We explore how this pandemic is affecting orthopaedic and neurosurgery residents and fellows and their spine surgery education and experience. We also examined measures taken by the residency and fellowship programs to protect their residents and fellows, and measures taken by regulatory agencies like the ACGME and the ABOS to give programs some flexibility during these difficult times. Conclusion: Orthopaedic and neurosurgery residents and fellows are often on the front lines of patient care. Programs have to ensure adequate resources and training, supervision, and work hour requirements are met. Residents and fellows need to be ready to assist with management of COVID-19 patients if necessary. Residency programs and spine surgery fellowships need to use objective metrics to assess the impact of the pandemic on the spine surgery education of their residents and fellows in order to address any potential area of weakness caused by the decreased exposure to spine surgery.

Slipped Capital Femoral Epiphysis in an Adult Patient With Kabuki Syndrome.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is a condition which predominantly occurs in adolescents. SCFE is extremely rare in adults, and nearly all previous reported cases have been associated with an endocrine disorder. METHODS: We present a case of a 19-year-old man with Kabuki syndrome who was diagnosed with an unstable SCFE requiring surgical fixation. A literature search on PubMed and Google Scholar was done looking for all published cases of delayed-onset SCFE. All previous reported cases were reviewed to determine the likely cause of the SCFE. RESULTS: No previous cases of SCFE were described in patients with Kabuki syndrome. Literature review revealed 27 articles describing 32 cases of delayed-onset SCFE. Thirty-one of these cases were associated with endocrine disorders or pituitary tumors. Endocrine disorders associated with delayed-onset SCFE included hypothyroidism, hypogonadism, and panhypopituitarism. Pituitary adenomas and craniopharyngiomas were also associated with delayed-onset SCFE. DISCUSSION: This is the first reported case of SCFE in a patient with Kabuki syndrome. Kabuki syndrome is a genetic disorder known to cause delayed growth, resulting in delayed physeal closure, placing the patients at risk of SCFE even into adulthood. The literature search revealed that nearly all previously described delayed-onset SCFE cases were associated with endocrine disorders or pituitary tumors. We recommend that all patients diagnosed with delayed-onset SCFE be evaluated for endocrine disorders, pituitary tumors, and/or genetic disorders which can cause delayed skeletal maturation as these disorders can range from severe endocrine disorders to intracranial tumors.

Focal Periphyseal Edema: An Uncommon Cause of Adolescent Knee Pain: A Report of Three Cases.

CASE: Focal periphyseal edema (FOPE) zones have only recently been described as a cause of joint pain in adolescence. The literature is limited to a few case reports and radiologic studies describing this symptomatic physeal pathology. This series describes 3 adolescent patients with magnetic resonance imaging (MRI) confirmed FOPE zones of the distal femur. Repeat MRI of 2 of the 3 patients showed improvement yet incomplete resolution of the bone edema, corresponding with persistent knee pain. CONCLUSIONS: FOPE zones usually improve with conservative treatment, but may be a cause of persistent knee pain in adolescents.

Unstable Pediatric Femur Fractures: Combined Intramedullary Flexible Nails and External Fixation.

INTRODUCTION: The treatment of pediatric femur fractures continues to evolve. In the past, many of these fractures required prolonged hospitalization in traction. More recently, flexible elastic nails have gained popularity. However, length unstable and comminuted fractures can present some unique challenges. To avoid common complications of elastic nailing in the setting of unstable fractures we describe a technique of augmenting this treatment with external fixation for cases requiring additional rotational or longitudinal stability. CASE REPORT: A series of two patients are described who underwent intramedullary flexible nails and external fixation for a closed unstable midshaft femur fracture: An 8-year-old male that sustained a left periprosthetic femur fracture after a fall on his scooter, and a 5-year-old female that sustained a right femur fracture after a fall from a wet decking. Both patients had their external fixator removed after 4 weeks and achieved radiographic and clinical fracture union at 8-week postoperatively. CONCLUSION: Treatment with elastic nails and external fixator for unstable pediatric femur fractures is a minimally invasive technique that safely provides fracture stability.

Intra-articular nodular fasciitis of the knee in a pediatric patient.

The differential diagnosis for an intra-articular lesion in the knee of a pediatric patient is broad. Diagnostic considerations include pigmented villonodular synovitis (PVNS)-the most common intra-articular tumor-and a variety of both benign and malignant tumors, including lipomas, hemangiopericytomas, nodular fasciitis, parosteal osteosarcomas, and fibromyxoid sarcomas. If there is concern over possible malignant lesions, a tumor surgeon should be consulted. Precise pathologic diagnosis is ideal for identifying these enigmatic lesions and for determining the appropriate treatment plan. This article presents the case of a 13-year-old boy who presented with 1-month duration of knee pain and no history of trauma to the extremity. Physical examination revealed pain along the medial and lateral joint lines, pain with range of motion, and limited range of motion of the affected knee. Magnetic resonance imaging revealed a 3×1×3-cm lesion in the posterolateral corner that was believed to be localized PVNS. Arthroscopically, there was no evidence of PVNS, but a posterolateral soft tissue mass was found and removed, which was pathologically diagnosed as a rare, benign, intra-articular nodular fasciitis. When working with intra-articular masses, it is important to assess the likelihood of malignancy and to both consult a tumor surgeon and use the appropriate surgical tumor principles when malignancy is a concern. Additionally, the pathology team should be consulted prior to surgery and be on standby during arthroscopic evaluation of the knee to help with precise diagnosis of the intra-articular mass. Discussing the case with the pathologist with imaging studies present is helpful and often aids in the diagnosis of the lesion.

Both bone forearm fractures in children and adolescents, which fixation strategy is superior - plates or nails? A systematic review and meta-analysis of observational studies.

OBJECTIVES: To determine which method of operative fixation, plate and screw, or intramedullary nails (IMN) fixation is superior for pediatric both bone forearm fractures (BBFF). DATA SOURCES: PubMed, EMBASE, and Cochrane, from 1980 to 2011, in English. STUDY SELECTION: We selected for detailed review all studies with children or adolescents with comparative data (or individual patient data) for BBFF fixed with IMN or open reduction internal fixation with plates and screws. Selected studies also required outcomes of interest including fracture union, complications, functional outcome, cosmesis, and the need for hardware removal. DATA EXTRACTION: Data were extracted from each study; publication bias was assessed using funnel plots and Egger statistic. Study quality was assessed using the standardized method described by Zaza et al. DATA SYNTHESIS: A DerSimonian and Laird random-effects model was used to assess differences between dichotomous variables. A continuity correction was applied in cases of zero events. A sensitivity analysis was performed with studies that separated out older children and adolescents. CONCLUSIONS: All studies identified were observational. IMN and plate and screw constructs are acceptable options in the fixation of pediatric BBFF. The literature fails to demonstrate a difference between IMN and plate and screw constructs. Outcomes were excellent in nearly 9 of 10 patients regardless of fixation strategy. Delayed unions and nonunions were rare and slightly more common in IMN, although the difference was not statistically significant. These results suggest that complication rates are similar, although the type of complication may vary. IMN provides improved cosmesis but, in general, requires a second operation to remove hardware.

Hip septic arthritis and other pediatric musculoskeletal infections in the era of methicillin-resistant Staphylococcus aureus.

Pediatric musculoskeletal infections can cause devastating complications (including death) in this era of methicillin-resistant Staphylococcus aureus and other virulent bacterial strains. The complexity and severity of these infections require timely diagnosis and treatment. A thorough emergency department evaluation, diagnostic workup, and early surgical intervention can influence outcomes. Septic arthritis of the hip is best treated with open drainage and antibiotic therapy to avoid osteonecrosis of the hip and joint damage. Because of genetic changes and inducible resistance, methicillin-resistant Staphylococcus aureus causes more complex infections than in the past. Deep, soft-tissue abscesses; pyomyositis; osteomyelitis; and septic arthritis often occur concurrently, causing destruction of musculoskeletal tissue. Severe and life-threatening complications, such as septic emboli, deep venous thrombosis, and multiorgan system failure may result from these infections.