Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study.

BACKGROUND: Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared. METHODS: Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs. RESULTS: When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting. CONCLUSION: While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear. LEVEL OF EVIDENCE: III, retrospective cohort study.

Midcarpal Instability.

Midcarpal instability (MCI) of the wrist represents multiple distinct clinical entities that all have in common abnormal force transmission across the midcarpal joint. This can be asymptomatic but can also result in painful wrist motion, a characteristic catch-up clunk, and symptoms of instability. The carpus is stabilized by numerous extrinsic and intrinsic ligaments. Dynamic joint reactive forces between the proximal and distal carpal rows help create reciprocal motion, which results in smooth, physiologic wrist mechanics. Diagnosis of MCI requires a thorough history, physical examination, and adequate imaging. MCI can be managed nonsurgically with activity modification, physical therapy, specialized orthotics, medications, and corticosteroid injections. A variety of surgical treatment options exists to treat symptomatic MCI. These include arthroscopic thermal capsulorrhaphy, ligament repair or reconstruction, radial osteotomies, and limited radiocarpal or intercarpal fusions. Capsulorrhaphy or ligament repair is favored for mild to moderate cases; osteotomies can be used for the correction of bony deformities contributing to instability, whereas partial wrist arthrodesis is indicated for severe or recurrent instability and fixed deformities.

Incisional Negative Pressure Wound Therapy Does Not Affect Deep Surgical Site Infection Rates in Neuromuscular Scoliosis Surgery.

Surgical site infection (SSI) is a devastating complication in patients with neuromuscular scoliosis (NMS) undergoing posterior spinal instrumented fusion (PSIF) for progressive scoliosis. Incisional negative pressure wound therapy (INPWT) has been used in other surgical fields to reduce SSI. Our purpose was to examine the prophylactic use of INPWT after NMS surgery to decrease SSI. At a single institution, 71 consecutive patients with NMS underwent PSIF from 2015 to 2019. Starting in 2017, all patients with NMS received INPWT postoperatively until discharge. Rates of deep SSI were compared between the two cohorts of patients. Additionally, patient demographic and operative factors such as American Society of Anesthesiologists score, number of levels instrumented, need for an anterior spinal release, need for spinal fusion to pelvis, blood loss, operative time, fluoroscopy time, length of stay, and transfusion requirement were analyzed for potential influence on deep SSI. There was no significant difference in deep SSI rates between patients who received INPWT (2 of 41) and those treated with a standard postoperative dressing (2 of 30; P=1.0). Although INPWT theoretically can stabilize the wound environment and prevent deep SSI, our findings do not support this. More research is needed to evaluate the efficacy of INPWT after PSIF for NMS. [Orthopedics. 2023;46(6):373-378.].

Five-Strand Hamstring Grafts are Biomechanically Comparable to Four-Strand Grafts and Offer Greater Diameter for Anterior Cruciate Ligament Reconstruction.

Purpose: The purpose of this study was to compare the biomechanics of 4-strand and 5-strand hamstring constructs for anterior cruciate ligament grafts. Methods: Thirty-six human cadaveric hamstring grafts were tested in 3 different conditions: (1) graft femoral fixation complex, (2) graft femoral and tibial fixation (GFTF) complex using a human model, and (3) GFTF complex using a porcine model. Grafts were tested on a tensile testing machine. Four-stranded grafts served as the control group, and 5-stranded grafts served as the experimental group. Cyclic elongation, ultimate load to failure, stiffness, and diameter of the grafts were analyzed. Results: Average 4-strand graft diameter was 7.96 mm compared to 9.32 mm for the 5-strand graft (P = .00017). Average stiffness of grafts ≥8 mm was 105.04 N/mm compared to 85.05 N/mm for grafts <8 mm (P = .04988). There was a positive correlation between graft diameter and stiffness (13.4 N/mm per every 1 mm increase in diameter, r 2 value of 13.1%, and F-significance of 0.02778). There were no significant differences in terms of ultimate load to failure, cyclic elongation, or stiffness between the experimental groups. Conclusion: Five-strand hamstring grafts offer greater diameter and are biomechanically comparable to 4-strand equivalents at time 0. Grafts >8 mm offer significantly greater stiffness compared to grafts sized <8 mm. There is a weak positive correlation between graft diameter and stiffness. Clinical Relevance: A potential drawback to hamstring grafts is their variability in size. Five-strand hamstring grafts provide increased diameter in comparison to 4-strand equivalents and might be used when quadrupled graft diameter is <8 mm.

Hip Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents.

Purpose: The purpose of this study was to evaluate case volume and variability of hip arthroscopy exposure among graduating orthopaedic residents. Methods: The Accreditation Council for Graduate Medical Education (ACGME) surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents were assessed. Arthroscopy procedures of the pelvis/hip were identified. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability. Results: There was no change in the number of hip arthroscopy procedures between 2016 and 2020 [average: 8.4 ± 10 (range: 0 to 87) vs. 9.8 ± 12 (range: 0 to 101)] (P = .995). There was a wide variability in case volume among residents. The 90th percentile of residents performed 24 cases in 2020, compared to 2 cases in the 30th percentile and 0 cases amongst the 10th percentile of residents. Conclusions: Despite the growing popularity of hip arthroscopy, resident exposure to this highly technical procedure remains limited, with about one-third of residents performing 2 or less cases by graduation. Clinical Relevance: Understanding case volume and variability is important for orthopaedic surgery programs to ensure that graduating residents are gaining adequate exposure.

Biomechanical Comparison of Meniscal Allograft Root Fixation Techniques: Anterograde Interference Bone Plug Fixation Yields Favorable Results Compared to Transosseous Suture Fixation Alone.

Purpose: To compare the biomechanical properties of 2 different fixation techniques (interference bone plug fixation vs transosseous suture fixation) of the posterior horn of the medial meniscus using a porcine model. Methods: Twenty-six matched pairs of fresh-frozen juvenile domestic porcine knees were used in this study. Specimens were randomly distributed among 3 groups: (1) native meniscus groups, (2) interference fixation, and (3) transosseous suture fixation. In each group, the posterior segments of the tested medial menisci were gripped with the freeze clamps and fixed to the tensile testing machine. Samples were preconditioned, followed by cyclic tension-relaxation for 1000 cycles between 10 and 30 N at 0.5 Hz and finally pulled to failure at a rate of 0.55 mm/s. The cyclic elongation, stiffness to failure, mode, and ultimate load to failure were recorded. Results: There was no significant difference in ultimate load to failure between the interference fixation (169.71 ± 71.98 N) and transosseous suture fixation (222.73 ± 72.40 N) groups (P = .118), both were significantly less than that of the native meniscus (405.46 ± 95.62) (P < .001). Interference fixation displayed cyclic elongation (1.04 ± 0.71 mm) and stiffness (69.10 ± 25.8 N/mm) that were not significantly different from the native meniscus tissue (0.78 ± 0.53 mm and 83.1 ±26.28 N/mm) (P = .359 and P = .224), in comparison to transosseous suture fixation, which did show increased cyclic elongation (1.85 ± 1.44 mm) (P = .047) and decreased stiffness (34.72 ± 10.2 N/mm) (P < .001). Conclusion: Interference fixation of the posterior horn of the medial meniscus has superior cyclic elongation and stiffness when compared to transosseous suture fixation. Interference fixation and the native meniscus model have a similar stiffness and cyclic elongation. Clinical Relevance: The significance of our study is that using interference fixation for meniscal allograft transplantation has the potential to reduce short term surgical failures as well as long term complication rates.

Posttraumatic Ulnar Translocation of the Carpus: A Case Report and Brief Review of the Literature.

We report a case of posttraumatic ulnar translocation of the carpus, which resulted after a fall from a six-foot ladder. This patient presented with multiple injuries to the skull bones, face, and limbs. A diagnosis of ulnar translocation of the carpus was missed on initial radiographs. Ulnar translocations require a high clinical index of suspicion and should be considered in the context of any high-impact injury to the wrist. A volar fleck just distal to the radial articular surface represents evidence of ligamentous disruption and should alert physicians that a more severe injury may be present. Nonsurgical and surgical treatment options are reviewed.

Twitter Mentions Influence Academic Citation Count of Shoulder and Elbow Surgery Publications.

Background Social media use among scholars and journals is growing and has augmented the academic impact of published articles in several areas of medicine. However, the influence of social media postings on academic citations of shoulder and elbow surgery publications is not known. In this study, we sought (1) to quantify the adoption of Twitter use for the dissemination of research publications by three prominent shoulder and elbow surgery journals and (2) to determine the correlation between Twitter mentions and academic citations in shoulder and elbow surgery publications. Methodology A total of 396 original research articles from three shoulder and elbow surgery journals (Journal of Shoulder and Elbow Surgery (JSES), Shoulder & Elbow, and JSES International) published in 2018 were assessed 34 to 45 months after print publication. For each article, the total number of Twitter mentions were obtained using Altmetric Bookmarklet and grouped into those tweeted by authors, an official outlet, or a third party. Article citation data was obtained using the Google Scholar search engine. Pearson correlation was used to determine the association between the number of Twitter mentions and citation count. Results Of all articles, 51% (202/396) had at least one Twitter mention. Of all Twitter mentions, 12.7% (367/2,879) occurred within the first week of online publication dates, while 51.5% (1,482/2,879) occurred between online and print publication dates. Articles mentioned on Twitter had 1.3-fold more Google Scholar citations (17.7 ± 15.2) than articles with no Twitter mentions (14.0 ± 15.7) (p = 0.017). The number of Twitter mentions had a weakly positive correlation with academic citation count (r = 0.25; p < 0.001). No significant difference in academic citation rates was found between articles tweeted by authors or official outlets when compared to articles tweeted by a third party only (p = 0.97 and p = 0.34, respectively). Conclusions Approximately half of shoulder and elbow surgery publications are shared on Twitter, with the majority of the activity occurring prior to their print publication date. The finding that tweeted articles have more academic citations within three years of release suggests that social media activity seems to amplify the academic impact of shoulder and elbow surgery publications.

Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review.

Background: Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery. Methods: A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted. Results: A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively. Conclusion: Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making.

Postoperative Rhabdomyolysis in the Bilateral Shoulder Areas After Cardiac Surgery.

Rhabdomyolysis (RML) is a disease that results from the death of muscle fibers and the release of intracellular contents into the bloodstream as a result of traumatic or non-traumatic muscle injury. Postoperative RML is a rare complication that may result from improper patient positioning, extended surgery time, or unique patient risk factors. We describe a case of a 43-year-old obese male who presented with postoperative bilateral shoulder RML after undergoing cardiothoracic surgery for aortic valve disease. To our knowledge, after a thorough review of the literature using PubMed, Medline, and Google Scholar, no previous studies have reported positioning injuries specific to obese cardiac surgical patients and their relation to RML.

Patella Sleeve Fracture with Medial Patellofemoral Ligament Tear and Lateral Femoral Condyle Fracture in an Adolescent: A Case Report.

CASE: A 12-year-old boy sustained a patella sleeve fracture of the superior pole, medial patellofemoral ligament tear, and lateral femoral condyle fracture after a direct contact sledding injury. He was managed nonoperatively with 5 weeks of cylinder cast immobilization with transition to a hinged knee brace and physiotherapy. By 3 months, he returned to sport activity without patellar instability. CONCLUSION: This is the first case to describe simultaneous development of these 3 injuries in an adolescent. We recommend that patients with patella sleeve fracture undergo magnetic resonance imaging to assess for local soft-tissue injury because this may influence treatment decisions.

Anterior Hip Dislocation After Hip Arthroscopy Complicated by Iliopsoas Bursitis.

Hip dislocation after hip arthroscopy is an uncommon postoperative complication. We report a case of a 51-year-old woman who underwent right hip arthroscopy and presented with an anterior hip dislocation on postoperative day five. The index surgery involved capsulotomy, cam lesion debridement, and femoroplasty for an anterosuperior labral tear and cam-type femoroacetabular impingement. The patient underwent an uneventful recovery course until eight weeks postoperatively she developed iliopsoas bursitis. Her symptoms were managed conservatively with activity modification and physical rehabilitation. Complete resolution of symptoms was reported by the six-month follow-up visit, and no further dislocations or instability had been reported at 12 months. Anterior hip dislocation is a rare complication following hip arthroscopy and patients may experience persistent iliopsoas bursitis several months following successful reduction.

Simultaneous Bilateral Patellar Tendon Rupture in a Patient With Osteogenesis Imperfecta.

Simultaneous bilateral patellar tendon rupture is an infrequent and debilitating injury. Although tendon rupture is associated with multiple systemic diseases, there is limited literature regarding its association with osteogenesis imperfecta and successful treatment techniques. We report a case of a 56-year-old man with a history of osteogenesis imperfecta type I who experienced bilateral patellar tendon rupture following a fall from standing height in the absence of other risk factors. Both injuries were effectively treated with primary open repair utilizing Krackow suture technique and transosseous tunnel fixation bilaterally. The patient demonstrated full functional recovery at 14-month follow-up. Osteogenesis imperfecta is a risk factor for the development of bilateral patellar tendon rupture. Open bilateral transosseous suture repair has proven to be successful despite defects in type 1 collagen and underlying tendon weakness.

Successful Coil Embolization Treatment of a Large Arterioportal Fistula: A Rare Cause of Mesenteric Ischemia.

Superior mesenteric arteriovenous fistulae (SMAVF) are a rare complication from trauma or iatrogenic surgical intervention. There are less than 50 cases reported in the literature and no clear guidelines as to the best practices for diagnosis and treatment. SMAVF are often asymptomatic but can present with nonspecific abdominal symptoms ranging from nausea and vomiting to gastrointestinal bleeding and mesenteric ischemia. Symptom onset, when present, is often delayed years after the inciting event, further complicating the diagnosis. We present a case of a 71-year-old man presenting with mesenteric ischemic symptoms secondary to a large SMAVF that was successfully treated with coil embolization. We describe our approach to treatment and describe the classical imaging findings. We, then, review the current literature and management recommendations.

Wide Variability of Pediatric Knee Arthroscopy Case Volume in Orthopaedic Surgery Residency.

PURPOSE: The purpose of this study was to evaluate orthopaedic surgery resident case volume and variability for adult and pediatric knee arthroscopy from 2016 to 2020. METHODS: The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents were analyzed. The average number of total (adult and pediatric), adult, and pediatric knee arthroscopy cases were compared from 2016 to 2020. The 10th and 90th percentiles of case volumes for adult and pediatric knee arthroscopy procedures were compared from 2016 to 2020 to determine caseload variability. RESULTS: There was an 18% increase in pediatric knee arthroscopy cases between 2016 and 2020 (average: 13.9 ± 10 to 16.4 ± 13; P < .005), a 5.4% decrease in adult knee arthroscopy cases (100 ± 45 to 94.6 ± 47; P < .027), and a 2.6% decrease in total knee arthroscopy (113.9 ± 47 to 111 ± 51; P = .264) cases. There was an 11-fold difference in the number of pediatric knee arthroscopy cases performed between the 10th and 90th percentile of residents in 2020 (3 vs 33 cases, respectively), a 3.28-fold difference for adult knee arthroscopy (47 vs 154, respectively), and a 2.98-fold difference for total knee arthroscopy (59 vs 176, respectively). CONCLUSIONS: Pediatric knee arthroscopy comprises a small yet growing percentage of total knee arthroscopy case volume of graduating orthopaedic surgery residents. However, wide variability in resident exposure is present and likely masked by the abundance of adult cases performed each year. CLINICAL RELEVANCE: The findings presented in this study may assist in optimizing arthroscopy resident education. Existing ACL reconstruction and knee arthroscopy case minimum requirements could be updated to include a set number of pediatric cases. These changes might help reduce case volume variability and discrepancies in resident education.