Fixation strength in arthroscopic labral repair of the hip: A head-to-head comparison of the biomechanical performance of a biocompatible vs. all-suture anchor in the setting of acetabuloplasty.

Much is known about the biomechanical performance of various types of suture anchors commonly used for labral fixation in the shoulder; however, similar studies in the hip are less common. We sought to compare all-suture and polyether ether ketone small-diameter anchors in the setting of labral repair during hip arthroscopy, with and without acetabuloplasty. We hypothesized that the biomechanical properties of the all-suture group when compared to polyether ether ketone anchors would be similar amongst native acetabula and significantly less following acetabuloplasty and that pullout forces would be reduced in the anterior and inferior regions of the acetabulum compared to the superior region. Bone density was measured in nine matched pairs of fresh-frozen cadaveric acetabula in the superior, anterosuperior, and anterior regions. Acetabuloplasty was performed in all three regions, while the contralateral acetabulum was left in situ as a control. Suture anchors were placed such that one each of two different types was placed within each region. Specimens were tested in cyclic fatigue and loaded to failure. The all-suture group had significantly higher cyclic displacement compared to the polyether ether ketone, but there was no significant difference in ultimate load, regardless of acetabuloplasty. Amongst all non-resected specimens, the lowest bone density was observed consistently in the inferior region. Our results indicate that, with or without acetabuloplasty, a small-diameter polyether ether ketone anchor appears to be more stable than an all-suture anchor, which needs to be set first.

Clinical and Radiologic Outcomes after Meniscal Root Repair: A Case Series.

This study aimed to describe the demographics, clinical outcomes, and radiologic outcomes of patients who underwent meniscal root repair at a single, large academic institution. Patients who underwent meniscal root repair between January 2011 and April 2015 were identified. Patient demographics, injury characteristics, and intraoperative findings of medial femoral condyle chondromalacia and other concomitant pathology were retrospectively recorded. Enrolled patients returned to clinic for prospectively collected International Knee Documentation Committee (IKDC) subjective and objective forms, knee radiographs, and magnetic resonance imaging (MRI). A total of 25 root injuries (23 patients) were included in the final analysis. Majority of root injuries were medial menisci (68%) and repaired using transosseous pull-out technique (80%). Most patients (65%) were male, relatively young (median age = 37 years), overweight (median body mass index [BMI] = 26 kg/m2), and reported a traumatic event associated with their injury (60%). Also, 36% (9/25) of root repairs were performed concomitantly with an anterior cruciate ligament (ACL) reconstruction; 100% (8/8) lateral meniscal root injuries were associated with a concomitant ACL injury compared with 6% (1/17) of medial root injuries. Overall, 53% (9/17) of medial meniscal root repairs were performed in the setting of high-grade (Outerbridge's grade III/IV) chondral pathology of the ipsilateral femoral condyle. Median follow-up was 16 months. The Kellgren-Lawrence radiographic scale progressed in two knees that underwent meniscal root repair based on comparison of preoperative to follow-up radiographs. MRI showed 88% (22/25) of meniscal roots had completely healed, 6% (1/17) of the medial root repairs showed evidence of extrusion, and 44% (11/25) of repairs were associated with progressive chondromalacia. All patients had normal or near normal IKDC objective scores at time of follow-up. Surgeons should have a high suspicion for concomitant ACL injuries in the setting of lateral meniscal root tears, and be wary of concomitant high-grade chondral damage in the setting of medial meniscal root tears. Most meniscal root repairs appeared completely healed with low rates of medial meniscal extrusion on MRI at short-term follow-up, despite a high rate of chondromalacia progression. Present study is a large case series with prospective follow-up and reflects level of evidence IV.

Promoting Bone Formation and Healing in Segmental Defects Through Ectopic Induced Membrane.

We aimed to determine whether addition of an in vivo ectopic induced membrane (EM) to the Masquelet Technique enhanced angiogenesis and bone formation in a segmental defect. After generating and stabilizing a diaphyseal femur defect, 10 rats received a polymethylmethacrylate (PMMA) spacer within the defect (control); 10 received another PMMA spacer implanted subcutaneously (EM). We removed the spacers and added autograft; the excised EM was added to their autograft (EM group). Post-mortem x-rays assessed bone formation and bridging. Osteogenesis in the proximal defect was significantly more uniform (p < 0.01), and there was greater amount of bone remodeling distally in the EM group (p < 0.05). There was no difference in bone formation (p = 0.19) but greater degrees of bridging in the EM group (2.20 vs. 1.20, p = 0.09). The EM resulted in more homogeneous proximal osteogenesis and increased bone remodeling distally. These findings could lead to more consistent and predictable bone healing. (Journal of Surgical Orthopaedic Advances 31(3):161-165, 2022).

A Randomized Trial of Preoperative Practice in a Simulated Operative Environment: 3D Printed Pilon Model Improves Resident Performance.

This study assessed the effect of preoperative planning using a 3D-printed periarticular fracture model on operative performance. A complex pilon fracture was 3D-printed, and a preoperative plan was developed. Orthopaedic surgery residents (n = 20) were randomized into two groups. Group 1 performed routine preoperative planning, while Group 2 was also practiced using a 3D-printed construct before performing fixation of the 3D-printed model. Resident performance was assessed using a video motion capture system and evaluated by blinded reviewers. Three residents (3D group) completed fixation within the allotted 45 minutes. The 3D group had less hand distance traveled for step 1 (89 m vs. 162 m, p = 0.04). The 3D group had better performance on three of the four components and more acceptable reductions (6 vs. 0, p = 0.009). Average global rating scale was higher in the 3D group (3.0 vs. 1.7, p = 0.0095). Use of 3D-printed models for preoperative planning improved resident performance. (Journal of Surgical Orthopaedic Advances 31(3):187-192, 2022).

Distal clavicle "A-frame" morphology: a reliable intraoperative guide for arthroscopic distal clavicle excision.

BACKGROUND: The purpose of this cadaveric study was to describe the characteristics of the "A-frame" morphology of the distal clavicle via computed tomography (CT) to determine whether it can be used as a reliable intraoperative guide for arthroscopic distal clavicle excision. METHODS: Twenty-eight fresh-frozen human cadaveric clavicles underwent a 3-dimensional CT scan using 1.0-mm cuts. The distance from the most lateral aspect of the clavicle to the point at which the superior cortex of the clavicle paralleled the inferior cortex was measured. Measurements were performed in a blinded fashion by a single author on 2 separate occasions. RESULTS: The A-frame was present in all specimens (28 of 28). On the first measurement, the mean distance from the distal clavicle to the point at which the A-frame disappeared was 1.00 cm (range, 0.90-1.08 cm; standard deviation, 0.5 mm). On the second measurement, the mean distance was 1.02 cm (range, 0.90-1.11 cm; standard deviation, 0.6 mm). The intrarater reliability between measurement occasions was 0.65 (95% confidence interval, 0.36-0.82; P < .001). CONCLUSIONS: This study demonstrated that the cross-sectional A-frame morphology of the distal clavicle was consistently visualized on CT scans. The A-frame disappeared 1.00-1.02 cm medial to the most lateral extent of the clavicle on CT scans. The disappearance of the A-frame morphology of the distal clavicle can serve as a reliable intraoperative guide for arthroscopic distal clavicle excision.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

OBJECTIVE: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN: Retrospective cohort study. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cyclic and Load-to-Failure Properties of All-Suture Anchors in Human Cadaveric Shoulder Greater Tuberosities.

PURPOSE: The purpose of this study was to evaluate the cyclic displacement, stiffness, and ultimate load to failure of 3 all-suture anchors in human cadaveric greater tuberosities. METHODS: Three all-suture anchors indicated for rotator cuff repair were tested in 14 matched pairs of human cadaver fresh-frozen humeri. Anchors were inserted at 3 locations from anterior to posterior along the greater tuberosity and placed 5 mm from the articular margin. The constructs were cycled from 10 to 60 N at 1 Hz for 200 cycles. The anchors that survived cycling were then subjected to a single pull to failure test. A Kruskal-Wallis 1-way analysis of variance on ranks was performed to compare the displacement, stiffness, and ultimate load to failure of the different anchors tested. RESULTS: One matched pair was excluded because of poor bone quality; therefore, 13 matched pairs were included in the study. After 20, 100, and 200 cycles, there was no difference in median displacement between the anchors tested (P = .23, P = .21, P = .18, respectively). The median ultimate load-to-failure between the Iconix (295.2 N, 95% confidence interval [CI], 125-762.2), JuggerKnot (287.6 N, 95% CI, 152.9-584.4), and Q-fix (333.3 N, 95% CI, 165.0-671.9) showed no statistically significant difference (P = .58). After 20, 100, and 200 cycles, there was no difference in median stiffness between the anchors tested (P = .41, P = .19, P = .26 respectively). Displacement greater than 5 mm occurred in 0 Iconix anchors (0%), 1 JuggerKnot anchor (3.64%), and 2 Q-fix anchors (7.69%). One JuggerKnot anchor failed by anchor pullout during cyclic loading. CONCLUSIONS: When tested in human cadaveric humeral greater tuberosities 3 all-suture anchors, the 2.9-mm JuggerKnot, the 2.8-mm Q-fix, and the 2.3-mm Iconix, showed no significant differences in median displacement or stiffness after 20, 100, or 200 cycles or in median ultimate load to failure. Although not statistically significant, the Iconix was the only anchor tested to have no failures, whereas the JuggerKnot had both a clinical and catastrophic failure and the Q-fix had 2 clinical failures. LEVEL OF EVIDENCE: Level V, Controlled Laboratory Study.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Visualization of Concurrent Anterolateral and Anterior Cruciate Ligament Injury on Magnetic Resonance Imaging.

PURPOSE: To investigate the ability to visualize the anterolateral ligament (ALL) on magnetic resonance imaging (MRI) and identify ALL injuries in an intact- anterior cruciate ligament (ACL) and torn-ACL cohort. We also aimed to assess inter-rater reliability between 2 radiologists when it comes to the aforementioned assessment. METHODS: MRIs that met inclusion and exclusion criteria were placed into a control (ACL-intact) or study (ACL-injured) cohort. MRIs were independently analyzed by 2 radiologists for data points pertaining to demographics, ALL visualization, presence of ALL injury, and concomitant knee abnormalities. Inter-rater reliabilities for visualizing the ALL and identifying ALL injuries were assessed. RESULTS: The control and study groups consisted of 116 and 82 MRIs, respectively. Age varied between the 2 groups, but sex distribution was similar. With near-perfect agreement (kappa = 0.92), both radiologists visualized at least part of the ALL in more than 95% of MRIs irrespective of ACL integrity. The mean incidence of ALL injury in the ACL injured group was 53.05% with minimal inter-rater agreement (kappa = 0.38). Segond fractures were noted in a mean 13.95% of MRIs with concomitant ALL and ACL injuries. CONCLUSIONS: The ALL was reliably visualized on MRI irrespective of whether the ACL was intact or torn. However, ALL injuries were not reliably diagnosed on MRI in the setting of an ACL tear. Poor interobserver reliability shows the potential for false-positive and -negative interpretation. These findings suggest that, in this study, ALL injuries could not be accurately diagnosed in the presence of an ACL tear using MRI. On the basis of these findings, it is recommended that physicians should not rely on MRI to diagnose an ALL injury in the presence of an ACL injury. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

OBJECTIVE: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. DESIGN: Multicenter retrospective cohort study. PATIENTS/PARTICIPANTS: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. INTERVENTION: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. MAIN OUTCOME: The main outcome was difference in complications between patients treated with volar versus dorsal approach. RESULTS: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. CONCLUSIONS: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cyclic and Load-to-Failure Properties of All-Suture Anchors in Human Cadaveric Shoulder Glenoid Bone.

PURPOSE: To evaluate the cyclic displacement and ultimate load to failure of 4 all-suture anchors in human cadaveric shoulder glenoid bone. METHODS: Four all-suture anchors indicated for glenoid labral repair were tested in 14 matched pairs of human cadaveric fresh-frozen glenoids. Anchors were inserted at 4 different locations for a total of 112 tests (12-, 3-, 6-, and 9-o'clock positions for right glenoids). Cyclic loading (10 to 60 N at 1 Hz for 200 cycles) and single pull-to-failure testing (33 mm/s) were performed. A Kruskal-Wallis 1-way analysis of variance with the Dunn multiple-comparison post hoc test was used for statistical analysis. RESULTS: One matched pair was excluded because of poor bone quality. Thus, 13 matched pairs were included in the study, and a total of 104 tests were performed. The Q-Fix anchors showed significantly less displacement after 100 cycles (mean ± standard deviation, 1.40 ± 0.97 mm; P < .001) and 200 cycles (1.53 ± 1.00 mm, P < .001) than all other anchors tested. The Q-Fix (191.3 ± 65.8 N), Suturefix (188.3 ± 61.4 N), and JuggerKnot (183.6 ± 63.5 N) anchors had significantly greater ultimate loads to failure than the Iconix anchors (143.5 ± 54.1 N) (P = .01, P = .012, and P = .021, respectively). Displacement greater than 5 mm occurred in 6 Iconix anchors (22.1%), 5 Suturefix anchors (19.2%), 4 JuggerKnot anchors (15.4%), and 0 Q-Fix anchors (0%). CONCLUSIONS: The Q-Fix anchors showed less displacement with cyclic loading than the Iconix, JuggerKnot, and Suturefix anchors. The Iconix anchors had a lower ultimate load to failure than the Q-Fix, Suturefix, and JuggerKnot anchors. Only the Q-Fix group had no anchors displace greater than 5 mm with cyclic loading. CLINICAL RELEVANCE: All-suture anchors vary in their deployment mechanism, which may alter their strength and performance. Operators must be aware of these anchors' propensity to displace while deploying them.

Electronically augmented gait abnormality assessment following lower extremity trauma.

BACKGROUND: Objective evaluation of patient outcomes has become an essential component of patient management. Along with patient-reported outcomes, performance-based measures (PBMs) such as gait analysis are an important part of this evaluation. The purpose of this study was to evaluate the validity of utilizing a wearable inertial measurement unit (IMU) in an outpatient clinic setting to assess its ability to provide clinically relevant data in patients with altered gait resulting from lower extremity trauma. METHODS: Five orthopaedic trauma patients with varying degrees of gait pathologies were compared to 5 healthy control subjects. Kinematic data were simultaneously recorded by the IMU and a gold standard Vicon video motion analysis system (Vicon Motion Systems Ltd, Oxford, UK) during a modified 10-m walk test. Raw data captured by the IMU were directly compared to Vicon data. Additionally, 5 objective gait parameters were compared for controls and the 5 trauma patients. RESULTS: The IMU data streams strongly correlated with Vicon data for measured variables used in the subsequent gait analysis: vertical acceleration, vertical displacement, pitch angular velocity, and roll angular velocity (Pearson r-value > 0.9 for all correlations). Quantitative kinematic data in post-trauma patients significantly differed from control data and correlated with observed gait pathology. CONCLUSIONS: When compared to the gold standard motion capture reference system (Vicon), an IMU can reliably and accurately measure clinically relevant gait parameters and differentiate between normal and pathologic gait patterns. This technology is easily integrated into clinical settings, requires minimal time, and represents a performance-based method for quantifiably assessing gait outcomes. LEVEL OF EVIDENCE: Diagnostic Level 1.

Greater Tuberosity Decortication Decreases Load to Failure of All-Suture Anchor Constructs in Rotator Cuff Repair.

PURPOSE: To evaluate the effect of greater tuberosity decortication on ultimate load to failure and displacement after cyclic loading with an all-suture anchor. METHODS: A 2.9-mm all-suture anchor was evaluated in decorticated and nondecorticated greater tuberosities of 10 matched pairs of human cadaveric shoulders. Greater tuberosity decortication was performed to a mean depth of 1.7 mm. Anchors were placed in the anterior, middle, and posterior tuberosity. Anchors were tested under cyclic loads followed by load-to-failure testing. Displacement after 20, 100, and 200 cycles and ultimate failure strength were determined. Clinical failure was defined as displacement greater than 5 mm during cyclic loading. RESULTS: After 20 and 100 cycles, there was no difference in mean displacement between the decorticated and nondecorticated cohorts (P = .139 and P = .127, respectively). The mean displacement after 200 cycles was greater in the decorticated cohort, although not significantly (3.4 vs 2.7 mm; P = .05). The mean ultimate load to failure was significantly lower in the decorticated cohort (314 vs 386 N, P = .049). There were 2 clinical failures in the decorticated specimens and 1 in the nondecorticated specimens. CONCLUSIONS: A minimal greater tuberosity decortication significantly decreases the ultimate load to failure of an all-suture anchor. However, decreased biomechanical strength may not necessitate actual clinical failure. CLINICAL RELEVANCE: A decrease in ultimate load to failure could increase the risk of catastrophic postoperative anchor failure. However, while this decrease in strength is statistically significant, the overall decrease in strength may not be sufficient in magnitude to translate to clinical failure.

Slight Reduction in the Insertion Depth for an All-Suture Anchor Decreases Cyclic Displacement in the Shoulder Glenoid.

PURPOSE: To determine if the depth of anchor insertion affects the biomechanical performance of a 1.5-mm all-suture anchor in glenoid bone. METHODS: A 1.5-mm all-suture anchor was tested in 8 matched pairs of human cadaver fresh-frozen glenoids. Anchors were inserted at 6 different locations and tested at 3 different depths: 21 mm (preset drilling depth), 17 mm, and 13 mm. Cyclic loading and destructive testing was performed. Displacement after 100 and 200 cycles, along with ultimate failure strength, was determined. RESULTS: After 100 and 200 cycles, anchors placed at 13 and 17 mm had undergone significantly less displacement than those at 21 mm (P < .05). No difference was observed in ultimate load to failure between anchors placed at 21 and 17 mm. However, the ultimate load to failure was significantly lower in anchors placed at 13 mm (P < .05). There were 5 clinical failures in anchors placed at 21 mm, one at 17 mm, and none at 13 mm. CONCLUSIONS: The 1.5-mm all-suture anchor tested in this study has an optimal insertion depth of 17 mm, 4 mm shallower than the preset drill depth. At the optimal insertion depth of 17 mm, it underwent significantly less displacement after cyclic loading without a reduction in the ultimate load to failure. CLINICAL RELEVANCE: Given the results of this study, the optimal insertion depth for this 1.5-mm all-suture anchor is 17 mm, 4 mm shallower than the preset drill depth.

Effectiveness of a Low Fidelity Cast Removal Module in Orthopaedic Surgical Simulation.

OBJECTIVE: The purpose of this study is to determine if an educational model during a surgical skills laboratory results in a significant reduction in cast saw blade temperatures generated during cast removal. DESIGN: As part of an orthopedic resident surgical skills laboratory an Institutional Review Board-approved study was performed. A total of 17 study subjects applied a short arm cast. Everyone removed 1 short arm cast with temperatures recorded on the saw blade. Following cast removal, an educational session was conducted on proper cast removal and blade cooling techniques. Everyone then removed a second cast. Blade temperatures were recorded. To assess reproducibility, the 5 PGY-1 orthopedic residents removed a short arm cast 3 months later. SETTING: Carolinas Medical Center, Charlotte, NC, tertiary care center PARTICIPANTS: A total of 17 study subjects with minimal casting experience (5 PGY-1 orthopedic residents and 12 senior medical students) applied a short arm cast. RESULTS: Following the educational session there was a significant reduction in mean and mean maximum blade temperatures (p < 0.05). During the second round of cast removal assessment of blade temperatures and specific techniques to cool the blade were observed among all participants. At 3 months' time, the mean and mean maximum blade temperatures remained significantly lower than before the educational session (p < 0.05). CONCLUSIONS: The intervention in this study reduced the maximum blade temperatures to levels below the threshold known to cause burns. This simple, low cost, and easily reproducible model can easily be disseminated across institutions and simulation laboratories.

Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block.

Postoperative pain control is a significant concern after total shoulder arthroplasty. Injectable periarticular liposomal bupivacaine, which has been found to decrease opioid use after orthopedic procedures, has been proposed as a viable alternative to regional anesthesia. This study compared the efficacy of liposomal bupivacaine vs interscalene block among patients undergoing total shoulder arthroplasty. A retrospective review was conducted of 79 patients who underwent anatomic total shoulder arthroplasty performed by a single surgeon between January 2013 and April 2015. Patient demographics, in-hospital Numeric Pain Rating Scale (NPRS) score obtained at 12-hour intervals, length of stay, and total in-hospital morphine equivalents in both the bupivacaine (n=25) and block (n=44) groups were recorded. Differences in length of stay, morphine equivalents, and age were assessed with Wilcoxon tests. Sex differences were assessed with the chi-square test. Repeated measures analysis with least square means was used to assess longitudinal changes in NPRS scores. No significant differences were found between groups for sex (P=.89), age (P=.81), American Society of Anesthesiologists classification (P=.50), preoperative opioid use (P=.41), length of stay (P=.32), or morphine equivalents (P=.71). The average NPRS score in the first 12 hours was 3.01 for the bupivacaine group and 4.41 for the interscalene block group (P=.25). By 48 hours postoperatively, average NPRS scores were similar (P=.93) for the 2 groups, 4.90 for the bupivacaine group and 4.19 for the interscalene block group. The findings for this cohort of patients undergoing anatomic total shoulder arthroplasty showed no significant difference for pain scores, postoperative narcotic use, or length of stay with injectable liposomal bupivacaine vs interscalene block. [Orthopedics. 2017; 40(5):e806-e811.].

Treatment of Periprosthetic Joint Infection Using Antimicrobials: Dilute Povidone-Iodine Lavage.

Periprosthetic joint infections (PJI) remain a challenge for the orthopaedic surgeon to treat and remain a leading cause of failure of both primary and revision total joint arthroplasty. Once a PJI develops, surgical treatment is generally indicated and includes an aggressive irrigation and debridement. One component of the irrigation and debridement involves the use of an antiseptic irrigating solution. In primary and revision TJA, dilute povidone-iodine lavage can be performed prior to wound closure. Approximately 17.5mL of 10% povidone-iodine is diluted with 500-1000cc of normal saline. The wound is then irrigated with the dilute povidone-iodine for 3 minutes. The dilute povidone-iodine is then thoroughly irrigated and washed out of the wound with normal saline prior to wound closure. The use of dilute povidone-iodine lavage prior to wound closure has been shown to reduce the risk of deep surgical site infection in multiple surgical specialties. In primary TJA, it has been demonstrated to reduce the risk of infection, without any associated adverse effects. It is also included in multiple protocols for the surgical treatment of PJI. Dilute povidone-iodine lavage provides a safe and inexpensive method to reduce the rate of PJI in TJA.

Patterns of Opioid Prescribing for an Orthopaedic Trauma Population.

OBJECTIVES: To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center. DESIGN: A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Adult patients with OT admitted over a 30-day period (n = 110). INTERVENTION: All discharge and follow-up opioid prescriptions were recorded. MAIN OUTCOME MEASUREMENTS: Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed. RESULTS: One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%). CONCLUSIONS: Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Functional Recovery Following Periprosthetic Distal Femur Fractures.

BACKGROUND: Treatment options for periprosthetic distal femur fractures include open reduction internal fixation (ORIF) and distal femoral replacement (DFR). The purpose of this study was to evaluate the complications, and functional recovery (ambulatory status, living situation, mortality) in patients undergoing operative treatment (DFR and ORIF) of periprosthetic distal femur fractures. METHODS: A retrospective review of 58 patients with distal femoral periprosthetic fractures treated with either ORIF or DFR was conducted. Surgical complications, discharge disposition, ambulatory status, living situation at 1 year, and mortality at 1 year were compared between patients treated with ORIF and DFR. Outcomes at 1 year were also compared between patients older and younger than 85 years of age. RESULTS: Fifty-eight patients with a mean age of 80 years (range, 61-95 years) met inclusion criteria. The mean follow-up was 29.5 months (range, 5-81 months). Patients undergoing DFR were significantly older than those who underwent ORIF (83 vs 78, P < .01). The 1-year mortality rate was 20.6%. There was no difference between groups with respect to mortality, complications, discharge disposition, or ambulatory status and living situation at 1 year. Patients who lost the ability to ambulate at 1 year were significantly older than patients who maintained the ability to ambulate (87.5 vs 76.4 years, P < .05). Patients older than 85 years were more likely to lose the ability to ambulate and to live in a skilled nursing facility at 1 year (P < .01). CONCLUSION: Distal femoral periprosthetic fractures have a high morbidity and mortality. Age at time of injury, not treatment rendered, is predictive of ambulatory status and living independence after periprosthetic distal femur fractures.

Effectiveness of a Low-Cost Drilling Module in Orthopaedic Surgical Simulation.

INTRODUCTION: Financial pressures and resident work hour regulations have led to adjunct means of resident education such as surgical simulation. The purpose of this study is to determine the effectiveness of a hands-on training session in orthopaedic drilling technique educational model during a surgical simulation on reducing drill plunging depth and to determine the effectiveness of senior residents teaching a hands-on training session in orthopaedic drilling technique. METHODS: A total of 13 participants (5 orthopaedic interns and 8 medical students) drilled until they penetrated the far cortex of a synthetic bone model and the plunging depth (PD) was measured. They were then randomized and underwent an education session with an attending orthopaedic surgeon or a senior resident. Next, the subjects drilled again with the PD being calculated. The preeducational and posteducational session were compared to determine if there was any improvement in PD and if there was a difference between educators. The cost of the model was also determined. RESULTS: The mean maximum PD and mean PD before the education session was 1.58 (1.40-2.10) and 1.50cm (1.36-1.76), respectively. Following the educational session, the mean maximum PD and mean PD were 0.53 (0.42-0.75) and 0.50cm (0.40-0.72), respectively. These were both significantly lower than before the education session (p <0.05). After the educational session taught by the attending versus the session taught by the resident, the mean maximum PD was 0.59 (0.42-0.75) and 0.49cm. (0.45-0.75), respectively (p = 0.44). After the educational session taught by the attending versus the session taught by the resident, the mean PD was 0.54 (0.40-0.72) and 0.47cm. (0.40-0.65), respectively (p = 0.44). The cost of the station per participant was $5.44. CONCLUSION: This study demonstrated a significant reduction in drilling PD with use of a low-cost training model and a formal didactic and skills session on proper drilling technique that can effectively be led by senior residents.