Biomechanical Head-to-Head Comparison of 2 Sutures and the Giftbox Versus Bunnell Techniques for Midsubstance Achilles Tendon Ruptures.

BACKGROUND: Acute midsubstance Achilles tendon ruptures are a common orthopaedic problem for which the optimal repair technique and suture type remain controversial. Head-to-head comparisons of current fixation constructs are needed to establish which stitch/suture combination is most biomechanically favorable. HYPOTHESIS: Of the tested fixation constructs, Giftbox repairs with Fiberwire will exhibit superior stiffness and strength during biomechanical testing. STUDY DESIGN: Controlled laboratory study. METHODS: Two biomechanical trials were performed, isolating stitch technique and suture type, respectively. In trial 1, 12 transected fresh-frozen cadaveric Achilles tendon pairs were randomized to receive either the Giftbox-modified Krackow or the Bunnell stitch with No. 2 Fiberwire suture. Each repair underwent cyclic loading, oscillating between 10 and 100 N at 2 Hz for 1000 cycles, with repair gapping measured at 500 and 1000 cycles. Load-to-failure testing was then performed, and clinical and catastrophic failure values were recorded. In trial 2, 10 additional paired cadaveric Achilles tendons were randomized to receive a Giftbox repair with either No. 2 Fiberwire or No. 2 Ultrabraid. Testing and data collections protocols in trial 2 replicated those used in trial 1. RESULTS: In trial 1, the Bunnell group had 2 failures during cyclic loading while the Giftbox had no failures. The mean tendon gapping after cyclic loading was significantly lower in the Giftbox repairs (0.13 vs 2.29 mm, P = .02). Giftbox repairs were significantly stiffer than Bunnell (47.5 vs 38.7 N/mm, P = .019) and showed more tendon elongation (5.9 ± 0.8 vs 4.5 ± 1.0 mm, P = .012) after 1000 cycles. Mean clinical load to failure was significantly higher for Giftbox repairs (373 vs 285 N, P = .02), while no significant difference in catastrophic load to failure was observed (mean, 379 vs 336 N; P = .61). In trial 2, there were no failures during cyclic loading. The Giftbox + Fiberwire repairs recorded higher clinical load-to-failure values compared with Giftbox + Ultrabraid (mean, 361 vs 239 N; P = .005). No other biomechanical differences were observed in trial 2. CONCLUSION: Simulated early rehabilitation biomechanical testing showed that Giftbox-modified Krackow Achilles repair technique with Fiberwire suture was stronger and more resistant to gap formation at the repair site than combinations that incorporated the Bunnell stitch or Ultrabraid suture. CLINICAL RELEVANCE: A more in-depth understanding of the biomechanical properties of the Giftbox repair will help inform surgical decision making because stronger repairs are less likely to fail during accelerated postoperative rehabilitation.

High Incidence of Undiagnosed Cervical Myelopathy in Patients With Hip Fracture Compared With Controls.

OBJECTIVES: To identify the incidence of undiagnosed cervical myelopathy in patients who fall and develop hip fractures compared with age-matched controls. DESIGN: Prospective, case-control study. SETTING: University level 1 Trauma Center. PATIENTS/PARTICIPANTS: Consecutive patients who presented with hip fractures after a fall. A total of 159 patients were screened; 66 patients (38 arthroplasty, 28 fracture) were eligible for enrollment in the study. Exclusion criteria included cognitive impairment, known diagnosis of cervical myelopathy, previous cervical spine surgery, inability to comply with examination, or refusal to participate. The control group was age-matched elderly patients who underwent total hip arthroplasty (THA). INTERVENTION: Patient interview and physical examination for cervical myelopathy. MAIN OUTCOME MEASUREMENTS: Myelopathy was diagnosed by clinical history elements (Japanese Orthopaedic Association score ≤15) and pathologic reflexes. Comparison of the incidence of myelopathy in the study population with the control population was performed using Fisher exact test. RESULTS: There were no statistically significant differences between the fracture and THA groups in mean patient age or male/female ratio. There was a statistically significant increased incidence of myelopathy in hip fracture patients (18%) compared with the THA group (0%, P = 0.01). CONCLUSIONS: Hip fracture is a complex multifactorial process, and most patients (60%) were excluded due to known cognitive impairment. However, 18% of previously undiagnosed patients who were cognitively intact manifested clinical findings consistent with cervical spondylotic myelopathy. Consideration should be given to screening for undiagnosed myelopathy among patients with hip fracture to reduce the risk of subsequent fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hospital-Based Acute Care After Total Hip and Knee Arthroplasty: Implications for Quality Measurement.

BACKGROUND: Although hospital readmissions are being adopted as a quality measure after total hip or knee arthroplasty, they may fail accurately capture the patient's postdischarge experience. METHODS: We studied 272,853 discharges from 517 hospitals to determine hospital emergency department (ED) visit and readmission rates. RESULTS: The hospital-level, 30-day, risk-standardized ED visit (median = 5.6% [2.4%-13.7%]) and hospital readmission (5.0% [2.6%-9.2%]) rates were similar and varied widely. A hospital's risk-standardized ED visit rate did not correlate with its readmission rate (r = -0.03, P = .50). If ED visits were included in a broader "readmission" measure, 246 (47.6%) hospitals would change perceived performance groups. CONCLUSION: Including ED visits in a broader, hospital-based, acute care measure may be warranted to better describe postdischarge health care utilization.

Conjoined nerve roots of the lumbar spine.

BACKGROUND CONTEXT: Conjoined nerve roots are a relatively uncommon finding but are frequently undiagnosed on preoperative imaging studies. The presence of a conjoined root anomaly represents a significant potential for neurologic injury when nerve root mobilization is necessary during spinal procedures. PURPOSE: This comprehensive review of conjoined lumbar nerve roots encompasses preoperative diagnosis by physical examination and radiographic imaging studies, as well as the intraoperative management of conjoined nerve roots. STUDY DESIGN: Systematic review of existing literature. RESULTS: Findings have been described on standard magnetic resonance imaging (MRI) and computed tomography imaging to increase preoperative diagnosis rates. The literature lacks concrete recommendations regarding intraoperative techniques for conjoined root identification and management. CONCLUSIONS: Preoperative recognition and diagnosis of this anomaly has proven to be the best way to improve the chances of a successful procedure and avoid inadvertently damaging the nerve roots intraoperatively. Several radiographic signs of conjoined lumbar nerve roots have been described using standard MRI techniques including coronal T1- and T2-weighted sequences. Intraoperative management of conjoined nerve roots has not changed significantly since they were first identified, although diagnostic accuracy has improved with advanced MRI techniques.