Intercondylar Notch Pathology.

The intercondylar notch of the knee is a relatively small area. However, numerous rare pathologies can arise in this region. A majority of the existing literature has focused on the cruciate ligament injuries, yet there are several other entities that can cause knee pain from within the intercondylar notch. This review focuses on identifying the various diagnostic and treatment options for rare benign and malignant lesions including ganglion cyst formation, mucoid degeneration, benign proliferative conditions, and intra-articular tumors. These entities are most often diagnosed with advanced imaging studies and treated arthroscopically. While rare, these pathologies are important to identify in patients with ongoing vague knee pain.

Increased Body Mass Index is Associated with Worse Mid- To Long-Term Patient Outcomes after Surgical Repair of Multiligamentous Knee Injuries.

We evaluated the relationship between elevated body mass index (BMI) and mid- to long-term outcomes after surgical treatment of multiligamentous knee injury (MLKI). Records identified patients treated surgically for MLKI at a single institution. Inclusion criteria: minimum 2 years since surgery, complete demographics, surgical data, sustained injuries to two or more ligaments in one or both knees, and available for follow-up. Patients were contacted to complete patient-reported outcomes assessments and were classified according to mechanism of injury. Multivariate logistic regression analysis was used to predict the impact of BMI on outcome scores. A total of 77 patients (72.7% male) were included with a mean age at the time of injury of 29.4 ± 11.0 years and a mean BMI of 30.5 ± 9.4 kg/m2. The mean length of follow-up was 7.4 years. For each 10 kg/m2 increase in BMI, there is a 0.9-point decrease in Tegner activity scale (p = 0.001), a 5-point decrease in Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain (p = 0.007), a 5-point decrease in KOOS-ADL (p = 0.003), a 10-point decrease in KOOS-QOL (p = 0.002), and an 11-point decrease in KOOS-Sport (p = 0.002). There were no significant correlations with BMI and Pain Catastrophizing Scale or Patient Health Questionnaire scores. Increasing BMI has a negative linear relationship with mid- to long-term clinical outcomes including pain, ability to perform activities of daily living, quality of life, and ability to perform more demanding physical activity after MLKI. BMI does not appear to have a significant relationship with knee swelling and mechanical symptoms or patients' mental health.

Infection Management for the Hand Surgeon.

Infections of the upper extremity can be challenging to diagnose and treat because of the complex anatomy and range of offending pathogens. Early recognition of infections that require an emergent surgical intervention, such as necrotizing fasciitis and septic joints, is imperative for good clinical outcomes. In addition, prompt diagnosis and intervention for deep closed space infections, such as deep abscesses or flexor tenosynovitis, is necessary to avoid chronic pain and dysfunction. Complicating factors such as underlying osteomyelitis, atypical pathogens, and immunocompromised states of patients should always be considered when treating upper-extremity infections.

Considerations for Hand Surgery in Patients With Scleroderma.

Systemic sclerosis (scleroderma, SSc) is an autoimmune disease that causes significant dysfunction to multiple organ systems, including the musculoskeletal system. It poses significant challenges to the hand surgeon, including calcinosis, ischemic changes, Raynaud phenomenon, tendinopathies, synovitis, and joint contractures. Patients with SSc also suffer from multiorgan dysfunction, which makes them high-risk surgical patients. The hand surgeon must understand the pathophysiology, treatment strategies, and special operative considerations required in this population to avoid complications and help maintain or improve hand function.

Utilizing A Percutaneous Versus Open Achilles Tendon Repair Technique for Treating Acute Achilles Tendon Ruptures in Physically Active Adults: A Critically Appraised Topic.

CLINICAL SCENARIO: Acute Achilles tendon ruptures can be devastating injuries with the potential to significantly alter an individual's ability to perform functional activities. Given the rise in the incidence of acute Achilles tendon ruptures, it is important to determine whether percutaneous versus open Achilles tendon repair facilitates superior outcomes. CLINICAL QUESTION: In physically active adults with an acute Achilles tendon rupture, does performing percutaneous Achilles tendon repair result in improved outcomes compared with open Achilles tendon repair? SUMMARY OF KEY FINDINGS: Percutaneous Achilles tendon repair has similar efficacy as open Achilles tendon repair in facilitating return to activity/sport, and demonstrates improvement in short-term functional outcomes with potentially lower wound complication rates. CLINICAL BOTTOM LINE: Evidence supports the utilization of percutaneous Achilles tendon repair in physically active adult patients with acute Achilles tendon ruptures. It is important to critically review the benefits, risks, and alternatives of each treatment option based on patient characteristics. In addition, postoperative expectations should be discussed with the patient to set appropriate goals for recovery and improve overall satisfaction. STRENGTH OF RECOMMENDATION: A grade B recommendation can be made based on "fair" to "good" evidence from 2 level 2b studies and 1 Level 1b study to support the utilization of percutaneous Achilles tendon repair techniques.

Minimally Invasive Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS).

Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities1,2. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures3,4. Description: Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable interference screws, following the angle that the suture-passing needles are in. After confirming function of the Achilles tendon, close the peritenon, deep tissues, and superficial tissues, and place the ankle in a splint in 15° of plantar flexion. Alternatives: Acute Achilles ruptures can be treated operatively or nonoperatively1,2. Operative techniques include open, percutaneous, or minimally invasive Achilles tendon repair. Open Achilles tendon repair involves making a 10-cm posteromedial incision to perform a primary repair5, while percutaneous Achilles tendon repair involves the use of medial and lateral mini-incisions to pass needles and sutures into the Achilles tendon to repair it6. Minimally invasive Achilles tendon repair involves the use of a small 3 to 4-cm incision to introduce instrumentation such as modified ring forceps or an Achillon device (Integra)7,8, along with a percutaneous technique, to repair the Achilles tendon. Nonoperative treatment can be utilized in patients with <5 mm of gapping between the ruptured tendon edges on dynamic ultrasound in 30° of plantar flexion9, in patients with limited activity, or in patients whose comorbidities make them high-risk surgical candidates. Nonoperative treatment includes a below-the-knee rigid cast in 30° of plantar flexion or the use of a functional splint in 30° of plantar flexion with gradual progression to a neutral position, along with early rehabilitation according to the postoperative protocol described in the present article. Rationale: This technique allows patients to begin early postoperative rehabilitation, limits wound and soft-tissue complications such as superficial and deep infections, and protects neurovascular structures such as the sural nerve that may be injured if utilizing other techniques. These benefits are achieved through the use of a minimally invasive knotless approach that places nearly all of the suture material into the Achilles tendon, reducing friction within the paratenon and potentially facilitating improved gliding. Additionally, securing the sutures into the calcaneus minimizes postoperative Achilles tendon elongation and facilitates early postoperative rehabilitation. Expected Outcomes: Patients undergoing this procedure can expect to return to their baseline physical activities by 5 months3, with the best functional results observed at ≥12 months postoperatively4. One retrospective cohort study compared the results of 101 patients who underwent Achilles repair with use of the PARS Jig and 169 patients who underwent open Achilles repair, and found that 98% of PARS patients returned to baseline activities in 5 months compared with 82% of patients undergoing open Achilles repair (p = 0.0001)3. Another retrospective chart review assessed the results of 19 patients who underwent Achilles repair with the PARS Jig4 and found that patients began to return to sport as early as 3 months postoperatively and that functional scores in patients increased as time progressed, with significant increases observed at 12 months and longer postoperatively. Important Tips: Locate the Achilles tendon rupture site prior to marking the transverse incision.Bluntly dissecting the paratenon during closure stimulates healing and reduces scarring, thereby maintaining the integrity of the tissue10.When advancing the PARS Jig, ensure that the proximal Achilles tendon remains inside the device.Maintaining meticulous suture management and organization prevents tangles and improves suture shuttling.Ensure that the Achilles tendon is tensioned with the ankle in 15° of plantar flexion prior to distal anchor fixation. Acronyms and Abbreviations: MRI = magnetic resonance imagingUS = ultrasoundBID = twice dailyPRN = as neededDVT = deep vein thrombosis.

Pain Management following Open Reduction and Internal Fixation of Distal Radius Fractures.

Background Distal radius fractures (DRF) are commonly treated with open reduction and internal fixation (ORIF). Few studies address perioperative and postoperative pain control for this procedure. Questions/Purpose We attempt to demonstrate efficacy of pain management modalities during the perioperative and acute postoperative period after ORIF. Specifically, does the type of perioperative anesthesia used during fixation of DRF affect pain control postoperatively? Does the quantity of narcotic pain medication prescribed or type of pain medication given postoperatively affect pain management? Methods We retrospectively reviewed 294 adult (≥18 years old) patients who underwent outpatient ORIF of acute DRF between December 2012 and December 2014. All procedures were performed with a standard volar plating technique through a flexor carpi radialis approach. Patient demographics, fracture laterality, severity of fracture, type of operative anesthesia, and details regarding postoperative oral pain medications were recorded. We reviewed the number and timing of patient phone calls regarding postoperative pain and refills of pain prescriptions. Results Two-hundred ninety-four patients (average age 48.7 years) were included. One-hundred twenty-two injuries were right-sided (41.5%), 168 were left-sided (57.1%), and four were bilateral (1.4%). One-hundred fifty-one patients (51.4%) received regional anesthesia prior to surgery. Average number of narcotics tablets prescribed was 58. There were 66 patients who called the orthopaedic patient hotline regarding pain-control issues at a median of 7.0 days postoperatively. One-hundred twenty-nine (43.9%) patients required refills of narcotic pain medication postoperatively. There was no significant difference in the number of calls or refills given with regard to the type of anesthesia used or postoperative pain regimen prescribed. Conclusions More than one-fifth of patients who underwent ORIF experienced pain severe enough to call our institution's orthopaedic hotline to ask for help at a median of 7 days after fixation. Clinical Relevance Our study demonstrates poor pain control regardless of intraoperative anesthesia or utilization of varying postoperative pain regimens.

Stress-induced Norepinephrine Downregulates CCL2 in Macrophages to Suppress Tumor Growth in a Model of Malignant Melanoma.

Psychological stressors have been implicated in the progression of various tumor types. We investigated a role for stress in tumor immune cell chemotaxis in the B16F10 mouse model of malignant melanoma. We exposed female mice to 6-hour periods of restraint stress (RST) for 7 days, then implanted B16F10 malignant melanoma tumor cells and continued the RST paradigm for 14 additional days. We determined serum corticosterone and liver catecholamine concentrations in these mice. To evaluate the tumor microenvironment, we performed IHC and examined cytokine expression profiles using ELISA-based analysis of tumor homogenates. We found that tumors in mice subjected to RST grew significantly slower, had reduced tumor C-C motif ligand 2 (CCL2), and contained fewer F4/80-positive macrophages than tumors from unstressed mice. We observed a concomitant increase in norepinephrine among the RST mice. An in vitro assay confirmed that norepinephrine downregulates CCL2 production in both mouse and human macrophages, and that pretreatment with the pan-ß-adrenergic receptor inhibitor nadolol rescues this activity. Furthermore, RST had no effect on tumor growth in transgenic CCL2-deficient mice. This study suggests that stress reduces malignant melanoma by reducing recruitment of tumor-promoting macrophages by CCL2.

Urinary tract infection (UTI) at time of geriatric hip fracture surgery increases the risk of experiencing adverse 30-day outcomes.

INTRODUCTION: Pre-operative urinary tract infection (UTI) may be associated with a high rate of complications following surgeries. Few studies have investigated the clinical impact of a pre-operative UTI on post-operative outcomes following surgeries for hip-fracture in geriatric patients. METHODS: The 2015-2016 ACS-NSQIP database was queried for patients undergoing hip fracture surgery using CPT-Codes for Total Hip Arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). Only patients ≥65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. RESULTS: Out of 31,621 patients undergoing surgical treatment for a hip fracture, 410 (1.3%) had UTI at the time of the surgery. Following adjusted logistic regression analysis, UTI present at the time of surgery was associated with a longer length of stay>5 days (OR 5.46 [95% CI 2.27-13.1]; p = 0.008), any complication (OR 1.33 [95% CI 1.49-1.63]; p = 0.007), infectious complications (OR 1.71 [95% CI 1.19-2.47]; p = 0.004), non-infectious complications (OR 1.28 [95% CI 1.04-1.58]; p = 0.021), 30-day unplanned re-operations (OR 1.96 [95% CI 1.25-3.06]; p = 0.003) and 30-day readmissions (OR 2.04 [95% CI 1.57-2.66]; p < 0.001). With regards to infectious complications, presence of a UTI at time of surgery was a significant independent predictor of sepsis (OR 2.44 [95% CI 1.24-4.80]; p = 0.010) and septic shock (OR 4.05 [95% CI 2.03-8.08]; p < 0.001). CONCLUSIONS: Patients undergoing hip-fracture surgery with a concurrent UTI at the time of surgery have more adverse 30-day outcomes as compared to hip fracture patients who do not present with a UTI. Despite adjustment for a delay in the time to surgery, the impact of UTI on post-operative outcomes remained significant. While it is difficult to eradicate a UTI in a non-elective population, the findings stress the need for clinical optimization and potential need for early recognition/management of UTI in patients who sustain a hip fracture to minimize the risk of adverse outcomes.

A Survey of Fellowship-Trained Upper Extremity Surgeons on Treatment of Lateral Epicondylitis.

Background: The aim of the study is to investigate current management strategies for lateral epicondylitis by fellowship-trained upper extremity surgeons. Methods: A 17-question survey of treatment approaches and outcomes related to lateral epicondylitis was sent to 3354 surgeons using the American Society for Surgery of the Hand and American Shoulder and Elbow Surgeons member databases. Results: Six hundred twelve upper extremity surgeons completed the survey. The 6 most frequently prescribed nonoperative treatments for lateral epicondylitis were home exercise program/stretching (81%), nonsteroidal anti-inflammatory drugs (75%), steroid injection (71%), counterforce bracing (68%), formal physical therapy (65%), and wrist brace (47%). Less commonly performed nonoperative treatment measures included platelet-rich plasma injection (16%), Tenex procedure (6%), and iontophoresis (2%). Conclusions: There is a lack of consensus in the literature for the management of lateral epicondylitis, which is reflected by individual variation in clinical treatment among the experts. Future prospective randomized control studies are needed to establish evidence-based practice standards for this common diagnosis.

Discharge to Inpatient Care Facility After Vertebroplasty/Kyphoplasty: Incidence, Risk Factors, and Postdischarge Outcomes.

INTRODUCTION: Vertebral compression fractures are a common clinical occurrence in elderly individuals with osteoporosis. No current evidence exists on risk factors and clinical impact of discharge to inpatient (IP) care facility after vertebral augmentation procedures. MATERIALS AND METHODS: The 2012-2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database files were queried using Current Procedural Terminology codes for vertebroplasty (22520, 22521, and 22522) and kyphoplasty (22523, 22524, and 22525). Discharge to IP care facility included skilled-care facilities and IP rehabilitation units. A total of 2361 patients were included in the final cohort. RESULTS: Of 2361 patients, 1962 (83.1%) were discharged home and 399 (16.9%) were discharged to an IP care facility. Multivariate analysis identified age ≥65 years (P < 0.001), dependent preoperative functional health status (P < 0.001), hypertension (P = 0.001), preoperative transfusion (P = 0.043), IP admission status (P < 0.001), thoracolumbar procedure versus thoracic-only procedure (P = 0.012), and length of stay >1 day (P < 0.001) to be significant predictors for a discharge to an IP care facility. In addition, discharge to an IP care facility was associated with a significant greater risk of 30-day mortality (P = 0.001). No significant associations were found with between IP-care discharge destination and any 30-day complication, 30-day readmission, and 30-day reoperation. CONCLUSIONS: Discharge to IP care facilities after vertebroplasty/kyphoplasty is associated with a 3.6 times greater odds of mortality as compared with home discharge. Providers can use the risk profile data to better allow preoperative stratification of patients to ensure that discharge location is appropriate to a patient's need to minimize the risk of adverse outcomes.

Lumbar Intervertebral Disc Herniation Masquerading as an Epidural Hematoma: A Case Report and Review of the Literature.

CASE: A 50-year-old man developed acute back and bilateral leg pain after minor trauma. Laboratory tests and routine radiographs were unremarkable. Magnetic resonance imaging (MRI) showed a 5 × 15 × 42-mm longitudinally oriented mass behind the L2-L3 interspace that obliterated the subarachnoid space and displaced the nerve roots. The mass was isointense on T1-weighted imaging and showed mixed low and high signals on T2-weighted imaging. Based on the clinical history and the imaging findings, a provisional diagnosis of spinal epidural hematoma (SEH) was made. A laminectomy was performed at L2-L3; intraoperatively, a large disc herniation was found at L2-L3, with no evidence of hematoma. CONCLUSION: MRI findings of SEH and disc herniation have been well described in the literature. To our knowledge, this is the third report of intraoperatively confirmed disc herniation with MRI findings suggestive of SEH These discordant MRI and intraoperative findings illustrate that an SEH and a disc herniation may not always be distinguishable on MRI and may require surgical confirmation.

Growth Factor Dose Tuning for Bone Progenitor Cell Proliferation and Differentiation on Resorbable Poly(propylene fumarate) Scaffolds.

One approach to the development of an artificial graft material could rely on uniform coverage of a resorbable biomaterial with bone extracellular matrix (ECM). To achieve this on the surface of poly(propylene fumarate) (PPF) scaffolds, we selected a growth factor regime of basic fibroblast growth factor (FGF-2) (5 ng/mL), platelet-derived growth factor (PDGF-BB) (40 ng/mL), and epidermal growth factor (EGF) (20 ng/mL) to stimulate proliferation of bone marrow-derived human mesenchymal stem cells (BM-hMSCs). Bone morphogenetic protein (BMP) 4 (50 ng/mL), 6 (50 ng/mL), and 7 (27 ng/mL) in the presence of the following osteogenic substances: dexamethasone (10(-7) M), ß-glycerophosphate (10 mM), and ascorbic acid (50 µg/mL) were chosen to induce differentiation of BM-hMSCs into ECM-secreting osteoblasts. These growth factors were also studied at 10× concentration to determine dose effect. Proliferation was analyzed by MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay, scanning electron microscopy (SEM), and toluidine blue staining, whereas differentiation was analyzed through alizarin red S staining and assay, alkaline phosphatase (ALP) staining and assay, and SEM. The proliferation study suggests that a combination of EGF, PDGF-BB, and FGF-2 growth factors at optimal concentration over a period of 1 week exhibits significantly (p = 0.001) higher number of cells (116,024 ± 5165) than these cytokines without EGF (91,706 ± 11,965). Increasing the dosage does not show any significant effect. The BM-hMSC differentiation study results show that ALP enzyme production and mineral deposition increase from day 14 to day 21 in all groups containing BMPs and osteogenic medium. However, mineralization is significantly higher in the BMP-7 group. Furthermore, the feasibility of translating the results from two dimensional thin films to three dimensional-printed PPF scaffolds was determined through uniform initial seeding and spreading of BM-hMSCs. Therefore, we have determined the optimum dose of growth factors for proliferation and differentiation of BM-hMSCs on the surface of PPF scaffolds, which can be used to produce ECM-coated implants for the treatment of bone defects.