Prophylactic Common Peroneal Nerve Release for Total Arthroplasty of the Valgus Knee: Surgical Technique and Early Outcomes.

Background: Common peroneal nerve (CPN) palsy after primary total knee arthroplasty represents a relatively rare but serious complication. Recently, there has been a growing interest in prophylactic CPN decompression in high-risk patients with significant combined valgus and flexion deformity. This study aimed to examine outcomes at our institution in those undergoing prophylactic CPN decompression at the time of total knee arthroplasty. Methods: A retrospective evaluation of a single-institution experience with selected patients at high risk for CPN palsy who underwent prophylactic nerve decompression through a separate incision at the time total knee arthroplasty was performed between July 1, 2018 and December 31, 2022. Patient demographics as well as perioperative and intraoperative clinical and radiographic measurements were collected and analyzed. Results: A total of 14 patients (15 knees) met our inclusion criteria. The mean preoperative femorotibial angle was 18.6° of valgus (range 13°-22°). The mean preoperative flexion contracture was 4.3° (range 0°-25°). The patients with flexion contractures preoperatively had a mean combined valgus/flexion contracture deformity of 28.8° (range 23°-38°) . There was preservation of nerve function in all knees. No knees required subsequent operative intervention within 90 days of surgery. Conclusions: Early experience with prophylactic CPN release in our high-risk population demonstrates preservation of nerve function in all patients and is reasonable to consider in patients with a large preoperative combined valgus/flexion deformity. Further studies with larger sample sizes would be beneficial in verification of the results with this technique, as well as determining an angular deformity threshold for which CPN release should be considered.

Prediction of suitable outpatient candidates following revision total knee arthroplasty using machine learning.

Aims: To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA. Methods: Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital length of stay between zero and four days were included. Demographic, preoperative, and intraoperative variables were analyzed. A multivariable logistic regression (MLR) model and various machine learning techniques were compared using area under the curve (AUC), calibration, and decision curve analysis. Important and significant variables were identified from the models. Results: Of the 5,600 patients included in this study, 342 (6.1%) underwent SDD. The random forest (RF) model performed the best overall, with an internally validated AUC of 0.810. The ten crucial factors favoring SDD in the RF model include operating time, anaesthesia type, age, BMI, American Society of Anesthesiologists grade, race, history of diabetes, rTKA type, sex, and smoking status. Eight of these variables were also found to be significant in the MLR model. Conclusion: The RF model displayed excellent accuracy and identified clinically important variables for determining candidates for SDD following rTKA. Machine learning techniques such as RF will allow clinicians to accurately risk-stratify their patients preoperatively, in order to optimize resources and improve patient outcomes.

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience.

INTRODUCTION: Ballistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm. PATIENTS AND METHODS: A retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed. RESULTS: The median age was 27 years (range: 18-62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up. CONCLUSION: Ballistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.

Extraoral anterior approach for the treatment of os odontoideum: illustrative case.

BACKGROUND: Os odontoideum is typically treated with instrumented fusion through a posterior cervical approach. When this approach fails, limited options for revision are available. Occipitocervical fusion and transoral anterior fusions have been utilized in the past but are associated with high morbidity and complications. OBSERVATIONS: Here the authors report a case of os odontoideum that was treated with an anterior cervical extraoral approach after failed posterior instrumented fusion. They discuss the challenges that can be encountered with the failure of fusion and the limited options when it comes to approach and fixation of os odontoideum. LESSONS: To the authors' knowledge and based on a review of the literature, this case represents the first use of an anterior extraoral prevascular approach to the high cervical spine to address os odontoideum. They demonstrate that this approach can be utilized as a reasonable alternative to transoral surgery and should be considered in cases where additional or alternative fixation is desired without the morbidity and complications associated with occipitocervical fusion or a transoral approach, especially in a younger patient population.

Effect of Change in USMLE Step 1 Grading on Orthopaedic Surgery Applicants: A Survey of Orthopaedic Surgery Residency Program Directors.

INTRODUCTION: Recently, the Federation of State Medical Boards and the National Board of Medical Examiners, cosponsors of the United States Medical Licensing Examination (USMLE), changed the USMLE Step 1 results from a three-digit score to a pass/fail format. The purpose of this study was to analyze the opinions of program directors (PDs) to predict how the evaluation of orthopaedic surgery residency applicants will change following the change. METHODS: A 17-question online survey was distributed to PDs via e-mail. This survey covered program demographics, questions regarding the relative importance of various factors for selection of interviews, and perceived changes and effect of the scoring change. Responses were aggregated and analyzed. RESULTS: PDs indicated that the three highest scored factors were (1) failure in prior attempts in USMLE/COMLEX examinations (4.7), (2) audition elective/rotation within your department (4.5), and (3) personal prior knowledge of the applicant (4.1). In addition, 38 PDs (81.1%) anticipate that they will require USMLE Step 2 clinical knowledge scores for interview consideration. CONCLUSION: Most orthopaedic surgery PDs think that the change in score reporting for the USMLE Step 1 will result in additional requirements and changes in how programs select applicants and do not support the decision.

The Effect of Turf Toe Injuries on Player Performance in the National Football League.

Background: "Turf toe" results from hyperdorsiflexion of the first metatarsophalangeal joint, injuring the plantar capsuloligamentous complex. We hypothesized that National Football League (NFL) player performance following turf toe injury would decrease in comparison to controls at the same position. Methods: Demographics, return to play, and season performance data on players sustaining turf toe injuries in the NFL from 2010-2015 were collected. An Offensive Power Rating (OPR=[total yards/10]+[total touchdowns x6]) or Defensive Power Rating (DPR=total tackles+[total sacks x2]+[total interceptions x2]) was calculated for each player. Control data were collected for NFL players in 2013 with no history of turf toe injury. Statistical analysis was performed using Wilcoxon Rank Sum tests. Results: Twenty-four injured players and 436 controls were included. Nineteen players returned to play within the regular season of injury (mean 36.7 ± 28.9 days). Seventeen players were removed from team injury reports for turf toe within the regular season (mean 42.6 ± 26.2 days). Three players required season-ending surgery. Comparison of 1-year post- versus pre-injury revealed an insignificant median OPR difference (-18.9 IQR -43.4 to 10.3 vs. control -12.2 IQR -46.2 to 47.7, p = 0.328) and median DPR difference (-1.0 IQR -26.0 to 17.0 vs. control 2.0 IQR -15.0 to 18.0, p = NA). Comparison of 2-year data revealed no significant median OPR difference (-32.6 IQR -122.2 to 1.0 vs. control -20.7 IQR -72.6 to 44.7, p = 0.327) and median DPR difference (-5.0 IQR -19.0 to 6.0 vs. control -4.5 IQR -22.0 to 12.5, p= NA). Conclusions: Turf toe results in significant loss of playing time. Despite the long recovery period, NFL players have similar performance following injury compared to controls. The effect of turf toe injuries on performance is variable.Level of evidence: IV.