An ex vivo sequential ligament transection model of flatfoot.

BACKGROUND: The ligaments implicated in the earliest stages of developing a progressive collapsing foot deformity are poorly understood. Commonly employed cadaveric flatfoot models are created from simultaneous transection of multiple ligaments, making it difficult to assess early changes in pressure distribution from ligaments critical for maintaining load distribution. A serial transection of ligaments may provide insight into changes in pressure distribution under the foot to identify a potential combination of ligaments that may be involved in early deformities. METHODS: Specimens were loaded using a custom designed axial and tendon loading system. Plantar pressure data for the forefoot and hindfoot were recorded before and after six sequential ligament complex transections. FINDINGS: Sectioning the plantar fascia (first) and short/long plantar ligaments (second) failed to generate appreciable differences in load distribution. Dividing the spring ligament (third) led to changes in hindfoot load distribution with a shift towards the lateral column indicative of hindfoot valgus angulation. All subsequent conditions resulted in similar patterns in hindfoot plantar load distribution. An anterior shift in the center of pressure only occurred after transection of all six ligament complexes. INTERPRETATION: Loss of the plantar fascia and short/long plantar ligaments are not critical in maintaining plantar load distribution or contact area. However, the additional loss of the spring ligament caused notable changes in hindfoot load distribution, indicating the combination of these three ligament complexes is particularly critical for preventing peritalar subluxation. Minimal changes in load distribution occurred when performing additional transections to reach a complete flatfoot deformity.

Sensitivity and Accuracy of High-Resolution Ultrasound for Diagnosis of Flexor Tendon Repair Integrity.

BACKGROUND: The authors examined whether ultrasound sensitivity, specificity, and accuracy in identifying intact repairs or flexor tendon gapping after zone 2 repair are affected by the number of suture strands crossing the repair or gap or imaging modality (static versus dynamic). METHODS: A total of 144 fresh-frozen cadaveric digits (thumbs excluded) were randomized to either an intact repair (0-mm gap) or simulated failed repair (4-mm gap), as well as to either a two- or eight-strand locked-cruciate repair of a zone 2 flexor digitorum profundus tendon laceration using 4-0 Fiberwire. Examinations were performed by a blinded musculoskeletal ultrasonographer in static and dynamic modes using an 18-MHz transducer. Gaps were remeasured after scanning, and the final gap width recorded. McNemar exact test was used to determine whether there were differences in sensitivity, specificity, and accuracy affected by modality (static versus dynamic), and chi-square test was used to compare sensitivity, specificity, and accuracy between number of strands (two versus eight) crossing the intact repair or repair gap (≥4 mm). RESULTS: Sensitivity, specificity, and accuracy improved with increased number of suture strands crossing the repair or gap (eight versus two), irrespective of modality (static versus dynamic), and dynamic compared with static scanning modes, irrespective of number of suture strands crossing the repair or gap site. CONCLUSIONS: The most sensitive and accurate means of assessing flexor tendon repair integrity and gapping were seen using the dynamic scanning mode. Increased number of suture strands did not negatively affect sensitivity, specificity, or accuracy, regardless of scanning mode (dynamic or static).

Comparative sensitivity and accuracy of 24 vs. 18 MHz ultrasound probes for the diagnosis of flexor tendon repair integrity.

Purpose: To determine whether a 24 MHz transducer significantly improves sensitivity, specificity and accuracy in evaluating flexor tendon repair integrity compared with an 18 MHz transducer. Methods: One hundred and twelve cadaveric digits were randomised to an intact repair or simulated 'failed' repair, and to a two- or eight-strand repair of a flexor digitorum profundus laceration. A blinded sonologist evaluated specimens in static mode using 18 and 24 MHz transducers. Gaps were remeasured after scanning, and final gap width recorded. McNemar's exact test calculated differences between sensitivity, specificity and accuracy, and chi-squared test to compare sensitivity, specificity and accuracy between number of strands (2 vs. 8) and repair gap (≥4 mm). Results: The 24 MHz transducer had higher sensitivity (81 vs. 59%), lower specificity (67 vs. 70%) and higher overall accuracy (74 vs. 64%), than the 18 MHz transducer. The difference for sensitivity was significant (P = 0.011), but not differences for specificity and overall accuracy (P > 0.05). Pearson's correlation (r = 0.61) demonstrated a moderate-to-strong positive correlation between measured and true gap sizes. Increased number of suture strands (2 vs. 8) did not impair sensitivity, specificity nor accuracy. Discussion: Ultrasound may tend to overestimate gap width, and a slight risk that some intact repairs, or those with small, clinically insignificant gaps may undergo surgical exploration that may not be indicated. Conclusions: A 24 MHz transducer is a more sensitive and accurate transducer for assessing flexor tendon repair integrity and measuring small gaps.

Establishing Confidence Intervals for Normal Radiographic Intracarpal Alignment Throughout the Arc of Wrist Motion: A Cadaveric Pilot Study.

BACKGROUND: High-quality lateral radiographs with the wrist in neutral (0°) or near neutral (less than 15° flexion or extension) are felt to be important for diagnosing carpal instability using intracarpal angular measurements, but may be unavailable. In addition, radiolunate (RLA) and capitolunate (CLA) measurement angles for defining carpal instability have poor validation. We sought to establish 95% confidence intervals (CIs) for predicted RLA and CLA throughout the arc of wrist motion in normal cadaveric wrists. METHODS: Fresh frozen cadaveric upper extremities were secured in a limb positioner. Scaphopisocapitate lateral radiographs were obtained throughout the arc of motion and RLA and CLA, and wrist flexion or extension angles (WA) were measured by a board-certified hand surgeon. Scatter plots of variables were constructed, and correlation coefficients calculated for areas under the curves. Regression equations for predicted RLA and CLA based on WA were developed. RESULTS: Both RLA and CLA correlated strongly with WA for each measurement in both flexion and extension (r = 0.7-0.8). Linear regression modeling demonstrated a good relationship between RLA (R2 = 84%) and CLA (R2 = 80%) with WA. Regression equations were constructed to give predicted values for RLA and CLA based on WA and 95% prediction CI. CONCLUSIONS: If RLA and CLA exceed 20° with neutral (0°) wrist alignment, it likely represents pathologic carpal alignment. Presented tables demonstrate 95% CI of RLA and CLA throughout the arc of wrist flexion/extension. Values outside of the 95% CI are also likely to indicate pathologic carpal alignment.

ACL Reconstruction With Quadriceps Soft Tissue Autograft Versus Bone-Patellar Tendon-Bone Autograft in Cutting and Pivoting Athletes: Outcomes at Minimum 2-Year Follow-up.

Background: The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports. Hypothesis: It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables. Results: A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group (P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) (P = .21). Conclusion: The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

Exacerbation of Spinal Stenosis Symptoms Following Neuraxial Anesthesia in an Achondroplastic Cesarean Section.

We report the case of an achondroplastic female who presented with acute neurologic decline following epidural anesthesia for an elective cesarean section. Achondroplasia presents unique anatomical challenges to anesthesiologists in perioperative management, and cesarean sections are standard for achondroplastic pregnancies. High rates of spinal stenosis and lumbar radiculopathy in this patient population make administration of epidural analgesia technically challenging and may increase the risk of neurologic injury. Ultrasound is an effective means of administering epidural anesthesia for most patients; however, its utility is user-dependent and more challenging for those with obesity and abnormal spinal anatomy, both of which are common in achondroplasia. Cephalic and thoracic anatomical features in achondroplasia can also make general anesthesia challenging. Therefore, preoperative imaging may help guide preoperative planning based on patient anatomy and individual risk factors to reduce the risks of complications in this patient population. This report includes details from the patient's prenatal care, cesarean section, and 18 months of follow-up.

Outcomes After Meniscal Root Repair in Patients With and Without Advanced Patellofemoral Chondromalacia: Comparison at 2-Year Follow-up.

Background: Meniscal root repair can improve patient outcomes significantly; however, several contraindications exist, including arthritic change to the medial or lateral tibiofemoral compartments. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of meniscal root repair in patients with advanced patellofemoral chondromalacia (PFC). It was hypothesized that the presence of advanced PFC would not significantly affect the postoperative outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was conducted of patients who underwent meniscal root repair with at least 2 years of follow-up data. Patients with chondromalacia as determined by arthroscopic visualization (defined as Outerbridge grade 3 or 4) were placed in the PFC group; patients with Outerbridge grade 0 to 2 chondromalacia were placed in the non-PFC group. Outcomes were measured by the Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form. Clinical outcomes including complications were also recorded. Quantitative data between the groups were analyzed using the 2-tailed independent-samples t test. Results: Overall, this study included 81 patients (35 in the PFC group, 46 in the non-PFC group). The mean follow-up times were 25.1 months in the PFC group and 24.8 months in the non-PFC group. In both groups, Lysholm and IKDC scores improved significantly with 24-month Lysholm scores averaging 85.86 in the PFC group and 86.61 in the non-PFC group (P = .62) and 24-month IKDC scores averaging 77.66 for the PFC group and 79.59 for the non-PFC group (P = .45). The cohorts demonstrated similar rates of retear, arthrofibrosis, infection, and progression to total knee arthroplasty. Conclusion: The presence of advanced PFC was not associated with inferior outcomes in patients who underwent posterior meniscal root repair, and rates of recurrent tears, postoperative infection, arthrofibrosis, and conversion to total knee arthroplasty were similar between the study groups. These findings suggest that PFC may not significantly alter the results of meniscal root repair and should not be considered an absolute contraindication for this procedure.

Inter- and Intra-observer Agreement of Visual Estimation, Goniometric and Radiographic Measurement of Passive Thumb Metacarpophalangeal Joint Hyperextension.

Background: Reliable methods for measuring range of motion is important for hand therapists. Currently, there is no gold standard for the measurement of thumb metacarpophalangeal joint (MCPJ) hyperextension. We hypothesised that visual and goniometric measurements of thumb MCPJ hyperextension vary greater than 10° from radiographic measurements, and between observers. Methods: Twenty-six fresh-frozen hands were measured by a senior orthopaedic resident and fellowship trained hand surgeon. Passive thumb MCPJ hyperextension was measured by visual estimation, goniometry and axis measurement on a lateral thumb radiograph. Raters were blinded to each other's and their own prior measurements. Descriptive statistics were recorded for measurement type and inter-observer agreement using a two-way intra-class correlation coefficient (ICC). Intra-observer agreement was calculated using concordance correlation coefficient (CCC). Bland-Altman plots identified trends, systemic differences or potential outliers. Results: Mean measurements for both raters were similar for visual estimation and radiographic measurements. Mean goniometric measurements were twice as high for Rater B, and closer to radiographic measurements. For both raters, mean radiographic measurements were 10° greater than the other two methods. For inter-rater agreement, measurements were within 10° most frequently with radiographic measurement, then visual estimates, and least by goniometer measurements. Rater B had better agreement comparing visual and goniometric to radiographic measurements. Conclusions: Radiographic measurement has the best inter-observer agreement and precision for evaluating passive thumb MCPJ hyperextension, especially considering adjunct corrective procedures when performing a soft-tissue basal joint arthroplasty. Rater experience improves precision, but there is still poor agreement between visual estimates and goniometer measurements compared to radiographic measurements, as the former two underestimate hyperextension by 10°. Development of a standard method of clinical measurement is needed to improve reliability.

Ninety-Day Readmission in Elective Revision Lumbar Fusion Surgery in the Inpatient Setting.

STUDY DESIGN: Retrospective review. OBJECTIVES: (1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days. METHODS: Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted. RESULTS: In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted. CONCLUSION: Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

Syndromic Scoliosis: National Trends in Surgical Management and Inpatient Hospital Outcomes: A 12-Year Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Evaluate the trends in management and inpatient outcomes in patients with syndromic scoliosis undergoing spinal deformity correction. SUMMARY OF BACKGROUND DATA: Syndromic scoliosis (SS) refers to scoliosis that is most commonly associated with systemic disease including Ehler Danhlos syndrome (EDS), Marfan syndrome (MF), Down syndrome (DS), Achondroplasia (AP), and Prader-Willi syndrome (PWS). Limited data exist evaluating hospital outcomes in patients with SS undergoing spinal deformity correction. METHODS: The Kids' Inpatient Database (KIDS) was queried from 2001 to 2012 to identify all pediatric patients with scoliosis undergoing spinal fusion. These patients were then sub-divided into two cohorts: (1) patients with idiopathic scoliosis (IS) and (2) patients with syndromic scoliosis. Trends in surgical management, and postoperative morbidity and mortality were assessed. Length of stay and total hospital charges were additionally analyzed. A sub-analysis to characterize outcomes in each syndrome was also performed. RESULTS: An estimated 1071 patients with SS were identified and compared with 24,989 pediatric patients with IS. MF (36.8%), Down syndrome (16.0%), and PWS (14.9%) were the most common diagnoses among patients with SS. Between 2001 and 2012, there was a significant decline in the number of anterior procedures performed in both cohorts. Conversely, the number of posterior based procedures increased. SS was associated with increased major complications (2.7% compared with 1.0% in IS; P < 0.001) and minor complication rates (41.0% compared with 28.5% in IS; P < 0.001). Patients with AP incurred the highest rate of major complications (10.7%), minor complications (60.8%), and intraoperative durotomies (6.1%). Total hospital charges increased significantly over the 12-year span. CONCLUSION: Trends in management of syndromic scoliosis have paralleled that of idiopathic scoliosis. Syndromic scoliosis is associated with increased risks with surgical deformity correction. Further prospective studies are warranted to evaluate the reasons for these differences. LEVEL OF EVIDENCE: 3.

Preoperative Dehydration does not Increase the Risk of Complications Following Elective Lumbar Surgery.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to evaluate the effect of preoperative dehydration on hospital length of stay (LOS), rates of 30-day postoperative complications, related reoperations, and readmissions. SUMMARY OF BACKGROUND DATA: Preoperative dehydration has long been associated with postoperative infection, deep vein thrombosis (DVT), acute renal failure, and an increased hospital LOS. To our knowledge, the effect of preoperative dehydration on complication rates for patients undergoing elective lumbar spine surgery has not been well described. METHODS: An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2006 to 2013 was performed. Patients undergoing elective lumbar procedures were identified and exclusion criteria eliminated patients who underwent any emergency procedures, infections, tumor cases, or revision surgeries. Patient dehydration was defined as preoperative blood urea nitrogen/creatinine (BUN/Cr) ratio greater than 20. RESULTS: Patients (4698; 34.5%) with preoperative dehydration based on BUN/Cr ratio were identified. Univariate analysis was suggestive of an association between preoperative dehydration and an increased risk of DVT (1.1% compared with 0.6%; P = 0.002), urinary tract infection (2.5% compared with 1.6%; P < 0.001), and need for transfusion postoperatively (17.6% compared with 14.4%; P < 0.001). However, on the basis of multivariate regression, no significant association between dehydration and increased odds of aforementioned outcomes was identified. CONCLUSION: Preoperative dehydration does not appear to negatively affect perioperative outcomes or readmission in patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE: 3.

Risk factors for delay in surgery for patients undergoing elective anterior cervical discectomy and fusion.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is well-tolerated by most patients and commonly necessitates only a short hospital admission. Surgical delay after hospital admission, however, may result in longer hospital stays, consequently increasing hospital resource utilization. The current study evaluates risk factors for surgical delay in patients undergoing elective ACDF. METHODS: A retrospective analysis of ACS-NSQIP data from 2006-2015 was performed. Patients undergoing elective ACDF were selected using current procedural terminology (CPT) codes (22251, 22252, 22554). A surgical delay was defined as surgery that occurred one day or later after initial hospital admission. Differences in outcomes between the non-delayed and delayed cohorts were evaluated with univariate analysis. Multivariate logistic regression was performed to identify risk factors for surgical delay. RESULTS: There were a total of 771 (2.0%) surgical delays out of 39,371 patients undergoing elective ACDF from 2006-2015. Multivariate analysis found partially dependent functional status (OR 5.88; 95% CI: 4.48-7.71; P<0.001), totally dependent functional status (OR 18.22; 95% CI: 9.60-34.59; P<0.001), ASA class 4 (OR 2.73; 95% CI: 1.70-4.38; P<0.001), bleeding disorders (OR 1.75; 95% CI: 1.08-2.85; P=0.024), male sex (OR 1.19; 95% CI: 1.03-1.38; P=0.019), and chronic steroid use (OR 1.76; 95% CI: 1.30-2.37; P<0.001) as independent predictors of delay. Univariate analysis found surgical delay was associated with a higher rate of post-operative major adverse events (4.8% vs. 1.1%; P<0.001), mortality (1.0% vs. 0.2%; P<0.001) and greater than five-fold increase in total length of stay (9.52 vs. 1.65 days; P<0.001). CONCLUSIONS: Impaired pre-operative functional status, a higher comorbidity burden, and chronic steroid use are risk factors for surgical delay, increased complications, and length of stay in patients undergoing elective ACDF. This is helpful information to consider given a rising incidence of cervical fusions in the Medicare population, a wide variation in costs, and increasing popularity of bundled-payment models. LEVEL OF EVIDENCE: 3.