Patient Positioning for Postless Hip Arthroscopy.

Hip arthroscopy has been on the rise since its inception. Initial descriptions of the procedure required skeletal traction of the operative extremity with countertraction provided by a perineal post. Perineal posts are associated with complications such as perineal nerve palsy, genital laceration, and hematoma formation. Postless traction has been developed to avoid complications related to use of perineal posts. A patient is positioned supine on a postless traction table (Guardian; Stryker, Greenwood Village, CO) with a disposable traction pad. The anterior superior iliac spine is positioned at the distal aspect of the semicircle cutout in the traction pad. The patient is placed in approximately 3° of Trendelenburg positioning. Both lower extremities are secured into traction boots. The operative extremity is prepared and draped in the standard sterile fashion. Traction is applied to the operative extremity with countertraction being applied manually to the pelvis during hip dislocation. Many pathologies around the hip including femoral acetabular impingement can be effectively managed with hip arthroscopy. Postless hip arthroscopy is an effective method of obtaining sufficient traction for hip dislocation. Significant complications related to the perineal post can be avoided with postless traction. We expect postless traction use to increase in hip arthroscopy.

All-Soft-Tissue Meniscus Allograft Transplantation With Circumferential Suture Tape Augmentation to Mitigate Hoop Stress and Promote Centralization.

Meniscus allograft transplantation (MAT) is a technically challenging procedure. Bone plugs, slot techniques, and all-soft-tissue fixation techniques have been described in the past. Each technique comes with advantages and disadvantages. Native menisci have circumferential collagen fibers to help resist hoop stress during loading cycles. Although hoop stress resistance is a known function of the menisci, its recreation in MAT has only been targeted indirectly through anatomic root placement. The authors describe the use of a high-tensile suture tape (i.e. InternalBrace) to promote centralization by directly mitigating hoop stresses through recreation of peripheral meniscus tensioning in MAT.

Editorial Commentary: Proper Anterior Cruciate Ligament Graft Choice Mitigates Against the Need for Anterolateral Ligament Reconstruction.

It is not coincidence that fervor surrounding anterolateral ligament (ALL) reconstruction increased as double-bundle anterior cruciate ligament reconstruction (ACLR) enthusiasm cooled. But perhaps we shifted our focus too soon, or perhaps we shifted our focus too much. But we must remember that the ACL is primary. Increases in ACL graft diameter by 1 or 2 mm can significantly increase graft strength and decrease revision rate. Biomechanical and clinical evidence suggests that quadriceps tendon ACLR and patellar tendon ACLR demonstrates less pivot shift phenomena than hamstring ACLR. In addition, As biologically active suture tapes become more mainstream, augmented allografts are an increasingly attractive option. Proper ACL graft choice mitigates against the need for ALL reconstruction. Risk factors for anterolateral rotatory instability may include low body mass index and lateral meniscal pathology, in addition to the well-known risks such as age, gender, activity level, and revision cases. Perhaps lateral extra-articular tenodesis should be reserved for high-risk cases.

Neutral Mechanical Alignment Alters the Native Distal Femoral Joint Line: A Virtual Three-Dimensional Planning Total Knee Arthroplasty Study.

BACKGROUND: Alternative alignment concepts have garnered great interest in an effort to improve patient satisfaction following primary total knee arthroplasty (TKA). The purpose of this study is to determine variation or deviation from an individual's native joint line in primary TKA using neutral mechanical versus a restricted kinematic technique. METHODS: An institutional review board-approved prospective cohort study was performed evaluating the effect of neutral mechanical alignment (nMA) versus a restricted kinematic alignment (rKA) on the native joint line in 100 consecutive patients undergoing primary TKA. Using preoperative computed tomography and intraoperative 3-dimensional software, 2 virtual preoperative plans were created: nMA and rKA. Templated bone resections were recorded. Change in joint line was calculated using known implant planar thickness and planned bone resection. RESULTS: nMA yielded significantly greater deviation from the patient's native joint line along the lateral compartment of the knee (lateral distal femoral condyle, lateral posterior femoral condyle, lateral tibial resection). With nMA, the lateral distal femoral joint line was distalized by a mean 4.3 versus 2.6 mm using rKA technique (P < .001). In rKA, >60% of knees had <3 mm of deviation from the native lateral posterior femoral offset, whereas in nMA, >95% of knees had ≥3 mm change in the lateral posterior femoral condylar offset. CONCLUSION: nMA-TKA resulted in statistically larger joint line deviations compared to rKA-TKA, most notably along the lateral distal femoral condyle joint line. Further analysis is needed to determine the clinical consequences of joint line deviation from the native anatomy using nMA as the target for primary TKA.

No difference in PROMs between robotic-assisted CR versus PS total knee arthroplasty: a preliminary study.

The purpose of this study was to determine if significant clinical differences exist in patient-reported outcome measures (PROMs) between PS and CR TKAs implanted using robotic-assisted technology. This was an IRB-approved retrospective study from an institutional database evaluating 214 knees in 190 patients. Inclusion criteria included: primary RA-TKA, age 22-89 at the time of surgery, preoperative coronal limb deformity within 15º of neutral alignment, and minimum 1-year follow-up. The PS cohort consisted of 103 patients with 107 RA-TKAs, whereas the CR cohort consisted of 87 patients with 107 RA-TKAs. Cohorts were compared on the basis of demographics and PROMs (KSS knee, KSS function, FJS-12, KOOS-JR, WOMAC, and 5-point satisfaction Likert scale) collected preoperatively and at 1-year follow-up. Statistical analyses comparing measures were conducted via Student's t tests for continuous data and Chi-squared analyses for categorical data. There were no significant differences identified in short-term PROMs at 1-year follow-up between cohorts (all p values > 0.05). 93.1% of patients with CR knees and 94.7% of patients with PS knees reported a satisfaction level of "very satisfied" or "satisfied". Revision arthroplasty occurred in six knees (2.8%, 3 knees in CR cohort, 3 knees in PS cohort) with no differences in overall complications between groups. The use of RA-TKA technology promoted high patient satisfaction scores within this study, independent of CR or PS implant type with no significant differences in PROMs, satisfaction, revisions, or complications between the two groups.

Intra-articular Fracture Pattern in Intercondylar Distal Femur Fractures: An Analysis of Frequency and Major Fracture Fragments.

INTRODUCTION: The treatment of intercondylar distal femur fractures requires anatomic reduction of intra-articular fragments and absolute fixation. Preoperative planning is necessary to understand fracture morphology. All fracture lines need to be recognized as the primary implant may not capture all articular fragments, mainly when coronal plane fractures are present. Oftentimes, independent interfragmentary compression screws are necessary. No recent studies have visually mapped out the distal femur articular fracture fragments necessary for absolute fixation. The objectives of this study are to determine the frequency of coronal plane fractures in intercondylar distal femur fractures and describe the pattern of intra-articular fracture fragments. MATERIALS AND METHODS: The hospital's trauma registry was queried for distal femur ORIF CPT codes logged in the past four years. A retrospective chart review was performed using the EMR and CT scans. Demographics and mechanisms of injury were analyzed. Fracture fragments were surveyed and drawn out by hand on a template for easy organization. Patients' fractures were categorized into the following groups: fractures with no intra-articular coronal plane fractures, those with medial coronal fractures, those with lateral coronal fractures, or those with both medial and lateral coronal fractures. Major fracture fragments were identified. RESULTS: A total of 55 patients were included. 26 patients (47%) were found to have no intra-articular coronal plane fractures; 6 patients (11%) were found to have medial coronal plane fractures; 15 patients (27%) were found to have lateral coronal plane fractures, and 8 patients (15%) had medial and lateral coronal plane fractures. Collectively, intra-articular coronal plane fractures were identified in 29 patients (53%) with intercondylar distal femur fractures. Four major fracture fragments along with intercondylar and condylar comminution sites were identified. DISCUSSION: Distal femur intra-articular coronal plane fractures can yield large anterior and posterior condylar fracture fragments of either the medial condyle, lateral condyle, or both condyles. Coronal plane fracture fragments must be identified to obtain absolute fixation. Our study found a higher coronal plane fracture line frequency (52.7%) than prior commonly cited studies. Surgeons must be on the lookout for anterior fracture fragments, posterior fracture fragments, and articular comminution when treating intercondylar femur fractures.

Corrosion Concerns? Trends in Metal-on-Polyethylene Total Hip Arthroplasty Revision Rates and Comparisons Against Ceramic-on-Polyethylene up to 10 Years of Follow-Up.

BACKGROUND: We compared the revision risk between metal-on-polyethylene (MOP) and ceramic-on-polyethylene (COP) total hip arthroplasty patients and evaluated temporal changes in short-term revision risks for MOP patients. METHODS: Primary MOP (n = 9480) and COP (n = 3620) total hip arthroplasties were evaluated from the Medicare data set (October 2005 to December 2015) for revision risk, with up to 10 years of follow-up using multivariate analysis. Temporal change in the short-term revision risk for MOP was evaluated (log-rank and Wilcoxon tests). RESULTS: Revision incidence was 3.8% for COP and 4.3% for MOP. MOP short-term revision risk did not change over time (P ≥ .844 at 1 year and .627 at 2 years). Dislocation was the most common reason for revision (MOP: 23.5%; COP: 24.8%). Overall adjusted revision risks were not different between MOP and COP up to 10 years of follow-up (P ≥ .181). CONCLUSIONS: Concerns with corrosion for metal heads do not appear to result in significantly elevated revision risk for MOP at up to 10 years. Corrosion does not appear as a primary reason for revision compared to other mechanisms.

All-terrain vehicle use related fracture rates, patterns, and associations from 2002 to 2015 in the USA.

BACKGROUND: Since their introduction to USA markets in the late 20th century, all-terrain vehicles (ATVs) have been a significant source of trauma. Many paediatric studies have demonstrated the disproportionate rate in which minors are affected by ATV-related trauma, but no studies have been performed on a large sample size spanning all age and geographic ranges. This study is the first to analyze ATV-related fracture rates, patterns, and associated risks across all ages nationwide. METHODS & STATISTICAL ANALYSIS: The National Electronic Injury Surveillance System (NEISS) was queried for ATV-related trauma for the years 2002-2015. The data were analyzed by age, sex, race, alcohol usage, helmet usage, type of injury, fracture location, and disposition from the emergency department (ED). Continuous data were analyzed using the t-test (2 groups) or ANOVA (≥3 groups). Discrete data were analyzed using χ2 tests. SUDAAN 10™ software was used to account for the stratified and weighted nature of the data. Significance was set at p < 0.05. RESULTS: There were an estimated 1,862,342 ED visits for ATV-related injuries from 2002 to 2015; 482,501 (25.9%) sustained fractures with a mean age of 27.5 years. Among those with fractures, 75.7% were male, 28.5% resulted in hospital admission, 43.9% occurred at home, and 57.5% were unhelmeted. Anatomically, 51.8% involved the upper extremity, 23.6% involved the lower extremity, 6.4% involved the spine, 8.5% involved the skull/face, and 9.7% involved the ribs/sternum. Alcohol use was most frequently associated with skull (13.2%) and cervical spine (13.0%) fractures. Patients with skull or facial fractures were unhelmeted 88% of the time, and 87% of skull fractures were associated with brain injury. ATV-related fractures peaked in 2007 at 44,283 and trended downward through 2014. CONCLUSION: This study is the first of its kind to analyze ATV-related trauma over all age groups throughout the entire USA. It can serve as a reference for clinical decision-making and future studies. It also reinforces the need for ATV regulation advocacy, specifically helmet use.