Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting. PURPOSE: To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool. STUDY DESIGN: Cohort study (economic and decision analysis); Level of evidence, 3. METHODS: All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs. RESULTS: There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction (P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs (P < .001). CONCLUSION: This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

Is the Lesser Trochanter Profile a Reliable Means of Restoring Anatomic Rotation After Femur Fracture Fixation?

BACKGROUND: Restoring normal femoral rotation is an important consideration when managing femur fractures. Femoral malrotation after fixation is common and several preventive techniques have been described. Use of the lesser trochanter profile is a simple method to prevent malrotation, because the profile changes with femoral rotation, but the accuracy of this method is unclear. QUESTIONS/PURPOSES: The purposes of this study were (1) to report the rotational profiles of uninjured femora in an adult population; and (2) to determine if the lesser trochanter profile was associated with variability in femoral rotation. METHODS: One hundred fifty-five consecutive patients (72% female and 28% male) with a mean age of 32 years (range, 12-56 years) with a CT scanogram were retrospectively evaluated. Patients were included if CT scanograms had adequate cuts of the proximal and distal femur. Patients were excluded if they had prior hip/femur surgery or anatomic abnormalities of the proximal femur. CT scanogram measurements of femoral rotation were compared with the lesser trochanter profile (distance from the tip of the lesser trochanter to the medial cortex of the femur) measured on weightbearing AP radiographs. These measurements were made by a single fellowship-trained orthopaedic surgeon and repeated for intraobserver reliability testing. Presence of rotational differences based on sex and laterality was assessed and correlation of the difference in lesser trochanter profile to the difference in femoral rotation was determined using a coefficient of determination (r). RESULTS: The mean femoral rotation was 10.9° (SD ± 8.8°) of anteversion. Mean right femoral rotation was 11.0° (SD ± 8.9°) and mean left femoral rotation was 10.7° (SD ± 8.7°) with a mean difference of 0.3° (95% confidence interval [CI], -1.7° to 2.3°; p = 0.76). Males had a mean rotation of 9.4°(SD ± 7.7°) and females had a mean rotation of 11.5° (SD ± 9.1°) with a mean difference of 2.1° (95% CI, -0.1° to 4.3°; p = 0.06). Mean lesser trochanter profile was 6.6 mm (SD ± 4.0 mm). Mean right lesser trochanter profile was 6.6 mm (SD ± 3.9 mm) and mean left lesser trochanter profile was 6.5 mm (SD ± 4.0 mm) with a mean difference of 0.1 mm (-0.8 mm to 1.0 mm, p = 0.86). The lesser trochanter profile varied between the sexes; males had a mean of 8.3 mm (SD ± 3.4), and females had a mean of 5.9 mm (SD ± 4.0). The mean difference between sexes was 2.5 mm (1.5-3.4 mm; p < 0.001). The magnitude of the lesser trochanter profile measurement and degree of femoral rotation were positively correlated such that increasing measures of the lesser trochanter profile were associated with increasing amounts of femoral anteversion. The lesser trochanter profile was associated with femoral version in a linear regression model (r = 0.64; p < 0.001). Thus, 64% of the difference in femoral rotation can be explained by the difference in the lesser trochanter profile. Intraobserver reliability for both the femoral version and lesser trochanter profile was noted to be excellent with intraclass correlation coefficients of 0.94 and 0.95, respectively. CONCLUSIONS: This study helps define the normal femoral rotation profile among adults without femoral injury or bone deformity and demonstrated no rotational differences between sexes. The lesser trochanter profile was found to be positively associated with femoral rotation. Increasing and decreasing lesser trochanter profile measurements are associated with increasing and decreasing amounts of femoral rotation, respectively. CLINICAL RELEVANCE: The lesser trochanter profile can determine the position of the femur in both anteversion and retroversion, supporting its use as a method to restore preinjury femoral rotation after fracture fixation. Although some variability in the rotation between sides may exist, matching the lesser trochanter profile between injured and uninjured femora can help reestablish native rotation.

The critical acromial point: the anatomic location of the lateral acromion in the critical shoulder angle.

BACKGROUND: Acromioplasty has been proposed as a means of altering elevated critical shoulder angles (CSAs). We aimed to localize the critical acromion point (CAP) responsible for the acromial contribution of the CSA and determine whether resection of the CAP can alter the CSA to a normal range. METHODS: The CAP and 3-dimensional (3D) CSAs were determined on 3D computed tomography reconstructions of 88 cadaveric shoulders and compared with corresponding CSAs on digitally reconstructed radiographs. The position of the CAP was fluoroscopically isolated in 20 of these specimens and the resulting fluoroscopic CSA compared with the corresponding 3D CAP and 3D CSA. We investigated the CSA before and after a virtual acromioplasty of 2.5 and 5 mm at the CAP in specimens with a CSA greater than 35°. RESULTS: The mean CAP was 21% ± 10% of the acromial anterior-posterior length from the anterolateral corner. There was no difference between the mean 3D CSA and the CSA on digitally reconstructed radiographs (32° vs 32°, P = .096). No difference between the mean fluoroscopic CSA and 3D CSA was found (31° vs 31°, P = .296). A 2.5-mm acromial resection failed to reduce the CSA to 35° or less in 7 of 13 shoulders, whereas a 5-mm resection reduced the CSA to 35° or less in 12 of 13. CONCLUSION: The CAP was localized to the anterolateral acromial edge and was easily identified fluoroscopically. A 5-mm acromial resection was effective in reducing the CSA to 35° or less. These data can guide surgeons in where and how to alter the CSA if future studies demonstrate a clinical benefit to surgically modifying this radiographic parameter.

Hip Arthroscopy Capsular Closure: The Figure of Eight Technique.

Hip arthroscopy techniques have continued to evolve for femoroacetabular impingement and other intra-articular pathologies. However, there is still debate about the importance and technique of routine capsular closure. We present an efficient and reliable technique for creating a watertight capsular closure to prevent iatrogenic macro and microinstability. This Technical Note details our stepwise technique using figure of eight sutures to obtain a complete and secure capsular closure.

Height, weight, and age predict quadriceps tendon length and thickness in skeletally immature patients.

BACKGROUND: Quadriceps tendon autografts have been used with success in adults and are becoming a popular graft option in pediatric patients because of size, decreased donor site morbidity, ease of harvest, and favorable biomechanical characteristics. However, little is known about the length and thickness of the quadriceps tendon in pediatric patients. PURPOSE: This study aimed to determine whether quadriceps tendon length and thickness follow a predictable pattern of development based on height, weight, age, and body mass index in skeletally immature patients. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The height, weight, age, and sex of 151 children between 4 and 16 years old were recorded. Ultrasound measurements of the length and thickness of bilateral quadriceps tendons were performed by a single technician and recorded for statistical analysis. RESULTS: The average quadriceps tendon length and thickness were 6.87 ± 1.49 cm and 0.37 ± 0.12 cm, respectively. Tendon length averaged 3.89 cm at age 4 years and 7.98 cm at 16 years, whereas thickness averaged 0.24 cm at 4 years and 0.40 cm at 16 years of age. There was no significant difference in tendon length or thickness between males and females (P = .97). Tendon length and thickness increased significantly with age, weight, and height (P < .01 for all). CONCLUSION: The quadriceps tendon is of sufficient length and thickness to be used as an autograft for pediatric patients. The size of the graft is predictable using the age, height, and weight of the patient. Graft length and thickness can be easily confirmed using ultrasound.

Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction.

INTRODUCTION: Our technique for physeal-sparing, anatomic anterior cruciate ligament (ACL) reconstruction reliably produces femoral tunnels that are of adequate length and that safely avoid the femoral physis without the addition of time-consuming surgical methods or substantial utilization of fluoroscopy. STEP 1 PREOPERATIVE PLANNING: Obtain radiographs and MRI of the knee as well as an anteroposterior radiograph of the hand (to obtain a bone age). STEP 2 PATIENT SETUP PORTAL PLACEMENT AND GRAFT HARVEST: The affected knee must be able to flex at least 90° with the end of the operative table lowered, in order to properly visualize the anatomy of the ACL femoral footprint. STEP 3 PREPARE ACL FOOTPRINT AND ESTABLISH FAR ANTEROMEDIAL PORTAL: Maintain soft-tissue remnants at both the femoral and the tibial footprint in order to individualize the anatomy. STEP 4 IDENTIFY EXTRA-ARTICULAR LANDMARKS AND PREPARE FEMORAL TUNNEL: Visualize and palpate your previously marked popliteal sulcus and lateral epicondyle; these landmarks are the crucial extra-articular points for establishing a safe femoral tunnel. STEP 5 PREPARE TIBIAL TUNNEL: The tibial tunnel can be safely drilled in a transphyseal manner in skeletally immature patients. STEP 6 FIX GRAFT: Use the Arthrex ACL TightRope RT for femoral fixation. STEP 7 POSTOPERATIVE CARE: As a skeletally immature athlete differs from a more mature athlete in several important ways, alter the postoperative protocol accordingly. RESULTS: Our clinical experience has corresponded to our MRI-based findings from our original study14, and we have not observed any physeal or chondral injuries leading to growth disturbances from our femoral tunnels. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Anatomic landmarks utilized for physeal-sparing, anatomic anterior cruciate ligament reconstruction: an MRI-based study.

BACKGROUND: Anterior cruciate ligament (ACL) injury and reconstruction in the skeletally immature patient are becoming more common. The purpose of this study was to develop a reproducible anatomic ACL reconstruction technique, based on intra-articular and extra-articular landmarks, that reliably produces a femoral tunnel of adequate length and diameter while avoiding the distal femoral physis. METHODS: Magnetic resonance images (MRIs) of one hundred and eighty-eight children (age range, six to seventeen years) were evaluated. Two extra-articular landmarks, the femoral insertion of the popliteus tendon and the lateral femoral epicondyle, and one intra-articular landmark, the central portion of the femoral footprint of the ACL, were identified. Computer software was used to plot these landmarks in all three planes and to draw lines representing two potential femoral tunnels. The first line connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, and the second connected the center of the ACL femoral footprint with the lateral femoral epicondyle. The length of each tunnel, the shortest distance from the center of each tunnel to the distal femoral physis, and the height of the lateral femoral condyle from the physis to the chondral surface and to the base of the cartilage cap were calculated. A three-dimensional MRI reconstruction was used to confirm that placement of a femoral tunnel with use of the chosen landmarks would avoid the distal femoral physis. RESULTS: The mean distance from the center of the preferred ACL tunnel, which connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, to the distal femoral physis was 12 mm, independent of sex (p = 0.94) or age, and the shortest distance was 8 mm. The length of this proposed tunnel averaged 30.1 mm in the boys and 27.4 mm in the girls (p < 0.001), and it averaged 25.4 mm at an age of six years and 29.7 mm at an age of seventeen years. The mean distance from the center of the alternative tunnel, which connected the center of the ACL femoral footprint with the lateral epicondyle, to the distal femoral physis was 8.8 mm in the boys and 8.9 mm in the girls (p = 0.55). The mean length of this alternative tunnel was 34.3 mm in the boys and 31.6 mm in the girls (p < 0.001). CONCLUSIONS: Drilling from the center of the ACL femoral footprint to the insertion of the popliteus tendon would have resulted in a mean tunnel length of 27 to 30 mm, and it would have allowed the safe placement of a femoral tunnel at least 7 mm in diameter in a patient six to seventeen years old. The center of the ACL femoral footprint and the popliteus insertion are easily identifiable landmarks and will allow safe, reproducible, anatomic ACL reconstruction in the skeletally immature patient.