Comparing Sex-Specific Outcomes After Medial Patellofemoral Ligament Reconstruction for Patellar Instability: A Systematic Review.

BACKGROUND: The impact of patient sex on outcomes after medial patellofemoral ligament ligament reconstruction (MPFLR) has not been well studied. PURPOSE: To conduct a systematic review to determine sex-based differences in outcomes after MPFLR for patellar instability and the proportion of studies examining this as a primary or secondary purpose. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed using the PubMed, Cochrane Library, PubMed Central, Ovid, and Embase databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were written in English, were performed on humans, consisted of patients who underwent MPFLR with allograft or autograft, evaluated at least 1 of the selected outcomes comparing male and female patients, and had statistical analysis available for relevant findings. Excluded were case reports, review studies or systematic reviews, studies that did not evaluate at least 1 sex-specific outcome, studies that included other injuries associated with patellofemoral instability injury, cadaveric studies, and those in which patients underwent concomitant procedures. RESULTS: The initial search yielded 3470 studies; 2647 studies remained after removing duplicates. Of the 401 studies that underwent full-text review, 10 met all inclusion criteria and were included for quantitative analysis. A meta-analysis could not be performed given the heterogeneity within the data set. Of the 2647 studies evaluated in this study, only 2 (0.08%) studies examined the impact of patient sex on MPFLR outcomes as a primary purpose and only 8 (0.30%) studies explored it as a secondary purpose. CONCLUSION: Only 0.38% of the articles compared outcomes between male and female patients after MPFLR. The limited data available were too heterogenous to draw any concrete conclusions about the impact of patient sex on outcomes after MPFLR. Further research in this area is warranted, as findings may influence treatment plans and improve patient outcomes.

Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures.

AIMS: Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy. MATERIALS AND METHODS: 3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models. RESULTS: The PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm. CONCLUSION: This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.

Diagnosis and management of McFarland fractures.

BACKGROUND: McFarland fracture is the eponym for a rare Salter Harris III or IV fracture involving the medial distal tibia. These fractures can be difficult to diagnose without a high index suspicion and appropriate radiographic imaging. These fractures may result in significant growth disturbances to the pediatric patient. When diagnosed and treated acutely, these fractures can be managed with cast immobilization and close follow up. If diagnoses in a delayed fashion they can result in significant morbidity including prolonged casting and possible surgical treatment. CASE REPORT: In this case report we discuss a pediatric patient with a delayed presentation McFarland fracture which was initially diagnosed and treated as an ankle sprain. He required a prolonged course of treatment and we describe his clinical progression. We review the literature regarding this fracture pattern including history, acute management and outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: McFarland fractures are rare Salter Harris III fractures of the medial malleolus. These ankle fractures affect patients nearing skeletal maturity and may be difficult to diagnose without the appropriate orthogonal X-ray imaging. Also, a missed diagnosis can lead to unnecessary morbidity to the patient. If diagnosed acutely, these fractures can be easily treated with immobilization but if allowed to become chronic they require prolonged periods of casting and possibly even surgical intervention. A patient with a specific constellation of symptoms and history should raise suspicion for these injuries and prompt a thorough workup.

The effects of partial carpal fusions on wrist range of motion.

UNLABELLED: The objective of this investigation was to evaluate the effects of different partial wrist fusions on wrist motion. A total of 20 cadaveric wrists were tested in the intact state and after undergoing either a four-corner fusion or 2- and 3-bone fusion. The moment-rotation behaviour was measured in 24 directions of wrist motion about the forearm axis. The 2- and 3-bone fusion groups demonstrated increased radial deviation and pure flexion. Pure flexion was decreased in the four-corner fusion group. Radial extension and pure extension were decreased in all treatments compared with normal range of motion. Increasing the number of carpal bones within the fusion construct did not alter the functional axis of the wrist. Essentially equivalent motion is possible with 2-bone, 3-bone and four-corner fusions, with the exceptions of pure flexion and radial deviation. This data may influence surgeons when choosing between treatment methods. LEVEL OF EVIDENCE: N/A.