Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint Arthroplasty - Literature-Supported Guidelines.

Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.

Looking beyond leaves: variation in nutrient leaching potential of seasonal litterfall among different species within an urban forest.

Urban litterfall that is deposited on impervious surface leaches nutrients into stormwater, contributing to downstream eutrophication. Previous studies have focused on the leaching potential of deciduous leaf litter, while other smaller-volume litterfall types-such as blossoms and fruit-may leach significant amounts of nitrogen, phosphorus, and carbon. These additional litterfall types represent an unaccounted-for source of nutrients to urban stormwater. We explored variation in leaching potential of dissolved nutrients and organic carbon across litter types and species by collecting litterfall (blossoms, fruit, leaves) from ten common urban tree species. After 24 h of leaching, we measured total phosphorus (TP), total dissolved nitrogen (TDN), and dissolved organic carbon (DOC) contributions and compared differences across litter types and species. Litter basket estimates then allowed us to quantify annual litterfall inputs. We found that blossoms leached 3-20 times more TDN and 1.5-7 times more TP than leaves of the same species. Furthermore, considering litterfall mass, several species had greater springtime nutrient-leaching potential compared to fall due to high leaching potential in blossoms and lower potential in leaves. We found mixed effects of leaf crushing and leachate solution (stormwater, salinity) on leaching rates. This study highlights the need to consider all litterfall types as well as variation in urban forest communities and conditions when seeking to budget, control, and maintain for potential nutrient sources from the urban forest. Supplementary information: The online version contains supplementary material available at 10.1007/s11252-022-01217-8.

Heterotopic Ossification Following Direct Anterior Total Hip Arthroplasty With and Without Postoperative Analgesic Nonsteroidal Anti-inflammatories.

BACKGROUND: Heterotopic ossification (HO) can result in poorer clinical outcomes following total hip arthroplasty (THA). Multiple modes of intervention have been evaluated for HO prevention, including the use of nonsteroidal anti-inflammatories. Additionally, multimodal pain management strategies including celecoxib have become more prominent. Therefore, this study aims to evaluate the influence of celecoxib as part of postoperative analgesia on the risk of developing HO following the direct anterior approach (DA) for THA. METHODS: A retrospective query identified primary DA THAs performed by a single surgeon between 2013 and 2020. Patients were grouped according to those who received 3 weeks celecoxib upon discharge, and those who did not. Radiographs were used to categorize patients according to the Brooker classification system for HO. Preoperative and 2-week, 6-week, 3-month, and 1-year postoperative X-rays were evaluated. RESULTS: A total of 688 DA THAs were included, demonstrating a 9.6% (n = 66) incidence of HO with Brooker classification: 1: 5.7% (n = 39); 2: 2.6% (n = 18); 3: 1.2% (n = 8); and 4: 0.1% (n = 1). Patients who did not receive celecoxib had a 14.3% (52/364) rate of HO following THA (odds ratio 4.53, P < .001) vs only 4.3% (14/324) in the celecoxib group (odds ratio 0.22, P < .001). Overall, 9 patients (1.3%) went on to develop significant HO (Booker 3 or greater): 8 (2.2%) in the control group and 1 (0.3%) in the celecoxib group (P < .001). CONCLUSION: Our findings suggest a significant reduction in the formation of HO following DA THA when using postoperative analgesic celecoxib as part of a multimodal pain protocol. Future prospective randomized studies are needed to identify ideal dosage, duration, and formulation to reduce the risk of HO while optimizing multimodal pain management.

Differences in morphological and physiological plasticity in two species of first-year conifer seedlings exposed to drought result in distinct survivorship patterns.

First-year tree seedlings represent a critical demographic life stage, functioning as a bottleneck to forest regeneration. Knowledge of how mortality is related to whole-seedling carbon and water relations is deficient and is required to understand how forest compositions will be altered in future climatic conditions. We performed a greenhouse drought experiment using first-year seedlings of two common pine species found in the Intermountain West, USA. Gas exchange, biomass gain, allometry and xylem water potentials were compared between well-watered and droughted seedlings from emergence until drought-induced mortality. In both species, morphological adjustments to confer drought tolerance, such as increased leaf mass per unit area, were not observed in seedlings exposed to drought, and droughted seedlings maintained photosynthesis and whole-seedling carbon gain well into the experiment. Yet, there were important differences between species in terms of carbon budgets, physiological responses and mortality patterns. In Pinus ponderosa P. & C. Lawson, physiological acclimation to drought was much greater, evident through stronger stomatal regulation and increased water-use efficiency. Photosynthesis and carbon budgets in P. ponderosa were greater than in Pinus contorta Dougl. ex. Loud., and survival was 100% until critical hydraulic thresholds in leaf water content and seedling water potentials were crossed. In P. contorta, physiological adjustments to drought were less, and mortality occurred much sooner and well before injurious hydraulic thresholds were approached. First-year conifer seedlings appear canalized for a suite of functional traits that prioritize short-term carbon gain over long-term drought tolerance, suggesting that conifer seedling survival is linked with carbon limitations, even during drought, with survival in species having narrower carbon survival margins being more hampered by carbon limitations.

Large variation in branch and branch-tip hydraulic functional traits in Douglas-fir (Pseudotsuga menziesii) approaching lower treeline.

Few studies have quantified intraspecific variation of hydraulic functional traits in conifers across elevation gradients that include range boundaries. In the Intermountain West, USA, the lower elevational limit of forests (lower treeline) is generally assumed to be caused by water limitations to growth and water relations, yet few studies directly show this. To test this assumption, we measured changes in a suite of traits that characterize drought tolerance such as drought-induced hydraulic vulnerability, hydraulic transport capacity and morphological traits in branch tips and branches of Douglas-fir (Pseudotsuga menziesii var. glauca (Mirb.) Franco) along a 400-m elevation gradient in southeastern Idaho that included lower treeline. As elevation decreased, vulnerability to hydraulic dysfunction and maximum conductivity both decreased in branches; some hydraulic safety-efficiency trade-offs were evident. In branch tips, the water potential at the turgor loss point decreased, while maximum conductance increased with decreasing elevation, highlighting that branch-tip-level responses to less moisture availability accompanied by warmer temperatures might not be coordinated with branch responses. As the range boundary was approached, we did not observe non-linear changes in parameters among sites or increased variance within sites, which current ecological hypotheses on range limits suggest. Our results indicate that there is substantial plasticity in hydraulic functional traits in branch tips and branches of Douglas-fir, although the direction of the trends along the elevation gradient sometimes differed between organs. Such plasticity may mitigate the negative impacts of future drought on Douglas-fir productivity, slowing shifts in its range that are expected to occur with climate change.

Snowmelt Timing Regulates Community Composition, Phenology, and Physiological Performance of Alpine Plants.

The spatial patterning of alpine plant communities is strongly influenced by the variation in physical factors such as temperature and moisture, which are strongly affected by snow depth and snowmelt patterns. Earlier snowmelt timing and greater soil-moisture limitations may favor wide-ranging species adapted to a broader set of ecohydrological conditions than alpine-restricted species. We asked how plant community composition, phenology, plant water relations, and photosynthetic gas exchange of alpine-restricted and wide-ranging species differ in their responses to a ca. 40-day snowmelt gradient in the Colorado Rocky Mountains (Lewisia pygmaea, Sibbaldia procumbens, and Hymenoxys grandiflora were alpine-restricted and Artemisia scopulorum, Carex rupestris, and Geum rossii were wide-ranging species). As hypothesized, species richness and foliar cover increased with earlier snowmelt, due to a greater abundance of wide-ranging species present in earlier melting plots. Flowering initiation occurred earlier with earlier snowmelt for 12 out of 19 species analyzed, while flowering duration was shortened with later snowmelt for six species (all but one were wide-ranging species). We observed >50% declines in net photosynthesis from July to September as soil moisture and plant water potentials declined. Early-season stomatal conductance was higher in wide-ranging species, indicating a more competitive strategy for water acquisition when soil moisture is high. Even so, there were no associated differences in photosynthesis or transpiration, suggesting no strong differences between these groups in physiology. Our findings reveal that plant species with different ranges (alpine-restricted vs. wide-ranging) could have differential phenological and physiological responses to snowmelt timing and associated soil moisture dry-down, and that alpine-restricted species' performance is more sensitive to snowmelt. As a result, alpine-restricted species may serve as better indicator species than their wide-ranging heterospecifics. Overall, alpine community composition and peak % cover are strongly structured by spatio-temporal patterns in snowmelt timing. Thus, near-term, community-wide changes (or variation) in phenology and physiology in response to shifts in snowmelt timing or rates of soil dry down are likely to be contingent on the legacy of past climate on community structure.

Ecotoxicological assessments show sucralose and fluoxetine affect the aquatic plant, Lemna minor.

Pharmaceuticals and personal care products (PPCP) are prevalent in aquatic systems, yet the fate and impacts on aquatic plants needs quantification for many compounds. We measured and detected sucralose (an artificial sweetener), fluoxetine (an antidepressant), and other PPCP in the Portneuf River in Idaho, USA, where Lemna minor (an aquatic plant in the environment and used in ecotoxicology studies) naturally occurs. Sucralose was hypothesized to negatively affect photosynthesis and growth of L. minor because sucralose is a chlorinated molecule that may be toxic or unusable for plant metabolism. A priori hypotheses were not created for fluoxetine due to lack of previous studies examining its impacts on plants. We conducted laboratory ecotoxicological assessments for a large range of concentrations of sucralose and fluoxetine on L. minor physiology and photosynthetic function. Frond green leaf area, root length, growth rate, photosynthetic capacity, and plant carbon isotopic composition (discrimination relative to a standard; δ13C) were measured among treatments ranging from 0 to 15000nmol/L-sucralose and 0-323nmol/L-fluoxetine. Contrary to our predictions, sucralose significantly increased green leaf area, photosynthetic capacity, and δ 13C of L. minor at environmentally relevant concentrations. The increase of δ 13C from sucralose amendments and an isotope-mixing model indicated substantial sucralose uptake and assimilation within the plant. Unlike humans who cannot break down and utilize sucralose, we documented that L. minor-a mixotrophic plant-can use sucralose as a sugar substitute to increase its green leaf area and photosynthetic capacity. Fluoxetine significantly decreased L. minor root growth, daily growth rate, and asexual reproduction at 323nmol/L-fluoxetine; however, ambiguity remains regarding the mechanisms responsible and the applicability of these extreme concentrations unprecedented in the natural environment. To our knowledge, this was the first study to show aquatic plants can uptake and metabolize sucralose as a carbon source. This study further supports the common notion that L. minor can be useful in bioremediation of PPCP from wastewaters.

Response of aboveground carbon balance to long-term, experimental enhancements in precipitation seasonality is contingent on plant community type in cold-desert rangelands.

Semi-arid rangelands are important carbon (C) pools at global scales. However, the degree of net C storage or release in water-limited systems is a function of precipitation amount and timing, as well as plant community composition. In northern latitudes of western North America, C storage in cold-desert ecosystems could increase with boosts in wintertime precipitation, in which climate models predict, due to increases in wintertime soil water storage that enhance summertime productivity. However, there are few long-term, manipulative field-based studies investigating how rangelands will respond to altered precipitation amount or timing. We measured aboveground C pools and fluxes at leaf, soil, and ecosystem scales over a single growing season in plots that had 200 mm of supplemental precipitation added in either winter or summer for the past 21 years, in shrub- and exotic-bunchgrass-dominated garden plots. At our cold-desert site (298 mm precipitation during the study year), we hypothesized that increased winter precipitation would stimulate the aboveground C uptake and storage relative to ambient conditions, especially in plots containing shrubs. Our hypotheses were generally supported: ecosystem C uptake and long-term biomass accumulation were greater in winter- and summer-irrigated plots compared to control plots in both vegetation communities. However, substantial increases in the aboveground biomass occurred only in winter-irrigated plots that contained shrubs. Our findings suggest that increases in winter precipitation will enhance C storage of this widespread ecosystem, and moreso in shrub- compared to grass-dominated communities.

Erratum to: Clinical Results and Failure Mechanisms of a Nonmodular Constrained Knee Without Stem Extensions.

[This corrects the article DOI: 10.1007/s11420-012-9277-9.].

Vegetation-zonation patterns across a temperate mountain cloud forest ecotone are not explained by variation in hydraulic functioning or water relations.

Many studies have demonstrated linkages between the occurrence of fog and ecophysiological functioning in cloud forests, but few have investigated hydraulic functioning as a determining factor that explains sharp changes in vegetation. The objective of this study was to compare the plant water status during cloud-immersed and non-immersed conditions and hydraulic vulnerability in branches and roots of species across a temperate, mountain fog ecotone. Because cloud forests are often dark, cool and very moist, we expected cloud forest species to have less drought-tolerant characteristics (i.e., lower Pe and P50-the pressures required to induce a 12 and 50% loss in hydraulic conductivity, respectively) relative to non-cloud forest species in adjacent (lower elevation) forests. Additionally, due to the ability of cloud forest species to absorb cloud-fog water, we predicted greater improvements in hydraulic functioning during fog in cloud forest species relative to non-cloud forest species. Across the cloud forest ecotone, most species measured were very resistant to losses in conductivity with branch P50 values from -4.5 to -6.0 MPa, hydraulic safety margins (Ψmin - P50) >1.5 MPa and low calculated hydraulic conductivity losses. Roots had greater vulnerabilities, with P50 values ranging from -1.4 to -2.5 MPa, leading to greater predicted losses in conductivity (∼20%). Calculated values suggested strong losses of midday leaf hydraulic conductance in three of the four species, supporting the hydraulic segmentation hypothesis. In both cloud forest and hardwood species, Ψs were greater on foggy days than sunny days, demonstrating the importance of fog periods to plant water balance across fog regimes. Thus, frequent fog did not result in systemic changes in hydraulic functioning or vulnerability to embolism across our temperate cloud forest ecotone. Finally, roots functioned with lower hydraulic conductivity than branches, suggesting that they may serve as more sensitive indicators of hydraulic functioning in these mesic, foggy ecosystems.

Linking carbon and water relations to drought-induced mortality in Pinus flexilis seedlings.

Survival of tree seedlings at high elevations has been shown to be limited by thermal constraints on carbon balance, but it is unknown if carbon relations also limit seedling survival at lower elevations, where water relations may be more important. We measured and modeled carbon fluxes and water relations in first-year Pinus flexilis seedlings in garden plots just beyond the warm edge of their natural range, and compared these with dry-mass gain and survival across two summers. We hypothesized that mortality in these seedlings would be associated with declines in water relations, more so than with carbon-balance limitations. Rather than gradual declines in survivorship across growing seasons, we observed sharp, large-scale mortality episodes that occurred once volumetric soil-moisture content dropped below 10%. By this point, seedling water potentials had decreased below -5 MPa, seedling hydraulic conductivity had decreased by 90% and seedling hydraulic resistance had increased by >900%. Additionally, non-structural carbohydrates accumulated in aboveground tissues at the end of both summers, suggesting impairments in phloem-transport from needles to roots. This resulted in low carbohydrate concentrations in roots, which likely impaired root growth and water uptake at the time of critically low soil moisture. While photosynthesis and respiration on a leaf area basis remained high until critical hydraulic thresholds were exceeded, modeled seedling gross primary productivity declined steadily throughout the summers. At the time of mortality, modeled productivity was insufficient to support seedling biomass-gain rates, metabolism and secondary costs. Thus the large-scale mortality events that we observed near the end of each summer were most directly linked with acute, episodic declines in plant hydraulic function that were linked with important changes in whole-seedling carbon relations.

Lower limb alignment control: is it more challenging in lateral compared to medial unicondylar knee arthroplasty?

INTRODUCTION: Limb alignment after unicondylar knee arthroplasty (UKA) has a significant impact on outcomes. The literature lacks lateral UKA alignment studies, making our understanding of this issue based on medial UKA. METHODS: We evaluated limb alignment in 241 patients who underwent medial (229 knees) or lateral (37 knees) UKA. Alignment was measured pre and postoperatively in radiographs and intra-operatively using a navigation system. We compared the percentage of over-correction and the difference between post-operative alignment and navigation measurement. RESULTS: Percentage of overcorrection was significantly higher in the lateral UKAs (11%) compared to the medial UKAs (4%). In medial UKAs, the mean difference between the intraoperative alignment and the post-operative was 1.33°. This was significantly lower than the mean 1.86° difference in the lateral UKAs. CONCLUSIONS: Our data demonstrated an increased risk of "overcorrection," and greater difficulty in predicting postoperative alignment using computer navigation, when performing lateral UKAs compared to medial UKAs.

Cruciate-retaining TKA is an option in patients with prior patellectomy.

BACKGROUND: The recommendation for using posterior-stabilized (PS) implants in patellectomy patients undergoing total knee arthroplasty (TKA) is based on older case series with heterogeneous patient populations. The use of cruciate-retaining implants in these patients has not been evaluated with more contemporary implant designs. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the survivorship and functional outcomes (Knee Society score, presence of an extensor lag, and range of motion) of cruciate-retaining (CR) TKA in patients with prior patellectomy. METHODS: Between 1986 and 2012, we performed 27 CR TKAs in 25 patients after patellectomy. Of those, 23 CR TKAs in 21 patients were available for followup at a minimum of 2 years (mean, 11.2 years; range, 2.3-25.1 years). In this retrospective study, we queried a prospectively maintained database to assess functional outcomes and survivorship. RESULTS: Aseptic loosening-free survival was 100% at 5 and 10 years, and survival with revision for any reason as the outcome was 96% at 5 years (95% confidence interval [CI], 87.7%-100%) and 84% at 10 years (95% CI, 69.5%-100%). One patient was revised for aseptic loosening at 10.2 years postoperatively. Mean Knee Society scores improved from 36±13 preoperatively to 92±9.6 at followup. Extensor lag was present in seven patients preoperatively and only three at followup. Average knee flexion at followup was 112°±12.5°. CONCLUSIONS: In this study we found good long-term survivorship and functional outcomes with a CR implant design in patients following patellectomy. Earlier studies have favored PS over CR implants for patients with patellectomies. We believe this series suggests that CR TKA is indeed an option in patients with patellectomy. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection.

Complications involving the knee extensor mechanism and patellofemoral joint occur in 1% to 12% of patients following total knee arthroplasty and have major negative effects on patient outcomes and satisfaction. The surgeon must be aware of intraoperative, postoperative, and patient-related factors that can increase the rate of these problems. This review focuses on six of the most commonly encountered problems: patellar tendon disruption, quadriceps tendon rupture, patellar crepitus and soft-tissue impingement, periprosthetic patellar fracture, patellofemoral instability, and osteonecrosis of the patella. The goals of this report are to (1) review the relevant anatomy of the knee extensor mechanism, (2) present risk factors that may lead to extensor mechanism complications, (3) provide a diagnostic and treatment algorithm for each of the aforementioned problems, and (4) review the specific surgical techniques of Achilles tendon allograft reconstruction and synthetic mesh augmentation. Extensor mechanism disorders following total knee arthroplasty remain difficult to manage effectively. Although various surgical techniques have been used, the results in patients with a prior total knee arthroplasty are inferior to the results in the young adult without such a prior procedure. Surgical attempts at restoration of the knee extensor mechanism are usually warranted; however, the outcomes of treatment of these complications are often poor, and management of patient expectations is important.

Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial.

BACKGROUND: Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic. QUESTIONS/PURPOSES: We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. METHODS: Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. RESULTS: The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups. CONCLUSIONS: A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Accelerometer-based, portable navigation vs imageless, large-console computer-assisted navigation in total knee arthroplasty: a comparison of radiographic results.

Computer-assisted surgery (CAS) systems improve alignment accuracy in total knee arthroplasty (TKA) but have not been widely implemented. Eighty knees underwent TKA using an accelerometer-based, portable navigation device (KneeAlign 2; OrthAlign Inc, Aliso Viejo, California), and the radiographic results were compared with 80 knees performed using a large-console, imageless CAS system (AchieveCAS; Smith and Nephew, Memphis, Tennessee). In the KneeAlign 2 cohort, 92.5% of patients had an alignment within 3° of a neutral mechanical axis (vs 86.3% with AchieveCAS, P < .01), 96.2% had a tibial component alignment within 2° of perpendicular to tibial mechanical axis (vs 97.5% with AchieveCAS, P = .8), and 94.9% had a femoral component alignment within 2° of perpendicular to the femoral mechanical axis (vs 92.5% with AchieveCAS, P < .01). The mean tourniquet time in the KneeAlign 2 cohort was 48.1 ± 10.2 minutes vs 54.1 ± 10.5 minutes in the AchieveCAS cohort (P < .01). Accelerometer-based, portable navigation is as accurate as large-console, imageless CAS systems in TKA.

Plasma 25-hydroxyvitamin d levels in operative patella fractures.

BACKGROUND: Patella fractures have not traditionally been considered "fragility" fractures. QUESTIONS/PURPOSE: The purpose of this study was to examine the demographic patterns (age and gender distribution) and plasma 25-hydroxyvitamin D levels of a cohort of patients with operative patella fractures. PATIENTS AND METHODS: Medical records were reviewed on all consecutive patients presenting to our institution with operative patella fractures from 2003 to 2009. Seventy-eight operative patella fractures (25 male, 53 female) were identified with a mean age of 58 years (range, 22-89 years). RESULTS: The majority of patients with patella fractures in this series were females over the age of 50 years who sustained low-energy falls from a standing height or less. Twenty-four patients (80%) had vitamin D insufficiency or deficiency at the time of injury. For 68 patients (87%), the patella fracture represented their first fracture. Patients with known osteoporosis risk factors did not have higher rates of vitamin D insufficiency/deficiency. CONCLUSIONS: The age and gender distribution, as well as the prevalence of vitamin D insufficiency/deficiency, of operative patella fractures, suggest that these patients likely have abnormal vitamin D levels and should undergo a metabolic bone work-up.

Treatment of Lisfranc fracture-dislocations with primary partial arthrodesis.

BACKGROUND: The optimal method of treatment for Lisfranc fracture-dislocations remains controversial, and the role of primary partial arthrodesis for combined osseous-ligamentous Lisfranc injuries is unclear. This study reviewed the outcomes of Lisfranc injuries treated by primary partial arthrodesis. METHODS: Patients who underwent primary partial arthrodesis for a primarily ligamentous or combined osseous and ligamentous Lisfranc fracture-dislocation were reviewed retrospectively and assessed at followup according to radiographic, clinical and standardized patient-based outcomes. Twenty-five patients (12 ligamentous, 13 combined), median age of 46 (range, 20 to 73) years, were followed for an average of 42 (range, 24 to 96) months. RESULTS: The average American Orthopedic Foot and Ankle Society (AOFAS) score was 81 points (scale 0 to 100), with patients in general losing points for mild pain, limitations of recreational activities, and fashionable footwear requirements. There was no statistical difference between ligamentous and combined injuries with regard to the physical or mental component scores on the SF-36. At latest followup, patients reported an average return to 85% of their preinjury activity level (range, 50% to 100%). Twenty-one patients (84%) expressed satisfaction with their outcome and at latest followup, the mean visual analog pain scale (VAS) score was 1.8 out of 10 (range, 0 to 8). Three patients showed radiographic signs of post-traumatic arthritis of adjacent joints. CONCLUSION: Treatment of both primarily ligamentous and combined osseous and ligamentous lisfranc injuries with primary partial arthrodesis produced good clinical and patient-based outcomes.

Surgical decision making for arthroscopic partial meniscectomy in patients aged over 40 years.

PURPOSE: To identify clinical variables that affect a surgeon's decision to recommend arthroscopic partial meniscectomy (APM). METHODS: Members of 2 orthopaedic specialty societies were invited to participate in an online survey by e-mail. The survey consisted of surgeon demographics and case scenarios to evaluate clinical decision making for APM. Posterior probabilities were calculated to determine the effect of clinical factors on the likelihood of recommending APM. RESULTS: Of the respondents with valid e-mail addresses, 733 (19.3%) returned a completed survey, but only 533 (14.1%) met the eligibility criteria (treated or referred an APM candidate within the past year). Respondents were aged 46.7 ± 9.4 and had performed a mean of 115 APMs in the previous year. Posterior probabilities for a combination of 6 clinical indicators identified 3 factors that most influenced a surgeon's decision to recommend APM: radiographic findings, McMurray test, and failure of nonoperative management. CONCLUSIONS: Significant variation exists among practicing orthopaedic surgeons with regard to decision making for APM. The 3 clinical factors that most influenced a surgeon's decision to recommend APM were normal radiographic findings, failed nonoperative treatment, and the presence of positive physical examination findings (i.e., positive McMurray test, joint line tenderness, and effusion). LEVEL OF EVIDENCE: Level III, decision analysis.

Popliteal venotomy during posterior cruciate ligament reconstruction in the setting of a popliteal artery bypass graft.

Injury to the vascular structures in the popliteal fossa during arthroscopic cruciate ligament reconstruction can be limb threatening or even life threatening. We present the first report, to our knowledge, of an isolated injury to a popliteal vein during arthroscopic posterior cruciate ligament reconstruction. Unfortunately, the venotomy led to cardiopulmonary arrest and flash pulmonary edema in this patient. Preoperative planning is paramount to assess risk of injury to vascular structures, which may be increased in patients who have had prior procedures on the affected knee. Furthermore, vascular surgery consultation preoperatively after a magnetic resonance angiogram or venogram and avoiding the use of epinephrine in the arthroscopy fluid should be considered when performing these higher-risk procedures.