Comparable Torque to Failure Using the Simple Stich Versus the Figure-of-Eight Configuration for Hip Capsular Closure Following an Interportal Capsulotomy: A Cadaveric Study.

PURPOSE: To measure and compare the torque to failure and stiffness of the capsular repair construct consisting of four-suture simple stitches to a two-figure of eight stitches repair construct in external rotation following an interportal capsulotomy. METHODS: Six pairs of fresh-frozen cadaveric hemipelves were divided into two capsular repair groups. All hips underwent a 40-mm interportal capsulotomy from the 12 o'clock position to the 3 o'clock position. Capsular closure was performed using either the two stitches in a figure of eight or with four simple stitches. Afterward, each hemipelvis was securely fixed to the frame of a mechanical testing system with the hip in 10° of extension and externally rotated to failure. Significance was set at P < .05. RESULTS: The average failure torque was 86.2 ± 18.9 N·m and 81.5 ± 8.9 N·m (P = .57) for the two stitches in a figure of eight and the four simple stitches, respectively. Failure stiffness was also not statistically different between groups and both capsular closure techniques failed at similar degrees of rotation (P = .65). CONCLUSION: Hip capsular repair using either the four simple stitch or two-figure of eight configurations following interportal capsulotomy demonstrated comparable failure torques and similar stiffness in a cadaveric model. CLINICAL RELEVANCE: Adequate and comprehensive capsular management in hip arthroscopy is critical. Capsular repair following capsulotomy in femoroacetabular impingement surgery has been associated with higher patient-reported outcomes when compared to capsulotomy without repair. Therefore, determining which capsular closure construct provides the higher failure torque is important.

An Increased Allograft Width for Circumferential Labral Reconstruction Better Restores Distractive Stability of the Hip: A Cadaveric Biomechanical Analysis.

BACKGROUND: Questions remain about whether circumferential labral reconstruction (CLR) using an iliotibial band (ITB) allograft can effectively restore the labral suction seal of the hip. HYPOTHESES: (1) CLR with an ITB allograft >6.5 mm would restore distractive stability force to that of the intact labrum. (2) CLR with an ITB allograft >6.5 mm would achieve significantly superior distractive stability force compared with CLR with an ITB allograft <6.5 mm. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 6 fresh-frozen pelves with attached femurs (n = 12 matched hemipelves) from male donors were procured and dissected free of all soft tissue, including the hip capsule but preserving the native labrum, transverse acetabular ligament, and ligamentum teres. Potted hemipelves were placed in a saline bath and securely fixed to the frame of a hydraulic testing system. A 500-N compressive load was applied, followed by femoral distraction at a rate of 5.0 mm/s until the suction seal ruptured. Force and femoral displacement were continually recorded. Force versus displacement curves were plotted, the maximum force was recorded, and the amount of femoral distraction to rupture the suction seal was determined. After intact testing, the labrum was excised, and specimens were retested using the same protocol. CLR was subsequently performed twice in a randomized fashion using (1) an ITB allograft with a width >6.5 mm (7.5-9.0 mm) and (2) an ITB allograft with a width <6.5 mm (4.5-6.0 mm). Specimens were retested after each CLR procedure. Force (in Newtons) and femoral distraction (in millimeters) required to rupture the suction seal were measured and compared between the 4 testing states (intact, deficient, CLR <6.5 mm, and CLR >6.5 mm) using repeated-measures analysis of variance. RESULTS: On average, intact specimens required 148.4 ± 33.1 N of force to rupture the hip suction seal, which significantly decreased to 44.3 N in the deficient state (P < .001). CLR with ITB allografts <6.5 mm did not improve the maximum force (63 ± 62 N) from the deficient state (P = .42) and remained significantly lower than the intact state (P < .01). CLR with ITB allografts >6.5 mm recorded significantly greater force to rupture the suction seal (135.8 ± 44.6 N) compared with both the deficient and CLR <6.5 mm states (P < .01), with a mean force comparable with the intact labrum (P = .59). The amount of femoral distraction to rupture the suction seal demonstrated similar findings. CONCLUSION: In a cadaveric model, CLR using ITB allografts >6.5 mm restored the distractive force and distance to the suction seal rupture to values comparable with hips with an intact labrum. CLR using ITB allografts >6.5 mm outperformed CLR with ITB allografts <6.5 mm, demonstrated by a significantly higher force to rupture the suction seal and increased distraction before the rupture. CLINICAL RELEVANCE: The results of this cadaveric investigation suggest that using wider labral allografts during CLR will provide the distractive force required to rupture the suction seal and immediate postoperative stability of the hip, although further studies are required to determine if these results translate to improved clinical outcomes.

Talar Osteolytic Lesion as the Initial Presentation of Terminal Primary Metastatic Adenocarcinoma: A Case Report.

The purpose of this case report is to present an osseous foot lesion as the initial presentation of advanced metastatic adenocarcinoma. A 65-year-old female presented with 5 months of atraumatic left ankle pain. Initial radiographs and computed tomography scan showed a lytic lesion in the talar dome and calcaneus. Further workup and evaluation revealed diffuse metastatic disease in the lung, abdomen, and brain. A biopsy of the talar lesion demonstrated metastatic adenocarcinoma, and the patient elected to transition to hospice care less than 2 months after initial diagnosis. Although exceedingly rare, metastatic disease should be included in the differential for any lesion in the distal extremities including the foot and ankle. Unfortunately, these patients may have widespread metastases and poor prognosis at the time of initial presentation. This case report describes an acrometastasis of a primary adenocarcinoma and highlights the importance of considering metastatic disease in the differential of foot and ankle lesions. Delay in recognition and diagnosis of metastatic disease may have devastating consequences, and physicians could benefit from a high index of suspicion when treating these patients.

Risk factors for venous thromboembolism in total shoulder arthroplasty.

BACKGROUND: Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning. METHODS: All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ2 and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE. RESULTS: The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development. CONCLUSION: Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.

Preoperative indications for total shoulder arthroplasty predict adverse postoperative complications.

BACKGROUND: Although studies have shown improved pain, function, and patient satisfaction after total shoulder arthroplasty (TSA), preoperative factors predicting poor outcomes are unexplored. Comparison of postoperative complications between osteoarthritis (OA), cuff arthropathy (CA), and fracture patients is important for identifying at-risk patients. METHODS: Primary TSAs from 2014 to 2016 with preoperative OA, CA, and proximal humerus fractures as indications were queried from the National Surgical Quality Improvement Program database. Short-interval postoperative complications were compared using multivariate binary logistic regression, and postoperative time to discharge between groups was analyzed using univariate analysis of variance with Tukey comparison. Statistical significance was defined as P < .05 using SPSS software version 23.0 (IBM Corp., Armonk, NY, USA). RESULTS: Of 9684 TSA cases, the primary indication was OA in 6571 patients, CA in 725 patients, and fractures in 646 patients. Compared with fractures, OA patients had statistically significant lower risk of dislocation, readmission, return to operating room, nonhome discharge, surgical site infection, perioperative bleeding requiring transfusion, and pulmonary embolism (all P < .05). Statistically significant lower risk of dislocation, nonhome discharge, and transfusion was also found between CA and fracture patients (all P < .03). However, in comparing CA vs. OA as preoperative indications, only postoperative venous thromboembolism (odds ratio, 4.5; P = .01) and surgical site infection (odds ratio, 3.7; P = .007) were significant. Mean differences in discharge time were significant between both OA and CA groups compared with fractures (P < .001), but there was no significance between OA and CA (P = .116). CONCLUSION: Proximal humerus fracture is a risk factor for increased postoperative complications compared with OA and CA. With new outcomes-based reimbursement models, nonroutine discharge and increased discharge time should be considered in arthroplasty planning.

An Arthroscopic Modification of Coracoclavicular Ligament Reconstruction and Distal Clavicle Fracture Fixation in the Lateral Position.

Distal clavicle fractures and acromioclavicular injuries are common shoulder injuries. Despite the frequency of these injuries, there is no gold standard for treatment. Recent suspensory fixation techniques have minimized the amount of hardware required for surgical treatment of both acromioclavicular separations and distal clavicle fractures. Advantages include reconstruction of ligamentous anatomy, minimal hardware irritation, earlier return to activity, and decreased need for hardware removal. These reconstructions are classically done in the beach chair position in an open fashion. Our preferred technique for treatment of unstable distal clavicle fractures and acromioclavicular injuries is arthroscopy-assisted coracoclavicular ligament reconstruction with or without distal clavicle fixation in the lateral decubitus position.

Early postoperative complications and discharge time in diabetic patients undergoing total shoulder arthroplasty.

PURPOSE: With the increasing elderly population and obesity epidemic, diabetes is an important factor in arthroplasty planning. Although research suggests diabetes is associated with increased postoperative morbidity after hip and knee replacement, the effect of diabetes and varying management with insulin versus non-insulin agents on total shoulder arthroplasty (TSA) is not established. METHODS: All TSAs from 2015 to 2016 were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Age, gender, BMI, steroid, ASA, operative time, and smoking status were compared between all diabetics, diabetics on insulin, diabetics on non-insulin agents, and non-diabetics to account for confounding variables. Thirty-day postoperative complications, readmission rate, surgical site infection (SSI), and non-routine discharge to rehabilitation were compared using bivariate and multivariate binary logistic regression. Postoperative time to discharge between diabetic groups was analyzed using univariate ANOVA with Tukey's test. RESULTS: The analysis included 7246 patients (insulin in 5% (n = 380), non-insulin in 13% (n = 922), and non-diabetics in 82% (n = 5944)). Diabetics were more likely to have an ASA ≥ 3 compared to non-diabetics (89.5% vs 50.1%; p < 0.001). Bivariate logistic regression showed statistical significance in readmission and non-routine discharge between all diabetics and non-diabetics (OR 1.7, 1.4; p = 0.001, 0.001), but there was no significance between SSI rate (0.3% vs 0.4%; p = 0.924). Multivariate logistic regression between groups showed significance in readmission between non-insulin diabetics vs non-diabetics (OR 1.5; p = 0.027), readmission and non-routine discharge in insulin vs non-diabetics (OR 2.1, 1.7; p = 0.003, < 0.001), and no significance between insulin and non-insulin diabetics. Postoperative days to discharge were 2.4, 2.0, and 1.8 days in insulin, non-insulin, and non-diabetics respectively. Mean differences were significant between all groups. CONCLUSIONS: Diabetic patients are at a higher risk for readmission and non-routine discharge compared to non-diabetics. Despite no increased risk in SSI, longer postoperative discharge time in diabetics should be considered in TSA planning. TRIAL REGISTRATION: Not applicable LEVEL OF EVIDENCE: Level III, case-control study.

A semi-quantitative technique to assess excursion of the flexor hallucis longus.

BACKGROUND: Recent research indicates that restriction in excursion of flexor hallucis longus (FHL) contributes to hallux rigidus development. As described in the literature, clinical evaluation of FHL excursion has poor interobserver reliability. A simple, inexpensive, easily used FHL relative excursion measurement device was developed and tested. METHODS: 64 subjects were enrolled with shoe size, height, weight, BMI, and age compared. Using a footplate and series of mechanical wedges, maximum ankle dorsiflexion was measured with the great toe in 15°, 30°, and 45° of dorsiflexion. RESULTS: Ankle dorsiflexion decrease with progressive hallux dorsiflexion increase was statistically significant with a linear correlation (r2=.814 p<.001) and was not statistically related to shoe size, height, weight, BMI, or age. CONCLUSIONS: This technique provides consistent assessment of the limitation to ankle dorsiflexion incurred by decreased FHL excursion, establishing groundwork for future studies to assess the relationship between diminished FHL excursion and FHL pathology.

Estradiol dose-dependent regulation of membrane estrogen receptor-α, metabotropic glutamate receptor-1a, and their complexes in the arcuate nucleus of the hypothalamus in female rats.

Sexual receptivity in the female rat is dependent on dose and duration of estradiol exposure. A 2 µg dose of estradiol benzoate (EB) primes reproductive behavior circuits without facilitating lordosis. However, 50 µg EB facilitates lordosis after 48 hours. Both EB doses activate membrane estrogen receptor-α (mERα) that complexes with and signals through metabotropic glutamate receptor-1a (mGluR1a). This mERα-mGluR1a signaling activates a multisynaptic lordosis-inhibiting circuit in the arcuate nucleus (ARH) that releases ß-endorphin in the medial preoptic nucleus (MPN), activating µ-opioid receptors (MOP). MPN MOP activation is maintained, inhibiting lordosis for 48 hours by 2 µg EB, whereas 50 µg EB at 48 hours deactivates MPN MOP, facilitating lordosis. We hypothesized that 50 µg EB down-regulates ERα and mERα-mGluR1a complexes in the ARH to remove mERα-mGluR1a signaling. In experiment I, 48 hours after 2 µg or 50 µg EB, the number of ARH ERα-immunopositive cells was reduced compared with controls. In experiment II, compared with oil controls, total ARH ERα protein was decreased 48 hours after 50 µg EB, but the 2 µg dose was not. These results indicate that both EB doses reduced the total number of cells expressing ERα, but 2 µg EB may have maintained or increased ERα expressed per cell, whereas 50 µg EB appeared to reduce total ERα per cell. In experiment III, coimmunoprecipitation and Western blot revealed that total mERα and coimmunoprecipitated mERα with mGluR1a were greater 48 hours after 2 µg EB treatment vs rats receiving 50 µg EB. These results indicate 2 µg EB maintains but 50 µg EB down-regulates mERα-mGluR1a to regulate the lordosis circuit activity.

Orphanin FQ in the mediobasal hypothalamus facilitates sexual receptivity through the deactivation of medial preoptic nucleus mu-opioid receptors.

Sexual receptivity, lordosis, can be induced by sequential estradiol and progesterone or extended exposure to high levels of estradiol in the female rat. In both cases estradiol initially inhibits lordosis through activation of ß-endorphin (ß-END) neurons of the arcuate nucleus of the hypothalamus (ARH) that activate µ-opioid receptors (MOP) in the medial preoptic nucleus (MPN). Subsequent progesterone or extended estradiol exposure deactivates MPN MOP to facilitate lordosis. Opioid receptor-like receptor-1 (ORL-1) is expressed in ARH and ventromedial hypothalamus (VMH). Infusions of its endogenous ligand, orphanin FQ (OFQ/N, aka nociceptin), into VMH-ARH region facilitate lordosis. Whether OFQ/N acts in ARH and/or VMH and whether OFQ/N is necessary for steroid facilitation of lordosis are unclear. In Exp I, OFQ/N infusions in VMH and ARH that facilitated lordosis also deactivated MPN MOP indicating that OFQ/N facilitation of lordosis requires deactivation of ascending ARH-MPN projections by directly inhibiting ARH ß-END neurons and/or through inhibition of excitatory VMH-ARH pathways to proopiomelanocortin neurons. It is unclear whether OFQ/N activates the VMH output motor pathways directly or via the deactivation of MPN MOP. In Exp II we tested whether ORL-1 activation is necessary for estradiol-only or estradiol+progesterone lordosis facilitation. Blocking ORL-1 with UFP-101 inhibited estradiol-only lordosis and MPN MOP deactivation but had no effect on estradiol+progesterone facilitation of lordosis and MOP deactivation. In conclusion, steroid facilitation of lordosis inhibits ARH ß-END neurons to deactivate MPN MOP, but estradiol-only and estradiol+progesterone treatments appear to use different neurotransmitter systems to inhibit ARH-MPN signaling.