Interdisciplinary Orthopedic Management of Pediatric Patella Dislocation and Instability: An Educational Case Series.

Pediatric patellar instability and/or dislocation is a challenging diagnosis category that requires an interdisciplinary team consisting of orthopedic surgeons and physical therapists for optimized patient outcomes. This educational case series outlines core concepts for three patients with unique patellar dislocation presentations. Case 1 is a 16-year-old male who presented with a history of five knee traumatic patellar dislocations with self-reduction and underwent knee arthroscopic surgery with debridement and microfracture of the patella chondral defect, arthroscopic lateral release to improve the patellar tilt, and medial patellofemoral ligament (MPFL) reconstruction. Case 2 is a 15-year-old female who presented with chronic knee pain and patella instability who underwent knee arthroscopic surgery with abrasion arthroplasty, microfracture of the patella, lateral release, tibial tubercle osteotomy medializing osteotomy, and MPFL reconstruction. Case 3 is a 14-year-old male who presented after a single episode of lateral patella dislocation and underwent open reduction and fixation of the lateral femoral condyle osteochondral fracture, a Grammont patellar medialization procedure, and MPFL reconstruction. All three patients received postoperative physical therapy (PT) to improve function and outcomes. These cases represent important concepts of patellar containment, risk factors for recurrent instability, associated pathology, and appropriate surgical care and postoperative rehabilitation. Furthermore, this case series highlights management decisions and pathways for three patients with different symptoms related to patellar instability, subsequent surgical correction, and postoperative physical therapy. Overall, interdisciplinary care of common pediatric orthopedic conditions can help improve patient outcomes and satisfaction. By understanding the biomechanics and decision-making surgical parameters regarding patellofemoral instability, clinicians can provide patients with better care.

Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study.

INTRODUCTION: Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction. METHODS: Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively. RESULTS: The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P < 0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P < 0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding. DISCUSSION: The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction. CLINICALTRIALGOV REGISTRATION NUMBER: NCT04246554.

Use of Anatomic Radiographic Horizons for the Lateral Center-Edge Angle in the Classification of Hip Dysplasia.

BACKGROUND: The lateral center-edge angle of Wiberg (LCEA) and Tönnis angle (TA) rely on a "horizon" that functions as a reference point for measurements of hip dysplasia on weightbearing anteroposterior pelvis radiographs. There are 3 different horizons that are currently utilized depending on surgeon preference: (1) a line parallel to the radiographic floor (F), (2) a line that connects the inferior portions of the acetabular teardrops (ATs), or (3) a line that connects the ischial tuberosities (ITs). It is imperative to accurately assess the degree of hip dysplasia on initial workup to select the appropriate surgical intervention. PURPOSE: To assess how the choice of a radiographic horizon affects the measurements of the LCEA and TA. The secondary purpose was to assess how the horizon affected the classification of hips as either normal, borderline dysplastic, or dysplastic. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The LCEA and TA were measured on all preoperative weightbearing anteroposterior pelvis radiographs for 186 consecutive patients who underwent hip preservation surgery between February 2016 and November 2020 (140 hip arthroscopic procedures, 46 combined hip arthroscopic procedures with periacetabular osteotomy), 3 times per hip, each time using an F, AT, and IT horizon. The Student t test was used to analyze the differences in the measurements of the LCEA and TA, and discordance rates in the dysplasia classification between horizons were quantified. RESULTS: For the entire study population, the mean LCEAF (23.4°± 7.4°) was significantly greater than the mean LCEAIT (23.1°± 7.2°) (95% CI, -0.634 to -0.003; P = .047) and mean LCEAAT (23.0°± 7.1°) (95% CI, -0.723 to -0.139; P = .004). There was no difference between the LCEAIT and LCEAAT (95% CI, -0.305 to 0.080; P = .251). When stratified by hip arthroscopic surgery, the mean LCEAF (26.3°± 5.6°) was significantly greater than the mean LCEAAT (25.8°± 5.3°) (95% CI, -0.845 to -0.162; P = .004). Overall, there was a 17.7% and 18.3% discordance rate in the dysplasia classification using the LCEAIT and LCEAAT compared with the LCEAF, respectively. There were no statistically significant differences between the mean TAIT, TAAT, and TAF for the entire study population, the arthroscopic surgery group, and the combined arthroscopic surgery and periacetabular osteotomy group. CONCLUSION: There was no statistical difference between the AT and IT horizons for LCEA measurements. The dysplasia classification was in better agreement between the 2 anatomic horizons compared with the F horizon. The TA was not affected by changes in the horizon.

Complete Isolated Ruptures of the Distal Biceps Brachii During Athletic Activity: A Systematic Review.

Complete, isolated ruptures of the distal biceps brachii sustained during athletic activities are uncommon. A systematic review of the literature was performed to identify complete distal biceps brachii tears experienced during athletic activities to determine injury prevalence, athletic activities/mechanisms responsible for injury and return to activity timing following operative management. A total of 10 studies, comprising 16 athletes undergoing surgery for 18 cases, were identified. Injuries were predominately associated with weightlifting. Injuries were treated utilizing a single incision in 56% of cases and primary repair performed in 89% of cases. Mean time to return to activity was 4.86 ± 1.14months. Athletes undergoing surgery ≤ 10 days following injury and those undergoing primary repair returned to activity significantly quicker. Isolated tears of the distal biceps remain uncommon during athletic activities, occurring primarily during weightlifting. Return to activity timing was not significantly delayed based on surgical approach, steroid use, or athlete age.

Surgical Technique of the "Up-The-Neck" View During Hip Arthroscopy for Femoroacetabular Impingement.

In the setting of femoroacetabular impingement, arthroscopy versus open surgery confers many advantages. However, inadequate bony resection remains a concern and is the leading cause of revision surgery. Several strategies have been described to ensure a more-complete resection during hip arthroscopy. In this current technique article, the authors describe a modified anterior portal site view called the "up-the-neck" view. This view allows for greater visualization of the femoral head-neck junction and alleviates challenges faced when assessing resection intraoperatively. The "up-the-neck" view is achieved by placing a 70° arthroscope in the anterior lateral portal and subsequently rotating the camera 90°. The head-neck junction will appear horizontally, rather than vertically, on this view, which allows for the easy identification of missed imperfections. This may reduce the need for revision surgery and future investigation is necessary to determine the reoperation rates following this technique.

Clinical Outcomes of the Traditional Latarjet Versus the Congruent Arc Modification for the Treatment of Recurrent Anterior Shoulder Instability: A Meta-analysis.

BACKGROUND: Few studies have compared clinical outcomes between the traditional Latarjet procedure for anterior shoulder instability and the congruent arc modification to the Latarjet procedure. PURPOSE: To systematically evaluate the literature for the incidence of recurrent instability, clinical outcomes, radiographic findings, and complications for the traditional Latarjet procedure and the congruent arc modification and to compare results of each search. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies published between January 1990 and October 2020 that described clinical outcomes of the traditional Latarjet and the congruent arc modification with a follow-up range of 2 to 10 years. The difference in surgical technique was analyzed using a chi-square test for categorical variables, while continuous variables were evaluated using a Student t test. RESULTS: In total, 26 studies met the inclusion criteria: 20 studies describing the traditional Latarjet procedure in 1412 shoulders, and 6 studies describing the congruent arc modification in 289 shoulders. No difference between procedures was found regarding patient age at surgery, follow-up time, Rowe or postoperative visual analog scores, early or late complications, return-to-sport timing, or incidence of improper graft placement or graft fracture. A significantly greater proportion of male patients underwent glenoid augmentation using the congruent arc modification versus traditional Latarjet (P < .001). When comparing outcomes, the traditional Latarjet procedure demonstrated a lower incidence of fibrous union or nonunion (P = .047) and broken, loose, or improperly placed screws (P < .001), and the congruent arc modification demonstrated improved outcomes with regard to overall return to sport (P < .001), return to sport at the same level (P < .001), incidence of subluxation (P = .003) or positive apprehension (P = .002), and revision surgery for recurrent instability (P = .027). CONCLUSION: Outcomes after the congruent arc modification proved at least equivalent to the traditional Latarjet procedure in terms of recurrent instability and return to sport, although early and late complications were equivalent. The congruent arc procedure may be an acceptable alternative to traditional Latarjet for the treatment of anterior shoulder instability with glenoid bone loss; however, long-term outcomes of this procedure are needed.

Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines.

BACKGROUND: Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. METHODS: In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents' prescribing practices, and methods of patient counseling regarding opioid use and disposal. RESULTS: A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient's symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. DISCUSSION: To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

Investigating the International Normalized Ratio Thresholds for Complication in Shoulder Arthroplasty.

BACKGROUND: In patients on warfarin anticoagulation therapy, elective shoulder arthroplasty surgeons must carefully balance bleeding and embolic risks. Currently, an international normalized ratio (INR) threshold of 1.5 is supported in the setting of elective surgery. However, no previous study has investigated the optimal preoperative INR target specifically in shoulder arthroplasty. The purpose of this study was to evaluate the association of preoperative INR with rates of transfusion, complication, and readmission/revision surgery in shoulder arthroplasty. METHODS: Patients who underwent elective shoulder arthroplasty were identified in a national database. The primary outcome of interest was the risk for all-cause complication at 30 days postoperatively. Major and minor complication, revision surgery, and readmission rates were also investigated. RESULTS: From 2006 to 2016, 1,014 procedures were identified who had undergone elective shoulder arthroplasty with a perioperative INR lab result within 24 hours of surgery. In our cohort, 550 patients (54.2%) were women, with an average age of 71.0 ± 9.8 years. After controlling for confounders, patients with a preoperative INR > 1.5 were 18.9 times as likely to have a major complication as those with a preoperative INR ≤ 1.0 (P = 0.003). Patients with an INR of 1.25 < INR ≤ 1.5 did not have a statistically significant risk of minor or major complication in comparison with those with an INR ≤ 1.0 (P = 0.23, P = 0.67). DISCUSSION: Although recent hip and knee arthroplasty literature has found that an INR < 1.25 may be an optimal preoperative INR goal, our results did not find an increased risk for bleeding and complication with an INR ≤ 1.5 for shoulder arthroplasty. These results support current guidelines recommending a preoperative INR ≤ 1.5 for shoulder arthroplasty.