The biomechanical effect of increased valgus on total knee arthroplasty: a cadaveric study.

The effects of valgus load on cadaveric knees following total knee arthroplasty (TKA) were investigated using a custom testing system. TKAs were performed on 8 cadaveric knees and tested at 0°, 30°, and 60° knee flexion in both neutral and 5° valgus. Fuji pressure sensitive film was used to quantify contact areas and pressures and MCL strain was determined using a Microscribe digitizing system. Lateral tibiofemoral pressures increased (P < 0.05) at all knee flexion angles with valgus loading. Patellofemoral contact characteristics did not change significantly (P > 0.05). Significant increases in strain were observed along the anterior and posterior border of the MCL at all knee flexion angles. These findings suggest that valgus loading increases TKA joint contact pressures and MCL strain with increasing knee flexion which may increase implant instability.

Bioinductive Collagen Implant Augmentation for the Repair of Chronic Lower Extremity Tendinopathies: A Report of Two Cases.

In this report, we present two cases of refractory chronic lower extremity tendinopathies treated with collagen bioinductive implant augmentation: a 20-year-old male football player with chronic patellar tendinopathy and a 40-year-old active female with chronic proximal hamstring tendinopathy. We demonstrate that bioaugmentation may represent an effective strategy in the surgical treatment of chronic tendinopathies. Both patients were able to return to their pre-injury activity levels at an accelerated rate.

Early Versus Delayed Active Range of Motion After Open Subpectoral Biceps Tenodesis.

BACKGROUND: Little is known regarding the effect of early active elbow range of motion (ROM) protocols on failure rates and outcomes after open subpectoral biceps tenodesis. HYPOTHESIS: We hypothesized that patients managed using an early active ROM protocol after open subpectoral biceps tenodesis would demonstrate similar failure rates and functional outcomes compared to patients managed using a traditional delayed active ROM protocol. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We evaluated 63 patients who underwent open subpectoral biceps tenodesis with unicortical suture button fixation. Based on surgeon preference, 22 patients were managed using an early active motion protocol consisting of no restrictions on elbow flexion or forearm supination, while 41 patients were managed using a delayed motion protocol postoperatively. Primary outcome measures included failure of biceps tenodesis and American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Secondary outcomes included shoulder and elbow ROM at 6 months postoperatively. RESULTS: The mean follow-up for the 63 patients was 24.2 months postoperatively. One patient (2.4%) in the delayed active motion cohort and no patients in the early active motion cohort experienced failure. Final outcome scores as well as 6-month shoulder and elbow ROM indicated excellent functional outcomes, with no significant difference between motion cohorts. The median postoperative ASES scores were 97.99 in the early active motion cohort (mean ± standard deviation [SD], 95.49 ± 7.68) and 95.42 in the delayed motion cohort (mean ± SD, 90.93 ± 16.08), while median postoperative SANE scores were 96 in the early motion cohort (mean ± SD, 94.23 ± 6.68) and 95 in the delayed motion cohort (mean ± SD, 88.39 ± 17.98). Subgroup analysis demonstrated no significant difference in outcome scores based on the performance of concomitant rotator cuff repair or hand dominance. CONCLUSION: Early active ROM after open subpectoral biceps tenodesis with unicortical suture button fixation resulted in low failure rates and excellent clinical outcomes, comparable to the results of patients managed using delayed active ROM protocols. This suggests that patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome.

Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature. PURPOSE: To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non-active-duty beneficiaries. STUDY DESIGN: Descriptive epidemiology study. METHODS: Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure-related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort. RESULTS: The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non-active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest. CONCLUSION: In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.

The Prevalence of Symptomatic Deep Venous Thrombosis and Pulmonary Embolism After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. The incidence and risk factors of venous thromboembolism (VTE) after ACL reconstruction remain unclear. PURPOSE: To define the incidence of VTE after ACL reconstruction and identify associated risk factors in a large cohort of patients. STUDY DESIGN: Descriptive epidemiological study. METHODS: All patients aged ≥18 years who underwent ACL reconstruction between 2005 and 2011 were identified from the Department of Defense Medical Data Repository. The prevalence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE), within 3 months of ACL reconstruction was queried. Univariate analyses were performed to define odds ratios (ORs) for demographic, medication use, and procedural-related risk factors. RESULTS: A total of 87 VTE events (0.53% [95% CI, 0.42%-0.65%]) occurred after 16,558 ACL reconstructions performed on 15,767 patients. DVT was documented after 55 procedures and PE after 35 procedures. Three patients were documented to have both DVT and PE within the study period. The odds of VTE increased in patients aged ≥35 years (OR, 1.96 [95% CI, 1.27-3.04]; P = .003). Nicotine history increased the odds of DVT (OR, 1.99 [95% CI, 1.15-3.43]; P = .014). Concomitant high tibial osteotomy (HTO) increased the odds of PE (OR, 18.31 [95% CI, 2.4-139.6]; P = .005), whereas concomitant posterior cruciate ligament (PCL) reconstruction increased the odds of both VTE (OR, 3.43 [95% CI, 1.07-11.2]; P = .38) and DVT (OR, 5.57 [95% CI, 1.71-18.14]; P = .004). Nonsteroidal drug use was associated with decreased odds for VTE and DVT (OR, 0.44 [95% CI, 0.28-0.70]; P < .001 and OR, 0.38 [95% CI, 0.22-0.69]; P < .001, respectively). Anticoagulants were associated with increased odds for VTE, DVT, and PE (OR, 98.32 [95% CI, 61.63-156.86]; P < .001; OR, 111.93 [95% CI, 63.95-195.92]; P < .001; and OR, 47.84 [95% CI, 22.55-101.52]; P < .001, respectively). No detectible difference in odds was found for sex, body mass index, or aspirin or cyclooxygenase-2 inhibitor use. CONCLUSION: The incidence of VTE after ACL reconstruction in this large population was low. Increased odds of VTE was identified in patients aged ≥35 years with a history of nicotine use, anticoagulant use, concomitant HTO, or concomitant PCL reconstruction. Controlled studies are necessary to determine the efficacy of chemoprophylaxis and to develop evidence-based clinical practice guidelines to minimize VTE after ACL reconstruction.

Transcutaneous oxygen measurements under hyperbaric oxygen conditions as a predictor for healing of problem wounds.

Controversy exists as to what transcutaneous oxygen (P(tc)O2) levels are required for wound healing and what role hyperbaric oxygen has for this. Current information suggests that 30 to 40 mmHg juxta-wound oxygen tensions in room air are required. We recorded P(tc)O2 measurements in room air and with hyperbaric oxygen in 190 patients with foot wounds; then looked retrospectively and prospectively whether there was any effect on healing. Transcutaneous oxygen measurements under hyperbaric oxygen conditions defined a responder group (P(tc)O2 > 200 mmHg) with a sensitivity of 0.80 and a positive predictive value of 0.88 for healing, regardless of room air measurements when hyperbaric oxygen was used as an adjunct to wound management. This information helps to objectify the indications for hyperbaric oxygen and predict healing especially in those patients with problem wounds of the foot and ankle.

Forefoot narrowing with external fixation for problem cleft wounds.

Healing of forefoot cleft wounds can be a difficult management problem in patients with peripheral vascular disease, diabetes or both. This is a prospective review of 15 patients with these conditions with nonhealing middle-ray cleft wounds managed with a temporary mini-external fixator to close the cleft wound. Fourteen (93%) of the 15 patients had a successful obliteration of the cleft and skin coverage. Twelve (80%) of 15 were able to resume their previous level of activity with the reconstructed, mechanically sound forefoot. Fourteen (93%) of the 15 patients received hyperbaric oxygen treatments as an adjunct to wound healing. All patients avoided a transmetatarsal or higher amputation.

Hyperbaric oxygen.

This cutting edge article discusses the most frequent uses of hyperbaric oxygen for the orthopedic surgeon. Hyperbaric oxygen therapy is an adjunct to orthopedic interventions when healing problems are anticipated due to wound hypoxia or uncontrolled infection.

Bad breaks. Keep the priority & care of orthopedic injuries in proper perspective.

The recognition and appropriate emergency management of orthopedic emergencies is essential to minimize damage and optimize outcome. Priorities, principles and good judgment can make a difference in the overall outcome for the injured patient. These orthopedic emergencies require a team approach to assessment and care. Therefore, collaboration with other EMS providers, nurses, physicians, surgeons and other health-care personnel is essential to the proper care of the patient.