Idiopathic Avascular Necrosis of the Capitate Treated with a Medial Femoral Trochlea Vascularized Osteochondral Flap: A Case Report.

CASE: Capitate avascular necrosis should be entertained in a differential diagnosis of young, active adults with midcarpal wrist pain. We present a case study of a 30-year-old laborer who developed avascular necrosis (AVN) of his right proximal capitate. Grip strength and wrist motion were limited on examination, with advanced imaging confirming AVN. A diagnostic arthroscopy confirmed the pathology. Treatment was completed with a medial femoral trochlea vascularized flap for cartilaginous resurfacing. At 10-month follow-up, the patient's capitate was healed with stable fixation, and he is working full-time as a laborer without restrictions. CONCLUSION: AVN of the capitate is a unique and challenging articular pathology that requires a thoughtful preoperative evaluation and meticulous surgical technique to reconstruct. The medial femoral trochlea (MFT) vascularized bone transfer with cartilaginous resurfacing is 1 available treatment option. This flap is harvested from the medial femur using microsurgical techniques, based on the descending genicular artery. Using a 2-surgeon approach, simultaneous dissection of the AVN is completed at the wrist. This flap is a vascularized option that can be used for both AVN and nonunion with structural deformity before salvage surgeries.

Preoperative Postvoid Residual Is Not Predictive of Postoperative Urinary Retention in Primary Total Joint Arthroplasty Patients.

Background: Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively. Methods: Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics. Results: Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02). Conclusions: PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Preparing for and Executing the Ideal Posterior Labral Repair.

Posterior labral tears are a source of pain and instability of the shoulder. Despite being relatively uncommon (reported in approximately 10% of instability cases), the incidence of posterior labral tear is increasingly recognized as underestimated in highly active populations. Posterior labral tears can result from a traumatic posterior dislocation or repetitive microtrauma, leading to posterior chondral/labral attrition. Patients often present with vague, deep-seated shoulder discomfort rather than the sensation of instability. Unfavorable results with nonsurgical management will indicate which patients will most benefit from surgery. Arthroscopic stabilization has proven to be an effective and reliable treatment, and many techniques for posterior labral repair have been described. It is important to highlight the evaluation, preparation, and execution of arthroscopic stabilization of an isolated posterior labral repair using high-strength knotless all-suture anchors to allow for a stable, efficient, reproducible, and reliable repair while maintaining a low-profile construct that minimizes damage to the surrounding tissue.

Rotator Cuff Repair with Knotless All-Suture Medial Row Anchors and Biceps Autograft Augmentation.

Incomplete healing and/or functional failure following rotator cuff tear repair remains a challenging problem for both patients and surgeons. Augmentation strategies are growing to increase healing through biologic and mechanical mechanisms to improve functional results after arthroscopic rotator cuff repair. The majority of currently described augmentation techniques use allograft tissue. An alternative, low-cost, autograft option for augmentation is the use of the long head of biceps tendon autograft as a free functional graft. Here, we describe the use of autograft biceps tendon as a viable option for augmentation of double-row rotator cuff repair with knotless all-suture suture anchors.

Arthroscopic Repair and Reconstruction of Coracoclavicular Ligament.

Acromioclavicular joint separations are common shoulder injuries that require prompt recognition, diagnosis, and treatment. Deciding on a treatment algorithm relies on a detailed knowledge of anatomy and a thorough understanding of the specific functional demands of the patient in question. When a repair or reconstruction is indicated, arthroscopic assistance can be a helpful tool to ensure a safe, anatomic reconstruction that minimizes morbidity and maximizes the potential return to high-level function.

Posterior Labral Repair Using Knotless "All-Suture" Suture Anchors.

Isolated posterior instability is well described but relatively uncommon, accounting for less than 10% of all shoulder instability cases. When nonoperative management fails, surgical outcomes demonstrate improved patient-reported outcomes with a high level of return to sport. Knotless suture anchor and "all-suture" suture anchor technology are now available and used for instability procedures in the shoulder. This technical description describes knotless "all-suture" suture anchor fixation for isolated posterior labral tears.

Arthroscopic Subscapularis Repair With Preserved Biceps Anatomy.

Arthroscopic subscapularis repair continues to improve with the advancement of surgical technique and critical focus on careful intraoperative evaluation. As identification of these tears increases, there is an expected increase in repair rates as well. Anatomically, the upper border of the subscapularis and the long head of the biceps (LHB) tendon are in close relation. Many surgeons have advocated concomitant LHB tenotomy versus tenodesis in conjunction with operative subscapularis tears. We hypothesized that in the setting of a preserved anatomic biceps pulley and no LHB pathology, isolated subscapularis repair would result in excellent clinical outcomes when compared with subscapularis repair and biceps tenotomy or tenodesis.

Low-Profile Cartilage Repair With Knotless All-Suture Anchors: Surgical Technique.

Osteochondral and pure chondral lesions of the knee are common after patellar dislocations. There are multiple described techniques for the fixation of these lesions, including metallic screws, bioabsorbable screws, bioabsorbable implants, and suture devices. The purpose of this article is to describe a surgical technique for surgical fixation of a lateral condyle chondral lesion using knotless all-suture anchors, with second-look knee arthroscopy illustrating healing of the cartilage repair.

Public Interest in Shoulder Platelet-Rich Plasma Injections Is Increasing: A 10-Year Google Trends Analysis.

Purpose: To quantify and analyze public interest trends in platelet-rich plasma (PRP) therapy for shoulder pathology between 2011 and 2020 using Google Trends data. Methods: Google Trends data were queried for online search data ranging from January 2011 to December 2020. Various combinations of terms related to PRP and shoulder pathology were queried. Terms related to corticosteroid therapy in association with shoulder pathology were also generated for comparative analysis. Analyses were performed regarding trends in online search volumes. Results: Linear models were generated to evaluated trends in the volume of online searches for PRP and corticosteroid therapy for shoulder pathology. For both the PRP and steroid groups, linear models showed a statistically significant increase in search volume for the period studied (P < .001). The PRP group showed a significantly greater growth rate than the steroid group (P < .001). There were no statistically significant differences in online search volume when compared between different geographic and socioeconomic locations. Conclusions: This study indicates consistently increasing public interest in PRP injections in the shoulder. The rate of online search volume growth of PRP is significantly greater than that of corticosteroid injections for the period studied. Clinical Relevance: Awareness of patient perceptions has value in informing shared decision making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

Anatomic glenohumeral arthroplasty: State of the art.

Anatomical total shoulder arthroplasty in its modern form where it reproduces the normal shoulder has been utilized clinically for more than half a century. As the technology and the designs have changed to recreate the humeral and glenoid sides of the joint, the sophistication of design has resulted in the growing number of cases annually worldwide. This increase is due in part to the increasing number of indications that the prosthesis can treat with successful results. On the humeral side, there have been design changes to better reflect the proximal humeral anatomy, and humeral stems are increasingly placed safely without cement. Platform systems which allow conversion of a failed arthroplasty to a reverse configuration without stem extraction is another design change. Similarly, there has been increasing utilization of short stem and stemless humeral components. Extensive experience with shorter stem and stemless devices, however, has yet to demonstrate the purported advantages of these devices, as recent studies have demonstrated equivalent blood loss, fracture rates, operative times, and outcome scores. Easier revision with these shorter stems remains to be definitively established, with only one study comparing the ease of revision between stem types. On the glenoid side, hybrid cementless glenoids, inlay glenoids, cementless all-polyethylene glenoids, and augmented glenoids have all been investigated; however, the indications for these devices remain unclear. Lastly, innovative surgical approaches to implanting shoulder arthroplasty and the use of patient specific guides and computerized planning, while interesting concepts, still await validation before they are utilized on a widespread basis. While reverse shoulder arthroplasty has been increasingly used to reconstruct the arthritic shoulder, anatomic glenohumeral replacement maintains a significant role in the armamentarium of the shoulder surgeon.

Increased Risk of Lateral Femoral Cutaneous Nerve Injury in Patients With Previous Hip Arthroscopy Who Underwent a Direct Anterior Approach Total Hip Arthroplasty.

Purpose: To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods: We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow-up (6 weeks) and 1-year (or most recent) follow-up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results: In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow-up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow-up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow-up (P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow-up. Conclusions: In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow-up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence: Level III, case-control study.

Mid-Term Outcomes of the All-Soft Quadriceps Tendon Autograft Are Noninferior to Hamstring Autograft in Primary Anterior Cruciate Ligament Reconstruction: Comparison With Minimum 5-Year Follow-Up.

PURPOSE: To compare the 5-year clinical and functional outcomes of the soft-tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. METHODS: A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft-tissue QT or double-tendon HT autograft with at least 5 years of follow-up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. RESULTS: A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2-years' postoperatively. At 5 years' postoperatively, the QT group demonstrated significantly greater IKDC (P = .018) and Lysholm (P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years' postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. CONCLUSIONS: Although the QT autograft demonstrated increased patient-reported outcome scores when compared with the HT at 5 years' postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years' postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid-term follow-up. LEVEL OF EVIDENCE: III, retrospective comparison study.

Orthopaedic Shoulder and Elbow Fellowship Directors in the United States Have Substantial Research Output but Lack Diversity.

Purpose: To investigate the characteristics of shoulder and elbow fellowship directors (FDs). Methods: FDs for shoulder and elbow fellowship programs in the United States were identified. Demographic, educational, and professional background data were collected from available curricula vitarum, institutional biographies, and the Scopus database. Data collected included age, sex, race/ethnicity, training locations, graduation years, advanced degrees, current institutional information, and personal research H-index. Results: Thirty current orthopaedic shoulder and elbow FDs were identified. The mean Scopus H-index was 25.5. The mean age of FDs was 52.1 years. In total, 29 FDs (96.7%) were male and 1 (3.3%) was female. In addition, 25 of the 30 (83.3%) were White (83.3%), 4 were Asian, and 1 (3.3%) was Hispanic. Two (6.7%) had a military affiliation. Mean time from fellowship training graduation to FD appointment was 13.5 years. Mean number of years as FD was 6.1 years, whereas the number of years tenure with an FD-affiliated institution was 13.0 years. Mean calendar years for completion of orthopaedic residency training and fellowship training were 1998 and 2000, respectively. The residencies that produced the most future FDs were Hospital of the University of Pennsylvania (n = 2) and University of Nebraska Medical Center/Creighton University Health Foundation (n = 2). The fellowship that produced the most future FDs was Columbia University (n = 6). Moderate correlation was found between age and Scopus H-index (r = 0.48; P = .04) and years as FD and Scopus H-index (r = 0.42; P = .03). Conclusions: Women and minorities are under-represented in leadership positions in shoulder and elbow surgery. Shoulder and elbow FDs have the highest H-index of any subspecialty reported in the orthopaedic literature. Research productivity is an important qualification when considering the characteristics of shoulder and elbow FDs. Clinical Relevance: Fellowship directors can have a profound influence on current and future orthopaedic surgeons. It is important to identify the traits that characterize current fellowship directors to have a better understanding of who we choose as leaders in our field.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience.

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from - unfortunately, there is no consensus on which treatments are "better" and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Does the Number of Preoperative Corticosteroid Injections Affect Clinical and Radiographic Outcomes of Trapeziectomy and Suspensionplasty?

PURPOSE: This study aimed to determine whether an increasing number of preoperative corticosteroid injections is associated with greater radiographic subsidence of the thumb metacarpal at long-term follow-up after abductor pollicis longus suspensionplasty, secondary to steroid-induced pathologic weakening of capsuloligamentous restraints surrounding the thumb carpometacarpophalangeal joint and greater extension of the lunate, but neither affect patient-reported outcomes nor revision rates. METHODS: A retrospective chart review was performed of patients who underwent primary trapeziectomy and abductor pollicis longus suspensionplasty by a single surgeon over a 10-year period. The number of preoperative corticosteroid injections in the trapeziometacarpal joint was documented, and patients were separated into 4 subgroups: 0, 1, 2, or 3 or more injections. Preoperative and final radiographs were evaluated for a change in the distance between the base of the thumb metacarpal and the distal pole of the scaphoid as a measure of thumb metacarpal subsidence and radiolunate angle as a measure of nondissociative carpal instability, which has been reported as a complication after basal joint arthroplasty. Additionally, the final patient-reported outcomes (Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and revision rates were also assessed. RESULTS: Of a total of 60 patients with an average age of 64 years that were included in the study, 16 (26.7%) received 0, 19 (31.7%) received 1, 12 (20%) received 2, and 13 (21.7%) received 3+ preoperative injections. The median postoperative follow-up was 92 months. The mean distance between the base of the thumb metacarpal and the distal pole of the scaphoid decreased by 2 mm, and the mean radiolunate angle increased by 4° across the entire cohort. When comparing subgroups, no differences were observed in either parameter or the final Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores. CONCLUSIONS: This study demonstrates no apparent detrimental effect of an increased number of preoperative corticosteroid injections on radiographic thumb metacarpal subsidence, increase in extension of radiolunate angle (nondissociative carpal instability), patient-reported outcomes, or revision rates at an average of almost 8 years after trapeziectomy and abductor pollicis longus suspensionplasty. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic Technique for Distal Tibial Allograft Bone Augmentation With Suture Anchor Fixation for Anterior Shoulder Instability.

Recurrent instability associated with glenoid bone loss is a commonly encountered problem after anterior shoulder dislocation. Surgical management with bony augmentation can be achieved with several allograft or autograft options. Fixation strategies also vary, including screw, suture button, or suture anchor fixation. Concerns exist regarding screw fixation because of the technical difficulty of a medial portal establishment, as well as the potential for graft osteolysis. Suture button fixation for osteochondral graft fixation has been previously described. However, no description of graft fixation using suture anchors exists. We describe an arthroscopic technique for glenoid augmentation using distal tibial allograft with suture anchor fixation.

Investigation of Fellowship Leadership in Orthopaedic Musculoskeletal Oncology.

INTRODUCTION: The purpose of this study was to determine the objective characteristics of orthopaedic musculoskeletal oncology fellowship directors (FDs) by concentrating on the demographics, academic background, institutional history, research experience, and professional affiliations of these leaders. METHODS: Data were collected for each FD through institutional biographies or publicly available curriculum vitae. The data collected for each FD included demographic, professional, and research information. RESULTS: Of the 19 FDs, 15 (78.9%) were male, and 4 (21.1%) were female. The mean age for all FDs was 49.2 ± 9.1 years. Most FDs were White (n = 16; 84.2%). The mean Scopus H-index, total number of citations, and total number of publications among all 19 FDs were 21.6 ± 13.8, 2,290.6 ± 2,709.0, and 84.0 ± 54.7, respectively. The mean number of years serving in the FD role was 7.1 ± 9.1 years, and the mean number of years that the FD was employed at his/her current institution was 11.1 ± 8.1 years. CONCLUSION: This study shows that orthopaedic musculoskeletal oncology FDs were mainly White (84.2%), male (78.9%), and in their late 40s; have filled their role as FD for an average of 7.1 years; and are very productive in research.

Clinical outcomes and survivorship of cementless triathlon total knee arthroplasties: a systematic review.

BACKGROUND: Over the last decade, cementless total knee arthroplasty has demonstrated improved outcomes and survivorship due to advances in technologies of implant design, manufacturing capabilities, and biomaterials. Due to increasing interest in cementless implant design for TKA, our aim was to perform a systematic review of the literature to evaluate the clinical outcomes and revision rates of the Triathlon Total Knee system over the past decade. METHODS: A systematic review of the literature was conducted following PRISMA guidelines for patients who underwent total knee arthroplasty with cementless Triathalon Total Knee System implants. Patients had a minimum of two-year follow-up and data included clinical outcome scores and survivorship data. RESULTS: Twenty studies were included in the final analysis. The survivability of the Stryker Triathlon TKA due to all causes was 98.7%, with an aseptic survivability of 99.2%. The overall revision incidence per 1,000 person-years was 3.4. Re-revision incidence per 1,000 person-years was 2.2 for infection, and 1.3 for aseptic loosening. The average KSS for pain was 92.2 and the average KSS for function was 82.7. CONCLUSIONS: This systematic review demonstrated excellent clinical outcomes and survivorship at a mean time of 3.8 years. Additional research is necessary to examine the long-term success of the Stryker Triathlon TKA and the use of cementless TKAs in obese and younger populations. LEVEL OF EVIDENCE: III.

Orthopaedic Residency Applicants' Perspective on Program-Based Social Media.

Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown. Methods: Applicants to the home institution's orthopaedic surgery residency program were sent an optional online survey during the 2020 to 2021 application cycle. No incentive was provided in exchange for participation. Results: Of 812 orthopaedic surgery applicants, 650 (80%) completed the survey. Program-based social media is widely accessed by applicants. Instagram is used by most applicants (61.9%), and nearly a third (28.7%) rely on it as their main resource when researching prospective residency programs. The majority (66.9%) agreed that social media can be successfully used to inform and interact with applicants. Most of the applicants (60.6%) also reported that social media had a positive impact on their perception of the associated program. Only 5.7% of respondents indicated that social media had a negative influence. The most effective uses of social media seem to be in allowing a program to display its culture and transparency. Conclusion: Social media plays a substantial role in the orthopaedic surgery residency application process, and its use continues to grow. Programs can use it to effectively engage with and inform prospective applicants. The impact of social media is positive on most of the applicants. Instagram is the preferred social media platform used by applicants, and nearly one-third rely on it as their main resource when researching programs. Investing time and resources into a social media presence seems to be a worthwhile pursuit for orthopaedic surgery programs as an important piece to a well-rounded recruitment effort of modern orthopaedic surgery applicants.