A Comparison of Two-Year Anterior Cruciate Ligament Reconstruction Clinical Outcomes Using All-Soft Tissue Quadriceps Tendon Autograft With Femoral/Tibial Cortical Suspensory Fixation Versus Tibial Interference Screw Fixation.

PURPOSE: To contribute to future quadriceps tendon harvest and fixation guidelines in the setting of anterior cruciate ligament reconstruction by comparing 2-year patient-reported subjective knee outcome scores and incidence of graft-related complications between the shorter harvest all-inside tibial-femoral suspensory fixation (TFSF) approach versus the longer harvest standard tibial interference screw fixation technique. METHODS: Patients who underwent primary anterior cruciate ligament reconstruction with all soft tissue quadriceps tendon autograft from January 2017 to May 2019 were identified for inclusion. Patients were matched into 2 cohorts of 62 based on reconstruction technique. All patients completed baseline and minimum 2-year International Knee Documentation Committee, Tegner Activity Level, and Lysholm questionnaires and were queried regarding subsequent procedures and complications to the operative knee. RESULTS: Average graft length for the all-inside TFSF was 69.55 (95% confidence interval 68.99-70.19) mm versus 79.27 (95% confidence interval 77.21-81.34) mm in the tibial screw fixation cohort (P = .00001). Two-year Lysholm scores were greater in the TFSF cohort (P = .04) but were not clinically significant. There was no difference in 2-year International Knee Documentation Committee (P = .09) or Tegner (P = .69) scores between cohorts, but more patients in the TFSF cohort returned to or exceeded their baseline activity level compared with the tibial screw fixation cohort (73% vs 61%, P = .25). Seven patients in the TFSF cohort versus 13 in the tibial screw fixation cohort reported anterior knee pain or kneeling difficulty (P = .22). There were no differences in reported complications. CONCLUSIONS: All-inside soft-tissue quadriceps tendon autograft with TFSF resulted in clinically comparable subjective outcome scores at 2 years to tibial screw fixation. There were also no differences in complications or reports of anterior knee pain or kneeling difficulty. All-inside TFSF can be a viable alternative to tibial screw fixation for all-soft tissue quadriceps autograft. LEVEL OF EVIDENCE: III, comparative therapeutic trial.

The 50 Most Cited Papers Concerning Open Fractures.

The purpose of this study is to identify and evaluate the top 50 most cited papers regarding open fractures. The ISI Web of Knowledge database was used to conduct a search query during May 2020 for articles pertaining to open fractures. The query used multiple Boolean operative combinations. The Boolean operative combination that yielded the largest search result was: "open fracture" OR "compound fracture" OR "gustilo" or "gustilo anderson" or "tscherne" or "oestern". Articles were sorted from highest to lowest number of total citations. Articles were refined to include peer-reviewed original articles, review papers, or editorials. Articles were then screened by title and abstract to confirm they pertained to open fractures. This review provides an analysis of the most influential published literature and recent trends with regards to the treatment and management of open fractures. This data can assist physicians in their search for impactful literature. (Journal of Surgical Orthopaedic Advances 31(2):076-085, 2022).

Prophylactic Radiotherapy for Prevention of Heterotopic Ossification After Periacetabular Fractures: A Review of Efficacy and Associated Conditions.

Prophylactic radiotherapy (XRT) is a commonly used treatment to decrease heterotopic ossification (HO) in patients with traumatic hip injuries. We conducted a retrospective review of patients at risk for HO who underwent XRT. Of the patients reviewed, 27.3% developed radiographic HO, 11.2% developed symptoms, and 2.0% required resection surgery. Patients were divided into primary (n = 71) and secondary prophylaxis (n = 27) cohorts. In the primary group, 25.0% developed radiographic HO, 5.6% developed symptoms, and 0 required surgery. In the secondary cohort, 33.3% of patients developed new radiographic HO, and 25.9% were symptomatic: four had a Brooker score of 3, and three had a score of 4 (p = 0.03), and 7.4% required surgical resection. (Journal of Surgical Orthopaedic Advances 31(2):113-118, 2022).

Pediatric injuries related to electric scooter use: a national database review.

Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of <0.05 was considered significant. Nine hundred and two pediatric patients were treated for an e-scooter injury at an emergency department (ED) between 2015 and 2019. Among those admitted (n = 47), 72.3% were men, and the average age at injury was 11.3 years. Among all injuries (n = 56), the most common diagnosis was fracture (24/56, 42.9%). The 19% (9/47) of patients that experienced polytrauma were significantly older than those with single injuries (P < 0.001). ED admissions grew by 616% from 2017 to 2018. Children experience a greater rate of fractures and polytrauma from e-scooters compared to adults, but fewer facial injuries despite a similar rate of head trauma. The incidence of pediatric head injuries indicates a lack of helmet use similar to adults. Lawmakers should consider bolstering e-scooter regulations to decrease pediatric injuries.

Epidemiology and Outcomes of Ankle Injuries in the National Football League.

Background: Traumatic ankle injuries are commonly complicated by persistent symptoms and the development of chronic ankle instability. Purpose: To describe the epidemiology of ankle injuries in the National Football League (NFL) and investigate the effects that ankle injuries have on performance metrics in the years after injury. Study Design: Descriptive epidemiologic study. Methods: Ankle injuries sustained by NFL players during the 2015-2016, 2016-2017, and 2017-2018 seasons were identified using the Pro Football Reference database. Cumulative incidence was calculated, and demographic identifiers were collected for each injury. The return-to-play (RTP) rate was also recorded. For each player who met inclusion for the performance analysis, power rating (PR) was calculated for the preinjury season (Y-1) and 2 postinjury seasons (Y+1 and Y+2) as follows: PR = (offensive yards/10) + (total touchdowns × 6) + (combined tackles) + (sacks × 2) + (interceptions × 2). Mean PRs were calculated for each season as well as the percentage change and mean difference in PR between Y-1 and Y+1 (ΔPR1%, ΔPR1) and between Y-1 and Y+2 (ΔPR2%, ΔPR2). Subgroup analyses of PR were performed by player position, injury type, and years of experience. Results: Overall, 668 ankle injuries were identified, with an average cumulative incidence across the 3 seasons of 11.2% and RTP rate of 91%. Of those injuries, 159 met inclusion criteria for the PR analysis. The mean overall PR (96.95 in Y-1) declined 22% in Y+1 to 76.10 (-20.85 [95% CI, -13.82 to -27.89]; P < .001) and 27% in Y+2 to 70.93 (-26.02 [95% CI, -18.04 to -34.00]; P < .001). The mean PR per game played (6.70 in Y-1) decreased 14% in Y+1 to 5.75 (-0.95 [95% CI, -0.56 to -1.34]; P < .001) and 17% in Y+2 to 5.54 (-1.16 [95% CI, -0.63 to -1.62]; P < .001). Conclusion: It was found that ankle injuries hampered the performance of NFL players, even multiple years after the injury occurred, despite a relatively high RTP rate. There was a decrease in total games played after ankle injuries as well as a decreased performance output per game played.

Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow.

OBJECTIVES: To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included. INTERVENTION: All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery. MAIN OUTCOMES MEASUREMENTS: The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint. RESULTS: Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified. CONCLUSIONS: Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Fifty Most-Cited Articles Regarding SLAP Lesions.

PURPOSE: To identify and evaluate the top 50 most-cited articles pertaining to SLAP tears. METHODS: The ISI Web of Knowledge database was used to conduct a query for articles pertaining to SLAP tears. Our query was conducted in April 2020 with multiple Boolean operative combinations performed by 2 independent reviewers. Articles on the final list were further reviewed to extract the following data: manuscript title, first author, total citation count, year of publication, citation density since publication, current citation rate since 2013, journal, country of origin, and level of evidence. RESULTS: Our initial search yielded 2,597 articles. Within this cohort, the top 50 publications pertaining to SLAP tears were identified that met our search criteria. The top article was cited 802 times while the 50th ranked article was cited 46 times. The average number of citations per publication was 131, whereas the average citation density since year of publication was 7.3. No strong correlations were found between citation density and year published. Twelve journals published articles pertaining to SLAP tears, with Arthroscopy accounting for the greatest number (15 articles, 30%). Most articles were graded with a level of evidence (LOE) of IV (n = 24, 48%), followed by review articles without LOE (n = 8, 16%). Only 2 articles achieved an LOE of I (4%). Articles typically addressed the arthroscopic management (n = 11, 22%), whereas anatomy/classification (n =10, 20%), and outcomes (n = 9, 18%) also were reported. CONCLUSIONS: This review provides a quantitative analysis of the most-referenced literature pertaining to SLAP tears. This body of knowledge helps surgeons search for literature regarding these injuries and identify trends regarding SLAP tear research. CLINICAL RELEVANCE: This research provides practitioners with an easily accessible and comprehensive collection of the major contributions regarding SLAP tears and offers insight into future areas for research.

Rehabilitation Protocols for Superior Capsular Reconstruction Are Variable: A Systematic Review.

PURPOSE: To screen manuscripts that discuss rehabilitation protocols for patients who underwent superior capsular reconstruction (SCR) to elucidate whether a standard rehabilitation algorithm exists for SCR. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (i.e., PRISMA) guidelines. PubMed (MEDLINE) and Embase were searched using pertinent Boolean operation terms "superior capsular reconstruction" and "rotator cuff repair rehabilitation," and articles that included rehabilitation protocols following superior capsular reconstruction surgery were reviewed. Two independent reviewers performed the search and quality assessment. RESULTS: A total of 549 articles were yielded after our database search. Fourteen studies fulfilled our inclusion criteria and were included in the review. Study designs included 9 editorials, 3 case series, and 2 case reports. Each study included in this review used a unique rehabilitation algorithm that posed significant variability between the protocols. Four phases were identified to summarize each protocol and were used as a basis of discussion-sling versus brace time (3-6 weeks for comfort/removal vs complete immobilization), passive range of motion (immediately after surgery to initiation at 6 weeks), active range of motion (4-8 weeks), and strengthening/return to full activity (12-52 weeks). Initiation of rehabilitation, length of time spent in each phase, types of exercises, and overarching goals for return to function were significantly variable and were decided upon by the surgeon based on current massive rotator cuff repair protocols. Presently, there is no standard rehabilitation protocol for SCR. CONCLUSIONS: SCR is a relatively new procedure that is gaining rapid popularity with promising outcomes. Based on our review, there is no standard rehabilitation protocol in place; thus, it is not possible to recommend an evidence-based rehabilitation protocol following SCR at this time. LEVEL OF EVIDENCE: Level V, systematic review of Level IV and V studies.

Diagnosis of Traumatic Ankle Arthrotomies Using Saline Load Tests, Methylene Blue, and Radiopaque Tracer: A Cadaveric Study.

BACKGROUND: The objective of this study was to define the volume (mLs) needed for a positive saline load challenge test in anterolateral (AL), anteromedial (AM), posterolateral (PL), or posteromedial (PM) ankle arthrotomy wounds using normal saline (NS) and methylene blue (MB). Another objective was to evaluate the use of fluoroscopy and iodinated contrast in the diagnosis of ankle arthrotomies. METHODS: Four cadaveric ankle specimens underwent standardized arthrotomy creation in either the AL, AM, PL, or PM portion of each specimen. An 18-gauge needle was used to inject fluid into each ankle, and the volumes needed for positive fluid challenges were recorded. All 4 ankles were tested 10 times (n = 40) with NS and 10 times using MB (n = 40). A fifth cadaveric ankle was injected with radiopaque contrast solution, and an arthrotomy was simulated and imaged with fluoroscopy.Statistical analyses compared the volumes of NS and MB needed for a positive test. In addition, the 25th, 50th, 75th, 90th, and 95th percentiles of volumes needed for a positive test was calculated. RESULTS: The volume of fluid necessary to detect 25%, 50%, 75%, 90%, and 95% of ankle arthrotomies from any site was 2.0 mL, 4.5 mL, 9.0 mL, 10 mL, and 10 mL, respectively. Anterior arthrotomies required less fluid (2.1 mL ± 0.5) than posterior arthrotomies (9.0 mL ± 1.2) for a positive test (P < .0001). There was no difference between the amount of NS (5.5 mL ± 3.6) vs MB (5.6 mL ± 3.7) needed for a positive challenge test (P = .739). CONCLUSION: Ninety-five percent of ankle arthrotomies could be diagnosed with 10 mL of injected fluid; there was no difference between the volume of NS vs MB needed. Fluoroscopy assisted with needle placement and can be combined with radiopaque contrast solution to diagnose ankle arthrotomies. CLINICAL RELEVANCE: The findings of this study may improve sensitivity and efficiency in the diagnosis of traumatic ankle arthrotomies, for which there is currently a paucity of literature.

Intra-articular Calcaneus Fractures: Current Concepts Review.

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures. Level of Evidence: Level V, expert opinion.

Unicondylar Knee Arthroplasty: A Bibliometric Analysis of the 50 Most Commonly Cited Studies.

BACKGROUND: Unicondylar knee arthroplasty (UKA) is an accepted treatment option for unicompartmental femorotibial degeneration and is gaining in popularity. The goal of this review is to evaluate the top 50 most cited articles pertaining to UKA to better help surgeons understand the trends, identify influential articles, and navigate this body of literature more effectively. METHODS: The Institute for Scientific Information Web of Knowledge database was used to identify all articles related to UKA. The initial screening was based on the number of citations for each article. The list was then refined to include only peer-reviewed original articles, review articles, or editorials. Data were extracted from the articles to rank the articles in the descending order from the most citations to the least. RESULTS: Initial search yielded 1844 articles. Fifty were identified to match the study criteria. The highest ranked article was cited a total of 463 times, whereas the lowest ranked article was cited 101 times. The average total number of citations per publication was 162. The earliest article on the list was published in 1978. The majority of publications assessed long-term outcomes of UKA (n = 6, 52%). The majority of articles were graded a level of evidence of III (n = 21 42%), whereas only 3 articles were graded a level I. CONCLUSIONS: This review provides a quantitative analysis of the most-cited literature pertaining to UKA, which has a paucity of level I studies.

An Elevated Metrorail as a Source of Orthopedic Injuries and Death at a Level-I Trauma Center.

Background: Elevated Metrorail systems differ from conventional trains by their slower speeds and collisions with pedestrians predominantly occurring at accessible stations or platforms. Here, the orthopedic implications of pedestrians struck by a Metrorail are evaluated, as were the correlations of substance abuse and psychiatric history on injury and death. Methods: Retrospective cohort study at a single Level-1 trauma center of patients requiring admission with orthopedic injuries following Metrorail impact from 1/2004-2/2017. Demographics, substance abuse, psychiatric history, intentionality, LOS, follow-up, fracture characteristics, and management were studied. Results: 33 patients sustained 104 total orthopedic injuries requiring admission; nine sustained 15 traumatic amputations. There were at least 37 open fractures, with some incomplete data in deceased (5) and amputation (9) patients. Suicide attempts were completed at 35.7% and were associated with a documented psychiatric illness and prior psychiatric evaluation. Spine injuries were associated with increased traumatic brain injuries, rib fractures, and open pelvic ring injuries, yet fewer humerus fractures. Open fractures were significantly predictive of death. 14 patients (42.4%) required ICU admission, and 26 (78.8%) patients required orthopaedic surgery (mean 1.3 ± 1.4 operations). Conclusions: Metrorail systems are unique sources of orthopaedic injuries requiring high rates of critical care and surgical intervention. Patients sustain multiple injuries, many with amputations. With this mechanism, there is a high rate of open fractures and suicide. Trauma centers should emphasize an extensive evaluation of orthopaedic injuries in this patient setting.Level of Evidence: II.

MRI Evaluation of Posterior Capsular Dehiscence After Posterior Approach Total Hip Arthroplasty.

INTRODUCTION: To our knowledge, no previous study has evaluated the use of MRI to diagnose posterior capsule dehiscence after posterior approach total hip arthroplasty (THA) with capsular repair and its association with postoperative posterior hip dislocation. METHODS: A retrospective chart review of patients who underwent posterior approach THA with capsulotomy repair was performed. Patients were identified who subsequently underwent MRI, and these studies were evaluated for signs of posterior capsular disruption. Each chart was then evaluated for episodes of postoperative hip dislocation. RESULTS: Six hundred seventy-five patients were included in the retrospective review. Thirty-two patients (17 women [aged 37 to 78 years] and 15 men [aged 34 to 80 years]) met the inclusion criteria. Fifteen patients of 32 (48.4%) developed posterior capsule dehiscence after repair (group 1). Seventeen patients of 32 (51.6%) did not have MRI evidence of posterior capsule dehiscence (group 2). In group 1, 2 patients of 15 (13.3%) experienced a posterior hip dislocation. No group 2 patients experienced a posterior hip dislocation. Overall, only 2 patients of 32 (6.3%) developed posterior hip dislocations. In group 1, 12 patients of 15 (80%) developed dehiscence at the lateral capsule margin at the greater trochanter suture repair site. The two patients in group 1 with posterior hip dislocations displayed MRI evidence of capsular dehiscence in this region. Two patients of 15 (13.3%) in group 1 demonstrated dehiscence at the central third of the posterior capsule, whereas 1 patient of 15 (6.6%) in group 1 demonstrated dehiscence at the medial/acetabular margin. No significant difference was found between the dislocation rates between groups 1 and 2 (P = 0.212). The distribution of capsular dehiscence (lateral, middle, and medial capsule) in group 1 was significant (P = 0.0006). DISCUSSION: MRI can effectively diagnose capsular dehiscence in patients who have undergone posterior THA. Most repaired capsules failed in the lateral repair region. MRI offers the potential to identify patients with a higher risk of implant dislocation. LEVEL OF EVIDENCE: Therapeutic level III.

Energy conserving thermoregulatory patterns and lower disease severity in a bat resistant to the impacts of white-nose syndrome.

The devastating bat fungal disease, white-nose syndrome (WNS), does not appear to affect all species equally. To experimentally determine susceptibility differences between species, we exposed hibernating naïve little brown myotis (Myotis lucifugus) and big brown bats (Eptesicus fuscus) to the fungus that causes WNS, Pseudogymnoascus destructans (Pd). After hibernating under identical conditions, Pd lesions were significantly more prevalent and more severe in little brown myotis. This species difference in pathology correlates with susceptibility to WNS in the wild and suggests that survival is related to different host physiological responses. We observed another fungal infection, associated with neutrophilic inflammation, that was equally present in all bats. This suggests that both species are capable of generating a response to cold tolerant fungi and that Pd may have evolved mechanisms for evading host responses that are effective in at least some bat species. These host-pathogen interactions are likely mediated not just by host physiological responses, but also by host behavior. Pd-exposed big brown bats, the less affected species, spent more time in torpor than did control animals, while little brown myotis did not exhibit this change. This differential thermoregulatory response to Pd infection by big brown bat hosts may allow for a more effective (or less pathological) immune response to tissue invasion.