The "Double Medial Malleolus": A New Physical Finding in Talocalcaneal Coalition.

PURPOSE: It has been the observation of the senior author that there is a bony fullness or "double medial malleolus" over the middle facet as a consistent finding with most talocalcaneal coalitions (TCC). To document this observation, we reviewed records and radiographs in 3 patient groups. METHODS: Part 1: retrospective chart review was completed for 111 feet to determine the clinical presence of a palpable "double medial malleolus." Part 2: computed tomography (CT) scans for evaluation of tarsal coalition or symptomatic flatfoot between January 2006 and December 2014 were retrospectively reviewed for the same cohort. Soft tissue thickness was measured as the shortest distance between bone and skin surface at both the medial malleolus and the middle facet/coalition. The volume of the middle facet or coalition was measured at their midpoint. These findings were compared among feet with TCC (n=53), calcaneonavicular coalition (CNC) (n=20), and flatfoot (n=38). RESULTS: Part 1-clinical: from medical records, 38 feet (34%) had documented record of a palpable medial prominence. Of the feet reviewed with a "double medial malleolus," all had TCC (no false positives or false negatives). Clinical and CT prominence demonstrated significant correlation (rs=0.519, P=0.001). Part 2-radiographic: CT observation of "double medial malleolus" is significantly associated with TCC (P<0.001). CT observation of double medial malleolus is 81% sensitive and 79% specific as a predictive test for TCC. The middle facet-to-skin distance was significantly closer in those with TCC versus controls (P<0.001). The ratio was larger in patients with TCC versus CNC (P=0.006) or flatfeet (P<0.001). Volume was nearly twice the size in patients with TCC versus the controls (P<0.001). CONCLUSIONS: TCCs have a bony prominence below the medial malleolus on clinical exam and CT scan not present in flatfeet or CNCs. This abnormal middle facet is almost twice the size of the normal middle facet. Obesity or severe valgus may mask this finding. If a palpable bony prominence is noted just below the medial malleolus during examination of a painful foot with a decrease in subtalar motion, the likely diagnosis is TCC. With this added clinical finding, appropriate images can be ordered to confirm the diagnosis of the latter. We advise CT scans with 3D images for surgical planning. The primary finding for tarsal coalitions in textbooks is decreased subtalar motion. This new finding of a palpable enlarged medial prominence just below the medial malleolus is highly associated with TCCs. LEVEL OF EVIDENCE: Level III.

Return to Duty in Military Members Following Surgical Treatment of Incomplete Femoral Neck Fractures.

The purpose of this study was to determine whether active duty military members treated surgically for incomplete femoral neck stress fractures (FNSFs) return to duty. A retrospective review of 53 patients was evaluated to determine the rate of return to duty (RTD) related to sex, branch of service, side of fracture, and signs of femoroacetabular impingement (FAI). Signs of FAI were measured and compared to RTD. Sixty-seven percent of the sample population did not return to duty. Eighty-three percent of Marine Corps members did not return to duty and 18% of Navy active duty members did not return to duty. This finding was statistically significant (p < .001). Average follow-up was 25 months. Surgical fixation of FNSFs does not seem to affect the ability to return to active duty; however, it did prevent progression to complete or displaced fracture in all of the study patients. (Journal of Surgical Orthopaedic Advances 27(4):312-316, 2018).

Double-Row Capsulolabral Repair Increases Load to Failure and Decreases Excessive Motion.

PURPOSE: Using a cadaver shoulder instability model and load-testing device, we compared biomechanical characteristics of double-row and single-row capsulolabral repairs. We hypothesized a greater reduction in glenohumeral motion and translation and a higher load to failure in a mattress double-row capsulolabral repair than in a single-row repair. METHODS: In 6 matched pairs of cadaveric shoulders, a capsulolabral injury was created. One shoulder was repaired with a single-row technique, and the other with a double-row mattress technique. Rotational range of motion, anterior-inferior translation, and humeral head kinematics were measured. Load-to-failure testing measured stiffness, yield load, deformation at yield load, energy absorbed at yield load, load to failure, deformation at ultimate load, and energy absorbed at ultimate load. RESULTS: Double-row repair significantly decreased external rotation and total range of motion compared with single-row repair. Both repairs decreased anterior-inferior translation compared with the capsulolabral-injured condition, however, no differences existed between repair types. Yield load in the single-row group was 171.3 ± 110.1 N, and in the double-row group it was 216.1 ± 83.1 N (P = .02). Ultimate load to failure in the single-row group was 224.5 ± 121.0 N, and in the double-row group it was 373.9 ± 172.0 N (P = .05). Energy absorbed at ultimate load in the single-row group was 1,745.4 ± 1,462.9 N-mm, and in the double-row group it was 4,649.8 ± 1,930.8 N-mm (P = .02). CONCLUSIONS: In cases of capsulolabral disruption, double-row repair techniques may result in decreased shoulder rotational range of motion and improved load-to-failure characteristics. CLINICAL RELEVANCE: In cases of capsulolabral disruption, repair techniques with double-row mattress repair may provide more secure fixation. Double-row capsulolabral repair decreases shoulder motion and increases load to failure, yield load, and energy absorbed at yield load more than single-row repair.

Targeted Muscle Reinnervation of the Brachium: An Anatomic Study of Musculocutaneous and Radial Nerve Motor Points Relative to Proximal Landmarks.

PURPOSE: Targeted muscle reinnervation (TMR) offers enhanced prosthetic use by harnessing additional neural control from unused nerves in the amputated limb. The purpose of this study was to document the location and number of motor end plates to each muscle commonly used in TMR in the brachium relative to proximally based bony landmarks. METHODS: We dissected 18 matched upper limbs (9 fresh-frozen cadavers). The locations of each of the nerves' muscular insertions into the medial biceps and brachialis were measured relative to the anterolateral tip of the acromion. The terminal branches to the lateral triceps were measured relative to the posterolateral tip of the acromion. Both the number of branches and the location of the muscular insertions were documented. Common descriptive statistics were used to describe the data. RESULTS: There was a median of 2 branches to the medial biceps located 19.6 cm from the anterolateral tip of the acromion (range, 15-25 cm). There was a median of 3.5 branches to the brachialis located 24.2 cm from the anterolateral tip of the acromion (range, 19-27.5 cm). There was a median of 2.5 branches to the lateral triceps located 21.6 cm from the posterolateral tip of the acromion (range, 11-29 cm). The mean distances to the primary branch muscle and the number of smaller branches were not significantly different when compared by sex or side. CONCLUSIONS: Motor points for the medial biceps, brachialis, and lateral triceps can be identified reliably using proximal landmarks in targeted muscle reinnervation. CLINICAL RELEVANCE: The data obtained from this study may assist the surgeon in localizing the nerve branches and muscular insertions for the commonly used muscles for TMR of the brachium.

Mental Skills for Orthopaedic Surgery.

Orthopaedic surgery training focuses primarily on the knowledge base and surgical techniques that comprise the fundamental and physical pillars of performance. It also pays much less attention to the mental pillar of performance than does the training of other specialists such as aviators, elite athletes, musicians, and Special Forces operators. However, mental skills optimize the ability to achieve the ideal state during surgery that includes absolute focus with the right amount of confidence and stress. The path to this state begins before surgery with visualization of the surgical steps and potential complications. On the day of surgery, the use of compartmentalization, performance aspirations, performance breathing, and keeping the team focused facilitates achieving and maintaining the proper mental state. Considering the similarities between surgery and other fields of expertise that do emphasize the mental pillar, including this training in orthopaedic residencies, is likely beneficial.

Femoral Fixation Strength as a Function of Bone Plug Length in Anterior Cruciate Ligament Reconstruction Utilizing Interference Screws.

PURPOSE: To determine femoral construct fixation strength as bone plug length decreases in anterior cruciate ligament reconstruction (ACLR). METHODS: Sixty fresh-frozen bone-patellar tendon-bone allografts were utilized and divided into 20-, 15-, and 10-mm length bone plug groups, subdivided further so that half utilized the patella side (P) for testing and half used the tibial side (T). Ten mm diameter recipient tunnels were created within the anatomic anterior cruciate ligament footprint of 60 cadaveric femurs. All bone plugs were 10 mm in diameter; grafts were fixed using a 7 × 23 mm metal interference screw. An Instron was used to determine the load to failure of each group. A one-way multivariate analysis of variance (MANOVA) was conducted to test the hypothesis that there would be one or more mean differences in fixation stability between 20- or 15-mm plug lengths (P or T) versus 10 mm T plug lengths when cross-compared, with no association between other P or T subgroups. RESULTS: The mean load to failure of the 20 mm plugs (20 P + T) was 457 ± 66N, 15 mm plugs (15 P + T) was 437 ± 74N, and 10 mm plugs (10 P + T) was 407 ± 107N. There was no significant difference between P + T groups: 20-versus 15-mm (p = 1.000), 15-versus 10-mm (p = 0.798), and 20-versus 10-mm (p = 0.200); P + T MANOVA (p = 0.291). Within groups, there was no significant difference between patella and tibial bone plug subgroups with a pullout force range between 469 ± 56N and 374 ± 116N and p-value ranging from p = 1.000 for longer bone plugs to p = 0.194 for shorter bone plugs; P versus T MANOVA (p = 0.113). CONCLUSION: In this human time zero cadaver model, there was no significant difference in construct failure between 20-,15-, and 10-mm bone plugs when fixed with an interference screw within the femoral tunnel, although fixation strength did trend down when from 20- to 15- to 10-mm bone plugs. CLINICAL RELEVANCE: There is a balance between optimal bone plug length on the femoral side for achieving adequate fixation as well as minimizing donor site morbidity and facilitating graft passage in ACLR. This study reveals utilizing shorter plugs with interference screw fixation is potentially acceptable on the femoral side if shorter plugs are harvested.

Infantile Myofibromatosis of the Femoral Neck: A Case Report.

CASE: A 15-month-old boy who was being followed for developmental dysplasia of the hip because of breech presentation was discovered to have a solitary infantile myofibroma in the left femoral neck. The patient was avoiding weight-bearing on the affected extremity; thus, stabilization of the femoral neck was performed using a proximal femur locking plate. Postoperatively, he achieved all gross motor developmental milestones. CONCLUSION: This report is the first to describe a solitary infantile myofibroma in the femoral neck and demonstrates the utility of operative stabilization of these lesions.

The inferior sacral iliac line as a horizontal reference plane in paediatric pelvic radiographs.

BACKGROUND: While often used, Hilgenreiner's line may not always be a reliable reference plane following triple innominate pelvic osteotomy or trauma to the triradiate cartilage. The inferior sacral-iliac line is a horizontal line connecting the sclerotic corners of the inferior sacral-iliac joints. This is a consistent landmark in the ossifying infant pelvis as well as the fully developed adult pelvis. The goal of this study was to determine if there is a difference in measurements between the inferior sacral-iliac line and Hilgenreiner's line in order to identify an alternative horizontal reference plane. METHODS: 3 reviewers (fellowship-trained paediatric orthopaedic surgeon, junior orthopaedic resident, senior orthopaedic resident) reviewed 100 paediatric non-osteotomized pelvises. The difference between Hilgenreiner's line and the inferior sacral-iliac line were measured and reported. Measurements were repeated a minimum of 48 hours apart, resulting in 600 comparisons between Hilgenreiner's line and the inferior sacral-iliac line. The standard error of measurement was calculated to assess the variation in measurements between each individual observer and the group as a whole. RESULTS: The mean standard error of measurement between Hilgenreiner's line and the inferior sacral-iliac line was 0.44° (95% CI, ± 0.86). Reviewers 1-3 demonstrated a mean standard error of measurement of 0.38, 0.28, and 0.35 (95% CI, ± 0.74, 0.55, and 0.86) respectively. There was no statistically significant difference between reviewers (p > 0.05). Intra-observer reliability for reviewers 1, 2, and 3 was 0.64 (0.47-0.76), 0.75 (0.63-0.83), and 0.54 (0.32-0.69) respectively, with an inter-observer reliability of 0.42 (0.20-0.60) degrees. CONCLUSIONS: In this proof-of-concept study, the inferior sacral-iliac line was found to be an appropriate alternative to Hilgenreiner's line that is easily identifiable for all levels of orthopaedic training. Future inferior sacral-iliac line studies should demonstrate the reliability of multiple acetabular measurements, both pre- and post-osteotomy.

Ankle Ganglion Associated with Tarsal Coalition: A Case Report with a 5-Year Follow-up.

CASE: Talocalcaneal coalition (TCC) is a common type of coalition, often neglected. This case is of a 10-year-old girl with a painful ankle mass, diagnosed with TCC and a ganglion cyst. Examination revealed stiff subtalar motion, a submalleolar prominence, and well-circumscribed, tender mass at the posteromedial ankle. Treatment options include short period of casting/observation, excision vs. aspiration of the cyst, resection of the TC coalition, or a combination of the above. She underwent TCC resection with cyst aspiration. CONCLUSION: At the 5-year follow-up, the patient's examination and imaging revealed normal motion without cyst recurrence, indicating resolution of the cyst with coalition resection.

An Osteochondral Allograft in a Patient with Ochronosis: A Case Report.

CASE: When a 31-year-old man with no prior medical history underwent diagnostic arthroscopy for posttraumatic knee pain, ochronotic arthropathy was identified. Subsequent blood tests led to the diagnosis of alkaptonuria. After a discussion regarding his future military career and prognosis, he elected to proceed with osteochondral allograft transplantation surgery (OATS). He was able to return to active-duty service with minimal knee pain. At the 32-month postoperative visit, he had functional, pain-free motion and an excellent Hospital for Special Surgery (HSS) knee score. CONCLUSION: Alkaptonuria is an uncommon metabolic disorder that causes arthropathy of peripheral joints. When there is a focal defect, an osteochondral allograft is a valid, joint-preserving option that allows return to activity.