Surgical Approach Does Not Influence Instability Risk in Revision Total Hip Arthroplasty.

BACKGROUND: Although the direct anterior (DA) approach has increased in popularity for primary total hip arthroplasty (THA), there is limited evidence regarding its use for revision THA. It is unknown whether the dislocation benefit seen in the primary setting translates to revision cases. METHODS: This retrospective review compared the dislocation rates of revision THA performed through DA versus postero-lateral (PL) approaches at a single institution (2011 to 2021). Exclusion criteria included revision for instability, ≥ 2 prior revisions, approaches other than DA or PL, and placement of dual-mobility or constrained liners. There were 182 hips in 173 patients that met the inclusion criteria. The average follow-up was 6.5 years (range, 2 to 8 years). RESULTS: There was a trend toward more both-component revisions being performed through the PL approach. There were no differences in dislocation rates between the DA revision and PL revision cohorts, which were 8.1% (5 of 72) and 7.5% (9 of 120), respectively (P = .999). Dislocation trended lower when the revision approach was discordant from the primary approach compared to cases where primary and revision had a concordant approach (4.9 versus 8.5%), but this was not statistically significant (P = .740). No significant differences were found in return to operating room, 90-day emergency department visits, or 90-day readmissions. However, the length of stay was significantly shorter in patients who had DA revisions after a primary PL procedure (P = .021). CONCLUSIONS: Dislocation rates following revision THA did not differ between the DA and PL approaches irrespective of the primary approach. Surgeons should choose their revision approach based on their experience and the specific needs of the patient.

Intermediate-term Outcomes in Adolescent Recurrent Ankle Instability Managed With a Modified Broström-Gould Procedure Augmented With Distal Fibular Periosteum Incorporation.

BACKGROUND: Once a child has developed chronic ankle instability with recurrent events despite conservative treatment, then ligamentous repair is warranted. We utilize a modification of the modified Broström-Gould technique that further incorporates the distal fibular periosteum into the construct. The purpose of this study was to describe the intermediate-term outcomes of our modified Broström-Gould technique for chronic lateral ankle instability in childhood athletes. METHODS: A retrospective review of children who underwent the surgical technique over a 10-year time period (2010 to 2019) was performed, excluding those with <2 years of follow-up. Demographic, surgical, and clinical data were recorded, as well as outcome scores: (1) the Marx activity scale, (2) University of California, Los Angeles activity score, and (3) foot and ankle outcomes score. Recurrent instability events, repeat surgeries, satisfaction with the surgical experience, and return to sport (if applicable) were also recorded. RESULTS: Forty-six children (43 females) with 1 bilateral ankle met the criteria with a mean age at surgery of 14.8 years, and a mean follow-up duration of 4.9 years. The mean Marx activity score was 9.0±5.1, the mean University of California, Los Angeles score was 8.3±1.8, and the mean total foot and ankle outcomes score was 84.0±15.6. Twenty-six ankles (55.3%) reported having at least 1 recurrent episode of instability and 6 of the ankles (12.8%) underwent revision surgery between 3.5 months and 6.5 years of the index procedure. Thirty-nine (84.8%) patients responded that they would undergo our surgery again. CONCLUSION: A modified Broström-Gould procedure can be performed in children with the incorporation of the adjacent periosteum, but recurrence of instability is distinctly possible with longer follow-up with a risk for revision surgery despite good subjective outcomes. LEVEL OF EVIDENCE: Level IV; retrospective case series.

Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients.

BACKGROUND: Although current clinical practice guidelines from the American Academy of Orthopaedic Surgeons suggest that Type II and III supracondylar humerus (SCH) fractures be treated by closed reduction and pin fixation, controversy remains as to whether type IIa fractures with no rotation or angular deformity require surgery. The purpose of our study was to prospectively compare radiographic and functional outcomes of type IIa SCH fractures treated with or without surgery. METHODS: Between 2017 and 2019, 105 patients between 2 and 12 years of age presenting with type IIa SCH fractures and without prior elbow trauma, neuromuscular or metabolic conditions, were prospectively enrolled. Ten orthopaedic surgeons managed the patients with 5 preferring surgical treatment and 5 preferring an initial attempt at nonoperative treatment. Patients in the nonoperative cohort were managed with a long-arm cast and close radiographic follow-up. Patients underwent a standardized protocol, including 3 to 4 weeks of casting, bilateral radiographic follow-up 6 months postinjury, and telephone follow-up at 6, 12, and 24 months. RESULTS: Ninety-nine patients met the inclusion criteria (45 nonoperative and 54 operatives). Of the nonoperative patients, 4 (9%) were converted to surgery up to their first clinical follow-up. No differences were identified between the cohorts with respect to demographic data, but patients undergoing surgery had on average 6 degrees more posterior angulation at the fracture site preoperatively (P<0.05). At the final clinical follow-up (mean=6 mo), the nonoperative group had more radiographic extension (176.9 vs 174.4 degrees, P=0.04) as measured by the hourglass angle, but no other clinical or radiographic differences were appreciated. Complications were similar between the nonoperative and operative groups: refracture (4.4 vs 5.6%), avascular necrosis (2.2 vs 1.9%) and infection (0 vs 1.9%) (P>0.05). Patient-reported outcomes at a mean of 24 months showed no differences between groups. CONCLUSION: Contrary to American Academy of Orthopaedic Surgeons guidelines, about 90% of patients with type IIa supracondylar fractures can be treated nonoperatively and will achieve good radiographic and functional outcomes with mild residual deformity improving over time. Patients treated nonoperatively must be monitored closely to assess for early loss of reduction and the need for surgical intervention.

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

BACKGROUND: Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing. METHODS: This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement. RESULTS: One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement. CONCLUSION: Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.

Assessment of Thresholds for Clinically Relevant Change in the Pediatric/Adolescent Shoulder Survey After Shoulder Instability Surgery: Factors Associated With Meaningful Improvement in Outcomes.

Background: The pediatric/adolescent shoulder survey (PASS) score is a subjective measure of shoulder symptomology in younger patients. Purpose: To establish the minimal clinically important difference (MCID) and minimal detectable change (MDC) for the PASS score in adolescents after surgical treatment for shoulder instability. Study Design: Case series; Level of evidence, 4. Methods: Included were patients aged 12.5 to 23 years who underwent surgical treatment for shoulder instability and who had completed PASS forms preoperatively and at 3 months postoperatively. The MCID was established using an anchor-based approach, with the Single Assessment Numeric Evaluation (SANE) and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) as anchors. Change in PASS score between anchor groups was determined using receiver operating characteristic curve analysis. MDC with 90% confidence (MDC90) was also calculated. Range of motion and strength data at 3-month follow-up were evaluated to identify the optimal postoperative PASS score. Factors associated with improvement in PASS score beyond the MDC90 and MCID were determined in a subset of patients with ≥6-month follow-up data. Results: A total of 95 patients were included. The mean PASS score improved significantly from preoperatively to postoperatively (57 ± 15 to 75 ± 16; P < .001). The anchor-based MCID ranged from 12.5 to 13.2 points, with an area under the receiver operating characteristic (AUC) curve of 0.87 for the SANE and 0.99 for the QuickDASH. The MDC90 was 16.5 points. The optimal PASS score at 3 months after surgery was ≥85 (AUC, 0.66). Shorter duration of symptoms, lower preoperative forward elevation, and higher preoperative external rotation were associated with improvement in PASS score above the MDC90 and/or MCID for the subset of patients (n = 25) with ≥6-month follow-up data. Increased number of suture anchors, less preoperative external rotation deficit, and number of previous dislocations had a moderate effect on improvement in outcomes. Conclusion: A postoperative increase in PASS score of ≥16.5 points had a 90% chance of being a true-positive change, while a score change of approximately 13 points was likely clinically relevant. The optimal PASS score after surgery was ≥85. Shorter duration of symptoms, preoperative range of motion, number of surgical anchors, and number of previous dislocations were associated with achieving a clinically relevant improvement in PASS score at minimum 6 months postoperatively.

Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study.

BACKGROUND: Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood. PURPOSE: To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction. RESULTS: Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling. CONCLUSION: Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft.

BACKGROUND: It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient. PURPOSE: To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities. RESULTS: A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037). CONCLUSION: Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.