Clinical and Radiologic Outcomes after Meniscal Root Repair: A Case Series.

This study aimed to describe the demographics, clinical outcomes, and radiologic outcomes of patients who underwent meniscal root repair at a single, large academic institution. Patients who underwent meniscal root repair between January 2011 and April 2015 were identified. Patient demographics, injury characteristics, and intraoperative findings of medial femoral condyle chondromalacia and other concomitant pathology were retrospectively recorded. Enrolled patients returned to clinic for prospectively collected International Knee Documentation Committee (IKDC) subjective and objective forms, knee radiographs, and magnetic resonance imaging (MRI). A total of 25 root injuries (23 patients) were included in the final analysis. Majority of root injuries were medial menisci (68%) and repaired using transosseous pull-out technique (80%). Most patients (65%) were male, relatively young (median age = 37 years), overweight (median body mass index [BMI] = 26 kg/m2), and reported a traumatic event associated with their injury (60%). Also, 36% (9/25) of root repairs were performed concomitantly with an anterior cruciate ligament (ACL) reconstruction; 100% (8/8) lateral meniscal root injuries were associated with a concomitant ACL injury compared with 6% (1/17) of medial root injuries. Overall, 53% (9/17) of medial meniscal root repairs were performed in the setting of high-grade (Outerbridge's grade III/IV) chondral pathology of the ipsilateral femoral condyle. Median follow-up was 16 months. The Kellgren-Lawrence radiographic scale progressed in two knees that underwent meniscal root repair based on comparison of preoperative to follow-up radiographs. MRI showed 88% (22/25) of meniscal roots had completely healed, 6% (1/17) of the medial root repairs showed evidence of extrusion, and 44% (11/25) of repairs were associated with progressive chondromalacia. All patients had normal or near normal IKDC objective scores at time of follow-up. Surgeons should have a high suspicion for concomitant ACL injuries in the setting of lateral meniscal root tears, and be wary of concomitant high-grade chondral damage in the setting of medial meniscal root tears. Most meniscal root repairs appeared completely healed with low rates of medial meniscal extrusion on MRI at short-term follow-up, despite a high rate of chondromalacia progression. Present study is a large case series with prospective follow-up and reflects level of evidence IV.

A Randomized Trial of Preoperative Practice in a Simulated Operative Environment: 3D Printed Pilon Model Improves Resident Performance.

This study assessed the effect of preoperative planning using a 3D-printed periarticular fracture model on operative performance. A complex pilon fracture was 3D-printed, and a preoperative plan was developed. Orthopaedic surgery residents (n = 20) were randomized into two groups. Group 1 performed routine preoperative planning, while Group 2 was also practiced using a 3D-printed construct before performing fixation of the 3D-printed model. Resident performance was assessed using a video motion capture system and evaluated by blinded reviewers. Three residents (3D group) completed fixation within the allotted 45 minutes. The 3D group had less hand distance traveled for step 1 (89 m vs. 162 m, p = 0.04). The 3D group had better performance on three of the four components and more acceptable reductions (6 vs. 0, p = 0.009). Average global rating scale was higher in the 3D group (3.0 vs. 1.7, p = 0.0095). Use of 3D-printed models for preoperative planning improved resident performance. (Journal of Surgical Orthopaedic Advances 31(3):187-192, 2022).

Distal clavicle "A-frame" morphology: a reliable intraoperative guide for arthroscopic distal clavicle excision.

BACKGROUND: The purpose of this cadaveric study was to describe the characteristics of the "A-frame" morphology of the distal clavicle via computed tomography (CT) to determine whether it can be used as a reliable intraoperative guide for arthroscopic distal clavicle excision. METHODS: Twenty-eight fresh-frozen human cadaveric clavicles underwent a 3-dimensional CT scan using 1.0-mm cuts. The distance from the most lateral aspect of the clavicle to the point at which the superior cortex of the clavicle paralleled the inferior cortex was measured. Measurements were performed in a blinded fashion by a single author on 2 separate occasions. RESULTS: The A-frame was present in all specimens (28 of 28). On the first measurement, the mean distance from the distal clavicle to the point at which the A-frame disappeared was 1.00 cm (range, 0.90-1.08 cm; standard deviation, 0.5 mm). On the second measurement, the mean distance was 1.02 cm (range, 0.90-1.11 cm; standard deviation, 0.6 mm). The intrarater reliability between measurement occasions was 0.65 (95% confidence interval, 0.36-0.82; P < .001). CONCLUSIONS: This study demonstrated that the cross-sectional A-frame morphology of the distal clavicle was consistently visualized on CT scans. The A-frame disappeared 1.00-1.02 cm medial to the most lateral extent of the clavicle on CT scans. The disappearance of the A-frame morphology of the distal clavicle can serve as a reliable intraoperative guide for arthroscopic distal clavicle excision.

Cyclic and Load-to-Failure Properties of All-Suture Anchors in Human Cadaveric Shoulder Greater Tuberosities.

PURPOSE: The purpose of this study was to evaluate the cyclic displacement, stiffness, and ultimate load to failure of 3 all-suture anchors in human cadaveric greater tuberosities. METHODS: Three all-suture anchors indicated for rotator cuff repair were tested in 14 matched pairs of human cadaver fresh-frozen humeri. Anchors were inserted at 3 locations from anterior to posterior along the greater tuberosity and placed 5 mm from the articular margin. The constructs were cycled from 10 to 60 N at 1 Hz for 200 cycles. The anchors that survived cycling were then subjected to a single pull to failure test. A Kruskal-Wallis 1-way analysis of variance on ranks was performed to compare the displacement, stiffness, and ultimate load to failure of the different anchors tested. RESULTS: One matched pair was excluded because of poor bone quality; therefore, 13 matched pairs were included in the study. After 20, 100, and 200 cycles, there was no difference in median displacement between the anchors tested (P = .23, P = .21, P = .18, respectively). The median ultimate load-to-failure between the Iconix (295.2 N, 95% confidence interval [CI], 125-762.2), JuggerKnot (287.6 N, 95% CI, 152.9-584.4), and Q-fix (333.3 N, 95% CI, 165.0-671.9) showed no statistically significant difference (P = .58). After 20, 100, and 200 cycles, there was no difference in median stiffness between the anchors tested (P = .41, P = .19, P = .26 respectively). Displacement greater than 5 mm occurred in 0 Iconix anchors (0%), 1 JuggerKnot anchor (3.64%), and 2 Q-fix anchors (7.69%). One JuggerKnot anchor failed by anchor pullout during cyclic loading. CONCLUSIONS: When tested in human cadaveric humeral greater tuberosities 3 all-suture anchors, the 2.9-mm JuggerKnot, the 2.8-mm Q-fix, and the 2.3-mm Iconix, showed no significant differences in median displacement or stiffness after 20, 100, or 200 cycles or in median ultimate load to failure. Although not statistically significant, the Iconix was the only anchor tested to have no failures, whereas the JuggerKnot had both a clinical and catastrophic failure and the Q-fix had 2 clinical failures. LEVEL OF EVIDENCE: Level V, Controlled Laboratory Study.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Visualization of Concurrent Anterolateral and Anterior Cruciate Ligament Injury on Magnetic Resonance Imaging.

PURPOSE: To investigate the ability to visualize the anterolateral ligament (ALL) on magnetic resonance imaging (MRI) and identify ALL injuries in an intact- anterior cruciate ligament (ACL) and torn-ACL cohort. We also aimed to assess inter-rater reliability between 2 radiologists when it comes to the aforementioned assessment. METHODS: MRIs that met inclusion and exclusion criteria were placed into a control (ACL-intact) or study (ACL-injured) cohort. MRIs were independently analyzed by 2 radiologists for data points pertaining to demographics, ALL visualization, presence of ALL injury, and concomitant knee abnormalities. Inter-rater reliabilities for visualizing the ALL and identifying ALL injuries were assessed. RESULTS: The control and study groups consisted of 116 and 82 MRIs, respectively. Age varied between the 2 groups, but sex distribution was similar. With near-perfect agreement (kappa = 0.92), both radiologists visualized at least part of the ALL in more than 95% of MRIs irrespective of ACL integrity. The mean incidence of ALL injury in the ACL injured group was 53.05% with minimal inter-rater agreement (kappa = 0.38). Segond fractures were noted in a mean 13.95% of MRIs with concomitant ALL and ACL injuries. CONCLUSIONS: The ALL was reliably visualized on MRI irrespective of whether the ACL was intact or torn. However, ALL injuries were not reliably diagnosed on MRI in the setting of an ACL tear. Poor interobserver reliability shows the potential for false-positive and -negative interpretation. These findings suggest that, in this study, ALL injuries could not be accurately diagnosed in the presence of an ACL tear using MRI. On the basis of these findings, it is recommended that physicians should not rely on MRI to diagnose an ALL injury in the presence of an ACL injury. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Cyclic and Load-to-Failure Properties of All-Suture Anchors in Human Cadaveric Shoulder Glenoid Bone.

PURPOSE: To evaluate the cyclic displacement and ultimate load to failure of 4 all-suture anchors in human cadaveric shoulder glenoid bone. METHODS: Four all-suture anchors indicated for glenoid labral repair were tested in 14 matched pairs of human cadaveric fresh-frozen glenoids. Anchors were inserted at 4 different locations for a total of 112 tests (12-, 3-, 6-, and 9-o'clock positions for right glenoids). Cyclic loading (10 to 60 N at 1 Hz for 200 cycles) and single pull-to-failure testing (33 mm/s) were performed. A Kruskal-Wallis 1-way analysis of variance with the Dunn multiple-comparison post hoc test was used for statistical analysis. RESULTS: One matched pair was excluded because of poor bone quality. Thus, 13 matched pairs were included in the study, and a total of 104 tests were performed. The Q-Fix anchors showed significantly less displacement after 100 cycles (mean ± standard deviation, 1.40 ± 0.97 mm; P < .001) and 200 cycles (1.53 ± 1.00 mm, P < .001) than all other anchors tested. The Q-Fix (191.3 ± 65.8 N), Suturefix (188.3 ± 61.4 N), and JuggerKnot (183.6 ± 63.5 N) anchors had significantly greater ultimate loads to failure than the Iconix anchors (143.5 ± 54.1 N) (P = .01, P = .012, and P = .021, respectively). Displacement greater than 5 mm occurred in 6 Iconix anchors (22.1%), 5 Suturefix anchors (19.2%), 4 JuggerKnot anchors (15.4%), and 0 Q-Fix anchors (0%). CONCLUSIONS: The Q-Fix anchors showed less displacement with cyclic loading than the Iconix, JuggerKnot, and Suturefix anchors. The Iconix anchors had a lower ultimate load to failure than the Q-Fix, Suturefix, and JuggerKnot anchors. Only the Q-Fix group had no anchors displace greater than 5 mm with cyclic loading. CLINICAL RELEVANCE: All-suture anchors vary in their deployment mechanism, which may alter their strength and performance. Operators must be aware of these anchors' propensity to displace while deploying them.

Greater Tuberosity Decortication Decreases Load to Failure of All-Suture Anchor Constructs in Rotator Cuff Repair.

PURPOSE: To evaluate the effect of greater tuberosity decortication on ultimate load to failure and displacement after cyclic loading with an all-suture anchor. METHODS: A 2.9-mm all-suture anchor was evaluated in decorticated and nondecorticated greater tuberosities of 10 matched pairs of human cadaveric shoulders. Greater tuberosity decortication was performed to a mean depth of 1.7 mm. Anchors were placed in the anterior, middle, and posterior tuberosity. Anchors were tested under cyclic loads followed by load-to-failure testing. Displacement after 20, 100, and 200 cycles and ultimate failure strength were determined. Clinical failure was defined as displacement greater than 5 mm during cyclic loading. RESULTS: After 20 and 100 cycles, there was no difference in mean displacement between the decorticated and nondecorticated cohorts (P = .139 and P = .127, respectively). The mean displacement after 200 cycles was greater in the decorticated cohort, although not significantly (3.4 vs 2.7 mm; P = .05). The mean ultimate load to failure was significantly lower in the decorticated cohort (314 vs 386 N, P = .049). There were 2 clinical failures in the decorticated specimens and 1 in the nondecorticated specimens. CONCLUSIONS: A minimal greater tuberosity decortication significantly decreases the ultimate load to failure of an all-suture anchor. However, decreased biomechanical strength may not necessitate actual clinical failure. CLINICAL RELEVANCE: A decrease in ultimate load to failure could increase the risk of catastrophic postoperative anchor failure. However, while this decrease in strength is statistically significant, the overall decrease in strength may not be sufficient in magnitude to translate to clinical failure.

Slight Reduction in the Insertion Depth for an All-Suture Anchor Decreases Cyclic Displacement in the Shoulder Glenoid.

PURPOSE: To determine if the depth of anchor insertion affects the biomechanical performance of a 1.5-mm all-suture anchor in glenoid bone. METHODS: A 1.5-mm all-suture anchor was tested in 8 matched pairs of human cadaver fresh-frozen glenoids. Anchors were inserted at 6 different locations and tested at 3 different depths: 21 mm (preset drilling depth), 17 mm, and 13 mm. Cyclic loading and destructive testing was performed. Displacement after 100 and 200 cycles, along with ultimate failure strength, was determined. RESULTS: After 100 and 200 cycles, anchors placed at 13 and 17 mm had undergone significantly less displacement than those at 21 mm (P < .05). No difference was observed in ultimate load to failure between anchors placed at 21 and 17 mm. However, the ultimate load to failure was significantly lower in anchors placed at 13 mm (P < .05). There were 5 clinical failures in anchors placed at 21 mm, one at 17 mm, and none at 13 mm. CONCLUSIONS: The 1.5-mm all-suture anchor tested in this study has an optimal insertion depth of 17 mm, 4 mm shallower than the preset drill depth. At the optimal insertion depth of 17 mm, it underwent significantly less displacement after cyclic loading without a reduction in the ultimate load to failure. CLINICAL RELEVANCE: Given the results of this study, the optimal insertion depth for this 1.5-mm all-suture anchor is 17 mm, 4 mm shallower than the preset drill depth.

Effectiveness of a Low Fidelity Cast Removal Module in Orthopaedic Surgical Simulation.

OBJECTIVE: The purpose of this study is to determine if an educational model during a surgical skills laboratory results in a significant reduction in cast saw blade temperatures generated during cast removal. DESIGN: As part of an orthopedic resident surgical skills laboratory an Institutional Review Board-approved study was performed. A total of 17 study subjects applied a short arm cast. Everyone removed 1 short arm cast with temperatures recorded on the saw blade. Following cast removal, an educational session was conducted on proper cast removal and blade cooling techniques. Everyone then removed a second cast. Blade temperatures were recorded. To assess reproducibility, the 5 PGY-1 orthopedic residents removed a short arm cast 3 months later. SETTING: Carolinas Medical Center, Charlotte, NC, tertiary care center PARTICIPANTS: A total of 17 study subjects with minimal casting experience (5 PGY-1 orthopedic residents and 12 senior medical students) applied a short arm cast. RESULTS: Following the educational session there was a significant reduction in mean and mean maximum blade temperatures (p < 0.05). During the second round of cast removal assessment of blade temperatures and specific techniques to cool the blade were observed among all participants. At 3 months' time, the mean and mean maximum blade temperatures remained significantly lower than before the educational session (p < 0.05). CONCLUSIONS: The intervention in this study reduced the maximum blade temperatures to levels below the threshold known to cause burns. This simple, low cost, and easily reproducible model can easily be disseminated across institutions and simulation laboratories.

Effectiveness of a Low-Cost Drilling Module in Orthopaedic Surgical Simulation.

INTRODUCTION: Financial pressures and resident work hour regulations have led to adjunct means of resident education such as surgical simulation. The purpose of this study is to determine the effectiveness of a hands-on training session in orthopaedic drilling technique educational model during a surgical simulation on reducing drill plunging depth and to determine the effectiveness of senior residents teaching a hands-on training session in orthopaedic drilling technique. METHODS: A total of 13 participants (5 orthopaedic interns and 8 medical students) drilled until they penetrated the far cortex of a synthetic bone model and the plunging depth (PD) was measured. They were then randomized and underwent an education session with an attending orthopaedic surgeon or a senior resident. Next, the subjects drilled again with the PD being calculated. The preeducational and posteducational session were compared to determine if there was any improvement in PD and if there was a difference between educators. The cost of the model was also determined. RESULTS: The mean maximum PD and mean PD before the education session was 1.58 (1.40-2.10) and 1.50cm (1.36-1.76), respectively. Following the educational session, the mean maximum PD and mean PD were 0.53 (0.42-0.75) and 0.50cm (0.40-0.72), respectively. These were both significantly lower than before the education session (p <0.05). After the educational session taught by the attending versus the session taught by the resident, the mean maximum PD was 0.59 (0.42-0.75) and 0.49cm. (0.45-0.75), respectively (p = 0.44). After the educational session taught by the attending versus the session taught by the resident, the mean PD was 0.54 (0.40-0.72) and 0.47cm. (0.40-0.65), respectively (p = 0.44). The cost of the station per participant was $5.44. CONCLUSION: This study demonstrated a significant reduction in drilling PD with use of a low-cost training model and a formal didactic and skills session on proper drilling technique that can effectively be led by senior residents.

The Fate of the Neuromuscular Hip After Spinal Fusion.

BACKGROUND: The goals of treatment of neuromuscular scoliosis are to achieve a balanced spine and level pelvis with most constructs including pelvic fixation. However, the pelvis can become a stiff "end vertebra" that prevents compensatory mechanisms to adjust to hip deformities in this patient population. The purpose of this study is to determine the frequency of hip pathology and surgery after spinal fusion in this patient population. METHODS: We performed a retrospective chart and radiographic review of cerebral palsy patients who underwent posterior spinal fusion (PSF) at our institution from 2005 to 2011. We collected radiographic data of preoperative and postoperative pelvic obliquity and hip reduction status and position (up, level, down). We further evaluated patients requiring hip surgery (containment or salvage). RESULTS: Of 47 patients with an average follow-up of 3.5 years after spinal fusion, 21 (45%) underwent a hip procedure. Thirty-eight patients (81%) demonstrated or developed hip subluxation/dislocation. Hip pathology occurred more often in the up hip, but the pathologic down hip more often underwent a hip surgery. Eight new hip subluxation/dislocations occurred after spine surgery. Three (38%) of the new postoperative subluxation/dislocations required hip surgery; all had pelvic obliquity <6 degrees. Eleven patients underwent hip surgery before PSF, 7 were varus femoral osteotomies for subluxation, whereas 5 hips required salvage. In follow-up after PSF, none of these had a new dislocation. Ten patients required hip surgery after PSF at a mean of 1.6 years after PSF. Eight patients had a salvage procedure for painful hip and 2 varus femoral osteotomies for subluxations. CONCLUSIONS: In our cerebral palsy patients who underwent PSF, 45% of these patients required a hip procedure. In the patients who had containment before PSF, the hips maintained reduction after spinal fixation. After correction of pelvic obliquity, 17% of patients had new-onset hip subluxation/dislocation after PSF. Postoperative subluxation/dislocation was not dependent on whether the hip was up or down preoperatively. LEVEL OF EVIDENCE: IV, Retrospective.

Clinical and morphologic factors associated with suture anchor refixation of labral tears in the hip.

BACKGROUND: The acetabular labrum is critical to hip function. Surgical options for treatment of a damaged labrum include removal, debridement, and refixation using suture anchors. QUESTIONS/PURPOSES: The purpose of this study is to determine if certain patient demographic and osseous morphological factors result in increased labral damage requiring refixation. METHODS: Data was collected prospectively from a consecutive series of 334 procedures performed from August 2010 to June 2011 for femoroacetabular impingement. Demographic data, including age, sex, and race, was collected from patient charts. Three-dimensional (3D) CT scans were reviewed to retrieve alpha angles, acetabular version, femoral version, and lateral center edge angle on the symptomatic hip. RESULTS: In 238 (71.3%) of the procedures, the labrum required refixation using suture anchors with a mean of 2.74 anchors being used. Of males, 78.8% required suture anchors and 62.3% of females required suture anchors. Among procedures requiring suture anchors, significantly more suture anchors were used in males (2.92) than females (2.47). Regression analysis showed a positive association between alpha angle, acetabular retroversion at 1 and 2 o'clock, and the number of suture anchors used. The mean alpha angle in the cohort that required suture anchors (63.1°) was significantly greater than the cohort that did not (59.4°). CONCLUSION: This study found femoral deformities to contribute more to labral damage than acetabular deformities and highlighted the importance of preoperative 3D CT scans. This study provides demographic and morphologic factors to review preoperatively to evaluate if extensive labral damage is present and if suture anchor refixation will be required.