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BACKGROUND: Fractures involving the anterolateral distal tibia, often referred to as Tillaux or Triplane fractures, are often treated operatively to achieve an anatomic reduction of the ankle joint articular surface. Although axial images from computed tomography scans are commonly obtained to measure displacement, no studies have examined these fracture patterns in the axial plane. This information may be useful to guide screw trajectory with only fluoroscopic imaging intraoperatively. METHODS: We queried an institutional radiology report database for all "Tillaux" or "triplane" fractures and manually reviewed to identify fractures with an anterolateral tibia fragment. The axial image immediately caudal to the physis or physeal scar was used for measurements. The angle between the incisura and the fracture line exiting the incisura was measured. The width of the fracture fragment and the anterior distal tibia was then measured perpendicular to the incisura, representing the width that would be seen on an intraoperative mortise. A cluster analysis was performed to identify fracture patterns. RESULTS: The average age of patients included in the study was 16 ± 2 years. Sixty-nine patients met inclusion criteria 32 patients with Tillaux fractures (46.4%) and 37 patients with triplane fractures (53.6%) met study inclusion criteria for a total of 69 patients. The cluster analysis demonstrated 3 fracture patterns. For type 1 (n=16), the mean was 24.5 ± 6.5 degrees from the incisura and the mean distance from the tibiofibular joint was 21.1 ± 6.3%. For type 2 (n=20), the mean was 58.6 ± 7.2 degrees and the mean distance was 48.7 ± 8.9%. For type 3 (n=33), the mean was 88.6 ± 6.3 degrees and the mean distance was 49.1 ± 9.7%. CONCLUSIONS: This is the first study to identify that pediatric distal tibia physeal fractures occur in 3 common patterns with consistent fragment sizes and fracture planes. This information can optimize screw start point and trajectory in the axial plane when referencing a mortise x-ray and C-arm beam. LEVEL OF EVIDENCE: Diagnostic, Level III.
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BACKGROUND: Recently, fluoroscopy-assisted computer navigation has been developed to assess intraoperative cup inclination/anteversion and leg-length discrepancy (LLD) in the operating room. However, there is a relative dearth of studies investigating the accuracy of this software compared with postoperative radiographs. MATERIALS AND METHODS: We prospectively enrolled 211 navigated anterior total hip arthroplasties using fluoroscopy-assisted computer navigation software. Intraoperative navigated measurements were compared with postoperative anteroposterior radiographs to assess accuracy of cup inclination/anteversion and LLD. Continuous variables were analyzed using the Student's t test, and categorical variables were analyzed using Fisher's exact test. RESULTS: On postoperative radiographs, 94.3% of cups (199 of 211) were positioned within the Lewinnek "safe zone," compared with 99.1% navigated intraoperatively (P=.01). Eighty-two percent of hips (174 of 211) were navigated intraoperatively to LLDs within ±2 mm; on postoperative radiographs, 65% of hips (138 of 211) had LLDs within ±2 mm (P=.0001). Intraoperatively, 100% of hips (211 of 211) were navigated to LLDs within ±5 mm; similarly, on postoperative radiographs, 98% of hips (207 of 211) had LLDs within ±5 mm (P=.12). CONCLUSION: A novel fluoroscopy-assisted computer navigation platform accurately assessed intraoperative cup position and LLD during anterior total hip arthroplasty. Careful attention to fluoroscopic technique, positioning of radiographic landmarks, and knowledge of the limitations of fluoroscopy, including parallax effect, are important concepts that surgeons should incorporate into their decision algorithm. [Orthopedics. 202x;4x(x):xx-xx.].
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At all levels of American football, knee injuries are common, with injuries to the anterior cruciate ligament (ACL) making up a significant proportion. Historically, ACL injuries were career-altering for professional players, but innovative techniques in surgery and rehabilitation have returned many to the field. While there is a consensus on surgical techniques for ACL reconstruction, significant discrepancies remain on injury prevention and rehabilitation programs. This review article describes the burden of ACL injury on players in the National Football League, best practices in injury prevention and rehabilitation, and evidence-based recommendations for preparing injured athletes to return to play.
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BACKGROUND: Some patients and clinicians have an explicit preference to associate symptoms with specific pathology. This bias can manifest in relatively specific names for illnesses with nonspecific symptoms and signs such as radial tunnel syndrome, repetitive strain injury, and fibromyalgia. This might be a manifestation of a desire for a sense of control and measurable as an unconscious bias for specific over non-specific illnesses. QUESTIONS: There are no factors independently associated with orthopedic surgeon unconscious bias against non-specific illness; Is there a relationship between clinician unconscious bias and clinician explicit preference regarding non-specific illness? PATIENTS AND METHODS: An implicit association test was used to evaluate clinician implicit bias regarding specific and nonspecific illnesses. Demographic information and explicit preference were collected from consented clinicians. RESULTS: Musculoskeletal clinicians have moderate explicit (conscious) and implicit (unconscious) bias in favor of specific illnesses over nonspecific illnesses. CONCLUSIONS: Musculoskeletal clinicians explicitly and implicitly favor specific over nonspecific illnesses. CLINICAL RELEVANCE: Given the notable prevalence of symptoms that are never associated with discrete pathology, care strategies designed to neutralize bias against non-specific illness have the potential to reduce low value tests and treatments; 2) avoid diagnoses that imply specific pathology when the illness is characterized by the absence of verifiable objective pathology; and 3) prioritize interventions known to enhance health among people with no identifiable pathology.