Editorial Commentary: Distal Tibia Allograft as an Option for Glenoid Reconstruction in Recurrent Shoulder Instability-It's All About the Bone?

Bony defects in recurrent shoulder instability can lead to the failure of soft tissue reconstruction. Many techniques have been developed to address glenoid defects in an attempt to prevent recurrent instability. However, the high complication rates with the Latarjet procedure have led surgeons to identify other sources of bone graft, including the distal tibia allograft (DTA). The DTA appears to be a suitable option for anterior glenoid reconstruction, highlighting the importance of reconstructing all bony defects and the versatility and efficacy of allograft bone blocks.

Efficacy of Celecoxib for Early Postoperative Pain Management in Hip Arthroscopy: A Prospective Randomized Placebo-Controlled Study.

PURPOSE: To determine whether 400 mg of celecoxib administered 1 hour before hip arthroscopy surgery would reduce pain, provide reduction in overall narcotic consumption, and lead to more rapid discharge from recovery rooms. METHODS: Ninety-eight patients were randomized to either the celecoxib group (n = 50) or the placebo group (n = 48). An a priori power analysis was done set to detect a difference of 0.50 on the visual analog scale (VAS), based on the senior author's preference. The number of patients planned for recruitment was rounded up to 100 to allow for flexibility in the study. Inclusion criteria were any patient at least 18 years old who underwent hip arthroscopy surgery performed by the senior author. All patients had less than Tönnis grade 2 arthritis. Exclusion criteria were allergy to sulfa-based drugs, prior adverse reaction to celecoxib, or patients who were on chronic narcotics for whom alternative pain management regimens were arranged before surgery. Randomization was performed on a 1:1 basis in blocks of 10 using sealed envelopes stating celecoxib or placebo. One hour before surgery, all patients received either 400 mg celecoxib or placebo. Patients were evaluated using a VAS preoperatively, immediately postoperatively, and at 1 and 2 hours postoperatively. Time from the operating room to "ready for discharge" and number of morphine equivalents of narcotic medication required in the postanesthesia care unit were recorded. RESULTS: Age and preoperative VAS were similar between the celecoxib and placebo control group, with average ages of 34.2 ± 11.9 and 35.8 ± 11.6 (P = .27) and preoperative VAS of 2.1 ± 2.06 and 2.3 ± 1.98 (P = .29), respectively. The celecoxib group had 26 females and 24 males, whereas the placebo group had 29 females and 19 males (P = .42). The most common surgical procedures were labral repair (31 patients in the celecoxib group and 29 patients in the placebo group), and labral repair with acetabular osteoplasty (13 patients in the celecoxib group and 11 patients in the placebo group). There were no significant differences in procedures performed between the 2 groups (P > .05). At 1 hour postoperatively, patients who received celecoxib had a lower pain score that was statistically significant compared with the placebo group (4.6 vs 5.4, P = .03). There was a significant difference in discharge time between patients who received celecoxib and the control group (152.9 minutes vs 172.9 minutes, P = .04). There was no significant difference found in morphine equivalents consumed in the postanesthesia care unit between the 2 groups (15.3 vs 15.4, P = .48). CONCLUSIONS: A preoperative dose of 400 mg of celecoxib led to statistically significantly reduced patient-reported pain on the VAS in the acute postoperative period after hip arthroscopy surgery, though the difference is not likely clinically significant. There was a significantly shorter time to discharge in patients who received celecoxib versus placebo. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Isolated Acetabuloplasty and Labral Repair for Combined-Type Femoroacetabular Impingement: Are We Doing Too Much?

PURPOSE: To evaluate patient outcomes after isolated arthroscopic volumetric acetabular osteoplasty and labral repair for the treatment of patients with combined femoroacetabular impingement (FAI) lesions. METHODS: A review of a prospectively collected registry identified 86 patients (106 hips) with an average age of 38.1 years (range, 17-59 years) with combined-type FAI that underwent isolated acetabular osteoplasty and labral repair. Preoperative α-angle, degree of radiographic degenerative changes, and presence of a crossover sign were recorded. Clinical outcomes were assessed with the modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and patient satisfaction score (out of 10) at a minimum 2-year follow-up. RESULTS: Clinical follow-up was obtained at a mean follow-up of 37.2 months (range, 27.9-79.2 months). Patients with Tönnis grade 0 and I findings had significantly higher mHHS (83.5 vs 71.5, P = .01), HOS-SSS (81.3 vs 59.9, P = .02), and iHOT-12 scores (71.1 vs 58.8, P = .04) compared to patients with Tonnis grade II changes. However, patient satisfaction scores (8.0 vs 7.2, P = .45) were no different. No significant difference was noted between unilateral and bilateral hip patient outcome scores. Patient age and preoperative α-angles did not correlate with any outcome scores (all R2 <0.05). There were no cases of revision surgery or progression to arthroplasty. CONCLUSIONS: Isolated acetabular decompression may adequately address the underlying impingement in combined-type FAI while avoiding the risks associated with femoral-sided decompression. Good to excellent patient-reported outcomes and satisfaction scores were noted with significantly higher scores in patients with minimal arthritic change. Patient age and preoperative α-angle had less effect on postoperative outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Internet resources for Tommy John injuries: what are patients reading?

BACKGROUND: The quality of medical information on the Internet has come under scrutiny. This study investigates the quality, accuracy, and readability of online information regarding ulnar collateral ligament (UCL) injuries. METHODS: Three search terms ("elbow ulnar collateral ligament injury," "tommy john injury," and "pitcher's elbow") were entered into 3 Internet search engines. Three independent reviewers evaluated the content and accuracy of the information with a set of predetermined scoring criteria. Website quality was further assessed by the Journal of the American Medical Association benchmark criteria and Health on the Net Foundation certification. Website readability was ascertained with the Flesch-Kincaid score. RESULTS: We evaluated 113 unique websites. The average quality for all websites was 8.88 ± 6.8 (maximum, 32 points). Website quality and accuracy were lower with use of the search term "pitcher's elbow" as compared with "elbow ulnar collateral ligament injury" or "tommy john injury" (P ≤ .001). Sites certified by the Health on the Net Foundation had higher quality scores than non-certified sites (P = .034). The mean reading grade level was 10.7. Reading level was significantly correlated with website accuracy and quality (P ≤ .001) and physician authorship (P = .012). Forty-three websites (38.1%) described surgical reconstruction; of these, 16 (37.2%) mentioned improved pitching performance postoperatively. CONCLUSIONS: Online information on UCL injuries is often inaccurate and written at an inappropriate reading level. Information quality depends on the search term used, website authorship, and commercial bias. Clinicians must be aware of factors influencing website quality in order to direct patients to appropriate resources.

Applying fault tree analysis to the prevention of wrong-site surgery.

Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.

The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) Research on Anterior Cruciate Ligament Reconstruction and Orthopaedic Practice.

With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.

Systematic review of autogenous osteochondral transplant outcomes.

PURPOSE: The goal of this systematic review was to present the current best evidence for clinical outcomes of osteochondral autograft transplantation to elucidate the efficacy of this procedure. METHODS: PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials were searched (key terms "knee," "osteochondral autograft transfer," or "mosaicplasty") to identify relevant literature between 1950 and 2013 in the English language. This evaluation included studies in pediatric and adult patients with grade 3 or 4 articular cartilage injuries; the studies had a minimum of 25 patients and at least 12 months of follow-up and compared osteochondral autograft transfers/mosiacplasty with another treatment modality. Articles were limited to full-text randomized controlled trials or cohort studies. Main outcomes studied were patient-reported and functional outcome, with secondary outcomes including effect of lesion size, return to sport and sport function, radiographic outcomes, and reoperation rates. RESULTS: There were a total of 9 studies with 607 patients studied in this systematic review. When osteochondral autologous transfer/mosaicplasty (OATM) was compared with microfracture (MF), patients with OATM had better clinical results, with a higher rate of return to sport and maintenance of their sports function from before surgery. Meanwhile, patients who underwent MF trended toward more reoperations, with deterioration around 4 years after surgery. When compared with autologous chondrocyte implantation (ACI), clinical outcome improvement was not conclusive; however, at 10-year follow-up, a greater failure rate was found to be present in the OATM group. CONCLUSIONS: Current evidence shows improved clinical outcomes with OATM when compared with preoperative conditions. These patients were able to return to sport as early as 6 months after the procedure. It could be suggested from the data that OATM procedures might be more appropriate for lesions that are smaller than 2 cm(2) with the known risk of failure between 2 and 4 years. Further high-quality prospective studies into the management of these articular cartilage injuries are necessary to provide a better framework within which to target intervention. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Short stem metaphyseal-engaging femoral implants: a case-controlled radiographic and clinical evaluation with eight year follow-up.

A prospective comparison of 148 hips in 139 consecutive patients treated with an off-the-shelf uncemented metaphyseal engaging (91-105 mm) stem and 69 hips in 61 patients treated with a custom uncemented metaphyseal engaging short stem was conducted to evaluate the mid-term clinical and radiographic results of an off-the-shelf metaphyseal-engaging short stem implant. All implants were radiographically stable with proximal bony in-growth. There was no significant difference in post-operative HHS (P <. 001) or WOMAC scores (P < .001) between cohorts. An off-the-shelf short femoral stem designed to fit and fill the metaphysis provides reliable fixation up to eight years with equivalent clinical and radiographic results to a customized implant.

Role of Lateral Extra-articular Tenodesis in Restraining Internal Tibial Rotation: In Vitro Biomechanical Assessment of Lateral Tissue Engagement.

BACKGROUND: The way in which force increases in the anterolateral tissues and the lateral extra-articular tenodesis (LET) tissue to resist internal rotation (IR) of the tibia after anterior cruciate ligament (ACL) reconstruction in isolation and after LET augmentation, respectively, is not well understood. PURPOSE: (1) To compare in a cadaveric model how force increases (ie, engages) in the anterolateral tissues with IR of the tibia after isolated ACL reconstruction and in the LET tissue after augmentation of the ACL reconstruction with LET and (2) to determine whether IR of the tibia is related to engagement of the LET tissue. STUDY DESIGN: Controlled laboratory study. METHODS: IR moments were applied to 9 human cadaveric knees at 0°, 30°, 60°, and 90° of flexion using a robotic manipulator. Each knee was tested in 2 states: (1) after isolated ACL reconstruction with intact anterolateral tissues and (2) after LET was performed using a modified Lemaire technique with the LET tissue fixed at 60° of flexion under 44 N of tension. Resultant forces carried by the anterolateral tissues and the LET tissue were determined via superposition. The way force increased in these tissues was characterized via parameters of tissue engagement, namely in situ slack, in situ stiffness, and tissue force at peak applied IR moment, and then compared (α < .05). IR was related to parameters of engagement of the LET tissue via simple linear regression (α < .05). RESULTS: The LET tissue exhibited less in situ slack than the anterolateral tissues at 30°, 60°, and 90° of flexion (P≤ .04) and greater in situ stiffness at 30° and 90° of flexion (P≤ .043). The LET tissue carried greater force at the peak applied IR moment at 0° and 30° of flexion (P≤ .01). IR was related to the in situ slack of the LET tissue (R2≥ 0.88; P≤ .0003). CONCLUSION: LET increased restraint to IR of the tibia compared with the anterolateral tissue, particularly at 30°, 60°, and 90° of flexion. IR of the tibia was positively associated with in situ slack of the LET tissue. CLINICAL RELEVANCE: Fixing the LET at 60° of flexion still provided IR restraint in the more functionally relevant flexion angle of 30°. Surgeons should pay close attention to the angle of internal and/or external tibial rotation when fixing the LET tissue intraoperatively because this surgical parameter is related to in situ slack of the LET tissue and, therefore, the amount of IR of the tibia.

Hand surface landmarks and measurements in the treatment of trigger thumb.

PURPOSE: To determine hand surface landmarks and measurements that may be useful in localizing the A1 pulley and digital neurovascular structures in the treatment of trigger thumb. METHODS: We highlighted 4 surface landmarks in 20 adult cadaveric hands: the radial border of the index finger, the ulnar border of the thumb, the thumb interphalangeal joint flexion creases, and the thumb metacarpophalangeal joint creases. We injected the radial arteries with red latex and dissected the thumbs. RESULTS: The proximal margin of the A1 pulley was located an average of 0.3 mm proximal (range, 3.2 mm proximal to 2.3 mm distal) to the most proximal metacarpophalangeal joint flexion crease. The ratio of measurements from the thumb tip to the midpoint of the interphalangeal joint flexion creases and from this point to the proximal margin of the A1 pulley averaged 1.1:1. The radial digital nerve crossed obliquely over the flexor pollicis longus tendon and approached the proximal margin of the A1 pulley at a mean distance of 2.7 mm (range, 0-12.9 mm). The ulnar digital nerve was located deep to intersecting lines drawn along the radial border of the index finger and the ulnar border of the thumb and coursed parallel to the A1 pulley at a mean distance of 5.4 mm (range, 0-11.1 mm). At the level of the A1 pulley, the digital arteries were positioned dorsal to the digital nerves, and both nerves were located 1.0 to 4.2 mm from the skin surface. CONCLUSIONS: The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. CLINICAL RELEVANCE: Awareness of topographical landmarks in localizing the A1 pulley and digital neurovascular structures and the relationships between the digital neurovascular structures and the A1 pulley may improve the safety and efficacy of trigger thumb treatment.

Flexor pollicis longus dysfunction after volar plate fixation of distal radius fractures.

PURPOSE: To evaluate the natural history and etiology of decreased thumb interphalangeal (IP) joint flexion after volar plate fixation of distal radius fractures. METHODS: A total of 46 patients who underwent volar plating of 48 distal radius fractures by a single surgeon were retrospectively studied. Of those patients, 24 (24 wrists) exhibited loss of thumb IP joint flexion (group 1) and 22 (24 wrists) retained thumb IP joint flexion (group 2) with attempted thumb opposition to the small finger after surgery. All patients were seen at regular intervals until IP joint flexion returned and fracture healing was confirmed radiographically. Patient demographics, fracture patterns, surgical variables, and final radiographs were compared between groups. Twenty patients in group 1 were seen after a mean of 6.5 months (range, 5-12 mo) for specific outcome measurements. Eight cadaveric specimens were used to replicate the flexor carpi radialis approach to the distal radius and evaluate flexor pollicis longus tendon excursion. RESULTS: There were no significant differences in fracture pattern, patient age or sex, injured extremity dominance, time to surgery, incision length, plate composition, plate length, tourniquet time, or final wrist radiographs between groups. In group 1, active thumb IP joint flexion returned on average 52 days (range, 19-143 d) postoperatively. At final evaluation in this group, mean IP joint flexion was 11° less than the contralateral thumb IP joint; however, patient-determined outcomes were favorable in most cases. In the cadaveric specimens, excursion of the flexor pollicis longus tendon decreased with sequential soft tissue dissection and retraction. CONCLUSIONS: Loss of thumb IP joint flexion after volar plating of distal radius fractures was common, and motion returned to near normal in most cases within 2 months. Partial stripping of the flexor pollicis longus muscle from investing fascia and bone and retraction of soft tissues are likely etiological factors.

Computer-assisted total knee arthroplasty for significant tibial deformities.

Computer-assisted total knee arthroplasty has been demonstrated to provide reproducible limb mechanical alignment within 3° from the neutral mechanical axis. However, restoring proper implant and extremity alignment remains a significant challenge with proximal tibial deficiencies. In this prospective study, we describe the use of computer navigation to quantify the amount of bone loss on the medial or lateral tibial plateau and the use of these data to assess the need for augmentation with metallic tibial wedges. In this study, we demonstrate that computer-assisted total knee arthroplasty in patients with significant tibial deformities can accurately measure severe tibial deformities, predict tibial augment thickness, and provide excellent mechanical alignment and restore the joint line without excessive bony resection, repeated osteotomies, and repeated augment trialing.

Internet search term affects the quality and accuracy of online information about developmental hip dysplasia.

BACKGROUND: The recent emphasis on shared decision-making has increased the role of the Internet as a readily accessible medical reference source for patients and families. However, the lack of professional review creates concern over the quality, accuracy, and readability of medical information available to patients on the Internet. METHODS: Three Internet search engines (Google, Yahoo, and Bing) were evaluated prospectively using 3 difference search terms of varying sophistication ("congenital hip dislocation," "developmental dysplasia of the hip," and "hip dysplasia in children"). Sixty-three unique Web sites were evaluated by each of 3 surgeons (2 fellowship-trained pediatric orthopaedic attendings and 1 orthopaedic chief resident) for quality and accuracy using a set of scoring criteria based on the AAOS/POSNA patient education Web site. The readability (literacy grade level) of each Web site was assessed using the Fleisch-Kincaid score. RESULTS: There were significant differences noted in quality, accuracy, and readability of information depending on the search term used. The search term "developmental dysplasia of the hip" provided higher quality and accuracy compared with the search term "congenital hip dislocation." Of the 63 total Web sites, 1 (1.6%) was below the sixth grade reading level recommended by the NIH for health education materials and 8 (12.7%) Web sites were below the average American reading level (eighth grade). CONCLUSIONS: The quality and accuracy of information available on the Internet regarding developmental hip dysplasia significantly varied with the search term used. Patients seeking information about DDH on the Internet may not understand the materials found because nearly all of the Web sites are written at a level above that recommended for publically distributed health information. CLINICAL RELEVANCE: Physicians should advise their patients to search for information using the term "developmental dysplasia of the hip" or, better yet, should refer patients to Web sites that they have personally reviewed for content and clarity. Orthopaedic surgeons, professional societies, and search engines should undertake efforts to ensure that patients have access to information about DDH that is both accurate and easily understandable.

Cartilage Restoration for Isolated Patellar Chondral Defects: An Updated Systematic Review.

Background: Patellar chondral lesions can be particularly challenging to manage in younger and more active populations. Purpose: To synthesize, organize, and summarize the results and complication rates of various patellar cartilage restoration techniques. Study Design: Systematic review; Level of evidence, 4. Methods: We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the Medline, Embase, Scopus, and Cochrane databases. Studies were included that reported on surgical treatment of patellar chondral defects with ≥5 patients and 12 months of follow-up data. Relevant demographic data from the included studies were extracted, and patient-reported outcome scores, visual analog scale for pain results, return-to-sport rate, complications, and concomitant procedures were documented. Results: There were 24 studies that met the inclusion criteria, with a total of 575 patients (male, n = 239; female, n = 336). In total, 6 surgical techniques were utilized. In 9 studies, the surgical procedure of choice was osteochondral autograft transplantation (OAT); 8 studies evaluated autologous chondrocyte implantation (ACI); 3 evaluated advanced microfracture/autologous matrix-induced chondrogenesis; 1 evaluated osteochondral allograft transplantation (OCA); 1 evaluated particulate juvenile articulated cartilage; and 2 evaluated a synthetic osteochondral graft. No uniform functional outcome score or assessment was utilized across studies. OAT was predominantly used for smaller chondral lesions (<2 cm2) and demonstrated minimal complication rates and satisfactory outcome scores. Advanced microfracture techniques showed promise, with improvement in outcome scores and zero complications. Matrix-induced ACI consistently exhibited higher mean improvement in the measured outcome scores and resulted in fewer complications when compared with previous generations of ACI. Conclusion: OAT and ACI were the most studied procedures for isolated patellar chondral defects. Advanced microfracture techniques showed promise, but indications (ie, size) and variability in techniques need to be elucidated in higher-level studies. Further prospective studies comparing OCA and matrix-induced ACI for larger patellar defects are necessary to determine the superior technique.

Automated Insulin Delivery with Remote Real-Time Continuous Glucose Monitoring for Hospitalized Patients with Diabetes: A Multicenter, Single-Arm, Feasibility Trial.

Introduction: Multiple daily injection insulin therapy frequently fails to meet hospital glycemic goals and is prone to hypoglycemia. Automated insulin delivery (AID) with remote glucose monitoring offers a solution to these shortcomings. Research Design and Methods: In a single-arm multicenter pilot trial, we tested the feasibility, safety, and effectiveness of the Omnipod 5 AID System with real-time continuous glucose monitoring (CGM) for up to 10 days in hospitalized patients with insulin-requiring diabetes on nonintensive care unit medical-surgical units. Primary endpoints included the proportion of time in automated mode and percent time-in-range (TIR 70-180 mg/dL) among participants with >48 h of CGM data. Safety endpoints included incidence of severe hypoglycemia and diabetes-related ketoacidosis (DKA). Additional glycemic endpoints, CGM accuracy, and patient satisfaction were also explored. Results: Twenty-two participants were enrolled; 18 used the system for a total of 96 days (mean 5.3 ± 3.1 days per patient), and 16 had sufficient CGM data required for analysis. Median percent time in automated mode was 95% (interquartile range 92%-98%) for the 18 system users, and the 16 participants with >48 h of CGM data achieved an overall TIR of 68% ± 16%, with 0.17% ± 0.3% time <70 mg/dL and 0.06% ± 0.2% time <54 mg/dL. Sensor mean glucose was 167 ± 21 mg/dL. There were no DKA or severe hypoglycemic events. All participants reported satisfaction with the system at study end. Conclusions: The use of AID with a disposable tubeless patch-pump along with remote real-time CGM is feasible in the hospital setting. These results warrant further investigation in randomized trials.

Stable fixation of short-stem femoral implants in patients 70 years and older.

BACKGROUND: Limitations of conventional uncemented femoral stems persist, including proximal-distal mismatch, nonideal load transfer, loss of bone, and difficulties with minimally invasive surgery. Metaphyseal-engaging short-stem implants have been designed to address these issues in THA. While these devices have been studied in younger patients, it is unclear whether they offer advantages in older patients. QUESTIONS/PURPOSES: We asked whether the stability and bony ingrowth of an off-the-shelf short stem in patients 70 years and older were similar to those achieved in patients younger than 70 years at 2-year followup. Furthermore, we asked whether pain and function scores were affected by age, bone quality, or varus alignment. PATIENTS AND METHODS: We retrospectively reviewed 60 patients (65 hips) 70 years and older (mean, 75 years; range, 70-86 years) treated with an uncemented short stem (range, 90-105 mm). We compared radiographic alignment, stability, and bony ingrowth, as well as Harris hip scores and WOMAC pain scores, to a cohort of 89 patients (91 hips) younger than 70 years. Minimum followup was 24 months (mean, 35 months; range, 24-60 months). RESULTS: Radiographs showed proximal bony ingrowth and stable fixation of all implants. Average Harris hip score at last followup was 88 (range, 70-100) for the 70 years and older cohort and 93 (range, 70-100) for younger than 70 years cohort; no patients reported thigh pain. Postoperative WOMAC scores averaged 6 (range, 0-43) and 5 (range, 0-25), respectively. CONCLUSIONS: Short-stem implants provide solid, dependable fixation in osteoporotic bone at minimum 2-year followup, while meeting some of the limitations in conventional primary THA. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Nonoperative management of scleroderma of the hand with tadalafil and subatmospheric pressure wound therapy: case report.

Scleroderma, or systemic sclerosis (SS), is an autoimmune disease leading to ischemic fibrosis and widespread collagen deposition, invariably affecting the hands. Optimized medical management remains the mainstay of therapy for SS. Surgery can be considered in refractory or severely disabling cases. However, microvascular insufficiency and fibrosis can lead to wound complications and, ultimately, amputation. We present the case of a 61-year-old man with a known history of scleroderma who presented with pain, chronic infection, and ulcerations in the left hand. Initially, amputation seemed a reasonable intervention. After medical optimization with tadalafil, his ulcerations persisted. Instead of amputation, we applied a subatmospheric pressure wound therapy device to his hand. In 4 months, his wounds had healed, there was no evidence of infection, and no digits were amputated.

The effect of search term on the quality and accuracy of online information regarding distal radius fractures.

PURPOSE: Recent emphasis on shared decision making and patient-centered research has increased the importance of patient education and health literacy. The internet is rapidly growing as a source of self-education for patients. However, concern exists over the quality, accuracy, and readability of the information. Our objective was to determine whether the quality, accuracy, and readability of information online about distal radius fractures vary with the search term. METHODS: This was a prospective evaluation of 3 search engines using 3 different search terms of varying sophistication ("distal radius fracture," "wrist fracture," and "broken wrist"). We evaluated 70 unique Web sites for quality, accuracy, and readability. We used comparative statistics to determine whether the search term affected the quality, accuracy, and readability of the Web sites found. Three orthopedic surgeons independently gauged quality and accuracy of information using a set of predetermined scoring criteria. We evaluated the readability of the Web site using the Fleisch-Kincaid score for reading grade level. RESULTS: There were significant differences in the quality, accuracy, and readability of information found, depending on the search term. We found higher quality and accuracy resulted from the search term "distal radius fracture," particularly compared with Web sites resulting from the term "broken wrist." The reading level was higher than recommended in 65 of the 70 Web sites and was significantly higher when searching with "distal radius fracture" than "wrist fracture" or "broken wrist." There was no correlation between Web site reading level and quality or accuracy. CONCLUSIONS: The readability of information about distal radius fractures in most Web sites was higher than the recommended reading level for the general public. The quality and accuracy of the information found significantly varied with the sophistication of the search term used. CLINICAL RELEVANCE: Physicians, professional societies, and search engines should consider efforts to improve internet access to high-quality information at an understandable level.

Chronic Quadriceps Tendon Ruptures: Primary Repair of Quadriceps Via Bioaugmentation and Patellar Tendon Lengthening.

Quadriceps tendon ruptures are devastating injuries that impair the extensor mechanism of the knee. Complete tears require prompt surgical intervention in order to ensure optimal clinical outcomes. Chronic, neglected ruptures- marked by severe extensor lag, muscular atrophy, and tendon retraction- are difficult to treat. Further, severe patella baja complicates surgical planning. While there is no consensus on optimal treatment for these injuries, many different techniques have been proposed. Unlike many of these approaches, our technique focuses on restoration of patellar height via patellar tendon lengthening. Once patellar height is restored, quadriceps tendon repair can be performed using the native quadriceps tendon. Both the patellar tendon lengthening and the quadriceps tendon repair are augmented with bioinductive implants to ensure optimal healing environments, enabling us to reestablish native extensor mechanism function.

Anteriorizing Tibial Tubercle Osteotomy for Patellofemoral Cartilage Lesions.

Patellofemoral chondral lesions are common and can lead to significant pain. A tibial tubercle osteotomy (TTO) functions to mechanically unload the patellofemoral joint and improve the clinical success of cartilage restoration procedures. The type of TTO performed is based on several factors. There is a subset of patients with patellofemoral cartilage disease who would benefit from a pure anteriorization of the tibial tubercle. We describe our technique for a pure anteriorization TTO, which functions to safely unload the patellofemoral joint in the appropriately indicated patient.