Short-Term Outcomes Following Endoscopic Proximal Hamstring Repair.

PURPOSE: The purpose of this study was to evaluate the outcomes of endoscopic proximal hamstring repair (ePHR), specifically: (1) functional and subjective outcomes, (2) effectiveness of treatment (preoperative-to-postoperative change), (3) complications, (4) acute versus chronic tears, and (5) partial versus complete tears. METHODS: A retrospective case series of a single-surgeon database for all patients who underwent ePHR between November 2014 and January 2019 with a minimum 1-year follow-up (range, 12 to 48 months) was performed. Charts were analyzed for preoperative and postoperative passive range of motion (PROM), strength, VAS pain, UCLA activity, and modified Harris Hip Score (mHHS). Manual muscle strength testing based on standard grading scale of 0 to 5 was performed. Complications including re-tear of the repair site, infection, iatrogenic nerve injury, inability to return to work/sport at the same level as preinjury, persistent hamstring weakness, pain with sitting, and subsequent surgery were recorded. RESULTS: We identified 20 ePHR (6 males, 14 females) with a mean age of 46 years (range, 18 to 63 years). At most recent follow-up, mean VAS pain was 1.85 (SD 2), UCLA activity was 8 (SD 2), mHHS was 90.6 (SD 10.5), and PROM hip flexion of 121.7° (SD 14.5°). Effectiveness of treatment demonstrated significant improvement in objective hamstring strength, hip flexion PROM by 17.3°, UCLA activity by 3, and VAS pain by 3 points. Subjective hamstring weakness was reported in 8 (42.1%) and persistent pain with sitting in 3 (15.8%). Return to work and sport were 100% and 95%, respectively. mHHS was significantly higher postoperatively in patients with complete versus partial tears (95.5 versus 85.7). CONCLUSION: Endoscopic proximal hamstring repair is an effective approach that provides patients significant improvement in pain and function. LEVEL OF EVIDENCE: IV, Case Series.

Ultrasound-Guided Calcium Debridement of the Shoulder Joint: A Case Series.

OBJECTIVE: Our purpose was to assess the outcomes of those who underwent an ultrasound-guided debridement of the deposits. Specifically, we analyzed: (1) function; (2) pain; (3) activity level; (4) patient satisfaction; and (5) complications. MATERIALS AND METHODS: A review of patients who underwent an ultrasound-guided debridement of calcific deposits about their shoulder joint between 2005 and 2015 was performed. Our final cohort consisted of 38 patients with a mean age of 53 years (range, 35 to 62 years)-11 men and 27 women-and a mean follow up of 32 months (range, 12 to 53 months). Functional outcomes, activity level, and pain level were assessed using the Disabilities of Arm, Shoulder, and Hand (DASH) scale, the University of Southern California (UCLA) activity scale, and the Visual Analog Scale (VAS). Additionally, patients were asked if they were satisfied with the outcomes of their procedure. All medical records were assessed for potential complications from this procedure. RESULTS: Excellent outcomes were achieved. The mean DASH score improved from 21 to 10 points (p=0.0001). Additionally, mean UCLA score increased from 2 to 7 points (p=0.0001). Furthermore, the mean reported VAS improved from 8 to 1.6 (p=0.0001). Ninety-seven percent of patients reported being satisfied. There were no reported complications in our cohort. CONCLUSION: We found that this procedure can result in effective pain relief and prevent or delay the need for more invasive procedures. Future studies should evaluate the role of calcium deposit size in the outcomes of those who undergo debridement.

No Decrease in Knee Survivorship or Outcomes Scores for Patients With HIV Infection Who Undergo TKA.

BACKGROUND: HIV is prevalent worldwide and numerous patients with this diagnosis ultimately may become candidates for TKA. Although some studies have suggested that complications are more common in patients with HIV who undergo TKA, these studies largely were done before the contemporary era of HIV management; moreover, it is unclear whether patients with HIV achieve lower patient-reported outcome scores or inferior implant survivorship. QUESTIONS/PURPOSES: We asked whether there were any differences in the outcomes of patients with HIV without hemophilia who undergo TKA compared with a matched control cohort in terms of: (1) patient-reported outcomes; (2) implant survivorship; and (3) complication rates. METHODS: Forty-five patients with HIV who had undergone 50 TKAs at three institutions with a minimum followup of 4 years between 2005 and 2011 were identified. An additional three patients were lost to followup before the fourth-year annual visit. All patients with HIV underwent thorough preoperative optimization with their primary care physician and infectious disease specialist. There were 31 men and 14 women with a mean age of 57 years and mean followup of 6 years (range, 4-10 years). These patients were compared with a matched cohort of 135 patients (one-to-three ratio) who did not have HIV and who had undergone a primary TKA by the same surgeons during this same period using the same implant. Matching criteria included patient age (within 2 years), BMI (within 2 kg/m2), surgeon performing TKA, followup (within 6 months), minimum followup of 4 years, sex ratio, and primary diagnosis (degenerative joint disease versus osteonecrosis). Approximately 10% of patients in the matching group had not returned for followup after their sixth annual visit. Outcomes evaluated included The Knee Society objective and function scores, University of California, Los Angeles (UCLA) activity scores, overall implant survivorship (free of revision) using Kaplan-Meier analysis, and complications. With the numbers available, there were no differences in preoperative Knee Society score or UCLA activity scores among the cohorts. RESULTS: With the numbers available, there were no differences in the mean Knee Society objective scores between patients with HIV (89 ± 11 points) and the matching cohort (91 ± 14 points) (95% CI, -7 to 3; p = 0.38). There were no differences among the Knee Society functional component as well (88 ± 12 points versus 90 ± 13 points; 95% CI, -6 to 2; p = 0.36) at latest followup. Similarly, there were no differences with the numbers available in the UCLA activity scores (6 ± 5 points [range, 4-7] versus 6 ± 7 points [range, 4-8]; p = 0.87) between the cohorts. With the numbers available, Kaplan-Meier analysis showed no significant difference in the overall implant survivorships between patients with HIV (98%; 95% CI, 94%-99%) compared with the matching group (99%; 95% CI, 98%-100%; p = 0.89). Postoperative complications were also comparable between the two groups. CONCLUSIONS: With the numbers available, we found that patients with HIV had no differences in clinical scores and implant survivorship compared with patients without the disease at mid-term followup. We believe practitioners should not be reluctant to perform TKA on this patient population. However, we believe the preoperative optimization process is crucial to achieving good outcomes and minimizing the risk of complications. Future comparative studies should have longer followup and a larger sample size with greater power to determine if there are differences in complications and implant survivorship. LEVEL OF EVIDENCE: Level III, therapeutic study.

A Systematic Review of Tennis Elbow Surgery: Open Versus Arthroscopic Versus Percutaneous Release of the Common Extensor Origin.

PURPOSE: To compare complications, function, pain, and patient satisfaction after conventional open, percutaneous, or arthroscopic release of the extensor origin for the treatment of lateral epicondylitis. METHODS: A thorough review of 4 databases-PubMed, EBSCOhost, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus, and Scopus-was performed to identify all studies that addressed surgical management of lateral epicondylitis. We included (1) studies published between 2000 and 2015 and (2) studies with clearly defined surgical techniques. We excluded (1) non-English-language manuscripts, (2) isolated case reports, (3) studies with fewer than 10 subjects, (4) animal studies, (5) studies with additional adjunctive procedures aside from release of the extensor origin, (6) clinical or systematic review manuscripts, (7) studies with a follow-up period of 6 months or less, and (8) studies in which less than 80% of patients completed follow-up. Each study was analyzed for complication rates, functional outcomes, pain, and patient satisfaction. RESULTS: Thirty reports were identified that included 848 open, 578 arthroscopic, and 178 percutaneous releases. Patients within each release group had a similar age (46 years vs 46 years vs 48 years; P = .9 and P = .4, respectively), whereas there was a longer follow-up time in patients who underwent surgery by an open technique (49.4 months vs 42.6 months vs 23 months, P < .001). There were no differences in complication rates among these techniques (3.8% vs 2.9% vs 3.9%; P = .5 and P = .9, respectively). However, open techniques were correlated with higher surgical-site infection rates than arthroscopic techniques (0.7% vs 0%, P = .04). Mean Disabilities of the Arm, Shoulder and Hand scores were substantially better with both open and arthroscopic techniques than with percutaneous release (19.9 points vs 21.3 points vs 29 points, P < .001). In addition, there was less pain reported in the arthroscopic and percutaneous release groups as opposed to their open counterparts (1.9 points vs 1.4 points vs 1.3 points, P < .0001). There were no differences among the techniques in patient satisfaction rate (93.7% vs 89% vs 88%; P = .08 and P = .07, respectively). CONCLUSIONS: Functional outcomes of open and arthroscopic releases may be superior to those of percutaneous release. In addition, patients may report less pain with arthroscopic and percutaneous techniques. Although the risk of complications is similar regardless of technique, patients may be counseled that their risk of infectious complications may be slightly higher with open releases. However, it is important to note that this statistical difference may not necessarily portend noticeable clinical differences. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV evidence.

Sexual Activity After Total Hip Arthroplasty: A Systematic Review of the Outcomes.

BACKGROUND: Total hip arthroplasty (THA) may have a marked positive impact on sexual activity. However, it is unclear how important regaining sexual activity is for patients undergoing THA or whether surgeons are aware of such concerns. The purpose of this systematic review was to evaluate the literature on the effect of THA on sexual activity before and after the procedure and to assess patient and surgeon perspectives. METHODS: A search of 4 electronic databases yielded 10 reports between 1970 and 2015. Nine evaluated the effects of THA on sexual activity in 1694 patients who had a mean age of 57 years (range 17-98 years). Two studies evaluated the perspective of 337 surgeons. Metrics evaluated included differences in patient and surgeon perspectives, improvements in sexual activity, and differences in outcomes between men and women. RESULTS: Seventy-six percent of patients identified hip arthritis as the primary cause of sexual problems with pain and stiffness being the most common complaints. Post THA, 44% of patients reported improvements in sexual satisfaction while 27% reported increased intercourse frequency. Patients returned to sexual activity at a mean 4-month post-THA. Eighty-six percent of surgeons rarely or never discuss sexual activity with their patients, and 61% believed that patients can resume sexual activity 1-month post-THA with many agreeing that certain positions were safer. CONCLUSION: The outcomes of this systematic review suggest that THA is associated with improved sexual activities and is an important topic for patients. However, surgeons may spend less time than is desired by the patients on this subject pre- and post-THA.

An Anterior Inferior Iliac Spine Avulsion Fracture in a 14-Year Old Boy on Human Growth Hormone.

We present the case of a young man with an anterior inferior iliac spine (AIIS) avulsion fracture who was taking human growth hormone (HGH) at the time his injury was diagnosed. He presented with chronic hip pain and no traumatic event. Physical exam revealed symptoms of hip impingement. Upon imaging, he was diagnosed with an AIIS avulsion fracture and underwent surgical repair. He returned to full activity six months post-operatively. At 18-months post-operatively, he was pain-free and performing all activities without difficulty. The role of HGH in his injury or recovery is not well understood and must be studied with large database studies.

Low Ankle Sprains: A Current Review of Diagnosis and Treatment.

LLow ankle sprains are common injuries in young athletes. Hence, it is imperative that low ankle sprains are diagnosed and treated quickly and effectively. We reviewed the: (1) anatomy; (2) imaging; (3) physical exam findings; and (4) treatment modalities regarding these injuries. Plain radiographs are standard of care and routine MRI is not recommended for suspected sprains. However, physical exam findings often may guide management decisions. The majority of patients diagnosed with low ankle sprains are treated with a one- to two-week immobilization period with physical therapy focused on peroneal proprioception and strength. If a prolonged non-operative course fails, or there is gross instability upon physical exam (grade III sprain), surgical reconstruction may be considered and may lead to excellent outcomes. When low ankle sprains do occur, the great majority may be treated non-operatively. In the event that conservative modalities fail, surgical reconstruction may be considered with an open modified Brostrom reconstruction as the current standard of care.

A Partial Posterior Bundle Ulnar Collateral Ligament Tear in a 10-year old Boy.

Medial-sided elbow pain is becoming more common among pediatric overhead sport athletes. One potential cause of this is a partial or complete tear of the ulnar collateral ligament (UCL). Because the growth plate remains open in many of these athletes, the most common injury experienced is an avulsion at the medial epicondyle. However, although rare, there is a potential to tear the UCL, with the most common tears occurring at the anterior bundle. However, tears to the posterior bundle are quite rare in pediatric patients. We aim to describe the case of a 10-year old boy who was diagnosed with a partial posterior bundle UCL tear and was successfully treated by cessation of throwing activities and physical therapy. He was able to return to baseball 10 months after his diagnosis.

Midterm Outcomes Following Total Knee Arthroplasty in Lupus Patients.

BACKGROUND: An increasing number of patients with systemic lupus erythematosus (SLE) are undergoing total knee arthroplasty (TKA), but there are few studies detailing their outcomes. The purpose of this study was to evaluate TKA cohort of patients who had SLE compared with a matched cohort who did not have this disease by analyzing (1) implant survivorship, (2) functional outcomes, (3) complication rates, (4) health-related quality of life, and (5) patient-perceived activity level. METHODS: A retrospective review of all patients who underwent TKA and had an International Classification of Diseases, Ninth Revision, code diagnosis for SLE was performed at 3 high-volume institutions. A total of 31 patients (34 arthroplasties) were identified, and they were compared with a matched cohort (1:3) who did not have SLE and had undergone a primary TKA during this same time period. RESULTS: After a mean 6-year follow-up (range, 2-10 years), both cohorts had similar implant survivorship (91% vs 99%). In addition, each cohort had similar complication rates (odds ratio = 1.9, 0.99-13). Functional outcomes were similar as measured by Knee Society Scores objective (90 vs 91 points) and functional (89 vs 90 points). There were no differences in Short Form-36 physical (47 vs 49 points) or mental components (51 vs 53 points). University of California Los Angeles activity scores were similar as well (5.1 vs 5.9 points). CONCLUSIONS: Our study demonstrated comparable excellent clinical and patient-reported outcomes of TKA in patients with or without SLE. Prospective studies are necessary to evaluate these outcomes at longer follow-up.

Total Shoulder Arthroplasty Demographics, Incidence, and Complications-A Nationwide Inpatient Sample Database Study.

INTRODUCTION: Total shoulder arthroplasty (TSA) has become a popular and successful surgery to treat advanced glenohumeral arthritis, rotator cuff arthropathy, and proximal humerus fractures. Historical data is available investigating the epidemiology of total shoulder arthroplasty with regard to patient characteristics, outcomes, and complications; however, there is a lack of studies investigating the most recent and up to date national trends related to shoulder replacement. The purpose of this study was to evaluate changes in the annual incidence, various demographics, and complications of TSA in America. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) was assessed to identify all patients who were admitted for TSA in the United States between 1998 and 2010. National trends in patient demographics, incidence, and length-of-stay (LOS) were analyzed for correlations. The impacts of contributing factors to each outcome were assessed using adjusted multivariable regression analysis. These were used to calculate odds ratios of cohort demographics and their association with complications and LOS. RESULTS: Admissions for TSA have risen (8,041 to 39,072 admissions). The majority of the cohort consisted of Caucasian men between the ages of 64 and 79 years. The incidence rate of complications has remained consistent. Female gender, age > 80 years, and higher Deyo Comorbidity scores were risk factors for higher complications. The LOS has decreased (2.96 to 2.21 days) during the study time period. Female gender, African-American race, Medicaid insurance, and higher Deyo Comorbidity scores were associated with longer stays. DISCUSSION: Our study demonstrates a rapid increase in incidence rates of TSAs within the 13-year period in the United States. An increased risk of complications was noted with older age, female gender, and increased Deyo score. CONCLUSION: Our findings may help health care providers identify ways to better manage this procedure and select patients.

Accuracy of in vivo palpation-guided acromioclavicular joint injection assessed with contrast material and fluoroscopic evaluations.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of in vivo acromioclavicular (AC) joint injections without fluoroscopic guidance and assess whether patient demographics affected the accuracy of injections. MATERIALS AND METHODS: A consecutive cohort of patients who presented with painful acromioclavicular joints was prospectively evaluated. All patients had clinical and radiographic evidence of AC arthritis, had failed conservative measures, and thus had received intraarticular corticosteroid injections. All injections were performed by experienced fellowship-trained musculoskeletal radiologists and by blinded digital palpation technique. Accuracy of injections was assessed with biplanar fluoroscopic views. RESULTS: Forty-one AC injections in 22 males and 16 females with a mean age of 51 years (range 18 to 78) were identified. Twenty-three injections were in the right shoulder and 18 in the left. Only 15 injections were confirmed to be in the intraarticular AC joint, yielding an accuracy of 36.5%. There were no significant differences in the mean age (54 vs. 52 years; p = 0.58), male-to-female ratio (p = 0.73), and side of the injection between the accurate and inaccurate injections, respectively. CONCLUSION: Based on the findings of the present study, the authors encourage the use of image guidance for corticosteroid treatment of the AC joint. LEVEL OF EVIDENCE: Level IV Therapeutic Case Series.

Visualization of the extra-articular portion of the long head of the biceps tendon during intra-articular shoulder arthroscopy.

PURPOSE: To quantify the amount of the extra-articular long head of the biceps tendon (LHBT) seen during intra-articular shoulder arthroscopy by pulling the tendon into the joint with a probe through an anterior portal while viewing through a standard posterior portal. METHODS: Intra-articular shoulder arthroscopy was performed on 10 forequarter cadaveric specimens. The extra-articular portion of the LHBT was evaluated by pulling the tendon into the joint with an arthroscopic probe inserted through an anterior portal. The tendon was marked at the pulley insertion on the humerus with a vascular clip before and after the tendon was pulled into the joint. An open deltopectoral approach was performed, and the amount of extra-articular tendon visualized was calculated as an absolute amount and in relation to nearby anatomic structures. RESULTS: An additional 1.9 cm (range, 1.4 to 2.6 cm) of extra-articular LHBT was viewed by pulling the tendon into the joint with an arthroscopic probe through an anterior portal during shoulder arthroscopy. This represented 30.8% of the extra-articular portion of the tendon, 47.7% of tendon in the bicipital groove, and 76.3% of the tendon that lies under the area from the pulley insertion to the distal edge of the transverse humeral ligament. CONCLUSIONS: During intra-articular shoulder arthroscopy, the extra-articular portion of the LHBT is incompletely visualized by pulling the tendon into the joint with a probe placed through an anterior portal while viewing through a standard posterior portal. CLINICAL RELEVANCE: An additional extra-articular portion of the LHBT may be viewed by pulling the tendon into the joint with an arthroscopic probe during shoulder arthroscopy.

Improved Outcomes with Arthroscopic Bone Marrow Aspirate Concentrate and Cartilage-Derived Matrix Implantation versus Chondroplasty for the Treatment of Focal Chondral Defects of the Knee Joint: A Retrospective Case Series.

Purpose: To compare the outcomes of patients undergoing treatment of focal chondral defects (FCDs) of the knee joint with chondroplasty versus bone marrow aspirate concentrate (BMAC) and cartilage-derived matrix (CDM) implantation. Methods: A retrospective chart review was performed for patients diagnosed with Outerbridge grade 3-4 FCDs. Patients were included if they were treated arthroscopically with BMAC/CDM implantation or chondroplasty alone between March 2016 and May 2019 and had more than 1-year follow-up. Postoperative outcomes included the visual analog scale (VAS) for pain; University of California, Los Angeles (UCLA) activity scores; Knee Outcome Survey (KOS) Activities of Daily Living (ADL) and Sports subscores; postoperative corticosteroid or hyaluronic acid injections; subsequent surgeries; and conversion to total knee arthroplasty. Results: A total of 98 patients were identified with a mean follow-up in BMAC/CDM of 24 months (range 13-41 months) and in chondroplasty of 44 months (range 34-55 months). A subanalysis was performed to control for significant differences in age, which yielded 39 patients, ages 40-60 years. Within the subanalysis group, mean VAS scores were significantly lower in the BMAC/CDM group (1.7 vs 4.4; P = .005) and mean UCLA scores were significantly greater (7.1 vs 5.0; P = .002). Mean improvement in VAS and UCLA scores were similar between the BMAC/CDM and chondroplasty groups (-3.7 vs -1.3; P = .71, 1.9 vs 0.1; P = .14, respectively). Mean KOS ADL and Sports subscores were significantly greater among patients in the BMAC/CDM group (87% vs 55%; P = .001, 71% vs 41%; P = .002, respectively). There were no differences in postoperative injections, subsequent surgeries, or conversion to total knee arthroplasty between the BMAC/CDM and chondroplasty groups. Conclusions: Patients with grade 3-4 FCDs of the knee had improved postoperative outcomes when treated with BMAC/CDM implantation versus chondroplasty alone, as evidenced by a significant improvement in VAS and UCLA scores and significantly greater postoperative KOS ADL, and KOS Sport subscores. Level of Evidence: IV, therapeutic case series.

Risk Factors for Requiring a Revision Anterior Cruciate Ligament Reconstruction: A Case-Control Study.

Anterior cruciate ligament (ACL) reconstruction is considered as a successful orthopaedic procedure that attempts to help patients return to their preinjury level of activity. However, some patients may need to undergo revision surgery, and this potentially may be associated with certain surgery-specific or patient risk factors. Therefore, the purpose of this study was to assess the potential role of (1) demographics, (2) family history, (3) graft choice, (4) sport, and (5) mechanism of injury (contact vs. noncontact) in the risk for needing a revision ACL for improved clinical outcomes. All patients who had undergone a primary ACL reconstruction between 2012 and 2016 were identified from at a single institution. About 312 patients who had a mean age of 24 years (range, 9-62 years) and a mean follow-up of 4 years (range, 1-10). Patients were further evaluated to identify those who had a revision. There were 19 patients (6.1%) with a mean age of 22 years (range, 13-38 years) and a mean follow-up of 5 years (range, 1-10) that required a revision reconstruction. Gender ratios (p = 0.56) and mean age (p = 0.44) were similar among the cohorts. Family history of ACL reconstruction had no association with revision risk (p = 0.57). Those with tibialis anterior allografts (37 vs. 4%; p = 0.0001) and hamstring allografts (16 vs. 1%; p = 0.0001) were far more likely to undergo a revision. Bone-tendon-bone (BTB) patella autografts were less likely (26 vs. 73%; p = 0.0001). Sport did not play a role in revision with those injured playing basketball (p = 0.61), football (p = 0.52), lacrosse (p = 0.52), soccer (p = 0.83), and volleyball (p = 0.61). There were a greater percentage of contact injuries that required revision (95 vs. 77%; p = 0.07). Graft selection played a significant role in requiring revision surgery with allografts portending to higher revision rates and BTB patella autografts conferring a lower risk.

Factors Complicating Discharge to Home following Total Knee Arthroplasty-A Single Institution Initiative.

Recently, with the Medicare bundled payments initiative for total knee arthroplasty (TKA), there has been a move by many institutions to further streamline costs associated with the entire operative and perioperative process. One of these cost-saving strategies has been to favor discharging patients to home with outpatient services as opposed to discharging to the relatively more expensive rehabilitation facilities. Our aim was to determine the success of a teaching institute's initiative in discharging patients to home instead of a rehabilitation facility. Specifically, we evaluated if there were differences in discharge disposition based off of (1) surgeon/patient preference, (2) length of stay, (3) demographics, and (4) postoperative complications. A retrospective review of all patients who had a TKA from 2015 to 2017 at a single teaching institution was performed and assessed discharge to home or to a rehabilitation facility. If they were not discharged to home, we evaluated why that did not happen, stratified the reason they were discharged to a rehabilitation facility into four groups based on (1) physician and occupational health team assessment, (2) patient preference, (3) physician preference, and (4) family or caretaker preference. A total of 229 patients were enrolled in this initiative, with 107 patients (47%) discharged to home with outpatient physical therapy services and 122 (53%) discharged to a rehabilitation facility. Of these, 35 patients (29%) went to these facilities because of physician and occupational health team assessment. However, 31 (25%) patients were due to patient preference, 32 (26%) were because of surgeon's preference, and 24 (20%) were not discharged to home because of family or caretaker preference. There were no differences in length of stay, gender, or complication rates between cohorts. Many patients can be safely discharged to home following TKA at a community teaching institution; however, there continues to be a strong prejudice by patients, physicians, and caretakers to be discharged to a rehabilitation facility despite the home discharge initiative.

Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture.

PURPOSE: A magnetic resonance imaging (MRI) scan of the elbow is often obtained to confirm the clinical suspicion of a distal biceps tendon rupture. The goal of this study was to evaluate the effectiveness of MRI in diagnosing partial and complete distal biceps tendon ruptures as determined at the time of surgery. METHODS: We identified 22 partial and 24 complete distal biceps tendon ruptures operated on by a single surgeon. The preoperative MRIs of these patients were obtained, along with MRIs of the elbow in 10 asymptomatic individuals. Two musculoskeletal radiologists read each MRI without knowledge of the diagnosis or the surgical findings. Their interpretations were compared with the intraoperative findings and the results were statistically analyzed. RESULTS: The overall sensitivity and specificity of MRI were 92.4% and 100%, respectively, in detecting distal biceps tendon ruptures. The sensitivity and specificity of MRI for complete tears were 100% and 82.8%, respectively. The sensitivity and specificity of MRI for partial tears were 59.1% and 100%, respectively. CONCLUSIONS: Magnetic resonance imaging is an effective tool for diagnosing distal biceps tendon ruptures. Although MRI is extremely sensitive in diagnosing complete tears, it is substantially less sensitive in diagnosing partial tears. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Accelerated Discharge following Total Knee Arthroplasty May Be Safe in a Teaching Institution.

Total knee arthroplasty (TKA) is one of the most commonly performed yet costly surgical procedures in orthopaedics. With national trends and reimbursements moving in favor of shorter hospital length-of-stay (LOS), it is important to understand the complications associated with discharging patients earlier. This is particularly more challenging in a teaching institution due to complexity and variety of layers of care. Therefore, the purpose of this study was to evaluate the 90-day postoperative outcomes among those who were discharged on postoperative day 2 (POD-2) and compare them to a cohort whom had a LOS ≥ 3 days. A retrospective review of all patients who underwent a primary TKA from at a single-teaching institution from 2015 to 2017 was performed. During this time, an accelerated discharge protocol was designed and implanted in our institution. We identified 485 patients who were then substratified into two groups: patients who were discharged on POD-2 (n = 91) with the accelerated protocol and those who were discharged ≥ 3 days (n = 394). Outcomes evaluated included (1) demographics, (2) readmission rates, (3) emergency room (ER) visits, and (4) complication rates within 90 days of TKA. The POD-2 cohort was significantly younger than patients with ≥ 3-day LOS (64 vs. 69 years; p = 0.0001). There were no differences in gender ratios between the 2-day and 3-day cohorts (women, 67 vs. 72%; p = 0.34). Readmission rates (2 vs. 5%; p = 0.31) and ER visits were similar between cohorts (9 vs. 6%; p = 0.4). Medical and surgical complication rates did not differ between the two cohorts, with an overall complication rate of 5.5% in POD-2 versus 5.6% in >3 days LOS (p = 0.97). Patients discharged on POD-2 from TKA did not demonstrate an increased risk of complications, ER visits, or readmissions within 90 days in a teaching institution. However, older patients tended to have a longer LOS.

National Trends in Orthopaedic Surgery Resident Adult Case Logs.

OBJECTIVE: Our purpose was to assess United States data to determine if there were changes in the number of adult cases that graduating orthopaedic surgery resident logged. DESIGN: We assessed the Accreditation Council for Graduate Medical Education data from 2010 to 2016 to identify the number of cases that were reported by graduating orthopaedic surgery residents through the United States. Specifically, we analyzed the mean total number of adult cases per graduating resident. We substratified the data based on the subspecialty to include total number of cases performed in: (1) upper extremity; (2) lower extremity; (3) spine; (4) oncology; and (5) trauma. SETTING: All data collection was performed at the Seton Hall School of Health and Medical Sciences. PARTICIPANTS: All United States orthopaedic surgery residents were considered participants RESULTS: During the study period, the total number of cases performed by each resident had decreased from 1791 to 1311 (p = 0.0001). There was only an increase in the number of pelvis/hip cases (p = 0.0001). Among upper extremity cases, there was a decrease in each subtype of cases (p = 0.0001). There was a decrease in the number of femur/knee, leg/ankle, and foot/toes cases per resident (p = 0.0001). Furthermore, there was a decrease in the number of spine and trauma cases performed (p = 0.0001). There was no difference in the number of oncology cases performed (p = 0.47). CONCLUSIONS: We noted a decrease in the number of cases logged by graduating residents over the past 6 academic years. This provides a great deal of insight into the need for residencies to ensure that the appropriate Accreditation Council for Graduate Medical Education bench marks are met. Future studies should analyze how cases may be increased.

Cervical Spinal Stenosis with Coexisting Rotator Cuff Tear: A Nationwide Review of Records from 2005 to 2014.

Rotator cuff tear (RCT) and cervical spinal stenosis (CSS) are common pathologies in the elderly. Both conditions may present with lateral shoulder pain and weakness or numbness of the upper extremity, potentially affecting patients' ability to live independently. Few data are available on the incidence of CSS among patients with concurrent RCT. The purpose of this study was to investigate the incidence of CSS among RCT patients, demographics, and surgical management using a national insurance database. The Medicare database was used to identify patients with RCT and concomitant CSS by ICD-9 codes from 2005-2014. Trends based on age, gender, and body mass index (BMI) were assessed. Utilization of open and arthroscopic rotator cuff repair (RCR) was compared. A total of 86,501 patients were identified. The number of patients diagnosed with RCT and CSS significantly increased (p< 0.0001). The incidence of CSS in patients with RCT increased from 9% to 13% (p < 0.05). Females < 64 years were more likely to exhibit combined pathology than age-matched males (OR 1.15, 95% CI 1.12 to 1.18) or females > 65 years (OR 1.64, 96% CI 1.61 to 1.67). A BMI of 30-40 kg/m2 demonstrated the highest incidence (43%, p < 0.0001). Arthroscopic RCR increased by 2% (p = 0.03) in RCT-CSS. The incidence of CSS in RCT patient is increasing. Orthopedic surgeons should maintain high clinical suspicion for concurrent CSS pathology in patients with RCT, particularly in obese female patients > 65 years with several medical comorbidities. Further investigation into the influence of these concurrent pathologies on patient outcomes is warranted.

Soft Tissue Reconstruction of the Proximal Tibiofibular Joint by Using Split Biceps Femoris Graft with 5-Year Clinical Follow-up.

Instability of the proximal tibiofibular joint (PTFJ) is a rare clinical condition that presents unique challenges to treatment. We present the case of an active 26-year-old woman with a 4-year history of recurrent PTFJ subluxations, treated surgically at our institution using a split biceps femoris tendon graft for PTFJ reconstruction. She underwent several attempts at nonoperative management until we decided to proceed with surgical intervention. A split biceps femoris graft was used to restore stability of the PTFJ. Approximately 5 years postoperatively, she achieved full range of motion as well as functional and clinical Knee Society Scores of 94 and 90 points, respectively. To the best of our knowledge, this is the first case report of PTFJ instability treated surgically with long-term follow-up. Future studies should focus on the long-term satisfactory outcomes of soft tissue stabilization of a chronically unstable PTFJ.