The Van Gorder approach for total elbow arthroplasty.

BACKGROUND: Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA. METHODS: All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed. RESULTS: A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits. CONCLUSIONS: This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.

Total shoulder arthroplasty for osteoarthritis in patients with Parkinson's disease: a matched comparison of 90-day adverse events and 5-year implant survival.

BACKGROUND: Patients with Parkinson's disease and shoulder osteoarthritis may be indicated for total shoulder arthroplasty. However, short- and long-term outcomes after total shoulder arthroplasty in this population remain poorly characterized. METHODS: A retrospective matched case-control study was performed using data abstracted from the 2010-2018 PearlDiver Mariner administrative database. Patients undergoing total shoulder arthroplasty were identified, and those with and without the diagnosis of Parkinson's disease were matched (1:10) based on age, gender, Elixhauser comorbidity index, diabetes, chronic kidney disease, obesity, coronary artery disease, and congestive heart failure. Ninety-day incidence of adverse events were compared with multivariate regressions. Implant survival was also assessed for up to 5 years, based on the occurrence of revision surgery. Kaplan-Meier implant survival curves were compared using a log-rank test. RESULTS: In total, 478 patients with Parkinson's disease were matched to 4715 patients without Parkinson's disease. After adjusting for demographic and comorbid factors, patients with Parkinson's disease had significantly higher odds of prosthetic dislocation (odds ratio = 3.07, P = .001), but did not experience increased odds of other 90-day adverse events. Five-year follow-up was available for 428 (89.5%) of those with Parkinson's disease and 3794 (80.5%) of those without Parkinson's disease. There was 97.2% implant survival in the Parkinson's disease cohort and 97.7% implant survival in the matched control cohort (not significantly different, P = .463). CONCLUSIONS: Patients with Parkinson's disease undergoing total shoulder arthroplasty, compared with patients without Parkinson's disease, have 3-fold higher odds of periprosthetic dislocation in the 90-day postoperative period, but equivalent rates of other short-term adverse events as well as implant survival at 5 years. Accordingly, surgeons should be mindful of the short-term risk of implant instability but should have confidence in long-term total shoulder implant success in the Parkinson's disease population.

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients.

BACKGROUND: Patients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied. METHODS: All patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint. RESULTS: Of 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon. CONCLUSION: Patients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.

Measuring Proximal Tibial Metaphyseal Width and Lateral Epiphyseal Height Improves Determination of Remaining Growth in Children.

BACKGROUND: Accurate assessments of skeletal maturity is of critical importance to guide type and timing of orthopaedic surgical interventions. Several quantitative markers of the proximal tibia were recently developed using historical knee radiographs. The purpose of the present study was to determine which marker would be most effective in assessment of full-length radiographs in a modern pediatric patient population. METHODS: All full-length radiographs at our institutions between 2013 and 2018 were reviewed. Inclusion criteria for our study required that the child reached final height as defined by 2 consecutive unchanged heights, at least 6 months apart, after age 16 for boys and 14 for girls. Patients with metabolic bone disease, prior surgery such as epiphysiodesis, or previous infections around the knee were excluded. Summary statistics for each of the 3 proximal tibial ratios were calculated and multiple linear regression was performed with percent of growth remaining as a dependent variable. A recommended regression model is presented and evaluated. RESULTS: A total of 692 full-length radiographs met inclusion criteria. Proximal tibial ratios were calculated and averaged values for each percent of growth remaining was presented. Multiple linear regression demonstrated that using all 3 variables led to overfitting of the model so tibial metaphyseal width/lateral tibial epiphyseal height was selected as the optimal ratio for use by clinicians. The optimal model for determining growth was found to have R2=0.723 in the developmental set and R2=0.762 in an excluded validation set. CONCLUSIONS: This study demonstrates that the proximal tibial metaphyseal width/lateral tibial epiphyseal height is the ideal measurement for clinicians seeking to determine growth remaining in children. It presents average values between 0% and 25% of growth remaining. This study also develops and validates a multivariable regression model for determining percentage of growth remaining in children that will allow for quantitative determination of growth using full-length radiographs. LEVEL OF EVIDENCE: Level III.

Predicting Growth Quantitatively Through Proximal Tibia Radiograph Markers.

BACKGROUND: The creation of accurate markers for skeletal maturity has been of significant interest to orthopaedic surgeons. They guide the management of diverse disorders such as adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injuries, and slipped capital femoral epiphysis. Multiple systems have been described to predict growth using radiographic skeletal markers; however, no such system has yet been developed for the proximal tibia. The purpose of this study was to establish quantitative radiographic parameters within the proximal tibia that can be used to assess degree of skeletal maturity. METHODS: From the Bolton Brush collection, 94 children, consisting of 49 girls and 4 boys between the ages of 3 and 18 years old, were followed annually throughout growth with serial radiographs and physical examinations. Final height at maturity was used to calculate the growth remaining at each visit. Multiple measurements for each knee radiograph were performed and correlated with the percentage of growth remaining. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were measured on each film and the composite ratios between each of these sets of variables along with their respective accuracy and reliability were calculated. Single and multiple linear regression models were constructed to determine accuracy of prediction. Interobserver and intraobserver studies were performed with 4 investigators ranging from medical student to senior attending and calculated using the intraclass correlation coefficient. All 4 examiners measured all of the subjects and the ratios created were averaged. RESULTS: Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were all found to be strongly correlated with growth remaining with R values ranging from 0.57 to 0.84. In addition, all 3 ratios were found to be reliable with intraobserver and interobserver intraclass correlation coefficients ranging from 0.92 to 0.94 and 0.80 to 0.94, respectively. A multiple linear regression model demonstrated that combining these 3 ratios allows for a predictive R value of 0.917, showing that these ratios when combined were highly predictive of growth remaining. All findings were independent of sex (P=0.996). CONCLUSIONS: We describe 3 measurements that can easily be obtained on an anteroposterior radiograph of the knee. We demonstrate that ratios of these variables can be measured reliably and correlate closely with remaining growth, independent of sex. Together, we believe that these factors will improve the accuracy of determining growth from lower extremity radiographs that include the proximal tibia. CLINICAL RELEVANCE: This study provides a new quantitative technique to evaluate growth in the lower extremity, which can inform a range of conditions including adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injury, and slipped capital femoral epiphyses.

Safe Zones for Cerclage Wiring of the Humeral Diaphysis.

Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc.

Performance of PROMIS Global-10 to Legacy Instruments in Patients With Lateral Epicondylitis.

PURPOSE: To validate the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 for patients who have lateral epicondylitis requiring surgical treatment in comparison with other gold standard patient-reported outcomes. METHODS: Sixty-two patients with lateral epicondylitis of the elbow were prospectively enrolled before arthroscopic treatment. Inclusion criteria were patients 18 years of age or older with a diagnosis of lateral epicondylitis. Each patient completed the PROMIS Global-10, EuroQol 5 Dimension (EQ-5D), American Shoulder and Elbow Surgeons (ASES) assessment form, Mayo Elbow Performance Score (MEPS), and Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Spearman correlations were calculated. Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS-10 and actual EQ-5D scores. RESULTS: Correlation between the PROMIS-10 and the EQ-5D was excellent (0.72, P < .0001). Bland-Altman 95% limits of agreement for estimated EQ-5D scores ranged from 0.33 below to 0.21 above actual EQ-5D scores. Correlation of the PROMIS-10 physical score was good to excellent with MEPS (0.61, P < .0001) and QuickDASH scores (0.64, P < .0001) and good with the ASES (0.58, P < .0001). Correlation of the PROMIS mental scores was good with QuickDASH (0.50, P < .0001) and poor with ASES (0.26, P = .0492) and MEPS (0.37, P = .0038). CONCLUSIONS: The PROMIS Global-10 physical scores showed good to excellent correlation with gold standard patient-reported outcome instruments, demonstrating it is a reliable tool for outcome assessment in populations with lateral epicondylitis. Despite the excellent correlation with the EQ-5D, the 95% limit of agreement and high variability among the estimated EQ-5D scores derived from the PROMIS-10 suggests that the PROMIS-10 cannot be used as a substitute for actual EQ-5D scores to derive quality-adjusted life years for economic evaluations and cost-effectiveness research. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on the basis of consecutive patients.

Humeral Head Ossification Predicts Peak Height Velocity Timing and Percentage of Growth Remaining in Children.

BACKGROUND: Understanding skeletal maturity is important in the management of idiopathic scoliosis. Iliac apophysis, triradiate cartilage, hand, and calcaneal ossification patterns have previously been described to assess both peak height velocity (PHV) and percent growth remaining; however, these markers may not be present on standard spine radiographs. The purpose of this study was to describe a novel maturity assessment method based on proximal humeral epiphyseal ossification patterns. METHODS: Ninety-four children were followed at least annually throughout growth with serial radiographs and physical examinations. The PHV of each child was determined by measuring the change in height observed at each visit and adjusting for the interval between visits. Percent growth remaining was determined by comparing current to final standing height. The humeral head periphyseal ossification was grouped into stages by 8 investigators ranging from medical student to attending surgeon. RESULTS: The morphologic changes involving the proximal humeral physis were categorized into 5 stages based on development of the humeral head epiphysis and fusion of the lateral margin of the physis. Our novel classification scheme was well distributed around the PHV and reliably correlated with age of peak growth and percent growth remaining with >70% nonoverlapping interquartile ranges. Furthermore, the scheme was extremely reliable with intraclass correlation coefficients of 0.96 and 0.95 for intraobserver and interobserver comparisons, respectively. CONCLUSIONS: The humeral head classification system described here was strongly correlated with age of PHV as well as percentage growth remaining. Furthermore, the staging system was extremely reliable in both interobserver and intraobserver correlations suggesting that it can be easily generalized. CLINICAL RELEVANCE: As a view of the humeral head is almost always present on standard scoliosis spine x-ray at our institution, our classification can be easily adapted by surgeons to gain additional insight into skeletal maturity of patients with scoliosis. We believe that our method will significantly improve the evaluation of the child with scoliosis without increasing radiation exposure, time, or cost.

The Posterior Trans-Septal Portal in Knee Arthroscopy Review of the Technique Evolution, Indications, and Technical Pearls.

Complete arthroscopic visualization of the posterior com-partment of the knee is limited when using the traditional anterior portals. The trans-septal portal technique, created in 1997, has allowed surgeons to view the complete posterior compartment of the knee in a less-invasive way compared to open surgery. Since the description of the posterior trans-septal portal, several authors have modified the technique. However, the paucity of literature describing the trans-septal portal technique hints that widespread arthroscopic adop-tion has not yet been achieved. While still in its infancy, the literature has cumulatively reported over 700 successful knee surgeries using the posterior trans-septal portal technique with no reports of neurovascular injury. However, creation of the trans-septal portal carries risks due to its close prox-imity to the popliteal and middle geniculate artery, giving surgeons little room for technical error when developing this portal. Knowledge of the posterior anatomy, the evolution of the trans-septal portal, and current recommendations and safety options for using the technique will benefit orthopedic surgeons looking to incorporate this technique into their surgical arsenal. Furthermore, utilization of the trans-septal portal technique offers a significant benefit to the surgical treatment of conditions that involve the need for posterior knee access or visualization.

Examining the Schenck KD I Classification in Patients With Documented Tibiofemoral Knee Dislocations: A Multicenter Retrospective Case Series.

Background: Acute tibiofemoral knee dislocations (KDs) with a single cruciate ligament remaining intact are rare and can be classified as Schenck KD I. The inclusion of multiligament knee injuries (MLKIs) has contributed to a recent surge in Schenck KD I prevalence and has convoluted the original definition of the classification. Purpose: To (1) report on a series of true Schenck KD I injuries with radiologically confirmed tibiofemoral dislocation and (2) introduce suffix modifications to further subclassify these injuries based on the reported cases. Study Design: Case series; Level of evidence, 4. Methods: A retrospective chart review identified all Schenck KD I MLKIs at 2 separate institutions between January 2001 and June 2022. Single-cruciate tears were included if a concomitant complete disruption of a collateral injury was present or injuries to the posterolateral corner, posteromedial corner, or extensor mechanism. All knee radiographs and magnetic resonance imaging scans were retrospectively reviewed by 2 board-certified orthopaedic sports medicine fellowship-trained surgeons. Only documented cases consistent with a complete tibiofemoral dislocation were included. Results: Of the 227 MLKIs, 63 (27.8%) were classified as KD I, and 12 (19.0%) of the 63 KD I injuries had a radiologically confirmed tibiofemoral dislocation. These 12 injuries were subclassified based on the following proposed suffix modifications: KD I-DA (anterior cruciate ligament [ACL] only; n = 3), KD I-DAM (ACL + medial collateral ligament [MCL]; n = 3), KD I-DPM (posterior cruciate ligament [PCL] + MCL; n = 2), KD I-DAL (ACL + lateral collateral ligament [LCL]; n = 1), and KD I-DPL (PCL + LCL; n = 3). Conclusion: The Schenck classification system should only be used to describe dislocations with bicruciate injuries or with single-cruciate injuries that have clinical and/or radiological evidence of tibiofemoral dislocation. Based on the presented cases, the authors recommend the suffix modifications for subclassifying Schenck KD I injuries with the goal of improving communication, surgical management, and the design of future outcome studies.

Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries.

Background: Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. Purpose/Hypothesis: The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. Results: In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001). Conclusion: Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

Rates of subsequent surgeries after meniscus repair with and without concurrent anterior cruciate ligament reconstruction.

OBJECTIVES: The purpose of this study was to compare the rates of secondary knee surgery for patients undergoing meniscus repair with or without concurrent anterior cruciate ligament reconstruction (ACLr). METHODS: Utilizing a large national database, patients with meniscal repair with or without concurrent arthroscopic ACLr were identified. The two cohorts were then queried for secondary surgical procedures of the knee within the following 2 years. Frequency, age distribution, rates of secondary surgery, and type of secondary procedures performed were compared. RESULTS: In total, 1,585 patients were identified: meniscus repair with ACLr was performed for 1,006 (63.5%) and isolated meniscal repair was performed for 579 (36.5%). Minimum of two year follow up was present for 487 (30.7% of the overall study population). Secondary surgery rates were not significantly different between meniscus repair with concurrent ACLr and isolated meniscus repairs with an overall mean follow up of 13 years (1.5-24 years) (10.6% vs. 13.6%, p = 0.126). For the 2 year follow up cohort, secondary surgery rates were not significantly different (19.3% vs. 25.6%, p = 0.1098). There were no differences in survivorship patterns between the two procedures, both in the larger cohort (p = 0.2016), and the cohort with minimum 2-year follow-up (p = 0.0586). CONCLUSION: The current study assessed secondary surgery rates in patients undergoing meniscus repair with or without concurrent ACLr in a large patient database. Based on this data, no significant difference in rates of secondary knee surgery was identified.

Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery.

Introduction: The timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients. Methods: All patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients. Results: A total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001). Conclusions: Patients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.

Acute Surgical Repair of Simultaneous Bilateral Proximal Hamstring Tendon Avulsion: A Case Report.

CASE: Proximal hamstring tendon avulsions are rare injuries that can be successfully treated with surgical intervention. However, there are limited reports on the surgical and postoperative management of patients with bilateral avulsions. We report a 54-year-old male gym teacher with acute bilateral proximal hamstring 3-tendon nonbony avulsions who underwent simultaneous surgical repairs and a unique postoperative rehabilitation course. At 1-year clinical follow-up, the patient demonstrated significant improvements in activity levels and functionality, with no complications. CONCLUSION: Bilateral proximal hamstring 3-tendon nonbony avulsions can be successfully treated with a simultaneous surgical repair and a modified postoperative rehabilitation course.

Gouty Tophi Encompassing Retained Suture Material 7 Years After Achilles Tendon Rupture Repair.

CASE: We report the case of a 32-year-old male patient with no history of gout who developed gouty tophi encompassing retained suture material 7 years after initial repair of a ruptured Achilles tendon. The patient had a posterior ankle mass concerning for abscess. Monosodium urate crystals were identified, and uric acid level was elevated at the time of irrigation and debridement. CONCLUSION: Surgical site gout is a rare but important phenomenon to recognize in the treatment of patients with Achilles tendon repairs, particularly in patients with a history of abscess, infection, or collections localized to retained suture material.

Unicompartmental Knee Arthroplasty in Octogenarians: A National Database Analysis Including Over 700 Octogenarians.

Background: Unicompartmental knee arthroplasty (UKA) may be considered for select patients to relieve pain and restore function of the knee joint. Little research to date has explored the complication profile of UKA in an older population. The current study uses a large national surgical database to examine the 30-day postoperative adverse events in octogenarians compared with those in nonoctogenarians. Material and methods: The 2012-2018 National Surgical Quality Improvement Program database was queried for all patients undergoing UKA for osteoarthritis. Those patients aged 80 years or older composed the octogenarian age group. Demographics and medical comorbidities were cataloged, in addition to 30-day adverse events. Multivariate regression analysis controlled for differences in demographics and comorbidities. Significance was set at P < .05. Results: A total of 10,103 patients undergoing UKA were identified, of which 728 (7.2%) were octogenarians. The octogenarian cohort had significantly higher comorbidity burden than nonoctogenarians. After controlling for demographics other than age, American Society of Anesthesiologists score, and medical comorbidities, octogenarians had higher 30-day odds of death (odds ratio [OR] = 6.12, P = .024), minor adverse events (OR = 2.97, P = .001), prolonged hospital length of stay (OR = 2.30, <0.001), nonhome discharge (OR = 4.50, P < .001), and readmission (OR = 1.72, P = .015), but did not experience increased odds of serious adverse events (OR = 1.07, P = .172) or return to the operating room (OR = 0.97, P = .881). Conclusion: The present study found a statistically significant increase in several adverse events within 30 days of surgery for patients aged ≥80 years when compared with patients younger than 80 years. Namely, UKA in octogenarians was associated with significantly increased odds of short-term mortality, urinary tract infection, transfusion, prolonged hospital stay, and readmission.

Publication Frequency and Google Trends Analysis of Popular Alternative Treatments to Arthritis.

BACKGROUND: Public interest in alternative, nonoperative treatments for the management of arthritis has increased. Few have been approved by the Food and Drug Administration. The present study aimed to evaluate trends in public and scientific interest in 4 such treatments by assessing Google Trends and publication frequency data, respectively. MATERIAL AND METHODS: Turmeric, stem cell therapy, platelet-rich plasma (PRP) therapy, and cannabidiol (CBD) were studied. For 2010-2019, Google Trends data and publication frequency data on PubMed were collected by year for arthritis and each of the 4 therapies. Linear, quadratic, and exponential regressions were applied, and the best model of growth was identified. RESULTS: From 2010 to 2019, Google Trends annual scores for arthritis and turmeric (exponential; R2: 90.5%, P < .001), CBD (exponential; R2: 99.3%, P < .001), stem cell therapy (exponential; R2: 86.7%, P < .001), and PRP therapy (linear; R2: 80.6%, P < .001) increased significantly. Search term frequencies for arthritis and CBD exhibited the highest increase (12,929%). Publications in arthritis and turmeric (linear; R2: 74%, P = .001), stem cell therapy (linear; R2: 94.8%, P < .0001), and PRP therapy (linear; R2: 97.1%, P < .0001) increased from 2010 to 2019. However, publications relating to arthritis and CBD have not increased (P = .122). CONCLUSION: Regression analysis indicates that public interest in alternative therapies have had a marked increase. The rise in public interest for CBD, and to a lesser extent, turmeric, stem cell therapy, and PRP, has dramatically outstripped scientific evidence on these therapies. Rigorously designed, clinical studies may be beneficial to keep up with the growing popularity of these treatments, especially CBD.

An Imaging Overview of the Posterior Septum of the Knee and Trans-Septal Portal Procedure: Normal Anatomy, Indications, and Unique Imaging Considerations.

The posterior trans-septal portal technique is an arthroscopic surgery of the knee providing surgeons with the ability to fully visualize the posterior compartment. With this procedure, portals are placed at the posteromedial and posterolateral aspect of the knee. Visualization of the medial and lateral posterior compartments then allows working space for the creation of the intra-articular portal that is made by dividing the posterior septum. We provide an imaging overview of the posterior septum, the trans-septal portal technique, possible indications, and introduce how surrounding anatomy may warrant unique imaging considerations.