Bicondylar tibial plateau fracture after posterior cruciate ligament reconstruction.

The authors present a report of a bicondylar tibial plateau fracture in an adolescent athlete after posterior cruciate ligament (PCL) reconstruction. The procedure was performed via arthroscopic transtibial PCL reconstruction with quadrupled semi-tendinosus and gracilis autograft. The patient recovered uneventfully postoperatively and was able to participate in high-level sports activity, such as baseball and track, with no limitations, no subjective complaints, and no episodes of instability. He continued to be asymptomatic up to 3.5 years postoperatively. Almost 4 years postoperatively, the patient reinjured the left knee during recreational noncontact football and was seen emergently. Plain radiographs, magnetic resonance image scan, and computed tomography scan at the time of injury showed a bicondylar tibial plateau fracture with intra-articular involvement. Operative intervention was undertaken for open reduction and internal fixation of the bicondylar tibial plateau fracture. A plate was placed along the medial aspect of the tibia with locking and nonlocking screws, and the joint line was restored appropriately. The patient recovered uneventfully and at the most recent follow-up had full active and passive range of motion, had no subjective or objective evidence of instability, and had returned to full activity with no restrictions. The patient had no history of multiple fractures or any medical or pharmacologic history that predisposed him to decreased bone density. This case shows a unique possible complication after transtibial PCL reconstruction in an adolescent patient.

Recurrent instability after revision anterior shoulder stabilization surgery.

PURPOSE: The purpose of this study was to perform a systematic review of the literature to compare outcomes of revision anterior stabilization surgeries based on technique. This study also sought to compare the impact of bone defects on outcomes. METHODS: A systematic review of the electronic databases PubMed, Cochrane Central Register of Controlled Trials, and Scopus was performed in July 2012 and March 2013. Of 345 articles identified in the search, 17 studies with Level I to IV Evidence satisfied the inclusion criteria and were analyzed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Recurrent instability was defined as redislocation, resubluxation, or a positive apprehensive test after revision surgery. Procedures were categorized as arthroscopic Bankart repair, open Bankart repair, Bristow-Latarjet procedure, and other open procedures. RESULTS: In total, 388 shoulders were studied. Male patients comprised 74.1% of patients, 66.7% of cases involved the dominant shoulder, the mean age was 28.2 years, and the mean follow-up period was 44.2 months. The surgical procedures classified as "other open procedures" had the highest rate of recurrent instability (42.7%), followed by arthroscopic Bankart repair (14.7%), the Bristow-Latarjet procedure (14.3%), and open Bankart repair (5.5%). Inconsistent reporting of bone defects precluded drawing significant conclusions. CONCLUSIONS: A number of different procedures are used to address recurrent instability after a primary operation for anterior shoulder instability has failed. There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Treatment of avascular necrosis of the femoral head utilising free vascularised fibular graft: a systematic review.

We conducted a systematic review to determine whether the literature supports the use of free vascularised fibular graft (FVFG) over other salvage procedures for the treatment of avascular necrosis (AVN) of the femoral head, and if there are patient-specific and defect-specific factors that may predict better outcomes after FVFG. Fifteen total studies were identified for inclusion. Three comparative studies showed an overall statistically significant superiority of FVFG over NVFG; two comparative studies demonstrated FVFG better than core decompression. One study show a better but not statistically significant superiority of FVFG comparing with vascularised iliac pedicle bone graft procedures, likely due to small sample size. This review suggests that vascularised fibular grafting is a better treatment option than core decompression and nonvascularised fibular grafting.

Continuous passive motion following cartilage surgery: does a common protocol exist?

Continuous passive motion (CPM) devices have the potential to improve the histological content as well as the rate and volume of chondrogenesis in repair tissue following chondral injury. However, clinical evidence is lacking to support broad implementation of CPM following cartilage restoration procedures. We searched PubMed, CINAHL, SPORTDiscus, and Cochrane for such terms as knee, continuous passive motion, CPM, ACI, ACT, autologous chondrocyte implantation, autologous chondrocyte transplantation, microfracture, marrow-stimulation technique, mosaicplasty, osteochondral autograft, and osteochondral allograft. Inclusion criteria were all English-language studies of human subjects, evidence levels I to IV, reporting the use of CPM following cartilage repair or restoration surgery in the knee. One hundred and seven studies met inclusion criteria. Sixty-three studies reported the use of CPM following autologous chondrocyte implantation; 28 reported the use of CPM following microfracture; 13 reported the use of CPM following osteochondral autograft; and 15 reported the use of CPM following osteochondral allograft (several studies reported > 1 type of cartilage procedure, which explains why the sum of all studies reporting a particular procedure [119] is greater than the number of studies included in the review [107]). Of the 5723 patients included, 60.8% were treated with autologous chondrocyte implantation, 23.1% were treated with microfracture, 6.4% were treated with osteochondral autograft, and 9.7% were treated with osteochondral allograft. Of the 6612 total defects, 5043 (76.3%) were tibiofemoral and 1569 (23.7%) were patellofemoral. Most reports of CPM use after cartilage restoration procedures did not include specific information on how it was implemented. Overall, the description of CPM protocols in published knee articular cartilage surgery studies was disappointing. The majority of studies did not describe common variables such as the duration of CPM therapy, the initiation of CPM therapy, and the initial range of motion used. The most commonly prescribed parameters within a CPM regimen are initiated on the first postoperative day, with an initial range-of-motion of 0 to 30 degrees and a frequency of 1 cycle per minute, and for 6 to 8 hours daily over 6 weeks. The lack of consistent standardized reporting of postoperative CPM protocols provides an impetus to researchers and clinicians to more clearly define and describe their use following knee articular surgery.

The basic science of continuous passive motion in promoting knee health: a systematic review of studies in a rabbit model.

PURPOSE: To determine whether the basic science evidence supports the use of continuous passive motion (CPM) after articular cartilage injury in the knee. METHODS: A systematic review was performed identifying and evaluating studies in animal models that focused on the basic science of CPM of the knee. Databases included in this review were PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE. All functional, gross anatomic, histologic, and histochemical outcomes were extracted and analyzed. RESULTS: Primary outcomes of CPM analyzed in rabbit animal models (19 studies) included histologic changes in articular cartilage (13 studies), biomechanical changes and nutrition of intra-articular tissue (3 studies), and anti-inflammatory biochemical changes (3 studies). Nine studies specifically examined osteochondral defects, 6 of which used autogenous periosteal grafts. Other pathologies included were antigen-induced arthritis, septic arthritis, medial collateral ligament reconstruction, hemarthrosis, and chymopapain-induced proteoglycan destruction. In comparison to immobilized knees, CPM therapy led to decreased joint stiffness and complications related to adhesions while promoting improved neochondrogenesis with formation and preservation of normal articular cartilage. CPM was also shown to create a strong anti-inflammatory environment by effectively clearing harmful, inflammatory particles from within the knee. CONCLUSIONS: Current basic science evidence from rabbit studies has shown that CPM for the knee significantly improves motion and biological properties of articular cartilage. This may be translated to potentially improved outcomes in the management of articular cartilage pathology of the knee. CLINICAL RELEVANCE: If the rabbit model is relevant to humans, CPM may contribute to improved knee health by preventing joint stiffness, preserving normal articular tissue with better histologic and biologic properties, and improving range of motion as compared with joint immobilization and intermittent active motion.

Outcomes after injury to the thumb ulnar collateral ligament--a systematic review.

OBJECTIVES: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction. DATA SOURCES: A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. MAIN RESULTS: Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Complications after surgery were rare. CONCLUSIONS: This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review.

BACKGROUND: Various methods of bony stabilization, including modifications of Bristow and Latarjet procedures, are considered gold-standard treatment for recurrent anterior shoulder instability but are associated with unique complications and risk of reoperation. The purpose of this study was to identify the prevalence of these complications. We hypothesized that the Bristow-Latarjet procedure would be a successful technique for treatment of shoulder instability but associated with a risk of recurrent postoperative instability, reoperation, and other complications. METHODS: A systematic review of multiple medical databases included studies reporting outcomes with complication and reoperation rates following original or modified versions of the Bristow or Latarjet shoulder stabilization surgeries. RESULTS: Forty-five studies were analyzed (1,904 shoulders) (all Level IV evidence). Most subjects were male (82%). The dominant shoulder was the operative shoulder in 64% of cases. Mean subject age was 25.8 years. Mean clinical follow-up was 6.8 years. Ninety percent of surgeries were done open; 9.3% were all-arthroscopic. Total complication rate was 30%. Recurrent anterior dislocation and subluxation rates were 2.9% and 5.8%, respectively. When reported, most dislocations occurred within the first year postoperatively (73%). Nearly 7% of patients required an unplanned reoperation following surgery. CONCLUSION: Osseous stabilization shoulder surgery using original or modified Bristow and Latarjet procedures has a 30% complication rate. Rates of recurrent dislocation and reoperation were 2.9% and 7%, respectively. Mild loss of external rotation is common. Reoperation rates were lower following all-arthroscopic techniques. There was a greater loss of postoperative external rotation with all-arthroscopic surgery.

Operative management of capitellar fractures: a systematic review.

PURPOSE: This study was conducted to evaluate reports of clinical outcomes of isolated capitellar fractures. MATERIALS AND METHODS: We conducted a systematic review of medical databases reporting clinical outcomes of patients undergoing nonoperative and operative management of isolated capitellar fractures. RESULTS: We identified 28 studies for inclusion comprising 174 patients. All included studies were level IV evidence. Capitellar fractures were more common among women than men and were more likely to involve the nondominant arm. Type I fractures (84%) were more common than type II (14%) and III fractures (2%). Operative and nonoperative management both led to satisfactory clinical outcomes. No significant difference in outcomes was observed in those undergoing operative management compared with those undergoing closed reduction and immobilization. CONCLUSIONS: Nonoperative and operative management of isolated capitellar fractures leads to satisfactory clinical outcomes as determined by postoperative range of motion, improvement in pain, and a return to previous levels of function. No statistical difference in outcomes was observed between those undergoing operative management compared with those treated with closed reduction and immobilization.

Lower-extremity soft tissue infections with intra-abdominal sources.

This article describes a series of 3 patients who presented with lower-extremity soft tissue infections. Each patient was treated with prompt debridement by an orthopedic surgeon (J.F.G.) and required at least 1 additional procedure by another surgeon.These infections vary from superficial cellulitis to rapidly advancing necrotizing fasciitis. At times, the source of these infections is clear. Other times, no obvious source of infection exists, in which case the abdomen must be considered as a possible source of infection. A high level of suspicion, complete history and physical examination, and appropriate ancillary studies are required to make an accurate and prompt diagnosis. Options for the treatment of the intra-abdominal source of infection depend on the etiology of the infection and anatomic location of the process. Psoas abscesses can often be decompressed by an interventional radiologist using computed tomography guidance. In the case of bowel involvement, such as suspected carcinoma or diverticulitis, a general surgeon is necessary. When the appropriate diagnosis is made, soft tissue infections of the thigh often respond to appropriate surgical debridement and antibiotic therapy. It is important to remember the whole patient when evaluating soft tissue infections, especially in the thigh. A low threshold for imaging of the abdomen and pelvis is important, especially when the physical examination or medical history reveals the abdomen as a possible source of infection.

Assessment of musculoskeletal physical examination skills and attitudes of orthopaedic residents.

BACKGROUND: Although the musculoskeletal physical examination is an essential part of patient encounters, we believe that it is underemphasized in residency education and that residents' physical examination skills may be lacking. We sought to assess attitudes regarding teaching of the physical examination in orthopaedic residencies, to assess physical examination knowledge and skills among residents, and to develop a method to track the skill level of residents in order to improve our physical examination curriculum. METHODS: We created a thirty-question multiple-choice musculoskeletal physical examination test and administered it to our residents. We created a five-question survey assessing attitudes toward physical examination teaching in orthopaedic residencies and distributed it to U.S. orthopaedic department chairs We developed an Objective Structured Clinical Examination (OSCE), in which standardized patients enact four clinical scenarios, to observe and assess physical examination skills. RESULTS: The mean score on the multiple-choice physical examination test was 76% despite the fact that our residents consistently scored above 90% on the Orthopaedic In-Training Examination. Department chairs and residents agreed that, although learning to perform the physical examination is important, there is not enough time in the clinical setting to observe and critique a resident's patient examination. The overall score of our residents on the OSCE was 66%. CONCLUSIONS: We have exposed a deficiency in the physical examination knowledge and skills of our residents. Although the musculoskeletal physical examination is a vital practice component, our data indicate that it is likely underemphasized in training. Clinic time alone is likely insufficient for the teaching and learning of the musculoskeletal physical examination.

Effectiveness of ultraporous ß-tricalcium phosphate (vitoss) as bone graft substitute for cavitary defects in benign and low-grade malignant bone tumors.

We retrospectively evaluated healing with ultraporous ß-tricalcium phosphate (ß-TCP [Vitoss; Orthovida, Malvern, Pennsylvania]) bone graft in patients who underwent surgical excision or curettage of benign bone lesions subsequently filled with bone void filler. Twentynine patients were treated with curettage and ultraporous ß-TCP morsels. Radiologic defect size at initial postoperative presentation and subsequent visits (minimum follow-up, 6 months) was evaluated. Results suggested that an ultraporous ß-TCP synthetic bone graft is effective in managing bone voids. The vast majority of patients who undergo curettage for benign bone lesions can expect to have complete or near complete healing of these defects within 6 months of their surgical procedure with use of ultraporous ß-TCP morsels.

Infrapatellar branch of saphenous neurectomy for painful neuroma: a case report.

We present the case of an 18-year-old woman who was healthy other than a history of multiple arthroscopic right knee surgeries culminating in subtotal lateral meniscectomy in a valgus knee. The patient was referred to our office for evaluation for realignment osteotomy and meniscal transplantation. Her diagnosed case of neuroma of the infrapatellar branch of the saphenous nerve was managed with neurectomy, which produced prompt and complete resolution of pain.

Implementation of an objective structured clinical exam (OSCE) into orthopedic surgery residency training.

OBJECTIVE: While the musculoskeletal (MSK) physical examination (PE) is an essential part of a patient encounter, we believe it is an underemphasized component of orthopedic residency education and that resident PE skills may be lacking. The purpose of this investigation was to (1) assess the attitudes regarding PE teaching in orthopedic residencies today; (2) develop an MSK objective structured clinical examination (OSCE) to assess the MSK PE knowledge and skills of our orthopedic residents. DESIGN: Prospective, uncontrolled, observational. SETTING: A major Midwestern tertiary referral center and academic medical center. PARTICIPANTS: The orthopedic surgery residents in our program. Twenty-two of 24 completed the OSCE. RESULTS: Surveys showed that residents agreed that although learning the PE is important, there is not enough time in clinic to actually observe and critique a resident examining a patient. For the 22 residents (postgraduate year [PGY] 2-5) who participated in the OSCE, the overall score was 66%. Scores were significantly better for the trauma scenario (78%; p < 0.05) than for the shoulder (67%), spine (64%), and knee (59%) encounters. The overall scores for each component of the OSCE were: (1) history 53%; (2) PE 60%; (3) 5-question posttest 64%; and (4) communication skills 90%. CONCLUSIONS: We have exposed a deficiency in the PE knowledge and skills of our residents. Clinic time alone may be insufficient to both teach and learn the MSK PE. The use of a MSK OSCE, while novel in orthopedics, will allow more direct observation of our residents MSK PE skills and also allow us to follow resident skills longitudinally through their training. We hope that our efforts will encourage other programs to assess their PE curriculum and perhaps prompt change.

Prediction of coracoid thickness using a glenoid width-based model: implications for bone reconstruction procedures in chronic anterior shoulder instability.

BACKGROUND: Chronic anterior shoulder instability with glenoid bone loss can be a very challenging clinical problem. Significant bone loss is commonly managed with the Latarjet procedure. However, in some cases with severe glenoid bone loss, iliac crest bone grafting is required to obtain a graft of adequate size. Iliac crest bone graft is associated with high rates of donor-site complications. Whereas glenoid dimensions can be determined by use of 3-dimensional computed tomography reconstructions, the thickness of the coracoid cannot be easily measured. This study aims to define a ratio between glenoid width and coracoid thickness that can be used in preoperative planning to determine whether coracoid transfer will yield adequate bone graft to restore glenoid contour or whether iliac crest bone graft must be taken. METHODS: We studied 100 paired cadaveric scapulae (50 male and 50 female scapulae). The bony dimensions of the coracoid and glenoid were measured for each specimen. RESULTS: Coracoid and glenoid dimensions are provided. The mean thickness of the male coracoid was 35.4% of the width of the glenoid. The mean female coracoid thickness was 34.4% of the glenoid width. DISCUSSION: A new biomorphologic model is presented to predict coracoid thickness and the ability of the Latarjet procedure to restore stability to a given bone-deficient glenoid. This model may aid the shoulder surgeon in preoperative planning and help promote successful outcomes in glenoid reconstruction surgery by determining whether a Latarjet procedure or iliac crest bone graft is the most appropriate procedure given the predicted amount of coracoid bone graft available.

Internal and external hemipelvectomy or flail hip in patients with sarcomas: quality-of-life and functional outcomes.

OBJECTIVE: We evaluated the quality-of-life of patients who have had an internal hemipelvectomy with and without (flail hip) prosthetic reconstruction and external hemipelvectomy. DESIGN: We reviewed the cases of 15 patients who had undergone either internal or external hemipelvectomy for tumor. Fifteen patients who were previously treated operatively with either a type II periacetabular internal (n = 5) or external (n = 10) hemipelvectomy were evaluated using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and the 36-item Short-Form Health Survey. There were 11 (73%) men and 4 (27%) women in the study, with a mean age at operation of 46.9 ± 18.0 yrs (range, 18-69 yrs). RESULTS: Follow-up was 30.6 ± 19.6 mos (range, 6-70 mos). Overall mean MSTS score was 45.2 (range, 6.7 to 83.3), and TESS score was 60.4 ± 16.1 (range, 31.8-88.0). The 36-item Short-Form Health Survey physical component score results were lower than the general population. TESS and MSTS were all positively correlated to physical component score. There were no significant influences of postsurgery time on MSTS, TESS, or physical component score. Age had a negative correlation with physical function. CONCLUSIONS: Quality-of-life and functional outcome were significantly reduced for patients with internal and external hemipelvectomies on the TESS, MSTS, and the 36-item Short-Form Health Survey physical component scores.

Chondroblastoma: a rare cause of femoral neck fracture in a teenager.

Chondroblastomas usually present in the epiphyseal region of bones in skeletally immature patients. These uncommon, benign tumors are usually treated with curettage and use of a bone-void filler. Here we report a case of a hip fracture secondary to an underlying chondroblastoma in a 19-year-old woman. Open biopsy with intraoperative frozen section pointed toward a diagnosis of chondroblastoma. Extended curettage was performed, followed by cryotherapy with a liquid nitrogen gun and filling of the defect with calcium phosphate bone substitute. The femoral neck fracture was stabilized with a sliding hip screw construct. The patient progressed well and continued to regain functional status. A final pathology report confirmed the lesion to be a chondroblastoma. Clinicians should have heightened awareness of a pathologic lesion in a young person presenting with a femoral neck fracture and should consider the uncommon differential diagnosis that the lesion is located in the greater trochanter apophysis.