Talk It Out to Walk It Out A Guide for Residents and Medical Students on the Fundamentals of Gait.

Although gait is one of the most globally ubiquitous concepts-traversing all geographic, cultural, and language barriers-it is often seen as an overwhelming and confusing concept. This review describes the phases and components of gait to help the clinician identify what is normal, evaluate what is not normal, and understand some common pathologic gait patterns seen in the different orthopedic subspecialties.

The Role of Distraction Osteogenesis in Limb Salvage for Tumors.

Modern technology and advances in medicine have facilitated increasing rates of limb salvage in the treatment of sarcomas. Orthopedic oncologists have a wide array of reconstruction options for limb salvage, ranging from allografts to endoprosthesis reconstruction. Limb lengthening is another option available to an orthopedic oncologist faced with bony defects and limb length discrepancies following resection. This review provides a brief history of limb lengthening, the principles of distraction osteogenesis, and current applications in orthopedic oncology. Considering the complications and challenges associated with the lengthening process, appropriate patient selection and thorough patient counseling is key to optimizing outcomes.

Hip morphology on initial ultrasound predicts hip morphology at one year in developmental dysplasia of the hip.

Purpose: This study aimed to determine whether point-of-care ultrasound performed during the Pavlik method treatment of developmental dysplasia of the hip predicts acetabular morphology at 12 months of age. Methods: We reviewed the medical records, ultrasounds, and radiographs of patients treated successfully with the Pavlik method between 2017 and 2019. We performed sonographic measurements on point-of-care ultrasound at the initial presentation, the Pavlik discontinuation, and an additional sonographic follow-up. We measured the acetabular index on a plain anteroposterior radiograph of the pelvis obtained at a minimum of 12 months of age. Spearman's rank correlation coefficient was used to analyze for correlation between sonographic measurements and the acetabular index. Results: A total of 72 patients were included in the final analysis. There were no residual or late dysplasia cases at the last radiographic follow-up (mean age = 14.8 ± 2.7 months). Sonographic parameters at the initial presentation significantly correlated with the acetabular index at the final radiographic follow-up (p < 0.001). Patients with worsening degrees of developmental dysplasia of the hip based on stability on sonographic testing (stable, unstable, or dislocated) had higher acetabular indices at the final radiographic follow-up (p < 0.05). Conclusion: Point-of-care ultrasound at initial presentation and the Pavlik discontinuation significantly correlate with acetabular morphology at 1-1.5 years of age. At initial presentation, hips that were unstable or dislocated on point-of-care ultrasound had significantly greater acetabular indices than stable hips at the final follow-up. Level of evidence: level IV case series.

Approach variation affects outcomes after operative repair of lateral tibial plateau fractures.

PURPOSE: To determine if the type of approach used for treatment of lateral split-depression tibial plateau fractures affects clinical outcome and complications rate. METHODS: This is a retrospective review of 169 patients who presented between 01/2005 and 12/2020 to a Level-I trauma center for operative management of an isolated lateral Schatzker II tibial plateau fractures (AO/OTA Type 41B3.1) treated through a single anterolateral approach: a 90-degree "L" (L), longitudinal vertical (V), or "lazy S" (S). Postoperative radiographic, clinical, and functional outcomes were assessed at 3, 6, 12 months, and beyond. RESULTS: Average time to radiographic healing was longer in the S incision cohort (p < 0.05). Furthermore, patients within the S incision cohort developed more postoperative wound complications at follow-up when compared to those within the L and V incision cohorts (p < 0.05). Additionally, reoperation rates were greater in the S incision cohort (p < 0.05). Lastly, on physical examination of the knee, patients within the S incision cohort had significantly poorer knee range of motion (p < 0.05). CONCLUSIONS: Our study demonstrates that skin incision type in the anterolateral approach to the proximal tibia has an association with outcomes following operative repair of tibial plateau fractures. The information from this study can be used to inform surgeons about the potential complications and long-term outcomes that patients may experience when undergoing operative repair of a tibial plateau fracture through a specific incision type. LEVEL OF EVIDENCE: III.

Correction to: Point of Care Ultrasound as Performed by the Clinician for the Enhancement of Physical Examination: A Technique Guide for Developmental Hip Dysplasia.

[This corrects the article DOI: 10.1007/s43465-021-00570-8.].

What is the Interobserver Reliability of an Ultrasound-enhanced Physical Examination of the Hip in Infants? A Prospective Study on the Ease of Acquiring Skills to Diagnose Hip Dysplasia.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common disorder found in newborns. The consequences of DDH can be mitigated with early diagnosis and nonoperative treatment, but existing approaches do not address the current training deficit in making an early diagnosis. QUESTION/PURPOSE: Can ultrasound be taught to and used reliably by different providers to identify DDH in neonates? METHODS: This was a prospective observational study of a series of neonates referred for an evaluation of their hips. An experienced clinician trained three second examiners (a pediatric orthopaedic surgeon, an orthopaedic resident, and a pediatrician) in performing an ultrasound-enhanced physical examination. The 2-hour training process included video and clinical didactic sessions aimed to teach examiners to differentiate between stable and unstable hips in newborns using ultrasound. The experienced clinician was a pediatric orthopaedic surgeon who uses ultrasound regularly in clinical practice. Materials required for training include one ultrasound device. A total of 227 infants (454 hips) were examined by one of the three second examiners and the experienced clinician (gold standard) to assess reliability. Of the 454 hips reviewed, there were 18 dislocations, 24 unstable hips, and 63 dysplastic hips, and the remainder had normal findings. The cohort was composed of a series of patients younger than 6 months referred to a specialty pediatric orthopaedic practice. RESULTS: Ultrasound-enhanced physical examination of the hip was easily taught, and the results were reliable among different levels of providers. The intraclass correlation coefficient between the gold-standard examiner and the other examiners for all hips was 0.915 (p = 0.001). When adjusting for only the binary outcome of normal versus abnormal hips, the intraclass correlation coefficient was 0.97 (p = 0.001). Thus, the agreement between learners and the experienced examiner was very high after learners completed the course. CONCLUSION: After a 2-hour course, physicians were able to understand and reliably examine neonatal children using ultrasound to assess for DDH. The success of the didactic approach outlined in this study supports the need for ultrasound-enhanced examination training for the diagnosis of DDH in orthopaedic surgery and pediatric residency core curriculums. Training programs would best be supported through established residency programs. Expansion of training more residents in the use of ultrasound-enhanced physical examinations would require a study to determine its efficacy. This finding highlights the need for further research in implementing ultrasound-enhanced physical examinations on a broader scale. LEVEL OF EVIDENCE: Level II, diagnostic study.

Point of Care Ultrasound as Performed by the Clinician for the Enhancement of Physical Examination: A Technique Guide for Developmental Hip Dysplasia.

Developmental dysplasia of the hip (DDH) is the most common anatomical pathology present in newborns. DDH is the most common orthopaedic disorder in newborns, with incidences cited from 4.4% to 51.8% depending on risk factors, populations and method of reporting. Traditionally, the standard physical exam for newborns includes the Barlow and Ortolani maneuvers. If either is positive by the pediatrician, the baby is then sent for evaluation by a pediatric orthopaedic surgeon. At this stage, either the pediatrician or pediatric orthopaedic surgeon obtains an ultrasound-the gold standard for DDH diagnosis. When early identification and treatment are not in place, it can lead to significant consequences on an individual's health and financial and public health implications for society at large. This is a detailed technique guide aimed to help physicians consistently perform thorough US evaluations of pediatric hips in order to successfully screen, diagnosis and manage treatment of DDH. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00570-8.

Changes in Synovial Fluid Biomarker Concentration Before and After ACL Reconstruction.

BACKGROUND: Synovial fluid biomarkers can highlight the molecular milieu associated with knee pathology and have been shown to be significantly different in patients with anterior cruciate ligament (ACL) injuries compared to uninjured controls. The purpose of the current study was to establish how synovial fluid biomarker concentrations change in patients undergoing ACL reconstruction between the immediate preoperative period to the acute postoperative period. METHODS: Patients were prospectively enrolled at the time of surgery from September 2016 to March 2017. Patients who had an operative knee synovial fluid sample obtained at the time of ACL reconstruction and provided a synovial fluid sample at their first postoperative appointment were included. The concentrations of 10 biomarkers were determined using a multiplex magnetic bead immunoassay. Biomarker concentrations before and after surgery were compared using a paired sample t-test. RESULTS: Eight patients with mean age of 33.4 years who underwent isolated ACL reconstruction using a bonepatellar tendon-bone autograft were included. The mean time between surgery and postoperative office visit was 10.4 days. There was a statistically significant increase in the concentrations of interleukin-6 (IL-6, p = 0.014), monocyte chemoattractant protein-1 (MCP-1, p = 0.024), human matrix metalloproteinase 3 (MMP-3, p = 0.00002), macrophage inflammatory protein-1 beta (MIP-1ß, p = 0.006), human interleukin-1 receptor antagonist (IL-1Ra, p = 0.017), and vascular endothelial growth factor (VEGF, p = 0.023) between the time of surgery and the first postoperative visit and a decrease in the concentration of tissue inhibitor of metalloproteinase-2 (p = 0.050). CONCLUSION: The molecular profile of the synovial fluid changes in the early postoperative period following arthroscopic ACL reconstruction. The concentration of proinflammatory markers (such as IL-6, MCP-1, MMP-3, and MIP-1ß) and growth factors including VEGF increases. The concentration of the anti-inflammatory marker tissue inhibitor of metalloproteinase-2 (TIMP-2) appears to decrease postoperatively.

Management of Meniscal Pathology: From Partial Meniscectomy to Transplantation.

Meniscal tears are common injuries that may result in functionally limiting pain, swelling, and mechanical symptoms. The management of meniscal pathology has evolved as surgeons' understanding of the important role the menisci play in normal knee kinematics increases. Recent emphasis on partial meniscectomy, expanding indications for meniscal repair, and the increased use of meniscal allograft transplantation have helped improve the outcomes of patients with a meniscal tear who undergo treatment. Orthopaedic surgeons should understand meniscal function, pathology, and treatment approaches.

Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis.

BACKGROUND: No meta-analysis has compared outcomes of operative and nonoperative proximal hamstring avulsion treatment. PURPOSE: To compare outcomes of operative and nonoperative proximal hamstring avulsion treatment, including acute, chronic, partial, and complete repairs. STUDY DESIGN: Meta-analysis. METHODS: PubMed, CINAHL, SPORTdiscus, Cochrane Library, EMBASE, and Web of Science were searched up to July 2016. Three authors screened the studies and performed quality assessment using criteria from the Methodologic Index for Nonrandomized Studies. A best evidence synthesis was subsequently used. RESULTS: Twenty-four studies (795 proximal hamstring avulsions) were included. Twenty-two studies included proximal hamstring avulsion repairs; 1 study had proximal hamstring avulsion repairs and a control group of nonoperatively treated proximal hamstring avulsions; and 1 study had solely nonoperatively treated proximal hamstring avulsions. The majority of studies were of low methodological quality. Overall, repairs had significantly higher patient satisfaction (90.81% vs 52.94%), hamstring strength (85.01% vs 63.95%), Lower Extremity Functional Scale scores (72.77 vs 69.53), and single-legged hop test results (119.1 vs 56.62 cm) (all P < .001); complications occurred in 23.17% of cases. Compared with chronic repairs, acute avulsion repairs had greater patient satisfaction (95.48% vs 83.79%), less pain (1.07 vs 3.71), and greater strength (85.2% vs 82.8%), as well as better scores for the Lower Extremity Functional Scale (75.64 vs 71.5), UCLA activity scale (University of California, Los Angeles; 8.57 vs 8.10), and Single Assessment Numeric Evaluation (93.36 vs 86.50) (all P < .001). Compared with partial avulsion repairs, complete avulsion repairs had higher patient satisfaction (89.64% vs 81.35%, P < .001), less pain (1.87 vs 4.60, P < .001), and higher return to sport or preinjury activity level, but this was insignificant (81.43% vs 73.83%, P = .082). Partial avulsion repairs had better hamstring strength (86.04% vs 83.71%, P < .001) and endurance (107.13% vs 100.17%, P < .001). Complete repairs had significantly higher complication rates (29.38% vs 11.27%, P = .001). CONCLUSION: Proximal hamstring avulsion repair resulted in superior outcomes as compared with nonoperative treatment, although the complication rate was 23.17%. The nonoperative group was quite small, making a true comparison difficult. Acute repairs have better outcomes than do chronic repairs. Complete avulsion repairs had higher patient satisfaction, less pain, and a higher complication rate than partial avulsion repairs, although partial avulsion repairs had better hamstring strength and endurance. Studies of high methodological quality are lacking in terms of investigating the outcomes of proximal hamstring avulsion repairs.

Open 4-Compartment Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg.

Chronic exertional compartment syndrome (CECS) is a significant source of lower extremity pain and morbidity in the athletic population. Although endoscopic techniques have been introduced, open fasciotomy remains the mainstay of surgical treatment because of the paucity of evidence in support of an endoscopic approach. The literature on surgical management of CECS is mixed, and overall success rates are modest at best. Optimizing surgical technique, including prevention of neurovascular injury and wound complications, can make a significant impact on the clinical outcome. Here we present our surgical technique, including pearls and pitfalls, for open 4-compartment fasciotomy for treatment of chronic exertional compartment syndrome.