The Intermalleolar Method for Intraoperative Rotational Assessment of the Tibia-A Prospective Clinical Validation Study.

OBJECTIVES: To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT). DESIGN: Prospective cohort study. SETTING: Academic Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023. OUTCOME MEASURES AND COMPARISONS: Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation. RESULTS: Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively. CONCLUSIONS: The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A Case of Iliopsoas Bursitis With Compressive Femoral Nerve Palsy Treated With Iliopsoas Tendon Release.

Iliopsoas bursitis is a well-established cause of groin pain after total hip arthroplasty (THA), and it can become dramatically more complex when associated with neurovascular compression. Iliopsoas bursitis may be caused by a variety of pathologies in the setting of a THA but most frequently due to a prominent acetabular component or implant wear. Here we report a rare case of a female patient presenting with iliopsoas tendonitis, an accompanying femoral nerve palsy, and debilitating pain beginning 12 years after a previously successful primary THA without apparent implant wear. Ultimately, our patient was treated successfully with iliopsoas tendon release for anterior prominence of the acetabular component.

Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study.

BACKGROUND. Superior labrum anterior and posterior (SLAP) tears are a common shoulder pathology. Although MRI is the imaging reference standard for diagnosis of this pathology, the cost-effectiveness of common MRI strategies is unclear. OBJECTIVE. The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. METHODS. We created decision analytic models from the perspective of the U.S. health care system over a 2-year time horizon for a hypothetical population of 25-year-old patients with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies, which included combinations of 1.5-T and 3-T MR arthrography (MRA) and unenhanced MRI protocols, and the resulting treatment applied for these patients. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years. Costs were estimated in 2017 U.S. dollars. RESULTS. When all imaging strategies were considered, the unenhanced 3-T MRI-based imaging strategy was the preferred and dominant option over 3-T MRA and 1.5-T imaging (MRI and MRA). When the model was run without 3-T imaging as an option, 1.5-T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. CONCLUSION. An unenhanced 3-T MRI-based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3-T imaging is not available, 1.5-T MRA is more cost-effective than 1.5-T MRI. The main driver of these results is the fact that 3-T MRI and 1.5-T MRA are the most specific tests in these respective scenarios, which results in fewer false-positives, prevents unnecessary surgeries, and leads to decreased costs. CLINICAL IMPACT. Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for radiologists, clinicians, and patients with SLAP tears who have access to various types of MRI options.