How to Recognize, Correct, and Avoid Intraoperative Complications During Anterior Cruciate Ligament Reconstructions.

Technical complications are a leading cause of graft failure following anterior cruciate ligament reconstructions. Complications can occur during any phase of the procedure, from graft harvesting to tunnel preparation to graft fixation. Predicting potential causes of technical difficulty and developing strategies to avoid potential pitfalls can limit the number of intraoperative complications. If adverse events do occur intraoperatively, prompt recognition and treatment can lead to favorable outcomes. It is important to discuss strategies to understand potential complications and develop tactics to avoid and correct adverse events that can occur during anterior cruciate ligament reconstruction.

Generation of 5-Strand Hamstring Autograft for Anterior Cruciate Ligament Reconstruction-A Technical Note.

Hamstring tendons are a very commonly used autograft for anterior cruciate ligament (ACL) reconstruction. Given that larger hamstring graft diameter has been shown to positively affect outcomes after ACL reconstruction, several techniques have been developed to optimize this variable. In this technical note, we describe the operative technique for generation of a 5-strand hamstring autograft via tripling of the semitendinosus tendon and doubling of the gracilis tendon, which can serve to maximize graft diameter, especially in patient populations with undersized hamstring tendons at baseline.

Novel Tools to Approach and Measure Outcomes in Patients with Fractures.

Upper extremity fractures are prevalent and pose a great burden to patients and society. In the US alone, the annual incidence of upper extremity fractures is 67.6 fractures per 10,000 persons. While the majority of patients with upper extremity fractures demonstrate satisfactory outcomes when treated appropriately (the details of which are discussed in prior articles), the importance of follow-up and outcome measurement cannot be understated. Outcome measurement allows for accountability and improvement in clinical outcomes and research. The purpose of this article is to describe recent advances in methods and tools for assessing clinical and research outcomes in hand and upper extremity care. Three specific advances that are broadly changing the landscape of follow-up care of our patients include: 1) telemedicine, 2) patient-reported outcome measurement, and 3) wearables/remote patient monitoring.

Age is predictive of higher rate of conversion to total hip arthroplasty after core decompression for osteonecrosis of the hip.

Background: Core decompression may be performed for early osteonecrosis with a goal of improving symptoms and potentially delaying the need for total hip arthroplasty. The effectiveness and complication rate of this procedure is not well understood given the relatively rare nature of hip osteonecrosis. Purpose: The purpose of this study is to determine time to total hip arthroplasty (THA) after core compression, assess predictors of early conversion to THA, and to examine complications after hip core decompressions. Methods: Using Current Procedural Terminology (CPT) codes, we queried the Mariner PearlDiver dataset for patients who underwent hip core decompression. Patient demographics were recorded and subsequent THA conversion within 2 years after surgery were tracked. Patient demographic factors, including age, sex, obesity, diabetes, prior fractures, steroid use, tobacco use, or alcohol use, were evaluated as possible predictors of early conversion to THA. International Classification of Diseases (ICD) codes were used to identify complications at 90 days after core decompression. Multiple linear regression was used to test if the patient demographics significantly predicted conversion to THA and complications after core decompression. Results: Between 2010 and 2020, 555 patients underwent hip core decompression. Within 2 years of core decompression, 226 patients converted to THA (40.7%). Age was the only significant risk factor for conversion to THA. The highest proportion of patients (61.1%, 138/226) who converted to THA were between age 40-59. The 90-day complication rate was 2.9% (16/555). The most common complication was femoral neck fracture (11/16 of all complications). Discussion: There is a high failure rate following core decompression for hip osteonecrosis with over one third of patients converting to THA within 2 years. Age was the only variable predictive of conversion to THA. The overall complication rate after core decompression is low at 90 days. Conclusion: Patients should be counseled regarding the risk of early conversion to THA if over 40 and the potential risk of femoral neck fracture.

Extensor Mechanism Reconstruction Using Achilles Tendon Allograft With Suture Tape Augmentation.

The management of chronic extensor mechanism injuries represents a significant challenge for orthopaedic surgeons, with numerous options for graft choice and fixation construct, but no clear consensus on which technique achieves optimal outcomes. Although there is little published data regarding outcomes of different fixation methods, small case series have demonstrated modest success using Achilles tendon bone block allografts and transverse patellar screw fixation. In this technical note, we describe a surgical technique for the treatment of a chronic inferior pole patella fracture, with extensor mechanism reconstruction using an Achilles tendon allograft with suture tape augmentation. Our technique describes the use of vertical cannulated screws in the patella for passing tape augmentation sutures, increased construct security by suturing of the Achilles graft directly to the quadriceps tendon, and the use of a post screw in the proximal tibia for suture tape augmentation.

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Volume and Variability of Foot and Ankle Case Exposure During Orthopaedic Residency: 2014-2019.

BACKGROUND: Exposure to a comprehensive breadth and volume of surgical cases is a fundamental component of orthopaedic education, though standardization of case exposures across residency programs is limited to a small amount of required case minimums. Significant variability in exposure to subspecialty cases, such as foot and ankle surgeries, can create distinctly different residency experiences. METHODS: Accreditation Council for Graduate Medical Education (ACGME) surgical case logs from 2014 to 2019 for leg/ankle and foot/toes were examined following the 2013 implementation of case minimums. Average surgical case volume across subcategories and the average volume of different residency percentiles were analyzed to assess variability. RESULTS: The mean total volume of case exposure for graduating orthopaedic residents has increased significantly since 2014 for both leg/ankle cases (28.6%) and foot/toes (27.8%), though totals were still down compared with when ACGME reporting began in 2007. Arthrodesis exposures have increased significantly for leg/ankle (69.2%) and foot/toes (93.8%) cases since 2014, and ankle arthroscopy has increased 20.7%. Disparities in total cases between 10th and 90th percentile programs have shown a nonsignificant decrease over time, with significant differences between leg/ankle arthrodesis (8-fold), leg/ankle arthroscopy (13-fold), and foot/toe arthrodesis (3.5-fold) in 2019. CONCLUSION: The mean volume of foot and ankle case exposures among graduating residents has continued to rise since the implementation of case minimums in 2013 but disparities in volume are present, most notably concerning arthrodesis and arthroscopy. Recognition and future attention toward addressing this variability can be meaningful in promoting a more comprehensive, standardized orthopaedics education. LEVEL OF EVIDENCE: Level III: Retrospective comparative study.

Evaluation of the PROMIS Upper Extremity Against Validated Patient-Reported Outcomes in Patients With Early Carpometacarpal Osteoarthritis.

PURPOSE: Internal consistency, construct, and criterion validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) v1.2 were evaluated in patients with early-stage carpometacarpal (CMC) osteoarthritis (OA). We hypothesized that in patients with early CMC OA, PROMIS UE scores would: (1) be lower than those in asymptomatic controls; (2) correlate with established patient-reported outcomes; (3) correlate with pinch and grip strengths; and (4) not correlate with radiographic disease progression. METHODS: Patients with early CMC OA (modified Eaton stage 0 or 1) and matched asymptomatic control patients completed the PROMIS UE, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation at 2 time points. The PROMIS UE's internal consistency was evaluated by Cronbach's alpha, construct validity by Spearman correlation coefficients among the patient-reported outcome measures, and criterion validity using measures of strength. A floor or ceiling effect was indicated if more than 15% of patients achieved the lowest or highest possible score. RESULTS: The PROMIS UE had high internal consistency. Patients with early CMC OA had a lower score than healthy controls (average, 42 vs 54, respectively). We observed moderate to high correlations between the PROMIS UEv1.2, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation and good criterion validity when compared to key pinch and grip strengths. The PROMIS UE did not correlate to radiographic disease severity. CONCLUSIONS: The PROMIS UE had a high correlation with Australian and Canadian Osteoarthritis Hand Index and a moderate correlation with Patient-Rated Wrist-Hand Evaluation. The PROMIS UE had high internal consistency and good criterion validity. CLINICAL RELEVANCE: The PROMIS UE is a valid assessment for disability in patients with early CMC OA and can serve as a clinical adjunct to an outcome assessment.

Avoiding Fifth Metatarsal Intramedullary Screw Head Cuboid Impingement: A Weightbearing Computed Tomography Anatomic Study.

BACKGROUND: Multiple case reports of fifth metatarsal (MT) intramedullary fixation highlight symptomatic hardware with screw head impingement on the cuboid. We developed a fifth MT intramedullary screw trajectory model using weightbearing computed tomography data. The goal was to assess for cuboid impingement with simulated intramedullary screw position. METHODS: For 20 weightbearing foot computed tomographs (CTs), an automated tool was used to simulate fifth MT screw fixation in the ideal trajectory down the shaft and with a 7-mm screw head. (1) The closest distance from the simulated ideal trajectory to the cuboid in 3 dimensions was measured. A measurement less than 3.5 mm (the radius of the screw head) indicated screw head impingement on the cuboid if not countersunk into the metatarsal. (2) In 3 dimensions, a simulated screw head was then advanced from the proximal tip of the metatarsal distally into the metatarsal until it was entirely avoiding the cuboid. RESULTS: In this model, 95% (19/20) of the patients would have cuboid impingement if the screw was not countersunk. The average ideal pin start distance was 0.15 mm (SD 2.4 mm) inside the cuboid. In this cohort, the screw head would have to be countersunk an average of 8.1 mm (SD 2.7 mm) relative to the proximal tip of the metatarsal to avoid cuboid impingement. For all cases, the simulated fluoroscopic oblique view was a reliable indicator of cuboid impingement, demonstrating visible overlapping of the screw with the cuboid. The overlap resolved on the oblique foot view once the screw was sufficiently countersunk, confirmed on 3-dimensional imaging. CONCLUSION: The ideal guidewire placement for fifth MT intramedullary fixation is directly against the cuboid. Approximately 95% of patients would have cuboid impingement if the screw is not countersunk. The oblique fluoroscopic view of the foot is a reliable assessment of screw head impingement on the cuboid. LEVEL OF EVIDENCE: Level III, retrospective study.

Psychological and Social Components of Recovery Following Anterior Cruciate Ligament Reconstruction in Young Athletes: A Narrative Review.

Anterior cruciate ligament (ACL) rupture is a common injury in young athletes. To restore knee stability and function, patients often undergo ACL reconstruction (ACLR). Historically, there has been a focus in this population on the epidemiology of ACL injury, the technical aspects of ACL reconstruction, and post-operative functional outcomes. Although increasingly recognized as an important aspect in recovery, there remains limited literature examining the psychological aspects of post-operative rehabilitation and return to play following youth ACL reconstruction. Despite technical surgical successes and well-designed rehabilitation programs, many athletes never reach their preinjury athletic performance level and some may never return to their primary sport. This suggests that other factors may influence recovery, and indeed this has been documented in the adult literature. In addition to restoration of functional strength and stability, psychological and social factors play an important role in the recovery and overall outcome of ACL injuries in the pediatric population. Factors such as psychological readiness to return-to-play (RTP), motivation, mood disturbance, locus of control, recovery expectations, fear of reinjury, and self-esteem are correlated to the RTP potential of the young athlete. A better understanding of these concepts may help to maximize young patients' outcomes after ACL reconstruction. The purpose of this article is to perform a narrative review of the current literature addressing psychosocial factors associated with recovery after ACL injury and subsequent reconstruction in young athletes. Our goal is to provide a resource for clinicians treating youth ACL injuries to help identify patients with maladaptive psychological responses after injury and encourage a multidisciplinary approach when treating young athletes with an ACL rupture.

An Approach to Robotic Testing of the Wrist Using Three-Dimensional Imaging and a Hybrid Testing Methodology.

Robotic technology is increasingly used for sophisticated in vitro testing designed to understand the subtleties of joint biomechanics. Typically, the joint coordinate systems in these studies are established via palpation and digitization of anatomic landmarks. We are interested in wrist mechanics in which overlying soft tissues and indistinct bony features can introduce considerable variation in landmark localization, leading to descriptions of kinematics and kinetics that may not appropriately align with the bony anatomy. In the wrist, testing is often performed using either load or displacement control with standard material testers. However, these control modes either do not consider all six degrees-of-freedom (DOF) or reflect the nonlinear mechanical properties of the wrist joint. The development of an appropriate protocol to investigate complexities of wrist mechanics would potentially advance our understanding of normal, pathological, and artificial wrist function. In this study, we report a novel methodology for using CT imaging to generate anatomically aligned coordinate systems and a new methodology for robotic testing of wrist. The methodology is demonstrated with the testing of 9 intact cadaver specimens in 24 unique directions of wrist motion to a resultant torque of 2.0 N·m. The mean orientation of the major principal axis of range of motion (ROM) envelope was oriented 12.1 ± 2.7 deg toward ulnar flexion, which was significantly different (p < 0.001) from the anatomical flexion/extension axis. The largest wrist ROM was 98 ± 9.3 deg in the direction of ulnar flexion, 15 deg ulnar from pure flexion, consistent with previous studies [1,2]. Interestingly, the radial and ulnar components of the resultant torque were the most dominant across all directions of wrist motion. The results of this study showed that we can efficiently register anatomical coordinate systems from CT imaging space to robotic test space adaptable to any cadaveric joint experiments and demonstrated a combined load-position strategy for robotic testing of wrist.