Risk Factors for Concomitant Meniscal Injury With Sport-Related Anterior Cruciate Ligament Injury.

Background: Previous studies of concomitant meniscal injury in athletes with anterior cruciate ligament (ACL) injury have examined age, sex, body mass index (BMI), injury mechanism, and time from injury to surgery as potential risk factors. Purpose: To identify additional risk factors for concomitant meniscal injury, including preinjury joint laxity and lower extremity alignment, in athletes with sport-related ACL injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study included 180 participants aged 13 to 26 years who underwent ACL reconstruction (ACLR) after a first-time ACL injury sustained during participation in sport. Contralateral lower extremity alignment and joint laxity were used as surrogate measures for the injured knee before trauma. Concomitant meniscal tear patterns were identified at the time of ACLR. Sex-specific analyses were conducted. Results: Concomitant meniscal injury was observed in 60.6% of the subjects. The prevalence of concomitant injury was higher in male than female participants (69.9% vs 54.2%; P = .035) due to a higher prevalence of lateral meniscal injuries (56.2% vs 38.3%; P = .018). Among male patients, there was a significant difference in the prevalence of concomitant lateral meniscal tear according to sport participation (≥9 vs <9 h/week: 67.4% vs 35.7%; P = .032). Among male patients, the likelihood of concomitant injury to both the lateral and medial menisci increased by 28.8% for each 1-mm decrease in navicular drop. Among female patients, the likelihood of concomitant injury to the lateral meniscus increased by 15% per degree increase in genu recurvatum and 14% per degree decrease in standing quadriceps angle, with similar effects on the likelihood of concurrent injury to both the lateral and medial menisci. Conclusion: Measures of lower extremity alignment and genu recurvatum previously identified as risk factors for ACL injury were also associated with concomitant meniscal injury in female patients while other risk factors, including BMI and joint laxity, were not. Increased time spent participating in sport and navicular drop were associated with concomitant meniscal injury in male patients.

Characterizing Intraoperative Vasopressor Use in Total Knee Arthroplasty: A Retrospective Cohort Study.

Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS)and narcotic use, and are increasingly important in delivering quality, cost savings, and shifting appropriate cases to an outpatient setting. The intraoperative use of vasopressors is independently associated with increased LOS and risk of adverse postoperative events including death, and in total hip arthroplasty, there is an increased risk for intensive care unit (ICU) admission. Our aim is to characterize the patient characteristics associated with vasopressor use specifically in total knee arthroplasty (TKA). We retrospectively reviewed the electronic medical records of a cohort of patients who underwent inpatient primary TKA at a single academic hospital from January 1, 2017 to December 31, 2018. Demographics, comorbidities, perioperative factors, and intraoperative medication administration were compared with multivariate regression to identify patients who may require intraoperative vasopressors. Out of these, 748 patients underwent TKA, 439 patients required intraoperative vasopressors, while 307 did not. Significant independent predictors of vasopressor use were older age (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.03-1.08) and history of a prior cerebrovascular accident (CVA; OR = 11.80, CI: 1.48-93.81). While not significant, male sex (OR = 0.72, CI: 0.50-1.04) and regional anesthesia (OR = 0.64, CI: 0.40-1.05) were nearing significance as negative independent predictors of vasopressor use. In a secondary analysis, we did not observe an increase in complications attributable to vasopressor administration intraoperatively. In conclusion, nearly 59% of patients undergoing TKA received intraoperative vasopressor support. History of stroke and older age were significantly associated with increased intraoperative vasopressor use. As the first study to examine vasopressor usage in a TKA patient population, we believe that understanding the association between patient characteristics and intraoperative vasopressor support will help orthopaedic surgeons select the appropriate surgical setting during preoperative optimization.

Natural History of Poland Syndrome: A Long-term Study of Functional and Psychosocial Outcomes.

BACKGROUND: Poland syndrome (PS) is a congenital condition characterized by pectoralis hypoplasia and an ipsilateral hand anomaly that frequently necessitates surgery in childhood. This study aimed to determine long-term functional and psychosocial implications of PS. METHODS: Patients underwent strength testing of their affected limb by comparing with their contralateral arm. They completed Disabilities of the Arm, Shoulder, and Hand (DASH), 36-item Short-Form Health Survey (SF-36), and several Patient-Reported Outcome Measurement Information System (PROMIS) surveys. Aggregate scores were compared with population norms. RESULTS: Twenty-eight patients were enrolled, and 16 returned for strength testing. The average age was 42 years (range, 18-65 years), and the average follow-up was 25 years (range, 1-52 years). Dynamometer testing showed decreased strength in shoulder internal rotation and abduction/adduction, hand grip, and key pinch/tip pinch. Average DASH and SF-36 scores were comparable with population norms. The PROMIS Upper Extremity score (46.2) was significantly lower than the average 50 (SD, 10.0); the Social Roles score (57.3) indicated significantly less disability than the general population. Seventy-nine percent reported higher than average satisfaction with life, 82% had normal self-esteem, and 21% and 4% met screening criteria for depression and anxiety, respectively. The Derriford Appearance Scale revealed that 68% of patients identified PS as their most self-conscious feature, with 36% reporting subsequent life adjustments. CONCLUSIONS: This cohort of PS patients self-reported more favorable functional, psychological, and emotional outcomes than expected based on significant shoulder and hand strength deficits. Despite these deficits, patients make adaptations, allowing fulfilling lives with psychosocial functioning similar to their peers.

Shuttling Technique for Directed Fibrin Clot Placement During Augmented Inside-Out Repair of Horizontal Meniscus Tears.

More meniscus tears are being repaired because this has been shown to delay the onset of osteoarthritis compared with partial meniscectomy. However, there still remains a subset of tears that may be viewed as less amenable to repair due to poorer healing potential. Fibrin clots have been used to augment healing for meniscus tears located in avascular regions due to their potential to promote healing and ability to be easily prepared at a low cost. Placement of fibrin clots within a meniscus repair can be technically challenging. Here, we describe a technique for placing a fibrin clot within a meniscus tear site repaired with an inside-out technique. A passing suture through the tear aids to shuttle the fibrin clot into the tear site and is then secured within the tear by tying down the repair sutures around the clot. This technique is efficient, less technically demanding, and can be accomplished without additional specialized instruments.

Reliability of a simple fluoroscopic image to assess leg length discrepancy during direct anterior approach total hip arthroplasty.

BACKGROUND: Direct anterior approach (DAA) total hip arthroplasty (THA) in a supine position provides a unique opportunity to assess leg length discrepancy (LLD) intra-operatively with fluoroscopy. Reported fluoroscopic techniques are useful but are generally complicated or costly. Despite the use of multiple techniques for leg length assessment, LLD continues to be a major post-operative source of patient dissatisfaction further emphasizing the importance of near-anatomic restoration. The utility of an alternative direct measurement of LLD on an intra-operative fluoroscopic pelvic image during DAA THA has not been reported. AIM: To determine the reliability of a novel simple intra-operative measurement of LLD using a parallel line technique on a single fluoroscopic digital image of the pelvis. METHODS: One hundred and seventy-one patients who underwent DAA THA were included for analysis. Intra-operative fluoroscopic and post-operative anterior-posterior radiographs were imported to TraumaCad and calibrated for LLD measurement. LLD was measured on each image using the right-left hip differences in lesser trochanter to pelvic reference line distances. Pelvic reference points included the teardrops and ischia. Fluoroscopic LLD was compared to the gold-standard measurement of LLD measured on a post-operative radiograph. RESULTS: Mean absolute difference in teardrop referenced LLD between fluoroscopic and post-operative radiographs was 2.17 mm and based on the ischia mean absolute difference was 2.63 mm. Linear regression of fluoroscopic and post-operative radiograph LLD based on teardrop and ischia LLD found r 2 values of 0.57 and 0.84, respectively. Mean absolute difference between fluoroscopic and post-operative x-ray LLD was within 5 mm in 95% of cases regardless of pelvic reference. CONCLUSION: This study demonstrates that a single fluoroscopic view obtained during DAA THA for leg length assessment is clinically useful.