Improved Functional Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy at Minimum 2-Year Follow-Up.

PURPOSE: To evaluate patient-reported outcomes (PROs) and survivorship at minimum 2-year follow-up after combined hip arthroscopy and periacetabular osteotomy (PAO) performed in the setting of a single anesthetic event. METHODS: Patients who underwent combined hip arthroscopy (M.J.P.) and PAO (J.M.M.) between January 2017 and June 2020 were identified. Preoperative and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport, modified Harris Hip Score (mHHS), Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form Survey Mental Component Scores (SF-12 MCS), and 12-Item Short Form Survey Physical Component Score were collected and compared in addition to revision rate, conversion to total hip arthroplasty (THA), and patient satisfaction. RESULTS: Twenty-four of 29 patients (83%) eligible for the study were available for 2-year minimum follow-up with a median follow-up time of 2.5 years (range, 2.0-5.0). There were 19 females and 5 males with mean age of 31 ± 12 years. Mean preoperative lateral center edge angle was 20° ± 5° and alpha angle was 71° ± 11°. One patient underwent reoperation for removal of a symptomatic iliac crest screw at 11.7 months after operation. Two patients, a 33-year-old woman and a 37-year-old man, were converted to THA at 2.6 and 1.3 years, respectively, following the combined procedure. Both patients had a Tönnis grade of 1 on radiographs, as well as bipolar Outerbridge grade III/IV defects requiring microfracture of the acetabulum. For patients who did not convert to THA (n = 22), there was significant improvement from before to after surgery for all scores (P < .05) except SF-12 MCS. The minimal clinically significant difference and patient-acceptable symptom state rates for HOS-ADL, HOS-Sport, and mHHS were 72%, 82%, 86%, and 95%, 91%, and 95%, respectively. Median patient satisfaction was 10 (range, 4 to 10). CONCLUSIONS: Single-stage combined hip arthroscopy with periacetabular osteotomy for patients with symptomatic hip dysplasia results in improvement in PROs and arthroplasty free survivorship of 92% at median 2.5 year follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Improved Mental Health Status and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is often a chronic problem, which can lead to a decrease in mental well-being. PURPOSE/HYPOTHESIS: The purpose of this study was to determine patient mental health improvement after hip arthroscopy and if this improvement correlated with improved outcomes. It was hypothesized that patients with low mental health (LMH) status would improve after hip arthroscopy for FAI and that their patient-reported outcomes (PROs) would significantly improve after surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent hip arthroscopy with labral repair between 2008 and 2015 were included. The minimum follow-up was 2 years. PROs included the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports (HOS-Sports), and 12-Item Short Form Health Survey (SF-12). The minimal clinically important difference and Patient Acceptable Symptom State (PASS) were determined for HOS-ADL, HOS-Sports, and the mHHS based on previously published studies. Patients who scored <46.5 on the SF-12 Mental Component Summary (MCS) were in the LMH group, and those who scored ≥46.5 were in the high mental health (HMH) group. RESULTS: In total, 120 (21%) of the 566 patients were in the LMH group and 446 (79%) patients were in the HMH group preoperatively. There was no difference in age or sex between groups. Patients in the LMH group had lower mHHS, HOS-ADL, and HOS-Sports at the mean 4-year follow-up and were less likely to reach PASS for the scores. Postoperatively, 84% (478/566) of the entire group was in the HMH group. A total of 88 (73%) of the LMH group improved to HMH. A multiple linear regression model for change in MCS identified independent predictors of changes in preoperative MCS to be LMH group preoperatively, change in HOS-Sports, and change in mHHS (r2 = 0.4; P < .001). CONCLUSION: HMH was achieved in 84% of the patients after hip arthroscopy for FAI. Improvement in MCS was correlated with function and activity, as indicated by a significant correlation with HOS-ADL and HOS-Sports. A small percentage of patients did see a decline in their MCS score. This study showed that patients with LMH scores before hip arthroscopy for FAI can improve to normal/high mental health, and this correlated with higher PROs.

Arthroscopic Core Decompression for Avascular Necrosis of the Femoral Head Using Multiple Small-Diameter Tunnels.

Avascular necrosis of the femoral head (AVNFH) is a debilitating disease that requires early intervention to prevent subchondral collapse and irreversible damage leading to premature hip replacement. Patients presenting with AVNFH can have concomitant intra-articular pathology, including femoroacetabular impingement (FAI), that contributes to their hip pain and dysfunction. It is important to restore the native hip anatomy in addition to providing revascularization of necrotic areas to reduce pain, improve function, and maximize efforts to preserve the joint. The purpose of this Technical Note is to describe our preferred arthroscopic approach to core decompression through the femoral neck in combination with femoral osteoplasty to address AVNFH and FAI in a single-staged and minimally invasive procedure.

Surgical Treatment of Acetabular Dysplasia With Labral Tears.

Acetabular dysplasia results in abnormal forces across the hip joint and can result in both labral tears and cartilage degeneration. A continuum exists from classic dysplasia to normal acetabular morphology. Diagnosis is aided by several radiographic measurements and parameters including a lateral center edge angle of less than 20°, an anterior center edge angle of less than 20°, a Sharp's angle of greater than 42°, and a Tonnis angle of greater than 10°, or version abnormalities. When patients with acetabular dysplasia present with intra-articular hip pain, skeletal maturity, and preserved radiographic joint space, a periacetabular osteotomy (PAO) is considered as a surgical treatment option when conservative measures have failed. The Bernese PAO was developed in 1984 as a way for reorienting the acetabulum to restore more normal femoral head coverage and orientation. The long-term results of this procedure have been promising with 10-year and 20-year survivorships of approximately 85% and 60%, respectively. When dysplasia is coupled with a labral tear or other intra-articular pathology including focal chondral damage, ligamentum teres tears, or capsular defects, hip arthroscopy and PAO are performed. Although there is a paucity in the literature of the long-term evidence for the combined procedure, early results indicate improved patient reported outcome measures. Appropriate treatment of borderline hip dysplasia remains controversial.

Infection and Mortality Rate in Hepatitis C and Cirrhotic Patients Undergoing Hip and Knee Replacement.

Liver disease carries significant risk in total joint arthroplasty (TJA). The authors sought to investigate the complications in hepatitis C virus (HCV) and cirrhosis patients after TJA. PRISMA guidelines extracted ten studies and meta-analytic analysis was performed. Five hundred and twenty-seven patients with liver disease underwent TJA. The complication rate was 38.9%, with 8% infection at 57 months. Cirrhotic patients had higher complication and infection rates compared to HCV patients (p < 0.001, p < 0.039, respectively). Mortality in cirrhosis patients was 17.8% at 36 months. Studies suggested Child Pugh Class A patients had significantly lower complications than Class B or C. One study revealed lower MELD (Model for End-Stage Liver Disease) scores < 10 carry a low mortality risk of 9.8% compared with 32% mortality if MELD score 10 or above. Cirrhosis has significant infection and mortality risk in total hip and knee arthroplasty. Surgeons can risk stratify these patients by MELD score and Child Pugh Class. (Journal of Surgical Orthopaedic Advances 31(1):001-006, 2022).

Superior gluteal artery injury risk from third sacral segment transsacral screw insertion.

OBJECTIVES: Iliosacral (IS) and transsacral (TS) screws are commonly used to stabilize pelvic ring injuries. The course of the superior gluteal artery (SGA) can be close to implant insertion paths. The third sacral segment (S3) has been described as a viable osseous fixation pathway (OFP) but the proximity of the SGA to the S3 screw path is unknown. METHODS: Fifty uninjured patients with contrasted pelvic computed tomograms (CTA) were identified with an S3 path large enough for a 7.0 mm TS screw. Starting sites for S1 IS or TS, S2 and S3 TS screws were located on the volume rendered lateral CTA image and transferred onto the surface rendered 3D CTA with the SGA clearly visible. The distance from screw start sites to the SGA was measured. A distance less than 3.5 mm was considered likely for injury. RESULTS: The average distances from screw start sites to the SGA were 23.0 ± 7.9 mm for S1 IS screws, 14.3 ± 6.4 mm for S2 TS screws and 25.9 ± 6.5 mm for S3 TS screws. No S1 IS screws, 5 S2 TS screws (10%), and no S3 TS screws were projected to cause injury to the SGA. CONCLUSIONS: The osseous start site and soft tissue path for an S3 TS screw is remote from the SGA. The S1 IS and S3 TS pathways are further away from the SGA while the S2 TS pathway is closer and may theoretically pose a higher injury risk in patients with an available S3 OFP.

Reoperations are few and confined to the most valgus phenotypes 4 years after unrestricted calipered kinematically aligned TKA.

PURPOSE: The present study determined the postoperative phenotypes after unrestricted calipered kinematically aligned (KA) total knee arthroplasty (TKA), whether any phenotypes were associated with reoperation, implant revision, and lower outcome scores at 4 years, and whether the proportion of TKAs within each phenotype was comparable to those of the nonarthritic contralateral limb. METHODS: From 1117 consecutive primary TKAs treated by one surgeon with unrestricted calipered KA, an observer identified all patients (N = 198) that otherwise had normal paired femora and tibiae on a long-leg CT scanogram. In both legs, the distal femur-mechanical axis angle (FMA), proximal tibia-mechanical axis angle (TMA), and the hip-knee-ankle angle (HKA) were measured. Each alignment angle was assigned to one of Hirschmann's five FMA, five TMA, and seven HKA phenotype categories. RESULTS: Three TKAs (1.5%) underwent reoperation for anterior knee pain or patellofemoral instability in the subgroup of patients with the more valgus phenotypes. There were no implant revisions for component loosening, wear, or tibiofemoral instability. The median Forgotten Joint Score (FJS) was similar between phenotypes. The median Oxford Knee Score (OKS) was similar between the TMA and HKA phenotypes and greatest in the most varus FMA phenotype. The phenotype proportions after calipered KA TKA were comparable to the contralateral leg. CONCLUSION: Unrestricted calipered KA's restoration of the wide range of phenotypes did not result in implant revision or poor FJS and OKS scores at a mean follow-up of 4 years. The few reoperated patients had a more valgus setting of the prosthetic trochlea than recommended for mechanical alignment. Designing a femoral component specifically for KA that restores patellofemoral kinematics with all phenotypes, especially the more valgus ones, is a strategy for reducing reoperation risk. LEVEL OF EVIDENCE: Therapeutic, Level III.

CT scans better assess lateral wall morphology of "stable appearing" intertrochanteric (IT) femur fractures and predict early failure of sliding hip screw (SHS) fixation.

To compare the efficacy of plain x-ray images and computed tomography (CT) to assess the morphology of the lateral wall (LW) component of intertrochanteric (IT) femur fractures and determine predictors of early fixation failure. DESIGN: Retrospective cohort study. SETTING: Level-one trauma center. PATIENTS/PARTICIPANTS: One hundred forty-two adult patients with IT fractures treated with either a sliding hip screw (SHS) or a cephalomedullary nail (CMN) who had both pre-op plain x-ray images and CT scans with at least 6 weeks of follow-up were reviewed. INTERVENTION: Preoperative CT scan and plain radiographs of the affected hip. MAIN OUTCOME MEASUREMENTS: Lateral wall assessment based on plain x-rays versus CT imaging in relation to implant failure. RESULTS: One hundred forty-two patients met inclusion criteria, 105 patients treated with a CMN, and 37 with a SHS. There was a poor correlation between the assessment of the LW on plain x-ray images and CT scans. Failures in the SHS group were significantly associated with all CT measurements (P < .05) but not with plain film LW assessment (P = .66). Fifteen patients had an early implant failure (6 CMN, 9 SHS). There were no statistically significant associations between any radiographic measurement (plain images and CT) and CMN failures. CONCLUSIONS: Plain film images are not accurate for assessing lateral wall morphology/integrity and are not predictive of SHS implant failures. Our novel CT measurements were effective at detecting lateral wall patterns at risk for treatment failure with SHS implants.Level of Evidence: Level III.

Aging Decreases the Ultimate Tensile Strength of Bone-Patellar Tendon-Bone Allografts.

PURPOSE: The purpose of this study was to determine whether aging imparts a clinically significant effect on the (1) mechanism of graft failure and (2) structural, material, and viscoelastic properties of patellar tendon allografts by evaluating these properties in younger donors (≤30 years of age) and older donors (>50 years of age). METHODS: A total of 34 younger (≤30 years of age) and 34 older (>50 years of age) nonirradiated, whole bone-tendon-bone allografts were prepared for testing by isolating the central third of the patellar tendon using a double-bladed 10-mm width scalpel under a 10-N load to ensure uniformity of harvest. Bone blocks were potted in polymethylmethacrylate within custom molds. Tendon length and cross-sectional area were measured using an area micrometer. A mechanical loading system was used to precondition the grafts for 100 cycles with a load between 50 N and 250 N (1 Hz). A creep load (500 N) was then applied at a rate of 100 mm/min (10 minutes). Grafts were allowed to recover at 1 N (10 minutes), followed by pull-to-failure at a rate of 100% strain per second. Mechanisms of failure (midsubstance vs avulsion) were noted and the structural, material, and viscoelastic properties calculated and compared between groups. RESULTS: There were 33 (97%) midsubstance tears in the younger group and 28 (82%) in the older group (P = .034). Younger grafts showed greater ultimate load to failure (1,782 N [1,533, 2,032] vs 1,319 N [1,103, 1,533]) (P = .006) and ultimate tensile stress (37.4 MPa [32.4, 42.4] vs 27.5 MPa [22.9, 32.0]) (P = .006). There were no significant differences in displacement (P = .595), stiffness (P = .950), strain (P = .783), elastic modulus (P = .114), creep displacement (P = .881), and creep strain (P = .614). CONCLUSIONS: This in vitro study suggests that aging weakens the bone-tendon junction and decreases the ultimate tensile strength of patellar tendon allografts. However, aging did not affect the displacement, strain, stiffness, elastic modulus, creep displacement, or creep strain of patellar tendon allografts. CLINICAL RELEVANCE: Surgeons should be aware that patellar tendon allografts from donors >50 years of age have a lower ultimate tensile stress than donors ≤30 years of age.

Three-Year Outcomes After MACI for Glenoid Cartilage Loss in an Adolescent Athlete: A Case Report.

CASE: We report the 3-year outcomes of a 14-year-old boy who anteriorly dislocated his shoulder playing football and suffered a 9-cm2 chondral defect of the anterior glenoid and subsequently treated with matrix-applied characterized autologous chondrocytes (MACI) of the defect with open labral repair. CONCLUSION: The management of glenohumeral chondral lesions in adolescent patients remains a challenge. Our case of the successful treatment of a glenoid chondral defect with MACI offers hope as a potential treatment option for adolescent patients with this challenging problem.

Outcomes in Patients with a Calipered Kinematically Aligned TKA That Already Had a Contralateral Mechanically Aligned TKA.

Prior studies suggest kinematically aligned (KA) total knee arthroplasty (TKA) provides some clinical benefits. There are no reports of self-reported outcome measures in patients treated with a calipered KA TKA that already had a contralateral mechanically aligned (MA) TKA. We performed a retrospective study and asked the following questions: (1) Were you satisfied with your MA TKA when you were treated with the KA TKA? (2) What are the Forgotten Joint Scores (FJS) and Oxford Knee Scores (OKS) in each of your knees? (3) Do you favor one knee? and (4) Did one knee recover faster? From January 2013 to January 2017, 2,378 consecutive primary TKAs were performed of which all were treated with calipered KA that uses serial verification checks incorporating measurements of bone resections and positions to restore the prearthritic or native joint lines accurately. A records review identified patients with a prior primary MA TKA in the contralateral limb. Excluded were those with a history of fracture, osteotomy, infection, or revision knee surgery in either limb. In September 2018, 78 patients (57 females) with a mean age of 73 years (range, 50-91 years) completed a follow-up evaluation consisting of the FJS and OKS questionnaires and three anchor questions. A total of 83% of patients were satisfied with the MA TKA and 92% were satisfied with the KA TKA. The KA TKA had a 15 point higher median FJS and a comparable OKS to that of the MA TKA. Also, 56% of patients favored the KA TKA, and 8% favored the MA TKA. Seventy four percent of patients favored the recovery of the KA TKA, and 6% favored the recovery of the MA TKA. Accordingly, a patient considering a contralateral KA TKA can expect that more often than not the KA TKA will have a higher FJS, a similar OKS, be their favorite knee, and recover faster. Present study is therapeutic and reflects level IV evidence.

Revision of a Medial UKA to a Kinematic Aligned TKA: Comparison of Operative Complexity, Postoperative Alignment, and Outcome Scores to a Primary TKA.

Revision of a medial unicompartmental knee arthroplasty (UKA) to a mechanically aligned total knee arthroplasty (MA TKA) is inferior to a primary TKA; however, revision with kinematic alignment (KA) has not been well studied. The present study determined whether patients revised with KA had a higher use of revision components, different postoperative alignment, and different clinical outcome scores from patients with a primary KA TKA. From 2006 to 2017, all patients suitable for a revision of a failed medial UKA to a TKA and a primary TKA were treated with KA. Reasons for the revision performed in ten females and six males at a mean age 67 ± 8 years included progression of osteoarthritis in the lateral hemi-joint (n = 6), aseptic loosening (n = 4), unremitting medial pain without loosening (n = 4), and insert wear (n = 2). Patients with a revision were matched 1:3 with a control cohort treated with a primary KA TKA. Revisions were performed with primary components without augments, stem extensions, or bone grafts. Seven postoperative alignment parameters of the limb and components were comparable to the control cohort (p > 0.05). At a mean follow-up of 5 years (1-10), implant survival was 100%, and the revision/primary group clinical outcome scores were 39/43 points for the Oxford Knee Score (OKS), 2.2/1.0 cm for the Visual Analog Pain Score, and 12/7 points for the Western Ontario and McMaster Universities Osteoarthritis Index score. When compared with primary KA TKA, surgeons that revise a failed medial UKA to a TKA with use of KA can expect similar operative complexity, comparable postoperative alignments, and a mean OKS of 39 points, which is higher than the mean 27 to 30 point range reported for revision of a failed UKA to a TKA with the use of MA.

Posterior pelvic ring bone density with implications for percutaneous screw fixation.

BACKGROUND: Although the second (S2) and third (S3) sacral segments have been established as potential osseous fixation pathways for screw fixation, the S2 body has been demonstrated to have inferior bone density when compared to the body of the first (S1) sacral segment. Caution regarding the use of iliosacral screws at this level has been advised as a result. As transiliac-transsacral screws traverse the lateral cortices of the posterior pelvis, they may be relying on bone with superior density for purchase, which could obviate this concern. The objective of this study was to compare the bone density of the posterior ilium and sacroiliac joint to that of the sacral body at the first (S1), second (S2), and third (S3) sacral levels. MATERIALS AND METHODS: A retrospective case series was performed, reviewing the CT scans of 100 patients without prior pelvic trauma. Each CT was confirmed to have available osseous fixation pathways at the first (S1), second (S2), and third (S3) sacral segments. The bone density of the posterior ilium/sacroiliac joint (PISJ) and sacral body (SB) was measured using the embedded standardized Hounsfield units (HU) tool at each sacral level. RESULTS: The average S2 PISJ bone density (320.1) was significantly higher than the S1 (286.5) and S3 (278.9) PISJ (p < 0.0001) and S1 and S3 PISJ was not statistically different. The S1 sacral body bone density (231.1) was significantly higher than the S2 (182.1) and S3 (126.8) bone density (p < 0.0001). The PISJ bone density is greater than the sacral body at every sacral level (p < 0.0001). CONCLUSION: The S2 PISJ bone density is significantly greater than S1. The S1, S2, and S3 PISJ bone density is greater than the sacral body at all sacral levels, and the S1 body has higher bone density than the S2 and S3 bodies. These differences in bone density may have implications for the stability of posterior pelvic ring fixation constructs with regard to screw purchase. LEVEL OF EVIDENCE: Level III-Case cohort series.

Low Superior Pubic Ramus Screw Failure Rate With Combined Anterior and Posterior Pelvic Ring Fixation.

OBJECTIVES: To determine whether fracture pattern, implant size, fixation direction, or the amount of posterior pelvic ring fixation influences superior ramus medullary screw fixation failure. DESIGN: Retrospective cohort review. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: After exclusion criteria, 95 patients with 111 superior ramus fractures with 3 months minimum follow-up were included. INTERVENTION: All patients underwent anterior and posterior pelvic ring fixation. MAIN OUTCOME MEASUREMENTS: Comparison of immediate postoperative radiographs and/or computer tomography scan with the latest postoperative image to calculate interval fracture displacement and implant position. Postoperative fracture displacement or implant position change greater than 1 cm were considered fixation failures. RESULTS: Five screws were defined as failures (4.5%), including 3 retrograde, 3 with bicortical fixation, 4 with a 4.5-mm screw, and 1 with a 7.0-mm screw. Fracture patterns included 2 oblique and 3 comminuted fractures. Based on the Nakatani classification, there were 3 zone II, 1 zone I, and 1 zone III. Failure modes included 3 with cut-out along the screw head and 1 cut-out and 1 cut-through at the screw tip. CONCLUSIONS: Our incidence of superior pubic ramus intramedullary screw fixation failure was 4.5%. Even with anterior and posterior fixation along with precise technique, failures still occur without a common failure predictor. The percutaneous advantages and proven strength provided by an intramedullary implant make it desirable to help reestablish global pelvic ring stability. Biomechanical and clinical studies are needed to further understand intramedullary superior ramus screw fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A cruciate-retaining implant can treat both knees of most windswept deformities when performed with calipered kinematically aligned TKA.

PURPOSE: Surgeons performing total knee arthroplasty (TKA) on the osteoarthritic valgus deformity often use a posterior stabilized (PS) and semi-constrained implants to substitute for the release of a contracted posterior cruciate ligament (PCL) instead of a cruciate retaining (CR) implant. Calipered kinematic alignment (KA) strives to retain the PCL and use a CR implant. The aim of this study of the windswept deformity was to determine whether the level of implant constraint, outcome scores, and alignment after bilateral calipered KA TKA are different between a pair of knees with a varus and valgus deformity in the same patient. METHODS: A review of a prospectively collected database identified all patients with a windswept deformity treated with bilateral TKA (n = 19) out of 2430 consecutive primary TKAs performed between 2014 and 2019. Operative reports determined the level of implant constraint. Patient response to the Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) assessed outcomes at a mean follow-up of 2.3 years. Postoperative alignment was measured on an A-P computer tomographic scanogram of the limb. RESULTS: CR implants were used in 15 of 19 (79%) valgus deformities and 17 of 19 (89%) of varus deformities (n.s.). No knees required a semi-constrained implant. There was no difference in the median postoperative FJS and OKS (n.s.), and a 1° or less difference in the mean postoperative distal lateral femoral angle (p = 0.005) and proximal medial tibial angle (n.s.) between the paired varus and valgus knee deformity. CONCLUSION: Based on this small series, surgeons that use calipered KA TKA can expect to use CR implants in most patients with windswept deformity and achieve comparable outcome scores and alignment between the paired varus and valgus deformity. LEVEL OF EVIDENCE: IV.

A Biomechanical Comparison of Trochanteric Versus Piriformis Reconstruction Nails for Femoral Neck Fracture Prophylaxis.

OBJECTIVES: To compare piriformis fossa to greater trochanteric entry cephalomedullary implants in an evaluation of femoral neck load to failure when the device is used for femoral shaft fractures with prophylaxis of an associated femoral neck fracture. METHODS: Thirty fourth-generation synthetic femur models were separated into 5 groups: intact femora, entry sites alone at the piriformis fossa or greater trochanter, and piriformis fossa and greater trochanteric entry sites after the insertion of a cephalomedullary nail. Each model was mechanically loaded with a flat plate against the superior femoral head along the mechanical axis and load to failure was recorded. RESULTS: Mean load to failure was 5487 ± 376 N in the intact femur, 3126 ± 387 N in the piriformis fossa entry site group, 3772 ± 558 N in the piriformis entry nail, 5332 ± 292 N for the greater trochanteric entry site, and 5406 ± 801 N for the greater trochanteric nail group. Both piriformis groups were significantly lower compared with the intact group. Both greater trochanteric groups were similar to the intact group and were statistically higher than the piriformis groups. CONCLUSIONS: A piriformis fossa entry site with or without an intramedullary implant weakens the femoral neck in load to failure testing. A greater trochanteric entry yields a load to failure equivalent to that of an intact femoral neck. Instrumentation with a greater trochanteric cephalomedullary nail is significantly stronger than a piriformis fossa cephalomedullary nail during axial loading in a composite femur model.

Preoperative 3D Modeling and Printing for Guiding Periacetabular Osteotomy.

INTRODUCTION: Achieving adequate acetabular correction in multiple planes is essential to the success of periacetabular osteotomy (PAO). Three-dimensional (3D) modeling and printing has the potential to improve preoperative planning by accurately guiding intraoperative correction. The authors therefore asked the following questions: (1) For a patient undergoing a PAO, does use of 3D modeling with intraoperative 3D-printed models create a reproducible surgical plan to obtain predetermined parameters of correction including lateral center edge angle (LCEA), anterior center edge angle (ACEA), Tonnis angle, and femoral head extrusion index (FHEI)? and (2) Can 3D computer modeling accurately predict when a normalized FHEI can be achieved without the need for a concomitant femoral-sided osteotomy? METHODS: A retrospective review was conducted on 42 consecutive patients that underwent a PAO. 3D modeling software was utilized to simulate a PAO in order to achieve normal LCEA, ACEA, Tonnis angle, and FHEI. If adequate FHEI was not achieved, a femoral osteotomy was simulated. 3D models were printed as intraoperative guides. Preoperative, simulated and postoperative radiographic ACEA, LCEA, Tonnis angle, and FHEI were measured and compared statistically. RESULTS: A total of 40 patients had a traditional PAO, and 2 had an anteverting-PAO. The simulated LCEA, ACEA, Tonnis angle, and FHEI were within a median difference of 3 degrees, 1 degrees, 1 degrees, and 0% of postoperative values, respectively, and showed no statistical difference. Of those that had a traditional PAO, all 34 patients were correctly predicted to need a traditional acetabular-sided correction alone and the other 6 were correctly predicted to need a concomitant femoral osteotomy for a correct prediction in 100% of patients. CONCLUSION: This study demonstrates that for PAO surgery, 3D modeling and printing allow the surgeon to accurately create a reproducible surgical plan to obtain predetermined postoperative hip coverage parameters. This new technology has the potential to improve preoperative/intraoperative decision making for hip dysplasia and other complex disorders of the hip.

National Metrics Improved Timeliness of Antibiotic Administration for Open Extremity Fractures.

INTRODUCTION: Antibiotics have been shown to be an essential component in the treatment of open extremity fractures. The American College of Surgeons' Trauma Quality Improvement Program, based on a committee of physician leaders including orthopaedic trauma surgeons, publishes best-practice guidelines for the management of open fractures. Accordingly, it established the tracking of antibiotic timing as a metric with a plan to use that metric before trauma center site reviews. Our hypothesis was that this physician-led effort at the national level would provide the necessary incentive to effect change within our institution. METHODS: A retrospective review of all patients treated at our institution for open extremity fractures was performed over 3 periods separated by 2 quality initiatives. The first initiative was an institution-driven effort to increase awareness and educate specific departments about the importance of prompt antibiotic administration. The second initiative was the tracking of antibiotic order and administration times with quarterly audits following newly published guidelines. RESULTS: Neither antibiotic order placement within 1 hour nor administration within 1 hour improved after our first institution-specific initiative. Both outcome measures significantly improved after the second quality initiative, as did median times from arrival to antibiotic order and administration. CONCLUSIONS: Metrics developed and measured by a physician-led national organization led to practice changes at our hospital. Tracking of antibiotic timing for open fracture treatment was more effective than institutional education of healthcare providers alone. This study suggests that nationally published guidelines, developed and measured by physician leaders, will be found to be relevant by other physicians and can be a powerful tool to drive change.

Effect of Postoperative Oral Antibiotics on Infections and Wound Healing Following Foot and Ankle Surgery.

BACKGROUND: There is controversy regarding the effectiveness of postoperative antibiotics to prevent wound infection. Some surgeons still use a routine postoperative oral antibiotic regimen. The purpose of this study was to review a series of cases and document statistically any difference in infection rates and whether routine postoperative antibiotics in foot and ankle surgery are justified. METHODS: A retrospective chart review of 649 patients was performed who underwent elective foot and ankle surgery. Six hundred thirty-one patient charts were included in the final analysis. Evaluated were patients who did and did not receive postoperative oral antibiotics in order to identify whether a difference in infection rate or wound healing occurred. The study also evaluated risk factors for developing infection following foot and ankle surgery. RESULTS: The number of infections in patients receiving postoperative oral antibiotics was 6 (3%), while the number of infections in those who did not receive postoperative oral antibiotics was 10 (2%) (P = .597). The difference of deep versus superficial infections and delays in wound healing between the 2 groups was not statistically significant. Patients who developed infections were older and had a higher prevalence of hypertension, a history of neoplasm, and a greater American Society of Anesthesiologists Classification of Physical Health. CONCLUSION: This study suggests that routine use of postoperative antibiotics in foot and ankle surgery does not affect wound complications or infection rates. Additionally, patients who are older and those with multiple medical problems may be at higher risk for developing postoperative infection following foot and ankle surgeries. LEVEL OF EVIDENCE: Level III, retrospective comparative series.