Midshaft Clavicle Fractures: When Is Surgical Management Indicated and Which Fixation Method Should Be Used?

For displaced midshaft clavicle fractures, operative treatment either with open reduction and plate fixation or with intramedullary fixation has been shown to provide earlier return to work and sport, improved functional outcomes, greater patient-reported satisfaction with appearance, and significantly decreased incidence of nonunion and malunion when compared with conservative treatment. Operative intervention is not without risks associated with surgery. Shared decision-making with the patient and understanding patient goals allows surgeons to recommend a management option that the patient will be comfortable with and will follow to achieve a satisfactory outcome.

Combined Assessments of Patellar Tendon and Hamstring Tendon Parameters on Preoperative Magnetic Resonance Imaging Can Improve Predictability of Hamstring Tendon Autograft Diameter in the Setting of Anterior Cruciate Ligament Reconstruction.

Purpose: To evaluate whether preoperative magnetic resonance imaging (MRI) measurements of multiple tendon autograft sources could be used to improve estimates of intraoperative hamstring tendon autograft (HTA) diameter. Methods: Patients who underwent anterior cruciate ligament reconstruction with HTA at our institution were identified through electronic health records. Preoperative MRI tendon measurements of the patellar tendon (PT) length, PT width, PT thickness, quadriceps tendon thickness, semitendinosus tendon (ST) cross-sectional area (CSA), and gracilis tendon (GT) CSA were conducted by 2 independent evaluators using digital imaging measurement tools. Results: A total of 53 patients met the inclusion criteria, with a mean HTA diameter of 7.98 ± 0.7 mm. Height greater than 1.63 m, weight greater than 63.4 kg, PT length greater than 4.2 cm, PT thickness greater than 0.33 cm, ST CSA greater than 10.8 mm2, and GT CSA greater than 6.3 mm2 were associated with an HTA of 8 mm or greater (P < .005). Female sex was associated with an HTA of less than 8 mm (P < .05). PT length, PT thickness, and GT CSA were the strongest predictors of an HTA of 8 mm or greater and were combined into an additive logistic regression model: Score = -23.24 + (1.68 × PT length) + (20.104 × PT thickness) + (1.48 × GT CSA). If the score was greater than 0.237, the HTA graft diameter was predicted to be 8 mm or greater with 83% specificity, 91% sensitivity, and 87% accuracy. Conclusions: By combining PT length and PT thickness measurements with GT CSA measurements in a logit function model, we were able to show improved overall specificity, sensitivity, and accuracy of estimated HTA diameters in our data set when compared with assessments of anthropometric, ST CSA, GT CSA, or combined ST-GT CSA measurements in isolation. Clinical Relevance: Preoperative MRI measurements may be used to screen whether a patient is likely to have an 8-mm graft in the setting of anterior cruciate ligament reconstruction with HTA and thus may help guide graft choice.

Quality and Variability of Physical Therapy Protocols Varies Widely for Osteochondral Allograft Transplantation of the Femoral Condyles.

OBJECTIVE: To assess the quality and variability of osteochondral allograft (OCA) transplantation rehabilitation protocols associated with academic orthopedic programs in the United States. DESIGN: A systematic review was performed to collect all publicly available online rehabilitation protocols for femoral condyle OCA transplant from US academic orthopedic programs participating in the Electronic Residency Application Service. These protocols were evaluated for inclusion of different rehabilitation components as well as timing of suggested initiation of these activities. RESULTS: A total of 22 protocols were included. Although 91% of protocols recommended bracing, wide variation exists in total time of utilization. Median time for full weight bearing (FWB) was 7 weeks (range 4-8). On average, each protocol mentioned 9 (range 2-18) different strengthening exercises. The median time suggested to return to high-impact activities was 9 months (range 8-12). Only 3 protocols (14%) offered criteria of advancement for each phase as well as criteria for discharge. CONCLUSION: Very few of the academic orthopedic programs have published online rehabilitation protocols following OCA transplantation. Although there is wide variation between the protocols, it allowed the identification of trends or patterns that are more common. However, there is need for more standardized evidence-based rehabilitation protocols which are easy to understand and follow by patients.

Lyme Disease Misinterpreted as Child Abuse.

Child abuse is one of the most common causes for child fatality in the United States. Inaccurate reporting of child abuse combined with scarcity of resources for child abuse evaluations can lead to unintended consequences for children and their families. The differential diagnosis of child abuse is varied. To our knowledge, there are no reports in the literature on Lyme disease mimicking child abuse. The current study presents the case of a child from an endemic area for Lyme disease presenting with skin bruising, fracture, and swollen knee. The child was reported for child abuse by the pediatrician and then referred to the orthopaedic surgeon for fracture care.

Trochlear Morphology Development: Study of Normal Pediatric Knee MRIs.

INTRODUCTION: Trochlear dysplasia is a known risk factor for patellar dislocations yet normal trochlea development is not well described. This study will define the articular cartilage (AC) and subchondral trochlear morphology development in pediatric patients using magnetic resonance imaging (MRI) evaluation. METHODS: A retrospective knee MRI review included patients aged 3 to 16 years with nonpatellofemoral-related diagnoses. International classification of diseases-9/International classification of diseases-10 codes were used to identify eligible study patients. Measurements of the trochlea were made on the basis of previously established methods using the axial MRI just distal to the physis at the deepest portion of the trochlear groove. Three linear [lateral trochlear height (LTH), medial trochlear height (MTH), and central trochlear height (CTH)] and 3 angular [sulcus angle (SA), lateral trochlear slope (LTS), and medial trochlear slope (MTS)] were made at AC and subchondral bone (SCB). The 12 measurements were made independently by 2 study authors. Inter-rater reliability was assessed using an interclass correlation coefficient for absolute agreement to the average of the scores. Trochlea measurements were summarized across age quartiles defined as first quartile (age, 5.1 to 8.3 y), second quartile (8.3 to 11.5 y), third quartile (11.5 to 14.3 y), fourth quartile (14.3to 16.9 y). Associations between age and trochlea measures were assessed using linear regression with Huber-White-adjusted SEs to account for clustering from a small number of patients (N=16) with >1 MRI. RESULTS: In total, 246 knee MRIs from 230 patients were included in this study; 113 patients (51%) were female, whereas 117 (49%) were male. A total of 116 MRIs (47%) were of the left knee and 130 (53%) were right knee. The average patient age was 11.4±3.4 years. Inter-rater agreement was high across all measures with interclass correlation coefficient values >0.7. Mean values for measurements are presented by age quartiles. LTH, MTH, and CTH showed a linear increase with age (range, 2 to 2.6 cm/y; P<0.001). SA, LTS, MTS measured at AC showed no change with age (P>0.05); however, LTS and MTS measured at SCB showed significant increases with age (0.6 and 0.9 degrees/y; P<0.001), whereas SA showed a decrease with age (-1.4 degrees/y; P<0.001). There were no significant differences found in the age associations by laterality, left versus right. There were no sex differences in the age associations for SA, LTS (P>0.05); however, for MTH, LTH, and CTH, males were found to have a significantly greater growth rate (P<0.001). CONCLUSIONS: This study found an increase in AC and SCB MTH, LTH, and CTH over time, as well as an increase in SCB LTS and MTS, with a decrease in SA. However, AC of the LTS and SA remained constant, with no significant change throughout growth. This normative data indicate that the LTS and SA of AC are predictors of final trochlea shape in normal development. Final trochlear morphologic development is nearly complete around age 12 years, with no significant changes occurring thereafter.

Porous Coatings in Retrieved Acetabular Components.

BACKGROUND: We evaluated bone volume fraction in retrieved acetabular shells with 2 types of porous coatings: (1) titanium fiber mesh (HG) components and (2) tantalum metal coating (TM) components. METHODS: Eight HG shells were matched to 8 TM shells for patient age, body mass index, and gender. The mean age at index surgery was 69 (51-82) years, mean body mass index was 28 (21-40), and patients were evenly divided between male and female (4:4). The length of implantation was 40 (16-96) months for the TM group and 156 (108-216) months for the HG group. Shells were embedded and two 5-mm thick cross-sections were cut through the apex of each component for backscatter scanning electron microscopy assessment. Backscatter scanning electron microscopy images were segmented to threshold for metal, bone, and available space for ingrowth. Slices were assessed regionally for ingrowth at the rim, equator, and pole of the acetabular shell. Differences were assessed using general estimating equations, and P values were adjusted for multiple comparisons using the Holm-Bonferroni step-down procedure. RESULTS: The mean bone volume fraction was 21 ± 17% for the HG shell and 7 ± 4% for the TM shell (P < .0001). The rim and pole regions both had less bone ingrowth than the equator. No association was found between bone ingrowth and length of implantation for either design. CONCLUSION: Adequate bone ingrowth is a requirement for successful biological fixation, but the amount of ingrowth may not be a driving factor. Both implants studied had successful outcomes and long-term fixation despite the observation of low amounts of ingrowth.

Recurrent Patellofemoral Instability in the Pediatric Patient: Management and Pitfalls.

PURPOSE OF REVIEW: The purpose of the review is to discuss the relevant pathoanatomy, management, complications, and technical considerations for recurrent patellofemoral instability (PFI) in the pediatric population. Special consideration is given to recent literature and management of the patient with repeat instability following surgery. RECENT FINDINGS: Patellar stabilization surgery is in principle dependent upon restoration of normal patellofemoral anatomy and dynamic alignment. Historically, treatment options have been numerous and include extensor mechanism realignment, trochleoplasty, and more recently repair and/or reconstruction of the medial patellofemoral ligament (MPFL) as a dynamic check rein during initial knee flexion. In skeletally immature patients, preference is given to physeal-sparing soft tissue procedures. While medial patellofemoral ligament reconstruction has become a popular option, postoperative failure is a persistent issue with rates ranging from 5 to 30% for PFI surgery in general without any single procedure (e.g., distal realignment, MPFL reconstruction) demonstrating clear superiority. Failure of surgical patellar stabilization is broadly believed to occur for three main reasons: (1) technical failure of the primary stabilization method, (2) unaddressed static and dynamic pathoanatomy during the primary stabilization, and (3) intrinsic risk factors (e.g., collagen disorders, ligamentous laxity). PFI is a common orthopedic condition affecting the pediatric and adolescent population. Treatment of repeat instability following surgery in the PFI patient requires understanding and addressing underlying pathoanatomic risk factors as well as risks and reasons for failure.

Have large femoral heads reduced prosthetic impingement in total hip arthroplasty?

BACKGROUND:: Prosthetic impingement is implicated in dislocation after total hip arthroplasty (THA). While use of larger diameter femoral heads reduces the incidence of dislocation, the effect of larger heads upon impingement rate is unknown. We assessed retrieved THA components for evidence of impingement to determine if large femoral heads reduced the rate of impingement in primary THA and what factors might influence impingement. METHODS:: Liners from 97 primary THAs retrieved at revision arthroplasty were scored for evidence of impingement, defined as wear or deformation on the rim of the component. Component inclination and version were measured from anteroposterior and cross-table lateral radiographs. RESULTS:: Independent of revision diagnosis, 77% of liners demonstrated evidence of impingement. Impingement was less prevalent and less severe as head size increased. Severe impingement was observed in 50% of the liners with 28-mm heads, 15% of liners with 32-mm heads, and 21% of liners with 36-mm heads. Regardless of head size, 76% of liners revised for instability demonstrated impingement. Decreased head-neck ratio, use of an elevated liner, increased length of implantation, and increased version were associated with increased severity of impingement. DISCUSSION:: We showed that larger head sizes are associated with decreased incidence of impingement on retrieved acetabular liners when compared to smaller head sizes. Larger heads have reduced but not eliminated impingement, which remains a potential source of instability.

Roux-Goldthwait and Medial Patellofemoral Ligament Reconstruction for Patella Realignment in the Skeletally Immature Patient.

Surgical management of patellofemoral instability is technically challenging in skeletally immature patients. Special considerations in this population include activity and sports limitations, recurrence rate, risk of long-term injury to patellofemoral cartilage, and potential for physeal disruption with operative intervention. Numerous procedures have been described to address causative pathoanatomy in the patellofemoral joint, as well as its static and dynamic stabilizers. We describe our technique of combined medial patellofemoral ligament and modified Roux-Goldthwait reconstruction to address both proximal and distal malalignment in a skeletally immature patient with open physes.

Preoperative Valgus Alignment Does Not Predict Inferior Outcome of Total Knee Arthroplasty.

BACKGROUND: Preoperative valgus deformity is present in an estimated 10-20% of patients undergoing total knee replacement (TKR). QUESTIONS/PURPOSES: The objective of this study was to compare the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after TKR in a matched cohort of patients with preoperative valgus and varus deformities. METHODS: This is a matched cohort study of 162 patients with varus native knees and 162 patients with valgus native knees who underwent TKR and were prospectively followed in our institutional registry. Patients matched were based on age, BMI, sex, and severity of preoperative knee deformity, which was classified as mild, moderate, severe varus or valgus, or no deformity. Outcomes were evaluated using the WOMAC preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. RESULTS: No significant difference was found between the matched varus and valgus cohorts in all WOMAC subdomain scores except for a marginally worse stiffness at 1 year in patients with valgus deformity (WOMAC stiffness, 75.1 varus vs. 70.1 valgus; P = 0.049). This is below the minimal clinically important difference for WOMAC scores. There was no significant difference in postoperative varus/valgus alignment between the two groups (P = 0.092). CONCLUSION: We found no clinically significant difference in any of the WOMAC domains in patients with preoperative varus deformity versus valgus deformity within the first year after TKR. These findings may allow surgeons to more appropriately counsel patients with osteoarthritis with valgus deformity that they can expect similar outcomes compared to patients with varus deformity.

Survivorship of Extensor Mechanism Allograft Reconstruction After Total Knee Arthroplasty.

BACKGROUND: Extensor mechanism disruption remains a devastating complication after total knee arthroplasty. The purpose of this study is to describe the outcomes of extensor mechanism allograft (EMA) reconstruction in a large single-center case series. METHODS: Consecutive patients with a previous total knee arthroplasty undergoing extensor mechanism reconstruction using a fresh-frozen EMA tensioned in full extension were identified retrospectively from single-center institutional database (N = 25 patients, 26 knees; mean follow-up 68 months [range 22-113 months]). The primary outcome was initial allograft failure, defined as removal of the allograft or extensor lag >30 degrees at most recent follow-up. RESULTS: Sixty-nine percent (18/26) of knees had retained their initial allograft reconstruction at their latest follow-up despite reoperation rates of 58% (15/26). A younger age was significantly associated with failure of the initial allograft reconstruction. Knee Society Scores increased from 101 (38 standard deviation [SD]) to 116 (40 SD) at most recent follow-up for the group as a whole (P = .4). Patients undergoing a reoperation for any cause had lower Knee Society Scores (101 [SD 38] vs 138 [SD 32], respectively; P = .04) at most recent follow-up. CONCLUSION: EMA reconstruction shows adequate overall intermediate-term survival; however, reoperation rates were high and associated with worse functional outcomes.

The Effect of Breathing, Movement, and Meditation on Psychological and Physical Symptoms and Inflammatory Biomarkers in Inflammatory Bowel Disease: A Randomized Controlled Trial.

BACKGROUND: This study evaluated the effects of the Breath-Body-Mind Workshop (BBMW) (breathing, movement, and meditation) on psychological and physical symptoms and inflammatory biomarkers in inflammatory bowel disease (IBD). METHODS: Twenty-nine IBD patients from the Jill Roberts IBD Center were randomized to BBMW or an educational seminar. Beck Anxiety Inventory, Beck Depression Inventory, Brief Symptom Inventory 18, IBD Questionnaire, Perceived Disability Scale, Perceived Stress Questionnaire, Digestive Disease Acceptance Questionnaire, Brief Illness Perception Questionnaire, fecal calprotectin, C-reactive protein, and physiological measures were obtained at baseline and weeks 6 and 26. RESULTS: The BBMW group significantly improved between baseline and week 6 on Brief Symptom Inventory 18 (P = 0.02), Beck Anxiety Inventory (P = 0.02), and IBD Questionnaire (P = 0.01) and between baseline and week 26 on Brief Symptom Inventory 18 (P = 0.04), Beck Anxiety Inventory (P = 0.03), Beck Depression Inventory (P = 0.01), IBD Questionnaire (P = 0.01), Perceived Disability Scale (P = 0.001), and Perceived Stress Questionnaire (P = 0.01) by paired t tests. No significant changes occurred in the educational seminar group at week 6 or 26. By week 26, median C-reactive protein values decreased significantly in the BBMW group (P = 0.01 by Wilcoxon signed-rank test) versus no significant change in the educational seminar group. CONCLUSIONS: In patients with IBD, participation in the BBMW was associated with significant improvements in psychological and physical symptoms, quality of life, and C-reactive protein. Mind-body interventions, such as BBMW, which emphasize Voluntarily Regulated Breathing Practices, may have significant long-lasting benefits for IBD symptoms, anxiety, depression, quality of life, and inflammation. BBMW, a promising adjunctive treatment for IBD, warrants further study.