Positive Deviance and Exploring the Role of Mental Health on Early Postoperative Recovery After Total Hip Arthroplasty: A Retrospective Analysis Using the PROMIS-10 Global Health.

INTRODUCTION: Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT. METHODS: This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition. RESULTS: A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group. DISCUSSION: The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT. LEVEL OF EVIDENCE: Diagnostic study-retrospective cohort study.

Influence of Anxiety and Depression on Opioid Use After Cervical Spine Fusion: An Analysis of a National Claims Database.

Patients with spine pathology demonstrate an above average rate of active psychiatric disorders, which can influence their recovery. This study was designed to understand how mental health diagnoses (ie, anxiety and depression) influence a patient's postoperative need for opioids after a single level cervical spine fusion. The PearlDiver database was used to identify patients. Patients were placed into one of four groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. Chi-square tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days after their fusion. A total of 168,967 patients who underwent an elective cervical spine fusion in the United States between 2010 and 2021 were included in this study. The control group filled significantly more opioid prescriptions within the first 90 days after their cervical fusion (P<.001). There was no difference among the study groups regarding the need to fill additional opioid prescriptions. Patients with a diagnosis of depression and/or anxiety may present as complex patients; however, results suggest they do not need additional opioids for pain control after a single level cervical spine fusion. [Orthopedics. 2024;47(2):89-94.].

Influence of Anxiety and Depression on Opioid Use Following Lumbar Spine Fusion: A Large Database Study.

STUDY DESIGN: Retrospective database. OBJECTIVE: The purpose of this study was to understand how a mental health disorder, specifically anxiety and depression, influences a patient's postoperative opioid needs following single-level lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Patients with spine pathology commonly demonstrate symptoms of an active psychiatric disorder. Mental health significantly influences how a patient perceives pain and a patient's opioid pain control needs after surgery. MATERIALS AND METHODS: The Pearldiver Patient Claims Database was used to identify patients undergoing single-level posterior spine fusion within the United States between 2010 and 2020. Patients were placed into 1 of 4 groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. χ 2 tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days following their fusion. RESULTS: The control group filled significantly more initial opioid prescriptions within the first 90 days following their spine fusion ( P <0.001). However, there was no difference among the study groups in regard to the additional need for prescriptions. CONCLUSION: Patients with mental health diagnoses may present as complex patients to spine surgeons; however, this study suggests they do not require additional opioid pain control following a single-level lumbar fusion.

Intravenous Versus Locally Injected Tranexamic Acid in a Fragility Hip Fracture Population: A Retrospective Review.

OBJECTIVES: Evaluate differences between blood transfusion and complication rates among fragility hip fracture patients treated with locally injected (Local) versus intravenous (IV) tranexamic acid (TXA). METHODS: Design: Retrospective comparative cohort. SETTING: Tertiary referral orthopaedic specialty hospital; Level I trauma center. PATIENT SELECTION CRITERIA: Patients aged 50 years and over who underwent surgical treatment for a proximal femur fragility fracture (Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 31A and 31B). Between March 2018 and April 2022 with or without the use of local TXA during wound closure or IV TXA. OUTCOME MEASURES AND COMPARISONS: Postoperative blood transfusion, venous thromboembolism, surgical site infections, and 30-day readmissions compared between those who received IV TXA, Local TXA, and controls that did not receive any TXA. RESULTS: Seven hundred forty-six patients (258 received IV TXA, 252 received Local TXA, and 236 controls that did not receive any TXA) were studied. Both Local and IV TXA groups received fewer blood transfusion versus controls. IV TXA was associated with a transfusion rate reduction of 12% compared with Local TXA ( P < 0.001). Regression analysis indicated that IV TXA reduced the odds of a postoperative blood transfusion by 48% compared with Local TXA ( P = 0.017). There were no differences in complication rates among the groups; however, patients receiving IV TXA had a significantly lower 30-day readmission rate (5%) than the control (13.9%) or Local (13.8%) TXA groups ( P = 0.001). CONCLUSIONS: IV TXA significantly reduced the risk of postoperative transfusion compared with controls and patients receiving Local TXA. There was no increased risk of complications, and a lower 30-day readmission was observed for the IV TXA group. IV TXA seems to be a safe and effective way to reduce postoperative blood transfusion in patients with fragility hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low Body Mass Index Patients Undergoing an Anterior Lumbar Fusion May Have an Increased Risk of Perioperative Complications.

BACKGROUND: Previous research has shown that underweight patients may be at a greater risk of experiencing postsurgical complications. The purpose of this study was to investigate the association between body mass index (BMI) and postoperative complications following single-level anterior lumbar fusion (ALF). METHODS: All single-level elective ALF procedures performed between 2010 and 2020 were identified in the PearlDiver Mariner Database. Patients were separated into 6 groups based on the World Health Organization BMI classifications. Differences in postsurgical complications (ie, deep vein thrombosis, pulmonary embolism, surgical site infection, hardware malfunction, wound dehiscence, and blood transfusion) among BMI categories were assessed using a χ2 contingency test. RESULTS: Results indicated that underweight patients (BMI <20) were at a significantly greater risk of developing deep vein thromboses, experiencing hardware malfunction, and requiring blood transfusion compared with any other BMI classification (P < 0.001). Results also demonstrated that underweight individuals had similar risks of developing surgical site infection and wound dehiscence compared with patients classified as having obesity class III. CONCLUSION: Underweight patients may be at a greater risk than currently believed of experiencing postoperative complications following single-level ALF procedures. CLINICAL RELEVANCE: Patients with a BMI of 20 or less should be carefully evaluated prior to surgical intervention to ensure they are optimized for surgery.

The effect of cannabis use on postoperative complications in patients undergoing spine surgery: A national database study.

Background: With the increased use of cannabis in the US, there is a significant need to understand the medical complications associated with its use in relationship to a surgical population. Cannabis has mainly been studied with respect to its qualities of pain treatment, yet few studies have investigated post-surgical complications associated with its use. Therefore, the purpose of this study was to explore the effect of cannabis use on complications in spine surgery, and compare these complications rates to opioid-related complications. Methods: This was a retrospective study conducted using the PearlDiver Database. Using ICD codes 40,989 patients that underwent lumbar spine fusion between January 2010 and October 2020 were identified and divided into 3 study groups (i.e., control, patients with known opioid use disorder, and patients identified as cannabis users). Differences in the incidence of complications within 30 days of the index procedure and pseudarthrosis rates at 18 months postindex procedure were assessed among study groups using a multivariate logistic regression. Results: Of 12.4% study population used cannabis and 38.8% had a known opioid use disorder. Results indicated increased odds of experiencing a VTE, hypoxia, myocardial infarction, and arrhythmia for both opioid and cannabis users compared to controls; however, when controlling for tobacco use there were no increased odds of complications within the cannabis group. The pseudarthrosis rate was greater in cannabis users (2.4%) than in controls (1.1%). Conclusions: The pseudarthrosis rate was significantly greater in patients using cannabis and opioids compared to the control group. However, when controlling for tobacco use, results suggested a possible negative synergistic between cannabis use and concomitant tobacco use that may influence bone fusion.

The influence of trunk mechanics on the assessment of elbow position in college aged pitchers.

Researchers have postulated that the rise in the incidence of pitching injuries is partially due to poor pitching mechanics. A topic that is often debated revolves around the correct positioning of the elbow in relationship to the body. Therefore, this study attempts to understand the associations of vertical or horizontal elbow positon with upper extremity joint moments, and ball velocity, and how elbow position is influenced by trunk position. Motion analysis data from 99 collegiate pitchers were analysed for this study. A random intercept, mixed-effects regression model was used to determine if statistically significant associations existed between elbow position and upper extremity joint moments and ball velocity. Results indicated that visual impressions of the elbow position were highly correlated with trunk position, whereas kinematic definitions of elbow position were correlated to the glenohumeral angle. Visual vertical and horizontal elbow position was associated with increased elbow varus moments (p = 0.001) and ball velocity (p = 0.019), respectively. Whereas kinematic elbow position was not associated with either upper extremity joint moments or ball velocity. Therefore, what coaches visually interpret as an improperly positioned elbow may actually be a combination of lateral lean, anterior tilt, and over rotation of the trunk.

Influence of stride length on upper extremity joint moments and ball velocity in collegiate baseball pitchers.

The initial stride down the mound is an important aspect of the baseball pitch. Understanding the implications of stride length is essential to appropriately coach baseball pitchers. The purpose of this study was to determine the association between normalised stride length and the elbow varus and glenohumeral internal rotation moments, ball velocity, trunk and pelvic rotation and forward trunk tilt. Motion analysis data collected from 99 collegiate pitchers were analysed for this study. A random intercept, mixed-effects regression model was used to determine if there were statistically significant associations between normalised stride length and the variables of interest. Secondary analyses were conducted to determine if an optimal stride length existed in this cohort. No significant associations were found between normalised stride length, ball velocity, or upper extremity joint moments. Additionally, no optimal stride length was identified; however, trends indicate that stride lengths between 131%-137% of a pitcher's leg length may be beneficial. Normalised stride length was associated with both trunk and pelvic rotation at foot contact (p < 0.001). Trunk and pelvic rotation has been previously shown to be associated with ball velocity and joint moments, indicating that stride length may have an indirect effect on ball velocity and joint moments.

Lateral Patellar Inclination Angle Measured via a Two-Image Technique on Axial Magnetic Resonance Imaging.

Lateral patellar inclination (LPI) measures patellar tilt and is historically described on axial X-ray or a single magnetic resonance image (MRI). Given the variability in patellar height, LPI may be better represented by performing this measurement on two separate axial MRI images. We hypothesized that a two-image LPI measurement would be different from the current single-image LPI and have similar, if not superior reliability. Sixty-five patients treated for patellar instability (PI) between 2014 and 2017 were identified. Single image and two-image LPI were measured on axial MRI images. All measurements were performed by two independent observers. Reliability analysis was based on three observers' measurements of 30 randomly selected patients. Both the one image and two image LPI showed good inter-rater reliability (intraclass correlation coefficient [ICC] = 0.71 and 0.89, respectively), although the two image LPI had less variability. Both single image and two image LPI had near perfect intra-rater reliability (ICC = 0.98 and 0.98, respectively). Average single image LPI (14.6 ± 9.9 degrees) was 6.1 ± 3.4 degrees less than the average two image LPI (19.6 ± 9.4 degrees) (p = 0.037). Referencing a previously described 13.5 degrees maximum threshold, 54% of the patients had excessive patellar tilt based on single image LPI, while 73% had pathologic patellar tilt based on two image LPI. Two image LPI has similar reliability with less inter-rater variability compared with the historical single image LPI measurement. Significantly greater patellar tilt was identified with two image LPI that was found with single image LPI. A larger percentage of patients were classified as having pathologic patellar tilt based on two image LPI than single image LPI. The two image LPI provides more consistent and representative measurements of patellar tilt. Previously described threshold values for patellar tilt should be re-examined using this new measurement technique to appropriately risk stratify patients with PI and patellofemoral pain.

Utility of Erector Spinae Plane Blocks for Postoperative Pain Management and Opioid Reduction Following Lumbar Fusions.

STUDY DESIGN: Retrospective. OBJECTIVE: The purpose of this study was to determine the utility of the erector spinae plane regional anesthesia (ESP) block in reducing opioid medication usage and postanesthesia care unit length of stay (PACU-LOS) for patients undergoing either a posterior or transforaminal lumbar interbody fusions (PLIF/TLIF). SUMMARY OF BACKGROUND DATA: Posterior lumbar spine fusion is a common surgical procedure typically associated with significant postoperative pain. Poorly controlled postoperative pain can lead to a number of poor outcomes. Although opioids are a mainstay for pain control, they are associated with adverse effects and a risk of dependence. Therefore, multimodal pain control has become more prevalent in orthopedics and combines traditional opioid and nonopioid pain mediation with general anesthesia protocols and regional nerve blocks. MATERIALS AND METHODS: A retrospective chart review was conducted for patients undergoing PLIFs or TLIFs between 2019 and 2021. Patients were placed into 2 groups, those receiving an ESP block and those that did not. T tests assuming unequal variances were used to assess differences in pain scores, opioid consumption, and PACU-LOS between groups. RESULTS: The study group demonstrated a 35% reduction in opioid use ( P =0.016), a 16% reduction in pain with activity ( P =0.042), and a 9.7% reduction in pain at rest ( P =0.219) compared with the control group. There were no significant differences in PACU-LOS between groups ( P =0.314). CONCLUSION: The use of an ESP block for patients undergoing PLIFs and TLIFs appears to be a safe and effective means to manage postoperative pain and reduce opioid consumption.

Utility of the transversus abdominis plane and rectus sheath blocks in patients undergoing anterior lumbar interbody fusions.

BACKGROUND CONTEXT: Anterior lumbar interbody fusion (ALIF) is a well-established technique to address numerous pathological conditions of the spine and to restore sagittal spine balance. Improving patient comfort and reducing opioid consumption following lumbar fusions is a significant goal for spine surgeons. Therefore, there is a growing need to explore multimodal options for pain management post-surgery. PURPOSE: Determine the effectiveness of combined transversus abdominis plane (TAP) and rectus sheath (RS) blocks in those undergoing (ALIF) as compared to a historical control. STUDY DESIGN/SETTING: Retrospective comparative cohort performed at a tertiary referral orthopedic specialty hospital. PATIENT SAMPLE: Of the 175 patients (88 patients received a combined regional block) who underwent an ALIF between January 1, 2018 and August 1, 2021. OUTCOME MEASURES: Pain scores both during activity and at rest, opioid consumption during the first 72 hours postoperatively, total postoperative anesthesia care unit length of stay (PACU LOS), 30-day emergency department visits, 30-day readmissions, and unplanned returns to the operating room. METHODS: Charts of patients undergoing an ALIF during the open period for this study were placed into two groups: those that received combined regional anesthesia and those that did not. A t test assuming unequal variances was used to determine if there were differences in outcome variables between the two groups. RESULTS: The study group, those receiving the combine block, demonstrated a statistically significant reduction in opioid pain medicine (24.8%), reported pain (10-13%), and PACU LOS (18.7%). There were no differences in complication rates between the two groups. CONCLUSIONS: The combined use of TAP and RS blocks appears to be a well-tolerated and effective means of pain management in this patient cohort.

Lead knee flexion angle is associated with both ball velocity and upper extremity joint moments in collegiate baseball pitchers.

An important aspect of the pitching motion is the lead leg knee angle, from initial lead foot contact to ball release, which can influence pitching performance and injury potential. Understanding the implication of this angle is essential to appropriately coach baseball pitchers. Therefore, the purpose of this study was to determine the lead leg knee flexion influence on both ball velocity and the elbow varus moment. Kinematic and kinetic data were collected using standard optoelectronic motion capture methods from 121 collegiate pitchers and analysed using a random intercept, mixed effects regression model to evaluate the association between the knee angle on peak ball velocity and peak elbow varus moment, independently. Statistically significant associations between the knee flexion angle and ball velocity as well as with the elbow varus moment were noted. The data indicated that a 10° increase in knee flexion at ball was associated with a 2.1 Nm reduction in the peak elbow varus moment (p = 0.021, r2 = 0.12) and a 0.2 m/s reduction in peak ball velocity (p = 0.010, r2 = 0.11). This study provides scientific evidence that the lead knee flexion angle influences both upper extremity stresses and ball velocity.

Lead Foot Progression Angle in Baseball Pitchers: Implications to Ball Velocity and Upper-Extremity Joint Moments.

The instant of foot contact is an important transition point during the pitch cycle between the linear portion of the pitch, as a pitcher strides down the mound and the rotational portion of the pitch. Understanding the implications of lead foot angle at foot contact is an essential information needed to assist pitching coaches in their work with individual pitchers. Therefore, the purpose of this study was to determine the association between lead foot progression angle at foot contact and ball velocity, elbow varus moment, and pelvic rotation. Kinematic and kinetic data were collected from 99 collegiate pitchers and analyzed using a random intercept, mixed-effects regression model. Significant associations were found between lead foot progression angle at foot contact and elbow varus moment (P = .004), as well as pelvic rotation throughout the pitching motion (P < .001). The data indicate that increased lead foot internal rotation at foot contact is associated with increases in the elbow varus moment but is not associated with ball velocity. This study provides scientific evidence that the rotational positioning of the lead foot can affect both pelvic motion and upper-extremity joint moments.

Efficacy and Safety of Locally Injected Tranexamic Acid in Hip Fracture Patients: A Retrospective Review.

OBJECTIVE: To determine whether locally injected tranexamic acid (TXA) used in the surgical treatment of fragility hip fractures can lower transfusion rates without increasing the risk of complications. DESIGN: Retrospective comparative cohort. SETTING: Tertiary referral orthopaedic specialty hospital, Level I trauma center. PATIENTS/PARTICIPANTS: A total of 490 patients (252 patients received TXA) 50 years of age and older who underwent surgery for a low-energy fragility fracture of the proximal femur between March 2018 and February 2020 were included in this study. INTERVENTION: Use of locally injected TXA at the time of wound closure. MAIN OUTCOME: The main outcomes of this study were the number of patients requiring postoperative blood transfusions, incidences of venous thromboembolism, and surgical site infections. RESULTS: A statistically significant difference was noted in the frequency of transfusion between patients who received TXA compared with those who did not receive TXA (33% vs. 43%, respectively) (P = 0.034). There were no significant differences in venous thromboembolism incidence (0.4% vs. 0.8% TXA vs. No TXA) (P = 0.526) or infections (0.4% vs. 0.4% TXA vs. No TXA) (P = 0.965). Regression analysis indicated that the use of TXA reduced the need for postoperative blood transfusion by 31% (odds ratio: 0.688, 95% CI: 0.477-0.993, P = 0.045). CONCLUSION: Locally injected TXA significantly reduced the need for postoperative transfusion in the surgical treatment of fragility hip fractures. In addition, there was no increased risk of complications in those receiving TXA versus those who did not. Locally injected TXA seems to be both a safe and effective way to reduce postoperative blood transfusions in patients with fragility hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Elbow flexion post ball release is associated with the elbow varus deceleration moments in baseball pitching.

The association between breaking pitches and elbow injury remains nebulous. Biomechanical studies have shown that throwing a fastball rather than a curveball results in greater elbow moments, despite some epidemiological studies and pitcher self-report indicating the opposite. This leads to the following question: Are biomechanical studies missing something that could explain this discrepancy? This study evaluated the association between elbow kinematics of baseball pitchers during the deceleration phase of the pitch and the elbow varus moment. Eighty-seven uninjured collegiate pitchers were analysed using 3-dimensional motion capture techniques. Results indicated that pitchers who remained in greater elbow flexion had greater post ball release elbow varus moments (EVMPBR) (p = 0.001). Regression analysis indicated that for every 10° of increased elbow flexion during follow-through the EVMPBR increased by 5.4 Nm for the fastball and 8.2 Nm for the curveball (p < 0.001). This suggests a concerning second stress on the elbow joint occurring during the deceleration phase of the pitch. The results showed that maintaining greater elbow flexion during the deceleration phase of the pitch can substantially increase the elbow varus moment after ball release (BR), especially when pitching the curveball. The results reinforce the need to emphasise appropriate pitching mechanics.

Deceleration phase elbow varus moments: a potential injury mechanism for collegiate baseball pitchers.

The incidence of elbow injury experienced by baseball pitchers is on the rise. Biomechanical investigations focusing on the acceleration phase of the pitch have yet to elucidate a singular cause for these injuries. Leading to the question is there an additional significant stress on the elbow during other phases of the pitch? This study sought to determine the magnitude of the elbow varus moment during the deceleration phase of the pitching cycle for the fastball, curveball, slider and change-up. Eighty-seven collegiate-level pitchers were evaluated using motion analysis techniques to determine the magnitude of the elbow varus moment occurring during the deceleration phase. The results indicated that the elbow varus moment during the deceleration phase of the pitch was typically between 40% and 50% of the peak acceleration phase moment and was greatest when throwing a slider. Results also indicated that more pitchers experienced deceleration phase moments in excess of 50% of the acceleration moment when throwing breaking pitches. These moments which are the result of the pitchers' need to rapidly decelerate their arm produce an additional significant elbow varus moment that results in additional stress to the elbow.

Lateral Trochlear Inclination Angle: Measurement via a 2-Image Technique to Reliably Characterize and Quantify Trochlear Dysplasia.

BACKGROUND: Trochlear dysplasia (TD) is a risk factor for patellar instability (PI). The Dejour classification categorizes TD but has suboptimal reliability. Lateral trochlear inclination (LTI) is a quantitative measurement of trochlear dysplasia on a single axial magnetic resonance imaging (MRI) scan. HYPOTHESIS: A modified LTI measurement technique using 2 different axial MRI scans that reference the most proximal aspect of the trochlear cartilage on 1 image and the fully formed posterior condyles on the second image would be as reliable as and significantly different from the single-image measurement technique for LTI. Further, the 2-image LTI would adequately represent overall proximal trochlear morphologic characteristics. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients aged 9 to 18 years treated for PI between 2014 and 2017 were identified. The Dejour classification was radiographically determined. Single-image LTI was measured on a single axial MRI scan at the most proximal aspect of visible trochlear cartilage. A 2-image LTI was measured from 2 separate MRI scans: 1 at the most proximal aspect of trochlear cartilage and the second at the fully formed posterior condyles. This 2-image LTI was repeated at 3 subsequent levels (the first measurement is referred to as LTI-1; repeated measurements are LTI-2, LTI-3, and LTI-4, moving distally). In total, 65 patients met the inclusion criteria, and 30 were randomly selected for reliability analysis. RESULTS: Inter- and intrarater reliability trended toward more variability for single-image LTI (intraclass correlation coefficient [ICC], 0.86 and 0.88, respectively) than for 2-image LTI (ICC, 0.97 and 0.96, respectively). The Dejour classification had lower intra- and interrater reliability (ICC, 0.31 and 0.73, respectively). Average single-image LTI (9.2° ± 12.6°) was greater than average 2-image LTI-1 (4.2° SD ± 11.9°) (P = .0125). Single-image LTI classified 60% of patients with PI as having TD, whereas the 2-image LTI classified 71% as having TD. The 2-image LTI was able to capture 91% of overall proximal trochlear morphologic characteristics. CONCLUSION: LTI has higher reliability when performed using a 2-image measurement technique compared with single-image LTI and Dejour classification. The strong correlation between 2-image LTI and average LTI shows that 91% of TD is represented on the most proximal axial image. Because the single-image measurement appears to underestimate dysplasia, previously described thresholds should be reexamined using this 2-image technique to appropriately characterize TD.

Demographics and Epidemiology of Discoid Menisci of the Knee: Analysis of a Large Regional Insurance Database.

BACKGROUND: A discoid meniscus is a morphological variant of normal knee joint meniscus shape and ultrastructure that can lead to traumatic tearing of this tissue and early joint osteoarthritis. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the prevalence of discoid menisci in a large, ethnically diverse regional cohort and to evaluate possible risk factors. The hypothesis was that there would be no difference in the epidemiological distribution of discoid menisci based on ethnicity or sex. STUDY DESIGN: Descriptive epidemiology study. METHODS: The study population was from a regional, integrated health care system cohort from Kaiser Permanente of Southern California that, as of 2016, included more than 4.5 million patients. Patient demographics included age, sex, and ethnicity within this cohort. Potential risk factors analyzed included age, sex, ethnicity, and body mass index (BMI). Unique characteristics of a discoid meniscus were analyzed, including a symptomatic versus asymptomatic meniscus, location of meniscal tear and type of meniscus, and frequency of meniscal surgical treatment. RESULTS: A total of 223 patients with a confirmed discoid meniscus were identified, yielding an overall prevalence rate of 4.88 per 100,000 patients. Those identifying as Black had the lowest prevalence (2.68/100,000), while Hispanic ethnicity had the highest (6.01/100,000). However, there was no significant difference with regard to ethnicity (P = .283), nor any significant difference between sexes. BMI did not significantly influence the rate of discoid menisci (P = .504). A majority (77.5%) of patients were symptomatic, while 22.5% of patients with discoid menisci were asymptomatic and discovered incidentally. Symptomatic discoid menisci were more likely to be operated on compared with asymptomatic discoid menisci (71% vs 14%, respectively; P = .001; odds ratio, 14.8 [95% CI, 5.8-37.2]). Horizontal and bucket-handle tears were the more common tear types. Of the discoid menisci in this cohort, 55.6% underwent surgery, with 95.2% undergoing reported saucerization. CONCLUSION: In this very diverse population-based cohort of patients, there did not seem to be a significant predilection of discoid menisci with regard to ethnicity. Neither sex nor BMI significantly influenced the rate of discoid menisci. More than three-quarters of those with a diagnosed discoid meniscus were symptomatic. Of the tears that occurred with discoid menisci, horizontal and bucket-handle tears made up the largest proportion.

Effect of Trochlear Dysplasia on Commonly Used Radiographic Parameters to Assess Patellar Instability.

BACKGROUND: Trochlear dysplasia (TD) is an important anatomic risk factor for patellar instability (PI). Several imaging-based risk factors for PI have been established, but it is unclear what effect TD has on these measurements, and the Dejour method of categorizing TD has been shown to be unreliable. The lateral trochlear inclination (LTI) is a quantifiable measurement of proximal trochlear morphology. Recently, a modified technique for measuring LTI referencing the posterior condylar angle has demonstrated near-perfect reliability and may serve as a new standard for quantifying TD. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate how TD, expressed in terms of LTI, affects historically used measures of PI, including the sulcus angle (SA), tibial tuberosity to trochlear groove (TT-TG) distance, lateral patellar inclination (LPI), and Caton-Deschamps (CD) ratio. We hypothesized that lower LTI (ie, more dysplastic trochlea) will correlate with higher SA and TT-TG distances, increased patellar tilt, and more patella alta. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients aged 9 to 18 years treated for PI between January 2014 and August 2017 were queried. On magnetic resonance imaging (MRI), LTI, SA, LPI, and the TT-TG measured at the most proximal (pTT-TG) and distal (dTT-TG) aspects of the fully formed trochlear groove were measured on axial images. CD ratio was measured using sagittal MRI as well as lateral radiographs. All measurements were performed by 2 independent observers. Patients were included if there was a diagnosis of PI that was confirmed with a chart review and if there were appropriate imaging studies to analyze. RESULTS: A total of 65 patients met inclusion criteria for this study. Average pTT-TG distance (15.7 ± 4.5 mm) was not significantly different from dTT-TG distance (15.7 ± 4.2 mm) (P = .94). LTI had a weak but significant inverse correlation with pTT-TG (r = -0.40; ß = -0.15 mm; P < .001) and SA (r = -0.43; ß = -0.478°; P < .001). There was a moderate and significant inverse correlation of LTI with dTT-TG (r = -0.593; ß = -0.21 mm; P < .001) and with LPI (r = -0.69; ß = -0.54°; P < .001). There was a weak but significant correlation between LTI and the MRI-based CD ratio (r = 0.279; ß = 0.149; P = .005). Radiograph-based CD ratio did not show a significant correlation with LTI (r = -0.189; P = .135). CONCLUSION: Smaller (ie, more dysplastic) LTI values correlated significantly with larger TT-TG, SA, LPI, and MRI-based CD ratio measurements. The relationship between SA and LTI is intuitive, but the relationship between LTI and the other analyzed variables suggests that they are dependent variables to TD and may not be consistent independent risk factors for PI. Together, these suggest that TD alters the radiographic interpretation of TT-TG and patellar tilt. The correlation between TD and patellar height is unclear and warrants further investigation.

Lower extremity characteristics in recurrent clubfoot: Clinical and gait analysis findings that may influence decisions for additional surgery.

BACKGROUND: Patients with recurrent clubfoot may seek intervention to address impairments that impact gait function. An understanding of these impairments and associated gait issues will provide valuable information about ongoing treatment requirements. RESEARCH QUESTION: The purpose of this study was to describe the prevalence of impairments and associated gait deviations in children with recurrent clubfoot and to evaluate whether these findings differ depending on unilateral or bilateral presentation. METHODS: Eighty-four affected feet (42 unilateral, 21 bilateral) were retrospectively reviewed. History, clinical exam, and gait data were collected. Statistical analysis included evaluations of associations between clinical exam and gait parameters and differences among patients with unilateral versus bilateral clubfoot and a database of healthy controls. RESULTS: The average age was 7.5 ±â€¯3.3 years for unilateral and 7.0 ±â€¯2.8 years for bilateral patients. Patients presented with limited passive ankle dorsiflexion (unilateral/bilateral:67%/57%), limited ankle plantar flexion strength (unilateral/bilateral:53%/55%), metatarsus adductus (unilateral/bilateral:86%/83%) and internal foot-thigh angles (unilateral/bilateral:83%/82%), while only a subset presented with internal bi-malleolar axis angles (unilateral/bilateral:36%/45%). The most common gait deviations were internal foot progression (unilateral/bilateral:76%/73%), external hip rotation (unilateral/bilateral:66%/69%), reduced peak ankle plantar flexion moments (unilateral/bilateral:84%/83%), and reduced peak ankle power generation (unilateral/bilateral:67%/74%). Passive dorsiflexion was significantly correlated with peak dorsiflexion during stance and swing in both groups. Patients with unilateral compared to bilateral clubfoot showed decreased peak dorsiflexion and an associated knee flexor moment. SIGNIFICANCE: Patients with recurrent clubfoot show gait deviations at the ankle that can be explained by joint level impairment and compensations at the knee, hip and pelvis. Patients with unilateral clubfoot typically show decreased dorsiflexion range of motion and associated greater gait impacts and compensations than bilateral clubfoot. Understanding the relationships between impairments and gait function and the implications of unilateral versus bilateral clubfoot will help improve prognostic ability and optimize future treatment outcomes.