FEAR index in predicting treatment among patients with femoroacetabular impingement and hip dysplasia and the relationship of femoral version.

The Femoro-Epiphyseal Acetabular Roof (FEAR) index is a newer measurement to identify the hip instability with borderline acetabular dysplasia. The purpose of this study is to (i) validate the FEAR index in determining the stability of the hip in patients who have previously been treated surgically for femoroacetabular impingement (FAI) and/or developmental dysplasia of the hip (DDH) and (ii) to examine the relationship between the FEAR index and femoral version, lateral center edge angle, Tönnis angle and alpha angle (AA). Patient demographics and radiographic measurements of 215 hips (178 patients), 116 hips treated with hip arthroscopy for FAI and 99 hips treated with periacetabular osteotomy (PAO) for DDH were compared between groups. The sensitivity and specificity of the FEAR index to detect the surgical procedure performed (PAO or hip arthroscopy) was calculated, and a threshold value was proposed. Pearson's correlation coefficients were used to describe the relationships between the FEAR index, femoral version and other radiographic measurements. The FEAR index was higher in patients with DDH versus FAI (DDH: 2.81 ± 0.50° versus FAI: -1.00 ± 0.21°, P < 0.001). A FEAR index threshold value of 3° had a sensitivity and specificity of 80% and 81%, respectively, for correctly predicting the surgical procedure performed. Femoral version was positively associated with the FEAR index in the setting of DDH (r = 0.36, P = 0.001) but not FAI (r = 0.02, P = 0.807). A FEAR index of 3° predicted treatment with 80% sensitivity and 81% specificity. In addition, femoral version significantly correlates with the FEAR index in the setting of DDH but not FAI.

Pre-Operative Medications as a Predictor for Post-Operative Complications Following Geriatric Hip Fracture Surgery.

Background: Fragility hip fractures are a common orthopedic injury seen in Emergency Departments, with variable outcomes that can range from average to devastating. Currently, few reliable metrics to predict which patients will suffer post-operative complications exist. The aim of this study was to determine if the number and type of pre-operative medications can help predict post-operative complications. Methods: A prospectively collected database of hip fracture patients was retrospectively reviewed. Patients with isolated greater trochanteric fractures, periprosthetic fractures, or re-fractures were excluded. Pre-operative baseline characteristics as well as number and type of post-operative complications were reviewed. Any complication within 6 months of surgery and complications that could be directly attributable to the surgical procedure within 2 years of surgery were examined. Major complications (return to the operating room, deep infection, pulmonary, cardiac, and hematologic) and minor medical complications were assessed. A multivariate regression model was performed to identify independent risk factors. Results: Three-hundred ninety-one patients were included. A majority were aged 80-90 and female, and lived at home prior to presentation. Overall, 33.7% of patients suffered a complication within a 2-year follow-up period. Mortality rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years, respectively. After assessing this relationship while controlling for age, sex, injury type, pre-operative residence, ambulatory status, ASA score, and CCI score, the relationship remained significant for both an increased number of complications (P = .048) and a higher likelihood of having a complication (P = .008). Cardiovascular (P = .003), pulmonary (P = .001), gout (P = .002), or diabetes (P = .042) medications were associated with a higher likelihood for experiencing a complication. Conclusions: Our study suggests that there is a strong and linear relationship between the number and type of pre-operative medications taken and risk of post-operative complications. This exists for up to 8 medications, at which point further increase does not contribute to an increased risk of complication. This relationship exists even after controlling for confounding variables and can be used by surgeons to better counsel patients and families regarding their specific risk for suffering perioperative complications.

The brief resilience scale is associated with pre- and short-term postoperative outcomes following hip arthroscopy.

BACKGROUND: Despite improving diagnostic and surgical techniques, some patients do not respond as well as others following hip arthroscopy. In most musculoskeletal studies, predictors for surgical outcomes focus solely on physical health prior to surgery. However, there likely exists a relationship between a patient's mental health and their postoperative patient-reported outcome measures (PROMs). METHODS: 40 patients who met indications for hip arthroscopy were enrolled in this prospective cohort study. All patients completed a baseline Brief Resilience Scale (BRS) and 4validated PROMs: modified Harris Hip Score (mHHS), visual analogue scale for pain (VAS), Hip Outcomes Score for Activities of Daily Living (HOS-Daily), and Hip Outcomes Score for Sports-Related Activities (HOS-Sport). For a secondary measure of psychometric evaluation, past medical histories of anxiety/depression were recorded. Patients were stratified into Low Resilience (LR < 21), Normal Resilience (NR 22-24), and High Resilience (HR > 25) by tertile to determine differences in PROMs. Comparisons and correlations of pre- and postoperative outcomes between resilience groups were performed. RESULTS: In comparing the LR and HR groups, there was a significant relationship between resilience and all PROMs both preoperatively and 6 months postoperatively (p < 0.05), with the exception of the HOS-Sports. Pearson Correlation Coefficients confirmed this trend in the mHHS and the HOS-Daily. Additionally, there were sixteen patients who were discharged prior to 6-month follow-up with an average resilience above the mean of total population (p < 0.0001). Resilience was associated with return to activity (p = 0.017). A past history of anxiety/depression was associated with lower resilience (p = 0.039). CONCLUSIONS: This study showed that HR hip arthroscopy patients had better PROMs than LR patients both preoperatively and postoperatively. HR patients were able to return to activity earlier and had lower rates of preoperative anxiety/depression. The BRS is a simple in-office screening tool, which may help guide patient and doctor communication and expectations.

Effect of Skeletal Maturity on Fixation Techniques for Tibial Eminence Fractures.

BACKGROUND: Several fixation methods have been reported for the operative treatment of tibial eminence fractures. Previous biomechanical studies have demonstrated that suture fixation may be a stronger construct; however, the maturity status of these specimens was not scrutinized. PURPOSE: To examine if suture fixation remains a biomechanically superior fixation method to screw fixation in both skeletally mature and immature specimens. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen total matched porcine (Yorkshire) knees (8 skeletally immature knees and 8 skeletally mature knees) were procured, and a standardized tibial eminence fracture was created. In each age-matched group of knees, 4 knees underwent randomization to fixation with 2 screws while 4 knees were randomized to fixation using a dual-suture technique. Once fixation was complete, the specimens underwent cyclic loading (200 cycles) in the anteroposterior plane of the tibia and load-to-failure testing, both with the knee positioned at 30° of flexion. Relevant measurements were recorded, and data were analyzed. RESULTS: Among mature specimens, load to failure was 1.9 times higher in the suture fixation group compared with the screw fixation group (1318.84 ± 305.55 vs 711.66 ± 279.95 N, respectively; P = .03). The load to failure was not significantly different between the groups in immature specimens (suture: 470.00 ± 161.91 N vs screw: 348.79 ± 102.46; P = .08). CONCLUSION: These findings suggest that suture fixation may represent a better construct choice for fixation of tibial eminence fractures in the skeletally mature population. However, in the skeletally immature population, fixation with screws or suture may be equivalent. Displacement after cyclic loading did not appear to differ by fixation method, nor did stiffness. CLINICAL RELEVANCE: A stronger fixation construct may be beneficial and allow for earlier range of motion to help potentially decrease postoperative stiffness. Clinical studies are warranted to see if these results may be replicated in humans.

Comparison of three fixation techniques for arcuate fractures.

PURPOSE: Proximal fibula avulsion fractures, or "arcuate fractures", are an often discussed but poorly defined injury pattern which represent a destabilizing injury to the posterolateral corner of the knee. Historical and recent literature discussing reconstruction and repair techniques exist, but there has been little biomechanical evaluation of repair techniques. The purpose of this study was to evaluate the strength of three type of fixation techniques for arcuate fractures: bone tunnels, a screw and washer, and a novel suture anchor technique. METHODS: A laboratory model of the arcuate fracture pattern was developed. This was used to create an arcuate fracture in 24 cadaveric specimens. Knees were randomized into fixation with either suture tunnel (ST), screw and washer (SW), or suture anchor (SA) repair. A previously published model for inducing varus stress was applied and a MTS testing system was used to assess fixation ultimate and yield strength. RESULTS: Fibular fracture occurred during the fixation of one specimen from the ST group and one from the SA group. Analysis of the remaining 22 specimens revealed a mean ultimate strength of 2422.48 N for the ST group, 2271.78 for SW, and 3041.66 for SA (p = 0.390). Yield strengths were 2065.28 for ST, 1882.43 for SW, and 2871.92 for SA (p = 0.224). Analyses of stiffness and total energy applied were not statistically different (p = 0.111 and 0.601, respectively). CONCLUSION: Biomechanical analysis of three types of arcuate fragment fixation revealed robust fixation among all methods, supporting surgeon preference for fixation. Fixation may depend on the size of bony fragment and whether or not the injury is a bony or soft tissue injury.

Open Surgical Stabilization of Glenohumeral Dislocations.

Traumatic anterior shoulder dislocations are the most common dislocations of the shoulder, and the recurrence rate is high when they are treated nonoperatively in young patients (<30 years old). This has led to a trend toward early surgical stabilization. Originally open Bankart repair was considered the standard of care, with good clinical outcomes and a low recurrence rate. However, the majority of Bankart repairs are now performed with newer arthroscopic techniques because of their potential advantages and similar results. Both open and arthroscopic repairs have been shown to decrease the recurrence rate to 6% to 23%. Although arthroscopic Bankart repair is now more common, open repair should be considered for younger patients participating in contact sports or military activity, osseous Bankart lesions, revision cases, shoulder instability with "subcritical" (20% to 25%) glenoid bone loss, ligamentous laxity, or cases not considered repairable with arthroscopic techniques. Therefore, knowing how to perform an open Bankart repair is essential. The major steps of the procedure are (1) preoperative planning, (2) induction of anesthesia, (3) patient positioning and setup, (4) examination under anesthesia, (5) possible arthroscopic examination of the shoulder, (6) incision along the anterior axillary fold, (7) exposure using the deltopectoral interval, (8) clavipectoral fascia incision, (9) vertical tenotomy of the subscapularis tendon, (10) dissection of the capsule from the subscapularis, (11) assessment of the quality of the capsule, (12) "T" capsulotomy, (13) repair of the Bankart lesion, (14) anterior capsulorrhaphy, (15) subscapularis repair, (16) possible closure of the rotator interval, (17) wound closure, and (18) postoperative rehabilitation. Studies have shown that surgical stabilization after traumatic anterior shoulder instability decreases the recurrence rate, and open and arthroscopic techniques have similar clinical outcomes.

The arcuate fracture: A descriptive radiographic study.

PURPOSE: To assess plain radiographic morphology of arcuate fractures in order to identify patterns and help shape treatment algorithm for proximal fibula fracture. METHODS: A search of radiographic reports at a level 1 trauma center from 2014 to 2016 using MONTAGE search software for the phrases "arcuate fracture", "fibular head avulsion", or "fibular head fracture" was conducted. Descriptive measurements were obtained including dimensions of the fragment, the displacement of the fragment from its anatomic position, and the orientation of the primary fracture line relative to the axis of the fibular diaphysis in both the sagittal and coronal plane. After review of the measurements and radiographs, fracture patterns were assessed based off previous knowledge previous knowledge of posterior lateral corner (PLC) anatomy. RESULTS: Radiographic reports of 48 knees (48 patients) met inclusion criteria. The distance of fractures from the proximal aspect of the fibula averaged 9.25 ± 5.53 mm on AP radiographs, and 9.42 ± 4.89 mm on lateral radiographs. The medial-to-lateral width of the proximal fragment averaged 20.09 ± 7.94 mm on AP radiographs, while the anterior-to-posterior width measured on lateral radiographs averaged 17.53 ± 8.48 mm. Orientation of the primary fracture line was calculated at an average of 23.04 ± 14.95° from the perpendicular on the AP view, and 21.55 ± 17.44° from the perpendicular on the lateral. Maximal displacement at the primary fracture line on the AP view was 4.95 ± 8.49 mm). Maximal displacement on the lateral measured 3.98 ± 7.01 mm. Recurring fracture patterns were identified and described. Assessment revealed 11 (22.9%) pattern 1 fractures, six (12.5%) pattern 2 fractures, 31 (64.58%) pattern 3 fractures, possibly correlating with anatomical features and fracture mechanism. CONCLUSIONS: These measurements and recurring patterns in our study shows the heterogeneity of the size and displacement of these fracture fragments and demonstrates the need for further studies in order to create an anatomic descriptive classification for arcuate fractures, which could be used for clinically for treatment.

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome.

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.

An accessory limb with lipomyelomeningocele in a male.

At 7 months, an infant born with a third limb attached to a lumbosacral mass with an associated lipomyelomeningocele underwent removal of the limb and spinal cord detethering. Depending on the complexity of the pathology and proximity of the limb to viscera, consultation with neurosurgical and surgical colleagues is recommended.