Elbow Ulnar Collateral Ligament (UCL) Repair Using Suture Augmentation, Anchors, and Bone Tunnels.

Ulnar collateral ligament (UCL) repair with suture augmentation has been increasingly used to treat UCL pathology in overhead athletes. For the appropriately indicated patient, UCL repair with suture augmentation without reconstruction has promising results. Advantages of repair with suture augmentation include earlier return to sport, low complication rate, and decreased operative time since there is no need for graft harvest. Previously reported techniques use suture anchors with high-tensile and collagen-coated nonabsorbable sutures. This article provides an alternative augmentation method using a combination of anchors and bone tunnels to obtain an isometric repair.

Capsule Closure of Periportal Capsulotomy for Hip Arthroscopy.

Multiple approaches for management of the hip capsule during hip arthroscopy for femoroacetabular impingement syndrome have been reported. Capsular closure is advocated in the setting of larger capsulotomies, including interportal and T-capsulotomies, to reduce the risk of iatrogenic instability or microinstability of the hip. The periportal capsulotomy technique has been described for conservative management of the capsule that would not necessitate closure. However, hip arthroscopy for patients with ligamentous laxity or joint hypermobility may warrant capsule closure or plication even with use of conservative capsulotomy techniques. We introduce a technique for closure of periportal capsulotomy as a means to repair or plicate the hip capsule in the at-risk hypermobile patient.

Patient perception of Achilles tendon rupture treatment.

The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopedic surgeons. Many patients' understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with demographic information and the health literacy of the patient. Patients presenting with an Achilles tendon injury were asked to fill out a demographic form, the Literacy in Musculoskeletal Problems (LiMP) survey, to assess musculoskeletal health literacy, and a 22-question survey on ATRs designed to assess patient knowledge and perception of ATRs. Seventy percent of patients responded that surgery with or without other modalities is the most appropriate treatment for ATRs, while only 20% of patients responded that nonoperative treatment is most appropriate. Perceptions of treatment were not associated with demographic data or LiMP scores and appear to be biased to some degree towards surgery. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive.

Injuries and Conditions Affecting the Elbow Flexor/Pronator Tendons.

Common flexor-pronator tendon injuries and medial epicondylitis can be successfully treated nonoperatively in most cases. Operative treatment is reserved for patients with continued symptoms despite adequate nonoperative treatment or in high-level athletes with complete rupture of the common flexor-pronator tendon. The physical examination and workup of patients with flexor-pronator tendon injuries should focus on related or concomitant pathologies of the medial elbow. The gold standard for surgical treatment of flexor-pronator tendon ruptures or medial epicondylitis includes tendon debridement and reattachment.

Outerbridge-Kashiwagi Procedure for the Treatment of a Supracondylar Humerus Fracture Malunion (O-K Procedure).

The Outerbridge-Kashiwagi (O-K) procedure has conventionally been used for the treatment of osteoarthritis of the elbow and to treat posttraumatic sequelae including posttraumatic arthritis, stiffness, contracture, and ulnar neuritis. The procedure involves exposure of the posterior elbow joint as well creating a window posteriorly through the olecranon fossa to target anterior aspects of the elbow. Several case series have shown the O-K procedure to have good functional outcomes with minimal complications. Used mostly for the surgical treatment of adult osteoarthritis, the O-K procedure has not been previously described for the treatment of a pediatric supracondylar humerus fracture malunion. This article and accompanying video will present the pearls and discuss the technique of the O-K procedure used to treat the loss of elbow flexion as a sequelae of supracondylar humerus fracture malunion.

Latissimus Dorsi Tendon Repair.

Latissimus dorsi tendon ruptures are less-common injuries that can occur in elite throwing athletes. Physical examination of the thrower with a latissimus injury may show ecchymosis of the upper arm and asymmetry of the posterior axillary fold along with possible weakness in shoulder adduction, extension, and internal rotation. Magnetic resonance imaging is used to confirm the diagnosis. Latissimus tendon ruptures are largely treated nonoperatively; surgical repair is only advocated for in professional throwing athletes with complete avulsion injuries or midsubstance latissimus tendon tears. Surgical repair options include the use of suture anchors, cortical suture buttons, or transosseous sutures via a single posterior axillary incision or a 2-incision technique. Given the limited literature on this topic, there have been no studies evaluating the different fixation options or surgical approaches for tendon repair. This article and accompanying video show the technique and discusses the technical pearls of a latissimus tendon repair using suture button fixation via a single-incision approach.

Elbow Common Flexor Tendon Repair Technique.

Medial epicondylitis, also known as "golfer's elbow," is a common orthopaedic condition that typically results from overuse of the flexor pronator mass. Repetitive eccentric loading of the muscles responsible for wrist flexion and forearm pronation leads to microtrauma and subsequent degeneration of the flexor pronator tendon. Patients with medial epicondylitis typically present in the fourth to sixth decade of life and have an insidious onset of medial elbow pain. Occasionally, medial epicondylitis may result from an acute traumatic event, such as an acute avulsion of the common flexor tendon. Patients should be examined for concomitant elbow pathologies, including ulnar neuritis and ulnar collateral ligament injury. T2-weighted magnetic resonance imaging can show increased signal intensity in the common flexor tendon or a complete rupture. Nonsurgical management is the mainstay of treatment; however, surgical treatment may be indicated in elite athletes and patients with persistent symptoms after conservative treatment. This technique article with accompanying video describes open debridement and repair of the flexor pronator tendon, with an emphasis on restoration of the anatomic footprint and compression across the repair site to promote biological healing.

Does Residency Selection Criteria Predict Performance in Orthopaedic Surgery Residency?

BACKGROUND: More than 1000 candidates applied for orthopaedic residency positions in 2014, and the competition is intense; approximately one-third of the candidates failed to secure a position in the match. However, the criteria used in the selection process often are subjective and studies have differed in terms of which criteria predict either objective measures or subjective ratings of resident performance by faculty. QUESTIONS/PURPOSES: Do preresidency selection factors serve as predictors of success in residency? Specifically, we asked which preresidency selection factors are associated or correlated with (1) objective measures of resident knowledge and performance; and (2) subjective ratings by faculty. METHODS: Charts of 60 orthopaedic residents from our institution were reviewed. Preresidency selection criteria examined included United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, Medical College Admission Test (MCAT) scores, number of clinical clerkship honors, number of letters of recommendation, number of away rotations, Alpha Omega Alpha (AOA) honor medical society membership, fourth-year subinternship at our institution, and number of publications. Resident performance was assessed using objective measures including American Board of Orthopaedic Surgery (ABOS) Part I scores and Orthopaedics In-Training Exam (OITE) scores and subjective ratings by faculty including global evaluation scores and faculty rankings of residents. We tested associations between preresidency criteria and the subsequent objective and subjective metrics using linear correlation analysis and Mann-Whitney tests when appropriate. RESULTS: Objective measures of resident performance namely, ABOS Part I scores, had a moderate linear correlation with the USMLE Step 2 scores (r = 0.55, p < 0.001) and number of clinical honors received in medical school (r = 0.45, p < 0.001). OITE scores had a weak linear correlation with the number of clinical honors (r = 0.35, p = 0.009) and USMLE Step 2 scores (r = 0.29, p = 0.02). With regards to subjective outcomes, AOA membership was associated with higher scores on the global evaluation (p = 0.005). AOA membership also correlated with higher global evaluation scores (r = 0.60, p = 0.005) with the strongest correlation existing between AOA membership and the "interpersonal and communication skills" subsection of the global evaluations. CONCLUSIONS: We found that USMLE Step 2, number of honors in medical school clerkships, and AOA membership demonstrated the strongest correlations with resident performance. Our goal in analyzing these data was to provide residency programs at large a sense of which criteria may be "high yield" in ranking applicants by analyzing data from within our own pool of residents. Similar studies across a broader scope of programs are warranted to confirm applicability of our findings. The continually emerging complexities of the field of orthopaedic surgery lend increasing importance to future work on the appropriate selection and training of orthopaedic residents.