Relative Sagittal Alignment of the Medial and Lateral Articular Surfaces of the Tibial Plateau Using Radiographic Parameters: A Radiographic Cadaveric Study.

OBJECTIVES: To characterize anatomic slope (sagittal alignment) of medial and lateral articular surfaces of the tibial plateau using x-ray and computed tomography (CT). METHODS: Fluoroscopy was used to acquire "perfect" anteroposterior (AP) images of 8 cadaveric knees by tilting a C-arm through a 30-degree cranial/caudal arc in 0.5-degree increments. Five surgeons independently selected perfect AP images that most accurately profiled medial and lateral articular surfaces. Corresponding angles were used to define tangent subchondral structures on sagittal CT that were considered as dominant bony landmarks in a protocol to determine tibial slope on sagittal CT in 46 additional cadaveric knees. RESULTS: Mean perfect C-arm AP angles were 4.2 degrees ± 2.6 degrees posterior for the medial plateau and 5.0 degrees ± 3.8 degrees posterior for the lateral plateau. It was noted that images acquired within a range of angles (medial range, 1.8 degrees ± 0.7 degrees; lateral range, 3.9 degrees ± 3.8 degrees) rather than a single angle adequately profiled each compartment. Using the CT protocol, mean medial slope (5.2 degrees ± 2.3 degrees posterior; range, 0.9-11.5 degrees) was less than lateral slope (7.5 degrees ± 3.0 degrees posterior; range 0.6-12.5 degrees; P < 0.001) in 54 knees. The difference between medial and lateral slopes in any individual specimen ranged from 3.1 degree more medially to 6.8 degrees more laterally. No differences were noted between right and left knees in paired specimens. CONCLUSIONS: On average, tibial slope in the lateral plateau is slightly greater than that in the medial plateau, and variation exists between compartments across patients. Because tibial slope is similar between contralateral limbs, evaluating slope on the uninjured side can provide a template for sagittal plane reduction of tibial plateau fractures.

Surgical outcomes of dual-plate fixation for periprosthetic femur fractures around a stable hip arthroplasty stem.

INTRODUCTION: The incidence of periprosthetic femur fractures is increasing. Multiple treatment methods exist to treat fractures surrounding stable hip arthroplasty implants including locking plate fixation, cable fixation, allograft augmentation, and revision arthroplasty. No consensus regarding optimal treatment has been reached, and significant complications remain. Recently, biomechanical studies have demonstrated the benefits of orthogonal dual-plate fixation, but little clinical data exist. The purpose of the current study was to investigate the clinical and radiographic outcomes of dual-plated periprosthetic femur fractures around stable hip stems. MATERIALS AND METHODS: Patients with periprosthetic femur fractures following hip arthroplasty with a stable femoral stem treated with dual-plate fixation were identified through chart review at a single institution. Fracture classification, fixation characteristics, radiographic outcomes, clinical outcomes and complications including re-operation were recorded. RESULTS: Over a 12-year period, 31 patients (mean age 77 years at surgery, range 48-94) underwent dual plating by three traumatologists for implant-stable periprosthetic femur fractures surrounding a hip arthroplasty stem. There were 27 Vancouver B1-type and 9 inter-prosthetic fractures. Average follow-up was 2 years. Of the 26 patients with minimum 6-month follow-up, 24 (92%) united after index surgery (mean time to union 6.0 months, range 1.5-14.0). Mean time to full weight-bearing post-operatively was 2.6 months (range 1.5-4.0 months). Two patients required secondary surgery to address nonunion. CONCLUSIONS: Dual-plating achieved high union rates with an acceptable complication profile for the treatment of periprosthetic femur fractures surrounding a stable hip arthroplasty stem. Our preferred fixation construct involves a lateral plate spanning the entire femur secured with non-locking bicortical screws supplemented with an anteriorly based reconstruction plate. Additional prospective research is required to confirm the results of this study.

The effect of calcar femoral neck plating on vascularity of the femoral head and neck.

AIMS: Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck. METHODS: A Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed. RESULTS: Quantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens. CONCLUSION: Calcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients. Cite this article: Bone Jt Open 2021;2(8):611-617.

Do psychiatric disorders affect patient reported outcomes and clinical outcomes post total hip and knee arthroplasty?

INTRODUCTION: The purpose of this study is to evaluate the role of major psychiatric illness on patient outcomes after total joint arthroplasty. METHODS: Patients with a diagnosis of a major psychiatric disorder undergoing total joint arthroplasty were retrospectively matched one-to-one with a cohort without such a diagnosis. Major psychiatric disorder in the registry was identified by diagnosis of anxiety, mood, or a psychotic disorder. Primary outcome of interest included perioperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included EuroQol-5D, adverse events, length of stay, 30-day readmission, and discharge destination. RESULTS: Total number of patients were 1828. The total hip arthroplasty (37.80 ± 17.91, p = 0.023) and the total knee arthroplasty psychiatric group (43.38 ± 18.41, p = 0.050) had significantly lower pre-operative WOMAC scores. At 3 months, the total hip arthroplasty (76.74 ± 16.94, p = 0.036) and total knee arthroplasty psychiatric group (71.09 ± 18.64, p < 0.01) again had significantly lower 3-month post-operative WOMAC score compared to the control groups. However, outcomes at 1 year were difficult to interpret, as patients with major psychiatric conditions had an extremely high loss to follow-up. Compared to the control groups, the total hip arthroplasty and total knee arthroplasty psychiatric group had an increased length of stay by 1.43 days (p < 0.01) and 0.77 days, respectively (p = 0.05). Similarly, the psychiatric groups were discharged directly home less often (total hip arthroplasty 86.9%, p = 0.024 and total knee arthroplasty 87.6%, p = 0.022) than the control groups. CONCLUSION: Patients with the diagnosis of a major psychiatric illness have an increased length of stay and are more likely to require a rehabilitation facility, compared to the control groups. Arguably, of utmost importance, there is a very high rate of loss to follow-up within the psychiatric groups. As such, we recommend these patients should be treated for their diagnosis prior to total joint arthroplasty. Furthermore, importance of clinical follow-up should be emphasized carefully.

Assessment of malreduction standards for the syndesmosis in bilateral CT scans of uninjured ankles.

AIMS: Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles. METHODS: Three observers reviewed 213 bilateral lower limb CT scans of uninjured ankles. Multiple measurements were recorded on the axial CT 1 cm above the plafond: anterior syndesmotic distance; posterior syndesmotic distance; central syndesmotic distance; fibular rotation; and sagittal fibular translation. Previously studied malreduction standards were evaluated on bilateral CT, including differences in: anterior, central and posterior syndesmotic distance; mean syndesmotic distance; fibular rotation; sagittal translational distance; and syndesmotic area. Unilateral CT was used to compare the anterior to posterior syndesmotic distances. RESULTS: A difference of anterior to posterior syndesmotic distance > 2 mm was observed in 89% of ankles (n = 190) on unilateral CT assessment. Using bilateral CT, we found that 35% (n = 75) of normal ankles would be considered malreduced by current malreduction parameters. In 50 patients (23%), only one parameter was anomalous, 18 patients (8%) had two positive parameters and seven patients (3%) had three. Difference in fibular rotation had the lowest false positive rate of all parameters at 6%, whereas posterior syndesmotic distance difference had the highest at 15%. CONCLUSION: In this study, 35% of native, uninjured syndesmoses (n = 75) would be classified as malreduced by current diagnostic standards on bilateral CT and 89% had an asymmetric incisura on unilateral CT (n = 190). Current radiological parameters are insufficient to differentiate mild inherent anatomical asymmetry from malreduction of the syndesmosis. Cite this article: Bone Joint J 2021;103-B(1):178-183.

The effects of dual plating on the vascularity of the distal femur.

AIMS: Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. METHODS: A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. RESULTS: Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. CONCLUSION: Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530-538.

Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists

Background: Management of chronic isolated scapholunate interosseous ligament (SLIL) injuries has generated a substantial volume of low-quality literature with descriptions of multiple new surgical techniques, and the impact of instability pattern and the optimal surgical technique remain unclear. The primary goal of this review was to compare clinical, radiographic and patient-rated outcomes between current surgical techniques. Methods: We performed a systematic literature search using multiple databases. We analyzed clinical, radiographic and patient-reported outcomes. We used a fixed-effects model weighted by sample size with combined outcomes estimated via least squares means with 95% confidence intervals. We also performed a subgroup analysis of static versus dynamic instability. Results: We assessed 805 procedures from 37 study groups, with 429 procedures used in subgroup analysis. There were no statistically significant differences in outcomes between surgical techniques or in subgroup analysis. Overall, postoperative wrist flexion and pain scores decreased, and grip strength and patient-rated outcomes improved. Conclusion: Compared to overall preoperative values, modest improvements in pain score, grip strength and functional outcome scores were obtained from a range of reconstructive procedures performed for chronic isolated SLIL injuries. No significant differences could be ascertained between surgical techniques, potentially owing to the low quality of evidence and procedure heterogeneity. This study provides accurate preoperative reference values for future studies, highlights the controversial clinical impact of instability classification, and the need for higher-quality multicentre or collaborative trials to improve our understanding and management of this common injury.

Contexte: La prise en charge des blessures chroniques du ligament interosseux scapho-lunaire (LISL) a généré un volume substantiel d'articles de faible qualité où sont décrites plusieurs nouvelles techniques chirurgicales, mais l'impact du modèle d'instabilité et la technique chirurgicale optimale restent à clarifier. Le principal objectif de cette revue était de comparer les résultats cliniques, radiographiques et autodéclarés par les patients entre les diverses techniques chirurgicales actuelles. Méthodes: Nous avons procédé à une interrogation systématique de la littérature dans plusieurs bases de données. Nous avons analysé les résultats cliniques, radiographiques et autodéclarés par les patients. Nous avons utilisé un modèle à effets fixes pondéré par la taille de l'échantillon, avec paramètres mixtes estimés par les moyennes des moindres carrés et des intervalles de confiance à 95 %. Nous avons aussi effectué une analyse de sous-groupes (instabilité radiographique dynamique c. statique). Résultats: Nous avons évalué 805 interventions dans 37 groupes étudiés, et 429 interventions ont été utilisées dans les analyses de sous-groupes. On n'a noté aucune différence statistiquement significative pour ce qui est des résultats entre les techniques chirurgicales ni dans les analyses de sous-groupes. Globalement, la flexion du poignet et la douleur ont diminué, et la force préhensile et autres paramètres autodéclarés par les patients se sont améliorés. Conclusion: Comparativement aux valeurs préopératoires globales, de modestes améliorations du score de douleur, de la force préhensile et des paramètres fonctionnels ont été obtenues au moyen de diverses interventions de reconstruction effectuées pour des blessures chroniques isolées du LISL. Aucune différence significative n'a pu être confirmée entre les techniques chirurgicales, probablement en raison de la faible qualité des données et de l'hétérogénéité des interventions. Cette étude fournit des valeurs de référence préopératoires précises pour de futures études et souligne l'impact clinique controversé de la classification de l'instabilité, ainsi que la nécessité de procéder à des essais multicentriques ou collaboratifs de meilleure qualité pour mieux comprendre et prendre en charge ce type fréquent de blessure.

Exertional Supraspinatus Syndrome: A Report of Two Cases.

CASE: We present 2 unique cases of exertional supraspinatus syndrome related to overexertion in 2 young men. In both cases, the diagnosis was delayed because the symptom was nonspecific shoulder pain; however, progressive pain, an elevated creatine kinase (CK) level, and either increased compartmental pressures or findings on magnetic resonance imaging eventually led to the appropriate diagnosis. CONCLUSION: The terms "supraspinatus compartment syndrome" and "supraspinatus rhabdomyolysis" are inappropriately used interchangeably. We believe that both conditions are part of a spectrum of pathology called exertional supraspinatus syndrome. It is important to differentiate between these conditions because a patient with supraspinatus compartment syndrome, which is distinguished by elevated compartment pressures, requires an immediate fasciotomy.

Evaluating the Utility of the Lateral Elbow Radiograph in Central Articular Olecranon Reduction: An Anatomic and Radiographic Study.

OBJECTIVES: The surgical reduction of intra-articular olecranon fractures is judged primarily on the lateral elbow radiograph, as orthogonal imaging of the articular surface is not obtainable. We sought to determine surgeon accuracy in identifying intra-articular olecranon malreductions on the lateral elbow radiograph. METHODS: Six human fresh-frozen cadaveric elbow specimens were sagittally sectioned in 5-mm increments after olecranon dissection, preservation of soft tissue envelope, and rigid fixation of the elbow in an external fixator. Three patterns of central intra-articular olecranon malreduction were created in each elbow using a ruler and bone saw. Perfect lateral elbow radiographs were taken of each malreduction, and these images were randomized along with x-rays of normal cadaveric olecranons. The image series was presented to 4 masked trauma-trained surgeons to determine whether the olecranon was malreduced or anatomic. Surgeons interpreted the same image series on 2 separate occasions separated by 6 weeks. Percent correct was recorded, and the interobserver and intraobserver reliability was calculated. RESULTS: Orthopedic trauma surgeons correctly identified olecranon malreductions only 73% of the time on the lateral elbow radiograph. Interobserver agreement was moderate for the first review of images and fair for the second review, with respective Fleiss Kappa values of 0.43 and 0.28. Intrarater reliability revealed moderate agreement with Cohen's Kappa value ranging from 0.56 to 0.66. CONCLUSIONS: Intra-articular olecranon malreductions are inconsistently recognized by trauma surgeons on the lateral elbow radiograph. Therefore, articular incongruity may still be present after surgical fixation of comminuted olecranon fractures. We must further define the radiographic anatomic representation of the articular olecranon to improve surgical reduction and clinical outcomes.

The impact of bariatric surgery on psychological health.

Obesity is associated with a relatively high prevalence of psychopathological conditions, which may have a significant negative impact on the quality of life. Bariatric surgery is an effective intervention in the morbidly obese to achieve marked weight loss and improve physical comorbidities, yet its impact on psychological health has yet to be determined. A review of the literature identified a trend suggesting improvements in psychological health after bariatric surgery. Majority of mental health gain is likely attributed to weight loss and resultant gains in body image, self-esteem, and self-concept; however, other important factors contributing to postoperative mental health include a patient's sense of taking control of his/her life and support from health care staff. Preoperative psychological health also plays an important role. In addition, the literature suggests similar benefit in the obese pediatric population. However, not all patients report psychological benefits after bariatric surgery. Some patients continue to struggle with weight loss, maintenance and regain, and resulting body image dissatisfaction. Severe preoperative psychopathology and patient expectation that life will dramatically change after surgery can also negatively impact psychological health after surgery. The health care team must address these issues in the perioperative period to maximize mental health gains after surgery.