Decreased Strength, Complication Rate and Higher Satisfaction in Conservative Treatment of Partial Distal Biceps Tendon Rupture Compared to Surgical Treatment: A Systematic Review.

Background: Treatment modalities for partial distal biceps tendon (DBT) ruptures include conservative management (immobilization, medication, and physical therapy) or surgery. Selecting treatment modality can present a challenge to both patient and provider. Hypothesis: It was hypothesized that patients undergoing surgical treatment for partial DBT rupture would have higher complications but better overall strength, range of motion (ROM), and patient satisfaction. Study Design: Systematic Review. Methods: A systematic review was performed in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Cochrane, Embase, and Medline databases were searched for studies published through May 2023. Studies were included if they examined patients with a partial DBT rupture who underwent treatment. Exclusion criteria were non-human studies, studies not in English, reviews, technical notes, letters to the editor, surgical technique papers, and studies reported in a prior review. Results: 13 studies consisting of 290 patients with a partial DBT tear were included in this review. 75% of the patients were male and the ages ranged from 23 - 75 years. The follow up for the patients ranged from 1 - 94 months. 55 patients underwent conservative treatment versus 256 patients underwent surgical treatment. Outcomes examined by the studies included pain, strength, range of motion (ROM), complications, patient reported outcomes (PROs), return to activity, and patient satisfaction. Conclusion: Treatment for partial DBT tear via surgery or conservative treatment both produce good clinical outcomes. There are similar outcomes between treatment options for pain and ROM. Conservative treatment had some poorer outcomes in terms of strength after treatment. Surgical treatment had more complications and a few patients with decreased satisfaction. Overall, both are viable treatment options, requiring a physician and patient discussion regarding the pros and cons of both options as a part of a shared decision-making process that incorporates patient priorities.

NSQIP data collection up to 30 postoperative days is sufficient to capture some complications in orthopedic surgeries.

PURPOSE: The primary aim of this study is to determine if the 30-day follow-up period used by the National Surgical Quality Improvement Program (NSIQP) is an appropriate timeframe to capture complications after orthopedic surgeries. METHODS: The 2019 NSQIP data were used. The independent variables were complication type. The dependent variable was days to complication. A Shapiro-Wilk test was used to determine if the data were normally distributed. RESULTS: 271,397 orthopedic cases were included. Myocardial infarction, pneumonia, ventilator over 48 h, progressive renal insufficiency, acute renal failure, stroke, and cardiac arrest had positive skewness and positive kurtosis. Deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, unplanned reoperation one, unplanned reoperation two, readmission two, and readmission three had negative kurtosis and negative skewness. Complications with positive kurtosis and positive skewness are more likely to be confined to the 30-day postoperative period, whereas complications with negative skewness and negative kurtosis may be underreported within the 30-day follow-up. CONCLUSIONS: These findings are useful in their ability to inform future orthopedic research using NSQIP which continues to generate new data for surgeons to consider for their postoperative care and complication management.

Dual Plating of Distal Femoral Fractures.

Background: Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse. Description: Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed. Alternatives: Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace1. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate. Rationale: Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength2,3. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone4-7. Adjunctive use of a medial plate also has been suggested to prevent varus collapse, particularly with metaphyseal comminution and poor bone quality2,3,8. Finally, in the periprosthetic fracture population, dual plating also removes the concern of incompatibility with a retrograde nail. Expected Outcomes: The outcomes of dual plating are promising, given the severity of the injury. When comparing operative to nonoperative treatment outcomes, nonoperatively managed patients had worse functional outcomes and higher rates of complications related to immobility1. Dual plating of supracondylar fractures and intra-articular distal femoral fractures yields nonunion rates ranging from 0% to 12.5%, lower than the 18% to 20% reported with lateral locking plates4-7,9-12. This reduction in nonunions has been shown to lead to fewer revisions when compared with single-plating techniques7. In prior studies, 95% of nonunions treated with the dual-plating technique achieved union postoperatively11. One concern when utilizing the medial approach is critical damage to medial vascularity; however, this result has not been reported in the literature, and there is a safe operating window13. Despite the benefits of dual plating, there are relatively high rates of infection following dual plating (0% to 16.7%) compared with lateral plating alone (3.6% to 8.5%)5,14-17. However, many of these studies are small case series, highlighting that a surgeon's comfort and skill with these procedures is paramount to patient outcomes. Important Tips: Meticulous placement and contouring of lateral and medial plates are required to prevent malreduction of the articular block that creates a "golf-club deformity."18,19During the medial approach, be aware of descending geniculate artery-particularly its muscular branch, which is ∼5 cm from the adductor tubercle/medial epicondyle, and its root, which enters the compartment at the adductor hiatus at ∼16 cm13.

Femoral rotational osteotomy for femoroacetabular impingement: A systematic review.

Purpose: To synthesize existing literature regarding the indications and outcomes of femoral rotational osteotomies (FDO) for femoroacetabular impingement (FAI) due to. Methods: Medline, Cochrane, and Embase were searched using keywords "femoroacetabular impingement", "rotational osteotomy" and others to identify FAI patients undergoing FDO. Double-screened studies were reviewed by blinded authors according to inclusion criteria. Data from full texts was extracted including study type, number of patients, sex, mean age, surgical indication, type of dysplasia, associated pathology, surgical technique, follow-up, and pre-op/post-op evaluations of the following: impingement test, femoral version (FV), 'other angles measured', outcome scores, range of motion (ROM). Results: 7 studies including 91 patients (97 FDO surgeries), 73 females (80 %) with mean age of 28.3 years, and follow-up mean of 2.44 ± 2.83 years. Pain or impingement was the most common clinical indication, while others included aberrant FV and ROM measurements for both anteverted and retroverted femurs. There were reports of FDO being performed with concomitant procedures addressing other pathology. Various outcome scores and ROM measurements showed postoperative improvement after FDO. Complication data was sparse, preventing aggregation. The rate of unplanned reoperation was 40 % (where reported), with 'hardware removal' being the most common. Conclusions: FDO is effective in treating FAI due to increased FV, improving clinical symptoms, and potentially delaying articular degeneration. Hardware removal surgery remains an inherent risk in undergoing FDO. Further work is needed to discover indications warranting FDO as a primary treatment versus hip arthroscopy. Level of evidence: This review contains 4 studies with Level IV evidence and 3 studies with Level III evidence.

Surgical Outcomes and Associated Injuries of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesions: A Systematic Review.

Introduction: Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesions can lead to chronic shoulder instability and repetitive dislocations in active populations. Objective: The purpose of this systematic review was to evaluate associated injuries and postoperative outcomes following ALPSA lesion repairs. Methods: Medline, Embase, Cochrane, and Web of Science were searched through May 2022 for studies that investigated management and surgical outcomes of ALPSA lesion repair. Data was extracted on the following topics: surgical management, surgical complications, associated injuries, follow-up duration, and outcome parameters, including recurrence rates, functional outcome scores, range-of-motion (ROM), and return to activity. Results: A total of 6 studies covering 202 patients met the inclusion criteria. In the included studies, 79% of patient were male with a mean age of 25.1 years. A total of 192 associated injuries were reported amongst 176 patients with the most common being Hill Sachs lesions (84, 43.8%), synovitis (35, 18.2%), SLAP tears (32, 16.7%) and glenoid erosions or lesions (30, 15.6%). All 202 patients were treated arthroscopically with no reported complications. 26 patients (12.9%) experienced operative failure as evidenced by recurrence of shoulder instability over a mean follow-up of 4.3 years. Various clinical outcome scores showed postoperative functional improvement and one study reported a 100% return to activity rate in 26 patients. Conclusion: Our findings suggest a high 12.9 % risk of recurrence following ALPSA repair but satisfactory functional outcomes, both of which should be weighed by physicians when considering arthroscopic repair. Physicians should also be cognizant of co-pathologies when examining patients with suspected ALPSA lesions.

Return to sport and active military duty after cervical disc arthroplasty: A systematic review.

Introduction: Cervical disc arthroplasty (CDA) has been established as an effective treatment for cervical disc degeneration or herniation in the general population. Return to sport (RTS) outcomes in athletes remain unclear. Objective: The purpose of this review was to evaluate RTS following single-level, multi-level, or hybrid CDA, with additional return to activity context provided by return to duty (RTD) outcomes in active-duty military. Methods: Medline, Embase, and Cochrane were searched through August 2022 for studies that reported RTS/RTD after CDA in athletic or active-duty populations. Data was extracted on the following topics: surgical failures/reoperations, surgical complications, RTS/RTD, and postoperative time to RTS/RTD. Results: Thirteen papers covering 56 athletes and 323 active-duty members were included. Athletes were 59% male with a mean age of 39.8 years and active-duty members were 84% male with a mean age of 40.9 years. Only 1 of 151 cases required reoperation and only 6 instances of surgical complications were reported. Classified as return to general sporting activity, RTS was observed in 100% of patients (n = 51/51) after an average of 10.1 weeks to training and 30.5 weeks to competition. RTD was observed in 88% of patients (n = 268/304) after an average of 11.1 weeks. Average follow-up was 53.1 months for athletes and 13.4 months for the active-duty population. Conclusion: CDA displays excellent RTS and RTD rates in physically demanding populations at rates superior or equivalent to alternative treatments. Surgeons should consider these findings when determining the optimal cervical disc treatment approach in active patients.

The Role of Cryotherapy After Total Knee Arthroplasty: A Systematic Review.

BACKGROUND: Previous research shows conflicting evidence regarding the postoperative role of cryotherapy after total knee arthroplasty (TKA). This systematic review aims to further investigate the effect of various methods of cryotherapy on the following: (1) pain; (2) swelling; (3) postoperative opioid use; and (4) range of motion (ROM). METHODS: A strategic keyword search of Medline, Cochrane, Embase, and CINAHL retrieved randomized controlled trials examining cryotherapy following TKA published between February 1, 2017, and February 24, 2022. The studied outcomes included pain ratings, knee/limb swelling, opioid use, and ROM. Six studies were selected for inclusion in this review. RESULTS: Opioid use was significantly decreased in cryotherapy groups compared to noncryotherapy groups within the first postoperative week only (P < .05). This effect may be augmented by the use of computer-assisted (temperature regulated) cryotherapy devices, compared to other modalities including ice packs. Pain ratings also decrease, but this decrease may not be clinically relevant. Cryotherapy appears to confer no consistent benefit to ROM and swelling at any time point. Computer-assisted cryotherapy may be associated with decreased opioid consumption after TKA compared to traditional ice packs. CONCLUSION: Cryotherapy's role after TKA appears to be in decreasing opioid consumption primarily in the first postoperative week. Pain ratings also decrease consistently with cryotherapy use, but this decrease may not be clinically relevant. Study heterogeneity requires further research focusing on optimizing cryotherapy modalities within the first postoperative week, and analyzing cost associated with modern outpatient postoperative TKA protocols.

Posterior Approach for Open Reduction and Internal Fixation for Scapular Fractures.

Background: This technique utilizes a full-thickness flap to provide a posterior approach to the scapula for open reduction and internal fracture fixation. The present video article outlines the Judet approach along with an incision modification tip for the surgeon's consideration. Description: Prior to making the incision, perform preoperative planning, patient and C-arm positioning, and identification of the primary fragments of the fracture that necessitate fixation on imaging. The Judet incision is made, and the full-thickness flap is retracted laterally (also described as a "boomerang-shaped" incision, allowing for the flap to be reflected medially). Next, detach and reflect the deltoid off the scapular spine superolaterally to reveal the internervous plane between the infraspinatus and teres minor. Utilize this interval to access the fracture sites while making sure to reflect the infraspinatus cranially, carefully minding the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. A longitudinal arthrotomy may then be created parallel to the posterior border of the glenoid, with careful attention paid toward protecting the labrum from iatrogenic injury. The arthrotomy will allow for intra-articular evaluation of the reduction if needed. Primary fractures are then reduced. Reduction is confirmed with use of fluoroscopy, and fixation is applied to maintain the reduction. Alternatives: Most scapular fractures do well with nonoperative treatment, and this has been well documented in the literature. Open reduction and internal fixation has been shown to offer good-to-excellent clinical outcomes with minimal risk of complications in patients with traumatic scapular fractures that necessitate operative treatment1. In certain fractures of the glenoid fossa, operative treatment is necessary to restore normal anatomy, provide stability to the glenohumeral joint, and facilitate functional rehabilitation. Operative treatment is typically reserved for injuries with intra-articular involvement that results in joint incongruity or joint instability2,3. When operative treatment is indicated, an open posterior approach is utilized for some fractures. The posterior Judet approach is the best-known operative technique for such fractures, while other modifications of the Judet technique have also been described in the literature3-5. Rationale: Reports state that scapular body or neck and glenoid fossa fractures account for up to 80% of scapular fractures6. Open reduction and internal fixation of the scapula is an invasive procedure, requiring large incisions and manipulation of soft tissues to expose the various possible fracture sites on the scapula. Thus, numerus surgical techniques have been described that allow surgeons to best tailor treatment to their patients on a case-by-case basis. However, the Judet approach is the workhorse approach for the operative treatment of scapular fractures and is a technique that should be mastered7. The Judet approach allows access to the posterior scapula and provides excellent exposure for fractures that require posterior fixation. The alternative boomerang-shaped incision represents a mirrored version of the Judet incision, with the skin flap reflected medially. The benefit of this modified approach is that it increases the degree of lateral surgical exposure of the scapula and provides easier access to the glenohumeral joint. Expected Outcomes: With this technique for open reduction and internal fixation of scapular fractures, patients can expect comparable outcomes to those described in the literature for the standard Judet technique. These outcomes have been reported as clinical scores and defined as good-to-excellent in a few retrospective case series1,2. Given the variability in scapular fracture morphology, a trauma surgeon should have a strong repertoire of approaches to address these fractures on a case-by-case basis. The Judet approach is one of these necessary approaches and has been shown in the literature to have acceptable outcomes1-3,7. Important Tips: Placing the vertical limb of the boomerang incision too medial can limit lateral exposure of the scapula and make glenohumeral joint access difficult. To avoid this, be sure that the vertical limb of the incision remains in line with the posterior axillary fold.Wound-healing complications can occur following such an extensive surgical approach. A thorough and secure wound closure with repair of the deltoid back to the scapular spine may avoid these problems.Difficulty with intra-articular visualization may occur. Placing a threaded pin into the humeral head or a small distractor across the glenohumeral joint (with a pin in the extra-articular proximal humerus) may improve visualization. Manipulation of the arm can also be beneficial in this regard.Lateral positioning offers easier imaging and allows for exposure to the coracoid or clavicle if these structures are also injured and require operative fixation.Drawing a boomerang-shaped incision with the horizontal limb paralleling the scapular spine and vertical limb along the posterior axillary fold of the arm allows the skin flap to be reflected medially, increasing the degree of lateral surgical exposure of the scapula.After identifying the internervous plane between the infraspinatus and teres minor, take care to reflect the infraspinatus cranially, protecting the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. Acronyms and Abbreviations: ORIF = open reduction and internal fixationK-wire = Kirschner wire.