Risk Factors for Requiring a Revision Anterior Cruciate Ligament Reconstruction: A Case-Control Study.

Anterior cruciate ligament (ACL) reconstruction is considered as a successful orthopaedic procedure that attempts to help patients return to their preinjury level of activity. However, some patients may need to undergo revision surgery, and this potentially may be associated with certain surgery-specific or patient risk factors. Therefore, the purpose of this study was to assess the potential role of (1) demographics, (2) family history, (3) graft choice, (4) sport, and (5) mechanism of injury (contact vs. noncontact) in the risk for needing a revision ACL for improved clinical outcomes. All patients who had undergone a primary ACL reconstruction between 2012 and 2016 were identified from at a single institution. About 312 patients who had a mean age of 24 years (range, 9-62 years) and a mean follow-up of 4 years (range, 1-10). Patients were further evaluated to identify those who had a revision. There were 19 patients (6.1%) with a mean age of 22 years (range, 13-38 years) and a mean follow-up of 5 years (range, 1-10) that required a revision reconstruction. Gender ratios (p = 0.56) and mean age (p = 0.44) were similar among the cohorts. Family history of ACL reconstruction had no association with revision risk (p = 0.57). Those with tibialis anterior allografts (37 vs. 4%; p = 0.0001) and hamstring allografts (16 vs. 1%; p = 0.0001) were far more likely to undergo a revision. Bone-tendon-bone (BTB) patella autografts were less likely (26 vs. 73%; p = 0.0001). Sport did not play a role in revision with those injured playing basketball (p = 0.61), football (p = 0.52), lacrosse (p = 0.52), soccer (p = 0.83), and volleyball (p = 0.61). There were a greater percentage of contact injuries that required revision (95 vs. 77%; p = 0.07). Graft selection played a significant role in requiring revision surgery with allografts portending to higher revision rates and BTB patella autografts conferring a lower risk.

Factors Complicating Discharge to Home following Total Knee Arthroplasty-A Single Institution Initiative.

Recently, with the Medicare bundled payments initiative for total knee arthroplasty (TKA), there has been a move by many institutions to further streamline costs associated with the entire operative and perioperative process. One of these cost-saving strategies has been to favor discharging patients to home with outpatient services as opposed to discharging to the relatively more expensive rehabilitation facilities. Our aim was to determine the success of a teaching institute's initiative in discharging patients to home instead of a rehabilitation facility. Specifically, we evaluated if there were differences in discharge disposition based off of (1) surgeon/patient preference, (2) length of stay, (3) demographics, and (4) postoperative complications. A retrospective review of all patients who had a TKA from 2015 to 2017 at a single teaching institution was performed and assessed discharge to home or to a rehabilitation facility. If they were not discharged to home, we evaluated why that did not happen, stratified the reason they were discharged to a rehabilitation facility into four groups based on (1) physician and occupational health team assessment, (2) patient preference, (3) physician preference, and (4) family or caretaker preference. A total of 229 patients were enrolled in this initiative, with 107 patients (47%) discharged to home with outpatient physical therapy services and 122 (53%) discharged to a rehabilitation facility. Of these, 35 patients (29%) went to these facilities because of physician and occupational health team assessment. However, 31 (25%) patients were due to patient preference, 32 (26%) were because of surgeon's preference, and 24 (20%) were not discharged to home because of family or caretaker preference. There were no differences in length of stay, gender, or complication rates between cohorts. Many patients can be safely discharged to home following TKA at a community teaching institution; however, there continues to be a strong prejudice by patients, physicians, and caretakers to be discharged to a rehabilitation facility despite the home discharge initiative.

Accelerated Discharge following Total Knee Arthroplasty May Be Safe in a Teaching Institution.

Total knee arthroplasty (TKA) is one of the most commonly performed yet costly surgical procedures in orthopaedics. With national trends and reimbursements moving in favor of shorter hospital length-of-stay (LOS), it is important to understand the complications associated with discharging patients earlier. This is particularly more challenging in a teaching institution due to complexity and variety of layers of care. Therefore, the purpose of this study was to evaluate the 90-day postoperative outcomes among those who were discharged on postoperative day 2 (POD-2) and compare them to a cohort whom had a LOS ≥ 3 days. A retrospective review of all patients who underwent a primary TKA from at a single-teaching institution from 2015 to 2017 was performed. During this time, an accelerated discharge protocol was designed and implanted in our institution. We identified 485 patients who were then substratified into two groups: patients who were discharged on POD-2 (n = 91) with the accelerated protocol and those who were discharged ≥ 3 days (n = 394). Outcomes evaluated included (1) demographics, (2) readmission rates, (3) emergency room (ER) visits, and (4) complication rates within 90 days of TKA. The POD-2 cohort was significantly younger than patients with ≥ 3-day LOS (64 vs. 69 years; p = 0.0001). There were no differences in gender ratios between the 2-day and 3-day cohorts (women, 67 vs. 72%; p = 0.34). Readmission rates (2 vs. 5%; p = 0.31) and ER visits were similar between cohorts (9 vs. 6%; p = 0.4). Medical and surgical complication rates did not differ between the two cohorts, with an overall complication rate of 5.5% in POD-2 versus 5.6% in >3 days LOS (p = 0.97). Patients discharged on POD-2 from TKA did not demonstrate an increased risk of complications, ER visits, or readmissions within 90 days in a teaching institution. However, older patients tended to have a longer LOS.

National Trends in Orthopaedic Surgery Resident Adult Case Logs.

OBJECTIVE: Our purpose was to assess United States data to determine if there were changes in the number of adult cases that graduating orthopaedic surgery resident logged. DESIGN: We assessed the Accreditation Council for Graduate Medical Education data from 2010 to 2016 to identify the number of cases that were reported by graduating orthopaedic surgery residents through the United States. Specifically, we analyzed the mean total number of adult cases per graduating resident. We substratified the data based on the subspecialty to include total number of cases performed in: (1) upper extremity; (2) lower extremity; (3) spine; (4) oncology; and (5) trauma. SETTING: All data collection was performed at the Seton Hall School of Health and Medical Sciences. PARTICIPANTS: All United States orthopaedic surgery residents were considered participants RESULTS: During the study period, the total number of cases performed by each resident had decreased from 1791 to 1311 (p = 0.0001). There was only an increase in the number of pelvis/hip cases (p = 0.0001). Among upper extremity cases, there was a decrease in each subtype of cases (p = 0.0001). There was a decrease in the number of femur/knee, leg/ankle, and foot/toes cases per resident (p = 0.0001). Furthermore, there was a decrease in the number of spine and trauma cases performed (p = 0.0001). There was no difference in the number of oncology cases performed (p = 0.47). CONCLUSIONS: We noted a decrease in the number of cases logged by graduating residents over the past 6 academic years. This provides a great deal of insight into the need for residencies to ensure that the appropriate Accreditation Council for Graduate Medical Education bench marks are met. Future studies should analyze how cases may be increased.

Ultrasound-Guided Calcium Debridement of the Shoulder Joint: A Case Series.

OBJECTIVE: Our purpose was to assess the outcomes of those who underwent an ultrasound-guided debridement of the deposits. Specifically, we analyzed: (1) function; (2) pain; (3) activity level; (4) patient satisfaction; and (5) complications. MATERIALS AND METHODS: A review of patients who underwent an ultrasound-guided debridement of calcific deposits about their shoulder joint between 2005 and 2015 was performed. Our final cohort consisted of 38 patients with a mean age of 53 years (range, 35 to 62 years)-11 men and 27 women-and a mean follow up of 32 months (range, 12 to 53 months). Functional outcomes, activity level, and pain level were assessed using the Disabilities of Arm, Shoulder, and Hand (DASH) scale, the University of Southern California (UCLA) activity scale, and the Visual Analog Scale (VAS). Additionally, patients were asked if they were satisfied with the outcomes of their procedure. All medical records were assessed for potential complications from this procedure. RESULTS: Excellent outcomes were achieved. The mean DASH score improved from 21 to 10 points (p=0.0001). Additionally, mean UCLA score increased from 2 to 7 points (p=0.0001). Furthermore, the mean reported VAS improved from 8 to 1.6 (p=0.0001). Ninety-seven percent of patients reported being satisfied. There were no reported complications in our cohort. CONCLUSION: We found that this procedure can result in effective pain relief and prevent or delay the need for more invasive procedures. Future studies should evaluate the role of calcium deposit size in the outcomes of those who undergo debridement.

Soft Tissue Reconstruction of the Proximal Tibiofibular Joint by Using Split Biceps Femoris Graft with 5-Year Clinical Follow-up.

Instability of the proximal tibiofibular joint (PTFJ) is a rare clinical condition that presents unique challenges to treatment. We present the case of an active 26-year-old woman with a 4-year history of recurrent PTFJ subluxations, treated surgically at our institution using a split biceps femoris tendon graft for PTFJ reconstruction. She underwent several attempts at nonoperative management until we decided to proceed with surgical intervention. A split biceps femoris graft was used to restore stability of the PTFJ. Approximately 5 years postoperatively, she achieved full range of motion as well as functional and clinical Knee Society Scores of 94 and 90 points, respectively. To the best of our knowledge, this is the first case report of PTFJ instability treated surgically with long-term follow-up. Future studies should focus on the long-term satisfactory outcomes of soft tissue stabilization of a chronically unstable PTFJ.

External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review.

PURPOSE: To evaluate the outcomes of surgical management for external snapping hip in terms of: (1) recurrence; (2) complications; and (3) return to pre-injury activities. METHODS: A thorough review of 4 electronic databases- EMBASE, CINAHL Plus, PubMed, and Scopus was performed to find all relevant studies for this review that were published between January 2000 and January 2017 that addressed surgical treatment for external snapping hip. The following reports were excluded: (1) non-English manuscripts; (2) n ⩽ 5; (3) clinical reviews; (4) surgical technique notes; (5) studies only analysing diagnosis; and (6) nonoperative management studies. After cross-referencing, a total of 7 reports were included. Each of these studies was analysed for the incidence of recurrence, revision surgery, complications, and return to pre-injury activity level. RESULTS: There was a recurrence rate of 7% ( n = 8 of 113 hips) with only 1 requiring revision surgery (1%). The cumulative complication rate was 9% ( n = 10 of 113) with all complications being residual weakness. Additionally, we found 98% ( n = 58 of 59) of the patients returned to their pre-injury level of activity. CONCLUSIONS: We found operative treatment for external snapping hip to be both safe and efficacious for returning patients to their pre-injury activities. When recurrence does occur, it often is painless and does not require revision surgery. Future studies should be larger and evaluate different surgical techniques to further elucidate the safety and efficacy of surgical treatment for external snapping hip.

Incidence of Neuraxial Abnormalities Is Approximately 8% Among Patients With Adolescent Idiopathic Scoliosis: A Meta-analysis.

BACKGROUND: Several studies have sought to address the role of routine preoperative MRI in patients with adolescent idiopathic scoliosis (AIS) undergoing deformity correction. Despite similar results regarding the prevalence of neuraxial anomalies detected on MRI, published conclusions conflict and give opposing recommendations. Lack of consensus has led to important variations in use of MRI before spinal surgery for patients with AIS. QUESTIONS/PURPOSES: This systematic review and meta-analysis of studies about patients with AIS evaluated (1) the overall proportion of neuraxial abnormalities; (2) the patient factors and curve characteristics that may be associated with abnormalities; and (3) the proportion of patients who underwent neurosurgical intervention before scoliosis surgery and the kinds of neuraxial lesions that were identified. METHODS: We performed a search of four electronic databases (PubMed, EMBASE, CINAHL Plus, and SCOPUS) utilizing search terms related to routine MRI and AIS, yielding 206 articles. Studies included had at least 20 participants, patients with ages 11 to 21 years, and a Methodological Index for Non-Randomized Studies (MINORS) study quality score of 8 and 16 points for noncomparative and comparative studies, respectively. Non-English manuscripts, animal studies, and those that did not include patients with AIS solely were excluded. Eighteen articles with 4746 patients were included for analysis of the overall proportion of neuraxial abnormalities, 12 articles with 3028 patients for analysis by sex, eight articles with 1603 patients for right main thoracic curve, eight articles with 665 patients for a left main thoracic curve, and 13 articles with 3063 patients and 230 (7.5%) abnormalities for number of neurosurgical interventions before scoliosis correction. The mean MINORS score for studies included was 14 (range, 10-20). Each study was analyzed for the proportion of patients identified with neuraxial abnormalities and associations with specific demographics. We determined the proportion of patients who underwent surgical interventions before scoliosis surgery as well as the types of neuraxial lesions identified. The articles were assessed for heterogeneity and publication bias. Because all groups were determined to be heterogeneous, a random-effects model was used for each group in this meta-analysis; with this analysis, an overlap of 95% confidence intervals suggests no difference at the p < 0.05 level, but this analytic approach does not provide p values. RESULTS: The pooled proportion of neuraxial abnormalities detected on MRI was 8% (95% confidence interval [CI], 6%-12%). With the numbers available, we found no difference in the proportion of male and female patients with neuraxial abnormalities (18% [95% CI, 11%-29%] versus 9% [95% CI, 6%-12%], respectively). Likewise, there was no difference in the proportion of pooled neuraxial abnormalities in right and left curves (9% [95% CI, 6%-14%] versus 15% [95% CI, 5%-35%], respectively). In the subset of abnormalities analyzed for number of neurosurgical interventions before scoliosis correction, the pooled proportion showed that 33% (95% CI, 24%-43%) underwent neurosurgical intervention before deformity correction. The most common abnormalities of the 367 found on MRI were syringomyelia in 127 patients (35%), Arnold-Chiari Type 1 malformation with syrinx in 103 patients (28%), and isolated Arnold-Chiari Type 1 malformation in 91 patients (25%). CONCLUSIONS: The proportion of patients with AIS who have neuraxial abnormalities is high (8%) and a large number undergo surgical intervention before scoliosis reconstruction. We did not find any particular demographic variables that indicated an increased risk of abnormality. Clinicians should consider advanced imaging before surgical intervention in the treatment of a patient with an idiopathic diagnosis. Preventable variables need to be identified by future studies to establish a better working treatment protocol for these patients. LEVEL OF EVIDENCE: Level III, diagnostic study.

Risk Factors for Contralateral ACL Injury: A Single Institution Case-Control Study.

Our purpose was to evaluate if there is any association between requiring contralateral anterior cruciate ligament (ACL) reconstruction and various: (1) demographics, (2) patient characteristics, and (3) surgery-specific factors. A prospectively collected database at a single institution was queried to find all patients who underwent primary ACL reconstruction between 2012 and 2014. We identified 312 primary ACL reconstruction patients with a mean age of 24 years and a mean follow-up of 3 years (range, 2-5 years). This cohort was compared with all those who had primary ACL reconstructions during the same time period without a contralateral procedure. We evaluated: (1) incidence, (2) demographic variables, (3) family history, (4) graft choice, (5) activity causing injury, and (6) mechanism of injury (contact versus noncontact). There were 16 patients (4.8%) with a mean age of 21 years and a mean follow-up of 3 years that required a contralateral reconstruction. More females required contralateral reconstruction when compared with the control cohort (p = 0.049). However, there was no difference in the mean age between the cohorts (p = 0.32). Those who underwent reconstruction using a tibialis anterior allograft were far more likely to require a contralateral reconstruction (p = 0.0002). Bone-tendon-bone patellar autograft (p = 0.16), hamstring autograft (p = 0.76), and hamstring allograft (p = 0.68) had similar incidences of contralateral ACL injury. Lacrosse was associated with higher risk of contralateral procedure (p = 0.03). Mechanism of injury had no association of contralateral reconstruction (p = 0.71). We found that those with the highest risk of contralateral ACL reconstruction following their index procedure were females, those with tibialis anterior allografts, and those who had their ipsilateral injury while playing lacrosse. These data may be used by practitioners when educating patients regarding their potential for requiring a contralateral reconstruction following their index procedure.

Detection of total hip arthroplasties at airport security checkpoints - how do updated security measures affect patients?

INTRODUCTION: There have been historical reports on the experiences of patients with total hip arthroplasty (THA) passing through standard metal detectors at airports. The purpose of this study was to analyse those who had recently passed through airport security and the incidence of: (i) triggering of the alarm; (ii) extra security searches; and (iii) perceived inconvenience. METHODS: A questionnaire was given to 125 patients with a THA during a follow-up appointment. Those who had passed through airport security after January 2014 met inclusion criteria. A survey was administered that addressed the number of encounters with airport security, frequency of metal detector activation, additional screening procedures utilised, whether security officials required prosthesis documentation, and perceived inconvenience. RESULTS: 51 patients met inclusion criteria. 10 patients (20%) reported triggered security scanners. 4 of the 10 patients stated they had surgical hardware elsewhere in the body. 13 of the 51 patients (25%) believed that having their THA increased the inconvenience of traveling. This is different from the historical cohort with standard metal detectors which patients reported a greater incidence of alarm triggering (n = 120 of 143; p = 0.0001) and perceived inconvenience (n = 99 of 143; p = 0.0001). DISCUSSIONS: The percentage of patients who have THA triggering security alarms has decreased. Furthermore, the number of patients who feel that their prosthesis caused traveling inconvenience has decreased. We feel that this decrease in alarms triggered and improved perceptions about inconvenience are related to the increased usage of new technology.

A Unique Case of Diagnosed Monocryl Allergy Following Hip Arthroscopy.

Following arthroscopic hip labral repair, trochanteric bursectomy and iliotibial band lengthening, a patient presented with signs and symptoms that are consistent with allergic reactions that were localized to incision sites. The patient reported discomfort due to pain and pruritus about the surgical sites and was treated with antibiotics, antihistamines, and anti-inflammatory medication. Her skin was kept under close observation and, upon consulting with a dermatologist, the diagnosis of Monocryl allergy was made. Amidst the rarity of skin irritation due to the material of sutures, it is important to monitor for a possible Monocryl allergy, and suture necessitation is crucial.

Medical Missions in Jordan: A Series of Upper-Extremity Orthopedic Injuries.

Worldwide, a great deal of disability is caused by musculoskeletal injuries from high-energy trauma. In nations affected by war, blast injuries associated with mines, missiles, high-powered gunshots, and bombings are one cause of these injuries. Medical missions carried out by those from developed nations is one way to address this. Therefore, it is critical that those who participate in these missions maintain a basic understanding the injuries that may be encountered in nations affected by war and violent conflict. We describe a small number of upper-extremity injuries seen by one orthopedic surgeon during his volunteer medical mission to Jordan. Many of these injuries resulted in the loss of function and/or limb, as these patients were treated without appropriate instrumentation or facilities in a suboptimal environment and in a delayed manner by surgeons who lacked optimal training. It is our hope that this case series will encourage studies that can offer guidance in the ways to treat such complex injuries with optimal safety and efficacy.

The Most Cited Original Articles on Anterior Cruciate Ligament Injuries in the Past 20 Years.

Anterior cruciate ligament (ACL) injuries continue to be a major focus in sports medicine research. With so many changes to our understanding of ACL anatomy and with rapid advances in reconstruction techniques and rehabilitation protocols within the past 20 years, it is important to identify the landmark research that has laid the foundation for current ACL treatments. Using the Web of Science citation index, a search was carried out for the 30 most cited articles on ACL injury published in the last 20 years. The generated list was sorted from highest to lowest citation number. Clinical studies were subcategorized as therapeutic, prognostic, diagnostic, or economic/decision analysis and assigned a level of evidence. Basic science articles were designated anatomic, animal, biomechanical, or clinical. The number of citations per year (citation density) was calculated. The search yielded 6,345 articles. The total number of citations among the top 30 ranged from 188 to 611. Citation density ranged from 10.1 to 66.2. Nineteen articles were clinical, 8 were basic science, and 3 were video analyses. Clinical articles were most commonly therapeutic (18 of 19; 95%). Basic science articles were most commonly biomechanical (7 of 8; 88%). The most common level of evidence was Level II (10 of 19; 53%). More than half of the articles in the top 30 (16 of 30; 53%) were published in The American Journal of Sports Medicine. Many of these articles have played a large role in shaping current clinical practice regarding ACL injuries. We hope that by compiling this list we can draw attention to the continued need for studies of the highest level of evidence.

Cultural Biases in Current Medical Practices with a Specific Attention to Orthopedic Surgery: a Review.

Due to the increasing diversity within the United States population, there is an ever-increasing need for increased education on cultural literacy and tolerance in medical schools and residency programs. The purpose of this article was to review how a person's culture can play a substantive role in effecting and influencing (1) medical diagnosis, (2) patient and health provider medical decision-making, (3) the patient's perception of disease, and (4) the doctor-patient relationships. Many of the decisions we make as orthopedic surgeons must account for the patient's cultural needs, as much of our work impacts patients' daily activities and function. When considering the patient's perception of disease, validated tools have been developed, such as the Patient-Specific Index, which can be used to assess the feelings, goals, and expectations of patients. Cultural competency should be a part of curricula at every level of medical education.

Iliotibial Band Lengthening: An Arthroscopic Surgical Technique.

Iliotibial (IT) band syndrome is a common cause of lateral knee pain in runners and cyclists. Many can be treated nonoperatively; however, some may require surgical lengthening of their IT band to achieve optimal pain relief and a return to preinjury level of activity. Several studies have been published detailing surgical lengthening procedures and satisfactory outcomes after these procedures. However, it is important to continue to improve on and optimize outcomes. We present our arthroscopic IT band-lengthening procedure.

A Single-Incision Technique for Distal Biceps Repair Using a Flexible Reamer.

Distal biceps tendon ruptures are rare injuries that usually occur in middle-aged men. Most of these injuries are repaired acutely to restore preinjury function and strength. There is concern regarding the higher prevalence of certain complications with the double-incision technique. As such, the single-incision technique has also been studied to determine if it may produce superior safety and efficacy. In addition, the point of fixation may be created with either a rigid or a flexible reamer. The authors describe a technique that uses a single-incision cortical fixation achieved with a flexible reamer. [Orthopedics. 2017; 40(4):e744-e748.].

Does Hepatitis C Affect the Clinical and Patient-Reported Outcomes of Primary Total Hip Arthroplasty at Midterm Follow-Up?

BACKGROUND: It is estimated that 3%-6% of orthopedic patients, many of whom may undergo lower extremity total joint arthroplasty, are infected with hepatitis C. The purpose of this study was to assess the outcomes of patients with hepatitis C who undergo total hip arthroplasty (THA) in comparison with a matched control cohort in terms of (1) patient-reported outcomes, (2) implant survivorship, and (3) complications. METHODS: Fifty-four hips in 49 hepatitis C-infected patients who underwent a primary THA between 2002 and 2011 were reviewed. This included 10 women and 39 men who had a mean age of 57 years and a mean 6.5-year follow-up. These patients were matched to 163 THAs (148 patients) who did not have this disease and underwent a THA during the same period. We compared implant survivorship, complication rates, Harris hip scores, and University of California, Los Angeles, activity scores. Radiographs were evaluated for loosening, fracture, malalignment, and osteolysis. RESULTS: The implant survivorship in the hepatitis C-infected patients and comparison group was 96.2% and 98.7%, respectively. The risk of revision surgery in the hepatitis C cohort was 3-fold higher than the comparison group; however, this difference was not significant (P = .26). The hepatitis C-infected cohort had a higher risk of surgical complications (odds ratio = 6.5; P = .034). There were no differences in postoperative Harris hip scores or University of California, Los Angeles, activity scores between the cohorts. CONCLUSION: Hepatitis C patients can achieve good implant survivorship and clinical outcomes after THA. However, these patients may be at an increased risk for surgical complications and revision rate.

Low Ankle Sprains: A Current Review of Diagnosis and Treatment.

LLow ankle sprains are common injuries in young athletes. Hence, it is imperative that low ankle sprains are diagnosed and treated quickly and effectively. We reviewed the: (1) anatomy; (2) imaging; (3) physical exam findings; and (4) treatment modalities regarding these injuries. Plain radiographs are standard of care and routine MRI is not recommended for suspected sprains. However, physical exam findings often may guide management decisions. The majority of patients diagnosed with low ankle sprains are treated with a one- to two-week immobilization period with physical therapy focused on peroneal proprioception and strength. If a prolonged non-operative course fails, or there is gross instability upon physical exam (grade III sprain), surgical reconstruction may be considered and may lead to excellent outcomes. When low ankle sprains do occur, the great majority may be treated non-operatively. In the event that conservative modalities fail, surgical reconstruction may be considered with an open modified Brostrom reconstruction as the current standard of care.