Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study.

BACKGROUND: Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD). METHODS: We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves. RESULTS: 2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores. CONCLUSIONS: These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.

Prospective Analysis of Simulated Pneumatic Tourniquet Use and Oedema Following Axillary Lymph Node Dissection.

Background: Tourniquet use during upper extremity surgery in patients with a history of axillary lymph node dissection (ALND) remains controversial due to the perceived but unproven risk of lymphoedema. We prospectively evaluated upper extremity swelling in patients with a history of unilateral ALND using a standardised tourniquet model. Methods: A tourniquet was applied to the upper arm bilaterally, with the unaffected side serving as an internal control. Each arm was subsequently held in an elevated position to reduce swelling. Hand volume was measured using an aqueous volumeter. Results: The patients' ALND arms experienced slightly greater increases in volume following tourniquet application compared to their healthy control arms. However, this amount of oedema was temporary and reversible, as both arms experienced spontaneous resolution of swelling with no significant difference in residual hand volume at the conclusion of the study. Conclusions: Tourniquet use may be safe in patients with a history of ALND. Further investigation is needed to verify this in a surgical setting. Level of Evidence: Level II (Therapeutic).

No Delay in Age of Crawling, Standing or Walking with Pavlik Harness Treatment: A Prospective Cohort Study.

BACKGROUND: Pavlik harness treatment is the standard of care for developmental dysplasia of the hip in infants younger than 6 months. The effect of Pavlik harness treatment on the achievement of motor milestones has not previously been reported. METHODS: In this prospective cohort study, 35 patients were prospectively enrolled to participate and received questionnaires with sequential clinical visits monitoring treatment of their developmental dysplasia of the hip. One-sample Student t -tests assessed differences in milestone attainment age, and the Benjamini-Hochberg procedure was conducted to decrease the false discovery rate. Post hoc power analyses of each test were conducted. The age of achievement of eight early motor milestones were recorded and compared with a previously published cohort of healthy infants. RESULTS: Infants treated with a Pavlik harness achieved four early motor milestones markedly later than the reported age of achievement in a historical control group. These milestones included "roll supine" (5.3 vs. 4.5 months; P = 0.039), "roll prone" (5.7 vs. 5.0 months; P = 0.039), "sit" (6.4 vs. 5.2 months; P < 0.001), and "crawl on stomach" (7.7 vs. 6.6 months; P = 0.039). However, there was no difference in time to achievement of later motor milestones of "crawl on knees," "pull to stand," and "independent walking." CONCLUSION: Several early motor milestones were achieved at a statistically significantly later time than historical control subjects not treated in a Pavlik harness. Despite statistical significance, the small delays in early motor milestones were not thought to be clinically significant. No differences were observed in the later motor milestones, including knee crawling, standing, and independent walking. Clinicians and parents may be reassured by these findings. LEVEL OF EVIDENCE: Therapeutic Level II-prospective study.

Can Caregivers Forecast Their Child's Postoperative Disability After Elective Orthopedic Surgery?

Background While there has been a growing emphasis on evaluating the patient's perspective of health outcomes, caregiver expectations of post-orthopedic procedure disability and pain in a pediatric population are yet to be investigated. This study evaluates whether caregivers' preoperative expectations of pain and function differ from their child's early outcomes after surgical orthopedic intervention. Methodology Patients eight to 18 years old undergoing elective orthopedic surgery were enrolled. The caregivers of consented patients completed a survey at the child's preoperative appointment to predict their postoperative pain and disability. The child was given the same survey during their postoperative visit four to six weeks after surgery to assess actual levels of functioning following the procedure. Scores were analyzed to study correlations between patient and caregiver responses (n = 48). Results Caregivers underestimated their child's postoperative psychosocial functioning, as evidenced by the Psychosocial Health Summary Score, and overestimated pain, as demonstrated by the Numeric Pain Rating Scale. The Pediatric Quality of Life Inventory scores showed caregivers had differing expectations of the impact surgery had across various aspects of the physical, emotional, social, and school functioning domains. Higher parental pain catastrophizing was associated with underestimated predictions of their child's psychosocial functioning after surgery. No significant difference was found in the patient's physical functioning, as shown by the Physical Health Summary Score. Conclusions Surgical intervention is a major event that can provoke anxiety for parents and caregivers. Understanding differences in caregiver perspectives and early postoperative patient outcomes provides physicians valuable insights. Explaining to caregivers that patient psychosocial factors and functional outcomes after surgery are commonly better than expected can alleviate anxiety and prevent catastrophizing. This knowledge can help guide caregiver expectations and plans for their child's postoperative pain control and functional recovery.

Conversations About Congenital Clubfoot: Investigating How Parents Share Information About a Structural Diagnosis With Their Children.

Background and objective Clubfoot is a common congenital musculoskeletal condition that is treated with manipulation and casting in the first few weeks of life, followed by bracing that extends into early childhood. While children typically do not recall treatment with Ponseti casting in infancy, childhood treatment and monitoring may result in a sense of heightened awareness. In light of this, this study explores how parents share information about clubfoot diagnosis and guide their children in understanding the importance of treatment. Methods Parents of clubfoot children aged 5-18 years were eligible to participate. Primary recruitment was done through social media via Facebook clubfoot support groups. Participants who gave consent completed an electronic survey and were invited to take part in a semi-structured interview to share additional experiences. Significant themes elicited from study interviews were analyzed along with survey responses. Results Survey responses were received from 74 parents, and 23 participated in the semi-structured interview. Of note, 91% of parents indicated discussing clubfoot with their children, beginning at a median age of three years. The age at which parents first discussed clubfoot with their child was significantly earlier for those who "strongly agree" that their children understand their condition versus those who "agree". Although 68% of parents indicated that receiving guidance from their orthopedic provider would be helpful for these discussions, only 18% noted receiving direct advice. Recurrent themes across interviews included being open and honest about the children's diagnosis and treatment, aiding the children in taking ownership of their diagnosis, and validating emotional responses throughout treatment.  Conclusions This study provides valuable insights into initiating conversations with children about structural diagnoses like congenital clubfoot. Recurrent themes from conversations with families provide information on helpful strategies to encourage early discussions about clubfoot diagnosis and treatment to aid children in taking ownership of their diagnosis.

Endoscopic iliopsoas lengthening for treatment of recalcitrant iliopsoas tendinitis after total hip arthroplasty.

Iliopsoas (IP) tendinitis from impingement upon the acetabular component after total hip arthroplasty (THA) has been treated with open and endoscopic IP tenotomy or acetabular component revision. This study describes the results of a consecutive series of patients treated with endoscopic IP tenotomy as a less invasive alternative. Twenty-eight patients with IP impingement after THA underwent endoscopic IP lengthening from 2012 to 2021 at a single-center academic institution. The follow-up of 24 of these patients was achieved with a mean follow-up of 7.6 months (range 1-28). Outcomes included the modified Harris Hip Score (mHHS), visual analog pain scale (VAS), satisfaction, component positioning and complications. Seventy-one percent of patients were satisfied or very satisfied after their operation. The median mHHS preoperatively was 57 (Interquartile range [IQR] 43-60) and postoperatively was 75 (IQR 66-92, P < 0.001). Clinically meaningful improvements in mHHS were seen in patients with VAS pain scores <5, cup prominence >8 mm, body mass index >30, and less than 2 years from their index THA. Two patients developed a deep infection 7 and 10 months postoperatively (neither related to the release), and one patient underwent open psoas release for persistent impingement. Endoscopic IP tenotomy is a safe and effective treatment for impingement after THA. Patients with cup prominence >8 mm, body mass index >30 and less than 2 years since their index THA may have more clinically meaningful improvements in pain and function.

Evaluating the Readability and Quality of Online Patient Education Materials for Pediatric ACL Tears.

BACKGROUND: As the rate of anterior cruciate ligament (ACL) tears increases in children, the internet has become a major source of information and education. In the United States, the average adult reads at about an eighth grade level. The National Institutes of Health recommends that patient education materials do not exceed a sixth-grade reading level. Therefore, the most accessed resources on the internet should be created with this in mind. The purpose of this study is to assess the readability and quality of online patient resources for pediatric ACL tears. METHODS: Google was queried using the term "Pediatric ACL Tear" on May 26, 2022. The most popular sites were identified through page one of a Google search. All content was evaluated to assure information was directed toward patients. To determine reading difficulty, the most widely accepted readability tests: Flesch Reading Ease Index, Flesch-Kincaid Grade Level, and Gunning Fog Index were calculated through plain text in Microsoft Word and URL in online readability checker Readable.io. RESULTS: The average grade level for all resources was above the recommended reading level based on both Microsoft Word and Readable.io calculations. Each source exceeded the NIH recommendation by 2.6 grade levels on average (Mean grade level readability was 8.6 ± 1.9). Four of the 6 sites were above the average US reading level, exceeding the eighth grade by an average of 1.5 grade levels. All 6 sites analyzed had a mean DISCERN score of 61.9, meeting the 'good quality' criteria. CONCLUSION: The most readily available online materials for Pediatric ACL tears were of 'good quality' but above both the NIH-recommended readability level and the average US adult reading level. With the increasing need for treatment of ACL tears in pediatric and adolescent patients and greater internet accessibility in these populations, it is important to consider the readability of these resources in support of increased health literacy and improved outcomes. CLINICAL RELEVANCE: It is important for physicians treating young patients with ACL tears to be aware of all sources of information and support, including content shared online as these platforms are increasingly utilized, especially by patients and families of lower socioeconomic status.

Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes.

BACKGROUND: Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes. PURPOSE: To describe the characteristics of tarsal navicular BSIs in adolescents. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed. RESULTS: Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery. CONCLUSION: Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

Can Hip Passive Range of Motion Predict Hip Microinstability? A Comparative Study.

Background: Hip microinstability is an increasingly recognized cause of pain and disability in young adults. It is unknown whether differences in passive hip range of motion (ROM) exist between patients with versus without hip microinstability. Hypothesis: Underlying ligamentous and capsular laxity will result in differences in clinically detectable passive ROM between patients with femoroacetabular impingement (FAI), patients with microinstability, and asymptomatic controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of all patients undergoing hip arthroscopy between 2012 and 2018 was conducted. Patients with a diagnosis of isolated microinstability based on intraoperative findings were identified and classified as having isolated FAI, instability, or FAI + instability. Patients without a history of hip injury were included as controls. Range of motion was recorded in the supine position for flexion, internal rotation, and external rotation. Univariate and multivariate analysis was performed on each measurement in isolation as well as combinations of motion to include total rotation arc, flexion + rotation arc, and flexion + 2× rotation arc Models were then created and tested to predict instability status. Results: In total, 263 hips were included: 69 with isolated instability, 50 with FAI, 50 with FAI + instability, and 94 control hips. A higher proportion of patients in the instability and FAI + instability groups were female compared with the FAI and control groups (P < .001). On univariate analysis, differences were found in all groups in all planes of motion (P < .001). Multivariable analysis demonstrated differences in all groups in flexion and flexion + rotation arc. In symptomatic patients, the best performing predictive model for hip microinstability was flexion + rotation arc ≥200° (Akaike information criterion, 132.3; P < .001) with a sensitivity of 68.9%, specificity of 80.0%, positive predictive value of 89.1%, and negative predictive value of 51.9%. Conclusion: Patients with hip microinstability had significantly greater ROM than symptomatic and asymptomatic cohorts without hip microinstability. Symptomatic patients with hip flexion + rotation arc ≥200° were highly likely to have positive intraoperative findings for hip microinstability, whereas instability status was difficult to predict in patients with a flexion + rotation arc of <200°.

Gadolinium injected concurrently with anesthetic can result in false-negative diagnostic intra-articular hip injections.

PURPOSE: The purpose of this paper was to evaluate the response to intra-articular hip injections with and without concurrent gadolinium administration. Our secondary outcome was to compare post-operative outcomes between patients with an initial false-negative gadolinium-containing injection and a matched control group. METHODS: Patients receiving a series of two hip diagnostic intra-articular injections (DIAI), the first with gadolinium for concurrent MRA and the second without gadolinium, were retrospectively identified. Pain response to DIAI, injectate volume, local anesthetic volume, inclusion of corticosteroids, and method of injection were compared between injections. False-negative injection was defined as < 50% pain relief with concurrent gadolinium, but ≥ 50% pain relief with subsequent anesthetic injection without gadolinium. False-negative injections in patients that ultimately underwent primary hip arthroscopy were identified from this cohort and matched in a 3:1 ratio to a control cohort to compare short-term post-operative single assessment numerical evaluation (SANE) outcomes. RESULTS: Forty-three patients underwent a series of anesthetic injections with and without gadolinium and met inclusion and exclusion criteria. Pain response was significantly different in injections performed with and without gadolinium (18% vs. 81%; p < 0.001). There were significant differences in total injectate volume, local anesthetic volume, corticosteroid use, and method of injection between injections, but these variables were not correlated with pain response. Fifteen patients with false-negative responses to injection underwent primary hip arthroscopy and were matched in a 3:1 ratio to a control cohort. There was no difference in short-term post-operative SANE scores between the gadolinium-sensitive and control groups (81.6 vs. 80.0, n.s.). CONCLUSION: Concurrent administration of intra-articular gadolinium with DIAI may result in a false-negative response to anesthetic. Additionally, in patients with initial false-negative DIAI with gadolinium, short-term post-operative outcomes after hip arthroscopy are similar to a matched cohort. LEVEL OF EVIDENCE: Level III.

Temporary Flexible Rods for Correction of Severe Pediatric Spinal Deformity.

Surgical correction of large, rigid scoliotic and kyphotic curves carries an increased risk of perioperative complications, such as neurological injury and excessive blood loss, compared with correction of less severe curves. Titanium temporary flexible rods (TFRs), designed for pediatric long bone fracture fixation, may be helpful as adjuncts to achieve gradual, stepwise intraoperative correction of severe pediatric spinal deformities. A retrospective review was conducted of spinal fusion cases for pediatric scoliosis or kyphosis at our institution that used TFRs as a correction technique from 2007 to 2019. Patients underwent posterior spinal fusion with predominantly pedicle screw instrumentation. Intraoperatively, a non-contoured titanium elastic nail was temporarily positioned in the screws unilaterally to achieve partial correction while the contralateral side was instrumented. Then, the TFR was removed and replaced with a permanent rod. Thirty-four patients with severe spinal deformities underwent posterior spinal fusion. Seventeen had scoliosis (mean major Cobb angle, 89.3°) and 17 had kyphosis (mean T5-T12 kyphosis, 73.8°). Idiopathic deformity was the most common etiology; neuromuscular, syndromic, and postsurgical causes contributed to the remainder of cases. All patients had Ponte osteotomies. Four patients (11.8%) had neuromonitoring alerts, 1 of which was related to insertion of the TFR; all were reversible. For patients with scoliosis, the mean postoperative Cobb angle measured 40.2° (53.6% correction). For patients with kyphosis, the mean postoperative T5-T12 angle measured 43.3° (30.4° of correction). TFRs appear to be helpful adjuncts for correction of severe pediatric spinal deformities, facilitating gradual intraoperative correction in a single-stage operation. Neuromonitoring alerts are common but reversible. [Orthopedics. 2023;46(4):234-241.].

Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware.

BACKGROUND: End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial. METHODS: Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes. RESULTS: The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware. CONCLUSIONS: TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes. LEVEL OF EVIDENCE: IV, cohort without control.

Distal Metaphyseal Ulnar Shortening Osteotomy Fixation: A Biomechanical Analysis.

PURPOSE: Ulnar shortening osteotomy can be used to treat ulnar impaction syndrome and other causes of ulnar wrist pain. Distal metaphyseal ulnar shortening osteotomy (DMUSO) is one technique that has been proposed to reduce the complications seen with a diaphyseal USO or a wafer resection. However, to our knowledge, the optimal fixation construct for DMUSO has not been studied. We sought to characterize the biomechanical stiffness and rotational stability of different DMUSO constructs. METHODS: A DMUSO was performed on 40 human cadaveric ulnas using 4 different fixation constructs (10 specimens per group): one 3.0 mm antegrade screw; two 2.2 mm antegrade screws; one 3.0 mm retrograde screw; and two 2.2 mm retrograde screws. Biaxial testing using axial load and cyclical axial torque was performed until failure, defined as 10° of rotation or 2 mm displacement. Specimens were assessed for stiffness at failure. Bone density was assessed using the second metacarpal cortical percentage. RESULTS: Bone density was similar between all 4 testing groups. Of the 4 groups, the 2 antegrade screw group exhibited the highest rotational stiffness of 232 ± 102 Nm/deg. In paired analysis, this was significantly greater than 1 retrograde screw constructs. In multivariable analysis, 2-screw constructs were significantly stiffer than 1 screw and antegrade constructs were significantly stiffer than retrograde. Maximum failure torque did not differ with orientation, but 2 screws failed at significantly higher torques. CONCLUSION: Using 2 screws for DMUSO fixation constructs may provide higher stiffness and maximum failure torque, and antegrade screw constructs may provide more stiffness than retrograde constructs. CLINICAL RELEVANCE: Antegrade screw fixation using 2 screws may provide the strongest construct for DMUSO. Antegrade fixation may be preferred because it avoids violating the distal radioulnar joint capsule and articular surface of the ulna.

The Influence of Race, Income, and Sex on Treatment and Complications of Common Pediatric Orthopedic Fractures.

Despite best intentions, health care disparities exist and can consequently impact patient care. Few studies have examined the impact of disparities in pediatric orthopedic populations. The current study aimed to determine if the treatment type or complication rates of supracondylar, both-bone forearm, or femur fractures are associated with race, ethnicity, sex, or socioeconomic status. The New York Healthcare Cost and Utilization Project's database was used to identify all pediatric patients treated for supracondylar humerus fractures, both-bone forearm fractures, and femoral shaft fractures in 2016. Risk-adjusted relationships with race, ethnicity, sex, hospital location, and median income by zip code were assessed with multivariable logistic regression. Patients who were non-White, resided in the zip codes with the lowest median income (<$42,999 annually), and were treated in metropolitan areas were more likely to receive nonoperative treatments for supracondylar humerus fractures. Female patients with a femoral shaft fracture were less likely to be treated with open reduction and internal fixation vs intramedullary fixation. Finally, complications were not associated with patient race, sex, or socioeconomic statuses. These findings bring attention to health care disparities in the treatment of common pediatric orthopedic fractures. Further studies investigating the underlying etiology behind these disparities are warranted. [Orthopedics. 2023;46(3):e156-e160.].

Characterization of Trapezial Pommel in Relation to Radiographic and Wear Patterns in Carpometacarpal Osteoarthritis.

BACKGROUND: Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation). METHODS: In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert's views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression. RESULTS: Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert's (rs = 0.51) and stress views (rs = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views. CONCLUSIONS: We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

Isolated Versus Full Component Revision in Total Knee Arthroplasty for Aseptic Loosening.

BACKGROUND: Revision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost; however, implant survivorship and clinical outcomes of these different operations are unclear. METHODS: Between January 2009 and December 2019, a consecutive cohort of revision TKA was reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles, Knee Society functional, knee osteoarthritis and outcome score for joint replacement, Veterans RAND 12 (VR-12) physical, and VR-12 mental). RESULTS: A total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, P = .343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [Hazard ratio 10.11, P < .001] and iliotibial band release was associated with more complications (Odds ratio 9.87, P = .027). Preoperative symptoms of instability were associated with the worst improvement in University of California Los Angeles score. Higher American Society of Anesthesiologists status and higher Charlson Comorbidity Index were related with worse VR-12 physical (-30.5, P = .008) and knee osteoarthritis and outcome score for joint replacement (-4.2, P = .050) scores, respectively. CONCLUSION: Isolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor American Society of Anesthesiologists status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement. LEVEL OF EVIDENCE: III, cohort with control.

Anatomic relationship of extensor indicis propius and extensor digitorum communis: Implications for tendon transfer.

BACKGROUND: The extensor indicis proprius (EIP) tendon is a frequently used donor for a variety of tendon transfers, most commonly for reconstruction of the extensor pollicis longus (EPL). EIP is known to have frequent anatomic variants including split tendons and variations in tendon arrangement. AIM: To characterize the anatomy of the EIP at the level of the extensor retinaculum, where tendon harvest is often performed, and share our preferred technique for EIP to EPL transfer. METHODS: Twenty-nine fresh-frozen cadaveric forearms without history of forearm or hand injury or surgery were dissected. Tendon circumference and relationship of the EIP and extensor digitorum communis to the index (EDCI) at the metacarpophalangeal (MCP) joint and the distal extensor retinaculum were recorded. Distance from the distal extensor retinaculum to the EIP myotendinous junction was measured. RESULTS: EIP was ulnar to the EDCI in 96.5% of specimens (28/29) at the distal edge of the extensor retinaculum. In the remaining specimen, EIP was volar to EDCI. Tendon circumference at the distal extensor retinaculum averaged (9.3 mm ± 1.7 mm) for EDCI and 11.1 mm (± 2.7 mm) for EIP (P = 0.0010). The tendon circumference at the index MCP joint averaged 11.0 mm (± 1.7 mm) for EDCI and 10.6 mm (± 2.1 mm) for EIP (P = 0.33). EIP had a greater circumference in 76% (22/29) of specimens at the distal extensor retinaculum whereas EIP had a greater circumference in only 31% (9/29) of specimens at the MCP joint. CONCLUSION: The EIP tendon is frequently ulnar to and greater in circumference than the EDCI at the distal extensor retinaculum, which can be taken into consideration for tendon transfers involving EIP.

Effectiveness of melatonin treatment for sleep disturbance in orthopaedic trauma patients: A prospective, randomized control trial.

OBJECTIVES: Explore sleep disturbance in postoperative orthopedic trauma patients and determine the impact of melatonin supplementation on postoperative sleep, pain, and quality of life. MATERIALS AND METHODS: In this prospective, randomized controlled trial at a Level I trauma center, 84 adult orthopedic trauma patients with operative fracture management were randomized 2-weeks postoperatively to either the melatonin or placebo group. Patients randomized to the melatonin group (42 subjects, mean age 41.8 ± 15.5 years) received 5 mg melatonin supplements. Patients in the placebo group (42 subjects, mean age 41.3 ± 14.0 years) received identical glucose tablets. Both groups were instructed to take the tablets 30 minutes before bed for 4 weeks and received sleep hygiene education and access to the Cognitive Behavioral Therapy for Insomnia (CBT-I) Coach app. MAIN OUTCOME MEASURES: Our primary outcome was sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes were pain measured by the Visual Analog Scale (VAS), quality of life measured by the 36-Item Short Form Survey (SF-36), and opioid use. RESULTS: Patients in both groups had significant sleep disturbance (PSQI ≥ 5) at 2-weeks (83%) and 6-weeks (67%) postoperatively. PSQI improved by 3.3 points (p<0.001) at follow-up, but there was no significant difference between groups (melatonin PSQI = 5.6, placebo PSQI = 6.1, P = 0.615). Compared to placebo, melatonin did not affect VAS, SF-36, or opioid use significantly. CONCLUSION: Sleep disturbance is prevalent in orthopedic trauma patients. Melatonin treatment did not significantly improve subjective sleep quality, pain, quality of life or opioid use. LEVEL OF EVIDENCE: Therapeutic Level I.

Prevalence of Positive Rapid Antigen Tests After 7-Day Isolation Following SARS-CoV-2 Infection in College Athletes During Omicron Variant Predominance.

Importance: The US Centers for Disease Control and Prevention shortened the recommended isolation period for SARS-CoV-2 infection from 10 days to 5 days in December 2021. It is unknown whether an individual with the infection may still have a positive result to a rapid antigen test and potentially be contagious at the end of this shortened isolation period. Objective: To estimate the proportion of individuals with SARS-CoV-2 infection whose rapid antigen test is still positive starting 7 days postdiagnosis. Design, Setting, and Participants: This case series analyzed student athletes at a National Collegiate Athletic Association Division I university campus who tested positive for SARS-CoV-2 between January 3 and May 6, 2022. Individuals underwent rapid antigen testing starting 7 days postdiagnosis to determine whether they could end their isolation period. Exposures: Rapid antigen testing 7 days after testing positive for SARS-CoV-2. Main Outcomes and Measures: Rapid antigen test results, symptom status, and SARS-CoV-2 variant identification via campus wastewater analysis. Results: A total of 264 student athletes (140 [53%] female; mean [SD] age, 20.1 [1.2] years; range, 18-25 years) representing 268 infections (177 [66%] symptomatic, 91 [34%] asymptomatic) were included in the study. Of the 248 infections in individuals who did a day 7 test, 67 (27%; 95% CI, 21%-33%) tests were still positive. Patients with symptomatic infections were significantly more likely to test positive on day 7 vs those who were asymptomatic (35%; 95% CI, 28%-43% vs 11%; 95% CI, 5%-18%; P < .001). Patients with the BA.2 variant were also significantly more likely to test positive on day 7 compared with those with the BA.1 variant (40%; 95% CI, 29%-51% vs 21%; 95% CI, 15%-27%; P = .007). Conclusions and Relevance: In this case series, rapid antigen tests remained positive in 27% of the individuals after 7 days of isolation, suggesting that the Centers for Disease Control and Prevention-recommended 5-day isolation period may be insufficient in preventing ongoing spread of disease. Further studies are needed to determine whether these findings are present in a more heterogeneous population and in subsequent variants.

Knowledge and Practices Related to Hip-Healthy Swaddling for Newborns Among Maternity Nurses.

OBJECTIVE: To assess the self-reported knowledge, education, and practices related to hip-healthy swaddling of newborns among nurses, how they teach this technique to parents, and the relationships among these factors. DESIGN: Descriptive cross-sectional exploratory survey. SETTING: Academic women and children's hospital with an average of 4,500 annual births. PARTICIPANTS: One hundred four registered maternity nurses who work primarily in the maternity unit. METHODS: At three staff meetings, we surveyed maternity nurses to determine their knowledge, education, and practices related to hip-healthy swaddling and how they teach this technique to parents. We analyzed results using descriptive statistics and chi-square and Fisher's exact tests. RESULTS: Of the 156 nurses in the maternity unit, 104 attended three staff meetings and completed the survey. Among the participants, 18.9% (18/95; 9 participants did not respond) were unable to identify the correct hip swaddling position. Overall, 64.2% (61/95; 9 participants did not respond) reported that they received education on general swaddling technique, yet 14.8% (9/61) of these participants were unable to identify the correct hip-healthy swaddling position. Among the participants, 99.0% (103/104) reported that nurses teach parents how to swaddle infants rather than other health care providers; 12.5% (13/104) of participants responded that medical doctors provide training as well. Overall, 67.0% (69/103; 1 participant did not respond) reported that they taught parents in >75% of parent interactions. CONCLUSION: Our results illustrate a gap in knowledge about hip-healthy swaddling among the maternity nurses who participated in this survey and a need for further education.