Suture Anchor Repair for Distal Patellar Tendon Avulsion in Tibial Tubercle Fractures: A Technical Description and Report of Two Cases.

Tibial tubercle avulsion fractures, though rare, pose a significant challenge in pediatric orthopedics, particularly in athletic adolescents. For nondisplaced fractures, conservative treatment involves the use of braces or casts, while displaced fractures necessitate operative intervention, often through screw fixation. Concomitant soft tissue injuries should also be identified and addressed operatively to ensure complete repair of the extensor mechanism. This paper introduces a method for open reduction and internal fixation (ORIF) of tibial tubercle fractures with suture anchor repair of the distal patellar tendon avulsion. Two case examples of 14-year-old males with displaced fractures undergoing this procedure are presented. After standard screw fixation of the displaced fragment was performed, a single suture anchor was placed into the tibia and an onlay tension slide technique was utilized to secure the distal patellar tendon avulsion. Both patients underwent immobilization and protected weightbearing for four weeks with physical therapy initiated at six weeks. At four months postoperatively, both patients had returned to competitive sports without issue. The described technique may represent a reliable and reproducible method for addressing the distal patellar tendon avulsion component of tibial tubercle fractures. Its biomechanical advantages contribute to the complete repair of the extensor mechanism, enabling a successful return to competitive athletics without hardware complications.

Orthopedic Team Surgeons in Major Professional Sports: An Analysis of Affiliation With the Top 10 Sports Medicine Fellowship Programs and Implications for Leadership and Diversity.

This paper examines the correlation between orthopedic team surgeons in major professional sports and their affiliation with the top 10 sports medicine fellowship programs. With a growing trend in post-residency fellowship training, particularly in sports medicine, the study focuses on the implications of fellowship program choice for aspiring major professional sports team physicians. By analyzing data from Major League Baseball (MLB), the National Basketball Association (NBA), the National Football League (NFL), and the National Hockey League (NHL), the research reveals that 61 of 124 (49.19%) team surgeons graduated from the top 10 sports medicine fellowship programs. The results identify a noticeable pipeline effect in professional sports, where teams often hire graduates from a select number of esteemed fellowship programs. The study suggests that choosing a fellowship program from the top 10 list may enhance the prospects of becoming a major league team surgeon. Additionally, our results found a significant gender disparity among team surgeons, with only two (1.6%) of all major professional team physicians being women. This emphasizes the imperative for diversity improvement in orthopedic sports medicine. In conclusion, the research underscores the impact of top-tier fellowship programs on professional team surgeons, with implications for aspiring sports medicine physicians and a call for addressing gender disparities.

Examining differences in trends in the orthopedic surgery match for osteopathic and allopathic medical graduates after the transition to single accreditation.

CONTEXT: The landscape of medical education in the United States has undergone significant changes, particularly with the rise of osteopathic medical students, constituting a substantial portion of medical school entrants. The merger of the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) in 2020 opened residency slots to allopathic graduates that were previously historically allocated to osteopathic (Doctor of Osteopathic Medicine [DO]) physicians. This has impacted various medical specialties, notably orthopedic surgery. Despite an increase in orthopedic surgery applicants, the match rates for DO candidates have faced challenges, raising concerns about the impact of this merger on the future of orthopedic training for DO students. OBJECTIVES: This research aims to analyze the trends in orthopedic surgery match rates for DO vs MD applicants since the single accreditation merger, which began in 2015 with a 5-year transition period that was finalized by 2020. By examining factors such as application numbers, research output, standardized test scores, and program director preferences, the study seeks to identify disparities and challenges faced by DO applicants in securing orthopedic surgery residencies. METHODS: This study utilized publicly available data from the National Residency Match Program (NRMP) 2018, 2020, and 2022 reports. Data encompassed applicant characteristics, including standardized test scores, research experiences, and match outcomes. The study also incorporated insights from NRMP program director surveys, focusing on interview and ranking practices. The analysis involved comparisons of application numbers, match rates, research productivity, and test scores between DO and MD applicants. Statistical analysis was employed to identify any statistically significant differences among the examined variables for the 3 years included in the study. RESULTS: The research revealed a consistent increase in orthopedic surgery applicants from both DO and MD backgrounds. However, MD applicants consistently had higher match rates compared to their DO counterparts, with the gap narrowing over the years. Notably, disparities persisted in research output, with MD applicants demonstrating a significant advantage in publications and presentations. Standardized test scores, although slightly higher for MD applicants, did not significantly impact the differences in match rates. MD applicants had statistically significantly higher numbers of applicants (P = .0010), number of publications (P = .0091), and number of research experiences (P = .0216) over the years examined. However, there was no statistically significant difference in the scores on Step 1 (P = .5038) or Step 2 (P = .4714) between MD and DO candidates. CONCLUSIONS: Despite progress in the acceptance and ranking of DO applicants by program directors, the study highlights enduring challenges in orthopedic surgery match rates between DO and MD candidates. The lack of research opportunities for DO students stands out as a crucial area for improvement, necessitating systemic changes within medical education. Addressing this disparity and ensuring equal access to research experiences could mitigate the gap in match rates, promoting a more equitable environment for all aspiring orthopedic surgeons, regardless of their medical background. Such efforts are vital to fostering inclusivity and enhancing opportunities for osteopathic medical students pursuing competitive specialties like orthopedic surgery.

Deep Venous Thrombosis of Non-operative Clavicle Fracture Following Low-Energy Injury Mechanism With Extension Into the Radial Vein: A Case Report.

Clavicle fractures are relatively common with the majority treated non-operatively. However, venous thromboembolism (VTE) in association with these fractures is rare, despite conservative treatment involving immobilization rather than surgical intervention. Surgery is a risk factor for thromboembolism and therefore more common when clavicle fractures are treated operatively. There have been a few published case reports of VTE following clavicle fractures that were managed non-operatively. Here we present a unique case of VTE involving the subclavian, brachial, and radial vein following a low-energy injury, with radial involvement being the most distal to date. A literature review is also presented to compare locations of VTE, injury factors, and timeline from injury to VTE presentation.

The Efficacy of Tranexamic Acid for Reducing Blood Transfusion Rates in Extracapsular Hip Fractures: A Single-Center Randomized Controlled Trial.

Perioperative allogenic blood transfusions for patients with hip fractures are associated with increased costs and complications. This prospective randomized controlled trial evaluated whether tranexamic acid (TXA) reduces blood transfusion rates and blood loss in extracapsular hip fractures, when administered at the time of hospital admission. Patients with closed intertrochanteric or subtrochanteric femur fractures undergoing intramedullary nailing (n=100) were enrolled from October 2015 to January 2019. On arrival to the hospital, patients were randomized to receive either 1 g of intravenous TXA or normal saline. Blood transfusion rates from hospital arrival to postoperative day 5 or discharge, blood loss from hospital arrival to postoperative day 3 or 4, intraoperative blood loss, length of hospital stay, 30-day mortality, and major complications were evaluated. Six patients from the TXA group and five from the placebo group were excluded because of canceled surgery, study drug infusion after incision, multiple fractures, or dropout. Patient characteristics were similar between the groups. Postoperative transfusion rates were 17.5% (7 of 40) in the TXA group and 36.7% (18 of 49) in the placebo group (relative risk, 0.48; 95% CI, 0.22-1.03; P=.046). Total blood loss was significantly less in the TXA group (mean difference, 367 mL; 95% CI, 76-657; P=.01). No significant differences were found for intraoperative blood loss, length of hospital stay, 30-day mortality, or 30-day major complications. TXA administered on hospital arrival decreased the risk of postoperative blood transfusion and mean perioperative blood loss in patients with extracapsular hip fractures. We recommend a single-dose intravenous administration of TXA at the time of hospital admission for patients with extracapsular hip fractures. [Orthopedics. 2023;46(5):e303-e309.].

Extensile Exposures in Revision and Complex Primary Total Knee Arthroplasty: A Review of Anatomy, Biomechanics, and Techniques.

Developing adequate exposure when performing a revision total knee arthroplasty is critical to an efficient and safe intraoperative course. Proper planning and knowledge of the relevant anatomy are important when dissecting scar tissue associated with previous trauma or surgery and navigating bone loss. We present a review of the different total knee arthroplasty extensile exposure techniques that have been described in the literature. Specific exposures discussed include the femoral peel, banana peel, medial epicondylar osteotomy, quadriceps snip, tibial tubercle osteotomy, wandering resident, and the V-Y quadricepsplasty with patella turndown. Furthermore, we review the histological healing potential, biomechanical principles that drive post-operative expectations, post-operative rehabilitation protocols, and reported functional outcomes of each technique.

The Utility of Acid-Fast Bacillus (AFB) and Fungal Cultures in Orthopaedic Infections.

Introduction When diagnosing suspected orthopaedic-related infections, fungal and acid-fast bacilli (AFB) cultures are often obtained intraoperatively. These cultures are difficult and time-consuming to grow and increase healthcare costs. This study aimed to quantify the rate of positive AFB and fungal cultures in orthopaedic infections and to compare potential risk factors for a positive result.  Methods Orthopaedic surgical cases for suspected infection at one institution from March 2013 through December 2019 were included. Data were collected on patient demographics and procedure characteristics for patients with surgical AFB or fungal lab tests ordered on the day of surgery. Results Of the 813 patients for whom intraoperative AFB or fungal cultures were ordered, 3.8% (N=31) had a positive result. Of the 31 positive results, 30 were from fungal cultures and one was from AFB cultures. Patients with a positive versus negative culture result did not differ significantly by age, sex, American Society of Anesthesiologists (ASA) score, diabetes, obesity, or HIV/AIDS. In both unadjusted and adjusted analyses, peripheral vascular disease (PVD) was associated with higher odds of a positive fungal culture result (adjusted OR (aOR)=3.5, 95%CI=1.3-8.4). Likewise, in both unadjusted and adjusted models, a hand/foot operating region was associated with higher odds of a positive fungal culture result compared with all other regions (aOR=4.2, 95%CI=1.9-9.8). Conclusion Intraoperative fungal and AFB cultures may not need to be obtained except in orthopaedic surgical cases for hand or foot infections or in patients with PVD.

A Single Dose Versus Two Doses of Tranexamic Acid for Extracapsular Hip Fractures.

Objective In this study, we aimed to compare the effectiveness of one dose of tranexamic acid (TXA) at the time of hospital admission versus two doses of TXA (one at the time of hospital admission and another dose intraoperatively) in reducing perioperative total blood loss in patients with extracapsular hip fractures. Methods This retrospective cohort study included 80 patients from a single institution who underwent surgical fixation for extracapsular hip fractures. Forty patients received a single dose of 1 gram of TXA at the time of hospital admission (per standardized protocol of an ongoing research study at the time), and 40 patients received the same dose of TXA on hospital admission as well as a second dose of 1 gram of TXA intraoperatively at the time of incision (per standard practice change following the completion of the research study). The primary study outcome of interest was total blood loss, which was calculated by estimating blood volume via Nadler's formula followed by calculating the total blood loss with the hemoglobin dilution method. Secondary outcomes included blood transfusion rates, hospital length of stay (LOS), and 30-day mortality. Results Patient gender, age, the American Society of Anesthesiologists (ASA) score, procedure length, fracture type, hardware type, and hemoglobin on hospital arrival were similar across the study groups (all p>0.05), though the twice-dosed group had a higher average BMI (26.4 kg/m2 vs. 24 kg/m2, p=0.04). When adjusting for BMI, the twice-dosed group was estimated to have a slightly larger but non-significant difference in total blood loss (115-ml difference, 95% CI: 158.2-389.3, p=0.40) compared to the single-dose TXA group. More patients in the twice-dosed group required blood transfusion compared to the single-dose TXA group, though this was not statistically significant (30.0% vs. 17.5%, adjusted OR=1.64, 95% CI: 0.55-5.12, p=0.38). The distribution of hospital LOS and 30-day mortality rates were similar across the groups (p=0.13 and p>0.99). Conclusion In the setting of surgically treated extracapsular hip fractures, patients who received one dose of TXA at the time of hospital admission and a second intraoperative dose of TXA did not demonstrate significant differences in total blood loss or a need for blood transfusion compared to patients who only received a single dose of TXA at the time of hospital admission.

Development of an Effective Treatment Algorithm for the Stubbed Great Toe.

While toe fractures are the most common fractures of the foot in the pediatric population, the majority of these injuries do not require aggressive treatment. However, the mechanism of stubbing the great toe with bleeding at the base of the nail, a laceration proximal to the nail fold, or signs of a displaced fracture through the physis of the distal phalanx signal a likely open fracture involving the distal phalanx of the great toe. Unrecognized open fractures can lead to mistreatment and consequently osteomyelitis or growth disturbances. We report a case of a patient who required open reduction and Kirschner wire (K-wire) stabilization of a Salter-Harris I fracture involving the distal phalanx of the great toe after delayed recognition of the initial injury and subsequent failure to obtain closed reduction with a digital block in the clinic setting. We present this case to demonstrate the importance of vigilance in the evaluation of stubbed great toe injuries and propose an algorithm to guide the management of these injuries.

Rotational Ankle Fracture Dislocation With Associated Lisfranc Fracture.

While ankle fractures most often result from a rotational injury, Lisfranc injuries are more commonly associated with an axial load on a plantarflexed foot. Due to differing mechanisms of injury, rotational ankle fractures with Lisfranc injuries are uncommon and rarely discussed in the literature. Here we present a case of a rotational ankle fracture-dislocation with a concomitant Lisfranc injury. The Lisfranc injury, which was ultimately treated nonoperatively, was discovered seven weeks after operative fixation of the ankle fracture. At the last follow-up nine months after the initial injury, the patient had mild midfoot soreness with activity but no evidence of deformity or arch collapse. Although no deformity was observed in our patient, missed Lisfranc injuries may result in significant functional deficits indicating the importance of recognizing the possibility of a dual injury.