A modified minimally invasive osteotomy for hallux valgus enables reduction of malpositioned sesamoid bones.

BACKGROUND: The current minimally invasive distal metatarsal osteotomy for hallux valgus (HV) is V-shaped, which prevents the correction of the rotational metatarsal head deformity and reduction of the sesamoid bones. We sought to determine the optimal method for sesamoid bone reduction during HV surgery. METHODS: We reviewed the medical records of 53 patients who underwent HV surgery between 2017 and 2019 using one of three techniques: open chevron osteotomy (n = 19), minimally invasive V-shaped osteotomy (n = 18), and a modified straight minimally invasive osteotomy (n = 16). The sesamoid position was graded using the Hardy and Clapham method on weight-bearing radiographs. RESULTS: When compared to open chevron and V-shaped osteotomies, the modified osteotomy resulted in significantly lower postoperative sesamoid position scores (3.74 ± 1.48, 4.61 ± 1.09, and 1.44 ± 0.81, respectively, P < 0.001). Furthermore, the mean change in postoperative sesamoid position score was greater (P < 0.001). CONCLUSION: The modified minimally invasive osteotomy was superior to the other two techniques in correcting HV deformity in all planes, including sesamoid reduction.

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery.

INTRODUCTION: Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications. METHODS: We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold. RESULTS: There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively). CONCLUSION: We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures.

BACKGROUND: Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN. PATIENTS AND METHODS: A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life. RESULTS: The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively). CONCLUSIONS: According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures. LEVEL OF EVIDENCE: Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.

[NOVEL CONCEPTS AND CHANGES IN TOTAL JOINT ARTHROPLASTY IN THE 21ST CENTURY].

INTRODUCTION: Total joint arthroplasty (TJA) is amongst the most common elective orthopedic surgeries. Since their introduction in 1951 there have been changes not only in prosthesis design and surgical approaches, but also in patient management, anesthesia, drug regimen and robotic arm assistance. These changes led to advancement in patient safety and shorter hospitalization. Today TJA is accessible for a wider age and function range of patients, which has led to an exponential growth in the number of procedures conducted.

Postoperative Weightbearing Protocols After Arthroscopic Surgery for Femoroacetabular Impingement Does Not Affect Patient Outcome: A Comparative Study With Minimum 2-Year Follow-up.

PURPOSE: To evaluate the effects of immediate postoperative weightbearing protocols after hip arthroscopy for femoroacetabular impingement (FAI) with minimum 2-year follow-up, as measured by patient-reported outcome measures and satisfaction rates. METHODS: Between January 2011 and June 2016, patients undergoing hip arthroscopy for FAI and labral tears were reviewed. Exclusion criteria was previous hip pathology or arthroscopy, active Workers' Compensation claims, and concomitant pathologies impeding weightbearing. Patients who were operated on before September 2013 were treated with 3 weeks of postoperative non-weightbearing (NWB), with weightbearing as tolerated (WBAT) thereafter. From October 2013, patients were allowed immediate postoperative WBAT. RESULTS: A total of 351 hip arthroscopic surgeries were performed; 133 of these patients met the inclusion criteria. Of the 133 included patients, 69 were in the NWB group and 64 were in the WBAT group. No differences were found in terms of sex (P = .603) or age (P = .241). No differences were found in postoperative scores (the Modified Harris Hip Score was 84.5 [range 79-89] for NWB vs 86.7 [78-89] for WBAT [P = .0.523], and the Hip Outcome Score was 83.1 [78-88] vs 88.4 [80-90], respectively; P = .130). Subjective rates of improvement, satisfaction score and the will to undergo surgery again did not differ between the groups (P = .674, P = .882, P = .730). The rate of subjects who met or exceeded the MCID in the NWB and WBAT groups was 82.6% and 81.2% for the Modified Harris Hip Score (P = .838) and 79.7% and 82.8% for the Hip Outcome Score (P = .647). There were no reported complications. Limitations include the possibility of the study being underpowered. CONCLUSIONS: After a 2-year minimum follow-up, patient-reported outcome measures and satisfactory rates with immediate weightbearing after hip arthroscopy for isolated FAI syndrome and labral tears do not differ significantly from results after strict NWB rehabilitation protocols. Revising weightbearing restrictions may allow for a more comfortable rehabilitation process after arthroscopic hip surgery for FAI and labral repair. LEVEL OF EVIDENCE: Level 3 - case-control study.

Subspinal impingement: clinical outcomes of arthroscopic decompression with one year minimum follow up.

PURPOSE: This study was designed to (1) evaluate the clinical outcomes after arthroscopic subspinal decompression in patients with hip impingement symptoms and low AIIS, and to (2) assess the presence of low anterior inferior iliac spine on the pre-operative radiographs of patients with established subspinal impingement diagnosed intra-operatively. METHODS: Retrospective analysis of patients who underwent arthroscopic subspinal decompression has been performed. The indications for surgery were femoroacetabular impingement (FAI), or subspinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine. RESULTS: Thirty-four patients underwent arthroscopic subspinal decompression between 2012 and 2015. The patients were followed for a median of 25 months (13-37 months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients and grade 3 anterior inferior iliac spine was found in 7 patients. MHHS, HOS, and HOSS scores increased from median (range) pre-operative scores of 55 (11-90), 48 (20-91) and 20 (0-80) to 95 (27-100), 94 (30-100) and 91 (5-100), respectively (p < 0.0001, p = 0.001, p < 0.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6/34 patients via AP radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21/34 (61.8%) patients. CONCLUSIONS: Arthroscopic subspinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13 months follow-up. Low AIIS is often under-diagnosed on AP pelvis and lateral frog radiographs and if left untreated, may result in unresolved symptoms and failed procedure. LEVEL OF EVIDENCE: IV.

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery.

BACKGROUND: Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated. PURPOSE AND CLINICAL RELEVANCE: Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery. METHODS: Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated. RESULTS: The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment. CONCLUSION: The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

MICA: A Learning Curve.

Techniques of minimally invasive bunion surgery have become increasingly popular in recent years. However, the learning curve involved in mastering these innovative techniques has not been described. To address this issue, a trained foot and ankle surgeon in a university hospital operated on 50 patients using the minimally invasive Chevron and Akin procedure over the course of 3 years, from January 2016 through December 2018. Surgery duration and x-ray exposure were documented. Results showed that surgery duration decreased from >2 hours in the first cases to a mean of ∼45 minutes in the third year. This learning curve plateaued by the 21st patient. The number of intraoperative fluoroscopy studies used decreased substantially over the first 27 surgeries, at which point the learning curve plateaued. In summary, it took about 27 procedures for an inexperienced surgeon to acquire the skill of performing minimally invasive Chevron and Akin osteotomy.

Merkel Cell Carcinoma of the Digit.

Merkel cell carcinoma (MCC) is a biologically aggressive neuroendocrine tumor of the skin. There are roughly 1500 new cases of MCC diagnosed every year in the United States, with an increased incidence over the past 15 years reaching up to 8%. Epidemiological studies show that the highest MCC incidence is seen in men older than 65 years, with a ratio of 0.23 per 10,000 among whites. Merkel cell carcinoma of the skin most commonly presents as a single, rapidly growing, flesh-colored, painless mass. Because MCC is uncommon, histopathological examination is usually delayed. Because of the high mortality rate associated with this aggressive tumor, a multidisciplinary panel is recommended to ensure high-quality coordinated care. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities, and performance status of the patient. We report a case of MCC to alert medical professionals of this potentially fatal tumor, as early diagnosis and treatment may improve morbidity and mortality rates.

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes.

PURPOSE AND HYPOTHESIS: The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair. METHODS: Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS). RESULTS: Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001). CONCLUSION: Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission. LEVEL OF EVIDENCE: IV.

[Carpal tunnel syndrome in pregnancy].

Pregnancy related carpal tunnel syndrome (PRCTS) is the most frequent mononeuropathy during pregnancy. The reported incidence of PRCTS varies widely and ranges from 0.8% to 70% depending on the diagnostic method and the physician. The etiology for PRCTS is related to hormonal fluctuations, fluid accumulation, glucose level fluctuations, median nerve hypersensitivity etc. The diagnosis of PRCS is the same as carpal tunnel syndrome (CTS) in the gereral population and includes a thorough history, typical symptoms and physical examination. Electrodiagnostic studies such as EMG are valuable tools for the ratification of the diagnosis of CTS in the general population. But in light of the fact that the EMG examination is painful and can cause discomfort to the patient, its routine use during pregnancy is controversial and is not required for determining the diagnosis. Generally, the syndrome tends to pass after birth, on the other hand, according to the literature, it might not pass in lactating women until they stop breastfeeding and even afterwards. Treatment of PRCS is mostly conservative, and if there is lack of improvement local intracarpal injection of a steroid is indicated. Intracarpal injections have demonstrated a significant decrease in symptoms and low recurrence in comparison to the general population, and do not put the fetus or his mother at risk. A surgical intervention is rarely indicated during pregnancy.

Pulmonary Embolism Post-Femoral Neck Fracture Surgery: A Critical Predictor of Five-Year Mortality.

Objectives: This study examines the impact of pulmonary embolism (PE) on mortality among patients with femoral neck fractures, exploring the predictive value of preoperative PE for postoperative occurrences and associated mortality over a 5-year follow-up period. Methods: We analyzed 2256 patients over 60 years old admitted with femoral neck fractures, focusing on those who developed DVT or PE postoperatively. Surgical intervention aimed within 48 hours without pharmacological thromboprophylaxis, utilizing mechanical prophylaxis instead. Postoperative management included Enoxaparin administration. Data analysis employed SPSS 21, with chi-squared tests, T-tests, and multivariate logistic regression to explore mortality and PE incidence. Results: PE was diagnosed in 1.4% of patients, with a notable mortality contrast between patients with PE (87%) and those without (59.7%) over 5 years. A history of preoperative PE emerged as a significant risk factor for postoperative PE. Despite surgical variations, no significant correlation was found between surgery type and PE incidence. Early postoperative weight-bearing and institutional rehabilitation did not significantly alter PE incidence rates. Conclusions: The study underscores the significant mortality risk associated with preoperative PE in femoral neck fracture patients. It highlights the necessity for vigilant PE risk assessment and management, challenging assumptions about the protective role of early mobility and rehabilitation in PE incidence. Further research is essential to refine patient care strategies and improve outcomes.

A Modified Triangular Arthroscopic Suture-Based Fixation for Tibial Eminence Fractures: Technique, Outcome and Literature Review.

Objectives: Tibial eminence fractures account for 2% to 5% of all knee injuries. Low-grade fractures, such as Type I, are typically treated conservatively, whereas high-grade fractures, such as Types III and IV, usually require surgical intervention. This paper describes a modified surgical arthroscopic technique, which employs pull-through triangle suture fixation for Type II and Type III arthroscopic intercondylar eminence avulsion fractures. In addition, we examined the efficacy and complication rate compared to the existing literature. Methods: Data were prospectively collected for knee arthroscopy surgeries and retrospectively analyzed with a minimum two-year follow-up. Twenty-three consecutive adults underwent arthroscopic treatment of displaced intercondylar Type II and Type III eminence fractures, as evidenced by clinical examination and imaging studies between May/2008 and May/2021. The patient's knee evaluation was performed using clinical symptoms and physical examination, along with International Knee Documentation Committee (IKDC) questionnaire and Tegner Activity Score. Compared to the literature, post-hoc power was calculated based on the mean Tegner Activity Score in our analysis. Results: fifteen females and eight males (mean age 33.9 years, range 19-56 years) were enrolled. The average postoperative follow-up was 35.4 months (27-53). The post-hoc power was 95% confidence in terms of the Tegner Activity Score. The mean ± standard deviation postoperative Tegner Activity Score was 8.2 ± 1.7 (6.8-10.0). Fifteen patients were classified as IKDC A (normal), six as IKDC B (nearly normal), and two as IKDC C (abnormal). The mean IKDC subjective score was 72.7 ± 23 (23-100). Twenty-four patients achieved normal flexion degrees compared with the unaffected side, while one patient achieved a flexion of only 0-90°. The group's mean flexion range of motion was 123 ± 16° (90-150°). Conclusion: This study presents a modified surgical arthroscopic suture fixation technique for tibial eminence fractures. The procedure is relatively simple and requires no more than basic arthroscopy equipment. The clinical and radiographic results indicate that this technique is safe, efficient, enables early initiation of rehabilitation, and has a lower complication rate in a variety of aspects compared with other fixation techniques used for tibial eminence fractures.

Augmented Ulnar Collateral Ligament Repair With Structural Bioinductive Scaffold: A Biomechanical Study.

BACKGROUND: Elbow ulnar collateral ligament (UCL) repair with suture brace augmentation shows good time-zero biomechanical strength and a more rapid return to play compared with UCL reconstruction. However, there are concerns about overconstraint or stress shielding with nonabsorbable suture tape. Recently, a collagen-based bioinductive absorbable structural scaffold has been approved by the Food and Drug Administration for augmentation of soft tissue repair. PURPOSE/HYPOTHESIS: This study aimed to assess the initial biomechanical performance of UCL repair augmented with this scaffold. We hypothesized that adding the bioinductive absorbable structural scaffold to primary UCL repair would impart additional time-zero restraint to the valgus opening. STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric elbow specimens-from midforearm to midhumerus-were utilized. In the native state, elbows underwent valgus stress testing at 30o, 60o, and 90o of flexion, with a cyclical valgus rotational torque. Changes in valgus rotation from 2- to 5-N·m torque were recorded as valgus gapping. Testing was then performed in 4 states: (1) native intact UCL-with dissection through skin, fascia, and muscle down to an intact UCL complex; (2) UCL-transected-distal transection of the ligament off the sublime tubercle; (3) augmented repair with bioinductive absorbable scaffold; and (4) repair alone without scaffold. The order of testing of repair states was alternated to account for possible plastic deformation during testing. RESULTS: The UCL-transected state showed the greatest increase in valgus gapping of all states at all flexion angles. Repair alone showed similar valgus gapping to that of the UCL-transected state at 30° (P = .62) and 60° of flexion (P = .11). Bioinductive absorbable scaffold-augmented repair showed less valgus gapping compared with repair alone at all flexion angles (P = .021, P = .024, and P = .024 at 30°, 60°, and 90°, respectively). Scaffold-augmented repair showed greater gapping compared with the native state at 30° (P = .021) and 90° (P = .039) but not at 60° of flexion (P = .059). There was no difference when testing augmented repair or repair alone first. CONCLUSION: UCL repair augmented with a bioinductive, biocomposite absorbable structural scaffold imparts additional biomechanical strength to UCL repair alone, without overconstraint beyond the native state. Further comparative studies are warranted. CLINICAL RELEVANCE: As augmented primary UCL repair becomes more commonly performed, use of an absorbable bioinductive scaffold may allow for improved time-zero mechanical strength, and thus more rapid rehabilitation, while avoiding long-term overconstraint or stress shielding.

Orthobiologic Techniques for Surgical Augmentation.

General awareness and clinical utilization of orthobiologic therapy has increased sharply in the recent years. Orthobiologics can be defined as "biological materials and substrates that promote bone, ligament, muscle, and tendon healing." There are 3 major strategies by which orthobiologics are thought to augment tissue repair or native biologic potential: factor-based, cell-based, and biomechanical augmentation. The purpose of this review is to synthesize the recent literature on orthobiologic techniques for surgical augmentation, with focus on several key areas including meniscus repair, osteochondral grafting, and rotator cuff repair.

The Effect of Warfarin Use on Postoperative Outcomes after Femoral Neck Surgery.

Introduction: Anticoagulation use in the elderly is common for patients undergoing femoral neck hip surgery. However, its use presents a challenge to balance it with associated comorbidities and benefits for the patients. As such, we attempted to compare the risk factors, perioperative outcomes, and postoperative outcomes of patients who used warfarin preoperatively and patients who used therapeutic enoxaparin. Methods: From 2003 through 2014, we queried our database to determine the cohorts of patients who used warfarin preoperatively and the patients who used therapeutic enoxaparin. Risk factors included age, gender, Body Mass Index (BMI) > 30, Atrial Fibrillation (AF), Chronic Heart Failure (CHF), and Chronic Renal Failure (CRF). Postoperative outcomes were also collected at each of the patients' follow-up visits, including number of hospitalization days, delays to theatre, and mortality rate. Results: The minimum follow-up was 24 months and the average follow-up was 39 months (range: 24-60 months). In the warfarin cohort, there were 140 patients and 2055 patients in the therapeutic enoxaparin cohort. Number of hospitalization days (8.7 vs. 9.8, p = 0.02), mortality rate (58.7% vs. 71.4%, p = 0.003), and delays to theatre (1.70 vs. 2.86, p < 0.0001) were significantly longer for the anticoagulant cohort than the therapeutic enoxaparin cohort. Warfarin use best predicted number of hospitalization days (p = 0.00) and delays to theatre (p = 0.01), while CHF was the best predictor of mortality rate (p = 0.00). Postoperative complications, such as Pulmonary Embolism (PE) (p = 0.90), Deep Vein Thrombosis (DVT) (p = 0.31), and Cerebrovascular Accidents (CVA) (p = 0.72), pain levels (p = 0.95), full weight-bearing status (p = 0.08), and rehabilitation use (p = 0.34) were similar between the cohorts. Conclusion: Warfarin use is associated with increased number of hospitalization days and delays to theatre, but does not affect the postoperative outcome, including DVT, CVA, and pain levels compared to therapeutic enoxaparin use. Warfarin use proved to be the best predictor of hospitalization days and delays to theatre while CHF predicted mortality rate.

Bifocal avulsion fracture and fixation of the patellar tendon: a case report.

Acute distal patella tendon avulsion from the tibial tubercle (TT) is a relatively rare injury that is usually described in the adolescents or elderly population in their 7th or 8th decades. Bifocal avulsion fractures of the patella tendon from the TT and the distal pole of the patella are exceptionally rare in adults. In this case report, we present a 52-year-old healthy old male who was treated for bifocal avulsion of the patellar tendon with open reduction and internal fixation augmented with two ULTRATAPE sutures. To our knowledge, this is the first case report to describe this injury in a healthy middle-aged patient.

Arthroscopic Treatment of Mild/Borderline Hip Dysplasia with Concomitant Femoroacetabular Impingement-Literature Review.

PURPOSE OF REVIEW: This literature review aims to survey the current knowledge about the management FAI in the setting of borderline hip dysplasia. RECENT FINDINGS: With better understanding, hip arthroscopy has recently been advocated for treating mild or borderline hip dysplasia (BDH) with concomitant femoroacetabular impingement (FAI) despite early studies that condemned its use. Recent outcome data have demonstrated that hip arthroscopy is a viable option in BDH, with and without FAI, and has been gaining wider acceptance. Hip arthroscopy can address the concomitant soft tissue and bony intra-articular pathologies and obviate the necessity for other surgeries. Moreover, hip arthroscopy may be used as an adjuvant treatment to other procedures such as a periacetabular osteotomy (PAO). Hip arthroscopy for BDH is an evolving procedure with promising short- and mid-term outcomes. The combination of BDH and FAI is becoming recognized as a problem in its own right, requiring dedicated treatment.

Bipolar hemiarthroplasty may reduce cerebrovascular accidents and improve early weight-bearing in the elderly after femoral neck fracture.

ABSTRACT: Cerebrovascular accidents (CVA) in the elderly population after femoral neck fracture remain great concern for physicians. Specifically, surgical fixation techniques, such as bipolar hemiarthroplasty (HA) and internal fixation play a significant role in influencing the occurrence of postoperative CVA in the elderly population.In order to identify 2 cohorts, we used a rigid selection process based on our institution's database. The cohorts were comprised of a HA cohort and a cannulated screw cohort, of which underwent femoral neck surgery, performed by 3 fellowship trained surgeons from 2003 to 2014. Risk factors were documented and measured, including Coumadin use and hypertension, and postoperative complications such as CVA and death rate were also recorded. A P-value of <.05 was determined to be statistically significant.A power analysis was performed and achieved a power of 0.95. We found a non-significant reduction in CVA for bipolar HA (3.6% CVA vs 0.0% in the non-CVA group, P = .48) and a non-significant increase in CVA for cannulated screw use (7.6% CVA vs 14.4% in the non-CVA group, P = .11). In addition, we found a significant difference in terms of weight-bearing status at 6-weeks postoperatively (0.95 vs 2.0, P < .0001), favoring the bipolar HA group.Among the advantages of bipolar HA surgery, surgeons should consider its value in reducing the occurrence of postoperative CVA. Furthermore, patients who underwent bipolar HA had improved weight-bearing status postoperatively compared with cannulated screw fixation.

Radiographic Bone Healing in Minimally Invasive Floating Metatarsal Osteotomy for Neuropathic Plantar Metatarsal Head Ulcers - A Retrospective Cohort Study.

Minimally invasive floating metatarsal osteotomy is an option for treating neuropathic ulcers under the metatarsal heads. This study presents the radiographic results of the floating metatarsal osteotomy. We reviewed files and radiographs at least 4 months after a floating metatarsal osteotomy in patients with diabetic neuropathy. In 71 osteotomies in 54 patients with late onset diabetes (mean age 61 ± 9, mean HbA1c 7.9 ± 1.9%), the primary ulcer healed within 3.5 ± 1.4 weeks. Of 66 osteotomies where radiographs were available 10 had non-union (15%, all asymptomatic), 15 (23%) had hypertrophic callus formation and 41 (62%) had normal union. One patient developed an ulcer under the hypertrophic callus. This necessitated callus resection. Asymptomatic non-union may happen in 15% of floating osteotomies, but the osteotomies appear to be relatively safe and effective for neuropathic plantar metatarsal head ulcers. Hypertropic callus causing local re-ulceration is rare and can be managed surgically.