Computer-Assisted Arthroscopic Cam Resection.

Determining the appropriate femoral cam resection during hip arthroscopy for femoroacetabular impingement syndrome is both critical for the patient and challenging for the surgeon. Incomplete bone resection is a leading cause of failed hip arthroscopy, whereas over-resection may increase the risk of femoral neck fracture. The alpha angle is a validated 2-dimensional radiographic measurement used to both diagnose femoroacetabular impingement syndrome preoperatively and to determine resection adequacy postoperatively. Computer-assisted intraoperative guidance systems enhance the accuracy of femoral cam resection, although a preoperative 3-dimensional computed tomography scan may be required. Other systems, such as the HipCheck software (Stryker, Kalamazoo, MI), have been developed to provide intraoperative guidance with live feedback using simultaneous alpha angle measurements overlayed on fluoroscopic images without the requirement for routine preoperative computed tomography. Via intraoperative touchscreen navigation, the surgeon identifies the midpoint of the femoral neck and femoral head. A commercial software program provides real-time alpha angle measurements, as well as enhanced visualization of the femoral cam deformity with an adjustable resection curve. Before the surgeon performs the cam resection, the software provides a template for appropriate resection depth in 6 positions of the hip. Upon completion of the femoral cam resection, the hip is again assessed in the same 6 positions and the alpha angle is assessed to ensure a complete resection.

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review.

PURPOSE: To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up. METHODS: A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale. RESULTS: Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%. CONCLUSIONS: The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level III, systematic review of Level I-III studies.

Shoulder Arthroplasty in the Upper Extremity Weight-bearing Patient: A Systematic Review of Clinical Outcomes and Complications.

BACKGROUND: Patients who rely on their upper extremities for ambulation, or upper extremity ambulators (UEAs), place considerable stress on their shoulders through the use of assistive devices like walkers, crutches, canes, and wheelchairs. It has been postulated that UEAs may be at increased risk for complications following shoulder arthroplasty. This study aimed to systematically review the literature related to (1) patient-reported outcomes measures (PROMs), (2) functional outcomes, and (3) complications in UEAs who undergo shoulder arthroplasty. METHODS: A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes of shoulder arthroplasty in UEAs. Patient demographics, clinical characteristics, PROMs, radiographic outcomes, and postoperative range of motion were collected and compared to control patients (i.e. bipedal ambulators) from the constituent studies. RESULTS: A total of eight studies evaluating 248 UEA cases and 206 control cases were included for review. Ambulatory assistive devices utilized by UEAs included walkers (39%), wheelchairs (38%), canes (22%), and a crutch (<1%). Among UEA cases, 197 (79%) reverse total shoulder arthroplasty, 37 (15%) anatomic total shoulder arthroplasty, and 14 (6%) hemiarthroplasty were performed. Overall, patients exhibited significant improvements in mean American Shoulder and Elbow Surgeons (ASES) scores, Constant-Murley scores, Simple Shoulder Test (SST) scores, and Visual Analog Scale (VAS) scores postoperatively. Among 3 studies that included comparison with control groups of bipedal ambulators, no significant differences in outcomes were identified. The overall clinical complication rate was 17% for UEAs compared to 9.1% for controls. The rate of revision surgery was 7.7% for UEAs and 4.9% for bipedal ambulators. CONCLUSIONS: UEAs experience satisfactory pain relief, functional improvements, and good subjective outcomes following shoulder arthroplasty. However, complication and revision rates are higher compared to those for bipedal ambulators, and the majority of UEAs undergo reverse shoulder arthroplasty (RSA) compared to anatomic total shoulder arthroplasty (aTSA).

Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review.

PURPOSE: To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes. METHODS: A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated. RESULTS: Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery. CONCLUSIONS: Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure. LEVEL OF EVIDENCE: IV; Systematic Review of Level III and IV studies.

Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review.

PURPOSE: To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS: A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS: A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS: MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Acellular Dermal Allograft and Tensor Fascia Lata Autograft Show Similar Patient Outcome Improvement and High Rates of Complications and Failures at a Minimum 2-Year Follow-Up: A Systematic Review.

PURPOSE: To compare clinical and radiologic outcomes following superior capsular reconstruction (SCR) using dermal allograft versus tensor fascia lata (TFL) autograft for massive rotator cuff tears with a minimum 2-year follow-up. METHODS: A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through September 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies evaluating clinical and radiologic outcomes, as well as complications following SCR for the treatment of massive rotator cuff tears were included. Study quality was assessed via the Newcastle-Ottawa Scale and the National Institutes of Health Quality Assessment. The mean change from preoperative to postoperative values (delta) was calculated for each outcome. RESULTS: Seventeen studies, consisting of 519 patients were identified. Mean duration of follow-up ranged from 24 to 60 months. Mean reduction in visual analog scale pain score ranged from 2.9 to 5.9 points following use of dermal allograft, and 3.4 to 7.0 points following TFL autograft reconstruction. Mean improvements in American Shoulder and Elbow Surgeons score were similar between groups (dermal allograft: 28.0-61.6; TFL autograft: 24.7-59.3). The mean increase in forward flexion ranged from 31° to 38° with dermal allograft, versus 19° to 69° with TFL autograft. Average improvement in active external rotation with dermal allograft ranged from -0.4° to 11° and from 2° to 22.4° using TFL autograft. A similar change in acromiohumeral distance following SCR (dermal allograft: 0.9-3.2 mm; TFL autograft: 0.3-3.6 mm) was appreciated. The rate of complications within the dermal allograft group ranged from 4.5% to 38.2% versus 13.3% to 86.4% following TFL autograft. Failure rate ranged from 4.5 to 38.2% following dermal allograft versus 4.5 to 86.4% with TFL autograft. CONCLUSIONS: Acellular dermal allograft versus TFL autograft for SCR both demonstrate improved VAS and American Shoulder and Elbow Surgeons scores, with increased values in flexion and external rotation, and increased visual analog scale, although with high variability. Both grafts demonstrate high rates of complications and failures at minimum 2-year follow-up. LEVEL OF EVIDENCE: IV; systematic review of level II-IV studies.

Computed Tomography-Based Preoperative Planning Provides a Pathology and Morphology-Specific Approach to Glenohumeral Instability With Bone Loss.

PURPOSE: To use computed tomography (CT) to determine a reproducible method of coracoid measurement to compare the ability of the classic Latarjet technique and the congruent arc modification (CAM) to restore native glenoid diameter and to develop a preoperative planning algorithm for glenoid restoration with a goal of achieving an on-track shoulder. METHODS: Coracoid dimensions were measured on multiplanar reconstructed shoulder CT scans of patients aged 18 to 45 years obtained between December 1, 2019, and March 13, 2020. Patients were excluded if CT demonstrated osteophyte formation, glenoid dysplasia, coracoid fracture, or tumor. The proportion of glenoid diameter able to be restored using classic Latarjet technique and CAM were calculated. A treatment algorithm was proposed considering the amount of bone loss present and coracoid dimensions. RESULTS: Coracoid dimensions of 117 consecutive patients were measured and varied considerably (length: 17.5-31.8 mm, width: 9.1-20.5 mm, thickness: 6.1-15.7 mm). While most patients had harvestable coracoid length ≥20 mm (male: 96.3% vs female: 94.4%, P = .65), only 27.8% of female patients had coracoid thickness ≥10 mm. When comparing Latarjet techniques, there was no difference in the proportion of patients in whom 30% glenoid diameter could be fully restored, but CAM was able to restore at least 35% in more male and female patients (98.8% vs 79.0% and 100% vs 61.1%, respectively, P = .00001). Intra- and inter-rater reliability was excellent ( intraclass correlation coefficient ≥0.950 for all dimensions). CONCLUSIONS: We describe a reliable method of measuring coracoid dimensions for preoperative planning of glenoid restoration. The classic Latarjet technique reliably restores the glenoid anteroposterior diameter with bone loss of up to 30%. The majority of female patients have coracoid thickness <10 mm, which may increase the risk of graft fracture when using CAM. The decision to use the classic Latarjet technique or CAM considers each individual's glenoid and coracoid dimensions with a goal of achieving an on-track shoulder. CLINICAL RELEVANCE: Our reliable method of coracoid measurement demonstrated the differing abilities of the classic Latarjet and CAM to restore the native glenoid diameter. An evidence-based algorithm using these measurements was developed to assist in preoperative planning for glenohumeral instability in the setting of bone loss, with a goal of achieving an on-track shoulder. Alternative techniques may be considered if an on-track shoulder cannot be achieved with Latarjet.

A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures.

BACKGROUND: Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins. METHODS: Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until ∼1.6 mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability. RESULTS: A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001). CONCLUSIONS: A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill. LEVEL OF EVIDENCE: Level II-economic.

Pediatric and adolescent ankle instability: diagnosis and treatment options.

PURPOSE OF REVIEW: The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and treatment for lateral ankle instability in pediatric patients. RECENT FINDINGS: Chronic ankle instability is a common sequela of lateral ankle sprain in young athletes. Incidence is increasing, possibly due in part to inadequate treatment of first-time ankle sprains, as well as increased youth participation in organized and competitive sports. The anterior talofibular ligament (ATFL) is injured in every case, whereas the calcaneofibular ligament (CFL) and syndesmosis may be involved in severe cases. A clinical history, focused physical exam, and appropriate radiographic studies aid in diagnosis, and predisposing factors must be identified. Early treatment of ankle sprains involves bracing or immobilization, followed by a course of physical therapy. Surgery involves anatomic repair of the torn ligaments, and may be required in cases of severe functional and mechanical instability with recurrent sprains refractory to nonsurgical management. Intraarticular disorders should be identified and may be addressed with ankle arthroscopy. SUMMARY: Prompt treatment of lateral ankle instability in young athletes is important to prevent chronic ankle instability. Many patients are successfully treated without surgery, and those requiring operative intervention improve function postoperatively.

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

BACKGROUND: Bernese periacetabular osteotomy (PAO) is a technically challenging procedure with potential risk for major complications and a previously reported steep learning curve. However, the impact of contemporary hip preservation fellowships on the learning curve of PAO has not been established. QUESTIONS/PURPOSES: (1) What was the frequency of major complications during the PAO learning curve of two surgeons who recently graduated from hip preservation fellowships? (2) Is increasing level of experience associated with the risk of a complication and with operative time, a possible surrogate measure of surgical performance? METHODS: We retrospectively studied 81 PAOs performed by one of two surgeons who recently graduated from a hip preservation fellowship during their first 4 years of practice in two institutions. One of the surgeons participated as a fellow in 78 PAOs with an increasing level of responsibility during the course of 1 full year. The other surgeon performed 41 PAOs as a fellow during 6 months, also with an increasing level of responsibility during that time. There were 68 (84%) female and 13 (16%) male patients (mean age, 18 years; range, 10-36 years). The frequency of complications was recorded early and at 1 year after surgery and graded according to a validated classification system describing five grades of complications. Complications that required surgical intervention (Grade III) and life-threatening complications (Grade IV) were considered major complications. Persistent pain after surgery, although considered a failure of PAO, was not considered a surgical complication as a result of the multifactorial etiology of pain after hip-preserving surgery. However, early reoperation and revision surgery were counted as complications. To evaluate the association between increasing level of experience and the occurrence of complications, we divided each surgeon's experience into his first 20 procedures (initial interval) and his second 20 (experienced interval) to test whether the incidence of complications or operative time was different between the two intervals. Because the association between experience and the likelihood of a complication was estimated to be consistent between the two surgeons, the analysis was performed with data pooled from the two surgeons. To test whether there was a difference in the likelihood of a complication in the initial and the experienced intervals, a multivariate logistic regression analysis was performed and the adjusted risk of a complication between the two intervals was calculated. Linear regression analyses were used to test the association between surgeon level of experience and operative time. RESULTS: The overall incidence of major (Grade III or Grade IV) complications was 6% (95% confidence interval [CI], 2%-14%). These included deep infection (3% [three of 81]), intraoperative posterior column fracture (1% [one of 81]), and pulmonary embolism (1% [one of 81]). With the numbers available, the risk of a complication did not decrease with increasing surgeon experience. After controlling for body mass index and surgeon, the frequency of a complication did not decrease in the experienced interval relative to the initial interval (odds ratio, 0.78; 95% CI, 0.25-2.4; p = 0.6623). The adjusted risk difference between the experienced interval relative and the initial interval was 6% (95% CI, -11% to 23%). When experience was modeled as a continuous variable (number of PAOs performed), increasing experience was not associated with a lower likelihood of a complication (odds ratio per one PAO increase in experience, 0.99; 95% CI, 0.94-1.04; p = 0.5478). However, after adjusting for body mass index and surgeon, increased experience was associated with a reduction in operative time (slope [change in log operative time per one procedure increase in experience], -0.005; 95% CI, -0.009 to -0.0005; p = 0.0292). For every one additional PAO increase in experience, there was a 0.45% decrease in operative time (95% CI, 0.05%-0.86% decrease]. CONCLUSIONS: With a case exposure greater than 40 PAOs and progressive surgical responsibility during contemporary structured training, two young surgeons were able to perform PAO with a low risk of complications. However, even with that surgical experience before independent practice, surgical time decreased over the first 40 PAOs they performed independently. Our data may help guide orthopaedic residency and hip preservation fellowship programs in establishing training requirements and assessing competency in PAO. LEVEL OF EVIDENCE: Level III, therapeutic study.

Update in Pediatric Musculoskeletal Infections: When It Is, When It Isn't, and What to Do.

Musculoskeletal infections, including osteomyelitis, septic arthritis, and pyomyositis, are a substantial cause of morbidity in children and adolescents. The increased virulence of infectious agents and the increased prevalence of antimicrobial-resistant pathogens, particularly methicillin-resistant Staphylococcus aureus, have resulted in a more complicated clinical course for diagnosis and management, which is evidenced by an increased length of hospital stays, incidence of complications, and number of surgical interventions. Musculoskeletal infections are a challenge for surgeons because they vary substantially in their presentation and in their required treatment, which is based on the causative organism, the location of the infection, and the age of the patient. The necessity for a prompt diagnosis is complicated by several diseases that may mimic musculoskeletal infection, including transient synovitis, autoimmune arthritis, and tumors. Recent innovations in diagnosis and management have provided surgeons with new options to differentiate musculoskeletal infections from these rapidly evolving disease pathologies. As diagnostic and treatment modalities improve, collaboration among surgeons from multiple disciplines is required to develop evidence-based clinical practice guidelines that minimize the effect of musculoskeletal infection and optimize clinical outcomes for patients.

Skeletally Immature Anterior Cruciate Ligament Injuries: Controversies and Management.

At one time, anterior cruciate ligament (ACL) tears in skeletally immature patients were considered rare. The recommended treatment option for skeletally immature patients with ACL tears was to modify activities until skeletal maturity, at which point definitive ACL reconstruction could be safely performed. The management of ACL tears in skeletally immature patients has evolved as a result of the increased frequency of ACL tears in younger patients and an increased awareness for the potential development or worsening of meniscal tears, chondral lesions, and degenerative changes that occur with the "wait-and-fix-later" approach. The surgical options for ACL reconstruction in skeletally immature patients include physeal-sparing, partial transphyseal, and complete transphyseal techniques. The timing and ideal technique for ACL reconstruction in skeletally immature patients are controversial. Accurate assessment of skeletal growth remaining and concerns for iatrogenic growth disturbances continually challenge treating physicians. Similar controversies with regard to the treatment of skeletally immature patients who have partial ACL tears or congenital absence of the ACL also exist.

Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients.

PURPOSE: To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. METHODS: Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. RESULTS: Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. CONCLUSIONS: The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Can a Novel, Low-Cost Simulation Model be Used to Teach Anterior Cruciate Ligament Graft Preparation?

BACKGROUND: This study evaluated an anterior cruciate ligament (ACL) graft preparation simulation learning model for use by orthopaedic surgery trainees. METHODS: A simulation model for ACL graft preparation was constructed using shoelace as graft material and a wooden graft preparation board that matched the dimensions of existing products. A 12-minute instructional video targeted at novice learners was created to accompany the simulation model. A prospective randomized controlled trial was conducted on orthopaedic surgery residents divided into 2 groups with equal distributions of postgraduate year (PGY) status. The intervention group learned ACL graft preparation via the Shoelace ACL Simulation Guide, whereas a control group viewed a standard instructional video. All participants then prepared an 8-strand ACL graft using allograft materials and were evaluated via a checklist of critical steps and a global assessment rating as provided by an expert blinded to group allocation. Participants' preintervention and postintervention self-assessment scores were also collected. RESULTS: Ten orthopaedic surgery residents from a single institution participated in the study, with even distributions across study groups of PGY-1, PGY-3, and PGY-4 residents. Preintervention self-assessments of knowledge and technical ability were similar between participant groups. The mean overall performance score was significantly greater in the shoelace simulation intervention group (22.6±1.5) than in the instructional video only control group (16.0±5.1) (P=0.043). Participants in the intervention group showed greater improvement in self-confidence in their technical ability than those in the control group (P=0.012). Groups demonstrated similar postintervention improvements in self-reported knowledge of ACL graft preparation (P=0.128). All participants who learned via the Shoelace ACL Simulation Guide strongly agreed that they would use the learning tool to prepare for ACL reconstruction surgery. CONCLUSIONS: A self-directed low-cost simulation model for soft tissue ACL graft preparation utilizing shoelaces resulted in improved performance metrics compared with standard video instruction. The teaching model may be incorporated easily and inexpensively into simulation curricula at other training programs. LEVEL OF EVIDENCE: Level II-therapeutic study.

Differentiating Shoulder Pathology from Cervical Spine Pathology: An Algorithmic Approach.

Accurate and timely diagnosis of musculoskeletal conditions is an essential component of high-quality orthopaedic care. The proximity of the shoulder to the cervical spine leads to a multitude of pathologic conditions whose clinical presentations overlap, posing a diagnostic challenge to orthopaedic providers. Missed or delayed diagnosis of the etiology for patient-described 'shoulder pain' causes frustration among patients, incurs increased healthcare costs, and delays treatment. Moreover, patients with concurrent conditions of the cervical spine and shoulder require deliberate consideration for how each condition contributes to patients' symptoms. The purpose of this review was to describe a systematic approach for evaluating and differentiating pathologies of the shoulder and cervical spine.

Symptomatic Coracoid Fracture Nonunion Treated with Arthroscopic Reduction and Suture Anchor Fixation: A Case Report.

CASE: A 15-year-old female rock climber presented with a traumatic coracoid process fracture of her dominant upper extremity that failed extensive nonoperative treatment. She was treated successfully by arthroscopic reduction and suture anchor fixation. CONCLUSION: A novel surgical technique for coracoid fracture that combines arthroscopic reduction with suture anchor fixation can result in expeditious and durable clinical improvement in a young, high-demand athlete.

Hip Arthroscopic Surgery With Chondrolabral Refixation, Osteochondroplasty, and Routine Capsular Closure for Femoroacetabular Impingement Syndrome: Clinical Outcomes at a Minimum 10-Year Follow-up.

BACKGROUND: Hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) has proven to be an effective surgical intervention, with high rates of return to sport and work as well as favorable outcomes at short- and midterm follow-up. However, limited data exist on outcomes at long-term follow-up. PURPOSE: To evaluate patient-reported outcomes (PROs) at a minimum 10-year follow-up after primary hip arthroscopic surgery including labral repair, femoral osteochondroplasty, acetabular osteochondroplasty, and capsular closure for FAIS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent primary hip arthroscopic surgery for FAIS between June 2012 and January 2013 were identified. PROs were collected preoperatively and at a minimum of 10 years postoperatively, including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain and satisfaction. Unique minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds were calculated, and their rates of achievement were analyzed. An alpha level of <.05 was used to determine statistical significance. RESULTS: A total of 94 patients (55 female; mean age, 34.3 ± 12.4 years) were analyzed with a mean follow-up of 10.1 ± 0.3 years (range, 10.0-10.7 years). Patients demonstrated significant 10-year improvement across all PRO measures (P < .001). MCID and PASS thresholds were calculated as follows: HOS-ADL (10.4 and 85.3, respectively), HOS-SS (14.6 and 60.2, respectively), mHHS (8.8 and 76.0, respectively), VAS pain (14.6 and 27.5, respectively), and iHOT-12 (PASS: 71.4). The majority of patients achieved the MCID and PASS for each PRO measure: HOS-ADL (73.4% and 70.9%, respectively), HOS-SS (78.5% and 77.2%, respectively), mHHS (81.0% and 70.9%, respectively), VAS pain (88.6% and 70.9%, respectively), and iHOT-12 (PASS: 73.4%). Overall, 9 patients (9.6%) underwent subsequent revision hip arthroscopic surgery at a mean 4.9 ± 3.7 years (range, 1.1-10.1 years) postoperatively, and 6 patients (6.4%) underwent conversion to total hip arthroplasty at a mean 4.1 ± 3.1 years (range, 0.9-9.3 years) postoperatively. CONCLUSION: Patients who underwent primary hip arthroscopic surgery for FAIS utilizing contemporary methods of labral repair, acetabular and/or femoral osteochondroplasty, and capsular closure commonly experienced sustained clinical improvement and reported high levels of satisfaction at a minimum 10-year follow-up with low rates of reoperation.

Association Between Proximal Hamstring Tear Characteristics and Achievement of Clinically Significant Outcomes After Endoscopic and Open Repair at Minimum 2-Year Follow-up.

BACKGROUND: The effect of preoperative tear characteristics and the relative efficacy of open versus endoscopic surgical techniques have not been elucidated for the surgical treatment of proximal hamstring tendon injuries. PURPOSE: (1) To report on achievement rates of clinically significant outcomes at a minimum 2-year follow-up for multiple patient-reported outcomes (PROs) after surgical treatment of proximal hamstring injuries, stratified according to severity of proximal hamstring injury, and (2) to compare clinical outcomes associated with endoscopic versus open surgical repair for a subset of similarly classified tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A single-surgeon clinical registry was queried for patients who underwent surgical repair for proximal hamstring ruptures between January 2012 and March 2021. Injuries were classified by magnetic resonance imaging as follows: grade 1, incomplete tear with the involvement of 1 or 2 tendons; grade 2, complete tear with the involvement of 3 tendons and ≤2-cm retraction; and grade 3, complete tear with the involvement of 3 tendons and >2-cm retraction. The Patient Acceptable Symptom State (PASS) for multiple PROs was calculated and compared among injury grades and between surgical techniques. RESULTS: Among 75 patients with a mean follow-up of 30.5 ± 5.1 months, 20 had grade 1 tears, 24 had grade 2 tears, and 31 had grade 3 tears. Favorable 2-year postoperative PROs were demonstrated by each grade for all measured PROs. Patients with grade 3 tears were noted to have significantly lower rates of 2-year PASS achievement for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Specific (HOS-SS) scales (P≤ .032). Among grade 2 tears, patients treated endoscopically demonstrated significantly greater HOS-SS (endoscopic, 91.7%; open, 58.3%; P = .045) and Patient-Reported Outcomes Measurement Information System for Physical Function (endoscopic, 80.0%; open, 50.0%; P = .033) PASS achievement rates compared with those treated with the open technique. Complication rates were highest in patients with grade 3 tears (45.2%, P = .043). CONCLUSION: Surgical repair of proximal hamstring tendon tears with varying extents of tendon retraction resulted in high rates of achieving PASS at the 2-year follow-up. Among complete tears with <2 cm of retraction, endoscopic repairs exhibited equal or higher rates of achieving PASS compared with open repairs across multiple PROs at 2 years postoperatively. However, patients with complete tears and retraction >2 cm achieved lower rates of PASS on the HOS-ADL and HOS-SS scales and had a higher rate of complications.

Short-Term Outcomes of Concomitant Patellofemoral Arthroplasty and Medial Patellofemoral Ligament Reconstruction to Treat Concurrent Patellofemoral Arthritis and Patellar Instability.

The purpose of this study was to evaluate the efficacy of combined patellofemoral arthroplasty (PFA) and medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral arthritis in the setting of concomitant patellar instability. Patients who underwent single-stage, combined PFA and MPFL reconstruction by a single surgeon at a tertiary-care orthopaedic center between 2016 and 2021 were identified. Postoperative radiographic and clinical outcomes at a minimum of 6 months were recorded using patient-reported outcome measures, including International Knee Documentation Committee (IKDC), Kujala, and VR-12. Early complications and rates of recurrent instability were also recorded. Of the 16 patients who met inclusion and exclusion criteria, 13 patients were available for final follow-up (81%; 51.7 ± 7.2 years, 11 females, 2 males) with a mean clinical follow-up of 1.3 ± 0.5 years (range: 0.5-2.3 years). Patients experienced significant improvements in patellar tilt and multiple patient-reported outcome metrics postoperatively, including IKDC, Kujala, VR-12 Mental Health, and VR-12 Physical Health. At the time of the most recent follow-up, no patient had experienced a postoperative dislocation or subluxation event. The findings suggest that concurrent PFA and MPFL reconstruction are associated with significant improvements in multiple patient-reported outcomes. Further studies are needed to evaluate the duration of clinical benefits achieved with this combined intervention.

Medial Meniscus Posterior Root Tears Lead to Changes in Joint Contact Mechanics at Low Flexion Angles During Simulated Gait.

BACKGROUND: Previous biomechanical studies evaluating medial meniscus posterior root tears (MMPRTs) are limited to low loads applied at specified loading angles, which cannot capture the effects of MMPRTs during the multidirectional forces and moments placed across the knee during physiological activities. PURPOSE: To quantify the effects of MMPRTs on knee joint contact mechanics during simulated gait. STUDY DESIGN: Controlled laboratory study. METHODS: Six human cadaveric knees were mounted on a robotic simulator programmed to apply dynamic forces, moments, and flexion angles to mimic level walking. Twelve cycles of multidirectional and dynamic standard gait input waveforms, normalized to specimen-specific body weight, were applied to the following conditions: (1) native, intact meniscus and (2) MMPRT. Peak contact stress, contact area, and the position of the weighted center of contact across the medial tibial plateau throughout the stance phase of gait were quantified using an electronic sensor placed across the medial tibial plateau. The difference between the intact state and MMPRT condition was calculated for each metric, and then the means and 95% CIs were computed. RESULTS: Despite heterogeneity in knee contact forces, MMPRTs significantly increased peak contact stress by a mean of 2 MPa across 20% to 37% of the simulated gait cycle and significantly decreased the contact area by a mean of 200 mm2 across 16% to 60% of the simulated gait cycle in comparison with the native state. There was no significant difference in the position of the weighted center of contact, in either the anterior-posterior or medial-lateral directions, after MMPRT. CONCLUSION: MMPRTs led to both a significant increase in peak contact stress and decreased contact areas for a portion of the simulated gait cycle ranging from 20% to 37% of gait, during which time the femur was flexed <15°. CLINICAL RELEVANCE: Contact mechanics are significantly affected after MMPRTs during early to midstance and at knee flexion angles lower than demonstrated previously. These data provide further biomechanical justification for treating MMPRTs.