The Boyd approach: a valuable alternative to treating simple to complex elbow fractures and dislocations.

BACKGROUND: The Boyd approach is a single-incision posterior approach to the proximal radius and ulna based on a lateral anconeus muscle reflection and release of the lateral collateral ligamentous complex. This approach remains a lesser-used technique following early reports of proximal radioulnar synostosis and postoperative elbow instability. Although limited by small case series, recent literature does not support these early reported complications. This study presents a single surgeon's outcomes using the Boyd approach for the treatment of simple to complex elbow injuries. METHODS: Following institutional review board approval, a retrospective review of all patients with simple to complex elbow injuries treated consecutively using a Boyd approach by a shoulder and elbow surgeon was conducted from 2016 to 2020. All patients with at least 1 postoperative clinic visit were included. Data collected included patient demographics, injury description, postoperative complications, elbow range of motion, and radiographic findings including heterotopic ossification and proximal radioulnar synostosis. Categorical and continuous variables were reported using descriptive statistics. RESULTS: A total of 44 patients were included with an average age of 49 years (range 13-82 years). The most commonly treated injuries were Monteggia fracture-dislocations (32%) and terrible triad injuries (18%). Average follow-up was 8 months (range 1-24 months). Final average elbow active arc of motion was from 20° (range 0°-70°) of extension to 124° (range 75°-150°) of flexion. Final supination and pronation were 53° (range 0°-80°) and 66° (range 0°-90°), respectively. There were no cases of proximal radioulnar synostosis. Heterotopic ossification contributing to less than functional elbow range of motion occurred in 2 (5%) patients who elected conservative management. There was 1 (2%) case of early postoperative posterolateral instability due to repair failure of injured ligaments that required revision using a ligament augmentation procedure. Five (11%) patients experienced postoperative neuropathy, including 4 (9%) with ulnar neuropathy. Of these, 1 underwent ulnar nerve transposition, 2 were improving, and 1 had persistent symptoms at final follow-up. CONCLUSIONS: This is the largest case series available demonstrating the safe utilization of the Boyd approach for the treatment of simple to complex elbow injuries. Postoperative complications including synostosis and elbow instability may not be as common as previously understood.

Preoperative Patient-Recorded Outcome Measures Predict Patient Discharge Location Following Unicondylar Knee Arthroplasty.

BACKGROUND: Advantages of unicondylar knee arthroplasty (UKA) over total knee arthroplasty include rapid recovery and shorter lengths of stay following surgery. Patients requiring extended postoperative care fail to recognize these benefits. Patient-reported outcome measures have proved useful in predicting outcomes following joint arthroplasty. The purpose of this study was to identify and report preoperative patient-reported outcome measures and clinical variables that predict discharge to skilled nursing facilities following UKA. METHODS: A prospective cohort of 174 patients was used to collect 36-Item Short Form scores and objective clinical data. Univariate and multivariate analysis with backward elimination were conducted to find a predictive risk model. RESULTS: The predictive model reported (78.7% concordance, receiver operating characteristic curve c-statistic 0.719, P = .0016) demonstrates that risk factors for discharge to skilled nursing facilities are: older age (odds ratio 4.18; 95% confidence interval [CI] 1.256-13.911, P = .019), bilateral UKA procedures (odds ratio 1.887; 95% CI 1.054-3.378, P = .0326) and lower patient-reported preoperative 36-Item Short Form physical function scores (odds ratio 0.968; CI 0.938-1, P = .0488). CONCLUSION: The information presented here regarding possible patient disposition following UKA could aid informed decision-making regarding patients' short-term needs following surgery and help streamline preoperative planning.

Republication of "Ankle Fracture-Dislocations: A Review".

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.

Effect of Fibular Malrotation on Tibiotalar Joint Contact Mechanics in a Weber B Ankle Fracture Model.

BACKGROUND: In minimally displaced Weber B ankle fractures, the distal fibular fracture fragment can be externally rotated. This malrotation is difficult to detect on radiographs and, when left malreduced through nonoperative treatment, may contribute to altered joint mechanics, predisposing to posttraumatic osteoarthritis. This study evaluates the effects of fibular malrotation on tibiotalar joint contact mechanics. METHODS: Six cadaveric ankles were tested using a materials testing system (MTS) machine. A tibiotalar joint sensor recorded contact area and pressure. Samples were tested in the intact, neutrally rotated, and malrotated state. Each trial applied a 686N axial load and a 147N Achilles tendon load in neutral position, 15° dorsiflexion, and 15° plantarflexion. RESULTS: In the comparison of malrotated to intact ankles, peak contact pressure was found to be significantly greater at neutral flexion (intact 5.56 MPa ± 1.39, malrotated 7.21 MPa ± 1.07, P = .03), not significantly different in dorsiflexion, and significantly decreased in plantarflexion (intact 11.2 MPa ± 3.04, malrotated 9.01 MPa ± 1.84, P = .01). Significant differences in contact area were not found between conditions. CONCLUSION: The findings suggest that fibular malrotation contributes to significant alterations in tibiotalar joint contact pressures, which may contribute to the development of posttraumatic osteoarthritis. When malrotation of the fibula is suspected on plain radiographs, a computer tomography (CT) scan should be obtained to evaluate its extent and further consideration should be given to surgical treatment. LEVELS OF EVIDENCE: Level V: Bench testing.

Trends in Utilization and Perioperative Outcomes in Robotic-assisted Bariatric surgery using the MBSAQIP database: A 4-Year Analysis.

PURPOSE: Robotic-assisted surgery has become increasingly popular across surgical subspecialties. We aimed to analyze trends in the national utilization and outcomes in bariatric surgery. MATERIALS AND METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®) data for 2015-2018 was queried. We included robotic-assisted sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), adjustable gastric band (AGB), biliopancreatic diversion with duodenal switch (BPD-DS), and revisional cases. The Kruskal-Wallis test or Wilcoxon rank-sum were used for comparing continuous variables and Cochran-Armitage trend analysis for categorical variables when comparing years, or with Fisher's Exact Test when directly comparing categories. RESULTS: Of 760,076 bariatric cases performed between 2015 and 2018, 7.4% with robotic and 90.4% with laparoscopic approach. SG constituted 61.3% of robotic volume. Utilization of robotic surgery increased 1.96-fold; SG represented the most substantial increase of 2.16-fold, followed by a 1.53-fold in RYGB. The 30-day readmission and re-intervention rates decreased from 5.63% to 4.78% (p<0.01), and 2.31% to 1.46% (p<0.01), respectively. The overall leak rate improved from 0.64% to 0.39% (p=0.01). Mortality and re-operations remained statistically unchanged. When compared to laparoscopic approach, the operative time were significantly longer in the robotic group. Regarding postoperative outcomes, when adjusted for patient characteristics, there were no differences between two approaches except a higher leak rate in robotic group in 2015. CONCLUSION: A steady increase in robotic bariatric surgery is apparent. While the operative time remains significantly longer in the robotic group, trends indicate improvement in key quality metrics and patient outcomes as utilization increases.

Anterior Percutaneous-Assisted Total Hip Arthroplasty: Surgical Technique and Early Outcomes.

BACKGROUND: Percutaneous-assisted arthroplasty was introduced to minimize complications traditionally associated with minimally invasive techniques, such as component malposition and periprosthetic fracture. Proponents of percutaneous-assisted techniques have more than 15 years of clinical utilization with good outcomes. This study reports our early experience, and outcomes, with an anterior percutaneous-assisted total hip arthroplasty (AnteriorPath). METHODS: A retrospective evaluation of a single-surgeon experience with the first 46 patients undergoing AnteriorPath using a cannula for acetabular cup instrumentation was compared with a similar-sized cohort undergoing traditional direct anterior (DA) total hip arthroplasty. Patients needed at least 2 postoperative visits for inclusion. Baseline preoperative characteristics, operative time, component positioning, and 6-week all-cause complications were evaluated. P values <.05 were considered statistically significant. RESULTS: Longer operative times were experienced with the AnteriorPath vs DA THA (93.6 minutes ± 38.6 vs 79.6 minutes ± 23.2, respectively, P = .0503). There were no significant differences in component abduction (40.14° DA vs 41.95° AnteriorPath, P = .1058). A statistically significant difference was found in component anteversion (32.8° DA vs 27.25° AnteriorPath, P = .0039). There were higher rates of short-term complications in patients undergoing DA THA (9.09% DA vs 2.5% AnteriorPath). CONCLUSIONS: Early experience with an AnteriorPath demonstrates similar short-term outcomes compared with traditional DA THA. The use of a percutaneous technique has also allowed for a smaller incision, in-line acetabular cup reaming and impaction under direct visualization, and limited trauma to surrounding soft tissues. Further long-term studies with a larger sample size are needed to evaluate the potential benefits and complications of this novel technique.