Percent articular exposure of the distal humerus with triceps fascial tongue approach compared with olecranon osteotomy.

BACKGROUND: Distal humerus fractures are common and can be difficult to treat. No one approach to the distal humerus has been shown to be superior to another; however, the olecranon osteotomy remains the gold standard for complex, intra-articular fractures. Understanding the percent of articular exposure with approaches to the distal humerus is important for success. The goal of this study is to show the percent of articular exposure of the triceps fascial tongue approach as compared with the olecranon osteotomy. METHODS: Twelve fresh frozen cadavers were separated randomly into 2 groups of 6 each. The first group of 6 specimens was allocated to the triceps fascial tongue approaches with the collaterals maintained and with the collaterals released off the ulna and elbow dislocated. The second group of 6 was allocated to the triceps fascial tongue approach while maintaining the collaterals followed by an olecranon osteotomy. The articular exposure was marked after performing each approach, and the percent of articular exposure was quantified by using 3D scanning. Standard deviations were calculated for each. RESULTS: The average percent visualization of the distal humerus articular surface in the fascial tongue approach while maintaining the collaterals was 36% in the first cohort and 37% in the second cohort with a standard deviation of 5% in both cohorts. The average percent of the distal humerus articular surface exposed in the fascial tongue approach with the collaterals released off the ulna and elbow dislocated was 85.09% with a standard deviation of 4%. The average percent of the distal humerus articular surface exposed in the olecranon osteotomy group was 57.9% with a standard deviation of 5%. CONCLUSION: The triceps fascial tongue approach allows for visualization of about one-third of the joint, which may be adequate for many intra-articular distal humerus fractures. For added exposure of the articular surface, the collaterals may be elevated from the ulna and the elbow dislocated allowing for a substantial increase in percent of articular exposure compared with the collateral retaining fascial tongue approach and the olecranon osteotomy.

Arthroscopic Treatment of Hip Pain in Adolescent Patients With Borderline Dysplasia of the Hip: Minimum 2-Year Follow-Up.

PURPOSE: To examine arthroscopic treatment of hip pain in patients with borderline hip dysplasia (lateral center edge angle [LCEA] between 20° and 25°). METHODS: From 2008 to 2013, patients below 18 years of age who underwent arthroscopic hip surgery with an LCEA between 20° and 25° were retrospectively matched 1:1 to a control group without dysplasia (LCEA ≥25°) based on age, gender, femoroplasty, labral treatment, and capsular plication. Indications for surgery included failure to improve with nonoperative treatments and anti-inflammatory medications after 3 months. Patient-reported outcome data were collected using modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale. RESULTS: From 2008 to 2013, 168 patients below the age of 18 underwent arthroscopic hip surgery. Twenty-one patients met inclusion criteria and were matched 1:1 to a control group. Follow-up was achieved for 17 patients in both groups (81%). Mean follow-up time, age, and LCEA were 2.19 years, 15.5 years, and 22.3° for the dysplastic group and 2.16 years, 16.0 years, and 31.2° for the control group, respectively. Preoperative patient-reported outcomes between groups were not statistically different. At the latest follow-up, both groups showed statistically significant improvement over baseline in modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale (P < .001). Latest follow-up scores were not statistically different between groups. CONCLUSIONS: This study shows favorable 2-year outcomes in adolescent patients with borderline dysplasia undergoing labral treatment and capsular plication. Outcomes in the borderline dysplastic patients were as good as those of a control group. Although adolescents with borderline dysplasia have traditionally been a challenging group of patients to treat, these results suggest that an arthroscopic approach that addresses both labral pathology and instability may be beneficial. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Survey mode influence on patient-reported outcome scores in orthopaedic surgery: telephone results may be positively biased.

PURPOSE: Patient-reported outcome (PRO) scores are used to evaluate treatment modalities in orthopaedic surgery. The method of PRO collection may introduce bias to reported surgical outcomes due to the presence of an interviewer. This study evaluates post-operative PROs for variation of outcomes between survey methods-in-person, online, or telephone. METHODS: From 2008 to 2011, 456 patients underwent arthroscopic surgical treatment for acetabular labral tears. All pre-operative surveys were completed in the clinic during pre-operative visit. Two-year follow-up questionnaires were completed by 385 (84 %) patients. The PRO data were prospectively collected pre- and post-operatively using five tools: modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADLS), Hip Outcome Score Sports-Specific Subscale (HOS-SSS), Non-Arthritic Hip Score (NAHS), and visual analog scale. Patients were grouped according to method of 2-year follow-up: in-person during follow-up visit (102 patients, 26 %), online by email prompt (138 patients, 36 %), or telephone with an interviewer (145 patients, 38 %). RESULTS: Pre-operative baseline PRO scores demonstrated no statistically significant difference between groups for mHHS, HOS-ADLS, HOS-SSS, and NAHS. Two-year post-operative PRO scores obtained by telephone were statistically greater than scores obtained in-person or online for mHHS (p < 0.001), HOS-ADLS (p < 0.001), and HOS-SSS (p < 0.01). CONCLUSION: This study demonstrates higher patient-reported outcome scores and greater improvement by telephone surveys compared to in-person or online. The variation of results between collection methods is indicative of a confounding variable. Clinically, it is important to understand these confounding variables in order to assess patient responses and guide treatment. LEVEL OF EVIDENCE: IV.

Outcomes of Revision Hip Arthroscopy: 2-Year Clinical Follow-up.

PURPOSE: To evaluate clinical outcomes, pain, and patient satisfaction following revision hip arthroscopy with a minimum 2-year follow-up. METHODS: From April 2008 to October 2011, data were prospectively collected on all patients undergoing revision hip arthroscopy. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures: the modified Harris hip score (mHHS), nonarthritic hip score (NAHS), hip outcome score-activities of daily living (HOS-ADL), and hip outcome score-sport-specific subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. The number of patients who underwent subsequent revision arthroscopy or total hip arthroplasty during the study period is also reported. RESULTS: Eighty-seven patients underwent revision hip arthroscopy during the study period. Seventy (80.5%) patients were included in our study. Average follow-up time was 28 months (range, 20 to 47.4 months). In terms of residual femoroacetabular impingement morphology, 45.7% of patients had preoperative alpha angles ≥ 55°, and 7.14% of patients had a lateral center-edge angle ≥ 40°. The score improvement from preoperative to 2-year follow-up was 57.84 to 73.65 for mHHS, 62.79 to 83.04 for HOS-ADL, 37.33 to 54.93 for HOS-SSS, and 55.65 to 70.79 for NAHS. VAS decreased from 6.72 to 4.08. All scores demonstrated statistically significant improvement (P < .001). Overall patient satisfaction was 7.67. Our success rate was 74.58%. Ten (14.29%) patients underwent total hip arthroplasty during the study period. Our hip survivorship was 85.7%. Five (7.14%) patients underwent secondary revision hip arthroscopy during the study period. We found an overall minor complication rate of 10%. CONCLUSIONS: Revision hip arthroscopy for all procedures performed on aggregate has improved clinical outcomes for all PROs, high survivorship, and high patient satisfaction scores at short-term follow-up. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty and the potential for revision surgery. LEVEL OF EVIDENCE: Level IV retrospective case series.

Acetabular Labral Base Repair Versus Circumferential Suture Repair: A Matched-Paired Comparison of Clinical Outcomes.

PURPOSE: To determine whether an acetabular labral repair technique would be superior to another repair technique based on clinical outcomes measured by patient-reported outcome (PRO) scores. METHODS: We identified 465 patients who underwent labral base repair or circumferential suture repair from February 2008 to February 2012. The type of repair performed was based on labral size and tear type. The 2 groups were pair matched for age within 5 years, sex, crossover sign within 15%, coxa profunda, Workers' Compensation status, and microfracture (femur, acetabulum, or none). Data were prospectively collected and retrospectively reviewed. PROs included a visual analog scale score and the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living, and Hip Outcome Score-Sports-Specific Subscale. RESULTS: One hundred ten patients met the inclusion criteria for labral base repair and were pair matched on a 1:1 basis with 110 patients who underwent circumferential suture repair. The mean follow-up period was 30 months for both groups, with a range of 19.2 to 60 months for the labral base repair group and 19.2 to 67 months for the circumferential suture repair group. Radiographic data were similar between groups with respect to the lateral center-edge angle (P = .906), acetabular inclination (P = .329), anterior center-edge angle (P = .208), alpha angle (P = .387), and joint space width (P = .388). All preoperative PRO scores were statistically similar. Both groups showed significant improvements in all PROs. There were no statistical differences in postoperative PRO scores at latest follow-up (modified Harris Hip Score, P = .215; Hip Outcome Score-Activities of Daily Living, P = .839; Hip Outcome Score-Sports-Specific Subscale, P = .561; Non-Arthritic Hip Score, P = .333; visual analog scale score, P = .373; and satisfaction, P = .483). There were similar rates of revision (n = 10 for both groups) and conversion to arthroplasty (n = 2 for both groups). CONCLUSIONS: On the basis of PRO scores at 2 years' follow-up, there is no difference in outcomes based on the type of labral repair performed. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical results of hip arthroscopy for labral tears: a comparison between intraoperative platelet-rich plasma and bupivacaine injection.

PURPOSE: The purpose of this prospective comparative study was to evaluate the effect of intraoperative platelet-rich plasma (PRP) injection on the outcomes of patients undergoing hip arthroscopy for labral treatment. METHODS: During the period from November 2010 through March 2012, all patients undergoing hip arthroscopy for labral tears were considered for this study. The study group received intra-articular PRP at the end of the operation, and the control group received an intra-articular injection of 0.25% bupivacaine. Selection for the study group was based on the day of the week on which the patient underwent surgery. The protocol included administration of 4 hip-specific patient-reported outcome tools. Patients also reported their pain score on a visual analog scale from 0 to 10. Scores were recorded at the preoperative visit and at 3 months and 2 years postoperatively. RESULTS: A minimum of 2 years' follow-up was available for 306 patients. Thirteen patients (4.2%) underwent conversion to total hip arthroplasty and 24 patients (7.8%) underwent revision hip arthroscopy, which left 91 patients in the study group and 180 patients in the control group. The study group had slightly higher pain scores than the control group (3.4 v 2.5) 2 years after surgery (P = .005). No difference in pain scores was identified at 3 months postoperatively. The 2-year modified Harris Hip Score was slightly lower in the study group (78.6) than in the control group (82.6) (P = .049). No significant difference was observed for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, or Non-Arthritic Hip Score at any time point. There was no significant difference between groups for conversion to total hip arthroplasty or revision surgery. CONCLUSIONS: On the basis of the results of this study, intraoperative PRP injection does not appear to improve the clinical results of patients undergoing hip arthroscopy for labral treatment. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Labral injury: radiographic predictors at the time of hip arthroscopy.

PURPOSE: The purpose of this study was to investigate the influence of multiple demographic and radiographic findings on the size of labral tears identified at the time of hip arthroscopy. METHODS: Data were prospectively collected for patients treated with arthroscopic labral repair or debridement from February 2008 to August 2011. Preoperative radiographic and demographic data were collected for 392 patients during the study period. Exclusion criteria included revision surgery and previous hip conditions. An anteroposterior pelvic view, 45° Dunn view, and false-profile view were used to measure Tönnis grade, neck-shaft angle, alpha angle, lateral center edge angle (LCEA), anterior center edge angle (ACEA), acetabular inclination, and the extent of crossover sign when present. At the time of surgery, labral tear size and location were documented for all patients, using traditional acetabular clock face nomenclature for sizing. A multiple linear regression analysis was then performed to assess the correlation of radiographic and demographic findings with the size of the labral tear. RESULTS: Regression analysis displayed statistical significance for sex (P < .0001), age (P < .0001), and alpha angle (P = .005) with labral tear size. For female patients, Tönnis grade (P = .0004) and neck-shaft angle (P = .004) correlated with labral tear size. This model accounted for only 26% of variation in labral tear size. CONCLUSIONS: Preoperative risk factors for the extent of labral tear size are male sex, increasing age, and increasing alpha angle. Labral tears were larger in female patients with higher Tönnis grades and lower neck-shaft angles. Measurements of acetabular coverage and version showed no correlation with labral tear size. The majority of labral tear size variation was not accounted for in this model. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy.

PURPOSE: To detail our early experience using concomitant hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of acetabular dysplasia. METHODS: We prospectively collected and retrospectively reviewed the surgical and outcome data of 17 patients who underwent concomitant hip arthroscopy and PAO between October 2010 and July 2013. Preoperative and postoperative range of motion, outcome and pain scores, and radiographic data were collected. Intraoperative arthroscopic findings and postoperative complications were recorded. RESULTS: The group consisted of 3 male and 14 female patients with a mean follow-up period of 2.4 years. Three patients had undergone previous surgery on the affected hip. Chondrolabral pathology was identified in all 17 patients. Twelve patients underwent labral repair, and five patients underwent partial labral debridement. No patient was converted to total hip arthroplasty or required revision surgery at short-term follow-up. All 4 patient-reported outcome scores showed statistically significant changes from baseline to latest follow-up (P < .001). An excellent outcome was obtained in 82% of patients (13 of 16). The lateral center-edge angle averaged 11° preoperatively and 29° postoperatively. The acetabular inclination averaged 18° preoperatively and 3° postoperatively. The anterior center-edge angle averaged 7° preoperatively and 27° postoperatively. At most recent radiographic follow-up, 1 patient had progression of arthritic changes but remained asymptomatic. No other patient showed any radiographic evidence of progression of arthritis. Complications included 3 superficial wound infections, 1 pulmonary embolism, and 1 temporary sciatic neurapraxia. CONCLUSIONS: Our initial experience with concomitant hip arthroscopy and PAO has been favorable. We noted that all our patients have evidence of chondrolabral damage at the time of PAO when the joint is distracted and evaluated. All patients in this series had intra-articular pathology treated arthroscopically and showed satisfactory mean clinical improvement. Hip arthroscopy with PAO did not appear to introduce complications beyond the PAO alone. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Treatment of Labral Tears in Patients Aged 60 Years or Older.

PURPOSE: The purpose of this study was to (1) evaluate the clinical outcomes of a series of patients aged 60 years or older who underwent hip arthroscopy for labral tears with minimum 2-year follow-up and (2) identify risk factors for conversion to total hip arthroplasty (THA). METHODS: Outcome data were prospectively collected and retrospectively reviewed in patients aged 60 years or older who underwent hip arthroscopy between April 2008 and May 2012. Four patient-reported outcome (PRO) scores, pain scores, and satisfaction ratings were collected. Conversion to THA and revision surgery rates were recorded. A subgroup analysis compared survivors with patients requiring THA. RESULTS: Minimum 2-year follow-up was available for 30 patients with a mean age of 63.9 years. The 2-year survivorship rate was 70%, with 9 patients undergoing conversion to THA at a mean of 1.1 years after hip arthroscopy. Two patients required additional surgery during the study period, for a reoperation rate of 37% (11 of 30 patients). The remaining cohort showed mean improvements in all PRO scores. All scores, except the sports-related PRO (P = .12), improved significantly from the preoperative baseline scores. Visual analog scale scores for pain decreased from a mean of 5.0 preoperatively to 2.7 postoperatively (P = .003). Patients who required conversion to THA had lower preoperative modified Harris Hip Scores (P = .015), lower preoperative Hip Outcome Score-Activity of Daily Living values (P = .01), higher pain scores (P = .05), greater acetabular inclination (P = .023), and more severe chondral damage (P = .033). CONCLUSIONS: Arthroscopic treatment of labral tears in patients aged 60 years or older should be approached with caution. Patients in this age group had an overall 2-year survivorship rate of 70% and should be counseled before surgery on the possibility of subsequent conversion to THA. Patients aged 60 years or older with poor preoperative PRO scores, high pain scores, radiographic evidence of borderline dysplasia, and severe chondral damage may be poor candidates for hip arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The learning curve associated with robotic-assisted total hip arthroplasty.

There are no reports examining the learning curve during the adoption of robotic assisted THA. The purpose of this study was to examine the learning curve of robotic assisted THA as measured by component position, operative time, and complications. The first 105 robotic-assisted THAs performed by a single surgeon were divided into three groups based on the order of surgery. Component position, operative time, intra-operative technical problems, and intra-operative complications were recorded. There was a decreased risk of acetabular component malpositioning with experience (P<0.05). Operative time appeared to decrease with increasing surgical experience (P<0.05). A learning curve was observed, as a decreased incidence of acetabular component outliers and decreased operative time were noted with increased experience.

Does Robotic-Assisted Computer Navigation Affect Acetabular Cup Positioning in Total Hip Arthroplasty in the Obese Patient? A Comparison Study.

Obese populations present challenges for acetabular cup placement during total hip arthroplasty (THA). This study examines the accuracy of acetabular cup inclination and version in the obese patient with robotic-assisted computer navigation. A total of 105 patients underwent robotic-assisted computer navigation THA with a posterior approach. Groups were divided on body mass index (BMI, kg/m(2)) of <30, 30-35, and >35. There was no statistical difference between the BMI <30 (n=59), BMI 30-35 (n=34) and BMI >35 (n=12) groups for acetabular inclination (P=0.43) or version (P=0.95). Robotic-assisted computer navigation provided accurate and reproducible placement of the acetabular cup within safe zones for inclination and version in the obese patient.

The effect of liposomal bupivacaine injection during total hip arthroplasty: a controlled cohort study.

BACKGROUND: Multimodal analgesia following total hip arthroplasty has been shown to improve patient satisfaction, participation with physical therapy, and allow early return to self care. Liposomal bupivacaine is a formulation of local anesthetic which has the potential to provide anesthesia for up to 72 hours following administration. The purpose of this study was to compare the effectiveness of liposomal bupivacaine with bupivacaine following total hip arthroplasty. METHODS: A retrospective chart review was performed on 28 patients undergoing total hip arthroplasty or hip resurfacing who received intraoperative administration of liposomal bupivacaine. A control group of 30 patients who had previously undergone total hip arthroplasty or hip resurfacing and had received intraoperative administration of bupivacaine also underwent a chart review. Length of stay, post-operative opioid use, and pain scores were compared for both groups. RESULTS: The average length of stay in the study group was 1.93 days and the control group length of stay was 2.47 days (p ≤ 0.05). Morphine equivalent use was less in the study group during the first 24 hours compared to the control group (p ≤0.05). During the second and third 24 hours the morphine equivalent use difference was not statistically significant. Visual analogue scores were not significantly different between groups at any time point. CONCLUSION: Liposomal bupivacaine administration during total hip arthroplasty appears to decrease the need for opioid use post operatively and decrease length of stay. The results of this study justify the need for a well-designed randomized controlled trial utilizing liposomal bupivacaine as part of multimodal analgesia during THA.

Safety measures in hip arthroscopy and their efficacy in minimizing complications: a systematic review of the evidence.

PURPOSE: The purpose of this systematic review was to evaluate the literature to determine complications of hip arthroscopy, with a secondary focus on how to minimize complications and risks. METHODS: Two independent reviewers performed a search of PubMed for articles that contained at least 1 of the following terms: complications and hip arthroscopy, hip impingement, femoral acetabular impingement and complications, or femoroacetabular impingement (FAI) and complications. The search was limited to articles published between 1999 and June 2013. An additional search was performed for articles evaluating techniques on how to minimize complications. RESULTS: We identified 81 studies (5,535 patients; 6,277 hips). The mean age was 35.48 years, and the mean body mass index was 25.20 kg/m(2). Of the participants, 52% were male and 48% were female. The majority of studies were Level IV Evidence (63%). A total of 285 complications were reported, for an overall rate of 4.5%. There were 26 major complications (0.41%) and a 4.1% minor complication rate. The overall reoperation rate was 4.03%. A total of 94 hips underwent revision arthroscopy. Regarding open procedures, 150 patients (93%) underwent either total hip arthroplasty or a hip resurfacing procedure. The conversion rate to total hip arthroplasty or a resurfacing procedure was 2.4%. CONCLUSIONS: Overall, primary hip arthroscopy is a successful procedure with low rates of major (0.41%) and minor (4.1%) complications. The reoperation rate was 4.03% in our review. There is admittedly a learning curve to performing hip arthroscopy, and we present a systematic review of the complications and how to minimize these complications with careful technique and planning. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to V studies.

The hip-spine syndrome: how does back pain impact the indications and outcomes of hip arthroscopy?

PURPOSE: Many patients presenting with hip disease also have coexisting lumbar spine disease (LSD). At present there is a paucity of literature examining the effect of arthroscopic hip surgery in patients with coexisting LSD. The purpose of this systematic review was to examine the relationship between the hip and lumbar spine to determine whether low back pain impacts the indications and outcomes for surgical intervention of the hip. METHODS: A systematic review of the literature was performed by a search of PubMed using the following search terms: (1) hip, back, and motion; (2) hip, back, and pain; and (3) hip, lumbar spine, and pain. Two reviewers searched for relevant articles that met established inclusion criteria. We excluded review articles, technique articles, articles reporting on the same patient population, and articles without reported patient data. Kinematic data pertaining to the hip for patients with low back pain was collected. Preoperative and postoperative data were collected for patients treated for hip disease in the setting of LSD. RESULTS: After examining 2,020 references and abstracts, 15 articles were selected for this review. Patients with low back pain consistently demonstrated decreased hip range of motion compared with controls. Patients undergoing hip surgery with coexisting LSD showed improvement in the modified Harris Hip Score (mHHS), Harris Hip Score (HHS), Visual Analog Scale (VAS), SF-36 scores, and the Owestry Disability Index. CONCLUSIONS: Patients with low back pain frequently have limited or altered hip range of motion, and these patients routinely improve after surgical intervention for hip disease. Surgical intervention for hip disease should be considered in the context of low back pain and LSD. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

The 3D-Printed Custom Elbow Prosthesis for Salvage Treatment of Complex Intra-Articular Distal Humerus Fracture Malunion.

Intra-articular fractures of the distal humerus are complex injuries that often require surgery with the goal of restoring elbow range-of-motion and function. Open reduction and internal fixation has been the preferred surgical modality; however, restoration of the medial and/or lateral columns can be complicated in fractures involving a major loss of the articular surface and bony structure. Over the past decade, 3-dimensional (3D) printing has made significant advances in the field of orthopedic surgery, specifically in guiding surgeon preoperative planning. Recently, the incorporation of 3D-printing has proven to provide a safe and reliable construct for the restoration of anatomy in complex trauma cases. We present a 47-year-old woman who sustained a complex, intra-articular distal humerus fracture with associated shearing of the capitellum that went onto malunion. Patient was treated with a patient-specific 3D-printed custom elbow prosthesis with excellent outcomes. Our goal was to shed light on the use of 3D-printing technology as a viable salvage option in treating complex, intra-articular distal humeral fractures associated with lateral condylar damage that subsequently went onto malunion.

Swan Neck Deformity: An Unusual Complication Following Trigger Finger Release.

Introduction: Swan neck deformity (SND) is a common pathologic finding often observed in patients with severe rheumatoid arthritis. However, it has also been seen in injuries such as mallet finger, flexor digitorum superficialis laceration, and intrinsic contracture. Open surgical release of a trigger finger most commonly involves the release of the A1 pulley to relieve a mechanical impingement. Bowstringing is a rare trigger finger release complication caused by excessive pulley resection, usually due to resection of the A2 pulley. As a result of this complication, the flexor tendons move away from their center of rotation, gaining an increased mechanical advantage over the extensors and can ultimately result in a SND. Case Report: We present a case report of a 61-year-old patient that presented to our clinic with a SND of the 4th digit following a trigger finger release. Conclusion: Our case demonstrated that a previous trigger finger release with disruption of the A2 pulley can cause a cascade of events that can result in SND.

Chronic Volar Distal Radial Ulnar Joint Dislocation: A Case Report with Proposed Treatment Algorithm.

CASE: We report the case of a 34-year-old woman with a chronic right volar dislocation of the distal radioulnar joint (DRUJ) and associated ulnar styloid fracture. The patient presented 1 month after a dog bite injury with wrist pain and limited range of motion, and radiographs demonstrated volar DRUJ dislocation. Closed reduction was unsuccessful, and thus, open reduction was performed. CONCLUSION: Isolated volar DRUJ dislocations in the absence of fractures are easy to misdiagnose on plain radiographs. We present our surgical technique and fixation algorithm for open reduction and stabilization for chronic volar DRUJ dislocations.

Biomechanical Analysis of Ideal Knee Flexion Angle for ACL Graft Tensioning Utilizing Multiple Femoral and Tibial Tunnel Locations.

Anterior cruciate ligament (ACL) graft failure rate has been reported to be greater than 5% at 5 years. Our study evaluated ACL excursion with anatomic and nonanatomic femoral and tibial tunnels to determine optimal flexion angle to tension the ACL to minimize excursion. Ten cadaveric knee specimens were used. The ACL was sectioned and the femoral and tibial attachments were marked. A 1/16-inch drill created a tunnel in the center of the ACL footprint on the tibia and femur and additional tunnels were made 5 mm from this. A suture was passed through each tunnel combination and attached to a string potentiometer. The knee was ranged from full extension to 120 degrees of flexion for 10 cycles while mounted in a custom fixture. The change in length (excursion) of the suture during movement was recorded for each combination of femoral and tibial tunnels. Anatomic reconstruction of the ACL with tunnel placement in the center of the femoral and tibial footprint did not result in an isometric graft, with excursion of the ACL during knee motion of 7.46 mm (standard deviation [SD]: 2.7mm), greatest at 2.84 degrees of flexion (SD: 4.22). The tunnel combination that resulted in the least excursion was a femoral footprint 5 mm anterior to the femoral and 5 mm posterior to the tibial footprint (4. 2mm, SD: 1.37 mm). The tunnel combination that resulted in the most excursion utilized femoral footprint 5 mm proximal to the femoral and 5 mm posterior to the tibial footprint (9.81 mm, SD: 2.68 mm). Anatomic ACL reconstruction results in significant excursion of the ACL throughout motion. If not tensioned properly, the ACL can stretch during range of motion, potentially leading to rerupture. To prevent stretching of the graft, the current biomechanical study recommends tensioning an anatomic ACL reconstruction at its point of maximal excursion, or between 0 and 5 degrees of flexion. The level of evidence is IV.

"Safe dissection parameters of the anconeus rotational flap for soft tissue coverage at the elbow".

Background: The anconeus is a small muscle located on the posterior elbow originating on the lateral epicondyle and inserting onto the proximal-lateral ulna that functions as an elbow extensor as well as dynamic stabilizer. The blood supply is tri-fold: medial/middle collateral artery (MCA), recurrent posterior interosseous artery (RPIA), and less commonly found, the posterior branch of the radial collateral artery. The anconeus has become a popular option for local soft tissue coverage about the elbow (distal triceps, olecranon, proximal forearm). The average defect size for consideration of local anconeus flap coverage is 5-7cm2. The aim of the study was to determine safe dissection parameters of the anconeus as well as map arterial pedicles to achieve successful local harvest of the muscle without devascularization. Materials and Methods: 8 fresh frozen cadaveric arms (all male, average age 63 years - 4 left arms, 4 right arms) from scapula to fingertip were obtained. First, the radial, ulnar and axillary arteries were dissected and isolated. The radial and ulnar arteries were transected. 100cc normal saline was injected through the axillary artery, sequentially clamping the radial followed by the ulnar artery so that adequate flow could be seen through all vessels. 100cc mixture of Biodür and hardener (10:1) was mixed and injected into the axillary artery. We first allowed free flow through both the ulnar and radial vessels followed by clamping of these vessels. This allowed the pressure to build up and fill the smaller vessels in the arms. After injection, the axillary artery was then clamped and the specimens were left to harden for 24-48 h. After hardening, dissection was performed by making a curvilinear incision centred over the lateral epicondyle. The anconeus was identified and the interval between the anconeus and ECU was then confirmed. Measurements of the anconeus muscle were taken. Blunt dissection was carried between anconeus and ECU until the RPIA was identified and protected. We isolated the MCA by dissecting proximally. This was found to run with the nerve to the anconeus. Once this vessel had been protected, the muscle reflected from distal to proximal staying along its ulnar border. The branches of the RPIA were ligated and the dissection was continued proximally. Measurements of the distances of the RPIA, MCA were taken. Results: The average distance of olecranon to muscle tip was 95.0mm. The average distance of lateral epicondyle (LE) to muscle tip was 90.8mm. The average distance of LE to olecranon was 49.8mm. The average location of the RPIA was 63.mm when measuring LE to vessel, 68.3mm when measuring olecranon to vessel, 18.3mm when measuring RPIA to muscle tip. The average RPIA diameter was 1.1mm and length was 36.4mm from the initial branching of the posterior interosseous artery. The average MCA diameter was 0.7mm. The posterior branch of the radial collateral artery was only found in 3/8 specimens. The RPIA and MCA were constant in all specimens. Dissection was safely carried to the border of the LE and olecranon without disruption of the MCA. CONCLUSIONS: Our conclusions determined that if dissection of the anconeus is undertaken, the RPIA remains constant between the interval of the ECU as well as anconeus at an average distance of 18.3mm from the tip of the muscle measuring proximally; moreover, the MCA was constant in all specimens found directly between the LE and olecranon always running with the nerve to the anconeus. When dissecting and mobilizing to ensure preservation of the MCA, dissection should be taken from distal to proximal as well as dissecting along the ulnar border of the anconeus. Proximal dissection can be taken as proximal as the border of the LE and olecranon as that did not disrupt MCA blood supply.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation.

PURPOSE OF REVIEW: Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population. RECENT FINDINGS: Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.