Level II.

Background The aims of this study were to evaluate the associated injuries occurring with acute perilunate instability and to assess the clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with a combined dorsal and volar approach. Methods A total of 45 patients (46 wrist injuries) with perilunate dislocations and fracture-dislocations were prospectively evaluated. The size of the mid-carpal ligament tear, the location of the scapholunate ligament tear, and the presence of osteochondral fragments and of the dorsal radiocarpal ligament avulsions were recorded at injury. Final clinical and radiographic outcomes were evaluated in 25 cases (25 wrists) with a minimum of 6 months of follow-up. Results Intraoperative examination of the 46 cases with operative treatment showed the volar carpal ligament tear to be present 100 % of the time and to be an average length of 3.4 cm. Complete avulsion of the dorsal extrinsic radiocarpal ligaments was found in 65.2 % of cases. The scapholunate ligament was torn in 35 cases. Osteochondral fragments were found either volarly or dorsally in 74 % of the cases. The average flexion-extension arc was 82°, forearm rotation was 155°, and grip strength averaged 59 % of the uninjured hand. The average final scapholunate angle was 55°and the scapholunate gap was 2.2 mm. Conclusion Treatment of perilunate fracture-dislocations with a combined volar and dorsal approach results in reasonable and functional clinical results. The incidence of associated injuries with these carpal dislocations is high. Although the perilunate fracture-dislocations have a slightly better radiologic alignment than the dislocation group, the clinical outcome is similar.

The noninvasive expandable prosthesis is used for limb-salvage surgery following tumor resection in skeletally immature patients. The purpose of this retrospective study is to report our experience with the Repiphysis (Wright Medical Technology, Inc; Arlington, Tennessee) noninvasive expandable prosthesis for both the lower extremity and compassionate use in the upper extremity in 12 patients between 2003 and 2008. Twelve prostheses were implanted in 12 patients with an average follow-up of 38 months (range, 12-78 months). Nine patients underwent a total of 38 expansion procedures. Mean total expansion was 4.5 cm (range, 0.8-9.9 cm). No complications of lengthening occurred. Seven nononcologic complications were noted. One infection was reported in 12 patients. The mean MSTS score after rehabilitation was 24.5 (range, 13-30). The Repiphysis noninvasive prosthesis provides acceptable functional outcomes for both upper and lower extremity implantation and appears to have an advantage as compared to conventional expandable prosthetics, which require open procedures that can potentially increase the risk of infection from repeated hardware exposure.

OBJECTIVEPosterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS.METHODSA retrospective review was performed of patients aged 10–18 years with AIS who were treated with PSF from 2014 to 2017 at a single children’s healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression.RESULTSA total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate.CONCLUSIONSThere appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.

Introduction:Orthopaedic surgery resident case exposure is an important component of surgical training and is monitored by the Accreditation Council for Graduate Medical Education (ACGME) to ensure resident readiness for graduation. The purpose of this study was to investigate trends in exposure to adult orthopaedic surgical procedures and analyze the impact of the 2013 update in ACGME case logging expectations.Methods:A retrospective review of ACGME case log data was conducted for adult orthopaedic procedures performed by graduating orthopaedic surgery residents from 2012 to 2020. Trends in the number of cases logged and the case share by anatomical location were investigated. Linear regression analysis was performed to analyze changes in case number over the 9-year period.Results:For all surgical categories, there was stability in the average case number per resident from 2012 to 2013, followed by a precipitous decrease from 2013 to 2014. From 2014 to 2020, there has been a gradual increase in case number for all categories except “other musculoskeletal (MSK),” resulting in a total 46% recovery since the 2014 decline. Concomitant with the decline, there was a relative increase in pelvis/hip and femur/knee procedures and decrease in shoulder, other MSK, and spine procedures. From 2014 to 2020, shoulder, humerus/elbow, pelvis/hip, leg/ankle, foot/toes, and spine cases have gradually accounted for a larger proportion of total cases while femur/knee and “other MSK” cases have accounted for less.Conclusions:The 2013 update in ACGME case logging expectations was associated with a significant decrease in case number. This is likely a reflection of residents correctly entering 1 primary Current Procedural Terminology code for each surgical case. Programs should be aware of a general increase in case number since 2014 and acknowledge the fact that some procedure types may be given priority from a logging standpoint when multiple Current Procedural Terminology codes apply.

Bucket-handle meniscal tears are extremely rare injuries in the pediatric population. Given the known sequelae of meniscal tears and the development of osteoarthritis, early diagnosis and treatment of pediatric meniscal tears are essential. The communication barrier between physicians and pediatric patients, however, creates difficulties in making the correct diagnosis of meniscal pathology. Providers should have a low threshold for obtaining further confirmatory advanced imaging if patients present with prolonged knee pain and swelling, with associated locking mechanical symptoms. Good clinical outcomes following meniscal repair have been observed, likely a result of the increased residual vascularity found within pediatric menisci. The youngest reported case of an isolated traumatic bucket-handle medial meniscal tear is examined in this article. A 2-year-old girl presented with right knee pain after a heavy object fell onto the knee several weeks earlier. On examination, the patient walked with a limp but lacked full range of active knee motion. The McMurray test elicited pain without a mechanical or palpable click. After the patient continued to exhibit limitations following conservative management, magnetic resonance imaging of the right knee was obtained, which showed a bucket-handle tear of the right medial meniscus. The patient subsequently underwent meniscal repair and, on recovery, was able to regain normal functioning of the right knee without limitations. [Orthopedics. 2018; 41(4):e580-e582.].

Background: Unstable slipped capital femoral epiphysis (SCFE) may lead to avascular necrosis (AVN) in up to 60% of patients. The aim of this study was to assess the best clinical evidence to determine the effect of capsular decompression (CD) on odds of AVN in unstable SCFE. Methods: Medline, Embase, and Cochrane databases were systematically searched for comparative studies investigating AVN rates in unstable SCFE treated with or without CD (aspiration, percutaneous, or open). Quality was evaluated by the Newcastle Ottawa Scale. A comparative analysis with pooled effect estimates using random-effects modeling was calculated. Secondary analysis pooled AVN rates from both comparative studies and case series. Results: Comparative analysis included 17 retrospective studies with 453 hips (201 with CD, 252 without CD). Thirty-four of 201 (17%) hips with CD developed AVN, while 67 of 252 (27%) hips without CD developed AVN. The odds of AVN for patients treated with or without CD [odds ratio=0.80, 95% confidence interval (CI): 0.48-1.35] was not statistically different. Subanalysis on patients treated with in situ pinning or positional reduction and pinning showed no difference in AVN rates with or without CD (odds ratio=0.97, 95% CI: 0.44-2.10). In the secondary analysis of 17 comparative studies and 23 case series, the average rate of AVN was 17%, 0.17 (95% CI: 0.13-0.23) for patients treated with CD (60/447 hips) and 28%, 0.28 (95% CI: 0.22-0.35) for patients treated without CD (129/464 hips). Conclusions: There was no statistically significant decrease in odds of AVN with CD. However, studies were limited by their retrospective nature and inadequate documentation of CD techniques; the majority lacked femoral head blood flow monitoring to demonstrate adequate decompression. Future prospective studies with carefully documented complete decompression may help to elucidate the effect of CD on AVN risk. Although there was no statistically different odds of AVN with or without CD, even this large meta-analysis was underpowered, and one cannot conclude that there was truly no difference in odds of AVN without an appropriately powered study. Therefore, we recommend routine CD for all unstable SCFEs pending additional research, as CD adds little to the surgical procedure and may minimize the risk of a devastating insult to the femoral head.

Introduction: Given the relative rarity of tibial tubercle fractures and the high proportion that undergo surgical treatment, there is little data on non-operative management of these injuries. Some patients that are initially treated non-surgically may ultimately require operative intervention. The purpose of this study was to identify risk factors for failed non-operative management of tibial tubercle fractures. Methods: This retrospective comparative study included patients younger than 18 years that underwent initial non-operative treatment of a tibial tubercle fracture at six tertiary children’s hospitals. Those that underwent primary surgical intervention were excluded. Demographic, radiographic, and clinical data were reviewed. Conversion to surgical fixation was considered a failure of non-operative treatment. Univariable analysis was followed by multivariate regression to adjust for confounders. Results: A total of 136 patients were included, of which 19.1% failed non-operative treatment and subsequently underwent surgery. The median age of patients that ultimately required surgery was 14.0 y [IQR (interquartile range) 2.5 y] compared to 12.0 y (IQR 2.0 y) for those that were successfully managed without surgery. Non-operative treatment failed in 7.8% of Ogden type I fractures, 66.7% of type II, 81.8% of type III, 35.7% of type IV, and 7.1% of type V (p<0.001). After adjusting for confounders, including weight and initial weight-bearing status, each year of increasing age raised the odds of failure by 1.9 (95% CI 1.2-3.0, p=0.006). Additionally, Ogden type II fractures had 23.4 times higher odds than type I (95% CI 2.1-260.8, p=0.01). Ogden type III fractures had 36.3 times higher odds of failing non-operative treatment than type I (95% CI 4.2-315.4, p=0.001). Conclusion: In this study of patients with a tibial tubercle fracture initially treated non-operatively, 19.1% ultimately underwent surgery. Increasing age and Ogden type II and III fracture classification were associated with failure of non-operative management. These results may help guide decision-making regarding surgical versus non-surgical treatment. Significance: There is little data on non-operative treatment of tibial tubercle fractures. This study identifies risk factors for failure of non-operative treatment and may aid clinical decision-making.