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Background: While often used, Hilgenreiner’s line may not always be a reliable reference plane following triple innominate pelvic osteotomy or trauma to the triradiate cartilage. The inferior sacral-iliac line is a horizontal line connecting the sclerotic corners of the inferior sacral-iliac joints. This is a consistent landmark in the ossifying infant pelvis as well as the fully developed adult pelvis. The goal of this study was to determine if there is a difference in measurements between the inferior sacral-iliac line and Hilgenreiner’s line in order to identify an alternative horizontal reference plane.Methods: 3 reviewers (fellowship-trained paediatric orthopaedic surgeon, junior orthopaedic resident, senior orthopaedic resident) reviewed 100 paediatric non-osteotomized pelvises. The difference between Hilgenreiner’s line and the inferior sacral-iliac line were measured and reported. Measurements were repeated a minimum of 48 hours apart, resulting in 600 comparisons between Hilgenreiner’s line and the inferior sacral-iliac line. The standard error of measurement was calculated to assess the variation in measurements between each individual observer and the group as a whole.Results: The mean standard error of measurement between Hilgenreiner’s line and the inferior sacral-iliac line was 0.44° (95% CI, ± 0.86). Reviewers 1–3 demonstrated a mean standard error of measurement of 0.38, 0.28, and 0.35 (95% CI, ± 0.74, 0.55, and 0.86) respectively. There was no statistically significant difference between reviewers (p> 0.05). Intra-observer reliability for reviewers 1, 2, and 3 was 0.64 (0.47–0.76), 0.75 (0.63–0.83), and 0.54 (0.32–0.69) respectively, with an inter-observer reliability of 0.42 (0.20–0.60) degrees.Conclusions: In this proof-of-concept study, the inferior sacral-iliac line was found to be an appropriate alternative to Hilgenreiner’s line that is easily identifiable for all levels of orthopaedic training. Future inferior sacral-iliac line studies should demonstrate the reliability of multiple acetabular measurements, both pre- and post-osteotomy.

Introduction: Perioperative multimodal protocols following total joint replacements have significantly decreased the amount of perioperative and postoperative opioids. Further identification of those requiring more or less opioids through individualisation, may further aid in reducing the amount prescribed. Therefore, the purpose of the study was to evaluate whether a patient’s grit, the measurable psychological strength of character to persevere during hardship, measured by postoperative opioid consumption.Methods: Consecutive patients who had undergone either primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) from February 2019 to August 2020 at our institution logged their opioid use for the first 2 weeks postoperatively, detailing the type, dosage, and number of narcotics they consumed. Those who completed their logs and a grit questionnaire had their average morphine equivalent dose (MED) and grit score calculated. Analysis was then performed to evaluate if any association existed between these 2 variables.Results: There was no correlation between grit score and postoperative opioid consumption in the first 2 weeks following discharge after total joint arthroplasty. A total of 144 patients were eligible to participate and a total of 86 patients met inclusion criteria, 48 patients in the TKA group and 38 in the THA group. Of all patients, 63% were male. The average MED was 95.5 for THAs and 192 for TKAs. The average grit score was 4.23 for THAs and 4.19 for TKAs.Conclusions: There is not an apparent association between grit score and postoperative opioid consumption in the first 2 weeks after total joint arthroplasty. General psychological resiliency may not be an important predictor of postoperative opioid use with modern postoperative protocols.

Background: The results of open hip abductor tendon repair remains poorly defined. We sought to present the results and complications of this procedure using modern suture anchor fixation.Materials and Methods: Our prospective institutional hip preservation registry was queried for all patients who underwent open hip abductor tendon repair with minimum 2-year follow-up were identified. Demographic, clinical, intraoperative, and functional outcome details were recorded. Patient-reported outcome scores (PROs) including the modified Harris Hip Score (mHHS), HOS-ADL, HOS-S, and iHOT-33 were collected for the preoperative and final postoperative state. Risk factors for lower final mHHS and change in mHHS were analysed using a multiple regression model.Results: A total of 21 patients with mean 48 months clinical follow-up (range 24–84 months). Median mHHS improved from 49.50 preoperatively to 82.50 postoperatively (p< 0.001), median HOS-ADL improved from 60.29 to 82.35 (p= 0.001), median HOS-S improved from 37.50 to 60.00 (p= 0.04), and median iHOT-33 improved from 29.81 to 70.15 (p= 0.001). All patients had +4 or +5 hip abductor strength at final in-person examination at mean 17 months postoperatively. All patients with a preoperative Trendelenburg gait had complete resolution at final examination. There 2 complications, and no patient had re-tear or revision surgery. LCEA < 25° and a history of prior ipsilateral hip surgery were independently predictive of smaller improvement in mHHS at final follow-up.Conclusions: Open abductor tendon repair is a safe and effective procedure that provides sustained symptomatic and functional improvements at mid-term follow-up.

Previous studies have shown relatively high rates of inappropriate referrals to pediatric orthopedic surgery. The purpose of this study was to determine the rate of inappropriate referrals in an egalitarian healthcare system. We reviewed all 400 referrals to our pediatric orthopedic surgery practice over a 2-year period and assessed the appropriateness of each based on the American Academy of Pediatrics guidelines. A total 206 (52%) referrals were deemed appropriate. There is a high rate of inappropriate referral to pediatric orthopedic surgery even within a closed, egalitarian healthcare system. Targeted education of primary care providers may help reduce this rate.

Hip abductor tears are increasingly recognized as a common source of lateral hip pain. Primary repair has generally shown excellent results. However, where repair is not possible or advanced muscle atrophy is present, few reconstructive options are available. Here we present the technique and results of a simplified method for transfer of the gluteus maximus tendon to the greater trochanter. Patients undergoing gluteus maximus tendon transfer were identified from our institution hip preservation registry. Electronic health records, imaging, and clinical examination findings were recorded for each patient and analyzed. Preoperative and postoperative patient-reported outcome scores were also collected for each patient including the modified Harris Hip Score (mHHS), Hip Outcome Score-Activity of Daily Living Scale (HOS-ADL), Hip Outcome Score-Sports Scale (HOS-S), and the International Hip Outcome Tool (iHOT-33). Six patients met inclusion criteria. All patients exhibited a Trendelenburg gait before surgery, and mean hip abduction strength preoperatively was 3.8/5. At final clinical follow-up, all patients had 5/5 hip abduction strength on manual muscle testing. No patient experienced a surgical complication. Three of the 6 patients had complete resolution of their Trendelenburg gait. At mean 3.8 years follow-up, mean improvement in HOS-ADL was 16.91, HOS-Sport=24.71, mHHS=18.42, and iHOT-33=42.74.

The effect of dedicated resident research time in terms of residency program research productivity remains largely unknown. We hypothesize that the quantity and quality of a residency program’s peer-reviewed publications (PRPs) increase proportionately with the amount of dedicated research time given to residents.

ObjectivesLisfranc injuries are relatively uncommon midfoot injuries disproportionately affecting young, active males. Previous studies in civilian populations have reported relatively good results with operative treatment. However, treatment results have not been specifically examined in military personnel, who may have higher physical demands than the general population. The purpose of this study was to examine rates of return to military duty following surgical treatment of isolated Lisfranc injuries.MethodsSurgical records and radiographic images from all active duty US military personnel treated for an isolated Lisfranc injury between January 2005 and July 2014 were examined. Demographic information, injury data, surgical details and subsequent return to duty information were recorded. The primary outcome was ability to return to unrestricted military duty following treatment. The secondary outcome was secondary conversion to a midfoot arthrodesis following initial open reduction internal fixation.ResultsTwenty-one patients meeting inclusion criteria were identified. Median patient age was 23 years, and mean follow-up was 43 months. Within this cohort, 14 patients were able to return to military service, while seven required a disability separation from the armed forces. Of the 18 patients who underwent initial fixation, eight were subsequently revised to midfoot arthrodesis for persistent pain.DiscussionMilitary personnel sustaining Lisfranc injuries have high rates of persistent pain and disability, even after optimal initial surgical treatment. Military surgeons should counsel patients on the career-threatening nature of this condition and high rates of secondary procedures.

Orthopedic trauma remains one of the most survivable battlefield injuries seen in modern conflicts. Translating research into practice is a critical bridge that permits surgeons to further optimize medical outcomes. Orthopedic surgeons serving in the military may treat little to no trauma in their stateside practice. In conflict zones, however, the majority of their patients will have traumatic injuries. Determining risk factors for nonevidence-based practice can help identify provider knowledge gaps, which can then be targeted before deployment. Surveys were developed which sought to identify factors contributing to continued medical education and practice, as well as scenario-based questions on military-relevant orthopedic trauma. Analysis of 188 survey respondents revealed that providers with military service and less than 10 years of practice are optimally bridging research into military-relevant orthopedic trauma practice.

Calcaneus fractures typically occur as a consequence of axial load. In the civilian population, this is most often because of motor vehicle accidents or falls from height. Early management of these injuries in the military population largely mirrored that of civilian surgeons. However, calcaneus fractures secondary to underfoot blasts became a significant source of morbidity and mortality in World War II. First described in the aftermath of large-scale naval battles between metal-deck ships, this "deck-slap" phenomenon is associated with high rates of concomitant injuries, infection, and amputation. We review the historical and contemporary management of calcaneus fractures by military orthopedic surgeons, as well as detailing the unique challenges faced in managing the soft-tissue component and associated injuries commonly observed in this population. Combat-related calcaneus fractures are associated with very high rates of concomitant injuries and extensive soft-tissue wounds. Despite significant research and technological advances, functional outcomes following these devastating injuries have remained unsatisfying.