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Background Reverse total shoulder arthroplasty (RSA) primarily varies between 2 implant design options: a 135 humeral stem inclination that closely resembles anatomic orientation, versus the Grammont-style 155 humeral stem inclination that further medializes and distalizes the center of rotation (COR). The purpose of this study was to compare deltoid force, glenoid strain, and simulated glenohumeral range of motion (ROM) between RSA 135 and RSA 155 designs, with a series of standardized permutations of glenosphere offset and rotator cuff pathology. Methods Twelve fresh-frozen cadaveric shoulder specimens were studied using a shoulder simulator. Native shoulder motion profiles for reproducible abduction range of motion were established using a customized testing device. Optical 3-dimensional tracking and pressure sensors were used to accurately record glenohumeral range of motion (ROM), deltoid force, and glenoid strain for RSA 135 and RSA 155 designs. For each cohort, all combinations of glenosphere offsets and rotator cuff tendon involvement were evaluated. Results There was no significant difference in the overall abduction ROM between the 155 and the 135 humeral stem implants (P = .75). Resting abduction angle and maximum abduction angle were significantly greater with a 155 + STD (standard offset) construct than with a 135 + STD construct (P Conclusion Overall, range of motion between the 135 and the 155 humeral stem inclinations was not significantly different. The cumulative deltoid force was lower in RSA shoulders when compared to native shoulders with massive rotator cuff tears, highlighting the utility of both implant designs. The Grammont-style 155 stem coupled with a 2.5 mm inferior offset glenosphere required less deltoid force to reach maximum abduction than did the more anatomic, lateralized 135 stem coupled with a 4 mm lateral offset glenosphere. Level of Evidence Controlled Laboratory Study

Background and hypothesis The treatment of periprosthetic joint infection is complicated by the presence of residual biofilm, which resists eradication owing to bacterial adherence to orthopedic implants. The purpose of this study was to compare Bactisure (Zimmer Biomet, Warsaw, IN, USA), povidone-iodine (Betadine), and chlorhexidine gluconate solution (Irrisept; Irrimax, Gainesville, FL, USA) in reducing biofilm formation of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes inoculated on cobalt-chrome, titanium, and stainless steel disks, representing metals commonly used for shoulder arthroplasty. The hypothesis was that there would be no significant difference in biofilm reduction among the 3 topical adjuvants. Methods Strains of S aureus (ATCC 35556), S epidermidis (ATCC 35984), and C acnes (LMG 16711) were grown on cobalt-chrome, titanium, and stainless steel disks. For each strain, the disks were divided into 4 groups: (1) control, (2) povidone-iodine (Betadine), (3) chlorhexidine gluconate (Irrisept), and (4) Bactisure. Bacteria were grown on 5% sheep blood agar plates. Biofilm eradication was quantified using adenosine triphosphate bioluminescence and compared with controls 48 and 72 hours after implementation of the topical adjuvant. Results At 72 hours after implementation of the topical adjuvant, a statistically significant reduction in colony-forming units was observed for all topical adjuvants across all tested metals, as compared with their respective control. With respect to the topical adjuvants themselves, Bactisure more consistently demonstrated the most significant reduction in colony-forming units across all bacteria when the tested medium was adjusted for, with the exception of S aureus, which showed similar results to Betadine at 72 hours. Conclusion By use of commonly encountered topical adjuvants on S aureus–, S epidermidis–, and C acnes–inoculated disks of various implant metals, a significant reduction in biofilm production was observed. Bactisure, a recent Food and Drug Administration–approved topical adjuvant, demonstrated the overall greatest efficacy of the agents studied.

To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus (PLRT). A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts. 115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%; p

To determine the prevalence of clinically diagnosed femoroacetabular impingement (FAI) in a consecutive series of patients presenting with proximal hamstring tendon injury and to correlate this with pelvic anatomic factors.The prevalence of clinically symptomatic cam-, pincer-, and mixed-type and overall FAI was calculated among a consecutive series of patients presenting to a hip preservation clinic with a confirmed clinical and radiographic diagnosis of proximal hamstring tendon injury between 2012 and 2017. The presence of a cam lesion was determined by an alpha angle50° on radiographs and computed tomography radial sequences of the head-neck junction and a femoral head-neck offset ratio0.18. Clinical diagnoses of osseous impingement were determined according to accepted pathomorphologic signs and measurements. A diagnosis of FAI was confirmed by imaging findings of acetabular overcoverage for pincer-type FAI and the presence of an anterior or lateral cam lesion for cam-type FAI.Overall, 120 hips in 97 patients (mean age, 45 years) were included in this study. A clinical diagnosis of FAI was noted in 70.8% of hips (pincer-type 9.2%, cam-type 40.8%, mixed-type 20.8%), an approximate 2- to 7-fold increased prevalence in comparison with the general population from prior studies.The prevalence of FAI is high in patients with symptomatic proximal hamstring tendon pathology. Because FAI results in restriction of hip range of motion and altered pelvic tilt, future studies are warranted to investigate whether the presence of FAI acts as a predisposing factor for injury to the hamstring muscle complex.Level IV, case series.

The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) undergoing hip arthroscopy with capsular repair versus non-repair. A multicenter clinical trial was performed with 31 patients (49 hips) undergoing hip arthroscopy for treatment of FAI. A small- to moderate-sized interportal capsulotomy was performed. Each hip was randomized to capsular repair versus non-repair of the interportal capsulotomy. MRI was performed at 6 and 24 weeks postoperatively and was analyzed by two musculoskeletal radiologists. Patients and the radiologists were blinded to the treatment applied. Capsular defect size and capsule thickness were recorded on each scan. Mean patient age was 31.4 years. Capsular repair was performed in 23 (46.9%) hips. Mean capsulotomy length was 35 mm at Center X and 23 mm at Center Y. At 6 weeks postoperatively, a healed hip capsule (with no apparent capsulotomy defect) was observed in 10 (43.4%) hips that underwent capsular repair and 4 (15.4%) hips that did not undergo capsular repair (P = 0.13). At 24 weeks postoperatively, 25/30 hips (83.3%) achieved complete closure of the capsulotomy defect, with no significant difference between treatment groups. Repair of an interportal capsulotomy following hip arthroscopy for FAI results in a non-significantly higher percentage of healed hip capsules at 6 weeks postoperatively compared with leaving the capsule unrepaired, though the difference normalizes by 24-week follow-up. Repair of a small- to moderate-sized interportal capsulotomy does not provide a radiographic advantage following hip arthroscopy for FAI.

BACKGROUND The purpose of this study was to investigate the effects of femoral version, cam-type femoroacetabular impingement (FAI), and the combination of the 2 on the passive hip range of motion (ROM). METHODS We prospectively analyzed a consecutive cohort of 220 patients (440 hips) who presented with unilateral or bilateral hip pain. The passive hip ROM was measured bilaterally with the patient in prone, supine, and lateral positions. Femoral version was measured and the presence of cam-type deformity was determined on preoperative computed tomography (CT) scans. Diagnostic findings of cam-type FAI included an alpha angle of >50° on CT radial sequences of the head-neck junction and a femoral head-neck offset ratio of

The purpose of this study was to determine independent factors, including timing of fasciotomy, that confer an increased risk of post-operative surgical site infection (SSI) in patients presenting with acute compartment syndrome (ACS) of the lower extremity. A retrospective analysis was performed on a consecutive cohort of 53 adult patients requiring fasciotomy for lower-extremity fractures complicated by ACS presenting to a single Level I trauma center over a seven-year study period. The primary outcome measure was the incidence of SSI (as defined by the CDC) occurring within 12 months of fasciotomy. Explanatory variables including site of ACS, time of injury, time of fasciotomy, operative findings, and requirement for additional soft tissue coverage procedures were recorded for all patients. Multivariate regression was used to determine independent predictors of post-operative SSI. post-operative SSI was detected in 16 (30.2%) patients. Compared to infection-free patients, patients with post-operative SSI had a significantly higher median age (52.0 vs. 37.0 years, p = 0.010), frequency of intra-operative myonecrosis at time of fasciotomy (31.2% vs. 5.4%, p = 0.021), and requirement for negative-pressure wound therapy [NPWT] (93.7% vs. 45.9%, p = 0.002). Multivariate logistic regression analysis confirmed that requirement for NPWT (odds ratio [OR], 17.10; 95% confidence interval [CI], 1.78–164.0; p = 0.014) and increasing age (OR, 1.07; 95% CI, 1.01–1.14; p = 0.037) were independent predictors of post-operative SSI. Timing of fasciotomy following injury was not independently related to the risk of SSI. ACS occurs on a spectrum of disease severity that evolves variably over time. Increasing age of the patient and requirement for NPWT following fasciotomy are independent predictors of post-operative SSI following emergent fasciotomy for ACS. Further studies are required to inform optimal treatment strategies in such patients. Level of Evidence: Therapeutic, Level III.

Long bone posttraumatic osteomyelitis (PTOM) is a relatively common complication following surgical fixation of open fractures. There is a lacking consensus on ideal strategies for diagnostic evaluation of long bone PTOM. While open bone biopsy and culture is considered the ‘gold diagnostic standard,’ its cost and invasiveness are often prohibitive and have prompted the search for alternate diagnostic methods. To evaluate the sensitivity and specificity of various diagnostic modalities relative to open bone biopsy and culture for the detection of long bone PTOM. Retrospective cohort study; Level of Evidence, III. Urban Level I trauma center and safety-net institution. A consecutive cohort of 159 adult patients presenting with long bone PTOM at our Level I trauma center between January 1, 2004, and December 31, 2013, were retrospectively identified. All included patients fulfilled diagnostic criteria for PTOM (as defined by the Center for Disease Control and Prevention) that involved a long bone (femur, fibula, tibia, humerus, radius, and ulna). Patients with diabetic foot infection, septic arthritis, osteomyelitis of the spine/pelvis/hand, or insufficient medical records were excluded. Sensitivity and specificity of deep wound culture, soft tissue histopathologic examination, and elevated levels of acute phase reactants [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and leukocyte count (WBC)] were determined using findings of open bone biopsy and culture as a reference standard. The most common pathogen isolated on open bone culture was staphylococci, contributing to 89 (57%) of 159 cases of long bone PTOM (p

To evaluate short-term clinical and functional outcomes following operative treatment of long bone post-traumatic osteomyelitis (PTOM). We retrospectively analyzed a consecutive cohort of 142 adult patients undergoing operative treatment of long bone PTOM at our Level I trauma center over a 10-year study period. In addition to subjective patient evaluations, surveyed postoperative outcomes included incidence of residual infection, fracture malunion or nonunion, and requirement for limb amputation. All included patients had a minimum follow-up of 12 months postoperatively. Patients suffering an adverse postoperative outcome tended to have a higher incidence of polymicrobial infection (25.4 vs. 11.4%, p = 0.042) and requirement for skin grafting (58.1 vs. 37.9%, p = 0.024) and free-flap procedures (43.6 vs. 19.5%, p = 0.003) compared to those achieving complete healing. Sequential administration of parenteral and oral antibiotic therapies was associated with a reduced incidence of adverse postoperative outcome (p = 0.047). Patients with long bone PTOM and extensive soft tissue defects often fail to develop complete remission of their symptoms by 12 months postoperatively. Sequential administration of parenteral and oral antibiotics may help to limit infection recurrence. Further research is required to inform optimal treatment strategy.

To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus (PLRT).A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts.115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%; p 0.001, respectively). Additionally, logistic regression analysis demonstrated that patients with PLRT were 5.3 times more likely to have a LFNS as compared to those without a lateral root tear (p 0.001).In patients with ACL tears, the presence of a LFNS on preoperative MRI may be predictive for a PLRT. As the LFNS occurs in almost 40% of the patients with combined ACL tears and PLRT, the LFNS may be a useful secondary diagnostic finding in early MRI diagnostic. Identifying PLRT on MRI is clinically relevant, as it prevents misdiagnosis and facilitates surgical decision-making, thus avoiding subsequent delayed treatment.Level IV.

To investigate the correlation between femoroacetabular cartilage thickness and lateral acetabular coverage in patients undergoing hip arthroscopy for a variety of indications. Articular cartilage at the hip is hypothesized to undergo adaptive change secondary to unique patterns of pathomechanical loading which results in a direct relationship between acetabular coverage and femoroacetabular cartilage thickness. A cohort of 252 patients presenting to our dedicated hip preservation service between June 2013 and June 2015 were retrospectively analysed. Preoperative radiographs and MRI studies were obtained for all symptomatic hips and classified according to radiographic lateral center edge angle (LCEA) as follows: normal acetabular coverage (25–40°), acetabular overcoverage (≥40°), borderline dysplasia (20–24.9°) and frank dysplasia (

Background:Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction.Purpose:To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence.Study Design:Case series; Level of evidence, 4.Methods:We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression.Results:Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery ( P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction ( P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6).Conclusion:Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.

UNLABELLED The management of posttraumatic long bone osteomyelitis remains a challenging clinical problem. A systematic approach is necessary, beginning with eradication of the infected bone and soft tissue. There are a number of options for reconstruction of the remaining bone defect, including the induced membrane technique developed by Masquelet. We describe our technique for the 2-stage treatment of long bone osteomyelitis. The first stage involves a radical debridement, stabilization of the bone with either external fixation or an antibiotic-coated intramedullary nail, and placement of a polymethylmethacrylate spacer. The second stage includes excision of the spacer and placement of autologous bone graft. Various resection methods, fixation strategies, antibiotic additives, and types of bone grafts or substitutes can be used. The purpose of our technical article is to share our personal experience and describe several nuances that are critical for the success of this treatment strategy. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Few studies have examined the utility of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) compared to the traditional Gustilo-Anderson classification for prediction of treatment outcomes in patients with open fractures. QUESTIONS/OBJECTIVES:: (1) How do the Gustilo-Anderson classification and OTA-OFC systems compare in accuracy of predicting limb amputation, infection, and need for soft tissue coverage? (2) Is there an OTA-OFC summative threshold score that may guide the discussion and decision-making with regard to limb salvage or amputation? DESIGN Retrospective observational cohort study; Level IV evidence. SETTING Level I trauma center and urban safety-net institution. PATIENTS/PARTICIPANTS Consecutive adult patients with open long bone fractures who underwent operative treatment between January 1, 2007 and December 31, 2012. MAIN OUTCOME AND MEASUREMENTS Postoperative complications of infection, early limb amputation, and requirement for soft-tissue procedures. RESULTS The study cohort comprised 512 patients with mean age 49.6 ± 14.9 years. Nineteen patients (3.7%) underwent amputation. The Gustilo-Anderson classification demonstrated no correlations with any of the primary outcome measures, while OTA-OFC summative scores significantly varied between all outcome comparison groups. The skin injury component of the OTA-OFC was an independent predictor of limb amputation (OR, 5.44; 95% CI, 2.37-12.47), and an OTA-OFC summative score of ≥10 best correlated with need for amputation (P < 0.001). Sensitivity and specificity of the reported model were 79% and 94%, respectively. CONCLUSIONS Our results should be interpreted with caution due to the retrospective nature of our study. Based on our data, the OTA-OFC is superior to the Gustilo-Anderson classification system for prediction of postoperative complications and treatment outcomes in patients with open long bone fractures. A summative threshold score of 10 seems to identify increased odds of successful limb salvage.

Background Femoroacetabular impingement represents a common cause of hip pain in adolescents. The purpose of the present study was to evaluate the safety and efficacy of simultaneous bilateral hip arthroscopy for bilateral symptomatic femoroacetabular impingement in adolescent athletes. Methods Clinical data were collected in a prospective database on patients who underwent unilateral or simultaneous bilateral hip arthroscopy and included complications, reoperation rate, and return to play time. Differences in International Hip Outcome Tool (iHOT)-12 scores according to hip side and postoperative follow-up time (preoperative, 1.5, 3, 6, 12, and 24 mo) were evaluated using a 2×6 repeated-measures analysis of variance with post hoc repeated-measures 1-way analysis of variance and Bonferroni-corrected paired t tests. Results In total, 24 patients (36 hips) were studied, of whom 12 underwent simultaneous bilateral hip arthroscopy (24 hips) and a case-matched control group of 12 patients underwent unilateral hip arthroscopy. There were 5 males in each group (41.7%). Average age was 15.7 and 16.5 years in the bilateral and unilateral groups, respectively. No patients were lost to follow-up. In the bilateral group, a significant increase in mean iHOT-12 score was observed between 1.5- and 3-month follow-up (61.8 vs. 82.8, respectively; P=0.003), and 6-, 12-, and 24-month follow-up (91.4, 95.1, and 96.6, respectively, P=0.004). At all follow-up times, there were no significant differences in mean iHOT-12 scores or other outcome measures between bilateral and unilateral cohorts. Time to return to preinjury level of activity was similar between the bilateral and unilateral groups (4.7 vs. 4.9 mo, respectively; P=0.40). One transient lateral femoral cutaneous nerve palsy occurred in each group, though no other complications were documented. No patients required revision surgery by latest follow-up. Conclusions Bilateral simultaneous hip arthroscopy is safe and reproducible in adolescent athletes, achieving equivalent outcomes, and similar rehabilitation time when compared with unilateral surgery. Level of evidence Level II-therapeutic study.

Background: Bone marrow contusions are common after an acute anterior cruciate ligament (ACL) injury. It is unknown whether the severity of this initial bruise can predict the potential of developing chondral changes even after ACL reconstructive surgery (ACLR). Purpose: To investigate whether the initial bone bruise area could be predictive of progressive chondral defects. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review was performed to capture patients with an acute ACL injury with pre- and post-ACLR magnetic resonance imaging (MRI) between January 2000 and December 2017. Lesion areas were measured on initial MRI, and chondral wear was graded on final imaging by use of the modified Outerbridge classification. An ordinal model was created to determine whether the initial area was a significant predictor for future chondral degeneration. Results: A total of 40 patients with a mean age of 34.5 ± 12.6 years were included for analysis. All patients underwent ACLR at a mean 139 ± 64 days from initial injury. A lateral tibial and femoral bone bruise was most commonly present in patients (77.5% and 62.5%, respectively). A medial femoral bone bruise was found in only 12.5% (5/40) of patients. The initial contusion area significantly correlated with increasing chondral wear over time in the tibia and lateral femoral condyle ( P < .001). Patients with a bone bruise encompassing 100% of the lateral femoral compartment on MRI had a 74% chance of having grade 3 or 4 chondral changes at 5 years ( P = .001). Absence of a bone bruise on initial MRI was the greatest predictor of no cartilage wear at 5 years in all compartments ( P < .001). The presence of a concomitant lateral meniscal injury increased the risk of developing type 3 or 4 chondral wear in the lateral tibial plateau ( P = .012) but did not pose increased risk of femoral wear ( P = .23). Conclusion: A significant relationship between area of initial bone bruise at the time of injury and progressive posttraumatic chondral disease was found in the tibial and lateral femoral compartments.

OBJECTIVES To compare the strength of fixation of percutaneous screw versus plate/screw fixation in a paired cadaver model of OTA 41-B3 (Schatzker type II) split-depression fractures of the lateral tibial plateau. METHODS Six matched pairs of cadaveric knees were acquired. An OTA 41-B3 (Schatzker type II) split-depression fracture was created in all specimens using a standardized method. One specimen from each matched pair of knees was fixed with percutaneous screws, and the other was fixed with a plate/screw construct. All specimens underwent augmentation of the central metaphyseal defect with calcium phosphate. Mean residual displacement (depression) was measured on thin-slice high-resolution computed tomography using a standardized methodology following 3 experimental conditions: (1) after they were fixed, before loading; (2) unloaded cycling (simulating postoperative range of motion exercises); and (3) loaded cycling (simulating postoperative weight-bearing). Load to failure was also compared. RESULTS After adjustment for baseline measurements, there was no significant difference in mean residual depression of the lateral tibial plateau between treatments groups after unloaded or loaded cyclic testing. Mean residual depression was less than 1 mm in both the treatment groups. Load to failure was statistically equivalent between treatment groups. CONCLUSIONS In our cadaveric study, in combination with calcium phosphate augmentation for both methods, percutaneous screw fixation conferred comparable strength of fixation compared with plate/screw constructs for treatment of OTA 41-B3 (Schatzker type II) tibial plateau fractures.

Background: Orientation abnormalities of the acetabulum and femur have been implicated in early-onset coxarthrosis. The purpose of this study was to identify clinical examination findings predictive of such hip morphologies. Methods: A consecutive cohort of 221 patients (442 hips) undergoing hip arthroscopy was included. Demographic characteristics including age, diagnosis, sex, height, weight, body mass index (BMI), and physical activity level were recorded. Passive range of motion was measured for all hips. Preoperative computed tomography scans were utilized to measure femoral torsion and central acetabular version, and a combined femoral torsion-acetabular version (COTAV) index was defined as their sum. Results: The study cohort comprised 221 patients (sixty-four males, 157 females) with a mean age of 32.5 years and mean BMI of 24.2 kg/m2. Overall, hips with femoral antetorsion and acetabular anteversion exhibited the greatest internal rotation range of motion at a neutral hip position (mean, 44.2°), whereas hips with femoral retrotorsion and acetabular retroversion demonstrated the lowest corresponding value (20.1°; p < 0.001). Femoral torsion was significantly associated with female sex (p < 0.001), BMI (p < 0.001), and presence of pathology corresponding to cam-type femoroacetabular impingement (FAI) (p = 0.044). Central acetabular version was significantly associated with age (p = 0.021), female sex (p < 0.001), and absence of mixed-type FAI pathology (p = 0.025). Increasing age and internal rotation range of motion at a neutral hip position were the most significant predictors of an increased COTAV index. Conclusions: This study confirmed that passive hip range of motion significantly predicts combined femoral torsion and central acetabular version. Accurate clinical assessment of the COTAV index may inform surgical decision-making in hip preservation surgery.

We prospectively evaluated the degree of absolute agreement between measurements of lateral center-edge angle (LCEA) on plain radiography (XR) and computed tomography (CT) in a consecutive cohort of 205 patients (410 hips) undergoing hip arthroscopy. Preoperative measurements of the LCEA were performed bilaterally utilizing standardized anteroposterior radiographs and coronal reformatted CT scans. Demographic variables including age, gender, height, weight, BMI and clinical diagnosis were recorded for all patients. Overall, measured values of the LCEA were 2.1° larger on CT compared with XR (32.9° versus 30.8°, P

Restoration of the sternoclavicular joint after posterior dislocation is important for upper limb function. The proximity of neuro-vascular mediastinal structures makes open reduction and internal fixation (ORIF) a high-risk procedure. The ideal treatment strategy is still debated. Our aim is to review the treatment of acute posterior sternoclavicular joint dislocation with a locking compression plate. We present our experience of transarticular plating using a locking compression plate for the treatment of three consecutive patients with posterior sternoclavicular dislocation (SCD). Our primary outcome measure was objective functional outcome using DASH (disability of the arm, shoulder and hand) and PROMIS (patient-reported outcomes measurement information system) questionnaires. All patients had a minimum follow-up of six months, and serial radiographs were reviewed to evaluate maintenance of reduction. All three patients presented a posterior SCD with instability refractory to closed reduction. In all three patients, we opted for surgical management using open reduction and fixation with a locking compression plate and allowed early mobilization at two weeks postoperatively. No complications were encountered during follow-up. Good functional outcomes were evidenced by DASH scores of 7.5, 20 and 30, and PROMIS scores were 53.8, 53.8 and 38.1 in each patient, respectively. Our experience of transarticular plating using a locking compression plate for posterior SCD is positive, as it allows early mobilization and resulted in good functional outcomes.

Purpose Our aim was to identify predictors of construct selection and recent trends for arthroscopic knotless rotator cuff repair (RCR). Methods A manual review of 1617 operative reports was performed. Results A medium-sized tear had a threefold increase in odds of single row (SR) knotless repair (OR, 6.91; p = 0.009) versus SR knotted (OR, 3.05; p = 0.003). Generalist orthopaedic surgeons were 79% less likely to perform SR knotless repairs versus sports medicine trained specialists (p Conclusion There was a significant increase from 2009 to 2016 in SR knotless and double row medial row knotless constructs contrasting the declining use of the SR knotted technique.

Techniques used in hip arthroscopy continue to evolve, and controversy surrounds the need for capsular repair following this surgical intervention. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) who underwent simultaneous bilateral hip arthroscopy through an interportal capsulotomy with each hip randomized to undergo capsular repair or not undergo such a repair.This double-blind, randomized controlled trial included 15 patients (30 hips), with a mean age of 29.2 years, who underwent simultaneous bilateral hip arthroscopy utilizing a small (3-cm) interportal capsulotomy for the treatment of FAI. The first hip treated in each patient was intraoperatively randomized to undergo capsular repair or no capsular repair. The contralateral hip then received the opposite treatment. MRI was performed at 6 and 24 weeks postoperatively, and the scans were analyzed by 2 musculoskeletal radiologists. The patients and the radiologists were blinded to the treatment performed on each hip. Capsular dimensions were measured at the level of the healing capsulotomy site and, for hips with a persistent defect, at locations both proximal and distal to the defect. These values were then analyzed at both time points to assess the rate and extent of capsular healing.At 6 weeks postoperatively, a continuous hip capsule (with no apparent capsulotomy defect) was observed in 8 hips treated with capsular repair and 3 hips without such a repair. Of the 19 hips with a discontinuous capsule at 6 weeks, 17 were available for follow-up at 24 weeks postoperatively; all 17 demonstrated progression to healing, with a contiguous appearance without defects and no difference in capsular dimensions between treatment cohorts.Arthroscopic repair of a small interportal hip capsulotomy site yields an insignificant increase in the percentage of continuous hip capsules seen on MRI at 6 weeks postoperatively compared with no repair. Repaired and unrepaired capsulotomy sites progressed to healing with a contiguous appearance on MRI by 24 weeks postoperatively.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to investigate the influence of immune deficiency status of HIV-positive patients on postoperative complication such as surgical site infection and nonunions. Retrospective observational cohort study: Level III. Level I trauma center. Consecutive adult HIV-positive patients with closed fractures who underwent operative treatment between January 1, 2001 and December 31, 2012. postoperative complication including infection and fracture nonunion. A total of 42 HIV-positive patients with closed fractures who underwent surgical fracture fixation were identified during the 12-year study time window. Of these, 18 patients were excluded due to incomplete medical records (n = 16) or open fractures (n = 2). The remaining 24 patients with closed fracture treated surgically (19 males and 5 females; mean age 45.1 ± 10.5 years; age range 20–67 years) were included in the study. Within a 6-month period from the time of injury, 16 patients had a CD4+ cell count >200 and five patients had a CD4+ cell count

The purposes of this study were (1) to define a normal prearthritic hip joint space width (JSW) in symptomatic and asymptomatic patients with various degrees of acetabular coverage based on the lateral center edge angle (LCEA) and (2) to determine predictors of JSW using patient-specific variables.In a consecutive series of patients presenting to a hip preservation clinic between July 2012 and April 2016, a standard weight-bearing anteroposterior pelvic view was obtained. JSW was defined as the distance between the bony contour of the acetabular rim and femoral head in 2 locations (lateral and medial weight-bearing zone). Hips with severe anatomic deformity, a Tönnis grade0, or a lateral or medial JSW2.5 mm were excluded. A linear mixed model analysis was performed in order to determine which variables (age, sex, side, height, weight, symptomatic/asymptomatic, LCEA, and clinical diagnosis) were significantly related to JSW.A total of 994 hips were included. LCEA was found to be a significant predictor of both the lateral and medial JSW, with a decreased JSW associated with increasing degrees of acetabular bony coverage (P.02). A mean 0.9 mm (20%) difference in medial JSW was found between patients with frank dysplasia (LCEA20°) compared with those with pincer-type FAI (LCEA ≥40°). There was no difference between symptomatic and asymptomatic hips, either for lateral (asymptomatic: 4.51 ± 0.83 mm; symptomatic: 4.52 ± 0.85 mm; P = .58) or medial JSW (asymptomatic: 4.02 ± 0.96 mm; symptomatic: 3.97 ± 0.84 mm; P = .49).The LCEA is a significant predictor of hip JSW, with the mean JSW decreasing with increasing degrees of acetabular bony coverage. Joint space is not a major factor in symptomatology in adults with prearthritic hip pain.Level III, retrospective comparative study.

Objectives: Techniques used in hip arthroscopy continue to evolve and controversy surrounds the need for capsule repair following surgical intervention. The purposes of this study were to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) undergoing hip arthroscopy with capsular repair versus non-repair. Methods: A multicenter clinical trial was performed with 35 patients (50 hips) undergoing hip arthroscopy for treatment of FAI. Each hip was preoperatively randomized to capsular repair versus non-repair. MRI evaluation was performed by a radiologist at 6 and 24 weeks postoperatively. Patients and the radiologist were blinded to the randomization. Capsular defect size and the thickness of the capsule at the capsulotomy site and at locations both proximal and distal to the defect were recorded on each scan to determine their change over time. Results: Compared to patients without capsular repair, those with capsular repair demonstrated significantly decreased mean capsular gapping at articular and muscular portions of the hip capsule at 6 weeks postoperatively (p < 0.001). This difference normalized between the two cohorts by 24 weeks postoperatively, with a significantly decreased mean capsular gapping at articular and muscular attachment sites of the hip capsule compared to 6 weeks postoperatively (p < 0.03). Defects were readily apparent on MRI imaging in regions where the capsule was not repaired. In contrast, irregular capsular thickening without a discrete defect was visible in most cases where the capsule was repaired at the time of arthroscopy. The appearance was variable after 24 weeks. The capsular defects that did close universally showed closure of the defect beginning at the muscular side of the capsule with bridging of capsular tissue then filling in on the articular side. Conclusion: Arthroscopic hip capsule repair results in significantly less capsule gapping at 6-week follow-up compared with non-repair, though the difference in gap size normalizes by 24-week follow-up.

The purpose of this study was to investigate the effect of general anesthesia on preoperative passive hip range of motion (ROM) in patients undergoing hip arthroscopy for various indications. A total of 260 consecutive patients undergoing hip arthroscopy were included in this study. Passive hip ROM was evaluated bilaterally in the clinic and subsequently under general anesthesia immediately preoperatively. Demographic variables, including age, height, weight, and clinical diagnosis, were recorded for all patients. Hips with pincer-type femoroacetabular impingement (FAI) and hips with acetabular dysplasia showed a mean increase of 4° and 6°, respectively, in hip external rotation at 90° of hip flexion (ER-90) with induction of anesthesia ( P =.018 and P =.021, respectively). In contrast, a statistically significant reduction in hip abduction (2°) and hip flexion (4°) was observed following induction of anesthesia in healthy contralateral hips of patients presenting with unilateral hip pathology ( P =.01 and P Orthopedics. 2016; 39(6):e1165–e1169.]

Background: Bony morphological abnormalities of the hip joint are often accompanied by adaptive soft tissue changes. These adaptive changes, if better understood and characterized, may serve to inform clinical decision making. Purpose: To investigate the correlation between the size of the hip labrum and lateral acetabular coverage in patients at our hip preservation clinic. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of 236 patients seen at a dedicated hip preservation service between June 2013 and June 2015 were retrospectively analyzed. Patients were grouped according to the degree of acetabular coverage, as measured by the lateral center-edge angle (LCEA): normal acetabular coverage (25°-39.9°), acetabular overcoverage (≥40°), borderline dysplasia (20°-24.9°), and frank dysplasia (Results: Frankly dysplastic and borderline dysplastic hips exhibited larger values of labral length at all locations when compared with hips with normal acetabular coverage ( P < .001) or acetabular overcoverage ( P < .001). Interestingly, mean labral length values in frank dysplasia were statistically similar to corresponding measurements in borderline dysplasia. In hips with frank dysplasia, borderline dysplasia, or normal acetabular coverage, labral length was consistently greatest at the lateral labrum and correspondingly lowest at the anteroinferior labrum ( P < .001). In hips with acetabular overcoverage, labral length did not vary significantly between the lateral, anterior, and anteroinferior locations. Multivariate analyses confirmed LCEA to be the strongest predictor of labral length, irrespective of measurement location. Conclusion: Patients with borderline dysplasia and frank dysplasia exhibited increased values of labral length in the weightbearing zone, potentially indicating a compensatory reaction to the lack of bony coverage. Labral length may serve as an instability marker and inform clinical decision making for patients with borderline dysplasia.

Post-traumatic long bone osteomyelitis (PTOM) is a relatively frequent occurrence in patients with severe open fractures and requires treatment to prevent limb-threatening complications. The Masquelet technique represents a length-independent, two-staged reconstruction that involves the induction of a periosteal membrane and use of an antibiotic-impregnated cement spacer for the treatment of segmental bone loss that result from bone infection. In this review, we summarize recent developments regarding the diagnosis and treatment of long bone PTOM, with a special emphasis on the use of the Masquelet technique for reconstruction of wide diaphyseal defects.

Symptomatic neuromas of the sural nerve are a rare but significant cause of pain and debilitation in athletes. Presentation is usually in the form of chronic pain and dysesthesias or paresthesias of the lateral foot and ankle. Treatment traditionally ranges from conservative measures, such as removing all external compressive forces, to administration of nonsteroidal anti-inflammatory drugs, vitamin B6, tricyclic antidepressants, antiepileptics, or topical anesthetics. This article reports a case of sural nerve entrapment in a 34-year-old male triathlete with a history of recurrent training-induced right-sided gastrocnemius strains. The patient presented with numbness in the right lateral foot and ankle that had persisted for 3 months, after he was treated unsuccessfully with extensive nonoperative measures, including anti-inflammatory drugs, activity modification, and a dedicated physical therapy program of stretching and strengthening. Orthopedic assessment showed worsening pain with forced passive dorsiflexion and manual pressure applied over the distal aspect of the gastrocnemius. Plain radiographs showed normal findings, but in-office ultrasound imaging showed evidence of sural nerve entrapment with edema and neuromatous scar formation in the absence of gastrocnemius or soleus pathology. Percutaneous ultrasound-guided hydrodissection of the sural nerve at the area of symptomatic neuroma and neural edema was performed the same day. The patient had complete relief of symptoms and full return to the preinjury level of participation in competitive sports. This case report shows that hydrodissection, when performed by an experienced physician, can be an effective, minimally invasive technique for neurolysis in the setting of sural nerve entrapment, resulting in improvement in clinical symptoms. [ Orthopedics. 2015; 38(11):e1046–e1050.]

Introduction Le diagnostic des osteomyelites post-traumatique (OMPT) est difficile et invasif, le gold standard restant la biopsie osseuse ouverte (BOO). Notre but est de comparer la sensibilite et specificite de differentes methodes diagnostiques a la BOO. Materiel et methodes Etude de cohorte retrospective monocentrique entre janvier 2004 et decembre 2013. Les patients inclus ont ete traites pour une OMPT d’un os long (femur, tibia, fibula, humerus, radius, ulna) selon les criteres diagnostiques du Center for Disease Control and Prevention (CDC). Les pieds diabetiques, arthrites septiques, spondylodiscites, osteomyelites de la main ou du basin ont ete exclus. Les donnees anatomiques, bacteriologiques, biologiques et epidemiologiques des patients ont ete collectees. Nous avons analyse les examens suivants : VS > 15 mm/h, CRP > 10 mg/L, hyperleucocytose, culture des tissus mous et histologie des tissus mous, en utilisant la BOO comme reference pour determiner leur sensibilite et specificite. Resultats Nous avons inclus 159 patients. L’âge moyen des patients etait 46,0 ± 13,2 ans, 20 (14,4 %) avaient une hepatite virale, 2 (1,3 %) etaient VIH+, 15 (9,4 %) SDF, 15 (9,4 %) diabetiques, 97 (61 %) fumeurs, 86 (54,1 %) avaient une consommation reguliere d’alcool et 47 (29,6 %) un usage de drogue. L’os le plus frequemment touche etait le tibia avec 83 cas (52,2 %), et la fracture initiale etait ouverte chez 58 patients (36,5 %). Les organismes les plus frequent etaient staphylocoque (57 %), streptocoques (11,6 %), et anaerobique (5,8 %), les infections polymicrobiennes representaient 19 %. Compare a la BOO, l’histologie des tissus mous montre une sensibilite de 69,8 % (IC 95 % : 53,7–82,3 %) et specificite de 38,9 % (IC 95 % : 18,3 %–63,9 %). La culture des tissus mous montre une de sensibilite 66,0 % (IC 95 % : 56,1–74,8 %) et specificite de 28,1 % (IC 95 % : 12,9–49,5 %). Parmi les marqueurs biologiques, CRP et VS ont des sensibilite et specificite comparables respectivement 81,7 et 18,1 contre 76,2 et 22,7. L’hyperleucocytose avait une sensibilite de 33,9 et specificite de 71,0. Ces differences etaient significatives pour la comparaison entre la specificite de l’histologie contre la culture des tissus mous et la sensibilite de l’hyperleucocytose contre les autres examens biologiques. Discussion Les marqueurs biologiques (CRP, VS, hyperleucocytose), les cultures et l’histologie des tissus mous montrent des sensibilites et specificites insuffisantes pour palier a la BOO dans le diagnostic des OMPT.