Abstract The quadriceps tendon autograft has become an attractive option for anterior cruciate ligament reconstruction (ACLR) because of its robust size and versatility as a graft. Emerging ...literature has shown impressive biomechanical viability and promising clinical outcomes. The substantial size of a quadriceps graft and the shorter graft requirement of the all-inside approach obviate the need to harvest a bone plug for supplemental graft length and allow the use of an all-soft-tissue graft. The recent development of sophisticated harvest tools has mitigated prior issues reported with quadriceps tendon harvest. Quadriceps graft harvest is now less technically challenging, more reproducible, and can be done through a minimally invasive incision. However, an optimal technique for attachment of the adjustable loop suspensory fixation devices to an all-soft-tissue quadriceps tendon graft has yet to be established. We describe our method for quadriceps tendon harvest and present the Quad Link technique for attachment of adjustable loop suspensory fixation devices to a quadriceps graft for ACLR.
Abstract Background Although preoperative risk assessment is multifactorial, subcutaneous fat thickness at the incision site has been associated with postoperative complications in studies of total ...hip arthroplasty (THA) and other procedures. This study compared subcutaneous fat thickness encountered in THA approaches using a lateral hip incision with that of approaches using an anterior incision and examined the relationship between body mass index (BMI) and fat distribution based on sex and age. Methods Subcutaneous fat measurements were obtained from 2004 patient CT images at positions that correspond with lateral and anterior incision sites for common approaches to THA. A thickness ratio (lateral/anterior) was calculated, and BMI, sex, and age were collected via chart review. Results Males and females had significantly different thickness ratio averages at 1.97 and 2.68, respectively. Thickness ratios were not significantly different between BMI groups. Lateral thickness averages were significantly different for males and females, and the interaction between sex and BMI group was significant. The relationship between BMI and the thickness ratio in males aged ≥65 years was significantly different from males of <65 years and females of all ages. Conclusion Regardless of BMI, sex, or age, incision site soft tissue thickness was greater for approaches using a lateral hip incision than for those with an anterior incision, and a positive relationship between BMI and both measurements was identified. The predominance of lateral fat was more pronounced in females of all age and BMI groups and less pronounced in obese males aged ≥65 years.
The role of telehealth in orthopedic surgery is rapidly expanding, a movement largely brought about by the coronavirus disease 2019 (COVID-19) pandemic. Virtual clinic encounters using a video chat ...platform or a simple telephone call offer the patient and surgeon numerous advantages that are now better appreciated by the orthopedic community at large. However, barriers to effective patient evaluation exist, and a successful patient assessment is highly dependent on technique. In particular, performing a shoulder physical examination during a virtual encounter poses many obstacles. We present a technique to complete a patient-led, comprehensive shoulder physical examination using an easy-to-understand pictorial guide called the Shoulder Telehealth Assessment Tool (STAT). A STAT form is provided to the patient and designed to be completed at home without the real-time instruction of a provider, before the virtual encounter. Parameters include assessments of all planes of shoulder range of motion, visual analog scale (VAS) and Single Assessment Numeric Evaluation (SANE) scores, and the components necessary to allow for conversion to an abbreviated Constant shoulder score if the provider so desires.
Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences ...in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs.
A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies.
Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes.
Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.
Abstract Bovine herpesvirus-1 (BoHV-1) causes significant disease in cattle. Control programs in North America incorporate vaccination with modified live viral (MLV) or killed (KV) vaccine. BoHV-1 ...strains are isolated from diseased animals or fetuses after vaccination. There are markers for differentiating MLV from field strains using whole-genome sequencing and analysis identifying single nucleotide polymorphisms (SNPs). Using multiple primer sets and sequencing of products permits association of BoHV-1 isolates with vaccines. To determine association between vaccine virus and strains isolated from clinical cases following vaccination, we analyzed 12 BoHV-1 isolates from animals with various clinical syndromes; 9 corresponded to BoHV-1.1 respiratory group. The remaining three corresponded to BoHV-1.2b, typically found in genital tracts of cattle. Four BoHV-1 isolates were identical to a vaccine strain; three were from post-vaccination abortion episodes with typical herpetic lesions whose dams had received MLV vaccine during pregnancy, and one from a heifer given a related MLV vaccine; Sequences of two respiratory isolates perfectly matched mutations characterizing RLB106 strain, a temperature sensitive mutant used in intranasal and parenteral vaccines. The last three respiratory strains clearly appeared related to a group of MLV vaccines. Previously the MLV vaccines were grouped into four groups based on SNPs patterns. In contrast with above-mentioned isolates that closely matched SNP patterns of their respective MLV vaccine virus, these 3 strains both lacked some and possessed a number of additional mutations compared to a group of MLV vaccine viral genome. Finding BoHV-1.2b in respiratory cases indicates focus should be given BoHV-1.2b as an emerging virus or a virus not recognized nor fully characterized in BRD.
Preoperative templating software and intraoperative navigation have the potential to impact baseplate augmentation utilization and increase screw length for baseplate fixation in reverse total ...shoulder arthroplasty (rTSA). We aimed to assess their impact on the (1) baseplate screw length, (2) number of screws used, and (3) frequency of augmented baseplate use in navigated rTSA.
We compared 51 patients who underwent navigated rTSA with 63 controls who underwent conventional rTSA at a single institution. Primary outcomes included the screw length, composite screw length, number of screws used, percentage of patients in whom 2 screws in total were used, and use of augmented baseplates.
Navigation resulted in the use of significantly longer individual screws (36.7 mm vs. 30 mm, P < .0001), greater composite screw length (84 mm vs. 76 mm, P = .048), and fewer screws (2.5 ± 0.7 vs. 2.8 ± 1, P = .047), as well as an increased frequency of using 2 screws in total (35 of 51 patients 68.6% vs. 32 of 63 controls 50.8%, P = .047). Preoperative templating resulted in more frequent augmented baseplate utilization (76.5% vs. 19.1%, P < .0001).
The difference in the screw length, number of screws used, and augmented baseplate use demonstrates the evolving role that computer navigation and preoperative templating play in surgical planning and the intraoperative technique for rTSA.
Prior investigations have utilized various surrogate markers of socioeconomic status to assess how health care disparities impact outcomes after rotator cuff repair (RCR). When taken as individual ...markers, these factors have inconsistent associations. Medicaid insurance status is an accessible marker that has recently been correlated with less optimal outcomes after RCR. Socioeconomic disparities exist within the non-Medicaid population as well and are arguably more difficult to characterize. The Area Deprivation Index (ADI) uses seventeen socioeconomic variables to establish a spectrum of neighborhood health care disparity. The purpose of this study was to determine the influence of neighborhood socioeconomic disadvantages, quantified by ADI, on 2-year patient reported outcome scores following RCR in the non-Medicaid population.
A retrospective review of patients who underwent RCR from 2015 to 2020 was performed. All procedures were performed by a group of 7 surgeons at a large academic center. Patient demographics and comorbidities were collected from charts. Rotator cuff tear size was assessed from arthroscopic pictures. ADI scores were calculated based on patients' home addresses using the Neighborhood Atlas tool. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score with a minimum follow-up of 2 years. A linear regression analysis with covariate control for age and patient comorbidities was performed.
There were 287 patients with a mean age of 60.11 years. The linear regression model between ADI and 2-year ASES score was significant (P = .02). When controlling for both age and patient comorbidities, every 0.9-point reduction in ADI resulted in a 1-point increase in the ASES score (P = .03). Patients with an ADI of 8, 9, or 10 had lower mean 2-year ASES scores than those with an ADI of 1 (87.08 vs. 93.19, P = .04), but both groups had similar change from preoperative ASES score (40.17 vs. 32.88, P = .12). The change in ASES score at 2-years in our study surpassed all established minimal clinically important difference values irrespective of ADI.
Patients with greater levels of disparity in their home neighborhoods have worse final ASES scores at 2 years, but patients significantly improve from their preoperative state regardless of social disadvantages. This is the first study to the authors' knowledge that examines ADI and outcomes following RCR. Providers should be aware that patients with higher ADI scores may have inferior preoperative shoulder function. The results of this study support the utilization of primary RCR in applicable tears regardless of socioeconomic status.
Purpose
To compare various nonarthroplasty treatment options for massive, irreparable rotator cuff tears, including allograft bridging/augmentation, debridement, partial repair, superior capsule ...reconstruction (SCR), subacromial balloon spacer, and tendon transfer.
Methods
A comprehensive search was conducted through the PubMed, MEDLINE, and EMBASE databases for all articles pertaining to nonarthroplasty treatment options for irreparable rotator cuff tears. Inclusion criteria included manuscripts published between 2009 and 2020 with at least 1 year follow-up and Level I–IV evidence. Articles were separated into six groups: debridement, arthroscopic and open repair, allograft bridging/augmentation, SCR, subacromial balloon spacer, and tendon transfer. Data points included range of motion (external rotation, abduction, forward flexion, and internal rotation), visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, rate of revision surgery, and rate of conversion to arthroplasty.
Results
A total of 83 studies and 3363 patients were included. All treatment options had statistically significant improvements in postoperative range of motion and patient-reported outcomes. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. The SCR subgroup had the greatest improvement in ASES scores postoperatively. The overall revision rate was 7.2% among all surgical options, with the allograft bridging/augmentation group having the lowest rate of revision at 0–8.3%. The overall rate of conversion to arthroplasty was 7.2%, with debridement having the greatest rate of conversion at 15.4%.
Conclusion
All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. However, these conclusions should be interpreted with caution due to the heterogeneous nature of the data, lack of prospective randomized control trials, and short-term follow-up. The findings of this study highlight the complexity of irreparable, massive rotator cuff tears, and the need for an individualized approach when treating these patients.
Level of evidence
Level IV.
Tumoral calcinosis is a hereditary disease of calcium and phosphate metabolism causing peri-articular tumors of calcium deposits. We present a case of tumoral calcinosis in a 13-year-old male with a ...history of a 12q13.11 genetic deletion. Surgical resection of the tumor necessitated resection of the ACL in its entirety with curettage and adjuvant therapy to the lateral femoral notch, which resulted in ligamentous instability and bony structural incompetency at the femoral insertion. Given the patient’s radiographically-apparent skeletal immaturity, and lack of reliable bony architecture to accommodate a femoral ACL tunnel, ACL reconstruction was performed using a physeal-sparing technique.
This is a case of tumoral calcinosis treated with, to our knowledge, the first ACL reconstruction using this modified open technique.
In this video, we present a unique approach to a purely ligamentous syndesmotic injury in a 16-year-old football player. Syndesmotic reduction was obtained using a large clamp and validated by ...matching fibular position to a fluoroscopic image of the contralateral ankle. Fixation was achieved using dual suture button devices in combination with a buttress plate. A small medial incision was used to protect the saphenous neurovascular bundle during button placement.
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