Elizabeth B. Gausden

Surgical options for anterior cruciate ligament reconstruction in the young child.

Purpose of review To review the most recent literature on the epidemiology, diagnosis, treatment, and outcomes of pediatric anterior cruciate ligament injury. Recent findings There is an increasing prevalence of anterior cruciate ligament injuries in pediatric and adolescent athletes, and nonoperative management of these injuries results in worse outcomes than surgical reconstruction. Prevention exercise protocols are cost-effective in preventing this injury in adolescent athletes. A number of techniques are currently in practice that address anterior cruciate ligament injuries in the skeletally immature, but there is no consensus on the optimal technique. Summary The reported clinical outcomes from anterior cruciate ligament reconstruction in young patients are favorable.

Opportunistic Osteoporosis Screening— Gleaning Additional Information from Diagnostic Wrist CT Scans

BACKGROUND Although screening for and treating osteoporosis can prevent subsequent fractures, the rates of such interventions are low following a distal radial fracture. One potential method for identifying metabolic bone disease is via Hounsfield unit (HU) measurements from diagnostic computed tomography (CT) scans. We hypothesized that HU values of the distal aspect of the radius could be used to assess local bone quality and would be predictive of distal radial fracture risk, thereby allowing the identification of patients in need of further management. METHODS Measurements of bone mineral density (BMD) were made for 100 patients on the basis of HU values of cancellous portions of the distal aspect of the radius, the ulnar head, and the capitate. The HU values in twenty-five male and twenty-five female patients with an acute distal radial fracture documented on CT were compared with those of age and sex-matched control patients who had a CT scan obtained for other indications. RESULTS Among the control patients, HU values decreased as age increased. When assessed on the basis of sex, both male and female patients with a distal radial fracture had significantly lower regional BMD compared with nonfracture control patients. A distal radial HU value of 218 for females and 246 for males optimized sensitivity and specificity; values below this threshold were associated with an increased risk of distal radial fracture. CONCLUSIONS HU measurements can be obtained from any diagnostic CT scan using modern software programs and can be obtained by physicians in the office setting with minimal effort and at no additional cost or radiation exposure to the patient. Regardless of imaging indications, we suggest that patients with HU values below the identified thresholds be considered for further metabolic bone disease work-up, such as additional imaging, laboratory assessments, the initiation of osteoporosis treatment, or appropriate referral.

Compartment Syndrome: Diagnosis, Management, and Unique Concerns in the Twenty-First Century

BackgroundCompartment syndrome is an elevation of intracompartmental pressure to a level that impairs circulation. While the most common etiology is trauma, other less common etiologies such as burns, emboli, and iatrogenic injuries can be equally troublesome and challenging to diagnose. The sequelae of a delayed diagnosis of compartment syndrome may be devastating. All care providers must understand the etiologies, high-risk situation, and the urgency of intervention.Questions/PurposesThis study was conducted to perform a comprehensive review of compartment syndrome discussing etiologies, risk stratification, clinical progression, noninvasive and invasive monitoring, documentation, medical-legal implication, and our step-by-step approach to compartment syndrome prevention, detection, and early intervention.MethodsA literature search was performed using the PubMed Database and the following search terms: “Compartment syndrome AND Extremity,” “Compartment syndrome AND Gluteal,” and Compartment syndrome AND Paraspinal.” A total of 2,068 articles were identified. Filters allowed for the exclusion of studies not printed in English (359) and those focusing on exertional compartment syndrome (84), leaving a total of 1,625 articles available for review.ResultsThe literature provides details regarding the etiologies, risk stratification, clinical progression, noninvasive and invasive monitoring, documentation, medical-legal implication, and our step-by-step approach to compartment syndrome prevention, detection, and early intervention. The development and progression of compartment syndrome is multifactorial, and as complexity of care increases, the opportunity for the syndrome to be missed is increased. Recent changes in the structure of in-hospital medical care including resident work hour restrictions and the incorporation of midlevel providers have increased the frequency of “signouts” or “patient handoffs” which present opportunities for the syndrome to be mismanaged.ConclusionThe changing dynamics of the health care team have prompted the need for a more explicit algorithm for managing patients at risk for compartment syndrome to ensure appropriate conveyance of information among team members.

Using Hounsfield Units to Assess Osteoporotic Status on Wrist Computed Tomography Scans: Comparison With Dual Energy X-Ray Absorptiometry.

PURPOSE Rates of evaluation and treatment for osteoporosis following distal radius fragility fractures remain low. As a subset of patients with these fractures undergo diagnostic computed tomography (CT) scan of the wrist, utilizing bone mineral density (BMD) measurements available with this imaging can be used to detect osteopenia or osteoporosis. This information may consequently prompt intervention to prevent a subsequent fracture. The purpose of this study was to determine if Hounsfield unit (HU) measurements at the wrist correlate with BMD measurements of the hip, femoral neck, and lumbar spine and to assess the ability of these HU measurements to detect osteoporosis of the hip. METHODS Forty-five female patients with distal radius fractures who underwent CT scan and dual energy x-ray absorptiometry scan as part of the management of their wrist fracture were identified. Bone mineral density measurements were made using the regional cancellous bone HU value at the capitate and compared with values obtained by a dual energy x-ray absorptiometry scan. RESULTS Hounsfield unit values at the capitate were significantly correlated with BMD and t scores at the femoral neck, hip, and lumbar spine. An HU threshold of 307 in the capitate optimized sensitivity (86%) and specificity (94%) for detecting osteoporotic patients. CONCLUSIONS By demonstrating that capitate HU measurements from clinical CT scans are correlated with BMD and t scores at the hip, femoral neck, and lumbar spine, our data suggest that clinical CT scans should have a role in detecting osteopenia and osteoporosis. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.

Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review.

Background: The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature. Methods: A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density. Results: Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia. Conclusions: Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research.

Extensor Mechanism Injuries of the Knee: Demographic Characteristics and Comorbidities from a Review of 726 Patient Records.

BACKGROUND The purpose of our study was to describe and compare extensor mechanism injuries with regard to age, sex, body mass index (BMI), and comorbidities. METHODS We identified patients who had undergone surgical management of an extensor mechanism injury at two institutions between 1986 and 2012. Data analyzed included age at the time of surgery, sex, height, weight, and the presence of medical comorbidities. Patients with chronic disruption of the quadriceps or patellar tendon, those undergoing revision surgery, or those with injuries in the setting of total knee arthroplasty were excluded. RESULTS Seven hundred and twenty-six patients were included. There were 427 (58.8%) patellar fractures, 210 (28.9%) quadriceps tendon ruptures, and eighty-nine (12.3%) patellar tendon ruptures. Sixty-seven percent of the patellar fractures occurred in females, while 91% of the quadriceps and 95.5% of the patellar tendon ruptures occurred in males (p < 0.001). Age distribution was significantly different among the groups: the mean patient age (and standard deviation) was 61.0 ± 13.1 years (range, twenty to ninety-two years) for quadriceps tendon rupture, 56.3 ± 17.4 years (range, sixteen to ninety-one years) for patellar fracture, and 39.5 ± 12.2 years (range, eighteen to seventy-two years) for patellar tendon rupture. Patellar fractures showed a bimodal distribution with regard to both age and sex: the median age of females was sixty-two years (range, sixteen to ninety-one years), and the median age of males was forty-seven years (range, sixteen to ninety-one years) (p < 0.001). BMI varied significantly among the cohorts: a mean of 25.0 ± 5.2 kg/m2 for patellar fracture, 28.7 ± 4.97 kg/m2 for patellar tendon rupture, and 30.0 ± 6.05 kg/m2 for quadriceps tendon rupture (p < 0.001). Ninety-six percent of the females with a quadriceps or patellar tendon injury had an underlying medical comorbidity compared with 68% of the males (p = 0.008). Of the patients with underlying comorbidities, 61% of the females had comorbidities that were considered to be risk factors for tendinopathy compared with 34% of the males (p = 0.008). CONCLUSIONS Females with an extensor mechanism injury are more likely to sustain a patellar fracture compared with males. Younger males are more likely to sustain a patellar fracture or patellar tendon rupture; however, we found that 43% of the patellar tendon ruptures were in patients over the age of forty. Medical comorbidities were common with tendon ruptures, and we found that they were significantly more common in females than in males. CLINICAL RELEVANCE Surgeons treating female patients with a tendinous extensor mechanism disruption should have a low threshold to initiate a medical work-up in search of a possible undiagnosed medical comorbidity.

How are we measuring clinically important outcome for operative treatments in sports medicine

ABSTRACT Objectives: Minimal clinically important difference (MCID) and other measures of minimum clinical importance are increasingly recognized as important clinical considerations for evaluating the efficacy of an intervention. As our interpretation of clinical outcome evolves beyond statistical significance, psychometric properties such as MCID will be increasingly important to various stakeholders in the orthopaedic community. The purpose of this study was to: 1) describe the state of clinically important outcome reporting and 2) describe the methods used to derive these psychometric values for sports medicine patients undergoing operative treatments. Methods: A review of the MEDLINE database was performed. Studies primarily deriving and reporting clinically important outcome measures for operative interventions in sports medicine were included. Demographic, methodological and psychometric properties of included studies were extracted. Level of Evidence and the Newcastle Ottawa Scale (NOS) were used to assess study quality. Statistical analysis was primarily descriptive. Results: Fifteen studies met inclusion criteria; 10 of the 15 studies were Level II evidence and mean NOS score was 5.3/9. Minimal detectable change (MDC) was the most commonly derived measure of clinical importance, calculated in 53.3% of studies, followed by MCID, calculated in 40.0% of studies. A combination of distribution and anchor-based methods was the most commonly used method to determine clinical importance (N = 7, 46.7%) followed by distribution only (N = 5, 33.3%). Predictors of clinically important change were reported in four studies and were most commonly related to pre-operative functional score. Conclusions: MDC and the MCID are the most commonly reported measures of clinically important outcome after operative treatment in sports medicine. A combination of both distribution and anchor-based methods is commonly used to derive these values. More attention should be paid to reporting outcomes that are clinically important and developing guidelines for reporting clinical meaningful outcome.

Subscapularis tendon loading during activities of daily living

BACKGROUND The purpose of this study was to determine the relative amount of load that is transmitted through the superior portion of the subscapularis during activities of daily living as compared with the load that is transmitted through the middle and inferior portions in a normal shoulder and in a shoulder with a supraspinatus tear. METHODS By use of the Newcastle shoulder model, the subscapularis was modeled with 3 lines of action encircling the humeral head. The load was measured in the entire subscapularis, and the percentage of this load in each of the 3 tendinous bands was calculated. Subsequently, a supraspinatus tear was simulated, and the forces generated by the subscapularis and glenohumeral joint contact forces were measured. RESULTS The maximum force produced by the entire subscapularis muscle for the various activities ranged from 3 to 43 N. Load sharing between the 3 subscapularis bands showed that the superior band bore the largest percentage of the total load of the muscle (95% ± 2%). The load in the subscapularis, particularly in the superior band, increased significantly when a supraspinatus tear was simulated (P < .0001). CONCLUSION The superior band of the subscapularis tendon bears the highest percentage of load compared with the middle or inferior band. The load in the subscapularis increased significantly in the presence of a simulated supraspinatus tear. Because a disproportionate amount of force is transmitted through the superior subscapularis, more clinical research is warranted to determine whether tears in this region should be routinely repaired.

Tranexamic acid in hip fracture patients: a protocol for a randomised, placebo controlled trial on the efficacy of tranexamic acid in reducing blood loss in hip fracture patients

Introduction There is a high incidence of blood transfusion following hip fractures in elderly patients. Tranexamic acid (TXA) has proven efficacy in decreasing blood loss in general trauma patients as well as patients undergoing elective orthopaedic surgery. A randomised controlled trial will measure the effect of TXA in a population of patients undergoing hip fracture surgery. Methods This is a double-blinded, randomised placebo-controlled trial. Patients admitted through the emergency room that are diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrolment and randomised to either treatment with 1 g of intravenous TXA or intravenous saline at the time of skin incision. Patients undergoing percutaneous intervention for non-displaced or minimally displaced femoral neck fractures will not be eligible for enrolment. Postoperative transfusion rates will be recorded and blood loss will be calculated from serial haematocrits. Ethics and dissemination This protocol was approved by the Institutional Review Board (IRB) and is registered with clinicaltrials.gov. The findings of the trial will be disseminated through peer-reviewed journals and conference presentations. Trial registration number NCT01940536.

Classification and assessment of juvenile osteochondritis dissecans knee lesions.

Purpose of review Juvenile osteochondritis dissecans (JOCD) knee lesions are common abnormalities in adolescents and children, and have higher rates of spontaneous healing with nonoperative management compared to adult osteochondritis dissecans (OCD) lesions. Multiple classification and assessment systems have been established in order to help clinicians determine which lesions are amenable to nonoperative management. However, these assessments often use adult OCD classification systems of lesion stability, which have poor reliability in JOCD lesions. The purpose of this review is to assess these various classification systems proposed for JOCD lesions. Recent findings Although arthroscopy remains the gold standard for the definitive assessment of lesion stability, recent evidence suggests that MRI characteristics indicative of instability in adult OCD lesions are not applicable in determining JOCD lesion instability. In addition, the correlation between arthroscopic and MRI indications of instability is highly varied in these younger patients. Summary In order for the pediatric orthopedic surgeon to more accurately predict treatment outcomes in patients with JOCD knee lesions, further investigation into the radiographic characteristics specific to JOCD lesion instability and healing is warranted.