Julie A. Neumann

Arthroscopic Treatment of Bucket-Handle Labral Tear and Acetabular Fracture

Traumatic hip dislocations are associated with chondral and labral pathology as well as loose bodies that can be incarcerated in the joint. These types of injury often lead to traumatic arthritis. In some cases an osseo-labral fragment may become incarcerated in the joint that is not readily visualized preoperatively. In place of open surgery, hip arthroscopy permits a technique to remove loose bodies and repair labral tears to restore joint congruity and achieve fracture reduction and fixation.

Staple Fixation for Akin Proximal Phalangeal Osteotomy in the Treatment of Hallux Valgus Interphalangeus

Background: The Akin proximal phalangeal osteotomy is commonly used in conjunction with metatarsal osteotomies to treat hallux valgus. Multiple fixation methods including suture, wire, screw, and staple fixation have been described. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate short-term postoperative outcomes in patients who underwent Akin osteotomy with staple fixation. Methods: Forty-four patients (51 feet) with painful hallux valgus were retrospectively reviewed at an average of 40.4 ± 15.8 (range, 25.9 to 79.9) weeks following an Akin osteotomy with staple fixation. Patient reported preoperative and postoperative Visual Analog Score (VAS) (0 to 10, 0 = no pain) was recorded. Level of activity was reported postoperatively. Hallux valgus angles (HVAs), intermetatarsal angles (IMAs), and hallux valgus interphalangeus angles (IPAs) were evaluated on preoperative as well as final postoperative radiographs. Postoperative clinical and radiographic examinations were used to evaluate for complications. Results: Mean VAS improved from 4.4 ± 2.6 to 1.0 ± 1.2 (P < .001). Activity level was classified as ability to bear weight as tolerated 3/51 (5.9%), ambulate 1 to 4 blocks 2/51 (3.9%), ambulate a minimum of 6 blocks 18/51 (35.3%), and ambulate an unlimited distance 28/51 (59.4%). Average HVA, IMA, and IPA improved from 25.6 ± 10.0 degrees to 14.1 ± 8.1 degrees (P < .001), 13.1 ± 4.6 degrees to 8.0 ± 3.0 degrees (P < .001), and 7.9 ± 3.4 degrees to −3.1 ± 6.4 degrees (P < .001), respectively. No major postoperative complications, including infections, nonunions, or recurrent deformities, were recorded. Two patients sustained breaches of the lateral cortex, but this was without appreciable complication. Three patients (5.9%) reported unilateral proximal-medial great phalanx tenderness. There was 1 revision for persistent deformity, specifically in the HVA and IPA angles. Conclusion: Akin osteotomy with staple fixation was a safe and effective procedure as part of a hallux valgus correction with improvement in pain and hallux valgus deformity with a low risk for complications. Level of Evidence: Level IV, case series.

Developing a model for effective leadership in healthcare: a concept mapping approach

Purpose Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies. Methods Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare. Results A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were “Acting with Personal Integrity”, “Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”, “Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service. Conclusion Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research.

Technique of Arthroscopic Treatment of Impingement After Total Ankle Arthroplasty.

Rates of medial and/or lateral gutter impingement after total ankle replacement are not insignificant. If impingement should occur, it typically arises an average of 17 months after total ankle replacement. Our patient underwent treatment for right ankle medial gutter bony impingement with arthroscopic debridement 5 years after her initial total ankle replacement. Standard anteromedial and anterolateral portals and a 30° 2.7-mm-diameter arthroscope were used. An aggressive soft-tissue and bony resection was performed using a combination of curettes, a 3.5-mm shaver, a 5.5-mm unsheathed burr, a drill, and a radiofrequency ablator. This case shows that arthroscopic treatment is an effective and potentially advantageous alternative to open treatment of impingement after total ankle replacement. In addition, symptoms of impingement often improve in a short amount of time after arthroscopic debridement of the medial and/or lateral gutter.

Outcomes After Dermal Allograft Reconstruction of Chronic or Subacute Pectoralis Major Tendon Ruptures

Background: Avoiding delay in the surgical management of pectoralis major (PM) ruptures optimizes outcomes. However, this is not always possible, and when a tear becomes chronic or when a subacute tear has poor tissue quality, a graft can facilitate reconstruction. Purpose: The primary aim was to evaluate the clinical outcomes of PM reconstruction with dermal allograft augmentation for chronic tears or for subacute tears with poor tissue quality. A second aim was to determine patient and surgical factors affecting outcome. Study Design: Case series; Level of evidence, 4. Methods: Nineteen consecutive patients (19 PM ruptures) with a mean ± SD age of 39.1 ± 8.4 years were retrospectively reviewed at 26.4 ± 16.0 months following PM tendon reconstruction with dermal allograft. Surgery was performed at 19.2 ± 41.2 months after injury (median, 7.6 months; range, 1.1-185.4 months). Several outcome scores were recorded pre- and postoperatively, including Disabilities of the Arm, Shoulder, and Hand (DASH), as well as visual analog scale (VAS) (range, 0-10; 0 = no pain) and Single Assessment Numeric Evaluation (SANE). Range of motion, Constant score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and complications/reoperations were recorded postoperatively. Results: Scores improved significantly for the DASH (preoperative, 34.9; postoperative, 8.0; P < .001) and VAS (preoperative, 5.0; postoperative, 1.5; P = .011). There was a trend toward improved SANE scores (preoperative, 15.0; postoperative, 80.0; P = .097), but the difference was not statistically significant, likely because of the small number of patients having preoperative SANE scores for review. Increased age was associated with higher VAS scores (r = 0.628, P = .016) and less forward flexion (r = –0.502, P = .048) and external rotation (r = –0.654, P = .006). Patients with workers’ compensation had lower scores for 3 measures: SANE (75.8 vs 88.4, P = .040), Constant (86.7 vs 93.4, P = .019), and ASES (81.9 vs 97.4, P = .016). Operating on the dominant extremity resulted in lower Constant scores (87.8 vs 95.4, P = .012). A 2-head tendon tear (107.5° vs 123.3°, P = .033) and the use of >1 graft (105.0° vs 121.3°, P = .040) resulted in decreased abduction. Conclusion: This was the first large series to observe patients with chronic or subacute PM tendon tears treated with dermal allograft reconstruction. PM tendon reconstruction with dermal allografts resulted in good objective and subjective patient-reported outcomes.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy: Is there a Difference in Perioperative Complications compared with Periacetabular Osteotomy Alone?

Purpose: To evaluate the safety of hip arthroscopy combined with a periacetabular osteotomy (PAO) compared with PAO alone in treating concomitant intra-articular pathology in hip dysplasia. Materials and methods: Forty-one patients (46 hips) with symptomatic hip dysplasia were retrospectively reviewed. Preand postoperative radiographic data and intraoperative data consisting of estimated blood loss, intraoperative and postoperative blood transfusions, operative time, and length of hospital stay were recorded. The complications occurring within the first 3 months after surgery including lateral femoral cutaneous and pudendal nerve neuropraxia, wound complications, and reoperations were recorded. Additionally, rates of deep venous thrombosis and other major adverse outcomes (myocardial infarction, pulmonary embolism, stroke, death) were examined. Results: Twenty-one patients (24 hips) underwent PAO alone. Twenty patients (22 hips) underwent hip arthroscopy followed immediately by PAO. There were no significant differences in the 90-day complication rates between the two groups, comparing the rate of neuropraxia (p = 0.155) and wound complications (p = 0.6). Operative time for PAO alone was 179 minutes (standard deviation [SD] ± 37) compared with 251 minutes (SD ± 52) for combined hip arthroscopy and PAO (p < 0.001). No incidence of deep vein thrombosis or major adverse events was noted in either group. Preoperative lateral center edge angle (LCEA) and acetabular index (AI) were 14° and 20° respectively, in the PAO-alone group and 19° and 16° respectively, in the combined group. Postoperatively, LCEA was 29° in the PAOalone group and 30° in the combined group. Postoperative AI was 11° in the PAO-alone group and 5° in the combined group. Conclusion: This study demonstrates that hip arthroscopy in combination with PAO to treat intra-articular pathology shows no difference in 90-day complication rates when compared with PAO alone. RETROSPECTIVE COMPARATIVE STUDY 1,2Fellow, 3Resident, 4,5Surgeon, 6Professor 1Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, USA 2Department of Orthopaedic Surgery, Rady Children’s Hospital San Diego, California, USA 3,4,6Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA 5Mount Kisco Medical Group, Fishkill, New York, USA Corresponding Author: Julie A Neumann, Fellow, KerlanJobe Orthopaedic Clinic, Los Angeles, California, USA, Phone: +2253175800, e-mail: Julie.Neumann.MD@gmail.com 10.5005/jp-journ ls-10017-1083 Level of evidence: Level III, retrospective comparative study

Reproducible transient asystolic arrest during intramedullary reaming of the femoral canal: A case report

The utilization of intramedullary devices in the surgical fixation of hip fractures is increasing. Although intramedullary devices offer many advantages in the treatment of these injuries, they are also associated with a unique set of potential complications, particularly during preparation of the femoral canal. Cardiac dysrhythmia resulting from reaming the femoral canal is rare and has not been previously described in detail in the literature. We present the case of a 69-year-old male with an infected right cephalomedullary femoral nail who underwent removal of hardware and experienced reproducible, transient asystolic cardiac arrest during reaming of the femoral canal and offer potential explanations for this event.

A Technique for Arthroscopic-Assisted Ligamentum Teres Augmentation Using a Suture Tape Augmentation

Ligamentum teres (LT) tears are a pathologic condition being identified at increasing frequency because of growing use of hip arthroscopy. The exact role of the LT is not well understood, but it has been shown in recent biomechanical studies to contribute to hip stability. Patients with hip pain, instability, and/or mechanical symptoms with advanced imaging findings showing LT pathology may benefit from an LT augmentation. We present an arthroscopic-assisted LT augmentation technique, which can be performed as an isolated procedure or in conjunction with an arthroscopic labral repair and/or debridement, chondroplasty, and femoroplasty.

Alternative Method to Remove Polyethylene Liner from Inbone Total Ankle Arthroplasty: Operative Technique

Total ankle arthroplasty (TAA) is an evolving treatment indicated in end-stage idiopathic, posttraumatic, or inflammatory ankle arthrosis. Currently, there are 4 Food and Drug Administration approved TAAs systems available in the United States, one of which is the INBONE TAA. The INBONE TAA is a thi

Interposition Porcine Acellular Dermal Matrix Xenograft Successful Alternative in Treatment for Massive Rotator Cuff

Objectives: Despite advances in the surgical techniques of rotator cuff repair (RCR), the management of massive rotator cuff tears in shoulders without glenohumeral arthritis poses a difficult problem for surgeons. Failure of massive rotator cuff repairs range from 20-90% at one to two years postoperatively using arthrography, ultrasound, or magnetic resonance imaging. Additionally, there are inconsistent outcomes reported with debridement alone of massive rotator cuff tears as well as limitations seen with other current methods of operative intervention including arthroplasty and tendon transfers. The purpose of this prospective, comparative study was to determine if the repair of massive rotator cuff tears using an interposition porcine acellular dermal matrix xenograft improves subjective function, pain, range of motion, and strength at greater than two years follow-up. To our knowledge, this is the largest prospective series reporting outcomes of using porcine acellular dermal matrix xenograft as an interposition graft. Methods: Thirty-seven patients (37 shoulders) with an average age of 66 years (range 51-80 years) were prospectively followed for 33 months (range 23-48) following massive RCR using porcine acellular dermal matrix interposition xenograft. Subjective outcomes were measured using the Visual Analog Scale (VAS) pain score (0-10, 0 = no pain), Modified American Shoulder and Elbow Score (M-ASES), and Short-Form12 (SF-12) scores. Preoperative and postoperative objective outcome measures included active range of motion and supraspinatus and infraspinatus manual muscle strength. Postoperative outcome measures included quantitative muscle strength using a dynamometer and static and dynamic ultrasonography to assess the integrity of the repair. Results: Average VAS pain score decreased from 4.5 to 1.1 (P<0.001). Average postoperative M-ASES was 89.23. Average postoperative SF-12 was 52.6. Mean forward flexion, external and internal rotation significantly improved from 133.2° to 157.9° (P=0.003), 51.56° to 64.25° (P=0.001), and 49.8° to 74.0° (P<0.001), respectively. Manual strength (10 point scale) in supraspinatus and infraspinatus increased from 7.3 to 8.9 (P<0.001) and 7.4 to 9.4 (P<0.001), respectively. Using a dynamometer, supraspinatus quantitative strength was a mean of 68.6N and infraspinatus quantitative strength was a mean of 50.6N. Ultrasound evaluation of repairs showed 33 (89.1%) to be fully intact, three (8.1%) had partial tears, and one repair (2.7%) was not intact. The one patient whose repair was not intact by ultrasound was a revision repair. No infections, evidence of inflammatory reaction, tissue rejection, or major adverse outcomes were identified. Three patients underwent ipsilateral shoulder surgery for lysis of adhesions due to post-operative decreased ROM during the follow-up period. Conclusion: Following repair of massive rotator cuff tears with interposition porcine acellular dermal matrix xenografts, patients had significant improvement in pain, range of motion, strength and reported good subjective function based on M-ASES and SF-12 scores. The repair was completely intact in 89% of patients, a vast improvement compared with results reported for primary repairs of massive rotator cuff tears. Tissue grafts such as the porcine acellular graft used in our study hold great promise in the treatment of massive, retracted rotator cuff tears.