Matthew J. Salzler

Complications After Arthroscopic Knee Surgery

Background: Knee arthroscopies are among the most common procedures performed by orthopaedic surgeons, yet little is known about the associated complications and complication rates. Purpose: To examine the nature and frequency of complications after the most common arthroscopic knee procedures, with particular attention to fellowship training, geographic location of practice, and age and sex of the patient. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Data were obtained from the American Board of Orthopaedic Surgery database for orthopaedic surgeons who sat for the part II examination from 2003 to 2009. The database was queried to determine the type and frequency of complications for patients who underwent knee arthroscopy and for those who underwent sports medicine knee arthroscopy, including arthroscopic partial meniscectomy, meniscal repair, chondroplasty, microfracture, anterior cruciate ligament reconstruction, or posterior cruciate ligament reconstruction. Factors affecting complication rates that were investigated included type of procedure, fellowship training status, geographic location of practice, and age and sex of the patient. Results: There were 4305 complications out of 92,565 knee arthroscopic procedures obtained from the American Board of Orthopaedic Surgery database for an overall candidate-reported complication rate of 4.7%. The complication rates were highest for posterior cruciate ligament reconstruction (20.1%) and anterior cruciate ligament reconstruction (9.0%); complication rates for meniscectomy, meniscal repair, and chondroplasty were 2.8%, 7.6%, and 3.6%, respectively. The complication rate for sports fellowship–trained candidates was higher than for non–sports trained candidates (5.1% sports, 4.1% no sports; P < .0001) and for male patients (4.9% male vs 4.3% female; P < .0001). Younger patients (<40 years; 6.2%) had a higher complication rate than older patients (≥40 years; 3.58%) (P < .0001). Procedure complexity is a likely confounding factor affecting sports-trained candidates and younger patients. There were no geographic differences (P = .125). The overall rate of pulmonary embolus was 0.11%. Surgical complications (3.68%) were more common than medical (0.77%) or anesthetic complications (0.22%), and infection was the most common complication overall (0.84%). Conclusion: The overall self-reported complication rate for arthroscopic knee procedures was 4.7%. Knee arthroscopy is not a benign procedure, and patients should be aware of the risk of complications.

Assessment and Treatment of Malnutrition in Orthopaedic Surgery

Malnutrition in orthopaedic patients, a condition that is overlooked and understudied, has substantial effects on outcomes1-6. Underweight and malnourished elderly patients are at risk of experiencing reduced well-being and autonomy as well as increased mortality as compared with their counterparts of normal weight7. Malnutrition may be simply defined as an imbalance of energy, protein, and nutrients leading to functional and compositional adverse effects on the body8,9. By this definition, as much as 15% of ambulatory and 65% of hospitalized patients are malnourished10. Without adequate nutrition, orthopaedic patients are more susceptible to infections, slower healing rates, and sarcopenia (reduced lean body mass and muscle function)8. Stratifying malnutrition on the basis of etiology (e.g., “starvation-related,” “chronic disease-related,” and “acute injury or illness-related”) facilitates the formation of a more clinically relevant definition11. In starvation, the primary problem is reduced intake, possibly due to socioeconomic factors or secondary to anorexia6. With chronic disease and acute injury, increases in resting energy expenditure and protein requirements due to the inflammatory response contribute to malnourishment7. The new etiology-based approach to the diagnosis of malnutrition …

A Review of Femoroacetabular Impingement and Hip Arthroscopy in the Athlete

Abstract Femoroacetabular impingement (FAI) is increasingly recognized as a pathological condition of the hip in athletes. Although it is not always symptomatic, the bone structure leading to FAI and its associated pathology can result in significant pain and performance decline in athletes. Recognition of athletes with symptomatic FAI is of the utmost importance, as prompt treatment is necessary in order to maintain desired sports activity levels and preserve joint function. This review explores the recent evidence on the evaluation, recognition, and treatment of femoroacetabular impingement, and discusses conservative management, postoperative rehabilitation, and treatment in the pediatric and master athlete populations.

Fluoroscopic Determination of the Tibial Insertion of the Posterior Cruciate Ligament in the Sagittal Plane

Background: Currently, placement of the tibial tunnel for arthroscopic transtibial posterior cruciate ligament (PCL) reconstruction relies on a limited arthroscopic view of the native insertion or the use of intraoperative imaging. No widely accepted method exists for intraoperative determination of PCL tibial tunnel placement, and current descriptions are cumbersome. Purpose: To identify the center of the PCL’s anatomic tibial insertion site as a percentage of the PCL facet length on a lateral radiograph of the knee so that it may be reliably located in the sagittal plane during surgical reconstruction. Study Design: Descriptive laboratory study. Methods: Twenty fresh-frozen cadaveric knees were dissected and the tibial insertions of the PCL were digitized with an optical tracing system. The digitized PCL footprints were mapped onto 3-dimensional computed tomography–acquired tibial models, and their center points were determined. A K-wire was then inserted into the center of the PCL’s tibial insertion under direct visualization, a direct lateral radiograph was obtained, and the center point was measured. The center locations for both methods were defined as a percentage of PCL facet length from anterior and proximal to posterior and distal, and intraobserver and interobserver reliability was tested with 4 different observers. Results: The average location of the PCL center on the 3-dimensional bone model method was 71.7% ± 5.6% along the PCL facet from anterior/proximal to posterior/distal. In the lateral radiographic method, the center of the PCL was at an average of 69.7% ± 4.9% of the facet length. There was no significant difference between the percentage measurements of the 2 methods (P = .13). Interobserver reliability (κ = 0.57) and intraobserver reliability (κ = 0.71) were moderate to strong. Conclusion: Locating the center of the tibial PCL insertion with fluoroscopy at a point that is 70% of the PCL tibial facet length on a true lateral radiograph is a reliable method for locating the PCL tibial insertion. Clinical Relevance: The method described in this study enables clinicians to identify the tibial location of the PCL insertion, which must be accurately determined during PCL reconstruction.

Tunnel Placement for the Acl During Reconstructive Surgery of the Knee: A Critical Analysis Review

Anterior cruciate ligament (ACL) surgery continues to evolve as we gain a better understanding of the anatomy and biomechanics of the ACL. In the late 1980s, there was a shift from a two-incision (rear-entry guide) to a single-incision (transtibial) technique. The impetus driving this was the potential to achieve equivalent tunnel placement more quickly and in a more cosmetic fashion1. However, when anatomic studies clearly defined the ACL femoral insertion site on the lateral intercondylar wall and not the roof, it was discovered that even when performed as described in the Surgical Techniques supplement of The Journal of Bone & Joint Surgery in 20052, the traditional transtibial technique placed the femoral tunnel higher (toward the apex of the notch as opposed to the wall) on the intercondylar notch, outside the native insertion site (Fig. 1)3-6. Some surgeons postulated that, even with adjustments to the traditional transtibial technique, transtibial drilling would always place the femoral tunnel higher on the intercondylar notch than the location of the native insertion site (Fig. 2, A ). In order to avoid placing the femoral tunnel on the intercondylar roof as is commonly associated with the transtibial technique (also known as the …

Distracted biking: an observational study

Commuting via bicycle is a very popular mode of transportation in the Northeastern United States. Boston, MA, has seen a rapid increase in bicycle ridership over the past decade, which has raised concerns and awareness about bicycle safety. An emerging topic in this field is distracted bicycle riding. This study was conducted to provide descriptive data on the prevalence and type of distracted bicycling in Boston at different times of day. This was a cross-sectional study in which observers tallied bicyclists at 4 high traffic intersections in Boston during various peak commuting hours for 2 types of distractions: auditory (earbuds/phones in or on ears), and visual/tactile (electronic device or other object in hand). Nineteen hundred seventy-four bicyclists were observed and 615 (31.2%), 95% CI [29, 33%], were distracted. Of those observed, auditory distractions were the most common (N = 349; 17.7%), 95% CI [16, 19], p = .0003, followed by visual/tactile distractions (N = 266; 13.5%), 95% CI [12, 15]. The highest proportion (40.7%), 95% CI [35, 46], of distracted bicyclists was observed during the midday commute (between 13:30 and 15:00). Distracted bicycling is a prevalent safety concern in the city of Boston, as almost a third of all bicyclists exhibited distracted behavior. Education and public awareness campaigns should be designed to decrease distracted bicycling behaviors and promote bicycle safety in Boston. An awareness of the prevalence of distracted biking can be utilized to promote bicycle safety campaigns dedicated to decreasing distracted bicycling and to provide a baseline against which improvements can be measured.

Injuries observed in a prospective transition from traditional to minimalist footwear: correlation of high impact transient forces and lower injury severity

ABSTRACT Objectives: Minimalist running is increasing in popularity based upon a concept that it can reduce impact forces and decrease injury rates. The purpose of this investigation is to identify the rate and severity of injuries in runners transitioning from traditional to minimalist footwear. The secondary aims were to identify factors correlated with injuries. Methods: Fourteen habitually shod (traditional running shoes) participants were enrolled for this prospective study investigating injury prevalence during transition from traditional running shoes to 5-toed minimalist shoes. Participants were uninjured, aged between 22-41 years, and ran at least twenty kilometers per week in traditional running shoes. Participants were given industry recommended guidelines for transition to minimalist footwear and fit with a 5-toed minimalist running shoe. They completed weekly logs for identification of injury, pain using Visual Analogue Scale (VAS), injury location, and severity. Foot strike pattern and impact forces were collected using 3D motion analysis at baseline, 4 weeks, and 12 weeks. Injuries were scored according to a modified Running Injury Severity Score (RISS). Results: Fourteen runners completed weekly training and injury logs over an average of 30 weeks. Twelve of 14 (86%) runners sustained injuries. Average injury onset was 6 weeks (range 1–27 weeks). Average weekly mileage of 23.9 miles/week prior to transition declined to 18.3 miles/week after the transition. The magnitude of the baseline impact transient peak in traditional shoes and in minimalist shoes negatively correlated with RISS scores (r = −0.45, p = 0.055 and r = −0.53, p = 0.026, respectively). Conclusion: High injury rates occurred during the transition from traditional to minimalist footwear. Non-compliance to transition guidelines and high injury rates suggest the need for improved education. High impact transient forces unexpectedly predicted lower modified RISS scores in this population.

Editorial Commentary: Platelet-Rich Plasma: Fountain of Youth, Cart Before the Horse, or Both?

Platelet-rich plasma (PRP) injections have gained widespread popularity for the treatment of many orthopaedic conditions including osteoarthritis of the knee. Despite its increasing usage, there is comparatively little evidence regarding the mechanisms of action and relative roles of the multiple growth factors contained within PRP. That said, although future research will clarify the issue, current evidence suggests that PRP is safe and, for the treatment of knee osteoarthritis, effective.

Early Versus Delayed ACL Reconstruction: Why Delayed Surgery Is Our Preferred Choice

Anterior cruciate ligament (ACL) reconstruction in most cases is an elective surgery with many potential complications. Early (non-emergent) surgery may increase the risk of certain complications including significant postoperative stiffness with loss of motion. Delaying surgery by a few weeks to allow the acutely injured knee to regain motion and gain quad control decreases the risk for these adverse effects. However, delayed ACL reconstruction with the intent of returning to normal activities months after the initial injury may lead to an increased risk of injury to cartilage and menisci. By choosing a delayed surgical treatment pathway, we are not intending to return the patient to sports; rather, we plan to get them through the acute inflammatory phase prior to reconstruction. We know by experience and by numerous well-designed studies that returning a patient with a potentially unstable knee to at risk activities including sports and certain occupations can lead to further injuries with irreversible damage.

Review of McGinty, Geuss and Marvin on partial or total meniscectomy

This classic discusses the original 1977 publication of ‘Partial or total meniscectomy: a comparative analysis’, which was the first to critically evaluate the outcomes of a total meniscectomy versus partial meniscectomy. It found that partial meniscectomy led to shorter hospital stays, a quicker recovery and, at an average of 5.5 years postoperatively, a better functional outcome and less radiographic joint space narrowing. This article, combined with other confirmatory studies, had international clinical significance as open total meniscectomies were replaced by open partial meniscectomies, and eventually arthroscopic partial meniscectomies, which became the most commonly performed orthopaedic procedure for much of the ensuing decades.