Michael S. Guss

Everything Achilles: Knowledge Update and Current Concepts in Management: AAOS Exhibit Selection.

Achilles tendon pathology is common and affects athletes and nonathletes alike. The cause is multifactorial and controversial, involving biological, anatomical, and mechanical factors. A variety of conditions characterized by Achilles tendon inflammation and/or degeneration can be clinically and histologically differentiated. These include insertional Achilles tendinopathy, retrocalcaneal bursitis, Achilles paratenonitis, Achilles tendinosis, and Achilles paratenonitis with tendinosis. The mainstay of treatment for all of these diagnoses is nonoperative. There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains.

Return to Play and Performance After Jones Fracture in National Basketball Association Athletes

Background: Basketball players are at risk for foot injuries, including Jones fractures. It is unknown how this injury affects the future play and performance of athletes. Hypothesis: National Basketball Association (NBA) players who sustain Jones fractures of the base of the fifth metatarsal have high rates of return to play and do not experience a decrease in performance on return to competition when compared with preinjury and with control-matched peers. Study Design: Retrospective cohort study. Level of Evidence: Level 5. Methods: Data on 26 elite basketball players with Jones fractures over 19 NBA seasons (1994-1995 to 2012-2013) were obtained from injury reports, press releases, player profiles, and online public databases. Variables included age, body mass index (BMI), player position, experience, and surgical treatment. Individual season statistics pre- and postinjury were collected. Twenty-six controls were identified by matched player position, age, and performance statistics. Results: The mean age at the time of injury was 24.8 years, mean BMI was 24.7 kg/m2, and the mean experience prior to injury was 4.1 NBA seasons. Return to previous level of competition was achieved by 85% of athletes. There was no change in player efficiency rating (PER) when pre- and postinjury performance was compared. When compared with controls, no decline in PER measured performance was identified. Conclusion: The majority of NBA players sustaining a Jones fracture return to their preinjury level of competition. These elite athletes demonstrate no decrease in performance on their return to play. Clinical Relevance: Jones fractures are well-studied injuries in terms of etiology, diagnosis, and management. However, the effect of these injuries on future performance of athletes is unknown. Using the findings of our study, orthopaedic surgeons may be better prepared to counsel and educate elite athletes who sustain a Jones fracture.

Complications in Operative Scheuermann Kyphosis: Do the Pitfalls Differ from Operative Adolescent Idiopathic Scoliosis?

Study Design. A prospective multicenter database of operative patients with Scheuermann kyphosis (SK) with minimum 1-year follow-up was studied for major complications compared with contemporaneous operative patients with adolescent idiopathic scoliosis (AIS) from the database. Objective. To evaluate complications associated with current surgical techniques in SK and AIS. Summary of Background Data. There is a paucity of literature regarding complications associated with SK surgical treatment, but prior data suggest an elevated neurological risk. Methods. Complication rates were compared using analysis of variance and Fisher exact test analyses. Major complications were those that were life-threatening, caused spinal cord, nerve root, or ocular injury or required reoperation including surgical site infections. A binary logistic regression determined the likelihood of complications based on diagnosis, levels fused, blood loss, operative time, and length of stay. Results. Ninety-seven patients with SK (57 males; mean age, 16.5 yr; 75.3° mean kyphosis) and 800 patients with AIS (622 females; mean age, 14.9 yr; 55.6° mean curvature) met inclusion criteria. Patients with SK had significantly more major complications than those with AIS (16.3% vs. 2.3%; P < 0.001). The SK group had more infections (10.3% vs. 0.75%) and reoperations (14.4% vs. 1.4%) (P < 0.001). Operative time was longer and more levels were fused in the SK group (P < 0.001). Surgical site infection was the most common complication. There were no significant differences in length of stay or blood loss. Patients with SK were 3.9× more likely to have a major complication than those with AIS (odds ratio: 0.26, P = 0.003). The number of levels fused was an independent predictor of major complications: each additional level fused increased the odds of a complication by 36% in both groups (odds ratio: 1.36, P = 0.034). Conclusion. Major complications are 3.9× more likely to occur in operative SK than in AIS. The number of levels fused is an independent risk factor for major complications. Patients with SK are at higher risk for infections and reoperation than those with AIS. Level of Evidence: 2

Performance Outcomes After Metacarpal Fractures in National Basketball Association Players

Background: The aim was to determine whether players in the National Basketball Association (NBA) who sustain metacarpal fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. Methods: Data for 32 NBA players with metacarpal fractures incurred over 11 seasons (2002-2003 to 2012-2013) were obtained from injury reports, press releases, and player profiles (www.nba.com and www.basketballreference.com). Player age, body mass index (BMI), position, shooting hand, number of years in the league, and treatment (surgical vs nonsurgical) were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury, including player efficiency rating (PER), were obtained. Thirty-two controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. Results: Mean age at the time of injury was 27 years with an average player BMI of 24. Players had a mean 5.6 seasons of NBA experience prior to injury. There was no significant change in PER when preinjury and postinjury performances were compared. Neither injury to their shooting hand nor operative management of the fracture led to a decrease in performance during the 2 seasons after injury. When compared with matched controls, no significant decline in performance in PER the first season and second season after injury was found. Conclusion: NBA players sustaining metacarpal fractures can reasonably expect to return to their preinjury performance levels following appropriate treatment.

Symptomatic venous thrombo-embolism in low-energy isolated fractures in hospitalised patients.

INTRODUCTION In the prevention of venous thrombo-embolic events (VTEs) in isolated low-energy fracture patients, management guidelines are conflicting and prior literature is lacking. We aimed to determine the incidence and factors associated with the development of symptomatic VTE in this patient cohort. MATERIALS AND METHODS To identify patients with isolated, low-energy fractures, we studied billing records from all admissions to our tertiary care orthopaedic hospital from 2007 to 2009. We used International Classification of Diseases, 9th Revision codes to identify patients who developed deep vein thrombosis (DVT) and/or pulmonary embolism (PE) during their hospital admission or within 90 days of discharge. We also collected data on socio-demographics, type of injury, fracture treatment, co-morbidities and anticoagulation therapy at time of admission. This study was a retrospective review of a database. RESULTS In total, 1701 admissions fit our criteria. Average patient age was 64.27 years and 64.4% were female. There were 479 (28.2%) upper extremity fractures and 1222 (71.8%) lower extremity fractures. Incidence of clinically significant VTE was 1.4%. Of the 24 patients with 25 documented VTE, there were 13 DVTs and 12 PEs, including 2 fatal PEs (0.012%). Nineteen VTEs occurred in association with lower extremity fractures and six with upper extremity fractures; 74% of patients were chemoprophylaxed. Patients with VTE had an average age of 69.5 years and an average body mass index (BMI) of 28 kgm(-2). Logistical regression analysis found female sex (p = 0.05) and elevated BMI (p = 0.003) to be the only significant predictors of VTE. CONCLUSIONS Clinically significant VTE among patients who sustained isolated, low-energy fractures was found to be low in the setting of standard VTE prophylaxis. Our incidence was consistent with that of patients undergoing total hip arthroplasty. Female sex and increased BMI were statistically significant predictors of VTE.

Evaluation of Automated Volumetric Cartilage Quantification for Hip Preservation Surgery

Automating the process of femoroacetabular cartilage identification from magnetic resonance imaging (MRI) images has important implications to guiding clinical care by providing a temporal metric that allows for optimizing the timing for joint preservation surgery. In this paper, we evaluate a new automated cartilage segmentation method using a time trial, segmented volume comparison, overlap metrics, and Euclidean distance mapping. We report interrater overlap metrics using the true fast imaging with steady-state precession MRI sequence of 0.874, 0.546, and 0.704 for the total overlap, union overlap, and mean overlap, respectively. This method was 3.28× faster than manual segmentation. This technique provides clinicians with volumetric cartilage information that is useful for optimizing the timing for joint preservation procedures.

Acute Scapholunate Ligament Instability

THE PATIENT A 31-year-old right-hand-dominant male professional dancer felt pain during hyperextension of his right wrist attempting to pick up his dance partner 2 weeks before presentation. He presents with pain and weakness in the right wrist. There is obvious swelling and tenderness dorsally at the scapholunate (SL) interval of the right wrist. His grip strength is measured 20% of the uninvolved side using a hand dynamometer. The scaphoid shift test was too painful to perform. A posteroanterior static wrist radiograph demonstrates an SL interval of 4 mm and a cortical ring sign. The lateral wrist radiograph reveals a radiolunate angle of 30 and an SL angle of 95 .

Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players

BACKGROUND We sought to determine whether professional baseball positional players who underwent medial ulnar collateral ligament (MUCL) reconstruction demonstrate decreases in performance on return to competition compared with preoperative performance metrics and their control-matched peers. METHODS Data for 35 Major League Baseball positional players who underwent MUCL reconstruction during 31 seasons were obtained. Twenty-six players met inclusion criteria. Individual statistics for the 2 seasons immediately before injury and the 2 seasons after injury included wins above replacement (WAR), on-base plus slugging (OPS), and isolated power (ISO). Twenty-six controls matched by player position, age, plate appearances, and performance statistics were identified. RESULTS Of the 35 athletes who underwent surgery, 7 did not return to their preinjury level of competition (return to play rate of 80%). In comparing preinjury with postinjury statistics, players exhibited a significant decrease in plate appearances, at-bats, and WAR 2 seasons after injury but did not demonstrate declines in WAR 1 season after injury. Compared with matched controls, athletes who underwent MUCL reconstruction did not demonstrate significant decline in statistical performance, including OPS, WAR, and ISO, after return to play from surgery. Of all positional players, catchers undergoing surgery demonstrated lowest rates of return to play (56%) along with statistically significant decreases in home run rate, runs batted in, and ISO. CONCLUSION Major League Baseball positional players undergoing MUCL reconstruction can reasonably expect to return to their preinjury level of competition and performance after surgery compared with their peers. Positional players return to play at a rate comparable to that of pitchers; catchers may experience more difficultly in returning to preinjury levels of play.

Scaphoid Healing Necessary for Unrestricted Activity: A Biomechanical Cadaver Model

PURPOSE To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid. METHODS Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoids distal pole. Load to failure and stiffness were measured. RESULTS Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control. CONCLUSIONS A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending. CLINICAL RELEVANCE This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.

Microsurgery Case Volume During Orthopedic Surgery Residency: A 7-Year Assessment

Background: Microsurgery is a specialized surgical technique with wide clinical application. The purpose of this study was to analyze case logs of graduating orthopedic surgery residents to assess trends in case volume for microsurgery procedures. Methods: Accreditation Council for Graduate Medical Education case log reports were analyzed for microsurgery experience from 2007 to 2013. The mean number of adult, pediatric, and total microsurgery cases was noted. In addition, the median number of microsurgery procedures performed by the 90th, 50th, and 10th percentiles of residents (by case volume) was recorded. Temporal changes in case volume were calculated utilizing linear regression analyses. Results: The proportion of microsurgery procedures increased significantly (1.3% to 2%; P = .024). The mean number of adult (24.5 to 41.9; P = .01), pediatric (1.9 to 3.4; P = .011), and total (26.3 to 45.3; P = .01) microsurgery procedures also increased significantly. Similarly, residents in both the 90th (63 to 109; P = .01) and 50th (10 to 21; P = .036) percentiles sustained significant increases in the median number of microsurgery procedures. No change was noted for residents in 10th percentile (0 to 0; P > .999). Graduating residents in the 90th percentile performed over 6 times more microsurgery procedures than residents in the 50th percentile. Conclusions: Microsurgical caseload is increasing among graduating orthopedic residents. However, there is substantial variability in resident microsurgery case volume. Future investigations are needed to explore the educational implications of these findings and should seek to correlate microsurgical caseload with competency.