Nathan T. Morrell

Tibial Tubercle-Trochlear Groove Distance: Defining Normal in a Pediatric Population

BACKGROUND The tibial tubercle-trochlear groove (TT-TG) distance is a useful tool in guiding surgical management for patients with recurrent lateral patellar instability. Current recommendations for tibial tubercle transfer are based on TT-TG distance thresholds derived from adult populations. Recurrent patellar instability, however, frequently affects children, but normal and pathological TT-TG values have not been established for pediatric patients. The objectives of this study were to (1) confirm that magnetic resonance imaging (MRI) measurements for TT-TG distance in a pediatric population are reliable and reproducible, (2) determine whether the TT-TG distance changes with age, (3) define normal TT-TG distances in a pediatric population, and (4) confirm that a subgroup of pediatric patients with patellar instability have higher TT-TG distances. METHODS Six hundred and eighteen MRIs were retrospectively collected for patients who were nine months to sixteen years old. Each MRI was measured twice in a blinded, randomized manner by each reviewer. Patient age, sex, knee laterality, magnet strength, underlying diagnosis, and pertinent previous surgical treatments were all recorded separately from the measurements. MRIs that were unreadable and those of patients who had previous extensor mechanism surgery, preexisting deformity, or destructive neoplasms were excluded. RESULTS There was excellent intraobserver and interobserver reliability of TT-TG distance measurements. TT-TG distance was associated with the natural logarithm of age (p < 0.001). A percentile-based growth chart was created to demonstrate this relationship. The median TT-TG distance for patients without patellar instability in this pediatric population was 8.5 mm (mean and 95% confidence interval, 8.6 ± 0.3 mm). Patients with patellar instability had higher TT-TG distances (median, 12.1 mm; p < 0.001). TT-TG distance measured nearly 2 mm less on MRIs performed with a 3-T magnet than on those acquired with a 1.5-T magnet (p < 0.001). CONCLUSIONS TT-TG distance changes with chronologic age in the pediatric population. As such, we developed a percentile-based growth chart in order to better depict normal TT-TG distances in the pediatric population. Like many issues in pediatric orthopaedics, an age-based approach for directing surgical treatment may be more appropriate for skeletally immature individuals with recurrent lateral patellar instability.

Trends in the orthopedic job market and the importance of fellowship subspecialty training.

Previous studies have examined possible incentives for pursuing orthopedic fellowship training, but we are unaware of previously published studies reporting the trends in the orthopedic job market since the acceptance of certain criteria for fellowship programs by the Accreditation Council for Graduate Medical Education (ACGME) in 1985. We hypothesized that, since the initiation of accredited postresidency fellowship programs, job opportunities for fellowship-trained orthopedic surgeons have increased and job opportunities for nonfellowship-trained orthopedic surgeons have decreased. We reviewed the job advertisements printed in the Journal of Bone and Joint Surgery, American Volume, for the years 1984, 1994, 2004, and 2009. We categorized the job opportunities as available for either a general (nonfellowship-trained) orthopedic surgeon or a fellowship-trained orthopedic surgeon. Based on the advertisements posted in the Journal of Bone and Joint Surgery, American Volume, a trend exists in the orthopedic job market toward seeking fellowship-trained orthopedic surgeons. In the years 1984, 1994, 2004, and 2009, the percentage of job opportunities seeking fellowship-trained orthopedic surgeons was 16.7% (95% confidence interval [CI], 13.1%-20.3%), 40.6% (95% CI, 38.1%-43.1%), 52.2% (95% CI, 48.5%-55.9%), and 68.2% (95% CI, 65.0%-71.4%), respectively. These differences were statistically significant (analysis of variance, P<.05). Fellowship training is thus a worthwhile endeavor.

Opening Wedge Trapezial Osteotomy as Possible Treatment for Early Trapeziometacarpal Osteoarthritis: A Biomechanical Investigation of Radial Subluxation, Contact Area, and Contact Pressure

PURPOSE Radial subluxation and cartilage thinning have been associated with initiation and accelerated development of osteoarthritis of the trapeziometacarpal joint. Few investigators have reported on the benefits of opening wedge trapezial osteotomy for altering the contact mechanics of the trapeziometacarpal joint as a possible deterrent to the initiation or progression of osteoarthritis. We used cadaveric specimens to determine whether opening wedge osteotomy of the trapezium was successful in reducing radial subluxation of the metacarpal base and to quantify the contact area and pressure on the trapezial surface during simulated lateral pinch. METHODS We used 8 fresh-frozen specimens in this study. The flexor pollicis longus, abductor pollicis longus, adductor pollicis, abductor pollicis brevis, and flexor pollicis brevis/opponens pollicis tendons were each loaded to simulate the thumb in lateral pinch position. We measured radial subluxation from anteroposterior radiographs before and after placement of a 15° wedge. We used real-time sensors to analyze contact pressure and contact area distribution on the trapezium. RESULTS Center of force in the normal joint under lateral pinch loading was primarily located in the dorsal region of the trapezium. After wedge placement, contact pressure increased in the ulnar-dorsal region by 76%. Mean contact area increased in the ulnar-dorsal region from 0.05 to 0.07 cm(2), and in the ulnar-volar region from 0.003 to 0.024 cm(2). The average reduction in joint subluxation was 64%. CONCLUSIONS The 15° opening wedge osteotomy of the trapezium reduced radial subluxation of the metacarpal on the trapezium and increased contact pressure and contact area away from the diseased compartments of the trapezial surface. Trapezial osteotomy addresses the 2 preeminent theories about the initiation and progression of osteoarthritis. CLINICAL RELEVANCE By reducing radial subluxation and altering contact pressure and contact area, trapezial osteotomy may prove an alternative to first metacarpal extension osteotomy or ligament reconstruction in early stages of degenerative arthritis of the trapeziometacarpal joint.

Late reconstruction of chronic distal biceps tendon ruptures using fascia lata autograft and suture anchor fixation.

Distal biceps tendon ruptures are a rare injury, and surgical reconstruction is typically recommended for chronic ruptures. There is no consensus regarding the most appropriate reconstruction technique. We present our experience with reconstruction of chronic distal biceps tendon ruptures with fascia lata autograft, secured to the bicipital tuberosity with suture anchors. A single anterior incision is used for all patients. Tension is set with the elbow in 50 degrees of flexion. Ninety-two percent of our patients reported improvement in elbow flexion and supination and were pleased with the surgery. Range of motion and isokinetic flexion and supination strength after this procedure was comparable with other distal biceps tendon reconstruction options using tendon grafts and suture anchor fixation from a single anterior approach. Furthermore, common complications associated with distal biceps tendon repair and reconstruction can be avoided with this technique. We therefore feel that this technique is a viable surgical treatment alternative with good subjective and objective outcomes. Level of Evidence: Level IV.

Partial trapeziectomy with capsular interposition arthroplasty (PTCI): a novel technique for thumb basal joint arthritis.

Introduction: Osteoarthritis of the thumb trapeziometacarpal (basal) joint is a very common problem facing the hand and upper extremity surgeon. Many surgical procedures have been described with varied results. We present the surgical technique—partial trapeziectomy with capsular interposition arthroplasty—used by the senior author over the last 10 years. The essential steps of the procedure are: bony resection of the base of the first metacarpal and the distal trapezium; interposition of a proximally based joint capsule flap; and reefing of periosteal flaps elevated from the first metacarpal and including the abductor pollicis longus tendon. This procedure utilizes capsular tissue as an interposition without ligament reconstruction, eliminating the need for tendon harvest and the morbidity associated with the harvest. The postoperative rehabilitation is simple and can be done at home. An illustrative case is presented. Level of Evidence: Level V.

The use of the Tsuge procedure for pedal macrodactyly: relevance in pediatric orthopedics.

Pedal macrodactyly is a rare clinical entity that poses a challenge to practicing pediatric orthopedic surgeons. Many treatment options have been proposed. In 1967, Kenya Tsuge proposed a method to decrease the length, width, and circumference of a macrodactylous digit, while maintaining the cosmetic benefit of keeping the nail. We retrospectively reviewed our experience with using this technique in four children (six toes) over a 4-year period. The surgery is described and our results reviewed. We believe that the Tsuge procedure is a technically feasible, effective, single-stage reconstructive technique for pedal macrodactyly that pediatric orthopedic surgeons should have in their armamentarium.

Scaphoid Nonunion Advanced Collapse: Scaphoid Excision and 4-Corner Arthrodesis

A 45-year-old male CEO of a financial firm presented with a 3 year history of gradually worsening wrist pain. He recalled injuring his wrist in his 20’s. A physician told him he had broken a “wrist bone” and he had worn a cast for 2 months. He had not had much pain until 3 years ago when he first noticed pain with exercise and weightlifting progressing to pain with most activities of daily living at present. He noticed that he has lost range of wrist motion and also noticed a “hard bump” on the dorsal-radial aspect of the wrist. He has tried a wrist splint, anti-inflammatory medicines and has had a corticosteroid injection into the wrist, all only providing short term relief of symptoms.

Tumor-Induced Rickets Presenting in an Adolescent

Rickets of any etiology is rarely encountered in modern clinical practice, and a primary presentation in an adolescent is even less common. Most cases of rickets are due to abnormalities in vitamin D intake, absorption, activity, or metabolism; others are related to phosphate deficiency from excessive renal excretion (e.g., X-linked dominant hypophosphatemic rickets). When a patient presents with no evidence of hereditary rickets and a standard workup fails to reveal the cause, unusual etiologies must be considered. Tumor-induced hypophosphatemia is a paraneoplastic condition that typically presents with osteomalacia in adults in their fifth decade of life1. We present a case of tumor-induced rickets in a previously healthy adolescent. The patient and his family were informed that data concerning the case would be submitted for publication, and they provided consent. A fourteen-year-old black adolescent presented to the pediatrician with the vague symptoms of bilateral knee and ankle pain, as well as generalized weakness. His mother was concerned that he “walked like a 70-year-old man.” He had no history of trauma or related family history. At the time of presentation, his height was at the 70th percentile and his weight was above the 90th percentile for age. He had no overt skeletal deformities. The pain was initially attributed to “growing pains.” He was prescribed nonsteroidal anti-inflammatory drugs, physical therapy, and shoe insoles. When the pain did not remit over the subsequent seven months, he was referred to a primary care sports medicine clinic where he was diagnosed with bilateral patellofemoral syndrome and bilateral pes planus. Radiographs of the knees obtained at that time demonstrated notable physeal widening and generalized demineralization of the cortices bilaterally (Fig. 1). Laboratory assessment was initiated (Table I). He was diagnosed with vitamin D deficiency and hypophosphatemic rickets and was prescribed calcitriol as well as sodium …

Isolated Distal Posterior Interosseous Nerve Palsy Mimicking Extensor Pollicis Longus Tendon Rupture

Relative to median and ulnar nerve pathology, posterior interosseous nerve (PIN) palsy is a rare clinical entity. Four types of PIN palsy have been described: type 1, in which there is both a drop-finger and drop-thumb deformity; type 2, in which there is an isolated drop-finger deformity; type 3, in which there is an isolated drop-thumb deformity; and type 4, in which there is an isolated palsy of the extensor pollicis longus (EPL). To the best of our knowledge, we present the second reported case in the English-language literature of a patient with type-4 PIN palsy. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A seventy-one-year-old right-hand-dominant man presented with the inability to extend the interphalangeal (IP) joint of the right thumb. The patient first noted this inability while lifting something heavy a week prior to presentation; he mentioned that the “knuckles popped.” The patient had a history of HLA-B27-positive inflammatory arthropathy (treated with adalimumab), as well as a history of hypothyroidism (treated with levothyroxine); both conditions had been well controlled for years. He denied any previous tendon ruptures or functional limitation in the right hand prior to presentation. Clinical examination demonstrated no active extension of the IP joint of the right thumb and inability to raise the thumb in line with the second metacarpal when the hand was placed flat on a table. Thumb IP joint extension by the tenodesis effect was equivocal. No masses were appreciated, and no obvious defects were palpable within the EPL tendon to Lister tubercle. He had full passive range of motion of the thumb IP joint. He had full function in all other radial nerve and PIN-innervated muscles; in particular, he had full strength of isolated index finger extension. He had no sensory …