Fellowship-trained Orthopaedic Surgeons Research Articles

2022 J. Leonard Goldner Award Winner: Passive Eversion Assessment for Progressive Collapsing Foot Deformity after Lateral Column Lengthening: A Cadaveric Biomechanical Study

Category: Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Lateral column lengthening (LCL) is an established procedure for progressive collapsing foot deformity (PCFD) patients. While functional improvements are often reported after LCL, increased post-surgical lateral foot pain, attributed to decreased subtalar joint motion, remains a concern. The optimal wedge size is determined intraoperatively by measuring passive eversion of the hindfoot to ensure adequate eversion motion and radiographic correction. However, it is unknown whether a subjective assessment of passive eversion is associated with objective postoperative measurements of foot stiffness, such as plantar pressure. Our goal was to quantify the relationship between eversion during a passive assessment and plantar pressures during simulations of level walking. We hypothesized that a strong relationship exists between the location of plantar pressure and the eversion measured with passive manipulation. Methods: A deformity was created in ten mid-tibia cadaveric specimens (four female, age range: 35-72) by transecting the spring ligament and medial talonavicular joint capsule followed by cyclic loading. A six degrees-of-freedom robotic gait simulator was used to simulate the stance phase of level walking. Joint kinematics and plantar pressure data were collected during each simulation. A passive assessment of hindfoot eversion was then conducted manually by a fellowship-trained orthopaedic surgeon and recorded by the motion capture system. Five conditions were tested: intact, PCFD, and three LCL wedge conditions (4, 6, 8mm). Outcome measures for each condition included the lateral-to-medial forefoot plantar pressure ratio during walking simulations and the peak subtalar eversion measured during the assessment. A linear mixed effects model was used to determine the association between the plantar pressure and LCL wedge thickness. Pearson correlation coefficients were calculated to determine the relationship between subtalar eversion and plantar pressure. Results: There was a significant relationship between the size of LCL wedge and the forefoot lateral-to-medial average pressure ratio (p<0.001). Every 2mm increase in LCL wedge size resulted in a 0.20 +- 0.03 increase in the LM ratio, indicating a significant lateral shift in plantar pressure with each increase in wedge size. The 4mm wedge was most effective in restoring plantar pressure and eversion to intact (Figure 1). The peak subtalar eversion measured during the assessment decreased with an increase in the size of the LCL wedge. A strong correlation (r(38)=0.51, p<0.01) was found between the LM ratio and the peak subtalar eversion. This indicates that a decrease in the eversion measured during passive assessment is strongly associated with a lateral shift in plantar pressure. Conclusion: This study demonstrates that reduced eversion following LCL is associated with increased lateral plantar pressure which is consistent with stiffness and lateral plantar pain that is a well-known complication of this surgery. Passive eversion measurement is likely to help predict functional performance. The 4mm wedge best restored outcomes to normal, whereas larger wedges resulted in increased lateral loading and decreased eversion. A change in correction of 2mm made a significant difference in loss of eversion motion and minimizing the amount of lengthening is strongly recommended.

Assessing the Accuracy, Quality, and Readability of Online Patient Resources on Achilles Tendonitis

Category: Other; Hindfoot Introduction/Purpose: The internet is full of websites focused on different medical topics. With such a large accumulation of information, patients should be able to rely upon the internet as a reliable source for information on common medical conditions such as Achilles tendonitis. However, the question remains as to the accuracy, quality and readability of such online patient resources. Consumers themselves commonly evaluate online medical sites by trustworthiness, expertise, and objectivity. The purpose of this study was to investigate the top search-engine-generated online resources for Achilles tendonitis for their content and accuracy. Methods: The term 'Achilles tendonitis' was searched using the three most population search engines. The first 50 sites from each search were recorded. Duplicate sites were eliminated. Sites were categorized based on authorship type. Each website was independently evaluated by two reviewers. Quality was evaluated utilizing the DISCERN score and the Journal of the American Medical Association (JAMA) benchmark criteria. Accuracy was evaluated using a novel Achilles tendinosis-specific content rubric developed with a foot and ankle fellowship-trained orthopaedic surgeon and the AAOS OrthoInfo webpage, similar to previous studies. Readability was evaluated using the Flesch Kincaid grade level (FKGL) and Flesch Reading Ease (FRE) formulas. Higher FRE scores indicate better readability. FKGL was also compared against an 8th grade level, which represents the average US reading level. Results: The search resulted in 77 unique websites with 60 sites included for analysis. The average DISCERN score in our investigation is 42.1 which places it in the 'fair' category. Commercial websites were found to have higher DISCERN scores as compared to websites created by physicians or medical groups as well as academic websites. Our study found an average JAMA quality benchmark score of 2.2 out of 4. Our study found that on average, online patient resources on Achilles tendinosis was written at a 9th grade reading level with a FKGL score of 9.8. Academic websites were found to be written at a significantly lower reading level of 8.8. The average FRE score was 53.28 which translates to the 'fairly difficult' category. Utilizing our own content scoring system to assess the accuracy of online resources, the websites had an average accuracy of 11.5 points out of 20 possible points. Conclusion: The average online patient resource on Achilles tendinosis is too complex for the average patient, inaccurate, and is of low quality. This study found that the average website had low quality as measured by the DISCERN and JAMA benchmark scores. The average accuracy was also low as measured by our novel content specific score. The websites were also difficult to read as measured by the FRE and FKGL scores. More emphasis on improving the readability, quality, and accuracy of online patient resources on Achilles tendinosis should be undertaken in order to improve patient healthcare.

The Incidence of Posterolateral Tibial Plateau and Central Lateral Femoral Condylar Impaction Fractures in a Pediatric and Young Adult Population.

Posterolateral tibial plateau and central lateral femoral condylar impaction fractures are known to occur in the setting of anterior cruciate ligament (ACL) tears. There have been no prior investigations into the incidence and morphology of posterolateral tibial plateau impaction fractures in the setting of ACL injury in a pediatric population. Patients between 9 and 22 years of age with knee magnetic resonance imagings (MRIs) performed demonstrating complete or partial ACL tear were included in this study. MRI reports were reviewed to denote the presence of posterior cruciate ligament, medial collateral ligament, or lateral collateral ligament injury, meniscus tears, cartilage lesions. MRIs were reviewed by 2 fellowship-trained orthopaedic surgeons to denote the presence of posterolateral tibial plateau and central lateral femoral condylar impaction fractures and physeal status of femoral and tibial physes. Statistical analysis performed included χ 2 analysis and the Student t testing. A total of 328 patients with a primary ACL tear were identified. The mean age of patients included was 16.5 years (range: 9.0-21.5). The incidence of posterolateral tibial plateau impaction fractures was 83/328 (25.3%) while the incidence of lateral femoral condylar impaction fractures was 119/328 (36.3%). Bipolar impaction fractures occurred in 37/328 (11.3%). Of the 83 tibial impaction fractures identified, 82 were low-grade morphologic subtypes. Patients with lateral tibial plateau impaction fractures were older than those with no fracture (17.2±2.2 vs. 16.3±2.1, P =0.001). Only 3/38 (7.9%) patients with an open tibial physis sustained a tibial plateau impaction fracture compared with 80/290 (27.6%) with a closed tibial physis (χ 2 value: 6.9, P =0.009). There was no difference in proportion of patients with lateral femoral condylar impaction fractures based on femoral physeal status ( P =0.484). The incidence of posterolateral tibial plateau impaction fractures in the setting of ACL tear in a pediatric and young adult patient population appears to be lower while lateral femoral condylar impaction fractures occur more frequently when comparing to previously reported incidences found in adult populations in the literature. Furthermore, posterolateral tibial plateau impaction fractures occur less frequently in those with an open proximal tibial physis and high-grade posterolateral tibial plateau bone loss is exceedingly rare in pediatric and young adult patients. Lateral femoral condylar impaction fractures are associated with lateral meniscal tears and medial meniscal ramp lesions. Level IV-cross-sectional study.

“You’re O.K. Anesthesia”: Closed Reduction of Displaced Pediatric Forearm and Wrist Fractures in the Office Without Anesthesia

Angulated wrist and forearm fractures are among the most common pediatric fractures, and they often require closed reduction with anesthesia. There are several issues associated with pediatric anesthesia including the low but non-zero risk of significant complications, increased physician and staff time and effort, and increased cost. Despite these issues, there have not been any studies to prove that using anesthesia results in better outcomes or higher caregiver satisfaction in comparison to performing closed reductions without anesthesia. The purpose of this study was to evaluate the quality of closed reductions of angulated pediatric wrist and forearm fractures and to determine caregiver satisfaction with an anesthesia-free reduction technique. This study included 54 pediatric patients with closed, angulated fractures of the radius or combined radial and ulnar shafts. All closed reductions were performed by a single pediatric fellowship-trained orthopaedic surgeon in the office setting without any anesthesia. Radiographs were obtained to assess the quality of the reduction. At the first follow-up visit, caregivers were asked about their interim use of pain medications. Caregivers were later surveyed about patient use of analgesics and their satisfaction with an anesthesia-free reduction technique. The average age of the 54 patients in this study was 9 years (1.8 to 16.8y). Thirty-three fractures were combined radial and ulnar forearm shaft fractures, 18 were distal radius fractures, and 3 were radial shaft fractures. ≤10 degrees of residual angulation was achieved in 98% of patients. Nine percent (5/54) of the patients used ibuprofen or acetaminophen for pain control. Seventy eight percent (42/54) of the caregivers responded to the telephone and email surveys. All responding caregivers stated that the patients returned to full function and had satisfactory outcomes. Ninety eight percent (41/42) of the caregivers stated they would choose the same anesthesia-free reduction technique again. Closed reduction of angulated pediatric wrist and forearm fractures in the office without anesthesia can achieve satisfactory reductions and high caregiver satisfaction while eliminating the risks and complications associated with pediatric anesthesia. Level IV Case series.

The First Tarsometatarsal Joint in Lisfranc Injuries.

Lisfranc injuries are among the most debilitating injuries to the foot. Characterization of first tarsometatarsal (TMT) joint involvement in Lisfranc injuries is limited. Multiple studies have indicated that this joint is damaged in a variety of Lisfranc injury patterns, but there is sparse information regarding how often and in what form. A retrospective review was performed of operative Lisfranc fractures from 2010 to 2020 with patients identified by Combined Procedural Terminology codes. Hardcastle and Myerson Lisfranc injury classifications and computed tomography and radiograph characterizations of the first TMT joint were evaluated by 3 foot and ankle fellowship-trained orthopaedic surgeons. Radiographic characteristics were collected. Light's kappa coefficient evaluated interrater reliability for injury classification. Injury mechanism and Lisfranc classification effects on the first TMT joint were further assessed using inferential statistics. Of 71 patients with a Lisfranc injury of which 37 (52%) were high energy, 61 (86%) showed radiographic evidence of first TMT joint injury. A fragment was present in the TMT articular surface in 33 (47%) with median size = 8.7 mm and medial capsular avulsion in n = 25 (35%). Forty-eight patients (68%) had medial/lateral TMT joint incongruence ≥2 mm (median overhang = 4 mm), 21 (30%) had dorsal/plantar incongruence (median overhang = 6 mm). Angulation of TMT articular surfaces ≥5 degrees on the transverse/anteroposterior plane occurred in n = 32 (45%) and in n = 12 (17%) on the sagittal/lateral plane, which significantly differed between classifications (P = .020). The overwhelming majority of Lisfranc midfoot injuries seen at our tertiary referral center had imaging evidence of damage to the first TMT joint (86%), and the incidence may be higher. The most common patterns of first TMT joint involvement we found were joint incongruity, articular surface fractures, angulation of the articular surfaces, and medial capsular ligament avulsion fractures. A better understanding of injuries to the first TMT joint can help orthopaedic surgeons with diagnosis.

Prevalence of femoroacetabular impingement in elite baseball players.

ABSTRACTCAM-type femoroacetabular impingement continues to be an underrecognized cause of hip pain in elite athletes. Properties inherent to baseball such as throwing mechanics and hitting may enhance the risk of developing a cam deformity. Our goal is to gain an appreciation of the radiographic prevalence of cam deformities in elite baseball players. Prospective evaluation and radiographs of 80 elite baseball players were obtained during the 2016 preseason entrance examination. A sports medicine fellowship-trained orthopedic surgeon with experience treating hip disorders used standard radiographic measurements to assess for the radiographic presence of cam impingement. Radiographs with an alpha angle >55° on modified Dunn views were defined as cam positive. Of the 122 elite baseball players included in our analysis, 80 completed radiographic evaluation. Only 7.3% (9/122) of players reported hip pain and 1.6% (4/244) had a positive anterior impingement test. The prevalence of cam deformities in right and left hips were 54/80 (67.5%) and 40/80 (50.0%), respectively. The mean alpha angle for cam-positive right and left hips were 64.7 ± 6.9° and 64.9 ± 5.8°, respectively. Outfielders had the highest risk of right-sided cam morphology (Relative Risk (RR) = 1.6). Right hip cam deformities were significantly higher in right-handed pitchers compared with left-handed pitchers (P = 0.02); however, there was no significant difference in left hip cam deformities between left- and right-handed pitchers (P = 0.307). Our data suggest that elite baseball players have a significantly higher prevalence of radiographic cam impingement than the general population.

Radiographic Assessment of Ankle Fracture Displacement: A Validation Study

Ankle fracture displacement is an important outcome in clinical research examining the effectiveness of surgical and rehabilitation interventions. However, the assessment of displacement remains subjective without well-described or validated measurement methods. The aim of this study was to assess inter- and intrarater reliability of ankle fracture displacement radiographic measures and select measurement thresholds that differentiate displaced and acceptably reduced fractures. Eight fellowship-trained orthopaedic surgeons evaluated a set of 26 postoperative ankle fracture radiographs on 2 occasions. Surgeons followed standardized instructions for making 5 measurements: coronal displacement (3) talar tilt (1), and sagittal displacement (1). Inter- and intraobserver interclass correlations were determined by random effects regression models. Logistic regression was used to determine the optimal sensitivity and specificity for the measurements with the highest correlation. Three of the 5 measures had excellent interobserver reliability (correlation coefficient > 0.75): (1) coronal plane distance between the lateral border of tibia and lateral border of talus, (2) coronal plane talar tilt, and (3) sagittal plane displacement. The threshold that best discriminated displaced from well-aligned fractures was 2 mm for coronal plane distance (sensitivity 82.1%, specificity 85.4%), 3 degrees for talar tilt (sensitivity 80.4%, specificity 82.2%), and 5 mm for sagittal plane distance (sensitivity 83.9%, specificity 84.9%). This study identified 3 reliable measures of ankle fracture displacement and determined optimal thresholds for discriminating between displaced and acceptably reduced fractures. These measurement criteria can be used for the design and conduct of clinical research studying the impact of surgical treatment and rehabilitation interventions.

Poster 175: Beach Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Posterior Shoulder Stabilization

Objectives:There are no studies that directly compare beach chair (BC) versus lateral decubitus (LD) position for arthroscopic treatment of posterior instability. In the few systematic reviews evaluating BC vs. LD, no difference had been demonstrated in regard to recurrence and revision rates. Additionally, bone loss was not accounted for in the recurrence rate. The purpose of this study is to identify predictors of shoulder instability recurrence and revision after posterior shoulder stabilization surgery in a young, high demand population and evaluate surgical position and glenoid bone loss as independent predictors of the outcomes of interest, recurrence and revision at short- and mid- term follow-up.Methods:A consecutive series of 147 arthroscopic posterior stabilization procedures were performed by sports medicine certified and fellowship trained orthopaedic surgeons from 2005-2019 in either the BC or LD position. Patients were included if they underwent an isolated primary arthroscopic posterior capsulolabral repair. Patients were excluded if concomitant anterior labral repair was performed at the time of surgery. Shoulders were additionally excluded if magnetic resonance imaging (MRI) was not available at the time of preoperative evaluation, or the patient was lost to follow up. All shoulders were evaluated for glenohumeral bone loss using the best-fit circle technique on the sagittal enface MRI. The primary outcomes of interest were recurrent instability and revision stabilization. Recurrent instability was defined as the presence of a recurrent pain limiting activities with physical exam consistent with recurrent posterior instability per clinical notes in the electronic medical record. Rates of recurrence and revision were calculated among the full cohort among patients with available 1-year or 5-year follow up. Patient and procedure characteristics were compared by BC or LD group using two sample t-tests or Chi-square tests.Results:A total of 147 shoulders with a mean age of 22.6 years (4.82 SD) underwent isolated arthroscopic repair and were followed for a mean 6.93 (3.29 SD) years. The overall recurrent instability and revisions rates were 16% (23/147) and 12% (18/147), respectively. With respect to surgical position, there was no significant difference in recurrence or revision (p-value >0.05). With respect to patient age, anchor number, and bone loss there was no significant difference in recurrence or revision with respect to patient age (p-value >0.05).Conclusions:Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrent instability and revision surgery after performing arthroscopic stabilization for isolated posterior shoulder instability in a high demand population in either the BC or LD position.

Poster 111: Poor Inter-observer Reliability of TT-TG Measurement Among Orthopaedic Sports Medicine Surgeons Regardless of Measurement Technique

Objectives:Tibial tubercle-trochlear groove distance (TT-TG) is an important radiologic parameter in the diagnosis and treatment of patellar instability. However, there is substantial heterogeneity in the literature regarding the most appropriate measurement protocol for assessing TT-TG distance. The objective of this study was to evaluate the inter- and intra-observer reliability of TT-TG distance measurement in healthy knees performed by fellowship-trained orthopaedic sports medicine surgeons.Methods:A convenience sample of 29 magnetic resonance imaging scans (MRIs) of the knee was assembled after screening to ensure there was no ligamentous rupture, meniscal pathology, cartilage injury, subchondral edema, or abnormal masses in the bone or muscle. An a priori power analysis determined that this number of MRIs would provide greater than 90% power to detect a statistically significant difference in intraclass correlation of 0.95 (a < 0.05). Three fellowship-trained orthopaedic sports medicine surgeons read the MRIs and recorded the TT-TG distance using their method of choice. After a minimum of 5 months, the MRIs were read again, this time using a standardized evidence-based method to measure the TT-TG distance. Kappa statistics were calculated to evaluate inter- and intra-observer reliability.Results:Among the initial TT-TG distance measurements, kappa was equal to -0.006 (P = 0.690) when assessing inter-observer reliability. Introduction of the standardized measurement protocol was associated with no significant change in inter-observer reliability (kappa = 0.124, P = 0.070). The individual TT slice that was selected for TT-TG distance measurement demonstrated a kappa statistic of 0.192 (P < 0.001) for the surgeons’ method of choice and a kappa statistic of 0.037 (P = 0.455) for the standardized method. Similarly, TG slice selection using the surgeons’ method of choice yielded a kappa statistic of -0.005 (P = 0.949) and a kappa statistic of -0.102 (P = 0.140) for the standardized method.Conclusions:Our findings demonstrate poor inter-observer reliability of TT-TG distance measurement in healthy knees that was not improved with the application of a standardized evidence-based measurement protocol. TT and TG slices selected by surgeons varied widely. Future research should focus on comparing TT-TG distance measurements across a wider variety of knees (ranging from healthy to those with patellar instability), as this may improve the inter-observer reliability of TT-TG measurement.Table I.Variation in TT-TG Distance Measurement and MRI Slice Selection Between Surgeons

Poster 259: Compartmental Static Anterior Tibial Translation After ACL Reconstruction: A Quantitative MRI Study

Objectives:Post-traumatic osteoarthritis (PTOA) develops in 50% of individuals who sustain an anterior cruciate ligament (ACL) injury. The mechanisms responsible for accelerated cartilage deterioration in ACL-injured knees are not well established. Abnormal tibiofemoral spatial relationship, resulting from ACL deficiency, has been purported as a potential contributor to altered cartilage loading and, consequently, accelerated PTOA. On magnetic resonance imaging (MRI), ACL-injured knees have been found to exhibit excess static anterior tibial translation (ATT) relative to control knees of separate, uninjured patients (Figure 1). However, the quantitative extent of ATT restoration following ACL reconstruction (ACLR) is largely unknown. We aimed to determine if ACLR restores static ATT in the lateral and medial compartments in comparison to the contralateral knee. We hypothesized that ACLR would not restore static ATT of the lateral and medial compartments back to the normal position.Methods:A prospective cohort study consisting of 30 patients with an acute ACL injury, with or without reparable meniscus tears, was designed. All patients underwent ACLR, performed by fellowship-trained orthopaedic surgeons using an anatomic, single bundle technique with accessory anteromedial portal drilling using autografts. MRI scans of both the injured and uninjured knees were performed 1) preoperatively within one month of ACL injury and 2) postoperatively six months after reconstruction. ATT of the lateral tibial plateau (LTP) and medial tibial plateau (MTP) were measured using a previously validated measurement method (Figure 2). This method entails identifying the mid-sagittal T1 MRI slice of the LTP and of the MTP. On each slice, the posterior aspect of the femoral condyle is located by plotting a best-fit ellipse to the condyle. The posterior aspect of the tibial plateau is then also identified. ATT for each compartment is then calculated as the anterior-to-posterior distance between tangential lines coincident with the posterior aspect of the femoral condyle and tibial plateau (Figure 2). Two-way analysis of variance (ANOVA) testing was performed to compare ATT between knees before and six months after ACLR. The two requisite factors for two-way ANOVA testing were limb, i.e. injured vs. uninjured, and time, i.e. preop vs. six months postop.Results:ACL-injured knees exhibited higher LTP ATT than uninjured control knees, regardless of timepoint (Pre-op: Injured = 5.73 ± 2.67mm; Uninjured = 3.35 ± 2.06mm. 6 months post-op: Injured = 4.81 ± 2.38mm; Uninjured = 3.36 ± 1.96mm, p < 0.001). LTP ATT trended towards decreasing in the injured limb after ACLR but this difference did not reach statistical significance (p for limb x time interaction = 0.053, Figure 3). ACL-injured knees also exhibited higher MTP ATT than uninjured control knees, regardless of timepoint (Pre-op: Injured = 1.52 ± 2.58mm; Uninjured = -0.12 ± 2.44mm. 6 months post-op: Injured = 1.46 ± 2.46mm; Uninjured = 0.07 ± 2.46mm, p < 0.001). MTP ATT did not change after ACLR as there was no significant interaction of limb x time (p = 0.486, Figure 4).Conclusions:ACLR did not restore pathologic ATT of the LTP and MTP back to levels present in uninjured knees. Persistent pathologic tibiofemoral relationships may contribute to abnormal cartilage loading over time and possible accelerated PTOA. Further study of early chondral changes after ACLR is necessary to elucidate if compartment-specific ATT is associated with local cartilage degeneration. Such understanding of the mechanistic factors responsible for PTOA after ACL injury may inform future potential preventative interventions.Figure 1.Pathologic anterior tibial translation (ATT) seen after ACL ruptureFigure 2.MRI ATT measurement method in lateral compartment of injured knee. Line 1 intersects the posterior tibia. Line 2 intersects the posterior femoral condyle. ATT is the AP distance between Line 1 and Line 2.Figure 3.Lateral Tibial Plateau ATTFigure 4.Medial Tibial Plateau ATT

Utilization of MRI in surgical decision making in the shoulder

BackgroundThe aim of this study is to evaluate both the utility of MRI scans and reports used in the current practice routine of shoulder surgeons and their surgical decision-making process.MethodsNinety-three shoulder-specialised orthopaedic surgeons of the Canadian Shoulder and Elbow Society (CSES) Orthopaedic Association were surveyed in 2020 anonymously online to help identify the use of MR-imaging and reports in managing shoulder disorders and surgical decision process.ResultsThirty out of 93 (32.25%) CSES fellowship-trained orthopaedic surgeons participated. Respondents request MRI scans in about 55% of rotator cuff (RC) pathology and 48% of shoulder instability cases. Fifty percent of patients with potential RC pathology arrive with a completed MRI scan prior first orthopaedic consult. Their surgical decision is primarily based on patient history (45–55%) and physical examination (23–42%) followed by MRI scan review (2.6–18%), reading MRI reports (0–1.6%) or viewing other imaging (3–23%) depending on the shoulder disease. Ninety percent of surgeons would not decide on surgery in ambiguous cases unless the MR-images were personally reviewed. Respondents stated that shoulder MRI scans are ordered too frequently prior specialist visit as identified in more than 50% of cases depending on pathology.ConclusionsThe decision-making process for shoulder surgery depends on the underlying pathology and patient history. The results demonstrate that orthopaedic surgeons are comfortable reviewing shoulder MRI scans without necessarily reading the MRI report prior to a surgical decision. MRI scans are becoming an increasingly important part of surgical management in shoulder pathologies but should not be used without assessment of patient history and or physical examination.

Determining health information-seeking behavior of shoulder patients.

Patients today have access to an increasing number of health resources to guide medical decision making, including specialist health care providers, the Internet, friends, and family members. No prior studies, to our knowledge, have comprehensively explored health information-seeking behavior (HISB) for patients being managed for shoulder pain. Our primary objective is to identify which health resources patients use and find helpful in a cohort of patients being either evaluated or managed for shoulder pain. With increased access to the Internet and its use, we also hope to quantify the extent of use of Internet resources and identify predictors of patient use. We interviewed a cohort of new and follow-up patients being surgically or nonoperatively managed for shoulder pain by a single fellowship-trained orthopedic surgeon. All patients were administered a questionnaire to determine HISB, which evaluated the types of resources used and those deemed most helpful in guiding medical decision making. For patients using the Internet, specific websites were documented. Additional variables that were collected included age, gender, ethnicity, and highest education attained. Multivariable logistic regression was used to evaluate predictors of Internet use. This study included 242 patients. A discussion with an orthopedic surgeon was reported to be the most informative for nonoperatively treated patients, first postoperative patients, and operative follow-up patients. Patients at the first postoperative visit reported YouTube as their preferred resource almost 4 times more than new patients (odds ratio [OR] 3.9, P=.015). Search engine use was significantly higher in patients at the first postoperative visit (OR 5.8, P=.004) and patients at subsequent surgical follow-up (OR 8.3, P=.001) compared with new patients. Having an undergraduate (OR 0.1, P=.037) or graduate degree (OR 0.03, P=.01) had a significant inverse association with difficulty of using Internet resources. Patients of Black race reported significantly higher rates of distrust for Internet resources than those of White race (OR 5.8, P<.001). This study highlights the patterns of HISB among patients with shoulder conditions. A face-to-face discussion with a physician or a shoulder surgeon was the most crucial resource for information compared to other resources. This study has also defined the preferred Internet resources for patients at different time points of care and the reasons for refraining from seeking health information on the Internet. Such findings can aid shoulder surgeons in understanding the optimal methods for delivering health information for different patient demographics and different phases of their care.

Humeral offset as a predictor of outcomes after reverse shoulder arthroplasty.

The Grammont-style reverse shoulder arthroplasty (RSA) relies on medialization and distalization of the shoulder center of rotation. Lateralized designs have recently gained popularity. The amount of lateralization, however, remains a controversial topic. The purpose of this study was to correlate the change in humeral offset (HO) with outcomes and complications following RSA. We hypothesized that a lateralized HO following RSA would be associated with improved range of motion (ROM), better patient-reported outcomes (PROs), and fewer complications. A consecutive series of 104 patients (109 shoulders) was retrospectively evaluated. All patients underwent primary RSA by 2 shoulder and elbow fellowship-trained orthopedic surgeons at 2 different centers. Inclusion criteria was a primary RSA with at least 1-year follow-up. All patients had the HO measured on a preoperative and a postoperative Grashey radiograph, and the change in HO was calculated (ΔHO=PostHO-PreHO). A negative value was defined as a medialized HO and a positive value as a lateralized HO. ROM and primary outcomes, including forward elevation (FE), external rotation (ER), internal rotation (IR), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, were collected. Complications and revisions were also reported. The mean age was 72 years with a mean follow-up of 22.3 months. The average FE (92° vs. 148°), ER (34° vs. 44°), SSV (35% vs. 87%), and ASES score (37.2 vs. 81.2) increased significantly (all P<.01) compared with preoperative values. The HO was medialized postoperatively in 63 shoulders and lateralized in 46 shoulders. No statistically significant differences in the mean values for postoperative FE (147° vs. 146°, P=.892), ER (43° vs. 45°, P=.582), IR (L3 vs. L3, P=.852), SSV (88% vs. 85%, P=.476), and ASES score (81.3 vs. 81.1, P=.961) were found between the groups. However, there was significantly more improvement in ER in the lateralized HO cohort than the medialized cohort (16° vs. 7°, P=.033). Six shoulders, 5 medialized and 1 lateralized HO, demonstrated scapular notching and remained asymptomatic. Five shoulders, 4 medialized and 1 lateralized HO, experienced at least 1 instability incident, and 2 shoulders with medialized HO had an acromion/scapular spine fracture. Overall, 2 shoulders with medialized HO underwent revision surgery because of instability. Although RSA provides significant improvement in ROM and PROs regardless of postoperative HO, restoring baseline HO or lateralization beyond baseline may be favorable for improving ER and decreasing complications following RSA.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population

Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population. Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status. There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination. We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population. These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Evaluation of the Relative Citation Ratio Among Academic Orthopedic Hand Surgeons: A Novel Measure of Research Impact.

Background: Publication metrics such as article citation count and the Hirsch index (h-index) are used to evaluate research productivity among academic faculty. However, these bibliometric indices are not field-normalized and yield inaccurate cross-specialty comparisons. We evaluate the use of the relative citation ratio (RCR), a new field-normalized article-level metric developed by the National Institutes of Health (NIH), among academic orthopedic hand surgeons and analyze physician factors associated with RCR values.Methods: A retrospective analysis was performed using the iCite database. Fellowship-trained orthopedic hand surgeons affiliated with accredited orthopedic surgery residency programs were included. Mean RCR, weighted RCR, and publication count were compared by sex, career duration, academic rank, and presence of additional degrees. Mean RCR represents the total number of citations per year of a publication divided by the average number of citations per year received by NIH-funded papers in the same field. Mean RCR serves as a measure of overall research impact. A value of 1.0 is the NIH-funded field-normalized standard. Weighted RCR is the sum of all article-level RCR scores and represents overall research productivity.Results: A total of 620 academic orthopedic hand surgeons from 164 programs were included. These physicians produced highly impactful research with a median RCR of 1.27 (interquartile range [IQR] 0.86-1.66). Weighted RCR was associated with advanced degree, advanced academic rank, and longer career duration.Conclusions: Fellowship-trained academic orthopedic hand surgeons produce highly impactful research. Our benchmark data can be used to assess grant outcomes, promotion, and continued evaluation of research productivity within the hand surgery community.

Ultrasound Can Determine Joint Distraction During Hip Arthroscopy but Fluoroscopic-Guided Portal Placement Is Superior

PurposeTo compare joint distraction measured on ultrasound (US) with joint space width (JSW) measured on fluoroscopy in hip arthroscopy and to determine whether ultrasound guidance is as safe and effective as fluoroscopy, the current gold standard, for establishing arthroscopic portals.MethodsCadaveric whole-body specimens were positioned supine and subjected to 60 lbs. of unilateral axial traction using a distal femoral Steinman pin. Joint distraction was measured via JSW on fluoroscopic and ultrasound images. A single, fellowship-trained orthopaedic surgeon established anterolateral arthroscopy portals via ultrasound or fluoroscopic guidance in a randomized sequence. Total procedure time, number of times the spinal needle pierced the capsule, and iatrogenic chondral or labral injury were recorded.ResultsTwelve full-body specimens (20 hips) underwent distraction, and 17 hips underwent portal placement with fluoroscopic (n = 8) or ultrasound (n = 9) guidance. JSW measured on ultrasound was significantly less laterally (13.0 vs 9.2 mm, P < .001), apically (16.7 vs 9.2 mm, P < .001), and medially (17.9 vs 9.2 mm, P < .001). Successful portal entry was achieved in every specimen. Average procedure time was 133 ± 51 seconds for the fluoroscopy group and 371 ± 260 seconds for the ultrasound group (P = .026). Fluoroscopic guidance required significantly less needle insertion attempts at 1.13 compared with 3.33 attempts for ultrasound (P = .022). Labral damage was greater in the ultrasound group at 66.67% compared with 12.50% for fluoroscopy (P = .0497).ConclusionsJoint distraction measured on ultrasound can be used to subjectively determine if the joint is adequately distracted in hip arthroscopy. Ultrasound-guided portal placement was associated with more needle insertion attempts, iatrogenic injury of the labrum, and overall procedure time in comparison to fluoroscopic guidance.Clinical RelevanceFluoroscopy is the gold standard to confirm adequate joint distraction, aid in establishing arthroscopy portals, and evaluate resection of the femoral head during hip arthroscopy but exposes the patient to ionizing radiation, requires additional operators in the operating room, and involves the need for a heavy lead shield. Alternatives to fluoroscopy are needed, but ultrasound has not proven superior in our cadaveric model.

Three-Dimensional Computed Tomography Reconstructions Do Not Improve the Interobserver Reliability of the AO/Orthopaedic Trauma Association and Young and Burgess Pelvic Fracture Classifications.

To evaluate the value of three-dimensional (3D) computed tomography (CT) scans on the interobserver and intraobserver reliability of AO/Orthopaedic Trauma Association (OTA) and Young and Burgess (YB) classifications for pelvic ring injuries. Seven reviewers (four fellowship-trained orthopaedic trauma surgeons and three fellows) independently classified 36 pelvic ring injuries using radiographs and axial two-dimensional (2D) CT scan images and then repeated this process 2months later with the addition of 3D CT images. Interobserver and intraobserver reliability was assessed. The interobserver reliability of the AO/OTA classification using 2D vs. 3D CT scans was considered fair (k 0.23, CI 0.17-0.29) vs. slight (k 0.16, CI 0.09-0.22), with no observed difference [mean difference (MD) -0.07, CI 0.16-0.01]. The interobserver reliability of the YB classification using 2D vs. 3D CT scans was considered fair for both (k 0.37, CI 0.32-0.42, vs. 0.37, CI 0.30-0.45), with no observed difference (MD -0.0005, CI -0.08 to 0.08).The intraobserver reliability of the AO/OTA vs. YB classifications was considered fair (k 0.35, CI 0.26-0.44) vs. moderate (k 0.49, CI 0.40-0.57), with the YB classification having higher kappa value (MD 0.13, CI 0.01-0.26, p = 0.03). The addition of 3D CT scan reconstructions to radiographs and 2D CT did not improve the interobserver reliability of AO/OTA and YB classifications for pelvic ring injuries.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy.

The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Inter-Rater Reliability of Clinical Testing for Laxity After Knee Arthroplasty

BackgroundThe clinical examination for laxity has been considered a mainstay in evaluation of the painful knee arthroplasty, especially for the diagnosis of instability. More than 10 mm of anterior-posterior (AP) translation in flexion has been described as important in the diagnosis of flexion instability. The inter-observer reliability of varus/valgus and AP laxity testing has not been tested. MethodsTen subjects with prior to total knee arthroplasty (TKA) were examined by 4 fellowship-trained orthopedic knee arthroplasty surgeons. Each surgeon evaluated each subject in random order and was blinded to the results of the other surgeons. Each surgeon performed an anterior drawer test at 30 and 90 degrees of flexion and graded the instability as 0-5 mm, 5-10 mm or >10 mm. Varus-valgus testing was also graded. Motion capture was used during the examination to determine the joint position and estimate joint reaction force during the examination. ResultsInter-rater reliability (IRR) was poor at 30 and 90 degrees for both the subjective rater score and the measured AP laxity in flexion (k = 018-0.22). Varus-valgus testing similarly had poor reliability. Force applied by the rater also had poor IRR. ConclusionClinical testing of knee laxity after TKA has poor reliability between surgeons using motion analysis. It is unclear if this is from differences in examiner technique or from differences in pain or quadriceps function of the subjects. Instability after TKA should not be diagnosed strictly by clinical testing and should involve a complete clinical assessment of the patient.

Robot-assisted (RA) versus conventional total knee replacement: a 2-year clinical comparison

Background: Robotic-assisted (RA) technology is becoming increasingly popular in total knee arthroplasty (TKA) due to its improved alignment, accuracy, and precision compared with the conventional TKA. Despite reported benefits, disagreements exist regarding patient-reported outcomes and complication rates comparing RA TKA and conventional TKA. Thus, the purpose of the study is to report differences in patient outcomes and complication rates between patients who underwent RA versus conventional TKA. Methods: The authors retrospectively reviewed 239 primary knee arthroplasty cases (n=137 robot-assisted and n=102 conventional TKA) performed by a single fellowship-trained orthopaedic surgeon from January 1, 2016 to February 26, 2019. The electronic medical record and patient outcomes database were reviewed for demographic characteristics (age, sex, body mass index, and comorbidities), patient-reported outcomes (Short Form Health Survey and Oxford Knee Score), 90-day complications, and revision rates. Results: There was no statistically significant difference in patient-reported outcomes between conventional versus RA groups at two time points: preoperative and 2-year. Differences remained insignificant after controlling for age, sex, body mass index, and comorbidities. There was no statistically significant difference between the conventional and RA groups in revision rates (0.7% and 1%, respectively; P=1.00) or complication rates (1.5% and 3.9%, respectively; P=0.406). Conclusions: There were no differences in 90-day complications, revisions, and patient-reported outcome scores between RA TKA and conventional TKA groups at short-term follow-up. Surgeons can expect similar clinical outcomes without an increase in complications while taking advantage of increased accuracy in alignment and component placement. Further long-term study of RA TKA outcomes is warranted. Level of Evidence: Level III.