Preinjury Activity Research Articles

Surgical treatment of anterior sternoclavicular dislocation associated with midshaft clavicle fracture: A case report.

A combination of an anterior sternoclavicular (SC) joint dislocation with a midshaft clavicle fracture is an extremely rare injury. If left untreated, it can lead to severely impaired function of the shoulder with a high risk for complications. A 45-year-old male patient presented with pain and impaired range of motion (ROM) in the left shoulder after a mountain bike crash. Radiographs and a computed tomography scan showed an anterior dislocation of the left SC joint and an ipsilateral midshaft fracture of the clavicle. Open reduction and internal fixation (ORIF) of the clavicle combined with SC joint stabilization using transosseous sutures was performed. Postoperatively, a shoulder-arm bandage was applied with passive motion starting on the first postoperative day. During follow-up, the patient showed an improved clinical function and could return to work after three weeks. Radiographs at eight weeks showed fracture healing without any signs of recurrent SC dislocation. At the final follow-up at 12 weeks, the patient returned to his pre-injury activity level and recreational sports. Despite minimal redislocation in the SC joint, the Constant-Murley Score showed a continuous improvement with 93%, compared to the contralateral side. In conclusion, surgical treatment of anterior SC joint dislocation with a midshaft clavicle fracture can restore shoulder function with no surgery-associated complications.

The effect of fear of reinjury on joint power distribution during a drop countermovement jump two years after an Achilles tendon rupture

The incidence of Achilles tendon rupture (ATR) is increasing and at least 20% do not return to preinjury activity. The aim of the study was to evaluate biomechanical differences between those assigned to a Fear group and No-Fear group based on fear of reinjury during activity after ATR, by evaluating a drop countermovement jump. Twenty-five participants were evaluated 23.5 months after ATR. Peak values for eccentric and concentric joint power were identified for ankles, knees, and hips. Participants were assigned to Fear group or No-Fear group depending on their answers to a question regarding fear of reinjury during activities. Interlimb peak power was compared between groups for landing and push-off with a mixed model ANOVA. Compared to the No-fear group, the Fear group presented significant decreased power in the ankle (P < .001) but increased power in the knee (P < .001) in involved limb during both phases. A 3-way interaction was found between group, side, and phase for frontal plane hip power (P < .001). Our findings indicate that those who are afraid of reinjury demonstrate higher interlimb differences compared to those who are not. They also compensate for ankle deficits with greater knee and hip power.

Primary Medial Patellofemoral Ligament Reconstruction in Military Servicemembers: Can We Reliably Restore Preinjury Function and Stability?

Background:Medial patellofemoral ligament (MPFL) reconstruction for patellar instability is a commonly performed procedure with a reported high rate of return to preinjury activity. However, no previous study has assessed the functional outcomes of military servicemembers undergoing MPFL reconstruction.Hypothesis:Primary MPFL reconstruction confers patellar stability, but with limited return to preinjury function and ability to maintain unrestricted military active duty status.Study Design:Case series; Level of evidence, 4.Methods:Using the Management Analysis and Reporting Tool database, we conducted a retrospective review of active duty servicemembers throughout the US Department of Defense Health System who underwent primary MPFL reconstruction between 2012 and 2015. Demographic variables were recorded as well as ability to return to impact activities—defined as running, jumping, rucking with a load >40 pounds (18 kg), and returning to airborne operations—and to remain on active duty status. The rates of recurrent instability and the need for subsequent surgeries were identified and assessed for statistical significance using uni- and multivariate analyses. Patients were evaluated for a minimum of 2 years postoperatively.Results:Of the 213 patients who underwent primary MPFL reconstruction, including 34 with concomitant tibial tubercle osteotomy, 19 (8.9%) patients developed recurrent instability. The presence of bilateral patellar instability was associated with higher recurrence rate. Patients with bilateral instability comprised 47.3% of those with recurrence but only 24.9% of patients without recurrence (P = .019). Impact activity restrictions were present in 57.6% of patients (n = 121), with 86 patients (52.1%) undergoing medical separation from the military. Patients who were prescribed activity restriction before surgery were significantly more likely to have postoperative activity restrictions (64.5%; P = .019), and junior enlisted servicemembers were more likely to be medically separated from service postoperatively than higher ranking senior enlisted members or officers.Conclusion:Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. Bilateral instability negatively affected return to impact activities. Military servicemembers, particularly junior enlisted members, should be counseled on this poor prognosis for a full return to unrestricted activity postoperatively.

Prediction of improvement after anterior cruciate ligament reconstruction.

ObjectiveThe retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not.MethodsWe retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4).ResultsThe proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5–13.3).ConclusionsFulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR.Level of evidenceCase-control study. Level of evidence 3.

Return to the original sport at only 3 months after an Achilles tendon rupture by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and excessively early rehabilitation after operative treatment in a male basketball player: A case report.

BackgroundAchilles tendon rupture is one of the most common serious injuries in athletes. Various studies to accelerate the healing process of the Achilles tendon have been performed as it takes a longer time to repair the tissue compared to other tendons. Here, we report a case of an acute Achilles tendon rupture in a male basketball player treated by a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate, which included a platelet-derived growth factor with an early rehabilitation protocol after the operative treatment to facilitate the biological healing of the injured tendon tissue. To the best of our knowledge, this case is the first instance that enabled the athlete to return to original sport activity at only 3-months after the injury.Case reportA 23-year-old male basketball player who belonged to a university basketball team sustained an Achilles tendon rupture during running in a training match. The remaining time period until the final tournament of the university league as a senior player was only 3 months. The patient received a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate and early rehabilitation protocol after operative treatment. Surgery was performed 4 days after the injury and the early rehabilitation protocols were applied postoperatively. A freeze-dried platelet-derived factor concentrate was injected into the ruptured site of the Achilles tendon under ultrasound guide at 4 weeks postoperatively. The patient could return to play at the pre-injury level without any symptoms and disfunctions at 3 months after surgery. At two years postoperatively, the patient could play basketball without symptoms or rerupture.ConclusionsWe reported a case of an Achilles tendon rupture which was treated by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and an early rehabilitation protocol after the operative treatment. The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury, suggesting that the role of applying excessively early rehabilitation of mechanical loading could facilitate tendon tissue healing when combined with an intra-tissue injection of freeze-dried platelet-derived factor concentrate.

Perilunate fracture-dislocations: Clinical and functional outcomes at a mean follow-up of 3.3 years

IntroductionPerilunate lesions in the carpus are severe injuries whose functional consequences can limit patients’ ability to regain their pre-injury activity levels. The aim of this study was to evaluate the outcomes of a series of patients who suffered a perilunate fracture-dislocation and to assess their ability to resume their social and professional activities. HypothesisAfter surgical management of this injury, the medium-term functional outcomes will allow patients to return to their pre-injury social and professional activities. Materials and methodsThis was a single center, retrospective study. Included patients were adults who had suffered a perilunate fracture-dislocation that was treated emergently. The clinical and functional assessment consisted of comparing the mobility and grip strength between the injured and contralateral wrists, determining the functional outcome scores and the resumption of social and professional activities. A radiological assessment was done to look for instability of the proximal row of the carpus, nonunion or necrosis of the carpal bones, loss of carpal height, and presence of carpal osteoarthritis. ResultsTen patients were included with a mean follow-up of 39.4 months. The mean flexion/extension arc decreased significantly to 88° (20°–150) which was 55% of the healthy contralateral side (p=0.0026) while the grip strength decreased but not significantly (40.6 Kg vs. healthy side 62.4 Kg, p=0.063). The mean MWS was 58.75 (40-100), the mean PRWE was 32.9 (4–67.5) and the mean QuickDASH was 30.2 (0–77). Six of the ten patients (60%) were able to return to work, although three required occupational reclassifications. Four patients had signs of proximal row instability. There were seven instances of radiocarpal osteoarthritis, two of which were combined with mid-carpal osteoarthritis. DiscussionThis study found shorter range of motion and worse patient-reported outcomes than other published studies, which may be due to the severity of the perilunate fracture-dislocation injuries and the inclusion of polytrauma patients. Nevertheless, the subjective scores were comparable. These injuries have serious consequences on social and professional activities of manual workers. Level of evidenceIV; retrospective study.

Clinical, Functional, and Physical Activity Outcomes 5 Years Following the Treatment Algorithm of the Delaware-Oslo ACL Cohort Study.

Anterior cruciate ligament (ACL) injuries can be treated with or without ACL reconstruction (ACLR), and more high-quality studies evaluating outcomes after the different treatment courses are needed. The purpose of the present study was to describe and compare 5-year clinical, functional, and physical activity outcomes for patients who followed our decision-making and treatment algorithm and chose (1) early ACLR with preoperative and postoperative rehabilitation, (2) delayed ACLR with preoperative and postoperative rehabilitation, or (3) progressive rehabilitation alone. Early ACLR was defined as that performed ≤6 months after the preoperative rehabilitation program, and late ACLR was defined as that performed >6 months after the preoperative rehabilitation program. We included 276 patients from a prospective cohort study. The patients had been active in jumping, pivoting, and cutting sports before the injury and sustained a unilateral ACL injury without substantial concomitant knee injuries. The patients chose their treatment through a shared decision-making process. At 5 years, we assessed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, sports participation, quadriceps muscle strength, single-legged hop performance, and new ipsilateral and contralateral knee injuries. The 5-year follow-up rate was 80%. At 5 years, 64% of the patients had undergone early ACLR, 11% had undergone delayed ACLR, and 25% had had progressive rehabilitation alone. Understandably, the choices that participants made differed by age, concomitant injuries, symptoms, and predominantly level-I versus level-II preinjury activity level. There were no significant differences in any clinical, functional, or physical activity outcomes among the treatment groups. Across treatment groups, 95% to 100% of patients were still active in some kind of sports and 65% to 88% had IKDC-SKF and KOOS scores above the threshold for a patient acceptable symptom state. Patients with ACL injury who were active in jumping, pivoting, and cutting sports prior to injury; who had no substantial concomitant knee injuries; and who followed our decision-making and treatment algorithm had good 5-year knee function and high sport participation rates. Three of 4 patients had undergone ACLR within 5 years. There were no significant differences in any outcomes among patients treated with early ACLR, delayed ACLR, or progressive rehabilitation alone. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

Objectiveto examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function. Designcross-sectional study. Setting: online survey platform. Participants119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy. Main outcome measuresA range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders. ResultsPsychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction. ConclusionThe current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.

Connecting With Trauma Patients After Discharge: A Phone Call Follow-Up Study.

Traumatic injury is sudden and unexpected. It may lead to long-standing physical and physiological consequences. Approximately 10% of the world's disease burden is attributable to traumatic injuries. At the commencement of the study, there was limited information regarding civilian trauma patients' recovery following discharge from the hospital. There are several reasons for this including lack of available resources for follow-up by clinical staff and often trauma patients have multiple injuries, which can result in fragmented care. This limits the ability to assess a patient's recovery following discharge from the hospital. This phone call follow-up study was conducted to assess the number of trauma patients who may be showing symptoms of physical and psychological distress after traumatic injury. The study was carried out in New South Wales (Australia) Metropolitan major (Level 1) trauma center. Consented patients were contacted at 72 hr, 1 month, and 3 months after discharge from the hospital. Many patients at all time points had difficulty coping with activities of daily living from pain (183 patients [64%], 121 patients [43%], and 58 patients [23%]), fatigue and sleep disturbance (110 patients [38%], 79 patients [28%], and 49 patients [20%]), as well as anxiety and frustration (38 patients [13%], 79 patients [28%], and 98 patients [39%]) regarding their recovery and returning to their preinjury activities. The research indicates that some trauma patients do not recover quickly physically or emotionally. These patients require identification and appropriate management of the consequences of trauma to enable them to return to their preinjury quality of life.

Comparative study of management of intertrochanteric fracture by dynamic hip screw and proximal femoral nailing

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; The purpose of the present study is to verify the theoretical advantages of the intramedullary device over the dynamic hip screw devices and also whether it actually alters the eventual functional outcome of the patient. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study is comparative prospective study in which 40 patients were taken and treated either with dynamic hip screw or proximal femoral nailing. The clinical data will be collected and compared with pre-injury activity and present functional level with modified Harris hip score.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; We found that there is no significant difference between Harris hip score in stable fracture (p value=0.222) fixed either with DHS or PFN. But there is statistically significant difference of score in unstable fracture (p value 0.040) treated by DHS and PFN. Functionally, utilizing the Harris hip scoring system, at the final follow-up, our study affirms PFN to be superior to DHS in unstable intertrochanteric fractures while in stable fractures, functional results are same. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; PFN is also found better in unstable fractures, because a greater number of patients having excellent Harris hip score. In stable fracture, functional result is same in both groups.&lt;/p&gt;

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts.

To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. Thirty-five QT patients (age 20; range 15-34years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15-32years) patients. The following assessments were performed at 6 and 12months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12months) and between-subject (Graft; QT and HT) factors. Patient reported outcome measures and hop performance improved between 6 and 12months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60deg/s (p < 0.001) and 180deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60deg/s (p < 0.01) and 180deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group. Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12months. This may have implications for decisions regarding return to sport. III.

Arthroscopic Soft Tissue Stabilization With Selective Augmentations for Traumatic Anterior Shoulder Instability in Competitive Collision Athletes

Background: Many surgeons prefer bony stabilization including Bristow or Latarjet procedures for shoulder instability in collision athletes, even though several potential complications have been reported. There has been a limited number of studies on the midterm outcomes of arthroscopic soft tissue stabilization for anterior shoulder instability in competitive collision athletes. Purpose: To assess the outcomes of arthroscopic soft tissue stabilization in combination with selective augmentation procedures for collision athletes with traumatic anterior shoulder instability Study Design: Case series; Level of evidence, 4. Methods: We retrospectively assessed rugby or American football players (<40 years old) who underwent arthroscopic Bankart or bony Bankart repair with selective augmentations (rotator interval closure and/or Hill-Sachs remplissage) for traumatic anterior shoulder instability between January 2012 and March 2017. Shoulders that required other bony procedures were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score and Subjective Shoulder Value sports score) were investigated. Results: This study included 113 shoulders in 100 patients with a mean age of 20 years (range, 15-36 years) at surgery. Rotator interval closure was performed on 36 shoulders in addition to Bankart repair, and rotator interval closure and Hill-Sachs remplissage were performed on 77 shoulders. The mean follow-up period was 44 months (range, 24-72 months). Of the 113 shoulders, 4 (3.5%) experienced postoperative dislocation, but there were no complications. A total of 93 athletes (93%) attained complete or near complete preinjury sports activity levels. The mean Rowe score significantly improved from 36 (range, 10-75) at presurgery to 96 (range, 35-100; P = .003) at postsurgery. The mean Subjective Shoulder Value sports score significantly improved after surgery, from a mean preoperative score of 22 (range, 0-50) to a postoperative score of 92 (range, 64-100; P = .002). Conclusion: Our treatment strategy, where arthroscopic soft tissue stabilization was combined with selected augmentations, provided good clinical outcomes for competitive collision athletes in terms of low rates of recurrence and complication, a high rate of return to sports, and good shoulder function.

Patient-reported function and psychological aspects, but not objectively assessed physical function, may impact return to sport within one year following anterior cruciate ligament reconstruction

Purpose: Anterior cruciate ligament (ACL) injury is a common sports-related injury with major consequences for the individual, such as impaired physical function, decreased quality of life, failure to return to sport and also a high risk of developing early-onset knee osteoarthritis. The main goal of rehabilitation following an ACL reconstruction (ACLR) is often return to sport. Despite this, many athletes never reach their pre-injury physical activity level. The main factors contributing to a failure of returning to sport after ACLR are however not entirely disentangled.

Arthroscopic fixation of avulsion fractures of tibial eminence using cannulated screws

Purpose Assessment of the short-term results of arthroscopic fixation of types II and III fractures of the tibial eminence using cannulated screws. Type of study This was a prospective study. Patents and methods A review of 16 patients with Meyers and McKeever type II or III fractures of the tibial eminence were treated with arthroscopic cannulated screw fixation at Zagazig University Hospital between May 2013 and January 2016. The International Knee Documentation Committee form, Lysholm Knee Score, and Tegner Activity scale for assessment were used for preoperative and postoperative assessments. The study group included seven men and nine women. Their average age was 25.4 years (range: 17.5–43 years). Mean follow-up time was 27 months (range: 24–32 months). The study included six type II and 10 type III fractures. Results At follow-up clinical examination, all the patients with types II and III lesions had a negative Lachman test result and a full range of motion, except one patient with flexion contractures (extension lag 10°). The mean Tegner score was 7 and mean Lysholm score was 96. All patients except one returned to preinjury activity levels. However, in general, the best outcomes were seen in younger patients who had significantly better scores for the International Knee Documentation Committee. In six cases, the intermeniscal ligament was interposed between the tibia and the avulsed fracture and was retracted to allow reduction of the fracture, and there were no significant differences in the outcomes of these patients. Conclusions Arthroscopic fixation with cannulated screws for types II and III of avulsion fractures of the tibial spine provides a satisfactory outcome. Arthroscopic treatment allows for complete inspection of the joint regarding associated injuries, fast rehabilitation, and decreased hospital stay. Moreover, fixation with cannulated screws gives firm fixation of the fragment and an early start of the range of motion.

Screw Fixation of Pediatric Tibial Tubercle Fractures.

Tibial tubercle fractures are rare injuries that account for <1% of physeal fractures. These fractures are thought to be increasing in frequency, particularly in young, adolescent males who participate in basketball and other sports with repeated running and jumping. The tibial apophysis becomes mechanically vulnerable as the proximal tibial physis closes from posteromedial to anterolateral, enabling the quadriceps to overpower the chondroepiphysis and avulse the proximal tibial epiphysis from the tibial metaphysis. Position the patient supine with the leg on a bump or bone foam. Perform a longitudinal incision centered over the fracture site (i.e., the tibial tubercle); a medial parapatellar incision may be utilized if an intra-articular component is present. Develop medial and lateral soft-tissue flaps to expose the fracture. Evaluate the soft-tissue stripping and capsule. Debride any hematoma, fracture fragments, and soft tissue from the fracture site with use of irrigation and a curet. Use a towel clip, bone clamp, and/or ballpoint pusher to reduce the fragment. Place 2 to 3 parallel guide pins from anterior to posterior, capturing fracture fragments within the epiphysis and apophysis under fluoroscopic guidance. Carefully place a guidewire in the distal fragment to avoid splitting the fragment, which is often small. An arthrotomy or arthroscopy is utilized to assess intra-articular reduction if necessary. Assess and measure pin lengths and placement with use of fluoroscopy. Place screws sequentially to avoid rotation of the fragment and take care to avoid splitting the fragment when placing distal screws. Repair any patellar, capsular, retinacular, or meniscal damage. A suture anchor may be utilized to repair the patellar tendon if necessary. The skin is closed in a layered fashion. Apply a cylinder cast or hinged knee braced locked in extension. Nonoperative treatment in a long-leg cast in extension may be considered for nondisplaced fractures or fractures that are stably reduced with <2 mm of displacement and acceptable alignment in the cast following reduction. Operative treatment is indicated for fractures with ≥2 mm of displacement, intra-articular extension with an incongruent joint, and for patients who will not tolerate being non-weightbearing in a cast. Closed reduction is generally attempted for fractures without intra-articular extension. If closed reduction is successful, fixation may be performed with Kirschner wires and/or percutaneous screws. Open reduction is often necessary and has been reported to be performed in as many as 98% of surgical cases for tubercle fractures2. This approach allows access to intra-articular displacement and the ability to obtain a stable, anatomic reduction while addressing concomitant soft-tissue injury, if present. The expectation following successful reduction and screw fixation of tibial tubercle fractures is that these young patients will be able to regain their motion and strength, and ultimately return to preinjury activity levels. A consecutive series of 86 patients with surgically treated tibial tubercle fractures found that all patients demonstrated full radiographic healing at the time of the latest follow-up (range, 3 to 34 months), return to full activities between 10 and 42 weeks, return of good to excellent range of motion in 89% of patients, and a 10% to 20% complication rate, including partial physeal arrest, decreased range of motion, quadriceps contracture, and painful implants. Additionally, a systematic review of 23 articles with 336 surgically treated tibial tubercle fractures found 98% of patients return to preinjury activity and knee range of motion with a 28% complication rate (most commonly due to painful implants). Place the fluoroscopic image view across the room from the surgeon for ease of viewing.Use computed tomography or magnetic resonance imaging if the fracture has intra-articular extension.Use 4.5 or 6.5-mm cannulated, partially threaded screws.Carefully monitor for compartment syndrome.Place screws by hand, sequentially.

Decision Making for Treatment After ACL Injury From an Orthopaedic Surgeon and Patient Perspective: Results From the NACOX Study.

Background:In the treatment of anterior cruciate ligament (ACL) injuries, there is little evidence of when and why a decision for ACL reconstruction (ACLR) or nonoperative treatment (non-ACLR) is made.Purpose:To (1) describe the key characteristics of ACL injury treatment decisions and (2) compare patient-reported knee instability, function, and preinjury activity level between patients with non-ACLR and ACLR treatment decisions.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 216 patients with acute ACL injury were evaluated during the first year after injury. The treatment decision was non-ACLR in 73 patients and ACLR in 143. Reasons guiding treatment decision were obtained from medical charts and questionnaires to patients and orthopaedic surgeons. Patient-reported instability and function were obtained via questionnaires and compared between patients with non-ACLR and ACLR treatment decisions. The ACLR treatment group was classified retrospectively by decision phase: acute phase (decision made between injury day and 31 days after injury), subacute phase (decision made between 32 days and up to 5 months after injury), and late phase (decision made 5-12 months after injury). Data were evaluated using descriptive statistics, and group comparisons were made using parametric or nonparametric tests as appropriate.Results:The main reasons for a non-ACLR treatment decision were no knee instability and no problems with knee function. The main reasons for an ACLR treatment decision were high activity demands and knee instability. Patients in the non-ACLR group were significantly older (P = .031) and had a lower preinjury activity level than did those in the acute-phase (P < .01) and subacute-phase (P = .006) ACLR decision groups. There were no differences in patient-reported instability and function between treatment decision groups at baseline, 4 weeks after injury, or 3 months after injury.Conclusion:Activity demands, not patient-reported knee instability, may be the most important factor in the decision-making process for treatment after ACL injury. We suggest a decision-making algorithm for patients with ACL injuries and no high activity demands; waiting for >3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management.Registration:NCT02931084 (ClinicalTrials.gov identifier).

Identification of Sarcopenia in Elderly Trauma Patients: The Value of Clinical Competency and Experience.

There is currently no standard definition of sarcopenia, which has often been associated with frailty. A commonly cited surrogate measure of sarcopenia is psoas muscle size. The purpose of this prospective study is to assess medical providers' capabilities to identify frail elderly trauma patients and consequent impact on outcomes after intensive care unit admission. Trauma intensive care unit patients over the age of 50 were enrolled. A preadmission functional status questionnaire was completed on admission. Attendings, residents, and nurses, blinded to their patient's sarcopenic status, completed surveys regarding 6-month prognosis. Chart review included cross-sectional psoas area measurements on computerized tomography scan. Finally, patients received phone calls 3 and 6months after admission to determine overall health and functional status. Seventy-six participants had an average age of 70years and a corrected psoas area of 383 ± 101mm2/m2. Injury Severity Score distribution (17.2 ± 8.9) was similar for both groups. Patients also had similar preinjury activities of daily living. Both groups had similar hospital courses. While sarcopenic patients were less likely to be predicted to survive to 6months (60% vs. 76%, P = 0.017), their actual 6-month mortality was similar (22% vs. 21%, P = 0.915). Despite similar objective measures of preadmission health and trauma injury severity, medical providers were able to recognize frail patients and predicted they would have worse outcomes. Interestingly, sarcopenic patients had similar outcomes to the control group. Additional studies are needed to further delineate factors influencing provider insight into functional reserves of elderly trauma patients.

A Simple Procedure for a Common Problem: Screw/Blade Exchange for Symptomatic Lateral Hardware Associated With Fracture Compression Following Dynamic Cephalomedullary Fixation of Pertrochanteric Hip Fractures

A Simple Procedure for a Common Problem: Screw/Blade Exchange for Symptomatic Lateral Hardware Associated With Fracture Compression Following Dynamic Cephalomedullary Fixation of Pertrochanteric Hip Fractures

Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial

IntroductionComparable data of functional outcomes of anterior cruciate ligament reconstruction using either hamstring- or quadriceps tendon grafts is controversial. This prospective, randomized controlled trial aims to provide data comparing both grafts regarding the functional outcome.Materials and methodsA two centre trial involving symptomatic patients 18 years of age or older with an anterior cruciate ligament tear was conducted. We randomly assigned 27 patients to quadruple hamstring tendon reconstruction and 24 to quadriceps tendon reconstruction. The patients were evaluated preoperatively, at 3, 6, 12 and 24 months post-surgery. The primary outcome parameter was the side-to-side knee laxity measured with an arthrometer. Secondary outcomes included results in the International Knee Documentation Committee (IKDC) and Lysholm Scores and isokinetic testing of strength in knee extension and flexion.ResultsForty-four patients (86%) completed the 2-year follow-up. There was significantly improved knee stability at all time intervals with no difference between the two study groups. The manual side-to-side displacement improved by 4.7 ± 3.0 mm in patients with hamstring tendon reconstruction and 5.5 ± 2.9 mm in patients with quadriceps tendon reconstruction. In addition, muscle strength and outcome scores (IKDC and Lysholm Score) did not show any differences between the hamstring tendon group and the quadriceps tendon group. Patients in the hamstring tendon group returned to their pre-injury activity level after 95.2 ± 45.5 days while patients in the quadriceps tendon group needed 82.1 ± 45.6 days.ConclusionQuadriceps and hamstring tendon autografts yield comparably good results in primary anterior cruciate ligament reconstruction.

Acute compartment syndrome in pediatric patients: a case series.

Pediatric acute compartment syndrome (ACS) is an orthopedic emergency which requires timely recognition and management. There are unique considerations in children, as they may present with a wide array of symptoms and capacities to communicate. We sought to investigate the presentations, treatments and outcomes of pediatric ACS, hypothesizing that decompressive fasciotomy results in good outcomes, even with delayed treatment (>24 h). We performed a retrospective review of pediatric ACS from 2009 to 2018. Exclusion criteria were age ≥18 years, exertional compartment syndrome, and incomplete data. Twenty-one patients (mean age 11 years) were included. Swelling (100%) and worsening pain (100%) were the most common presenting signs and symptoms followed by paresthesias (75%). Increasing analgesia requirements were documented in six (29%) patients. Compartment pressures were measured in 52% of patients. All patients were managed with decompressive fasciotomies, which were performed at a median time of 20 h from injury. Strength and range of motion deficits (10%) were the most commonly reported complications. There were no infections. All patients who were treated in a delayed fashion (≥24 h) were found to have a good functional recovery, but 38% had minor complications. Overall, patients had good outcomes, achieving full functional recovery with return to preinjury activity level. Pediatric ACS should be approached as a distinct clinical entity from adult ACS, where risks of infection and wound complications from delayed fasciotomy generally outweigh the benefits. We recommend considering decompressive fasciotomy for all cases of pediatric ACS, including those with prolonged time from injury to diagnosis.