Anterior shoulder instability includes a broad range of physical findings, ranging from seemingly benign subluxations to complete dislocation of the humeral head from the glenohumeral joint. Of those presenting with primary anterior instability, as many as 40% to more than 95% go on to develop recurrent instability depending on the targeted patient population.1-4 Recurrent instability further destabilizes the shoulder because of weakening of critical capsuloligamentous structures.5 Repeated translation of the humeral head over the glenoid rim can lead to bony lesions to the glenoid, bony Bankart of bone atrition6,7 as well as the humeral head (ie, Hill-Sachs lesion).8,9 Surgical intervention is often turned to as a means of decreasing the risk of recurrent dislocation, preventing progression of glenoid and humeral bone loss, and maintaining appropriate quality of life.9,10 Surgical procedures for the treatment of anterior shoulder instability include both open and arthroscopic soft-t issue procedures such as the Bankart repair. When bone involvement is present, several surgical options are available. In situations with minimal glenoid bone involvement, an open or arthroscopic Bankart repair incorporating any bone fragment may be performed. Large degrees of glenoid bone involvement lends itself to bony procedures like the Latarjet, Bristow, iliac crest bone graft, and distal tibial allograft (DTA).11-14 Additionally, the use of an iliac crest bone graft or DTA is often reserved for revision scenarios.9,15 Hill-Sachs lesions can also play a major role in recurrent anterior shoulder instability.16 Soft-tissue procedures like remplissage or bony procedures like bulk allograft transplant may be necessary to address humeral head bone loss.17,18 The majority of patients with recurrent anterior instability exhibit a bony Bankart lesion or glenoid rim irregularities, but may also exhibit "bipolar bone loss" in the scenario of bony changes to both the glenoid and humeral head.8,19,20 Although traditionally bone loss thresholds surpassing 20% have been linked to increased risk of failure with soft-tissue repair,21,22 new literature has suggested that "subcritical" glenoid bone loss may also pose heightened risks of recurrent instability.23-25 As a result, bony techniques are receiving increased consideration, particularly in cases of recurrent instability and even primary instability in patients with significant bone loss.26,27

AbstractThe tibial tubercle–trochlear groove (TT-TG) distance is currently utilized to evaluate knee alignment in patients with patellar instability. Sagittal plane pathology measured by the sagittal tibial tubercle–trochlear groove (sTT-TG) distance has been described in instability but may also be important to consider in patients with cartilage injury. This study aims to (1) describe interobserver reliability of the sTT-TG distance and (2) characterize the change in the sTT-TG distance with respect to changing knee flexion angles. In this cadaveric study, six nonpaired cadaveric knees underwent magnetic resonance imaging (MRI) studies at each of the following degrees of knee flexion: −5, 0, 5, 10, 15, and 20. The sTT-TG distance was measured on the axial T2 sequence. Four reviewers measured this distance for each cadaver at each flexion angle. Intraclass correlation coefficients were calculated to determine interobserver reliability and reproducibility of the sTT-TG measurement. Analysis of variance (ANOVA) tests and Friedman's tests with a Bonferroni's correction were performed for each cadaver to compare sTT-TG distances at each flexion angle. Significance was defined as p < 0.05. There was excellent interobserver reliability of the sTT-TG distance with all intraclass correlation coefficients >0.9. The tibial tubercle progressively becomes more posterior in relation to the trochlear groove (more negative sTT-TG distance) with increasing knee flexion. The sTT-TG distance is a measurement that is reliable between attending surgeons and across training levels. The sTT-TG distance is affected by small changes in knee flexion angle. Awareness of knee flexion angle on MRI is important when this measurement is utilized by surgeons.

Although literature describing the increased risk of postoperative infection for patients undergoing lower extremity arthroplasty with a preoperative urinary tract infection (UTI) is inconclusive, this relationship has yet to be adequately studied for shoulder arthroplasty. The goals of the present study were to examine the association between preoperative UTIs and their timing with periprosthetic joint infection (PJI) after shoulder arthroplasty. Patients undergoing primary shoulder arthroplasty diagnosed with a UTI in the preoperative period were identified in an insurance database and separated into mutually exclusive groups based on one-week intervals up to six weeks before surgery. A matched control cohort without a preoperative UTI was created for comparison. The incidence of PJI within two years after shoulder arthroplasty was then assessed for each cohort and compared using a logistic regression analysis. Compared with matched controls, patients with a UTI diagnosed within 1 week before shoulder arthroplasty (odds ratio, 2.73; 95% confidence interval, 1.67-4.46; P < .001) and within 1 to 2 weeks preoperatively (odds ratio, 1.77; 95% confidence interval, 1.24-2.52; P = .002) experienced significantly higher rates of PJI within 2 years postoperatively. There were no significant differences in the incidence of PJI between patients diagnosed with a UTI greater than 2 weeks before surgery and matched controls (P > .05). Patients diagnosed with a UTI within 2 weeks before shoulder arthroplasty may be at an increased risk of postoperative PJI. Level III, Database Case-control Prognosis Study

BackgroundThe goals of this study were to determine the incidence in the United States of preoperative three-dimensional imaging prior to anatomic total shoulder arthroplasty for osteoarthritis and to determine if preoperative imaging is associated with decreased complication rates.MethodsUsing a Medicare insurance database, we identified all patients who underwent computed tomography (n = 9380) and/or magnetic resonance imaging (n = 15,653) prior to anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis from 2005 to 2014. The incidence of imaging over time was analyzed and complication rates compared between patients with imaging to matched controls.ResultsThe incidence of preoperative three-dimensional imaging significantly increased over time, with computed tomography increasing more than magnetic resonance imaging. Compared to controls, patients with preoperative computed tomography imaging had significantly lower revision rates at two years (odds ratio 0.72 (0.64-0.82), p = 0.008). There were no other significant differences in the other complications studied.ConclusionsThe use of preoperative three-dimensional imaging for anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis has increased dramatically, with the use of computed tomography increasing the most. Patients who underwent preoperative computed tomography imaging experienced lower revision rates at two years postoperatively compared to matched controls without such imaging.Level of evidenceLevel III, retrospective comparative study.

PURPOSE:To evaluate the effect of acromioplasty using a cutting block technique on bony coverage as measured by the critical shoulder angle (CSA) and acromial index (AI).METHODS:This study is a retrospective radiographic review using data from a previous prospective randomized clinical trial that offered enrollment to patients aged 18 years or older with a full-thickness tear of the superior rotator cuff between October 2007 and January 2011. Each patient was allocated to repair with either acromioplasty using a cutting block technique or non-acromioplasty treatment arms in a blinded fashion. Medical and demographic information was recorded for each patient. Between January 2017 and December 2017, patients were contacted for repeat follow-up clinical evaluation and radiographs. Measurements of acromial index and critical shoulder angle were performed on pre- and postoperative radiographs by a single reviewer.RESULTS:Seventy-one (75%) patients were available for follow up. The 2 groups were similar in terms of baseline demographics and acromial type. When compared with preoperative measures, acromioplasty did not result in significant reductions in mean CSA (34.5° vs 35.5°; P = .293) or AI (0.68 vs 0.66; P = .283). Furthermore, postoperative CSA (34.5° vs 36.2°, P = .052) and AI (0.66 vs 0.67, P = .535) demonstrated no statistically significant differences between patients with and without acromioplasty, respectively.CONCLUSIONS:There was no statistically significant change in either the CSA or AI following acromioplasty, nor was there a significant postoperative difference in CSA or AI between the group that underwent acromioplasty and the group that did not.CLINICAL RELEVANCE:Some studies suggest a greater postoperative CSA may result in greater risk of retear after arthroscopic rotator cuff repair. The CSA and AI may not be modifiable with acromioplasty.

Reconstructive Anterior Cruciate Ligament surgery (ACLR) is a common sports related injury, with success rates of above 75% in the literature. Many patients are athletes that expect to return to their previous level of play postoperatively. Despite the high success rate of ACL reconstruction, the procedure is not without complications that ultimately require a revision operation. While some literature suggests comparable outcomes of revision ACL reconstruction (RACLR), others purport only a 54% return to previous activity level in patients. Furthermore, the procedure can be more technically challenging depending on the patient anatomy, activity level, and type of graft used in the index procedure. This chapter highlights the various pitfalls that may occur throughout the process of ACLR revision surgery. The surgeon should meticulously evaluate factors that may have led to the initial graft’s failure, as covered in the preoperative section. The most common reason for failure is improperly positioned tunnels at the time of initial reconstructive surgery, however several other factors may predispose patients to ruptured grafts including tibial slope, concomitant ligamentous injuries, and osteolysis at the bone-graft interface. Oftentimes, RACLR requires a staged procedure to address initial tunnel issues. The algorithm for utilizing bony dowels to reposition tunnels, complications that arise with their use, and the evaluation of graft incorporation is outlined in the intraoperative section. Lastly, RACLR has many of the same complications as the index reconstructive procedure, notably arthrofibrosis, venous thrombi, and infection, which is highlighted in the postoperative section. Ultimately, more high-level research is needed to identify the exact method of maximizing patient outcomes in RACLR and rehabilitation protocols in the postoperative period.

For patients with patellofemoral pain who fail exhaustive nonoperative treatment, surgical intervention may be a viable option for selected patients who have pain on the bases of pathomechanics and/or cartilage lesions. Treatments may be directed at proximal soft tissues and distally at the tibial tubercle such as in a tibial tubercle osteotomy. Tibial tubercle osteotomies can include medialization, anteriorization and/or distalization of the tibial tubercle. Proximaltaization can also be performed in the setting of patella baja, however, it is rarely performed and is outside the scope of this article. Medialization may be used to improve force vectors and contact area, anteriorization can decrease contact pressures, and distalization can normalize patellar height. Factors influencing which techniques are used include concomitant chondral pathology and specific measurements on imaging such as the tibial tubercle-trochlear groove distance, tibial tubercle-posterior cruciate ligament distance, and Caton-Deschamps Index. The following article reviews the indications for and techniques of anteriorization, medialization, distalization, and combinations of the 3, for tibial tubercle osteotomies. (C) 2019 Published by Elsevier Inc.

Chronic ankle instability is associated with intra-articular and extra-articular ankle pathologies, including osteochondral lesions of the talus. Patients with these lesions are at risk for treatment failure for their ankle instability. Identifying these patients is important and helps to guide operative versus nonoperative treatment. There is no literature examining which patient characteristics may be used to predict concomitant osteochondral lesions of the talus. A retrospective chart review was performed on patients (N = 192) who underwent a primary Broström-Gould lateral ankle ligament reconstruction for chronic ankle instability from 2010 to 2014. Preoperative findings, magnetic resonance imaging, and operative procedures were documented. Patients with and without a lesion were divided into 2 cohorts. Fifty-three (27.6%) patients had 1 lesion identified on preoperative magnetic resonance imaging. Forty (69.0%) of these lesions were medial, 18 (31.0%) were lateral, and 5 patients had both. Female sex was a negative predictor of a concomitant lesion (p = .013). Patients were less likely to have concomitant peroneal tendinopathy (30.2% vs 48.9%; p = .019) in the presence of a lesion. However, sports participation was a positive predictor of a concomitant lesion (p = .001). The remainder of the variables (age, body mass index, smoking, trauma, duration, contralateral instability, global laxity) did not show a significant difference. In patients who underwent lateral ankle ligament reconstruction, females were less likely to have a lesion than males. Patients with peroneal tendinopathy were less likely to have a lesion compared with patients without. Additionally, athletic participation was a positive predictor of a concomitant lesion.

The importance of cost control in total knee arthroplasty is increasing in the United States secondary to both changing economic realities of healthcare and the increasing prevalence of joint replacement. Surgeons play a critical role in cost containment and may soon be incentivized to make cost-effective decisions under proposed gainsharing programs. The purpose of this study is to examine the cost-effectiveness of all-polyethylene tibial (APT) components and determine what difference in revision rate would make modular metal-backed tibial (MBT) implants a more cost-effective intervention. Markov models were constructed using variable implant failure rates and previously published probabilities. Cost data were obtained from both our institution and published United States implant list prices, and modeled with a 3.0% discount rate. The decision tree was continued over a 20-year timeframe. Using our institutional cost data and model assumptions with a 1.0% annual failure rate for MBT components, an annual failure rate of 1.6% for APT components would be required to achieve equivalency in cost. Over a 20-year period, a failure rate of >27% for the APT component would be necessary to achieve equivalent cost compared with the proposed failure rate of 18% with MBT components. A sensitivity analysis was performed with different assumptions for MBT annual failure rates. Given our assumptions, the APT component is cost-saving if the excess cumulative revision rate increases by <9% in 20 years compared with that of the MBT implant. Surgeons, payers, and hospitals should consider this approach when evaluating implants. Consideration should also be given to the decreased utility associated with revision surgery.

Context : Postoperative rehabilitation is critical to optimize outcomes after anterior cruciate ligament reconstruction (ACLR). However, the relationship between physical therapy (PT) and clinical outcomes is unclear. Objective : To describe PT characteristics following ACLR and to assess the relationships between PT characteristics, surgical procedure, and clinical outcomes. Design : Cross-sectional. Setting : Laboratory. Patients (or Other Participants) : A total of 60 patients (31 females/29 males, age = 22.4 [9.2] y, height = 171.7 [9.9] cm, and mass = 70.2 [14.7] kg) with a history of primary unilateral ACLR (53.6% patellar tendon and 46.4% hamstring) participated. Intervention(s) : Patients completed a performance assessment and rated subjective knee function prior to physician clearance (mean = 6.3 [1.3] mo postoperatively) and were contacted within 6 months of clearance to complete a PT questionnaire. Main Outcome Measures : PT questionnaire item response, knee extension maximum voluntary isometric contraction (MVIC) torque, peak isokinetic knee extension torque, single leg hop distance, and International Knee Documentation Committee were measured. Correlations assessed relationships between PT quantity and clinical outcomes. Independent t tests compared PT quantity and clinical outcomes based on return-to-sport status, readiness to return to sport, and surgical procedure. Results : Patients completed regular PT (2 d/wk, 25 wk, 58 visits) and were most likely to conclude when discharged by the therapist (68.3%). More than half (56.7%) returned to sport, yet most (73.3%) felt unready at discharge. Isokinetic torque was correlated with days of PT/week ( r = .29, P = .03). Isokinetic torque and hop symmetry were reduced in patients who returned to sport ( P < .05). Patients who felt ready to return completed fewer weeks of PT ( P < .05). Patients with a patellar tendon graft completed more days of PT/week and total visits, but demonstrated lower MVIC torque, MVIC symmetry, and isokinetic symmetry ( P < .05). Conclusions : Many patients felt unready to return to sport at PT discharge. PT frequency was associated with isokinetic torque, yet this relationship was small. Outcomes were reduced in patients who returned to sport, suggesting premature resumption of preinjury activity.

BACKGROUND:The medical relevance and cost-benefit of routine radiographs after primary anatomic total shoulder arthroplasty (TSA) up to a year postoperatively are unknown. This study was performed to assess the medical relevance and cost-benefit of radiography after TSA during the first postoperative year. METHODS:During the period 2010 to 2015, 160 consecutive patients undergoing anatomic TSA by a single fellowship-trained surgeon had radiographs obtained at 2 weeks, 6 weeks, 4 months, and 1 year postoperatively. Radiographs and clinic notes were assessed to determine if a change in postoperative care happened because of radiographic findings, including postoperative fracture, hardware complication, or any concerning radiographic feature. Cost data and amount billed were obtained. RESULTS:Patients underwent radiography at 1.8 ± 0.2 weeks, 6.5 ± 1.2 weeks, 14.9 ± 2.9 weeks, and 46.8 ± 19.5 weeks postoperatively. Findings on the radiologist's reading were normal/unremarkable for 100.0%, 96.8%, 95.9%, and 95.2%, respectively, at each visit. Results were documented in the note for 92.5%, 97.4%, 98.0%, and 92.4%, respectively, at each visit. Review of the radiographs yielded no change in management based on these parameters. The amount billed for radiographs was $284,281 ($1776.76 per patient). CONCLUSIONS:A lack of clinically meaningful impact from routine postoperative radiography does not justify the per-patient expense, as routine imaging did not cause a change in postoperative management. The available data suggest that routine radiographs after primary anatomic TSA may be unnecessary or perhaps the described frequency in which radiographs are obtained is in excess.

CASE:We report the successful treatment of a Nocardia cyriacigeorgica periprosthetic joint infection (PJI) that occurred at the site of a total knee arthroplasty. To our knowledge, this organism has not previously been reported in the literature as a cause of PJI. Given the need for a prolonged duration of treatment for this organism (a minimum of 6 to 12 months), modifications to the standard 2-stage revision were made in consultation with infectious-disease specialists. CONCLUSION:PJI is a devastating complication that leads to substantial patient morbidity and utilization of health-care resources. As the number of PJIs continues to rise, new and increasingly challenging infections are being encountered more frequently. In the case described here, the second stage of the revision was delayed for 6 months and antibiotics were continued for 7 months after the second operation, for a total of 13 months of antibiotic treatment. The present report provides a possible treatment plan for patients infected with durable bacteria similar to N. cyriacigeorgica.

Background To determine patient-related risk factors for infection following knee arthroscopy using two large databases. Methods A private-payer (PP) and Medicare national insurance database were queried for patients undergoing simple knee arthroscopy procedures from 2005 to 2015. Patients undergoing concomitant open or complex procedures with grafts were excluded. Postoperative infection within 90 days was assessed using ICD-9 and CPT codes. A multivariate logistic regression analysis was utilized to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals were calculated for each risk factor, with P <0.05 considered statistically significant. Results One hundred thousand three hundred ninety nine patients from the PP database and 629,842 patients from the Medicare database met all inclusion and exclusion criteria. In the PP database, there were 250 patients with documented infections (0.25%); the incidence of infection was similar in the Medicare database (1755 patients, 0.28%). There were numerous patient-related comorbidities and demographics independently associated with a significantly increased risk of postoperative infection that were similar across the PP and Medicare patient populations, respectively, including younger age (OR = 1.27, 1.43), morbid obesity (OR = 1.26, 1.74), tobacco use (OR = 1.34, 1.48), inflammatory arthritis (OR = 1.61, 1.60), chronic kidney disease (OR = 1.65, 1.14), hemodialysis (OR = 1.93, 1.36), depression (OR = 2.02, 1.73), and a hypercoagulable disorder (OR = 2.76, 1.58). Conclusion The present study identified numerous patient-related risk factors independently associated with an increased risk of infection following knee arthroscopy in PP and Medicare-aged patients.

BACKGROUND:Given the overall success of anterior cruciate ligament (ACL) reconstruction and the infrequent occurrence of complications detectable on radiographs, the clinical utility and cost-effectiveness of routine radiographs in the early postoperative setting is questionable.METHODS:Nine hundred thirty-three consecutive adult patients undergoing uncomplicated ACL reconstruction at a single institution were retrospectively reviewed to determine whether a postoperative knee radiograph was obtained within the first three months postoperatively. Images, reports and clinical notes were reviewed to determine if any clinical management change occurred due to x-ray findings. Radiograph charges, including imaging, technical and professional charges were calculated.RESULTS:Five hundred ninety-nine of 933 primary ACL reconstruction patients (64.8%) had postoperative knee radiography at an average of 6.3±3.5 weeks postoperatively. A musculoskeletal radiologist read 97.7% of x-rays as normal. In the associated visit note, 70.3% of x-ray results were documented. Only 14.1% of patients with a postoperative x-ray had subsequent imaging. There were no significant management changes based on the routine postoperative radiographs using the defined criteria. A total of $336,683 ($562 per patient) was billed to patients for postoperative radiographs.CONCLUSIONS:Routine early postoperative radiography after primary ACL reconstruction is of questionable utility. The significant per-patient expense is not balanced by the low yield of clinically meaningful data, as nearly all radiographs in the present series were normal and none resulted in significant changes in postoperative clinical management. These results suggest that routine radiographs after uncomplicated ACL reconstruction may be unnecessary although larger, multicenter studies are necessary to confirm these findings.LEVEL OF EVIDENCE:Level IV, retrospective case series.

BACKGROUND:Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers. METHODS:We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845). RESULTS:MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048). CONCLUSIONS:MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.

A 32-year-old male recreational athlete presented with activity-related chronic dorsal midfoot pain. Conservative treatment, including a prolonged period of immobilization, physical therapy, nonsteroidal anti-inflammatory drugs, and use of a bone stimulator, failed to resolve his symptoms. Computed tomography and magnetic resonance imaging demonstrated a cystic appearing focus within the navicular in conjunction with a osteochondral lesion within the proximal articular surface of the navicular. This case report presents an arthroscopically assisted treatment of a navicular osteochondral lesion using curettage and backfilling with fibrin glue, flowable collagen, and autogenous bone grafting. Levels of Evidence: Therapeutic, Level IV

Loss of the extensor mechanism at the distal interphalangeal (DIP) joint leads to mallet finger also known as baseball finger or drop finger. This can be secondary to tendon substance disruption or to a bony avulsion. Soft tissue mallet finger is the result of a rupture of the extensor tendon in Zone 1, and a bony mallet finger is the result of an avulsion of the extensor tendon from the distal phalanx with a small fragment of bone attached to the avulsed tendon. Mallet finger leads to an imbalance in the distribution of the extensor force between the proximal interphalangeal (PIP) and DIP joints. If left untreated, mallet finger leads to a swan neck deformity from PIP joint hyper extension and DIP joint flexion. Most mallet finger injuries can be managed non-surgically, but occasionally surgery is recommended for either an acute or a chronic mallet finger or for salvage of failed prior treatment.