Faculty Bibliography

BACKGROUND:Genu valgum is a known risk factor for recurrent patellar instability, and surgical correction of deformity can be utilized as part of the management strategy to improve tracking and optimize outcomes. Tibial tuberosity-trochlear groove (TT-TG) distance is a widely used objective measurement of the lateral quadriceps force vector in patients with patellar instability. The evidence documenting the effect of lateral opening wedge distal femoral osteotomy (LOWDFO) and medial closing wedge high tibial osteotomy (MCWHTO) on TT-TG is limited, with minimal data directly comparing the biomechanical implications of one versus the other. PURPOSE/HYPOTHESIS/OBJECTIVE:The purpose of this study was to directly compare LOWDFO and MCWHTO using a computer model to determine the effect of each osteotomy on TT-TG distance. It was hypothesized that LOWDFO would have a greater effect on TT-TG distance, given the position farther away from the tibial tubercle. STUDY DESIGN/METHODS:Descriptive laboratory study. METHODS:A total of 22 knees from 21 patients with patellar instability and valgus malalignment were processed using 3D Slicer (Version 5.4.0) to convert their respective DICOM images into .stl mesh files to be used with Fusion (Autodesk; Version 2601.1.37) computer-aided design software. LOWDFOs and MCWHTOs were then simulated from 0° to 12° in 2° increments. TT-TG distance was then measured after each osteotomy. RESULTS:< .001). CONCLUSION/CONCLUSIONS:LOWDFO results in a significantly larger magnitude of change in the TT-TG compared with MCWHTO, with distal femoral osteotomy at almost a 1:1 change with TT-TG compared with the correction angle, and high tibial osteotomy about 1:4. CLINICAL RELEVANCE/CONCLUSIONS:The LOWDFO may be a more effective procedure in reducing the TT-TG distance, which is important when addressing patellar instability in patients with valgus malalignment.

Patient-specific instrumentation (PSI) may help improve outcomes following high tibial osteotomy (HTO). Three-dimensional preoperative planning allows for multiplanar osteotomy templating that can precisely restore the mechanical axis while limiting unintended sagittal plane abnormalities, facilitating execution of complex biplanar corrections. Patient-specific cutting guides and anatomically contoured implants reduce risk for intraoperative complications and streamlines operative efficiency. Though lacking long-term data to establish clinical superiority of PSI over traditional HTO techniques, early reports demonstrate PSI is highly accurate, safe, and effective. Understanding the advantages and limitations of PSI is crucial in making informed decisions when implementing this new technology in osteotomy surgery.

Multiligament knee injuries (MLKIs) are rare injuries that can result in devastating outcomes and functional impairment, especially in the setting of concomitant peroneal nerve injuries. Incidence of common peroneal nerve (CPN) injuries in MLKIs or knee dislocations ranges from 10% to 40%, with significant morbidity associated, especially in the setting of complete rupture. Treatment for MLKI with associated CPN injury depends on the degree of ligamentous and nerve injury. Options for the MLKI include nonoperative, repair, or reconstruction. Options for the CPN include included observation, neurolysis, direct nerve repair, and nerve grafting. In this Technical Note and associated video, we present a technique for an anterior cruciate ligament and posterolateral corner reconstruction with nerve reconstruction in the setting of a multiligament knee injury with complete CPN rupture.

Management of first-time shoulder dislocations in young active patients presents a significant challenge due to the high likelihood of recurrent anterior shoulder instability. Repeated instability events can result in poor outcomes because each dislocation contributes dose-dependent damage to the glenohumeral joint. Various validated techniques are available for reducing glenohumeral dislocations. For in-season athletes sustaining a shoulder dislocation, management requires balancing a rapid return to play with the heightened risk of recurrent instability. In-season surgical management is typically reserved for athletes experiencing recurrent instability or substantial osseous deficits. When surgical intervention is necessary, the approach is guided by the extent of critical glenoid bone loss and whether the humeral head bone defect engages with the glenoid.

BACKGROUND:The objective of this study was to survey a cross-section of US female orthopaedic surgeons evaluating their education and attitudes on radiation safety and adherence to safety recommendations. METHODS:An online survey was distributed to female orthopaedic surgery faculty through the Forum, a society for women in orthopaedic surgery, and through internal institutional education networks (residency and fellowship programs). The first component of the survey gathered demographic information including practice setting, US state, and years in practice. The second component was a 10-question knowledge assessment. The third component captured personal experiences among respondents including satisfaction with radiation safety training, radiation safety practices, and level of concern regarding exposure risk. Responses from 66 participants from differing geographic locations were collected using Research Electronic Data Capture. RESULTS:Sixty-six female orthopaedic surgeons from 21 states completed the survey. Regular dosimeter usage was reported by 24.2% of respondents, and 36.4% of respondents reported always having well-fitted radiation protective equipment provided. The majority (56.1%) stated that they worry about the risks of radiation to their health. Regarding their radiation safety training, 60.6% of respondents rated their training as unsatisfactory or extremely unsatisfactory, and 90.9% of respondents stated that they think training efforts for radiation safety can improve. CONCLUSIONS:Female orthopaedic surgeons demonstrated an inadequate knowledge of adherence to radiation safety protocols and the majority expressed concern with long-term radiation exposure, particularly regarding health and pregnancy risk. To enhance radiation safety awareness and adherence among female orthopaedic surgeons, strategies should be tailored to this demographic, fostering confidence in their knowledge of radiation exposure and bolstering safety measures.

BACKGROUND:The COVID-19 pandemic led to increased sedentary behavior and body mass index during 2020, which may decondition musculotendinous units and lead to increased risk for injury. As patients return to pre-COVID levels of activity, we hypothesize that there will be a resultant rebound increase in tendon ruptures. LEVEL OF EVIDENCE/METHODS:III, descriptive epidemiology study. METHODS:The electronic medical record was queried for current procedural terminology codes for tendon ruptures (Achilles, patella, quadriceps, hamstring, distal biceps, triceps, and pectoralis major) from January 2017 to December 2021 at a single academic urban center. Data were reviewed to ensure only acute tendon rupture repairs were included. The years 2017-2019 were used as a proxy for pre-COVID rates, 2020 as a proxy for the COVID quarantine, and 2021 as a proxy for "post-COVID" activity. Univariate analysis was performed for comparative data. RESULTS:A total of 1,879 patients (82.8% male, mean age 47.8 years) who sustained tendon injuries and underwent surgical repair were identified. There were 589 (31.3%) Achilles tendon repairs, 181 (9.6%) patella tendon repairs, 414 (22.0%) quadriceps tendon repairs, 100 (5.3%) hamstring tendon repairs, 397 (21.1%) distal biceps repairs, 105 (5.6%) triceps repairs, and 93 (4.9%) pectoralis tendon repairs. The total number of tendon injuries per year was 2017-357 (19.0%), 2018-380 (20.2%), 2019-380 (20.2%), 2020-308 (16.4%), and 2021-454 (24.2%). The rates in 2017, 2018, and 2019 were within 1% of each other, but there were a 3.8% decrease in rate of tendon injuries from 2019 to 2020 and a 7.8% increase in rate of tendon injuries from 2020 to 2021. When analyzed by quarter, a linear regression model demonstrated a statistically significant increase in case counts over the period from Q2 2020 to Q2 2021 (β = 21.20; 95% confidence interval = 13.62-28.78, P-value < .01). CONCLUSIONS:A "COVID rebound" of tendon rupture repairs in 2021 from a prolonged period of inactivity during 2020 occurred at a single academic center. As patients return to pre-COVID levels of activity that may be unsuitable to their deconditioned state, healthcare providers should counsel patients appropriately on return to activity or sport following long periods of induced inactivity.

The knee is a complex joint composed of a combination of osseous, musculotendinous, ligamentous, neurovascular, and intra-articular structures, which must be taken into consideration when performing surgical approaches, whether it be for trauma, replacement, or joint preservation surgery. A wide variety of surgical approaches exist for exposure of the lateral side of the knee, including approaches to the distal femur, knee joint, and proximal tibia. Care must be taken to choose the appropriate approach depending on the procedure being performed to best preserve and protect important neurovascular structures. This review thoroughly describes the most frequently used surgical approaches to the lateral knee. The common themes and anatomical considerations presented in this review, in combination with continued experience, can provide surgeons with familiarity with various ways of accessing the knee joint.

The need to perform revision anterior cruciate ligament reconstruction (ACLR) has several etiologies such as infection, arthrofibrosis, cyclops lesions, and graft failure, which should be distinguished before revision ACLR. Even the definition of graft failure varies within the literature. ACLR graft failure falls into modifiable, surgeon-controlled factors, such as tunnel position, graft choice, and alignment, and nonmodifiable factors, such as patient age, tissue quality, or secondary traumatic reruptures. In this review, we describe a facile framework for the workup of modifiable ACLR graft failure.