Faculty Bibliography

Dislocation is one of the most common complications of total hip arthroplasty (THA). Because of the growing number of patients undergoing THA annually and the immense number of patients who have previously undergone the procedure, familiarity with the diagnosis and treatment of this complication is critical. Although the most common direction of dislocation is posterior, anterior dislocations do occur, and correctly identifying the direction of dislocation is important before attempted closed reduction as both the reduction maneuvers used and the postoperative instructions afterward are distinct for an anterior as opposed to a posterior dislocation. We present the current case of an anterior hip dislocation that was unable to be closed reduced as the direction of dislocation was presumed to be posterior. Although a shoot through lateral is recommended in all cases to confirm the direction of dislocation, we highlight how the physician can differentiate the direction of dislocation based on the position of the foot and location of the lesser trochanter on the anteroposterior radiograph.

BACKGROUND:Anterior cruciate ligament (ACL) rupture is a significant injury in male National Hockey League (NHL) players. PURPOSE/OBJECTIVE:To determine (1) the return to sport (RTS) rate in the NHL following ACL reconstruction, (2) performance on RTS, and (3) the difference in RTS and performance between players who underwent ACL reconstruction and controls. STUDY DESIGN/METHODS:Cohort study; Level of evidence, 3. METHODS:NHL players undergoing ACL reconstruction were evaluated. All demographic data were analyzed. Matched controls were selected from the NHL during the same years as those undergoing ACL reconstruction. The "index year" (relative to the number of years of experience in the NHL) in controls was the same as the year that cases underwent ACL reconstruction. RTS and performance in the NHL were analyzed and compared between cases and controls. Student t tests were performed for analysis of within- and between-group variables. Bonferroni correction was used in the setting of multiple comparisons. RESULTS:A total of 36 players (37 knees) meeting the inclusion criteria underwent ACL reconstruction while in the NHL. Thirty-five players were able to RTS in the NHL (97%), and 1 player returned to the international Kontinental Hockey League. Of the players who RTS in the NHL, 100% were able to RTS the season after ACL reconstruction (mean, 7.8 ± 2.4 months). Length of career in the NHL after ACL reconstruction was 4.47 ± 3.3 years. The revision rate was 2.5%. There were significantly more cases playing in the NHL at 3 (P = .027) and 4 (P = .029) years following surgery compared with controls (index year). After ACL reconstruction, player performance was not significantly different from preinjury performance. Following ACL reconstruction (or index year in controls), cases played significantly more minutes, took more shots, had better shooting percentages, and scored more goals and points than did controls (P < .01 for all). Control players did not significantly outperform cases after ACL reconstruction in any performance measure. CONCLUSION/CONCLUSIONS:There is a high RTS rate in the NHL following ACL reconstruction. All players who RTS did so the season following surgery. Performance following ACL reconstruction was not significantly different from preinjury. Cases performed better than did controls in several performance measures. Controls did not outperform cases in any measured performance variable.

BACKGROUND:Achilles tendon ruptures are one of the most commonly treated injuries by orthopaedic surgeons and general practitioners. Achilles tendon ruptures have classically been thought to affect the middle-aged "weekend warrior" participating in basketball, volleyball, soccer, or any other ground sport that requires speed and agility; however, with a more active elderly population, these tears are becoming more common in older patients. PURPOSE/OBJECTIVE:To report trends in nonoperative and operative treatment of Achilles tendon tears in the United States from 2005 to 2011 in patients registered with a large Medicare database. STUDY DESIGN/METHODS:Descriptive epidemiological study. METHODS:Patients who underwent nonoperative and operative treatment of Achilles tendon ruptures by either primary repair or primary repair with graft (International Classification of Diseases 9 [ICD-9] diagnosis code 727.67, Current Procedural Terminology [CPT] codes 27650 and 27652) for the years 2005 to 2011 were identified using the PearlDiver Medicare Database. Demographic and utilization data available within the database were extracted for patients who underwent nonoperative as well as operative treatment for Achilles tendon ruptures. Statistical analysis involved Student t tests, chi-square tests, and linear regression analyses, with statistical significance set at P < .05. RESULTS:From 2005 to 2011, there were a total of 14,127 Achilles tendon ruptures. Of these, 9814 were managed nonoperatively, 3531 were treated with primary repair, and 782 were treated with primary repair with graft. The incidence of Achilles tendon increased from 0.67 per 10,000 in 2005 to 1.08 per 10,000 in 2011 (P < .01). There was no significant difference in the number of Achilles ruptures between males (6636) and females (7582) (P > .05). There was an increase in the overall number of Achilles tendon ruptures over time (1689 in 2005 compared with 2788 in 2011; P < .001) but no difference in the percentage of Achilles ruptures treated operatively (P > .05). Older patients were more likely to be treated nonoperatively (P < .05). No differences in operative versus nonoperative treatment were seen between yearly quarter (P > .05), sex (P > .05), or region (P > .05). CONCLUSION/CONCLUSIONS:The incidence of Achilles tendon ruptures is increasing with time, but the trend in operative and nonoperative treatment has not changed between 2005 and 2011. Older patients, especially those older than 85 years, are more likely to be treated nonoperatively. No differences in treatment patterns were seen based on sex, region, or yearly quarter.

Chondral injuries of the hip joint are often symptomatic and affect patient activity level. Several procedures are available for addressing chondral injuries, including microfracture. Microfracture is a marrow-stimulating procedure, which creates subchondral perforation in the bone, allowing pluripotent mesenchymal stem cells to migrate from the marrow into the chondral defect and form fibrocartilaginous tissue. In the knee, microfracture has been shown to relieve pain symptoms. In the hip, microfracture has been studied to a lesser extent, but published studies have shown promising clinical outcomes. The depth, joint congruity, and geometry of the hip joint make microfracture technically challenging. The most common technique uses hip-specific microfracture awls, but the trajectory of impaction is not perpendicular to the subchondral plate. Consequently, the parallel direction of impaction creates poorly defined channels. We describe an arthroscopic microfracture technique for the hip using a flexible microfracture drill. The drill and angled guides simplify access to the chondral defect. The microfracture drill creates clear osseous channels, avoiding compaction of the surrounding bone and obstruction of the channels. Furthermore, this technique allows for better control of the angle and depth of the drill holes, which enhances reproducibility and may yield improved clinical outcomes.

Tibial tuberosity osteotomy (TTO) is a well-described treatment option for a broad range of patellofemoral joint disorders, including patellofemoral instability, patellar and trochlear focal chondral lesions, and patellofemoral arthritis. The purpose of this article is to review the evolution of the TTO procedure, from the original Hauser procedure to the current anteromedialization procedure, as well as discuss the pertinent anatomy and radiographs that accompany this procedure. The article highlights the surgical techniques for some of the more commonly performed TTO procedures and discusses the outcomes of the various TTO techniques. Complications, as well as clinical pearls to avoid these complications, are also included.

Anterior cruciate ligament (ACL) rupture is a significant injury in National Football League (NFL) quarterbacks. The purpose of this study was to determine (1) return-to-sport (RTS) rate in NFL quarterbacks following ACL reconstruction, (2) performance upon RTS, and (3) the difference in RTS and performance between players who underwent ACL reconstruction and controls. Thirteen quarterbacks (14 knees) who met inclusion criteria underwent ACL reconstruction while in the NFL. Matched controls were selected from the NFL during the same time span to compare and analyze age, body mass index (BMI), position, performance, and NFL experience. Student t tests were performed for analysis of within- and between-group variables. Bonferroni correction was used in the setting of multiple comparisons. Twelve quarterbacks (13 knees; 92%) were able to RTS in the NFL. Mean player age was 27.2±2.39 years. Mean career length in the NFL following ACL reconstruction was 4.85±2.7 years. Only 1 player needed revision ACL reconstruction. In both cases and controls, player performance was not significantly different from preinjury performance after ACL reconstruction (or index year in controls). There was also no significant performance difference between case and control quarterbacks following ACL reconstruction (or index year in controls). There is a high rate of RTS in the NFL following ACL reconstruction. In-game performance following ACL reconstruction was not significantly different from preinjury or from controls.

BACKGROUND:Radial head fractures are one of the more common fractures of the body, and the most common fractures around the elbow. CASE REPORT/METHODS:While these can present in isolation, concomitant injuries to the ulna, elbow joint and surrounding ligaments, interosseous membrane, proximal radioulnar joint, and distal radioulnar joint can also occur. It is imperative that the treating surgeon rules out any concomitant injuries when evaluating a patient with a radial head fracture as the treatment options vary greatly depending on the structures which are damaged. CONCLUSIONS:Radial head resection, a viable treatment option for isolated radial head fractures, can lead to long-term sequelae if performed for a radial head fracture accompanied by interosseous membrane and distal radioulnar joint injury; this combination is termed an Essex-Lopresti injury. We will review the topic of Essex-Lopresti injuries, and discuss proper treatment options for these injuries.

PURPOSE/OBJECTIVE:This study aimed to determine practice patterns for National Football League (NFL) and National Collegiate Athletic Association (NCAA) Division I football team orthopaedic surgeons regarding management of anterior cruciate ligament (ACL) tears in elite, young, and middle-aged recreational athletes. METHODS:Two hundred sixty-seven NFL and NCAA Division I team orthopaedic surgeons were surveyed through an online survey. A 9-question survey assessed surgeon experience, graft choice, femoral tunnel drilling access, number of graft bundles, and rehabilitation after ACL reconstruction. RESULTS:One hundred thirty-seven team orthopaedic surgeons (51%) responded (mean experience 16.75 ± 8.7 years). Surgeons performed 82 ± 50 ACL reconstructions in 2012. One hundred eighteen surgeons (86%) would use bone-patellar tendon-bone (BPTB) autografts to treat their starting running backs. Ninety (67%) surgeons drill the femoral tunnel through an accessory anteromedial portal (26% through a transtibial portal). Only 1 surgeon prefers a double-bundle to a single-bundle reconstruction. Seventy-seven (55.8%) surgeons recommend waiting at least 6 months before return to sport, whereas 17 (12.3%) wait at least 9 months. No surgeon recommends waiting 12 months or more before return to sport. Eighty-eight (64%) surgeons do not recommend a brace for their starting running backs during sport once they return to play. CONCLUSIONS:BPTB is the most frequently used graft for ACL reconstruction by NFL and NCAA Division I team physicians in their elite-level running backs. Nearly all surgeons always use a single-bundle technique, and most do not recommend a brace on return to sport in running backs. Return to sport most commonly occurs at least 6 months postoperatively, with some surgeons requiring a normal examination and normal return-to-sport testing (single leg hop).

PURPOSE/OBJECTIVE:Guided growth has long been used to treat growth deformities, but the Eight-Plate(®) system has recently become more widely used by pediatric orthopaedists. Because the current literature lacks evaluation of functional status in the immediate post-operative period, we investigated functional status following use of the Eight-Plate(®) system. METHODS:We evaluated post-operative delay in return of function following treatment with the Eight-Plate(®) system at two weeks after surgery. Fifty-one consecutive patients with a growth deformity were treated with the Eight-Plate(®) system. Patients were comprised of 32 male and 19 female patients with an average age of 11 years (range 2-17.9 years). RESULTS:Among study participants, 19 patients (37.3 %) had post-operative delay of function. The rate of delayed function for patients 10 years of age or younger and 11 years of age or older was respectively 11.8 and 50 % (P = 0.002). Six of the 19 patients were treated with four or more plates, of which five patients (83.3 %) developed delayed return of function. The rate of delayed function in patients with at least one femoral plate compared to no femoral plate was respectively 45 and 9.1 % (P = 0.006). Bilateral operations were associated with a 66.7 % rate of delayed function compared to 25 % with unilateral operations (P = 0.004). When patients with delay of function were treated with physical therapy, 12 of 13 patients (92.3 %) had complete resolution of their symptoms. CONCLUSION/CONCLUSIONS:Statistical significance demonstrated that patients at the greatest risk were 11 years of age or older, with four or more plates, with femoral plates, or with bilateral operations. Patients with delayed function were readily corrected by physical therapy.