A recent randomized controlled trial compared early anterior cruciate ligament reconstruction with a program of initial rehabilitation, with delayed anterior cruciate ligament reconstruction if needed. The authors reported that the improvement in Knee Injury and Osteoarthritis Outcome Scores was nearly identical in both groups and concluded that in young, active adults with acute ACL (anterior cruciate ligament) tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. Yet, in making that assessment, the authors did not account for the fact that there were more meniscal injuries in the group with delayed anterior cruciate ligament surgery. Establishing the true superiority of one strategy requires consideration of meniscal injury, as well as a further determination if the apparent protective effect regarding meniscal tears found in the cohort of patients with early anterior cruciate ligament reconstruction is offset by the costs of additional reconstructive surgery. That analysis of offsetting utility, omitted in the randomized controlled trial noted above, is provided in the present study.

A decision analysis model considering the options and probabilities described in the randomized controlled trial was constructed: the functional outcome of all groups was assumed to be equal, the likelihood of a patient eventually needing surgery despite initially choosing a program of rehabilitation was 37%, and the likelihood of needing a meniscectomy was 23% for the early surgery group and 35% for the rehabilitation and deferred anterior cruciate ligament reconstruction group.

The early surgery option is the preferable therapeutic approach as long as the costs of a potential meniscal tear are at least 5.25 times the costs of reconstructive surgery.

Early surgery for anterior cruciate ligament tears may be the preferred approach for some patients, on the basis of the utility values they assign to the possible treatment outcomes. The reported randomized controlled trial did not establish a dominant strategy. Indeed, early surgery may be the more effective approach overall.

The reported complication rates of ankle arthroscopy, as well as the types of complications, refer to cases performed fifteen to twenty years ago and include a mixture of invasive and noninvasive distraction methods. As ankle arthroscopy has matured with a move away from invasive distraction and the introduction of improved instruments, it is unclear whether the previously reported complications are reflective of contemporary ankle arthroscopy. We sought to evaluate the types and rates of complications that are associated with contemporary ankle arthroscopy that utilizes noninvasive ankle distraction and a padded foot strap.

We retrospectively reviewed 294 consecutive arthroscopies. All patients underwent the same intraoperative noninvasive distraction protocol. Demographic data, diagnoses, duration of follow-up data, and procedure-related complications were identified, recorded, and analyzed.

All 294 cases were eligible for review. There were twenty complications, resulting in an overall complication rate of 6.8%. There were four non-neurologic complications, including one case of deep venous thrombosis, one case of prolonged portal drainage, and two cases of superficial infection. There were sixteen neurologic complications; six were related to the anterolateral portal, and eight patients had dysesthesias involving the dorsal part of the midfoot. When analyzed as a group, patients who were receiving Workers’ Compensation had a higher complication rate than patients who were not receiving Workers’ Compensation (21% versus 4.7%, respectively).

Contemporary ankle arthroscopy performed with use of a noninvasive distraction technique is a safe procedure. Our observed complication rate of 6.8% is lower than that reported in a previous benchmark study, although our patients who were receiving Workers’ Compensation had a significantly higher risk of having nerve symptoms. An important benefit of the use of contemporary ankle arthroscopy, in which small-joint arthroscopic instruments and noninvasive distraction techniques are used, is a marked reduction in the rate of non-neurologic complications.

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

The medial patellomeniscal ligament has been determined in vitro to be the only substantial distal-medial restraint to lateral patellar displacement. The purpose of this study of prospectively collected data was to determine if isolated deficiency of the medial patellomeniscal ligament, resulting in excessive lateral patellar translation and associated symptoms, could be identified. We hypothesized that, if symptoms were associated with isolated deficiency of that ligament, the laxity and symptoms should resolve after plication of that ligament alone.

Testing for lateral patellar displacement in the extended knee by exertion of force through the distal patellar attachment of the medial patellomeniscal ligament was performed on 745 patients with patellofemoral syndromes during a twenty-eight-month period. In addition, the ability to recognize pathologically increased lateral patellar translation preoperatively with use of such testing was compared with the ability to recognize increased lateral translation with testing in 439 patients undergoing arthroscopy under anesthesia during that period for any reason. Preoperative symptoms and impairment in knees with isolated deficiency of the medial patellomeniscal ligament were documented and compared with the postoperative results.

Isolated medial patellomeniscal ligament deficiency was identified with testing under anesthesia in twenty-three of the 439 knees undergoing arthroscopy for any reason, and twenty of those twenty-three cases had been detected preoperatively with use of lateral patellar displacement testing. Isolated medial patellomeniscal ligament plication was performed in these twenty-three cases, and follow-up data at a mean of 30.8 months were available for twenty-one of the cases. The mean International Knee Documentation Committee subjective score increased from 38.9 preoperatively to 84.6 postoperatively, and recurrent symptomatic pathological lateral patellar translation was present in only one patient.

Isolated deficiency of the medial patellomeniscal ligament can be detected by physical examination. Restoration of the normal length of the ligament by plication can lead to resolution of detectable patellar subluxation and its associated symptoms.

Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Total knee arthroplasty carries major risks, including death. Conventional studies have compared the mortality rate following total knee arthroplasty with standardized mortality ratios or age and sex-matched populations. The purpose of the present study was to compare the mortality rate in a population of patients who were managed with total knee arthroplasty with that in patients who were awaiting surgery.

All patients undergoing primary total knee arthroplasty from 2000 to 2007 at a single institution were recorded. In the same period, all patients who were added to the waiting list for total knee arthroplasty were recorded. The mortality rate and time to death were calculated, and death certificates were retrieved for those who died within thirty or ninety days after the index event.

Two thousand, six hundred and ninety-five patients undergoing primary total knee arthroplasty were used for the thirty-day mortality calculation, and 2527 were used for the ninety-day mortality calculation. These patients were compared with 5857 and 5689 patients who were added to the waiting list for the thirty-day and ninety-day mortality calculations, respectively. There was no difference between the populations in terms of age or sex (p > 0.05). The thirty-day mortality following surgery was significantly greater for the surgery group (0.371%; 95% confidence interval, 0.202% to 0.682%) than for the waiting list group (0.0683%; 95% confidence interval, 0.0266% to 0.1755%) (odds ratio, 5.45; 95% confidence interval, 1.81 to 16.43). The ninety-day mortality was also significantly greater for the surgery group (0.792%; 95% confidence interval, 0.513% to 1.219%) than for the waiting list group (0.387%; 95% confidence interval, 0.256% to 0.585%) (odds ratio, 2.05; 95% confidence interval, 1.13 to 3.74).

Primary total knee arthroplasty is associated with an increased risk of death at thirty and ninety days after the operation when compared with a population awaiting the same procedure. Increasing age was a risk factor for death following total knee arthroplasty.

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

The use of a Gotfried percutaneous compression plate provides a minimally invasive technique for the fixation of intertrochanteric proximal femoral fractures. The purpose of this study was to determine if the percutaneous compression plate provided advantages compared with the sliding hip screw for treatment of A1 and A2 AO/OTA intertrochanteric proximal femoral fractures.

An institutional review board-approved, prospective, randomized, single-blinded study was conducted at a level-I trauma center between July 2004 and September 2007. All patients who met the study criteria and provided informed consent were randomized to treatment with a sliding hip screw or percutaneous compression plate. Of the sixty-six patients who consented to participate, thirty-three were randomized to be treated with a sliding hip screw and thirty-three, with a percutaneous compression plate. Data evaluated included surgical time, incision length, blood loss, need for blood transfusion, and postoperative functional status. Follow-up included clinical findings, radiographs until healing was confirmed, functional and pain assessment scores, and the Short Form-36. The median follow-up period for surviving patients was thirty-six months.

Sixty-six patients, forty-seven women and nineteen men, with a mean age of seventy-seven years were entered into the study. The treatment groups were similar with respect to study variables (p > 0.05). Operative times (forty-eight vs. seventy-eight minutes), incision length (56 vs. 82 mm), and blood loss (41 vs. 101 mL) significantly favored the percutaneous compression plate group (p < 0.001). The groups were similar immediately postoperatively; however, by discharge, fewer patients with a percutaneous compression plate required walking aids (40% vs. 59%). This trend continued throughout the study but was not significant. Pain with activity was lower throughout the study for the percutaneous compression plate group, but the difference was significant only at the three-month interval.

Previously published reports showing shorter operative times and less blood loss with the percutaneous compression plate were reaffirmed. Compared with the sliding hip screw, the percutaneous compression plate resulted in a larger percentage of patients who were able to walk independently, consistently lower levels of pain with activity, and improved quality of life according to multiple scales of the Short Form-36, but the differences were not significant. Significant differences favoring the percutaneous compression plate were found with regard to operating times, incision length, and blood loss.

Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Currently, the most common clinical scenario for compartment syndrome in children is acute traumatic compartment syndrome of the leg. We studied the cause, diagnosis, treatment, and outcome of acute traumatic compartment syndrome of the leg in children.

Forty-three cases of acute traumatic compartment syndrome of the leg in forty-two skeletally immature patients were collected from two large pediatric trauma centers over a seventeen-year period. All children with acute traumatic compartment syndrome underwent fasciotomy. The mechanism of injury, date and time of injury, time to diagnosis, compartment pressures, time to fasciotomy, and outcome at the time of the latest follow-up were recorded.

Thirty-five (83%) of the forty-two patients were injured in a motor-vehicle accident and sustained tibial and fibular fractures. The average time from injury to fasciotomy was 20.5 hours (range, 3.9 to 118 hours). In general, the functional outcome was excellent at the time of the latest follow-up. No cases of infection were noted when fasciotomy was performed long after the injury. At the time of the latest follow-up, forty-one (95%) of forty-three cases were associated with no sequelae (such as pain, loss of function, or decreased sensation). The two patients who lost function had fasciotomy 82.5 and eighty-six hours after the injury.

Despite a long period from injury to fasciotomy, most children who are managed for acute traumatic compartment syndrome of the leg have an excellent outcome. This delay may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. The results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury. Fasciotomy during the acute swelling phase, even long after injury, produced excellent results with no cases of infection.

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

The purpose of this study was to evaluate the biomedical and psychosocial factors associated with disability at a minimum of six months following upper-extremity nerve injury.

This cross-sectional study included patients who were assessed between six months and fifteen years following an upper-extremity nerve injury. Assessment measures included patient self-report questionnaires (the Disabilities of the Arm, Shoulder and Hand Questionnaire [DASH]; pain questionnaires; and general health and mental health questionnaires). DASH scores were compared by using unpaired t tests (sex, Workers’ Compensation/litigation, affected limb, marital status, education, and geographic location), analysis of variance (nerve injured, work status, and income), or correlations (age and time since injury). Multivariable linear regression analysis was used to evaluate the predictors of the DASH scores.

The sample included 158 patients with a mean age (and standard deviation) of 41 ± 16 years. The median time from injury was fourteen months (range, six to 167 months). The DASH scores were significantly higher for patients receiving Workers’ Compensation or involved in litigation (p = 0.02), had a brachial plexus injury (p = 0.001), or were unemployed (p < 0.001). There was a significant positive correlation between the DASH scores and pain intensity (r = 0.51, p < 0.001). In the multivariable regression analysis of the predictors of the DASH scores, the following predictors explained 52.7% of the variance in the final model: pain intensity (Beta = 0.230, p = 0.006), brachial plexus injury (Beta = –0.220, p = 0.000), time since injury (Beta = –0.198, p = 0.002), pain catastrophizing score (Beta = 0.192, p = 0.025), age (Beta = 0.187, p = 0.002), work status (Beta = 0.179, p = 0.008), cold sensitivity (Beta = 0.171, p = 0.015), depression score (Beta = 0.133, p = 0.066), Workers’ Compensation/litigation (Beta = 0.116, p = 0.049), and female sex (Beta = –0.104, p = 0.090).

Patients with a peripheral nerve injury report substantial disability, pain, and cold sensitivity. Disability as measured with the DASH was predicted by brachial plexus injury, older age, pain intensity, work status, time since injury, cold sensitivity, and pain catastrophizing.

Prognostic Level II. See Instructions to Authors for a complete description of Levels of Evidence.

Surgical treatment of displaced intra-articular fractures of the calcaneus is a standard procedure in many institutions. To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques.

All patients who underwent percutaneous screw fixation according to the method of Forgon and Zadravecz between 1998 and 2006 were selected. Postoperative infections were recorded. During follow-up, pain, functional outcome, range of motion, and change in footwear were evaluated with the use of the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients also completed a general health status form (Short Form-36 [SF-36]) and a visual analog scale (VAS) for patient satisfaction. Subsequent subtalar arthrodesis and the removal of irritating screws were performed when indicated.

We reviewed the cases of thirty-seven patients who had a combined total of thirty-nine displaced intra-articular calcaneal fractures and a follow-up period of at least twenty-four months. Five wound infections occurred, two of which were superficial and three of which were deep. At a mean follow-up time of sixty-six months, the mean AOFAS and MFS scores were 84 and 86 points, respectively, of 100 possible points. The mean score on the SF-36 was 76 points, and the mean score on the visual analog scale for patient satisfaction was 7.9 points of 10 possible points. Twenty-nine patients (78%) were able to wear normal shoes. At the time of follow-up, subtalar arthrodesis had been performed in two patients and seventeen patients (46%) had undergone an uncomplicated removal of painful screws. No substantial correlation was found between the severity of the fracture (Sanders classification) or the quality of the reduction when correlated with functional outcome parameters.

We consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Implant arthroplasty of the wrist offers pain relief with preservation of motion to patients with rheumatoid arthritis, although few studies have investigated the long-term results of this procedure. The purpose of the present study is to report the prospective results of total wrist arthroplasty with use of the Universal wrist prosthesis in a consecutive series of patients with rheumatoid arthritis who were managed by a single surgeon.

Twenty-four wrist arthroplasties in twenty patients with rheumatoid arthritis were followed prospectively. Nineteen wrists in fifteen patients were followed clinically and radiographically for a mean of 7.3 years (range, 5.0 to 10.8 years) after the index procedure. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, wrist range of motion, and standard radiographic findings.

The average DASH score improved from 62 points preoperatively to 40 points at the time of the latest follow-up. The mean wrist flexion and extension at the time of the latest follow-up were 42° and 20°, respectively, for a mean improvement in the total flexion-extension arc of 14°. A total of nine wrists (45%) in eight patients underwent revision surgery because of a loose carpal component at the time of the latest follow-up. One patient underwent wrist arthrodesis because of recurrent wrist instability. Two additional wrists in two patients had radiographic evidence of carpal component subsidence at the time of the latest follow-up. The implant survival rates at five and seven years for the original prosthetic components were 75% and 60%, respectively.

The results for the Universal wrist prosthesis at a minimum of five years of follow-up include a high rate of failure, most often because of carpal component loosening, resulting in revision of ten (50%) of twenty wrists at the time of the latest follow-up (with the inclusion of one revision in a patient who died before five years). Patients with a stable prosthesis maintained a functional range of motion and had improvement in patient-reported outcome measures.

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Bisphosphonate therapy has been shown to preserve the osteonecrotic femoral head in experimental and short-term clinical studies. However, a lack of new bone formation within the preserved femoral head due to the inhibition of bone remodeling is a concern. The purpose of this investigation was to determine if combined therapy consisting of ibandronate and bone morphogenetic protein-2 (BMP-2) can preserve the shape of the femoral head and stimulate new bone formation in an immature animal model of ischemic osteonecrosis.

Ischemic osteonecrosis was surgically induced in immature pigs. Four groups were studied: normal, treated with saline solution, treated with ibandronate, and treated with both ibandronate and BMP-2 (the ibandronate + BMP-2 group). The animals were killed eight weeks after surgery. Radiographic, histological, and histomorphometric assessments were performed.

Radiographic assessment showed better preservation of the femoral head shape—i.e., a 54% (CI [95% confidence interval]: 22%, 86%) higher mean epiphyseal quotient—in the ibandronate + BMP-2 group than in the saline group. Histological assessment showed increased trabecular bone in the ibandronate + BMP-2 group as compared with that in the saline group. The mean values for trabecular bone volume, thickness, and number and for osteoblast surface were an average of 400% (CI: 242%, 558%), 212% (CI: 166%, 259%), 71% (CI: 6%, 137%), and 2402% (CI: 2113%, 2693%) higher, respectively, in the ibandronate + BMP-2 group than in the saline group. The osteoclast number was significantly reduced in the ibandronate + BMP-2 group compared with that in the saline group (–59% [CI: –75%, –42%]). The mean osteoblast surface value in the ibandronate + BMP-2 group was significantly higher (2567% [CI: 2258%, 2877%]) than that in the ibandronate group. Heterotopic ossifications were present in the capsule of the hip joint in the ibandronate + BMP-2 group.

A combination of ibandronate and BMP-2 decreased femoral head deformity while stimulating bone formation in an immature animal model of ischemic osteonecrosis.

The findings provide a proof of concept that a combination of antiresorptive and anabolic agents can significantly improve bone healing and decrease deformity following ischemic osteonecrosis in the immature femoral head of a pig. Additional studies are needed to investigate whether heterotopic ossification can be prevented.