Publications

BACKGROUND: Knowledge regarding the biomechanics of the meniscus has grown exponentially throughout the last four decades. Numerous studies have helped develop this knowledge, but these studies have varied widely in their approach to analyzing the meniscus. As one of the subcategories of mechanical phenomena Medical Subject Headings (MeSH) terms, mechanical stress was introduced in 1973. This study aims to provide an up-to-date chronological overview and highlights the evolutionary comprehension and understanding of meniscus biomechanics over the past forty years.

METHODS: A literature review was conducted in April 2021 through PubMed. As a result, fifty-seven papers were chosen for this narrative review and divided into categories; Cadaveric, Finite element (FE) modeling, and Kinematic studies.

RESULTS: Investigations in the 1970s and 1980s focused primarily on cadaveric biomechanics. These studies have generated the fundamental knowledge basis for the emergence of FE model studies in the 1990s. As FE model studies started to show comparable results to the gold standard cadaveric models in the 2000s, the need for understanding changes in tissue stress during various movements triggered the start of cadaveric and FE model studies on kinematics.

CONCLUSION: This study focuses on a chronological examination of studies on meniscus biomechanics in order to introduce concepts, theories, methods, and developments achieved over the past 40 years and also to identify the likely direction for future research. The biomechanics of intact meniscus and various types of meniscal tears has been broadly studied. Nevertheless, the biomechanics of meniscal tears, meniscectomy, or repairs in the knee with other concurrent problems such as torn cruciate ligaments or genu-valgum or genu-varum have not been extensively studied.

BACKGROUND: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.

HYPOTHESIS: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.

RESULTS: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).

CONCLUSION: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Background: The optimal treatment of human bites to the dorsal metacarpophalangeal region (ie, "fight bite") in the absence of gross purulence is controversial. Few studies have compared the outcomes of operative debridement with expectant wound care and oral antibiotics. Methods: We performed a retrospective chart review of all patients evaluated at a Level 1 trauma center over a 10-year period. We compared demographic and clinical characteristics of patients across treatment and outcome groups using the Fisher exact test. Logistic regression models were used to describe the relationships between the outcome and treatment variables. Results: We identified 115 patients with a mean age of 29 years. The mean follow-up was 51.8 days. Seventy-two (63%) patients were treated with antibiotics only. Thirty-two (28%) patients were treated with irrigation in the emergency department (ED) and expectant wound care. Eleven (9%) patients were treated with irrigation and debridement in the operating room. No demographic variables were found to correlate with the treatment selected. A 12% complication rate (major and minor) was observed. After adjusting for duration of follow-up and days to presentation, neither the treatment rendered nor the antibiotics selected influenced the rate of complications. Time to presentation >24 hours was the only variable associated with higher complication rate (P = .003). Conclusions: Not all fight bites require operative intervention. Irrigation in the ED with expectant wound care and oral antibiotics can be sufficient for patients presenting within 24 hours of injury in the absence of gross purulence.

BACKGROUND: Fibroadipose vascular anomaly (FAVA) is a recently-defined vascular malformation often involving the extremities and presenting in childhood. Patients may present to orthopaedic surgeons with pain, swelling, joint contractures, and leg length discrepancy. There is no established therapy or treatment paradigm. We report on outcomes following surgical excision for patients with this condition.

METHODS: Between 2007 and 2016, all 35 patients that underwent excision of lower-extremity FAVA were retrospectively reviewed using a combination of medical records, radiologic findings, and telemedicine reviews.

RESULTS: Mean age at initial presentation was 12.3±6.8 years. Mean follow-up from time of definitive diagnosis at our institution was 66 months (range: 12 to 161 mo). Mean follow-up after surgery was 35 months (range: 6 to 138 mo). Females were affected more than males (71% vs. 29%). The most common location of FAVA was in the calf (49%), followed by the thigh (40%). The most commonly involved muscle was gastrocnemius (29%), followed by the quadriceps (26%). At latest follow-up after surgery, there was an improvement in the proportion of patients with pain at rest (63% vs. 29%), pain with activity (100% vs. 60%), as well as analgesia use (94% vs. 37%). Fourteen patients (40%) had symptomatic residual disease or recurrence of FAVA requiring further treatment. Six patients (17%) required further surgery and 6 (17%) required further interventional radiologic procedures. Three patients (9%) required eventual amputation for intractable pain and loss of function. Lesions with direct nerve involvement were associated with persistent neuropathic symptoms at latest follow-up (P=0.002) as well as symptomatic residual disease and/or recurrence requiring further treatment (P=0.01). Seventeen patients (49%) had 19 preoperative joint contractures. Eighteen of the 19 contractures (95%) had sustained improvement at latest follow-up.

CONCLUSIONS: In carefully selected patients, surgical excision of FAVA results in improvement of symptoms. However, symptomatic residual disease and/or recurrence are not uncommon. Direct nerve involvement is associated with a worse outcome.

LEVEL OF EVIDENCE: Level IV-case series.

PURPOSE: To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions.

METHODS: We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications.

RESULTS: We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12-169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal.

CONCLUSIONS: For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

PURPOSE: A paucity of evidence exists regarding the optimal treatment of open fractures of the distal radius. The purpose of this study was to compare short-term complication rates between various treatment options following open fractures of the distal radius.

METHODS: We performed a retrospective review of all open fractures of the distal radius at a single level 1 trauma center over a 10-year period. The primary outcome measure was the number of minor and major complications. Demographic and clinical characteristics of patients across treatment and outcome groups were compared and models were used to describe the relationships between outcome and treatment.

RESULTS: Ninety patients met the inclusion criteria for evaluation. An even distribution between high-energy (n = 45) and low-energy (n = 45) injuries was seen with 61 fractures Gustilo I (67%), 19 Gustilo II (22%), and 10 Gustilo III (11%). The majority of fractures were intra-articular (n = 48 AO type C vs n = 42 AO type A/B). Fractures were treated with immediate open reduction internal fixation (ORIF) in 67 cases (74%), external fixation in 12 (13%), initial external fixation followed by ORIF at a later time in 8 (9%), or closed reduction and percutaneous pinning in 3 (4%). We observed 33 complications (37%) of which 24 were major and 9 minor. Mechanism of injury and type of treatment were the only variables shown to correlate with an increased rate of complications.

CONCLUSIONS: We conclude that open fractures of the distal radius treated by immediate ORIF at the time of index debridement can result in satisfactory outcomes compared with other forms of treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

BACKGROUND: Osseous tumors of the shoulder girdle occur most frequently in the proximal humerus, scapula and clavicle. Prior studies have determined that tumors occurring in the scapula have a higher risk of malignancy, but few have looked exclusively at tumors of this site to describe incidence, clinical features and potential predictors of malignancy. As imaging technologies for diagnosis have improved, it is important to re-evaluate if patterns of incidence have changed and if new imaging findings could potentially be predictors of malignancy.

METHODS: This retrospective analysis identified 173 patients from a pediatric and an adult hospital between 1990 and 2015. All patients with tumors of the scapula either of bony origin or with bony invasion were included. Diagnosis, tumor location, and patient demographics were collected. Bivariate and logistic regression analyses were performed to identify potential predictors of malignancy.

RESULTS: Chondrosarcoma and osteochondroma were the most common malignant and benign tumors, respectively. Benign tumors were more prevalent in the pediatric population. Tumors occurred most frequently in the body of the scapula. Risk for malignancy increased with age (OR 1.09, 95% CI 1.05-1.12), tumors invading multiple sites (OR 10.85, 95% CI 2.37-49.72) and tumors that were lucent (OR 7.02, 95% CI 1.14-43.21) or had a mixed radiographic appearance (OR 11.47, 95% CI 1.36-99.65).

CONCLUSIONS: Including neoplasia in the differential diagnosis for shoulder complaints is important because the scapula is a site of increased risk of malignancy. Patterns of incidence and prevalence have not changed in the last years with the use of more advance techniques of imaging studies. Older age, lucent or mixed imaging, and tumors that span multiple sites of the scapula were found to be predictors of malignancy. Additional cross-sectional anatomy studies may be warranted for further evaluation in patients presenting with these characteristics given the higher concern for malignant disease.

LEVEL OF EVIDENCE: Level IV, Prognostic Study.

BACKGROUND: Talus fractures are severe injuries typically occurring after high-energy trauma. As a result, associated injuries to different anatomic sites and organ systems occur with high frequency. The objective of this study was to determine what injuries occur with high incidence in patients presenting with major fractures of the talus and to identify clinical injury patterns that may warrant special attention in these patients.

METHODS: We performed a retrospective review of patients presenting to 3 level 1 trauma centers with fractures of the talar neck, body, or head over a 14-year period. Patient charts were reviewed for associated orthopedic and nonorthopedic injuries identified during the initial patient encounter and hospitalization.

RESULTS: In total, 262 fractures in 258 unique patients met criteria for inclusion. Overall, 33.3% of talus fractures occurred in isolation. One or more associated injuries were identified in the remainder of cases (66.7%). The incidence of associated injuries was similar across fracture patterns. Mean total number of injuries per patient was 2.2 (range, 0-15). The ipsilateral foot was the most frequent site of associated orthopedic injury. Noncontiguous injuries occurred in 36% of cases. Lumbar spine injury occurred in 10.5% of cases. Lower extremity vascular injury was uncommon but bore significant association with open talus fractures.

CONCLUSION: Talus fractures are commonly associated with injuries to different anatomic sites and organ systems. A similar rate of lumbar spine trauma may occur with major talus fractures as has been historically associated with calcaneal fractures. Thorough evaluation and a high index of suspicion are necessary when evaluating patients with major fractures of the talus to avoid missing concomitant injuries.

LEVEL OF EVIDENCE: Level IV, retrospective case series.

OBJECTIVE: Although the number of female medical school graduates has dramatically increased over the last decades, Orthopaedic surgery continues to struggle in attracting women and under-represented minorities to the field. Potential barriers include limited exposure during medical school and the scarcity of female mentors. We hypothesized that a structured, low-cost, workshop for medical students allowing exposure to orthopaedic surgery would increase students' interest in the field. Our primary outcome was the perceived satisfaction with the program and the number of students who subsequently expressed an interest in pursuing a career in orthopaedic surgery. Our secondary outcome was the number of student participants who subsequently matched in orthopaedic surgery.

DESIGN: Combining female faculty from surrounding hospitals, we developed a free half-day program including skills workshops and panel discussions for women medical students in the region. Participants were asked to complete an anonymous survey grading their satisfaction with the utility of the information presented, the comfort level in interacting with faculty and how the experience may have impacted their potential interest in orthopaedic surgery. Eligible participants were contacted by email to determine their ultimate career choices and match results. Furthermore, participants were followed over time to determine how many chose and matched into an orthopaedic surgery residency.

SETTING: The workshop took place in Boston at the Harvard Medical School affiliated hospitals.

PARTICIPANTS: Student participants were invited from all New England allopathic and osteopathic medical schools. Faculty participants included staff, residents and fellows from the Harvard Combined Orthopaedic Residency Program.

RESULTS: Over 3 years, 155 female medical students participated in the program and 97% found it useful. Among 59 students who have since become eligible for the match, 22 matched into an orthopaedic surgery residency. Eight of 36 (22%) match eligible first and second year participants matched in orthopaedic surgery while 14 of 23 (61%) match eligible third and fourth year student attendees successfully matched in orthopaedic surgery programs.

CONCLUSIONS: Taking advantage of local resources, we demonstrated that outreach is effective in enhancing students' interest in the field. We encourage as many programs as possible to consider similar initiatives.

BACKGROUND:  This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes.

METHODS:  All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs).

RESULTS:  Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15-2.87, p = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0-1.94, p = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22-2.12, p < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times.

CONCLUSION:  DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars.