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Although infrequent, some pathological conditions of the knee are often misdiagnosed. Several miscellaneous complex knee pathological conditions and their treatments are outlined. Patellofemoral arthritis, when refractory, can be treated with an arthroscopic partial lateral facetectomy of the patella using a motorised burr to decrease the pain associated with the patellofemoral arthritis. Additionally, symptomatic fabella syndrome can be a difficult diagnosis to make, is often misdiagnosed and can be treated with an open excision. Snapping hamstrings are also often misdiagnosed; they are caused by friction between the hamstrings of the pes tendons medially and can be treated with sectioning or harvesting the gracilis or semitendinosus from their insertion on the anteromedial tibia. Symptomatic decreased knee extension in the setting of osteoarthritis is often the result of bony osteophyte overgrowth of the femoral notch. Arthroscopic notchplasty can be an effective adjunct in restoring knee extension in otherwise highly functional patients. Symptomatic proximal tibiofibular joint instability most often results from disruption of the posterior tibiofibular ligaments and can present as both pain over the posterolateral knee with deep squats or dysaesthesias along the common peroneal nerve distribution. Reconstruction of these ligaments is outlined as an effective treatment for this condition. Finally, severe patella baja is a condition that can be debilitating and difficult to treat. Patellar tenotomy to allow proximal migration is described as a valid technique for restoring range of motion and function.

Background: Acetabular labral reconstruction has demonstrated good results for labral lesions not amenable to labral repair. Purpose: To determine the predictors of outcomes at a minimum 2 years after labral reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients included in the study underwent labral reconstruction with a minimum 2-year follow-up. The primary outcome variable was the Hip Outcome Score–Activities of Daily Living (HOS-ADL). Secondary outcome measures included the 12-item Short Form Health Survey physical component summary (SF-12 PCS) and patient satisfaction with surgical outcomes. Preoperative and intraoperative variables assessed included demographics, prior surgery, chronicity of symptoms, radiographic measurements, preoperative outcome scores, and findings at arthroscopic surgery. Predictors were assessed using logistic regression with restricted cubic splines. Bivariate statistics assessed risk factors for reoperation including revision arthroscopic surgery and total hip arthroplasty (THA). Results: Three hundred seventeen of 368 labral reconstructions were available for follow-up (86.1%). Of these, 42 were converted to THA (13.2%) and 35 required revision arthroscopic surgery after labral reconstruction (11.0%). Factors associated with THA included older age, ≥2 previous surgeries, ≤2 mm of joint space, and lateral center edge angle (LCEA) 2 mm ( P = .004), and no prior surgery ( P = .039). Predictors of improvement for the SF-12 PCS included higher preoperative SF-12 PCS scores ( P < .001), subacute chronicity (3 months to 1 year) of symptoms ( P = .013), and joint space >2 mm ( P = .046). Joint space >2 mm ( P < .001) and higher preoperative SF-12 scores (PCS: P = .034; mental component summary: P = .039) predicted higher satisfaction. Conclusion: At a minimum 2 years’ follow-up, patients who did not undergo conversion to THA (13.2%) or require revision (11.0%), reported significant improvement in outcome scores and high satisfaction with outcomes. Predictors of revision or THA included ≥2 previous surgeries, low LCEA, female sex for revision, and narrowed joint space for THA. Higher preoperative outcome scores were the most significant predictors of improvement after labral reconstruction. Lower preoperative scores, joint space narrowing, and history of surgery were predictive of an inferior result and decreased postoperative satisfaction.

Os acromiale occur frequently in the population and can be a cause of significant shoulder dysfunction and rotator cuff impingement. When symptomatic os acromiale fail conservative management, surgical intervention may become necessary. The purpose of this article is to describe our preferred surgical technique for osteosynthesis of os acromiale using cannulated screws and tension-band wiring.

Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.

Tightness or contracture of the pectoralis minor muscle can cause significant scapular dysfunction and is typically seen in patients with scapular dyskinesis and abnormal scapular protraction. When nonoperative treatment in these patients has failed, pectoralis tenotomy aims to resect the pectoralis minor tendon from the medial aspect of the coracoid process in order to decrease the force on the scapula, thereby improving scapular dynamics.

Case: We report the case of a 14-year-old girl with an aneurysmal bone cyst of the scaphoid successfully treated with curettage, phenol adjuvant therapy, and bone-grafting. Conclusion: Aneurysmal bone cysts rarely arise in the carpal bones, especially the scaphoid. This lesion may represent a rare yet treatable cause of wrist dysfunction in some patients. Curettage, phenol adjuvant therapy, and bone-grafting resulted in a good clinical outcome for our patient.

Biological augmentation and therapeutics are being increasingly used in musculoskeletal and orthopaedic care. Platelet-rich plasma (PRP) is produced from centrifugation of peripheral blood, a process that concentrates platelets within autologous plasma. The process of PRP preparation is fundamental in controlling the contents, and it influences its therapeutic potential. Platelets contain alpha granules that store and release a variety of growth factors and other proteins that may augment the healing environment; PRP also has the added benefit of promoting postsurgical hemostasis. The purpose of this report was to detail our institutional preparation protocol and method of administration of PRP during hip arthroscopy.

Femoral shaft fractures are common injuries with an incidence of 37.1 per 100,000 person-years in the United States. Retrograde femoral nailing is an increasingly used treatment strategy to manage these injuries, particularly in fractures below stemmed hip prostheses, in supracondylar or distal femur fractures, in fractures in pregnant or obese patients, and when concomitant ipsilateral acetabular/pelvic ring fractures are present. Retrograde fixation has been shown to be a viable option with union rates comparable to antegrade intramedullary nailing. Despite having excellent results in the treatment of femoral fractures, retrograde femoral nails have been associated with iatrogenic patellofemoral chondral damage that may occur because of malpositioning of the intramedullary nail at the entry point. The objective of this case report is to describe 2 patients who suffered iatrogenic trochlear chondral defects after retrograde femoral nailing and subsequently underwent osteoarticular allograft transplantation surgery.

Hip arthroscopy is a technically demanding procedure that is currently characterized by a "steep" learning curve. Therefore, achieving an advanced technical level is often challenging, especially for the amateur hip arthroscopist. Hand laterality when training in hip arthroscopy is an aspect that has been omitted. In addition, the technical differences regarding the handling of the surgical instruments when performing hip arthroscopy on the left versus right hip can influence the technical excellence. This Technical Note summarizes our preferred hip arthroscopy technique by comparing the surgeon's hand position when operating on the left versus right hip. We also emphasize how the surgeon's hand laterality affects the instrument manipulation during the procedure and potentially the clinical outcomes.

Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.

Complex proximal humerus fractures in elderly patients represent a difficult problem for orthopaedic surgeons. Classically, treatment methods have included nonoperative management, open reduction and internal fixation, and hemiarthroplasty. Outcomes of nonoperative management for these complex fractures have been poor, and results of traditional operative techniques are variable at best. Over the past several years, reverse total shoulder arthroplasty (RTSA) has been increasingly employed in these injuries with encouraging results. RTSA may represent a valuable treatment option for select patients. This article reviews the existing data on RTSA in the treatment of complex proximal humerus fractures in the elderly population as well as the authors' experience with this technique.

Thoracic outlet syndrome is a well-described disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. Neurogenic thoracic outlet syndrome is the most common manifestation, presenting with pain, numbness, tingling, weakness, and vasomotor changes of the upper extremity. Vascular complications of thoracic outlet syndrome are uncommon and include thromboembolic phenomena and swelling. The clinical presentation is highly variable, and no reproducible study exists to confirm the diagnosis; instead, the diagnosis is based on a physician's judgment after a meticulous history and physical examination. Both nonsurgical and surgical treatment methods are available for thoracic outlet syndrome. Whereas nonsurgical management appears to be effective in some persons, surgical treatment has been shown to provide predictable long-term cure rates for carefully selected patients. In addition, physicians who do not regularly treat patients with thoracic outlet syndrome may not have an accurate view of this disorder, its treatment, or the possible success rate of treatment.

One of the main challenges of peripheral nerve surgery continues to be knowing when to operate and what strategies to use intraoperatively. Nevertheless, new techniques are increasingly allowing peripheral nerve surgeons to assess and treat nerve lesions with more precision. This chapter seeks to summarize the surgeon’s options for analyzing peripheral nerves intraoperatively. Methods discussed include electrodiagnostics, specifically intraoperative nerve actions potentials, somatosensory and motor-evoked potentials, histochemical stains, and radioisotopic analysis.

Management of recurrent anterior glenohumeral instability with bone loss is challenging and may necessitate osseous augmentation.Glenoid and humeral-head osseous deficits should be managed simultaneously when there is severe bipolar bone loss. This is determined on the basis of the size of glenoid b

As the anterior intrapelvic approach (AIP or modified Stoppa) has become more popular, its utility has evolved to address specific problems that are not well addressed by the ilioinguinal approach. These include anterior column (AC) fractures associated with medialization of the femoral head (protrusio) and impaction of the superomedial acetabular dome. If left unaddressed, these problems may lead to poor clinical outcomes. The AIP approach, in contrast to the ilioinguinal approach, takes a more direct path to the medial elements of the AC in the true pelvis. This exposure allows access to the impacted dome segment through the displaced AC fracture and wide visualization of the quadrilateral surface, which in turn allows direct reduction and optimal implant placement to neutralize the fracture's deforming forces. The purpose of this article is to discuss the reduction of dome impaction and the quadrilateral surface using the AIP approach.

Background:Shoulder instability is a common cause of pain and dysfunction in young, active patients. While studies have analyzed risk factors for recurrent instability and failure after instability surgery, few have examined which variables are associated with initial surgery in this patient population.Purpose:To identify variables that may be associated with surgical intervention in patients with shoulder instability in the context of the FEDS (frequency, etiology, direction, severity) classification, a system that may be useful in the surgical treatment of shoulder instability patients.Study Design:Cohort study (prognosis); Level of evidence, 2.Methods:A database of patients treated for shoulder instability from 3 separate institutions from 2005 to 2010 was generated using International Classification of Diseases–9th Revision data. Data were collected via retrospective review. Injury data were categorized according to the FEDS system. Data were analyzed for significance, with the primary outcome of surgical intervention. Summary statistics were used to assess which variables were associated with eventual surgery. To test the unadjusted bivariate associations between shoulder surgery and each data point, Pearson chi-square tests were used for categorical variables and Wilcoxon tests were used for continuous variables.Results:Over the study time period, 377 patients were treated for shoulder instability. Patients who had surgery were more likely younger, had recurrent instability, and had their initial injury while playing a sport. Most patients had anterior instability; however, there was a greater proportion of posterior instability patients in the operative group. Severity of dislocation, measured by whether the patient required help to relocate the shoulder, was not significantly associated with eventual surgery. While imaging was not available for all patients, surgical patients were more likely to have magnetic resonance imaging findings of anterior labral injury and less likely to have a supraspinatus or subscapularis tear.Conclusion:Patients who underwent surgery for shoulder instability were younger, more likely to have experienced recurrent instability, and more likely to have sustained their original injury while playing sports. The FEDS classification, particularly the frequency and etiology of the patient’s shoulder instability, may be helpful in identifying patients with a higher likelihood of undergoing surgical treatment.

The need for quality research to promote evidence-based practice and optimize patient care is well recognized. This is particularly relevant in orthopedic trauma care, as trauma is a leading cause of morbidity and mortality worldwide. Across the spectrum of academic, clinical, and health care administration physician roles, research remains fundamental to bridging theory, practice, and education. A gap exists, however, between research and practice, especially for those physicians practicing outside traditional academic centers. Orthopedic trauma surgeons are well situated to contribute to important research; however the majority of those in practice at non-academic centers do not have a significant research component structured into their physician role. In this article, the authors outline the importance of orthopedic trauma surgeons outside of academic centers being engaged in research and present some advice on how to effectively participate in these endeavors. In this setting, orthopedic trauma research involvement includes asking researchable questions, being a savvy manager of research collaborators, staff, and funding, and finding one's own level of research involvement.