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The purpose of this study was to directly compare hip distraction distance and traction force data for hip arthroscopy performed using a post-based versus a postless system.Adult patients undergoing primary hip arthroscopy for femoroacetabular impingement were prospectively enrolled. Arthroscopy performed before March 26105 patients underwent hip arthroscopy with a post-based system and 51 patients underwent the procedure with a postless system. Mean holding traction force (67.5 ± 14.0 vs. 55.8 ± 15.3 kgf) and mean maximum traction force (96.0 ± 16.6 vs. 69.9 ± 14.1 kgf) were significantly lower in the postless group. In a multivariable analysis, postless traction was an independent predictor of decreased k-hold (ß = -31.4; 95% CI[-61.2, -1.6]) and of decreased k-max (ß = -90.4, 95% CI[-127.8, -53.1]). Male gender, Beighton score = 0, and poor hamstring flexibility were also predictors of increased k-hold and k-max in the multivariable model.Postless traction systems decrease the amount of traction force required for adequate hip distraction for both maximal and holding traction forces when compared to post-based systems. Postless traction systems may help further reduce distraction-type neurologic injuries and pain following hip arthroscopy by lowering the traction force required to safely distract the hip.Prospective cohort, historical control comparative study, Level III.

Background: There is no consensus surgical treatment algorithm for talar body fractures, with authors recommending both soft tissue–only and osteotomy-based approaches. This study evaluates talar dome access via dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches. Methods: Ten cadaveric legs (5 matched pairs) were included. An mPM approach, between flexor hallucis longus and Achilles tendon, and an ATL approach, utilizing the anterolateral interval with transection of anterior talofibular ligament and calcaneofibular ligament, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4 mm of tibiotalar distraction using an external fixator. Specimens were analyzed by computed tomography (CT). Primary outcome was accessible DSA. Student t tests compared DSA accessed by different exposure methods. Results: An initial mPM approach exposed 25.6% and 33.6% of DSA without and with distraction ( P = .002). An initial ATL approach accessed 47.0% and 58.1% of DSA without and with distraction, respectively ( P = .003). Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach ( P = .96 and .37, respectively). The central talar dome was inaccessible in an almond-shaped area, tapered at the medial and lateral ends. Anterior, lateral, and posterior articular margins were able to be fully exposed, often with overlapping exposure between posterior and anterior approaches, with distraction reliably improving lateral visualization. Conclusion: Dual approaches provided access to greater than 70% and 85% of talar DSA without and with distraction, respectively. Order of approach did not significantly affect exposure and thus should be determined by surgeon discretion. These results may promote soft tissue–only treatment strategies in talar body fracture care with an extensile exposure of the talar dome surface. Careful preoperative planning optimizes the advantages of this approach. Level of Evidence: Level IV, case series.

BACKGROUND Cadaveric models demonstrate that failure of hip capsular repair is dependent on the robustness of the repair construct. In vivo data on capsular repair construct efficacy are limited. We investigated the effect of a figure-of-8 capsular repair on hip distraction resistance relative to native and post-capsulotomy states. We hypothesized that an unrepaired capsulotomy would demonstrate increased axial distraction compared with the native state and that capsular repair would restore distraction resistance to native levels. METHODS Patients undergoing primary hip arthroscopy by a single surgeon were prospectively enrolled between March 2020 and June 2020. Prior to any instrumentation, fluoroscopic images of the operative hip were obtained at 12.5-lbs (5.7-kg) traction intervals, up to 100 lbs (45.4 kg). Anterolateral, modified anterior, and distal anterolateral portals were established. Following interportal capsulotomy, labral repair, and osteochondroplasty, fluoroscopic images were reobtained at each traction interval. Capsular repair was performed with use of a figure-of-8 suture configuration. Traction was reapplied and fluoroscopic images were again obtained. Joint distraction distance was measured at each traction interval for all 3 capsular states. Anteroposterior pelvic radiographs were utilized to scale fluoroscopic images to obtain joint space measurements in millimeters. RESULTS A total of 31 hips in 31 patients were included. Capsulotomy resulted in significant increases in distraction distance from 25 (11.3 kg) to 100 lbs of traction compared with both native and capsular repair states (all comparisons, p ≤ 0.017). Capsular repair yielded a significantly greater distraction distance compared with the native state at 37.5 lbs (17.0 kg; 5.49 versus 4.98 mm, respectively; p = 0.012) and 50 lbs (22.7 kg; 6.08 versus 5.35 mm; p < 0.001). The mean difference in distraction distance between native and capsular repair states from 25 to 100 lbs of traction was 0.01 mm. CONCLUSIONS This in vivo model demonstrates that an unrepaired interportal capsulotomy significantly increases axial distraction distance compared with the native, intact hip capsule. Performing a complete capsular closure reconstitutes resistance to axial distraction intraoperatively. Future research should evaluate the in vivo effects and associated clinical outcomes of other published capsular repair techniques and assess the durability of capsular repairs over time.

Distal femur fractures are challenging injuries historically associated with high rates of nonunion and varus collapse with operative management. As a result, clinical and research interest in dual plating (DP) of distal femur fractures has seen a dramatic increase in recent years. The purpose of this study was to systematically review the literature regarding vascular anatomy and biomechanics of distal femur fractures treated with DP constructs. A systematic literature review of two medical databases (PubMed & Scopus) was performed to identify peer-reviewed studies on the anatomy and biomechanics regarding DP of distal femur fractures. A total of 1,001 papers were evaluated and 14 papers met inclusion criteria (6 anatomy and 8 biomechanics). Methodological quality scores were used to assess quality and potential bias in the included studies. In the biomechanical studies, DP constructs demonstrated greater axial and rotational stiffness, as well as less displacement and fewer incidences of failure compared to all other constructs. Vascular studies showed that the femoral artery crosses the mid-shaft femur approximately 16.0–18.8 cm proximal to the adductor tubercle and it is located on average 16.6–31.1 mm from the femoral shaft at this location, suggesting that medial plate application can be achieved safely in the distal femur. The methodological quality of the included studies was good for biomechanical studies (Traa score 79.1; range 53–92.5) and excellent for anatomical studies (QUACs score 81.9; range 69.0–88.5). Existing biomechanics literature suggests that DP constructs are mechanically stronger than other constructs commonly used in the treatment of distal femur fractures. Furthermore, medial distal femoral anatomy allows for safe application of DP constructs, even in a minimally invasive fashion. Dual plating should be considered for patients with distal femur fractures that have risk factors for instability, varus collapse, or nonunion.

To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment.Level 1 trauma center.A retrospective cohort study.There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents.The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans.Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans ( P0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans and 93% of the time with reformatted CT scans ( P = 0.87). However, of those who had dysplasia (n = 22), only 12% were believed to have a safe corridor on original scans compared with 35% on reformatted scans ( P0.001).CT scan reformatting parallel to the S1 superior end plate increases the likelihood of identifying a safe corridor for a TS screw, especially in patients with evidence of sacral dysplasia. The authors would recommend the routine use of reformatting CT scans in this manner to provide a better understanding of the upper sacral segment osseous fixation pathways.

Hypothesis: The purpose of this study was to determine the clinical outcomes of arthroscopic labral repair for anteroinferior glenohumeral instability with the use of double-loaded suture anchors. Methods: This study evaluated a series of consecutive patients treated after the senior author changed from single- to double-loaded suture anchors for the treatment of anteroinferior glenohumeral instability with a minimum follow-up period of 2 years. We collected the following outcomes at final follow-up: visual analog scale pain score, Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, and instability recurrence data. Results: A total of 41 consecutive patients underwent arthroscopic labral repair with double-loaded anchors, of whom 30 (71%) were able to be contacted at a minimum of 2 years postoperatively. These patients included 4 contact or collision athletes (13%). The patients had an average of 12 ± 13 prior dislocations over an average period of 56 ± 57 months preoperatively. Mean glenoid bone loss measured 16% ± 10%, and 67% (18 of 27 patients) had glenoid bone loss ≥ 13.5%. Intraoperatively, 3.2 ± 0.4 anchors were used. No posterior repairs or remplissage procedures were performed. At an average of 6.7 ± 2.7 years' follow-up, the visual analog scale pain score was 0.8 ± 1.4; Simple Shoulder Test score, 11 ± 2; and American Shoulder and Elbow Surgeons score, 90 ± 14. Patients with bone loss < 13.5% had a 0% redislocation rate and 11% subluxation rate, whereas those with bone loss ≥ 13.5% had a 6% reoperation rate, 22% redislocation rate, and 22% subluxation rate. Conclusion: Arthroscopic labral repair with double-loaded anchors provides satisfactory clinical results at early to mid-term outcome assessment when glenoid bone loss is

This study evaluated the effects of venting and capsulotomy on the ratio of normalized distraction distance to traction force, correlating this trend with patient demographic factors. A ratio was chosen to capture the total effect of each intervention on the hip joint. During primary hip arthroscopy, continuous traction force was recorded, and fluoroscopic images were acquired to measure joint distraction before and after the application of traction, venting and interportal capsulotomy. Distraction–traction force ratios were compared using a one-sided paired t-test. A linear regression model was used to determine the relationship between age, sex and body mass index and pre- and post-intervention distraction–traction force ratios. Seventy-two adult patients and 73 hips were included. There was an increase in hip distraction with a decrease in traction force post-venting and capsulotomy (both P’s

Extremity compartment syndrome (ECS) is a morbid condition resulting in permanent myoneural damage. Currently, the diagnosis of compartment syndrome relies on clinical symptoms and/or intracompartment pressure measurements, both of which are poor predictors of ECS. Animal models have been used to better define cellular mechanisms, diagnosis, and treatment of ECS. However, no standardized model exists. The purpose of this study was to identify existing animal research on extremity compartment syndrome to summarize the current state of the literature and to identify weaknesses that could be improved with additional research.A MEDLINE database search and reverse inclusion protocol were utilized. We included all animal models of ECS.Forty-one studies were included. Dogs were the most commonly used model species, followed by pigs and rats. Most studies sought to better define the pathophysiology of compartment syndrome. Other studies evaluated experimental diagnostic modalities or potential treatments. The most common compartment syndrome model was intracompartment infusion, followed by tourniquet and intracompartment balloon models. Few models incorporated additional soft tissue or osseous injury. Only 65.9% of the reviewed studies confirmed that their model created myoneural injury similar to extremity compartment syndrome.Study purpose, methodology, and outcome measures varied widely across included studies. A standardized definition for animal compartment syndrome would direct more consistent research in this field. Few animal models have investigated the pathophysiologic relationship between traumatic injury and the development of compartment syndrome. A validated, clinically relevant animal model of extremity compartment syndrome would spur improvement in diagnosis and therapeutic interventions.

Background: Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction. Methods: Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro–computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals. Results: The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction ( P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction ( P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02). Conclusion: The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially. Level of Evidence: Level V, Cadaveric Study.

To determine, in the context of measuring bone loss in shoulder instability, whether measurement differences between magnetic resonance imaging (MRI) and computed tomography (CT), linear-based and area-based methods, and observers altered the proposed treatment when a standardized algorithm was applied.This was a retrospective, comparative imaging study of preoperative patients with anterior shoulder instability with both an MRI and CT scan within 1 year of one another. On parasagittal images reoriented en face to the glenoid, 2 attending orthopaedic surgeons measured glenoid width, glenoid area, glenoid defect width, and glenoid defect area. On axial images maximal Hill-Sachs width was measured. From these, linear percent glenoid bone loss (%GBL) and area %GBL were calculated, and on-versus off-track was determined. With these results, a recommended treatment was determined by applying a standardized algorithm, in which the Latarjet procedure was selected for %GBL20%, arthroscopic labral repair and remplissage for off-track lesions with %GBL20%, and arthroscopic labral repair on-track shoulders with %GBL20%.In total, 53 patients with mean ± standard deviation 45 ± 83 days between scans were include with a CT linear %GBL of 23.5 ± 9.6% (range 0%-47%). CT lead to larger measurements of %GBL than MRI (linear P = .008, area P = .003), and fewer shoulders being considered on-track (33.0% vs 40.5%), which would alter treatment in 25% to 34%. Linear measurements produced larger values for %GBL (CT, P.001; MRI, P.001), which would alter treatment in 25%. For %GBL, inter-rater reliability was good, with intraclass correlation coefficients varying from 0.727 to 0.832 and Kappa varying from 0.57 to 0.62, but these inter-rater differences would alter treatment in 31%.The significant differences in bone loss measurement between imaging modality, measurement method, and observers may lead to differences in treatment in up to 34% of cases. Linear CT measurements resulted in the most aggressive treatment recommendations.Retrospective Comparative Study: Diagnostic, Level III.

Distal femur fractures are challenging injuries historically associated with high rates of nonunion and varus collapse with operative management. As a result, clinical and research interest in dual plating (DP) of distal femur fractures has seen a dramatic increase in recent years. The purpose of this study was to systematically review the literature regarding vascular anatomy and biomechanics of distal femur fractures treated with DP constructs.A systematic literature review of two medical databases (PubMedScopus) was performed to identify peer-reviewed studies on the anatomy and biomechanics regarding DP of distal femur fractures. A total of 1,001 papers were evaluated and 14 papers met inclusion criteria (6 anatomy and 8 biomechanics). Methodological quality scores were used to assess quality and potential bias in the included studies.In the biomechanical studies, DP constructs demonstrated greater axial and rotational stiffness, as well as less displacement and fewer incidences of failure compared to all other constructs. Vascular studies showed that the femoral artery crosses the mid-shaft femur approximately 16.0-18.8 cm proximal to the adductor tubercle and it is located on average 16.6-31.1 mm from the femoral shaft at this location, suggesting that medial plate application can be achieved safely in the distal femur. The methodological quality of the included studies was good for biomechanical studies (Traa score 79.1; range 53-92.5) and excellent for anatomical studies (QUACs score 81.9; range 69.0-88.5).Existing biomechanics literature suggests that DP constructs are mechanically stronger than other constructs commonly used in the treatment of distal femur fractures. Furthermore, medial distal femoral anatomy allows for safe application of DP constructs, even in a minimally invasive fashion. Dual plating should be considered for patients with distal femur fractures that have risk factors for instability, varus collapse, or nonunion.

To compare intraoperative hip joint distractibility between hips that previously underwent arthroscopic surgery and the contralateral hip with no history of surgical manipulation.Patients undergoing revision hip arthroscopy between April 2019 and December 2020, who previously underwent arthroscopic hip surgery for femoroacetabular impingement syndrome, were prospectively enrolled. Exclusion criteria were any contralateral hip surgery. Before instrumentation, fluoroscopic images of both hips were obtained at 25 lbs traction intervals up to 100 lbs. Total joint space was measured at each traction interval. Distraction was calculated as the difference between the baseline joint space and the total joint space at each subsequent traction interval. Wilcoxon signed ranks tests and McNemar tests were used to compare distraction between revision and native contralateral hips.Forty-seven patients were included. Mean distraction of operative hips was significantly greater than mean distraction of nonoperative hips at traction intervals of 50 lbs (2.13 vs 1.04 mm, P = .002), 75 lbs (6.39 vs 3.70 mm, P.001), and 100 lbs (8.24 vs 5.39, P.001). Mean total joint space of operative hips was significantly greater than mean total joint space of nonoperative hips at traction intervals of 50 lbs (6.60 vs 5.39 mm, P.001), 75 lbs (10.86 vs 8.05 mm, P.001), and 100 lbs (12.73 vs 9.73, P.001). A greater percentage of operative hips achieved all distraction thresholds, in 2-mm intervals up to 10-mm, at each traction interval.In the majority of patients undergoing revision hip arthroscopy, previous arthroscopic hip surgery increases axial distractibility of the hip joint compared with the native contralateral hip at axial traction forces of 50-100 lbs. Increased axial distractibility following hip arthroscopy may be suggestive of hip instability and can be assessed on a stress examination with the patient under anesthesia.III, case-control study.

OBJECTIVE To evaluate the accessible area of the talar dome through 2 standard posterior approaches [posteromedial (PM) and posterolateral (PL)] with and without distraction. METHODS A standard PM or PL approach was performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals. RESULTS The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach. CONCLUSION The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided.

Purpose: To quantify the magnetic resonance arthrography (MRA) capsular morphologic findings associated with postarthroscopy hip instability. Methods: Among patients with clinically significant iatrogenic hip instability at a single center, patients with preindex and postindex surgery MRAs were identified. These MRAs were compared regarding effective intracapsular volume calculated by semi-automated 3-dimensional pixel intensity region segmentation, 2-dimensional anterior proximal intracapsular area in the femoral neck axial plane reconstruction, maximal anterior fluid pocket depth, capsule retraction distance, and capsular instability grade. Morphological measurements were conducted using Horos image processing software. Paired t-test, paired Wilcoxon signed rank test, and the McNemar test were used for identifying statistical significance. Results: In 42 patients, mean effective intracapsular volume was significantly greater in the postindex surgery MRAs (19.44 cm3 vs 17.26 cm3; P = .006). Proximal anterosuperior (12-3 o'clock) intracapsular area was also significantly greater after index surgery (2.84 cm2 vs 1.43 cm2; P < .001. Proximal anteroinferior (3-6 o'clock) intracapsular area (1.34 cm2 vs 0.97 cm2; P = .002), capsule deficiency grade (P < .001), anterior capsule retraction distance (4.83 mm vs 0.34 mm; P < .001), and maximum anterior fluid depth (8.33 mm vs 4.90 mm; P

Iatrogenic hip instability is increasingly recognized as a cause of persistent pain and disability after hip arthroscopy. Many authors currently advocate capsular repair to reduce postoperative instability. However, anatomic deficiencies in the anterosuperior capsule can prevent a functional capsular repair, particularly in the revision setting. Capsular reconstruction has been shown to restore biomechanical stabilization in cadaveric models and improve short-term patient outcomes in patients with primary hip arthroscopy failure. Arthroscopic hip capsular reconstruction is technically challenging, largely owing to complex suture management and difficulties with graft placement and sizing. This article describes the capsular reconstruction technique, detailing the technical aspects of anterosuperior capsular defect identification; capsular preparation; suture management; and dermal allograft sizing, preparation, and positioning., Technique Video Video 1 Narrated key steps of arthroscopic reconstruction of the anterosuperior hip capsule in a right hip, as viewed from the anterolateral portal (superior view using a 70° scope). The anterolateral and modified anterior portals are established through the defect of the previous interportal capsulotomy. After defect identification and measurement, the dermal allograft is oversized by 5 mm in length and width. Sutures are placed circumferentially along the periphery of the capsular defect. In the absence of viable acetabular-sided capsule, suture anchors are placed to secure the graft. Sutures are brought out one by one through a 10-mm cannula and passed through the dermal allograft using a suture-passing device. A knot pusher is placed over one of the sutures in the graft and used to parachute the graft down through the cannula. The graft is secured in place by sequentially tying the sutures, beginning with those closest to the camera and working toward the medial side to facilitate visualization and suture management. Meticulous suture management is a key technical aspect of this procedure.

Background The purpose of this study was to determine the short-term outcomes for patients who underwent revision surgery for shoulder instability, including both revision arthroscopic repair and Latarjet. Methods This study included patients who underwent revision of a prior arthroscopic labral repair to arthroscopic labral repair or Latarjet at our institution from 2012 to 2017. After collection of preoperative demographic data, preoperative 3-dimensional imaging was reviewed to determine percent glenoid bone loss (%GBL) and to determine whether each shoulder was on-track or off-track. Patients were contacted to obtain postoperative patient-reported outcome metrics including visual analog scale pain, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and instability recurrence (full dislocation, subluxation, or subjective apprehension) data at a minimum of 2 years postoperatively. Results Of 62 patients who met criteria, 45 patients were able to be contacted. Of them, 21 underwent revision arthroscopy and 24 underwent a Latarjet procedure. In the revision arthroscopy group, 5 of 15 had %GBL >20% and 4 of 21 were contact athletes. In the Latarjet group, 11 of 22 had %GBL >20% and 5 of 24 were contact athletes. Of 21 revision arthroscopy patients, 8 underwent concomitant remplissage. Eight of 21 patients in the revision arthroscopy group and 7 of 21 patients in the Latarjet group reported instability postoperatively. Three of 21 patients in the revision arthroscopy group and 2 of 21 patients in the Latarjet group reported full dislocations postoperatively. Zero patients in the revision arthroscopy group and 1 of 21 patients in the Latarjet group underwent reoperation. Conclusion Our results suggest that both revision Latarjet and arthroscopic stabilization can be of benefit in select circumstances. However, in revision settings, postoperative instability symptoms are common with both procedures.

This study evaluates the effect of venting on distraction of the hip during arthroscopy on a post-free traction table for fixed traction forces ranging from 0 to 100 pounds (lbs).Patients underwent surgery by the senior author (S.K.A.) between November 2018 and July 2019. Inclusion criteria were primary hip arthroscopy requiring central compartment access. Patients were positioned in 10-15° Trendelenburg on a post-free traction table. Prior to instrumentation, fluoroscopic images of the operated hip joint were taken at 25-lb intervals from 0 to 100 lbs of axial traction. Traction was released for 15 minutes. Venting with 20 mL of air was performed and fluoroscopic images were repeated at all traction intervals. Joint displacement was measured at all intervals. An unvented control group underwent the same axial traction protocol for comparison.Sixty-one consecutive patients underwent study protocol. Fifty-eight hips in 57 patients were included. Thirty-two (55.2%) were female; mean age was 31 ± 13 years and mean body mass index was 25.7 ± 6.2. Paired samples analysis demonstrated mean differences in distraction distance prior to and after venting of 0.27, 2.60, 4.09, 4.54, and 2.31 mm at 0, 25, 50, 75, and 100 lbs of traction, which were significant (P.001) at all traction intervals. Significantly more vented hips distracted at least 10 mm at 25-100 lbs traction (P ≤ .001). An unvented control group showed no significant differences between the first and second traction application.Venting prior to applying traction on a post-free traction table increases the distraction distance achieved for a given traction force at multiple levels of traction in comparison to the pre-vented state. Our results suggest venting the hip joint prior to the application of traction may serve to reduce the maximal amount of traction required to safely instrument the hip arthroscopically.IV, case series.

BACKGROUND: Diffusion tensor tractography (DTT) has recently been shown to accurately detect nerve injury and regeneration. This study assesses whether 7-tesla (7T) DTT imaging is a viable modality to observe axonal outgrowth in a 4 cm rabbit sciatic nerve injury model fixed by a reverse autograft surgical technique. METHODS: Transection injury of unilateral sciatic nerve (4 cm long) was performed in 25 rabbits and repaired using a reverse autograft (RA) surgical technique. Analysis of the nerve autograft was performed at 3, 6, and 11 weeks postoperatively and compared to normal contralateral sciatic nerve, used as control group. High-resolution DTT from ex vivo sciatic nerves were obtained using 3D diffusion-weighted spin-echo acquisitions at 7-T. Total axons and motor and sensory axons were counted at defined lengths along the graft. RESULTS: At 11 weeks, histologically, the total axon count of the RA group was equivalent to the contralateral uninjured nerve control group. Similarly, by qualitative DTT visualization, the 11-week RA group showed increased fiber tracts compared to the 3 and 6 weeks counterparts. Upon immunohistochemical evaluation, 11-week motor axon counts did not significantly differ between reverse autograft and control; but significantly decreased sensory axon counts remained. Nerves explanted at 3 weeks and 6 weeks showed decreased motor and sensory axon counts. DISCUSSION: 7-T DTT is an effective imaging modality that may be used qualitatively to visualize axonal outgrowth and regeneration. This has implications for the development of technology that non-invasively monitors peripheral nerve regeneration in a variety of clinical settings.

Background Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. Study Design A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. Setting This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. Participants The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. Results Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. Conclusion The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals.