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Femoral nerve palsy is a rare but devastating complication of anterior total hip arthroplasty. Its etiology is still unknown, but several studies have suggested that anterior acetabular retractors may place the femoral nerve at increased risk. This study hypothesized that hip extension and traction places tension on the femoral nerve, offering an additional explanation for the development of femoral nerve palsy. A spring device was secured across 6 transected femoral nerves from 5 lower extremity cadavers and the hip was extended and pulled into traction with and without retractor placement. The change in spring length was used to determine femoral nerve tension. The average spring length changed +8.83 mm with hip extension, +3.73 mm with traction, -0.7 mm with traction and placement of the anterior acetabular retractor, and -1.15 mm with extension and placement of the femoral retractor. Femoral nerve tension was greatest with hip extension followed by traction. Acetabular and femoral retractor placement decreased average femoral nerve tension in both traction and hip extension. This may be due to medialization of the femoral nerve by the retractors, reducing the overall distance traveled, and thereby reducing tension. Previous studies have found femoral nerve pressure to be greatest during anterior acetabular retractor placement. It is likely that both pressure and tension contribute to femoral nerve palsy. Careful retractor placement, staying safely on anterior acetabular bone, and efficient femoral preparation to decrease time under hip extension and traction may help to minimize the risk of femoral nerve palsy., (©Copyright 2022 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Total hip arthroplasty (THA) is a common orthopedic procedure which has been growing in popularity with the elderly population. With more surgeons completing anterior THAs, intraoperative radiographs have become commonplace. Unfortunately, there is a lack of education in regard to obtaining, optimizing, and interpreting these radiographs. The purpose of this study was to develop and test the efficacy of an online learning tool that medical students, residents, and C-arm technicians could use to improve their understanding of THA radiography. The learning tool taught users how to obtain an optimal AP pelvis radiograph and how to interpret radiographs so THA components could be placed in their optimal position. This learning tool was sent to medical students, orthopedic surgery residents, and C-arm technicians along with a pre-test, post-test, and feedback survey. Twenty users (eleven medical students and nine orthopedic surgery residents) completed the learning tool. Post-test scores (M=96.4%, SD=2.9%) were significantly greater than pre-test scores (M=68.3%, SD=23.9%) for all users (t=5.5069, P<.0001). The user's level of training was positively correlated with pre-test scores. Surveys from the users revealed that the learning tool provided significant learning opportunities, was relatively easy to understand, but was slightly too long. Users felt that this learning tool would be best suited for senior medical students, junior orthopedic surgery residents, and C-arm technicians. With the positive results of this study, the authors hope to further develop this learning tool for widespread adoption and to develop similar learning tools in the future., (©Copyright 2022 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

»: Surfing is safe: the risk of injury ranges from 0.26 to 0.90 injuries per surfer per year, 0.06 to 3.5 injuries per 1,000 days of surfing, and 1.1 to 13.0 injuries per 1,000 hours of surfing., »: The most common acute surfing injuries are lacerations, contusions, and sprains; the head and the neck as well as the lower extremities are the locations that are affected most., »: The most common mechanism of injury is striking a surfer's own board or that of another surfer., »: A pathology that is unique to surfers is surfer's myelopathy; bites and/or stings by sea life and infections caused by marine life also occur in surfers., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A676)., (Copyright © 2021 Written work prepared by employees of the Federal Government as part of their official duties is, under the United States Copyright Act, a ‘work of the United States Government’ for which copyright protection under that Act is not available. As such, copyright protection does not extend to the contributions of employees of the Federal Government prepared as part of their employment.)

Understanding the impact of pathologic spinopelvic mobility on total hip arthroplasty instability requires an appreciation of the dynamic interplay between and the spine, hip and pelvis. This complex interdependent relationship changes with position, pathology and surgical intervention. Spinal pathology may prevent normal dynamic motion leading to spinopelvic stiffness and abnormal pelvic position. Patients at high risk for pathologic spinopelvic motion and subsequent total hip arthroplasty (THA) dislocation should be assessed with a functional imaging series with lateral standing, sitting and AP standing radiographs. Common patterns of stiffness and imbalance as well as proposed surgical treatment algorithms are presented and discussed in this review., Competing Interests: None of the authors identify any conflicts of interest., (©Copyright 2019 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

The Maisonneuve fracture consists of a proximal fibular fracture with associated syndesmotic ligament disruption and injury to the medial ankle structures. The accepted mechanism of injury is an external rotation force applied to the ankle with the foot in either supination or pronation. Because most Maisonneuve fractures involve complete syndesmotic disruption, operative treatment is usually indicated. A case report is presented of an unusual fracture pattern-i.e., that of a distal fibular fracture with lateral ankle dislocation associated with a Maisonneuve fracture. To our knowledge, only two other similar cases are reported in the English literature.

Absence of the long head of the biceps brachii tendon is rare (only 1 case reported). We believe that our article is the first to report this anomaly as associated with VATER complex (vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies).

Background: Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations., Hypothesis: Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment., Study Design: Prospective, randomized clinical trial., Methods: Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months., Results: Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability., Conclusions: Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.

Destructive posttraumatic synovitis is a rare entity usually involving the knee. This case report details the evaluation and treatment of a rapidly progressive and destructive subtalar lesion that occurred in a healthy 27-year-old man after incidental trauma. Initial orthopedic evaluation revealed diffuse ankle tenderness and mild effusion. Radiographic and laboratory studies showed normal findings. Bone scan revealed significantly increased uptake in the talus. Subsequent computed tomography scan and magnetic resonance imaging studies showed a lateral soft-tissue mass invading both the talus and calcaneus with destruction of the subtalar joint. Tissue biopsy samples revealed hypertrophic synovium with villous projections, occasional giant cells, and occasional hemosiderin deposits. The lesion caused rapid and progressive destruction of the subtalar joint despite aggressive conservative measures. Ultimately, the patient underwent a subtalar arthrodesis that led to the resolution of his symptoms and resumption of work and recreational activities. While posttraumatic synovitis is a rarely encountered condition, the orthopedic surgeon must have an index of suspicion, perform a systematic evaluation, and render definitive treatment to ensure a successful outcome.

The correct placement of the femoral tunnel is of critical importance in successfully reconstructing a knee with a deficient anterior cruciate ligament. By inserting the femoral guide pin through the anteromedial portal with the knee fully flexed, and subsequently withdrawing the pin from the anterior thigh until just the end of the pin remains at the insertion site at the posterior aspect of the intercondylar notch, the knee can then be safely extended and a thorough arthroscopic evaluation performed. In addition, the arthroscope can now be introduced into the medial portal to better evaluate the pin placement. Thus, visualization of the pin position and accurate placement based upon the intended tunnel size can be confirmed prior to drilling of the femoral tunnel, and more reproducibility in anterior cruciate ligament reconstructions can be achieved.

Wilms' tumor is a renal tumor that develops in childhood and is one of the most common malignant tumors in children under 5 years old. Bone metastases are extremely rare in Wilms' tumor, with only two reported cases in adults. We report the case of a patient who underwent nephrectomy for Wilms' tumor at the age of 10 years and presented with a bone mass in his left femur 13 years later.