Yu, Kristin E.

Abstract » A thorough understanding of glenoid deformity is essential to anticipate intraoperative needs and manage bony deficiencies. Management strategies include eccentric reaming, alternate scapular line baseplate orientation, bone grafting, or metallic augmentation as either “off-the-shelf” or custom baseplates. Accurate implantation of the glenoid component in the presence of glenoid bone loss (GBL) may also benefit from shoulderspecific guides, navigation, or robotic assistance. » GBL can negatively affect outcomes due to compromised bony fixation, altered soft tissue tensioning, and component malposition, which can contribute to impingement, dislocation, aseptic loosening, polyethylene wear, and component failure. » In this article, we provide a comprehensive review of published literature regarding the management of GBL in primary RSA and provide additional insight on the effectiveness of current approaches to manage bony deficiency.

Background: Trochlear dysplasia is important in recurrent patellofemoral instability (PFI); reliable metrics are essential to understand this condition and help define optimal treatment. One such measurement is the entry point to transition point (EP-TP) angle, which describes 2 components of patellar tracking from full knee extension to flexion: (1) mediodistal movement and (2) pure distal movement. Currently, measurement of this metric relies on 3-dimensional (3D) models. Purpose: To further develop the EP-TP angle metric to allow its digital measurement, to establish cohort and interrater reliability values, and to evaluate its appropriateness for clinical use. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A data set composed of 30 recurrent PFI patient knees and 30 control knees was acquired. Each knee came with anterior views of the distal femur and curvature maps, which highlighted relevant structures such as the trochlear groove and the medial and proximal ridge. Three raters measured EP-TP angles utilizing a digital tool with and without the curvature maps. Significance of differences in means, presence of a TP, and interrater reliability with intraclass correlation coefficients were tested and evaluated according to an established guideline (<0.5, poor reliability; >0.5-0.75, moderate; >0.75-0.9, good; >0.9 excellent reliability). A significance level of .05 corrected with the Bonferroni method was assumed. Results: PFI knees had a significantly higher EP-TP angle than the control cohort (48.9° ± 10.8° vs 11.8° ± 14.6°; P < .001). Patients had a greater TP prevalence than controls (96.7% vs 10.0%). Interrater reliability for the EP-TP angle with curvature maps was significantly better than without (0.84 [95% CI, 0.76-0.89] vs 0.67 [95% CI, 0.55-0.78]; P < .001). Conclusion: The EP-TP angle is significantly different between PFI patients and controls. This study presents a digital approach for measuring the EP-TP angle, in contrast with the initially described method, which required 3D prints. This digital approach, when aided with curvature mapping, yields better reliability.

Abstract Three‐dimensional (3D) modeling using digital or printed models provides a unique perspective that caters to cognitive spatial ability in a way that can add to our understanding and mental representations of human anatomy. This is particularly useful in the setting of trochlear dysplasia, where the morphology of the groove can exhibit substantial variability and complexity. Using 3D reformatted images and models, a pragmatic understanding of how morphology influences patellofemoral pathology can be gleaned. Further, this perspective facilitates cognition of what patellar tracking may look like after realignment procedures. Using 3D modeling, concepts such as patella alta, trochlear depth, lateralization of the patellar entry point, trochlear curvature, and the presence of a proximal trochlear spur can help afford a better understanding of how trochlear anatomy may influence tracking while also providing insight as to the ideal tracking path. The use of 3D has recently emerged as a useful tool in multiple surgical subspecialties, particularly in situations involving surgical planning or complex anatomy. Given the complexity and variation in trochlear morphology in patients with trochlear dysplasia who develop either patellar instability or focal overloading, 3D modeling is well‐suited to provide a perspective that can add to our understanding of trochlear dysplasia, and potentially even how we diagnose and treat it. Level of Evidence Level V, expert opinion.

Purpose To create a metric for evaluating the degree of laterality of the patella’s entry into the trochlea, the entry point–trochlear groove (EP‐TG) angle, and to evaluate if this laterality is associated with recurrent patella instability. Methods The time frame of the study was January 2020 to February 2023. The inclusion criteria were patients treated by the senior author (J.P.F.) (with the exception of 2 patients who were treated by another provider at the institution who was aware of the study) who have been diagnosed with recurrent atraumatic patellar dislocations. Controls without knee pathology were selected from the New Mexico Decedent Imaging Database (NMDID). Simpleware ScanIP was used to create 3‐dimensional (3D) models of the distal femurs from computed tomography scans. Anteroposterior images of these 3D models were uploaded to a custom EP‐TG angle measuring tool. Three measurers used the tool to measure the EP‐TG angle of the distal femurs. Results Twenty‐eight patients were included for the recurrent dislocator group. Twenty‐four decedents from the NMDID were selected for the control group, each with a left or right knee chosen randomly for measurement. A 1‐sided Mann‐Whitney U test, used to evaluate whether the recurrent dislocators had higher EP‐TG angle values, yielded a P value <.001, demonstrating a high level of significance. A Bayesian mixed‐effect model, used to determine how different the EP‐TG angles are between the 2 groups, gave a posterior predictive interval of [11.93°, 19.12°] for the EP‐TG angle shift of dislocators. The intraclass correlation coefficient was 0.648. Conclusions The morphologic entry point of the patella into the proximal trochlea is more lateral in recurrent patella dislocators than in controls. This increased laterality can be measured by the EP‐TG angle, which may be useful information for optimizing treatment of recurrent patella instability. Level of Evidence Level III, case control study.

Background: The Latarjet procedure is effective for patients with anterior glenohumeral instability with substantial glenoid bone loss due to its triple blocking effect. Indications: Indications include high-risk patients with recurrent anterior glenohumeral instability with any glenoid bone loss or low-risk patients with 15% to 30% glenoid bone loss. Technique Description: An incision is made lateral to the coracoid and the deltopectoral interval is established. The pectoralis minor is released medially off the coracoid and the coracoacromial (CA) ligament is released close to the acromion. The coracoid is cut with a right-angle saw and the inferior coracoid is decorticated with a burr. Two holes are pre-drilled in the coracoid. The subscapularis is split between the upper two-thirds and lower one-third with the arm in external rotation. The capsule is split vertically at the joint line and the humeral head is retracted. The anterior glenoid is decorticated with a burr, and a hole is drilled inferiorly. The depth is measured and added to the depth of the inferior bone block hole. A fully threaded 3.5-mm solid stainless steel screw is placed in the inferior hole. Care is taken to ensure that the lateral border of the bone block is flush with the articular margin. This is repeated for the superior hole. A 1.8-mm knotless suture anchor is placed between the screws. The repair stitch is passed through the capsule and loaded onto the anchor and tensioned. The CA ligament is laid over the capsule and repaired. The subscapularis split is repaired side to side and the wound is closed in layers. Results: High return-to-sport rates, including at the same level of play, have been observed among young competitive athletes with significant glenoid bone loss who underwent a Latarjet, with similarly favorable results in older patients. Ninety-day complication rates have been reported around 9%, 5% of which constituted graft or hardware failures. Discussion/Conclusion: The Latarjet procedure is an effective option for indicated patients with anterior glenohumeral instability and may be enhanced with solid screws, proper anatomic technique, and capsulolabral repair augmentation. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: The purpose of this study was to validate the Foot and Ankle Outcome Score (FAOS) for osteochondral lesions of the talus (OLTs). We hypothesize that the FAOS will meet all 4 psychometric criteria for validity in this patient population. Methods: From 2008 to 2014, a total of 208 patients with OLTs were included in the construct validity portion of the study. All patients completed FAOS and 12-Item Short-Form Health Survey (SF-12) scores. Twenty additional patients were prospectively recruited and were asked to complete questionnaires to determine the relevance of each of the FAOS questions as it related to their OLT. Forty-four patients completed the FAOS 1 month after the first FAOS to assess reliability via Spearman correlation coefficient. Responsiveness of the FAOS was assessed with 54 patients who had both preoperative and postoperative FAOS scores via Student paired t test with significance determined as P < .05. In total, 229 unique patients were included in this study. Results: Statistically significant associations were found between all FAOS and SF-12 subscales ( P < .01). The FAOS symptoms subscale demonstrated the lowest correlation with the SF-12 physical health domains. No floor or ceiling effects were identified. Weak correlations were calculated between the 5 FAOS subscales and the SF-12 mental component summary score. All FAOS domains met the threshold for acceptable content validity (score > 2.0). All FAOS subscales demonstrated acceptable test-retest reliability, with ICC values ranging from 0.81 (ADL) to 0.92 (Pain). Conclusion: This study demonstrates the acceptable yet moderate construct and content validity, reliability, and responsiveness of the FAOS for patients with OLTs of the ankle joint. We endorse the use of the FAOS in evaluating ankle OLTs in both the research and clinical setting and consider it a useful patient-reported, self-administered instrument following surgical intervention. Level of Evidence: Level IV, retrospective case study.

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force across the elbow during throwing. The incidence of MUCL continues to rise, and injuries are common in overhead throwing athletes often leading to elbow pain and instability. While MUCL reconstruction remains the gold standard for high-level throwing athletes with midsubstance tears, MUCL repair remains an option for select athletes and affords good functional outcomes with quicker return to sport compared with reconstruction. Indications: Indications for MUCL repair include acute injuries, proximal or distal avulsions, young and lower demand athletes, non-throwing athletes, or older athletes who may be nearing retirement. Technique Description: An incision is made over the medial elbow from the medial epicondyle to the sublime tubercle. Dissection is carried down to fascia which is split in line with its fibers. The flexor pronator muscle group is bluntly divided, and the ligament exposed. Care is taken to identify and dissect the native ligament. The avulsed portion of the ligament is secured with a 0 FiberWire suture in a running locked whipstitch fashion. The footprint of the avulsed ligament is gently debrided and prepared using a scalpel. The 0-FiberWire suture tails are then loaded onto a suture anchor preloaded with suture tape. This is then secured at the footprint of the ligament. The FiberWires are cut, and the suture tape is then pulled back over the native ligament and fixed at the other attachment site for the ligament. 0-Vicryl sutures are then used to suture the internal brace to the underlying ligament so the construct would move as a single unit. Results: Biomechanical testing has demonstrated that MUCL repair with internal brace augmentation has similar time-zero failure strength when compared with the original Jobe reconstruction technique while also having greater resistance to gapping. In addition, recent literature has shown that well-selected patients can have excellent functional outcomes and quicker return to sport with MUCL repair as opposed to reconstruction. Discussion: Medial ulnar collateral ligament repair with internal brace augmentation can be a successful treatment in the appropriately indicated athlete to allow for good functional results and quicker return to sport. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Abstract Trochlear dysplasia is a major contributor to patellofemoral instability and subsequent failure of isolated soft tissue reconstruction procedures in the treatment of recurrent patellar dislocation and/or subluxation. Trochleoplasty procedures aim to address abnormal osseous trochlear morphologic factors that contribute to patellar maltracking. However, teaching these techniques is limited by the lack of reliable training models for trochlear dysplasia and trochleoplasty simulation. Although a cadaveric knee model of trochlear dysplasia for trochleoplasty simulation has been recently described, cadaveric knees are less amenable for use in trochleoplasty planning and surgeon training because of the absence of reliable, natural dysplastic anatomic relationships, such as suprapatellar spurs due to the rarity of dysplastic cadavers and the high cost of cadaveric specimens. Furthermore, readily available sawbone models represent “normal” osseous trochlear morphology and are difficult to modify and bend due to their material composition. Given this, we have developed a cost‐effective, reliable, and anatomically accurate three‐dimensional (3D) knee model of trochlear dysplasia for trochleoplasty simulation and trainee education. Technique Video video See video under supplementary data.

ABSTRACT Fracture healing is impaired in the setting of infection, which begets protracted inflammation. The most problematic causative agent of musculoskeletal infection is methicillin-resistant Staphylococcus aureus (MRSA). We hypothesized that modulation of excessive inflammation combined with cell-penetrating antibiotic treatments facilitates fracture healing in a murine MRSA-infected femoral fracture model. Sterile and MRSA-contaminated open transverse femoral osteotomies were induced in 10-week-old male C57BL/6 mice and fixed via intramedullary nailing. In the initial therapeutic cohort, empty, vancomycin (V), rifampin (R), vancomycin-rifampin (VR), or vancomycin-rifampin-trametinib (VRT) hydrogels were applied to the fracture site intraoperatively. Rifampin was included because of its ability to penetrate eukaryotic cells to target intracellular bacteria. Unbiased screening demonstrated ERK activation was upregulated in the setting of MRSA infection. As such, the FDA-approved mitogen-activated protein kinase kinase (MEK)1-pERK1/2 inhibitor trametinib was evaluated as an adjunctive therapeutic agent to selectively mitigate excessive inflammation after infected fracture. Two additional cohorts were created mimicking immediate and delayed postoperative antibiotic administration. Systemic vancomycin or VR was administered for 2 weeks, followed by 2 weeks of VRT hydrogel or oral trametinib therapy. Hematologic, histological, and cytokine analyses were performed using serum and tissue isolates obtained at distinct postoperative intervals. Radiography and micro-computed tomography (μCT) were employed to assess fracture healing. Pro-inflammatory cytokine levels remained elevated in MRSA-infected mice with antibiotic treatment alone, but increasingly normalized with trametinib therapy. Impaired callus formation and malunion were consistently observed in the MRSA-infected groups and was partially salvaged with systemic antibiotic treatment alone. Mice that received VR alongside adjuvant MEK1-pERK1/2 inhibition displayed the greatest restoration of bone and osseous union. A combinatorial approach involving adjuvant cell-penetrating antibiotic treatments alongside mitigation of excessive inflammation enhanced healing of infected fractures. © 2022 American Society for Bone and Mineral Research (ASBMR).