Driven by increasing emphasis on problem-based and self-directed learning, medical students and doctors in orthopedic specialty training rely increasingly on the internet as learning resource. As students or residents performance on physical examination may be less supervised in comparison to other clinical skills (for example surgical competence), online videos may provide a valuable source for education of physical examination skills. Cognitive psychological research has shown that videos can help viewers to understand techniques and manage the sequential steps of physical examination and approach to patients. YouTube is the largest open-access video platform available and provides access to thousands of educational videos on orthopedics-related topics. VuMedi, G9MD, and Orthobullets are examples of online platforms requiring user-registration with video content that is more directly focused on orthopedic topics. The objective of this study was to investigate the accuracy and quality of instructional videos on the physical examination of the elbow and identify factors influencing the educational usefulness. A YouTube, VuMedi, Orthobullets, and G9MD search was performed on October 7, 2018 for videos on the physical examination of the elbow. We included both basic examination and disease specific tests. The included videos were rated for accuracy and quality by two independent authors using a modified version of a validated scoring system. Inter-rater reliability was analyzed using mean difference and intra-class correlation coefficient. Twenty-three out of 126 videos were indicated as useful for educational purposes. Accuracy, quality and total scores were statistically significant higher for videos from specialized platforms compared to YouTube: 16.5 (95% CI 16 to 17) vs. 12.816 (95% CI 12.3 to 13.3) respectively. Video accuracy and quality were highly variable and did not correlate. The number of days online, views, and likes showed no or weak correlation with accuracy and quality. For the total score, our assessment tool showed excellent inter-rater reliability of 0.93 (95% CI 0.09–0.95) and a mean difference of 0.024 point between the two observers (p=0.871). There is considerable variation in accuracy and quality of online available videos on the physical examination of the elbow. We indicated 23 educationally useful videos and provided an assessment method. This assessment method can be useful for both viewers to assess reliability of a video and educators interested in creating videos

Purpose: In evaluating injury severity of acute medial collateral ligament (MCL) injuries, the current standard is to perform a history and physical examination and static MRI of the injured joint. With recent advances in dynamic MR imaging technology, we hypothesized that concurrent physical examination and dynamic MRI of the knee joint in patients with acute MCL injuries is feasible and would provide new insight into the injured joint kinematics while correlating to clinical and diagnostic imaging criteria for injury severity. Method: 10 patients (5 male, 5 female) with isolated, unilateral, acute MCL injuries were prospectively enrolled in the study. An orthopedic surgeon performed initial physical examination and clinical grading. Dynamic MRI with concurrent physical examination was performed in a 1.5T wide-bore magnet and compared to the uninjured knee as a control. The dynamic MR imaging data was compared with morphologic MCL changes on static MRI, with dynamic examination of the contralateral knee and with the clinical grading of MCL injury. The width of the medial joint space and the opening angle between the femur and tibia were measured. Results: Clinically, one patient had grade 1 and nine had grade 2 injuries. Using morphologic MRI criteria there were nine grade 2 and one grade 3 injuries. Mean and median medial opening angles of all affected knees was 2.8/2.5 mm and 2.8/2.6°, respectively, as compared to 1.8/1.8 mm and 2.2/2.1° in the normal side. Measurements of medial joint-space opening showed little quantitative difference between grade 1, 2 and 3 injuries. Interobserver agreement (intraclass correlation coefficients) varied from 0.9 to 0.93. Conclusion: Dynamic MR imaging with concurrent physical examination is feasible and correlates to clinical and morphologic grading of severity. Our study suggests that traditional clinical grading systems of MCL injuries overestimate medial joint space opening

Purpose: To quantify how well the physical examination of the shoulder predicts patient-reported functional outcome in a cohort of patients with previous proximal humerus fractures. Method: Potential subjects were identified from a recent study cohort of proximal humerus fracture patients treated within the past six years. The cohort consisted of all fracture types and treatment modalities. Participants underwent a focused physical examination of their injured shoulder containing the components of the Constant-Murley shoulder score: range of motion for forward flexion, abduction, internal rotation, external rotation, and abduction strength measured by an IsoBex muscle strength analyzer. Participants also completed the following patient-reported functional outcome questionnaires: Disabilities of Arm, Shoulder, Hand (DASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), and Oxford Shoulder Score (OSS). Forward- and backward-stepwise linear regression was used to assess the relationship between the functional outcomes and the physical exam measurements. Results: Thirty-one subjects with a mean age of 70 ± 8 years participated. Sixteen patients were previously treated with ORIF and 15 were treated with sling immobilization. The mean physical examination measures were: flexion 117° ± 31°, abduction 117° ± 37°, internal rotation 7° ± 2°, external rotation 7° ± 4°, and strength 6 ± 5 Newtons. The mean functional outcome scores were: DASH 21 ± 19, ASES 82 ± 17, SST 8 ± 3, and Oxford 20 ± 8. Using linear regression, adjusted R-squared statistics suggest components of the physical exam can explain 38% of the Oxford, 50% of the DASH, 58% of the SST, and 70% of the ASES variance. Abduction strength was a significant predictor for all functional outcomes. Combinations of flexion, abduction, or internal rotation were also significant predictors depending on the outcome instrument being modeled. Conclusion: Physical exam of the shoulder accounts for differing amounts of patient-reported functional outcome variance. Abduction strength is the most consistent predictor of functional outcome within this cohort of proximal humerus fracture patients

Background:. The origin of a valgus deformity affects the algorithmic and individualized approach used in total knee arthroplasty in valgus knees. We developed a new physical examination technique, the swing test, to evaluate whether valgus malalignment is present when the knee flexes. Methods:. We performed the swing test on 44 valgus knees in 44 consecutive patients, and we conducted traditional malalignment analysis on each patient's long-film radiographs and computed tomography images to evaluate origin of valgus deformity. We did a diagnostic test to compare the results of the swing test with those of traditional malalignment analysis. Results:. For the swing test, there were positive findings in 22 cases and negative findings in the other 22 cases, whereas for traditional malalignment analysis, there were positive findings in 26 cases and negative findings in 18. The sensitivity, specificity, and accuracy for the swing test were 84.6%, 100%, and 90.9%, respectively. Conclusions:. The swing test is an effective technique in evaluating whether valgus deformity exists when the knee is flexed. Level of Evidence: Level III. See Instructions to Authors for a complete description of levels of evidence

To test the knowledge of clinicians in Orthopaedic clinics and Emergency departments of the surface anatomical landmarks that should be examined during assessment of foot and ankle injuries. Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for their relevance in assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talo-fibular ligament (ATFL). Two participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. One hundred and seven clinicians correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 45%. The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lacking in anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even mal-treatment of patients. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate

Aim: To test the knowledge of clinicians in orthopaedic clinics and emergency departments of the surface anatomical landmarks, that should be examined during assessment of foot and ankle injuries. Methods: Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for its relevance to assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talofibular ligament (ATFL). Results: 2 participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 (sd: 1.5 and range: 0–6). 107 correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 44%. Discussion: The knowledge of surface anatomy of junior orthopaedic and emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lack of anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even maltreatment of patients. Clinicians are becoming more reliant on unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate

Purpose: Complete distal biceps tendon ruptures (DBTRs) require prompt surgical management for optimal functional and aesthetic outcome. Waiting for confirmatory diagnostic imaging can often delay timely surgical referral of these injuries. The need exists for a valid and reliable diagnostic tool to expedite appropriate referrals for surgery.

Method: Based on the hypothesis that complete distal biceps tendon rupture leads to an objectively measurable increase in the “biceps crease interval” (BCI) due to proximal retraction of the musculotendinous complex, three independent examiners established “normal” biceps crease intervals (N-BCI) for 80 males (average age = 43 years) with no history of biceps injury. Given acceptable inter-rater reliability (ICC > 0.70), a mean N-BCI value was established and a normal biceps crease ratio (N-BCR) between right and left arms was calculated. Correlations with arm dominance, biceps circumference, and age were determined. Diagnostic N-BCI and N-BCR thresholds were applied to 23 consecutive patients presenting with a possible complete DBTR to determine the diagnostic value of the BCI Test. A definitive diagnosis was confirmed at surgery and/or by radiographic imaging.

Results: The BCI Test had acceptable inter-rater reliability (ICC= 0.794, p = < 0.001). The mean N-BCI for both dominant and non-dominant arms was 4.8 +/− 0.6 cm. The mean N-BCR was 1.0 +/− 0.1. Applied to an injured population, using a diagnostic threshold of two standard deviations above “normal” values (BCI > 6.0 cm, BCR > 1.2), the BCI Test had a sensitivity of 92% and a diagnostic accuracy of 93%.

Conclusion: The BCI Test is an objective, valid and reliable test that can be used by clinicians to facilitate rapid diagnosis and surgical referral of suspected complete DBTRs.

Aims. Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population. Methods. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria. Results. The incidence of DDH within the UK over the last 25 years is 7.3/1,000 live births with females making up 86% of the DDH population (odds ratio 6.14 (95% confidence interval 3.3 to 11.5); p < 0.001). The incidence of DDH significantly increased following the change in the Newborn and Infant Physical Examination (NIPE) guidance from 6.5/1,000 to 9.4/1,000 live births (p < 0.001). The rate of late presentation also increased following the changes to the NIPE guidance, rising from 0.7/1,000 to 1.2/1,000 live births (p < 0.001). However, despite this increase in late-presenting cases, there was no change in the rates of surgical intervention (0.8/1,000 live births; p = 0.940). Conclusion. The literature demonstrates that the implementation of a selective screening programme increased the incidence of DDH diagnosis in the UK while subsequently increasing the rates of late presentation and failing in its goal of reducing the rates of surgical intervention for DDH. Cite this article: Bone Jt Open 2023;4(8):635–642

Hip Osteoarthritis (HOA) is the most common joint disorder and a major cause of disability in the adult population, leading to total hip replacement (THR). Recently, evidence has mounted for a prominent etiologic role of femoroacetabular impingement (FAI) in the development of early OA in the non-dysplastic hip. FAI is a pathological mechanical process, caused by abnormalities of the acetabulum and/or femur leading to damage the soft tissue structures. FAI can determine chondro-labral damage and groin pain in young adults and can accelerate HOA progression in middle-aged adults. The aim of the study was to determine if the presence of calcium crystal in synovial fluid (SF) at the time of FAI surgery affects the clinical outcomes to be used as diagnostic and predictive biomarker. 49 patients with FAI undergoing arthroscopy were enrolled after providing informed consent; 37 SFs were collected by arthrocentesis at the time of surgery and 35 analyzed (66% males), median age 35 years with standard deviation (SD) 9.7 and body mass index (BMI) 23.4 kg/m. 2. ; e SD 3. At the time of surgery, chondral pathology using the Outerbridge score, labral pathology and macroscopic synovial pathology based on direct arthroscopic visualization were evaluated. Physical examination and clinical assessment using the Hip disability & Osteoarthritis Outcome Score (HOOS) were performed at the time of surgery and at 6 months of follow up. As positive controls of OA signs, SF samples were also collected from cohort of 15 patients with HOA undergoing THR and 12 were analysed. 45% FAI patients showed CAM deformity; 88% presented labral lesion or instability and 68% radiographic labral calcification. 4 patients out of 35 showed moderate radiographic signs of OA (Kellegren-Lawrence score = 3). Pre-operative HOOS median value was 61.3% (68.10-40.03) with interquartile range (IQR) of 75-25% and post-operative HOOS median value 90% with IQR 93.8-80.60. In both FAI and OA patients the calcium crystal level in SFs negatively correlated with glycosaminoglycan (component of the extracellular matrix) released, which is a marker of cartilage damage (Spearman rho=-0.601, p<0.001). In FAI patients a worst articular function after surgery, measured with the HOOS questionnaire, was associated with both acetabular and femoral chondropathy and degenerative labral lesion. Moreover, radiographic labral calcification was also significantly associated with pain, worst articular function and labral lesion. Calcium crystal level in SFs was associated with labral lesions and OA signs. We concluded that the levels of calcium crystals in FAI patients are correlated with joint damage, OA signs and worst post-operative outcome. The presence of calcium crystals in SF of FAI patients might be a potential new biomarker that might help clinicians to make an early diagnosis, evaluate disease progression and monitor treatment response

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice. A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (12 weeks - 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up. A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m2), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05). We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice. A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (<6wks from injury) and delayed surgical intervention (>12 weeks – 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up. A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m. 2. ), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p<0.001). Multivariable linear regression analyses of the four domains of the MLQOL did not demonstrate an independent association with early versus delayed surgery status (p>0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05). We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction

Latissimus dorsi anterior to major transfers have been advocated in the setting of loss of external rotation and elevation in conjunction with reverse shoulder replacement. Reverse shoulder replacement is a prosthesis specifically designed for shoulders with poor rotator cuff function. In the vast majority of cases, some teres minor function at the minimum is maintained in shoulders destined for a reverse shoulder replacement. However, in certain circumstances there is complete loss of any external rotation, and a muscle transfer can be performed in order to restore some external rotation function. A reverse shoulder replacement in the absence of any rotator cuff function goes into obligate internal rotation with elevation. A minimum of external rotation strength is necessary in order to maintain the arm in normal rotation. The first tip is patient selection. Physical examination of active external rotation, external rotation strength and forward elevation should be just performed. A latissimus transfer is indicated in patients who cannot maintain their arm in neutral to at least a few degrees of external rotation. A lag sign is another physical examination finding which can indicate complete loss of rotator cuff function. The latissimus dorsi transfer is performed by first identifying and releasing the latissimus from its insertion on the anterior humerus. The arthroplasty is performed. The passage for the latissimus muscle is developed carefully and being mindful of the axillary nerve in particular. The latissimus is directed inferior to the nerve and around the medial and posterior aspect of the proximal humerus. Different ways of securing the transfer to the humerus have been described including bone tunnels and anchors. Often it is easier to place the anchors and/or the bone tunnels prior to inserting the humeral prosthesis. The latissimus is secured in the new position, enabling it to participate in external rotation. The value of this is difficult to clearly establish. Most studies are evidence level IV and there are no good comparative studies in a controlled patient population. This is a good option for shoulders with no active external rotation, but they may increase overall complication rate. Complications include dislocation, infection, and transient nerve palsy

Purpose of the study: Ankle sprains constitute a serious public health problem with nearly 6000 consultations daily in France. The prognosis is generally good if a precise clinical diagnosis can be established and appropriate treatment undertaken. The purpose of this study was to ascertain the pertinence of the initial physical examination which determines the treatment by correlating it with the results of a high-resolution ultrasound examination. Material and methods: This prospective study included 23 patients, mean age 30.7 years, who were followed regularly for three months. A total of 154 ultrasound explorations were performed. The initial treatment for these patients who consulted a hospital emergency room for ankle trauma was established on the basis of the Ottawa criteria. The ankles were examined by a senior physician and an ultrasonographic exploration was performed 3.9 days on average after the first consultation in the emergency room. Standard protocols were used for the physical examination and for the ultrasonography. Results: The initial results confirmed a lesion of the lateral collateral ligament in 91% of cases with an initial tear of the anterior talofibular ligament in half of the cases and a injury to the calcaneofibular ligament in one out of five cases. One quarter of the patients had an isolated lesion. One out of ten presented a lesion of the syndesmosis and one out of three lesions of the fibular tendons. The standard ankle examination performed by the senior physician established correct diagnosis of the precise lesion in 80% of the cases. Discussion: Lesions of the mid food and of the syndesmosis are diagnosed clinically, ultrasonography is not contributive. The stage of the initial lesion was compared with the stage at three months: in 7 out of 10 cases, the anterior talofibular and the calcaneofibular ligaments had healed correctly. Physical examination is essential but ultrasonography provides certain complementary information at a time when the physical examination can be hindered by the pain and potentially the lesser experience of emergency room examinators. Conclusion: In light of the evidence provided by this study, it can be confirmed that the initial diagnosis of ankle sprain established in an emergency room setting can be corrected by a physical examination performed by an experienced clinician. At the present time, it is not possible to demonstrate the specific contribution of ultrasonography for the management of ankle sprains. This would require a prospective study over a longer period and should be designed to demonstrate the relationship between injury of the fibular tendons and ankle stability

Introduction and Objective. Pectus carinatum is a common congenital anterior chest wall deformity, characterized by outward protrusion of sternum and ribcage resulted from rib cartilage overgrowth. The protrusion may be symmetrical or asymmetrical. Pectus carinatum association with mitral valve diseases, Marfan's syndrome, and scoliosis enforces that poor connective tissue development as possible etiological factor. Despite the coexistence of pectus carinatum and scoliosis has attracted the attention of some researchers, the association between pectus carinatum and the other spinal deformities has not been studied comprehensively. The frequency of spinal deformity in patients with pectus carinatum and the mutual relationships of their subtypes are needed to be studied to determine the epidemiological character of the combined deformity and to plan patient evaluation and management. Our study aimed to investigate the association, define the incidence and evaluate the characteristics between different types of spinal deformities and Pectus carinatum. Materials and Methods. Radiological and physical examinations were performed for 117 pectus carinatum patients in Marmara university hospital/Turkey in the years between 2006 and 2013. The incidence of spinal deformity was calculated. Spinal deformities were classified as scoliosis, kyphosis, kyphoscoliosis, and spinal asymmetry, whereas pectus carinatum were subdivided into symmetric and asymmetric subgroups. The relationship between spinal deformities and the symmetrical-asymmetric subtype of pectus excavatum was statistically analyzed, Pearson chi-square test was used to compare the association of qualitative data. The significance level was accepted as p <0.05. Lastly, the angular values of the deformities of scoliosis and kyphosis patients were measured using the Cobb method. In this way, the magnitude of the deformity was given as a numerical value. Results. Spinal deformity was detected in 23 (17 symmetrical PE and 6 asymmetrical PE) of 117 pectus excavatum patients. Scoliosis and kyphosis were seen equally in symmetrical pectus carinatum, whereas scoliosis was seen in 33.3% and kyphosis in 50% in asymmetric pectus carinatum patients, respectively. However, there were no statistically significant differences in the distribution of scoliosis and kyphosis in patients with symmetrical and asymmetrical PE. Idiopathic scoliosis constituted the most common scoliosis group. Congenital kyphosis was not found in any kyphosis patient. The average Cobb angle of scoliosis patients was 32°, and the mean T2-T12 kyphosis angle of these patients was 55.5°, while the average kyphosis angle of those with kyphosis deformity was 71°. Conclusions. Patients with Pectus carinatum have a higher incidence of spinal deformities than the normal population. Such high concomitant incidence should be taken under consideration in evaluating and treating patients presenting with either deformity

Introduction. Torsional malalignment syndrome (TMS) is a unique combination of rotational deformities in the lower limb, often leading to severe patellofemoral joint pain and disability. Surgical management of this condition usually consists of two osteotomies in each affected limb, with simultaneous correction of both femoral anteversion and external tibial torsion. However, we believe that a single supratubercular osteotomy followed by tibial derotation with the Taylor Spatial Frame (TSF) can be used to provide a significant improvement in both appearance and function. Materials and Methods. This is a retrospective case analysis in which we will be reviewing 16 osteotomies performed by one surgeon between 2006 and 2017. The study includes 11 patients with a mean age of 16.7 ± 0.8 years. Pre and post-operatively, patients were fully evaluated through history and physical examination, and CT rotational profiling. Statistical analyses were performed in order to determine whether or not any observed clinical or cosmetic improvements were statistically significant. Results. The results show significant improvements in scores reported on post-operative functional assessment, with mean Oxford Knee Score (OKS) increasing by 18.3 and mean Kujala Anterior Knee Pain Scale (AKPS) also increasing by 31.4. In addition to this, post-operative clinical assessment showed a reduced thigh-foot angle (TFA) in all cases, by a mean value of 31.9o. The angle of the transmalleolar axis (TMA) was successfully reduced in 14/16 cases, by a mean value of 8.6o. Statistical analysis showed all of these results to be statistically significant where p<0.05. Conclusions. The results show that supratubercular osteotomy, followed by gradual correction with TSF, can be used to provide a significant improvement in both appearance and function for patients suffering from TMS

Purpose. Although multiple surgical options exist for chronic static scapholunate dissociation, no single procedure has been found to be superior clinically or kinematically. We hypothesize that the reduction and association of the scaphoid and lunate (RASL procedure) is a safe and effective procedure that improves function and alleviates pain in the injured wrist. The purpose of this study is to report long-term follow-up of patients undergoing the RASL procedure over a 20-year period. Method. Between December 1991 and September 2008, the senior author performed 36 RASL procedures for chronic static scapholunate dissociation. This reconstruction involves reduction of the rotational deformity and diastasis between the scaphoid and lunate through a dorsal approach to the wrist. Maintenance of reduction is accomplished with a cannulated, headless, smooth-shafted compression screw directed from the scaphoid to the lunate along the anatomic axis of rotation between the two bones. For the purposes of this study, patients were evaluated by visual analog pain scale (VAS), Disability of the Arm, Shoulder and Hand questionnaire (DASH), SF-36 health survey, physical examination and radiographs. Results. Thirty-two of 36 patients were available for questionnaires and 23 available for questionnaires and physical examination, with an average time to final follow-up of 6.2 years post-operatively. The mean DASH score was 16.6, and other patient-based outcomes showed similarly favorable results. Range of motion was well preserved with 80% of the contralateral flexion-extension arc being maintained in those available for physical examination. Grip strength was well preserved at 90% of the contralateral side. X-rays showed significant decreases in scapholunate gap (p < 0.001) and scapholunate angle (p < 0.001) as compared to preoperative films. In the 32 patients followed, there were 2 treatment failures going on to have salvage procedures for progression to scapholunate advanced collapse deformities. These patients were included in the final analysis. Conclusion. The RASL procedure is a safe and effective treatment for chronic static scapholunate dissociation. It re-aligns the scaphoid and lunate, restores function, reduces pain, and appears to be robust over time

Introduction. The COVID-19 pandemic led to a swift adoption of telehealth in orthopedic surgery. The purpose of this study was to analyze patient and surgeon satisfaction with a rapid expansion of telehealth use during COVID-19 pandemic within the division of adult reconstructive surgery at a major urban academic hospital. Methods. 334 hip and knee arthroplasty patients who completed a telemedicine visit from March 30th, 2020 through April 30th, 2020 were sent a 14-question survey. Eight adult reconstructive surgeons who used telemedicine were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modeling. Results. 20.4% of patients (68/334) and 100% of surgeons (8/8) completed the surveys. Patients were on average “Satisfied” with their telemedicine visits (4.10/5.00 ± 0.98), 54.4% considered themselves high-risk for COVID-19 complications, and 27.9% reported that they preferred future visits to be conducted using telemedicine for reasons unrelated to COVID-19. Multivariate ordinal logistic regression modeling revealed that patients reported higher satisfaction if their surgeon effectively responded to their questions/concerns (OR 3.977; 95% CI 1.260 to 13.190, p=0.019) and if their visit had higher audiovisual quality (OR 2.46; 95% CI 1.052 to 6.219, p=0.042). Surgeons were “Satisfied” with their telemedicine experience (3.63/5.00 ± 0.92), felt that physical exams conducted via telemedicine were “Slightly Effective” (1.88/5.00 ± 0.99), and believed that 43.5% of visits required an in-person component. Most adult reconstructive surgeons would continue to use telemedicine in the future (87.5%). Conclusion. Telehealth emerged as a valuable tool during the COVID-19 pandemic. Arthroplasty patients and surgeons were generally satisfied with telehealth and see a role for telehealth after the pandemic. Future investigations should explore how to improve telehealth physical examinations and identify which types of visits and patient concerns are reliably addressed using telehealth

Lymph node metastasis are a rare occurrence in soft tissue sarcomas of the extremity, arising in less than 5% of patients. Few studies have evaluated the prognosis and survival of patients with a lymph node metastasis. Early reports compared lymph node involvement to lung metastasis, while others suggested a slightly better outcome. The purpose of this study was to evaluate the impact of lymph node metastasis on patient survival and to investigate the histologic and clinical features associated with lymph node involvement. A retrospective review was done of the prospectively collected soft tissue sarcoma database at our institution. Two thousand forty-five patients had surgery for soft tissue sarcoma of an extremity between January 1986 and August 2017. Included patients either presented with a synchronous lymph node metastasis or were diagnosed with a lymph node metastasis after their initial treatment. Demographic, treatment, and outcome data for patients with lymph node involvement were obtained from the clinical and radiographic records. Lymph node metastases were identified as palpable adenopathy by physical examination and were further characterized on cross-sectional imaging by computed tomography (CT) or magnetic resonance imaging (MRI) scans. All cases were confirmed by pathologic examination of biopsy specimens. A pathologist with expertise in sarcoma determined the histologic type and graded tumors as 1, 2, or 3. One hundred eighteen patients with a mean age of 55.7 (SD=18.9) were included in our study. Seventy-two (61.3%) out of 119 patients were male. Thirty six patients (57.1%) had lymph node involvement at diagnosis. The mean follow-up from the date of the first surgery was 56.3 months. The most common histological diagnoses were Malignant fibrous histiocytoma (35) and liposarcoma (12). Ninety eight patients (89%) underwent surgical treatment of the lymph node metastasis while 21 (17.6%) were treated with chemotherapy and/or radiation therapy. The mean survival was 52.6 months (range 1–307). Our results suggest that patients with a lymph node metastasis have a better prognosis than previously described. Their overall survival is superior to patients diagnosed with lung metastasis. A signifant proportion of patients may expect long term survival after surgical excision of lymph node metastasis. Furthermore, our study also indicates that different histological subtypes such as liposarcoma or malignant peripheral nerve sheath tumor (MPNST) may also be responsible for lymph node metastasis. Additional studies to further improve the treatment of soft tissue sarcoma nodal metastasis are warranted

Purpose: The purpose of this study was to evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) in the diagnosis of medial and lateral meniscal injury in operated and non-operated knees. Material and methods: This prospective longitudinal study was conducted between January 1st 1995 and December 31st 1997. Each patient had a physical examination, a standard radiography study, and an MRI and an arthroscopy. The MRI was performed with two machines running at 1.5 Tesla and 0.5 Tesla. Spin-echo T2 slices were obtained in the saggital plane, and spin-echo fat saturation slices in the frontal and axial planes. Arthroscopy was performed and/or controlled by the same operator. Results: The protocol included 132 patients. Ten patients (ten knees) had another arthroscopy after arthroscopic meniscectomy. Mean time between the physical examination and MRI was 57 days, it was 69 days between MRI and arthroscopy. Sensitivity, specificity, positive predictive value, negative predictive value and precision were, respectively, 94.8%, 61.%, 86.7%, 81.5% and 85.6% for the medial meniscus and 73%, 93.3%, 76% 93.5% and 90.1% for the lateral meniscus. Discussion: Arthroscopy remains the gold standard for prospective comparative studies (Reigher 1986, Jackson 1988, Kelly 1991). MRI is the examination of choice for the diagnosis of meniscal injury in non-operated knees (Polly 1988). Most false positives concern injuries located on the posterior part of the medial meniscus. For radiologists (Mink 1988), these false negatives would result from poor analysis by the arthroscopic surgeon (Quinn 1991). Arthroscopists point out that radiologists overestimate injuries of the posterior segment (Barronian 1989, Fischer 1991, Spiers 1994). These false negatives involve the lateral meniscus (Cheung 1997). Our study corroborates the results reported in the literature. For repeated arthroscopies, no conclusion can be drawn from the interval of confidence observed in a population of ten knees. Nevertheless, in these knees, the MRI provided a good means of identifying recurrent lesions of both the medial and lateral menisci. Conclusion: The physical examination provide a strong clue to meniscal injury in non-operated knees, so it is not necessary to perform an MRI before arthroscopy In all other cases, particularly there is recurrence, MRI can identify injury to the medial or lateral menisci with good sensitivity and specificity. In most cases, if the MRI is negative, it is not necessary to perform arthroscopy to search for a meniscal injury

Integrated Regional Orthopaedic (MSK) Assessment clinics (ROAC) are now mandated in many provinces for the assessment and triage of patients referred for total joint arthroplasty (TJA). Their introduction underscores the lack of means for Primary Care Physicians (PCP) to appropriately refer patients for surgical consideration. Thus, problems arise when patients who are clear candidates for surgery are subject to a significant extra step in the care pathway by attending a ROAC while those who have insufficient problems are also seen, contributing to costs and crowding the access portal. We postulated that a patient reported outcome measure, decision aid combined with a validated grading of a weight bearing knee X-ray would provide an inexpensive yet effective tool to significantly improve the referral process for Knee OA (compared with the current mechanism). To date we have enrolled two hundred and forty-five consenting patients to the study, all referred by their PCP to the ROAC with a diagnosis of symptomatic Knee Osteoarthritis. All patients were evaluated as per the current ROAC protocol which included a medical history, physical examination and an X-ray (standing AP, lateral and patella-femoral skyline). Prior to the visit, subjects were sent a copy of a patient decision aid, Oxford Knee Score (OKS) and requested to answer whether their current clinical status described as Patient Acceptable Symptom State (PASS2) was acceptable. All radiographs were analyzed and scored for OA severity using the validated grading from 0 – 13. Of the 245 cases, 200 completed OKS and PASS2 uestionnaires and had standing X-rays for evaluation (only 120 completed the decision aid and these were left out of this report). Of the 200 included cases, 104 were referred from the ROAC to see a surgeon. In analysis, we found that a self-reported PASS 2 answer NO and an AP X-ray graded at 6 or above predicted over 75% of those patients that were referred. This represents a 3.4 greater likelihood of referral using this simple analysis. The OKS did not modify this prediction. Thus, use of a validated grading of a standing AP X-ray along with a response, ‘readiness for surgery’ indicated 75% of patients appropriate for surgical consideration. Patients with less severe gradings are likely being unnecessarily referred to ROAC leading to overuse of scarce resources, crowding the access and adding to costs, others, who score higher, are being needlessly delayed. The ability to discreetly screen for the best possible candidates should be a continued focus of ROAC and will lead to improved use of expensive resources, overall patient care and satisfaction and the provision of tools to the PCP for appropriate referral