All Articles

Rita Th. Harmsen^1*, Marjolein E.M. den Ouden², Pieter F. Schillemans³, Henk W. Elzevier¹, Rob G. Nelissen¹, Brenda L. Den Oudsten⁴

¹Departments of Orthopaedics, Biomedical Data Sciences and Department of Urology and Medical Decision Making (H.W.E.), Leiden University Medical Center, The Netherlands

²Research Group Technology, Health & Care, Academy of Social Work, University of Applied Science Saxion, Enschede, The Netherlands

³Private Center of Ultra Sonography Care, NV Hoorn, The Netherlands

⁴Center of Research on Psychological and Somatic Disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands

Background: In-depth insight into couples’ experiences of sexual activity before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is lacking. The aim of this study was to explore patients’ and partners’ experiences, complemented by surgeons’ opinions on safe resumption of sexual activity after surgery.

Methods: Mixed method study: 1) Semi-structured interviews among sexually active couples, 1.5 years postoperatively and 2) A survey among surgeons about recommendations of sexual activity after THA/TKA.

Results: Of the 150 invited couples, 90 (60%) responded (THA: n=39; TKA: n=42). Five couples participated (THA: n=3; TKA: n=2), while 85 (94%) couples refused participation. Two themes emerged: “Couples physically and mentally adjusted to the new situation” and “Couples undoubtedly trusted the surgeon as the provider of information.” In total, 27% (47/175) of THA surgeons participated. Fifty percent agreed with the recommended sexual positions researched by Charbonnier et al. Opinions differed widely regarding when to safely resume sexual activity. Of the TKA surgeons, 36% (76/211) responded. Almost all surgeons (95%) agreed that there were no restrictions. However, some discomfort was expected when patients bend the knee or kneel during sex. Half of the surgeons indicated that providing information about sex was necessary.

Conclusions: All couples physically and mentally adapted to the new situation without considering safety measures. Patients trusted surgeons in providing safety information. Surgeons should inform patients succinct and explicitly, especially since surgeons’ recommendations showed great variability. More motion research on hip and knee may add to uniform guidelines.

Akshay V. Daji¹, Devin Q. John¹, Raj D. Rao^2*

¹HCA JFK Hospital/University of Miami Miller School of Medicine Orthopaedic Surgery Residency Program, FL, USA

²West Palm Beach VA Healthcare System, West Palm Beach, FL, USA

Dariush Dowlat Alizadeh^2*, Seyyed Mohammad Jalil Abrisham¹, Mohammad Reza Sobhan¹

¹Department of Orthopedics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

²Orthopedic Surgery, Trauma Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

Background and Aim: Sagittal imbalance is often presented as one of the major problems in individuals suffering from orthopedic pain, particularly those affected by destructive hip joint osteoarthritis. In this regard, total hip arthroplasty (THA) as a therapeutic procedure for such patients has resulted in the restoration of sagittal balance. Therefore, the present study aimed to evaluate the changes in sagittal balance using EOS imaging before and after THA and also reflect on its effect on hip joint function, knee pain, and disability percentage due to low back pain (LBP).

Methods: Utilizing a prospective cohort study, a total number of 24 patients suffering from extreme unilateral hip osteoarthritis and in need of unilateral THA were selected based on the inclusion and exclusion criteria, and then, sagittal balance parameters, including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sacrofemoral angle (SFA), sacrofemoral distance (SFD), lumbar lordosis (LL), and stem angle (SA) were investigated after performing standing radiographs by means of the EOS device. One year after THA, all the above-mentioned parameters were also measured by EOS imaging before and after the surgery and the patients completed some questionnaires, which is the Oswestry Low Back Pain Disability Index (OLBPDI) to evaluate disability percentage resulting in LBP, the Knee Injury and Osteoarthritis Outcome Score (KOOS) instrument to assess knee pain, and the Harris Hip Score (HHS) measure to rate hip joint function, and then the results were analyzed using the SPSS Statistics software (ver. 17).

Results: The patients consisted of 13 males (54.2%) and 11 females (45.8%) with the mean age of 52.87±13.05. The mean score of the preoperative PI was also equal to 54.74±10.66 and it was 58.19±11.58 after the surgery (p=0.025). However, the mean values of other parameters at the preoperative stage did not show any significant changes. As well, hip joint function and knee pain resulting from LBP improved in the patients after the surgery (p<0.001).

Conclusion: The study findings demonstrated that THA probably influenced sagittal balance through PI. Moreover, the postoperative hip joint function, knee pain, and disability percentage caused by LBP significantly enhanced compared with those before the surgery. Thus, it was concluded that the evaluation of sagittal balance parameters could help patients with orthopedic pain.

Michael Tang¹, William Fowler¹, Oday Al-Dadah^1,2*

¹Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, Harton Lane, South Tyneside, United Kingdom

²Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle-upon-Tyne, United Kingdom

Objectives: The Nottingham hip fracture score (NHFS) and the Surgical outcome risk tool (SORT) are both validated scoring systems used to predict mortality rates in patient with Fractured neck of femur (FnF). The primary aim of this study was to compare the accuracy of the predicted 30-day mortality rates between NHFS and SORT in patients with FnF. The secondary aim was to investigate the influence of patient and surgical factors on 30-day mortality.

Methods: The NHFS and SORT score was collected from 212 patients admitted with FnF. Variables including hip fracture type, surgical procedure and peri-operative haemoglobin, gender and ASA grade were also collected and further analysed to assess their influence on 30-day mortality rates.

Results: Overall actual 30-day mortality rate for the study population was 11.3% (n=24). There was a significant difference between the mean predicted 30-day mortality for the NHFS (8.0%) and the SORT score (7.0%, p=0.006). The was no difference in mortality rates between the different fracture types (p=0.889). There was a significant difference in mortality rates when comparing surgical procedures (p=0.031). Patients who had a notable fall in haemoglobin peri-operatively had significantly higher mortality rates (p<0.001). Males had significantly higher mortality rates compared to females (20.0% vs 8.6% respectively, p=0.027). Higher ASA grades also had significantly higher mortality rates (p=0.003).

Conclusion: NHFS was found to be significantly more accurate at calculating 30-day mortality rates compared to the SORT score in patients with FnF. Surgical procedure and patient factors including gender, ASA grade and peri-operative haemoglobin also significantly influenced mortality rates but fracture type did not.

Thomas J. Kean

Biionix Cluster, Internal Medicine, College of Medicine, University of Central Florida, Orlando, FL, USA

Amina Ait Belmahjoub Aamre MD¹, Sergio Barroso Rosa FEBOT PhD^1,2*

¹Department of Medical and Surgical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain

²Department of Orthopaedics, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Las Palmas de Gran Canaria, Spain

Introduction: Currently there are limited options for shoulder adhesive capsulitis treatment, some of which do not have sufficient backing scientific evidence. This entails a relevant setback for patients, especially in severe or refractory cases. In recent years, remote arterial embolization therapies have demonstrated usefulness in the management of diverse musculoskeletal conditions. This systematic review examines the therapeutic role of arterial embolization in patients with shoulder adhesive capsulitis.

Methods: A systematic review of articles published to date was performed, according to the methodology in the Cochrane Systematic Reviews Manual (MECIR) and the PRISMA checklists. PubMed, Scopus, Google Scholar, three other databases and three trial registries were examined for relevant studies. The ROBINS-I tool was used for quality assessment of included studies.

Results: Ninety four potential articles were found, seven of which were included. In the selected studies, arterial embolization was carried out in 127 patients, 113 of whom had abnormal vessels. In all studies, a reduction in pain and improvement in mobility was observed in less than six months after the procedure. There were no major adverse effects or recurrent symptoms reported. Due to large data heterogeneity, a meta-analysis was not performed. Three literature reviews were also included as part of the background discussion.

Conclusions: Arterial embolization is an effective and safe treatment option in patients with shoulder adhesive capsulitis, resulting in reduced pain and restored joint function. Controlled randomized trials are required to evaluate the attributable effect of the technique to the reported clinical improvement.

Lauren McMichan¹*, Dawn A. Skelton², Sebastien F.M. Chastin^2,3, Alexandra Mavroeidi¹

¹Department of Physical Activity for Health, School of Psychological Science and Health, University of Strathclyde, Glasgow, UK

²Research Centre for Health (ReaCH), Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK

³Department of Movement and Sports Science, Ghent University, Ghent, Belgium

Introduction: Understanding daily movement patterns (i.e., the relative proportion of time spent on Sedentary behaviour (SB), light physical activity (LPA), moderate-vigorous physical activity (MVPA) and sleep) to establish links with chronic diseases is a contemporary topic. Little research has looked at the effects of 24-hour movement behaviour on bone health (particularly bone mineral density (BMD)) despite investigation on other health parameters.

The aim of this rapid narrative review was to build on previous work published on the association between SB and BMD in older adults by investigating the association of the more holistic 24- hour movement behaviours in relation to BMD.

Methods: A database search of Web of Science and NIH PubMed was conducted using broad MeSH terms (older adults, sedentary, and bone). Searches were limited from the year 2019 onward.

Results/Discussion: Five published articles were reviewed, and there are discrepancies amongst the findings which could be attributed to the different measurement methods (Peripheral Quantitative Computed Tomography (pQCT) versus Dual-energy X-Ray Absorptiometry (DEXA)) and the sites of measured BMD. There are also notable differences between genders, with BMD in men appearing to be most reliant on time spent in MVPA, compared to women who appear to see benefit to BMD with replacement of SB with LPA and not require more time spent in MVPA. This highlights the complexity of movement behaviours and requires further research.

Marcus Wong^*, Jonathan J Lee, Jaime Guerrero, Sean M Barber

Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA

Eiko Sakai^1*, Mari Sato², Chikara Sato^2,3,4

¹Division of Dental Pharmacology, Department of Developmental and Reconstructive Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

²National Institute of Advanced Industrial Science and Technology, Tsukuba, Japan

³School of Integrative and Global Majors (SIGMA), University of Tsukuba, Tsukuba, Japan

⁴Biological Science Course, Graduate School of Science and Engineering, Aoyama Gakuin University, Sagamihara, Japan

Jennifer R. Arthurs¹, Zubin Master²,  Shane A. Shapiro^3*

¹Regenerative Medicine Therapeutics Program, Mayo Clinic, Jacksonville, Florida, USA

²Biomedical Ethics Research Program and the Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA

³Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA

Stem cell therapies occupy a unique place in the American public’s consciousness which has led to excessive enthusiasm over their potential to cure orthopedic conditions. Much has been written about direct-to-consumer marketing of cell therapies for a myriad of medical conditions. Far less has been studied on the attitudes that drive many patients to seek stem cell and orthobiologic therapies for musculoskeletal conditions. Previously published research on patient motivations for seeking stem cell therapy to treat orthopedic maladies such as osteoarthritis and chronic tendinopathies has shown that some patients were motivated by factors not supported by current medical evidence. These differing responses strongly suggest the need for patient-centered counseling to address misinformation about stem cell therapies for musculoskeletal conditions and increase health literacy about outcomes of orthobiologics.

Aneesh G. Patankar¹*, Suleiman Y. Sudah², Christopher R. Michel², David S. Constantinescu³, Mariano E. Menendez⁴, Jeremy B. Ruskin⁵, Ajul Shah⁶

¹Rutgers, Robert Wood Johnson Medical School, Piscataway, NJ, USA

²Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA

³Department of Orthopedic Surgery, University of Miami, Miami, FL, USA

⁴Midwest Orthopaedics at Rush, Rush University, Chicago, IL, USA

⁵Central Jersey Hand Surgery, Eatontown, NJ, USA

⁶The Center for Hand and Upper Extremity Surgery, Institute for Advanced Reconstruction, Shrewsbury, NJ, USA

Purpose: Sociodemographic factors have been shown to influence musculoskeletal health. However, little is known regarding the frequency of reporting and analysis of certain sociodemographic variables (e.g., age, sex, height, weight, body mass index (BMI), race, and ethnicity) in randomized clinical trials (RCTs) pertaining to hand surgery. The purpose of this study was to assess the rate of reporting and analysis of these variables in RCTs published in the Journal of Hand Surgery (JHS).

Methods: A systematic review was conducted of RCTs published in JHS between 2015 and 2021. For each study, we determined whether the following sociodemographic variables were reported and/or analyzed: age, sex, height, weight, BMI, race, and ethnicity. Frequencies were reported by year and as a cumulative total. Studies were evaluated using the Cochrane risk-of-bias tool.

Results: A total of 45 RCTs met inclusion criteria, with about half (53.3%) originating from the United States. Age (97.8%) and sex (91.1%) were the most frequently reported sociodemographic variables, followed by race (17.8%), BMI (11.1%), and ethnicity (8.9%). Age (17.8%) was the most frequently analyzed variable, followed by sex (13.3%), and race (4.4%); the remaining variables were not analyzed in any study.

Conclusions: While age and sex are reported at a high rate, only about 1 in 4 RCTs published in JHS report either race or ethnicity. All sociodemographic variables were infrequently included as part of statistical analysis. The significance of these findings should be recognized and used to interpret and enhance the methodology of future RCTs.

Kathryn A. Barth, Claire D. Eliasberg, Karen M. Sutton^*

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA

There has been an increasing focus on sex-specific differences within the context of sports medicine. Differences exist between the sexes leading to disparities in the types of injuries female athletes sustain and the rates at which they experience them. Recognition and awareness of subtle differences between the sexes can lead to a more nuanced diagnosis and treatment of such injuries. The purpose of this study is to review shoulder pathologies that are relevant to the female athlete, specifically adhesive capsulitis, multidirectional instability, and traumatic unidirectional shoulder instability, and highlight the differences in diagnosis, treatment, and outcomes between the sexes. Women suffer from adhesive capsulitis at a greater rate than men and there are risk factors such as breast cancer surgery that are unique to women. Females are much more likely to experience atraumatic shoulder instability than their male counterparts. While females represent a minority of patients who suffer traumatic unidirectional shoulder instability, they should not be overlooked with regards to this condition. There are challenges related to the diagnosis and treatment of these pathologies that are distinctive to female athletes.

Ryan S. Marder, Neil V. Shah, Aditya V. Maheshwari^*

Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA

Jenna M. Wahbeh^1,2, Claire J. Bogosian^1,3, Natalie M. Kistler^1,4, Sang-Hyun Park^1,5, Edward Ebramzadeh^1,4,5, Sophia N. Sangiorgio^1,2,5*

¹The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, CA, USA

²Department of Bioengineering, University of California, Los Angeles, CA, USA

³Department of Bioengineering, University of California, Berkeley, CA, USA

⁴Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA

⁵Department of Orthopaedic Surgery, University of California, Los Angeles, CA, USA

Background: Reviews of total disc arthroplasty (TDA) performance have focused on prospective randomized controlled trials (RCTs), excluding potentially important clinical information reported by others. The goal of the present study was to perform a comprehensive review, including both RCTs and non-randomized cohorts with more than five years of clinical outcome. We further explored the differences in outcome between prospective RCT and non-randomized, including retrospective studies.

Methods: A systematic literature review was performed following PRISMA guidelines. Inclusion criteria were: clinical follow-up ≥ 5 years with quantitative clinical and radiographic outcome. All studies that met these criteria, including retrospective and non-randomized studies, were included, for a total of 62 studies. As anterior cervical discectomies and fusion (ACDF) was included as a control group in the majority of the studies, comparisons between TDA and ACDF were conducted.

Results: Overall, there was a statistically significant difference between the rates of secondary surgeries reported for prospective RCTs and all other studies, with reoperation rates of 5.4% for prospective RCT studies v. 7.5% in all others (P<0.01). Including all studies, the reoperation rate for TDA patients was 5.6% and for fusion patients (included as control groups), 7.8%, (P=0.06). Overall, the reported incidence of adjacent segment degeneration was 26.2% in TDA patients and 43.9% in fusion patients (P<0.001).

Conclusions: These findings demonstrated the need for including all available data to assess the current outcomes of cervical disc arthroplasty and account for potential biases.

Ann Spence^1*, Carrie Gilligan, Janine Bartholomew²

¹Department of Nursing, Carlow University, Pittsburgh, PA, USA

²Department of Biology, Portage Learning, Beaver Falls, PA, USA

Ashim Gupta

General Therapeutics, Cleveland Heights, OH, USA

Future Biologics, Lawrenceville, GA, USA

South Texas Orthopaedic Research Institute(STORI Inc.), Laredo, TX, USA

Adeel Hamid^*, Usman Gill, Mian Hanif

Department of Orthopaedic Surgery, Lahore General Hospital and Post Graduate Medical Institute, Lahore, Pakistan

In order to achieve good results following Total hip replacement , proper and reproducible acetabular cup placement is of paramount importance. The safe zone described by Lewwinick is still considered to be the target cup position. Various techniques have been used to improve the precision and accuracy of cup placement including the use of computer navigation which is often prohibitively expensive for developing countries. We present a ‘No touch smartphone technique’ to check positioning of acetabular cup intra operatively, without compromising the sterility of the operative field which we have found to be simple, quick, inexpensive and reproducible.

Jingqiao Chen^1,3#, Kaiwei Shen^1#, Zhiming Lu^1,2, Eryou Feng^1*

¹Department of Arthrosis Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China

²The Third School of Clinical Medicine, Fujian Medical University, Fuzhou Fujian, China

³The Second School of Clinical Medicine, Fujian University of Traditional Chinese Medicine, Fujian, China

^#These authors contributed equally to this work

Background: Patients with severe lumbar spine diseases run a high risk of dislocation after total hip arthroplasty. Therefore, it is essential to determine the pathological effect of common lumbar diseases on pelvic motions before the surgery.

Aim: This study reviewed the literature on the hip-spine relationship during total hip arthroplasty and explored the degenerative presentations and management of four common lumbar disorders. The review showed that patients with the spinal deformity in ankylosing spondylitis (AS) were characterized by thoracolumbar kyphosis with corresponding hip extension and pelvic retroversion, prone to anterior hip dislocation; patients with lumbar spinal fusion (LSF) were more susceptible to prosthetic impingement and ultimate dislocation, especially in the limited posterior tilt of the pelvis while sitting; those with degenerative disc disease (DDD) had a greater compensatory pelvic posterior angle while standing and greater hip joint flexion while sitting to compensate for the reduced lumbar flexion; those with degenerative lumbar spondylolisthesis (DSPL) demonstrated a pelvic flexibility with a much wider range and relative acetabular anteversion, especially when standing.

Recommendation: According to the literature, spinal osteotomy and total hip arthroplasty are the most common surgical interventions in AS cases. DSPL is classified into the Flexible & Unbalanced type and should be placed more posteriorly, but the literature suggests that patients with lumbar instability should first be placed in a more predictable position. In contrast, LSF and DDD are categorized as the Rigid & Balanced type. For these two types of disorders, the literature suggests that acetabular prostheses require more anterior tilt at the time of implantation.

Conclusion: These findings indicate that for degenerative lumbar disorders, a balance between stable component implantation and minimal wear should be based on the different changes in spinopelvic mobility.

Ryan P. Hubble^1,2, Henry Wang^1,3, Paul Nagelkirk³, Jason M. Avedesian^1,4, Robert Wilkinson^1,3, D. Clark Dickin^1,3*

¹Biomechanics Laboratory, Ball State University, Muncie, IN, USA

²Wesley College of Health and Behavioral Sciences, Public and Allied Health, Delaware State University, Dover, DE, USA

³School of Kinesiology, Ball State University, Muncie, IN, USA

⁴Clemson University, Clemson, SC, USA

Plyometric training is one commonly used method of improving jump performance through improving explosive power generation. Research has also demonstrated that whole body vibration (WBV) can improve jumping and enhance explosive strength especially when supplementing resistance and plyometric training programs. With the drop jump being a common training skill, proper lower extremity landing mechanics are important to consider. Limited evidence suggests that WBV may reduce ground reaction forces and improve knee stability however, its influence on knee loading have not been reported. This study sought to examine the effects of WBV on ground reaction forces and knee valgus during a drop jump. 19 participants (10 female) completed drop jumps pre, immediately post, 10 & 20 minutes post WBV. Results were analyzed by repeated measures ANOVA. Main findings indicated that valgus knee angle increased significantly (p=0.011) post vibration and remained elevated across the 10 & 20 minute post vibration time intervals. Significant differences between sexes revealed that females demonstrated greater internal knee abduction moments (p=0.038). Findings that WBV increases knee valgus angle, a position linked to anterior cruciate ligament injury, suggest further investigation understand the effects of WBV on neuromuscular control and eccentric loading. Strength and conditioning professionals should exercise caution when incorporating WBV into plyometric protocols.

Adel A Elbeialy^1*, Abdlnby M Bauomi², Basma M Elnaggar¹, Hala M Elzomor¹

¹Department of Rheumatology, Al-Azhar faculty of Medicine, Cairo, Egypt

²Department of Radiology, Al-Azhar faculty of Medicine, Cairo, Egypt

Freddy Mertens Bombah¹*, Alphonse Ngalame², René Essomba³, Yannick Ekani Boukar², Enrique Zoa Nkoa⁴, Daniel Handy Eone⁴

¹Department of Surgery and Specialty, Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Cameroon

²Department of Gynecology and Obstetrics, Faculty of Health Sciences, University of Buea, Cameroon

³Department of Surgery and Specialty, Higher Institute of Medical Technology, University of Douala, Cameroon

⁴Department of Surgery and Specialty, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon

Introduction: Obstetric fractures or Birth fractures are rare events following childbirth. Although fracture of the femur is a relatively uncommon injury, it is the most common fracture of the lower extremity in the newborn. Since evolution of cesarean section rates in Africa, it is one of the most commonly practiced modes of delivery for breech. We described one case of fracture of the femur at cesarean section treated at Adlucem hospital in bonabéri-Douala (Cameroon).

Case report: A 2.1 kg male infant was delivered by lower segment cesarean section for breech presentation. Clinical and radiological examination showed shaft fracture of femur with good evolution.

Discussion: Fractures of the long bones are associated with cesarean section, breech delivery with assistance and low birth weight. Femoral fractures are the most associated long bones fracture with cesarean section.

Conclusion: The clinical and paraclinical diagnosis is simple and the management is mostly non-operative. It is important to explain to the parents and especially to the mother the benignity of the lesion.

Nicholas M Bertha, Adeshina Adeyemo, Kevin J Perry, Gary F Updegrove^*

Department of Bone and Joint, Penn State Milton Hershey Medical Center, Hershey, Pennsylvania, USA

Gregory W. Kunis¹*, Joshua A. Berko¹, Jeffrey C. Shogan¹, Joshua B. Sharan¹, Derek Jones²

¹Nova Southeastern University, Kiran C. Patel College of Osteopathic Medicine, Florida, USA

²Department of Orthopedic Surgery, Broward Health, Florida, USA

Intro: Tibial tuberosity avulsion fractures are rare fracture patterns accounting for less than 1% of all pediatric fractures. These fractures occur when there is a sudden unbalancing of forces through the patellar tendon that separates the tibial tubercle from the anterior portion of the proximal tibia. These forces are commonly introduced in sporting activities and show a predominance for adolescent males. Treatment with open reduction internal fixation commonly results in favorable outcomes with minimal complications. In this presentation, we explore a case of a tibial tuberosity avulsion fracture and give an in-depth review of all aspects concerning this fracture pattern.

Case Description: A 14-year-old male with no significant past medical history presented via emergency medical services after a ground level fall while playing basketball. Radiographs of the left knee and tibia revealed an Ogden Type III, distracted avulsion fracture of the tibial tuberosity with suprapatellar effusion. Surgical intervention was achieved through open reduction internal fixation of the left tibial tubercle.

Discussion: Although a relatively rare fracture pattern, this case demonstrates a classic presentation and treatment of a tibial tuberosity avulsion fracture. This case serves as a reminder that despite the rarity of the injury, a clinician with an appropriate index of suspicion can accurately diagnose and treat this fracture and achieve positive outcomes in returning the patient to pre-injury activities. For those reasons, we provide a comprehensive overview of all aspects regarding this fracture pattern including the anatomy, embryology, mechanism of action, predisposing conditions, treatment considerations, complications and associated injuries.

Spencer W. Sullivan*, Ioonna Félix

Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA

This clinical case presents an elite level 23-year-old female tennis athlete with a high-grade partial thickness tear of the supraspinatus with associated pain, dysfunction, and deficits in strength and range of motion (ROM) of her trunk and lower extremities. The purpose was to determine the efficacy of using a regional interdependence approach in the treatment of a partial supraspinatus tear with associated kinetic chain deficits in an elite level athlete. Following 24 physical therapy sessions, pain, mobility (ROM), strength, and function improved in the dominant shoulder in addition to further symmetry of the trunk and lower extremity due to a regional interdependence rehabilitation approach and returned to elite level of play. As a result of this case, it is important for clinicians to consider a comprehensive, global approach to patient rehabilitation following injury.

Jamie Heimroth^1*, Max L. Willinger¹, Nipun Sodhi¹, Luke J. Garbarino¹, Peter A. Gold¹, Jonathan R. Danoff², Sreevathsa Boraiah²

¹Department of Orthopedic Surgery, Long Island Jewish Medical Center, Queens, NY, USA

²Department of Orthopedic Surgery, North Shore University Hospital, Manhasset, NY, USA

Chronic refractory pain after total joint replacement is debilitating and a source of dissatisfaction for patients. The management of pain following total joint replacement varies during the acute postoperative period compared to the 3 months postoperative at which point the pain is considered chronic pain. Acute postoperative pain relief programs have seen promising results with multimodal pain control through the use of combinations of opioids, acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids and ketamine. The addition of regional blocks to the multimodal regimen has improved acute postoperative pain control following total joint replacements. On the other hand, chronic pain can be successfully managed with options including genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). While there is still minimal data on chronic pain relief regimens, meta-analyses and case reports have demonstrated the effectiveness and promising outcomes. This paper aims to evaluate the current medications and treatment options for managing refractory pain following TJA.