Utilising the impact of COVID-19 on trauma throughput to adapt elective care models for more efficient trauma care

BACKGROUND

Coronavirus disease 2019 (COVID-19) has necessitated adaptations in local trauma services, with implementation of novel methods of practice, strategic adaptations, and shifting of resource management. Many of these may serve the driver for landmark changes to future healthcare provision.

AIM

To analyse the impact of COVID-19 on service provision by comparing throughput and productivity metrics with preceding years to identify differences in practice that were successful, cost-effective, and sustainable.

METHODS

We quantified orthopaedic trauma care provision at a single University Teaching Hospital over a three consecutive year period, from 1^st January 2018 to 31^st December 2020. Each year was split into four phases based on the 2020 national COVID-19 pandemic periods. We quantitatively analysed change in rates of inpatient trauma operative case load, sub-specialty variation, theatre throughput, and changes in management strategy. Qualitative analysis was based on multidisciplinary team interviews to highlight changes to care pathways.

RESULTS

Of 1704 cases were admitted in 2020, 11.9% and 12.4% fewer than 2019 and 2018, respectively. During phase 1, hip fractures encompassed the majority (48.8%) of trauma throughput, with all other subspecialties seeing a reduction. Mean length of stay was shorter during phase 1 (5.7 d); however, the time in theatre was longer (144.3 min). Both, Charlson (0.90) and Elixhauser (1.55) Comorbidity Indices indicated the most co-morbid admissions during 2020 phase 1.

CONCLUSION

COVID-19 has resulted in a paradigm shift in how care is accessed and delivered, with many evolving changes and adaptations likely to leave an impression upon healthcare provision in the future.

Adjunctive platelet-rich plasma and hyaluronic acid injection after arthroscopic debridement in Kellgren-Lawrence grade 3 and 4 knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common cause of pain and disability, predominantly affecting the knee. The current management of knee OA falls short of completely stopping disease progression, particularly in Kellgren-Lawrence (KL) grade 3 and 4 knee OA. As such, joint replacement is often recommended, although only 15%-33% of candidates accept it. Alternative therapeutic options are still needed to prevent the progression of joint damage and delay the need for knee arthroplasty.

AIM

To investigate the effect of adjunctive platelet rich plasma (PRP) and hyaluronic acid (HA) after arthroscopic debridement in KL grade 3 and 4 knee OA.

METHODS

This retrospective cohort study used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and WOMAC sub-scores (pain, stiffness, and function) to assess 21 patients, grouped according to medical record data of treatment received: Arthroscopic debridement (n = 7); arthroscopic debridement with PRP (n = 7); or arthroscopic debridement with HA (n = 7). WOMAC scores and sub-scores at baseline and at 3 mo and 5 mo posttreatment were recorded. The three-group data were statistically analyzed using the tests of paired t, one-way analysis of variance, and post hoc least significant difference.

RESULTS

All three treatment groups showed significant improvements in WOMAC score and sub-scores from before treatment to 3 mo and 5 mo after treatment. However, the arthroscopic debridement with PRP treatment group, in particular, showed a significantly lower WOMAC pain score than the group who received arthroscopic debridement alone at 5 mo after the procedure (P = 0.03).

CONCLUSION

Compared to arthroscopic debridement alone, adjunctive PRP after arthroscopic debridement significantly lessened the patients’ pain symptom.

Short arm cast is as effective as long arm cast in maintaining distal radius fracture reduction: Results of the SLA-VER noninferiority trial

BACKGROUND

Distal radius fractures (DRFs) are a common challenge in orthopaedic trauma care, yet for those fractures that are treated nonoperatively, strong evidence to guide cast treatment is still lacking.

AIM

To compare the efficacy of below elbow cast (BEC) and above elbow cast (AEC) in maintaining reduction of manipulated DRFs.

METHODS

We conducted a prospective, monocentric, randomized, parallel-group, open label, blinded, noninferiority trial comparing the efficacy of BEC and AEC in the nonoperative treatment of DRFs. Two hundred and eighty patients > 18 years of age diagnosed with DRFs were successfully randomized and included for analysis over a 3-year period. Noninferiority thresholds were defined as a 2 mm difference for radial length (RL), a 3° difference for radial inclination (RI), and volar tilt (VT). The trial is registered at Clinicaltrials.gov (NCT03468023).

RESULTS

One hundred and forty-three patients were treated with BEC, and 137 were treated with AEC. The mean time of immobilization was 33 d. The mean loss of RL, RI, and VT was 1.59 mm, 2.83°, and 4.11° for BEC and 1.63 mm, 2.54°, and 3.52° for AEC, respectively. The end treatment differences between BEC and AEC in RL, RI, and VT loss were respectively 0.04 mm (95%CI: -0.36-0.44), -0.29° (95%CI: -1.03-0.45), and 0.59° (95%CI: -1.39-2.57), and they were all below the prefixed noninferiority thresholds. The rate of loss of reduction was similar.

CONCLUSION

BEC performs as well as AEC in maintaining the reduction of a manipulated DRF. Being more comfortable to patients, BEC may be preferable for nonoperative treatment of DRFs.

Consensus Delphi study on guidelines for the assessment of anterior cruciate ligament injuries in children

Background: Knee examination guidelines in minors are intended to aid decision-making in the management of knee instability. Clinical question: A Delphi study was conducted with a formal consensus process using a validated methodology with sufficient scientific evidence. A group consensus meeting was held to develop recommendations and practical guidelines for use in the assessment of instability injuries in children. Key findings: there is a lack of evidence to analyse anterior cruciate ligament injuries in children and their subsequent surgical management if necessary. Diagnostic guidelines and clinical assessment of the patient based on a thorough examination of the knee are performed and a guide to anterior cruciate ligament exploration in children is developed. Clinical application: In the absence of a strong evidence base, these established guidelines are intended to assist in that decision-making process to help the clinician decide on the most optimal treatment with the aim of benefiting the patient as much as possible. Following this expert consensus, surgical treatment is advised when the patient has a subjective sensation of instability accompanied by a pivot shift test ++, and may include an anterior drawer test + and a Lachman test +. If these conditions are not present, the conservative approach should be chosen, as the anatomical and functional development of children, together with a physiotherapy programme, may improve the evolution of the injury.

Revision anterior cruciate ligament reconstruction: Return to sports at a minimum 5-year follow-up

BACKGROUND

Between 43% and 75% of patients who undergo primary anterior cruciate ligament (ACL) surgery return to sport activity. However, after a revision ACL reconstruction (ACLR) the rate of return to sports is variable. A few publications have reported returns to sports incidence between 56% to 100% after revision ACLR.

AIM

To determine return to sports and functional outcomes after a single-stage revision ACLR with a 5-year minimum follow-up at a single institution.

METHODS

All patients operated between 2010 and 2016 with a minimum 5 years of follow-up were included. Type of sport, intensity, frequency, expectation, time to return to sport and failure rate were recorded. Lysholm, Tegner and International Knee Documentation Committee forms were evaluated prior to the first ACLR surgery, at 6 mo after primary surgery and after revision ACLR at 5 years minimum of follow-up. Objective stability was tested with the knee arthrometer test (KT-1000 knee arthrometer, Medmetric Corp).

RESULTS

A total of 41 patients who underwent revision ACLR during that period of time were contacted and available for follow-up. Median patient age at time of revision was 29 years old [interquartile range (IQR): 24.0-36.0], and 39 (95.0%) were male. The median time from revision procedure to follow-up was 70 mo (IQR: 58.0-81.0). Regarding return to sports, 16 (39.0%) were at the same level compared to preinjury period, and 25 patients (61.0%) returned at a lower level. Sixty-three percent categorized the sport as very important and 37.0% as important. One patient (2.4%) failed with a recurrent ACL torn. Mean preoperative Lysholm and subjective International Knee Documentation Committee scores were 58.8 [standard deviation (SD) 16] and 50 (SD 11), respectively. At follow-up, mean Lysholm and subjective International Knee Documentation Committee scores were 89 (SD 8) and 82 (SD 9) (P = 0.0001). Mean Tegner score prior to primary ACLR was 6.7 (SD 1.3), 5.1 (1.5 SD) prior to revision ACLR and 5.6 (1.6 SD) at follow-up (P = 0.0002). Overall, knee arthrometer test measurement showed an average of 6 mm (IQR: 4.0-6.0) side-to-side difference of displacement prior to revision ACLR and 3mm (IQR: 1.5-4.0) after revision.

CONCLUSION

Almost 40.0% of patients returned to preinjury sports level and 60.0% to a lower level. These may be useful when counseling a patient regarding sports expectations after a revision ACLR.

Histological difference in ligament flavum between degenerative lumbar canal stenosis and non-stenotic group: A prospective, comparative study

BACKGROUND

Ligament flavum (LF) hypertropy is the main etiopathogenesis of lumbar canal stenosis (LCS). The purely elastic LF undergoes a morphological adaptation including a reduction in the elastic fibers and a consequent increase in the collagen content, fibrosis, cicatrization, and calcification. However, the morphometric analysis can delineate the LF in patients with LCS from those without LCS, which would help in better understanding LCS pathogenesis.

AIM

To compare the histopathological changes in LF between the degenerative LCS and non-stenotic (non-LCS) group.

METHODS

The present prospective study was conducted in 82 patients who were divided into two groups, namely LCS and non-LCS. Demographic details of the patients such as duration of symptoms, level of involvement, and number of segments were recorded. The LF obtained from both groups was histopathologically examined for the fibrosis score, elastic fiber degeneration, calcification, and chondroid metaplasia. Morphometrical details included a change in elastin and collagen percentages, elastin/collagen ratio, elastic fiber fragmentation, and ligamentocyte numbers. All parameters were compared between the two groups by using the independent t test, Chi-square test, and Pearson’s correlation test.

RESULTS

Out of 82 cases, 74 were analysed, 34 in LCS and 40 in non-LCS group. The mean ± SD age of presentation in LCS and non- LCS group was 49.2 ± 8.9 and 43.1 ± 14.3 respectively. The LCS group (n = 34) exhibited significant differences in fibrosis (P = 0.002), elastic fiber degeneration (P = 0.01), % elastic fragmentation (66.5 ± 16.3 vs 29.5 ± 16.9), % elastic, content (26.9 ± 6.7 vs 34.7 ± 8.4), % collagen content (63.6 ± 10.4 vs 54.9 ± 6.4), reduction of elastic/collagen (0.4 ± 0.1 vs 0.6 ± 0.1), and ligamentocyte number (39.1 ± 19.1 vs 53.5 ± 26.9) as compared to non-LCS group (n = 40). The calcification (P = 0.08) and Pearson’s correlation between duration and loss of elastin was not significant. The difference in LF morphology is consistent in patient’s ≥ 40 years of age among the groups as found in subgroup analysis. Similarly in the patents < 40 and > 40 in the non-LCS group.

CONCLUSION

LF is vital in the pathogenesis of LCS. The purely elastic LF undergoes a morphological adaptation that includes a reduction in the elastic fibers with a consequent increase in the collagen content, fibrosis, cicatrization, and calcification. The present study provides a detailed morphometric analysis to semiquantitatively delineate the LF changes in patients with LCS from those in patients without LCS.

Calcium pyrophosphate dihydrate crystals in a 9-year-old with osteomyelitis of the knee: A case report

BACKGROUND

Calcium pyrophosphate dihydrate deposition disease (CPPD), or pseudogout, is an inflammatory arthritis common among elderly patients, but rarely seen in patients under the age of 40. In the rare cases presented of young patients with CPPD, genetic predisposition or related metabolic conditions were almost always identified.

CASE SUMMARY

The authors report the case of a 9-year-old boy with no past medical history who presented with acute knee pain and swelling after a cat scratch injury 5 d prior. Synovial fluid analysis identified calcium pyrophosphate dihydrate crystals. Further MRI analysis identified osteomyelitis and a small soft tissue abscess.

CONCLUSION

This case presents the extremely rare diagnostic finding of calcium pyrophosphate dihydrate crystals in a previously healthy pediatric patient. The presence of osteomyelitis presents a unique insight into the pathogenesis of these crystals in pediatric patients. More research needs to be done on the role of CPPD in pediatric arthritis and joint infection.

Evolution of evidence in spinal surgery – past, present and future Scientometric analysis of randomized controlled trials in spinal surgery

BACKGROUND

Spine surgery is evolving and in the due course of its evolution, it is useful to have a comprehensive summary of the process to have a greater understanding to refine our future directives. With the multiple domains of research in the spine, it has become difficult for a surgeon to find the potential hotspots in research or identify the emerging research frontiers.

AIM

To analyze RCTs (1990–2019) for potential research domains along with their research networks and identify the hot topics for future research.

METHODS

A comprehensive and systematic analysis of all the RCTs published on spinal surgery from 1990 to 2019 retrieved from the Web of Science Core Collection database. Scientometric and visual analysis of their characteristics, cooperation networks, keywords, and citations were made using CiteSpace software. Journal and article impact index were retrieved from Reference Citation Analysis (RCA) Database.

RESULTS

A total of 696 RCTs were published on spinal surgery from 1990 to 2019; of which, the United States (n = 263) and China (n = 71) made a significant contribution. Thomas Jefferson University (n = 16) was the leading contributor to RCTs on spinal surgery. Weinstein JN was the most cited author in the field followed by Deyo RA. Spine (n = 559) remained the top-cited journal for RCTs on spinal surgery. On literature co-citation analysis, spinal stenosis, anterior cervical discectomy and fusion, degenerative disc disease, and minimally invasive decompression were identified as the hotspots and potential research frontiers.

CONCLUSION

The identified hotspots that extending the frontiers in the management of degenerative disorders of the spine through further research holds the potential for advancement in spinal care.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review

BACKGROUND

Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions.

AIM

To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures.

METHODS

We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published.

RESULTS

Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes.

CONCLUSION

The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.

Return to work following shoulder arthroplasty: A systematic review

BACKGROUND

Many patients prioritize the ability to return to work (RTW) after shoulder replacement surgeries such as total shoulder arthroplasty (TSA), reverse TSA (rTSA), and shoulder hemiarthroplasty (HA). Due to satisfactory clinical and functional long-term outcomes, the number of shoulder replacements performed will continue to rise into this next decade. With younger individuals who compose a significant amount of the workforce receiving shoulder replacements, patients will begin to place a higher priority on their ability to RTW following shoulder arthroplasty.

AIM

To summarize RTW outcomes following TSA, rTSA, and HA, and analyze the effects of workers’ compensation status on RTW rates and ability.

METHODS

This systematic review and analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search regarding RTW following shoulder arthroplasty was performed using four databases (PubMed, Scopus, Embase, and Cochrane Library), and the Reference Citation Analysis (https://www.referencecitationanalysis.com/). All studies in English relevant to shoulder arthroplasty and RTW through January 2021 that had a level of evidence I to IV were included. Nonclinical studies, literature reviews, case reports, and those not reporting on RTW after shoulder arthroplasty were excluded.

RESULTS

The majority of patients undergoing TSA, rTSA, or HA were able to RTW between one to four months, depending on work demand stratification. While sedentary or light demand jobs generally have higher rates of RTW, moderate or heavy demand jobs tend to have poorer rates of return. The rates of RTW following TSA (71%-93%) were consistently higher than those reported for HA (69%-82%) and rTSA (56%-65%). Furthermore, workers’ compensation status negatively influenced clinical outcomes following shoulder arthroplasty. Through a pooled means analysis, we proposed guidelines for the average time to RTW after TSA, rTSA, and HA. For TSA, rTSA, and HA, the average time to RTW regardless of work demand stratification was 1.93 ± 3.74 mo, 2.3 ± 2.4 mo, and 2.29 ± 3.66 mo, respectively.

CONCLUSION

The majority of patients are able to RTW following shoulder arthroplasty. Understanding outcomes for rates of RTW following shoulder arthroplasty would assist in managing expectations in clinical practice.

Anterolateral complex of the knee: State of the art

Rotatory instability of the knee represents the main reason for failure and poor clinical outcomes regarding anterior cruciate ligament (ACL) reconstruction techniques. It is now clear that the anterolateral complex (ALC) of the knee possesses a fundamental role, in association with the ACL, in controlling internal rotation. Over the past decade, ever since the anterolateral ligament has been identified and described as a distinct structure, there has been a renewed interest in the scientific community about the whole ALC: Lateral extra-articular tenodesis have made a comeback in association with ACL reconstructions to improve functional outcomes, reducing the risks of graft failure and associated injuries. Modern ACL reconstruction surgery must therefore investigate residual instability and proceed, when necessary, to extra-articular techniques, whether functional tenodesis or anatomical reconstruction.This review aims to investigate the latest anatomical and histological descriptions, and the role in rotational control and knee biomechanics of the ALC and its components. The diagnostic tools for its identification, different reconstruction techniques, and possible surgical indications are described.. In addition, clinical and functional results available in the literature are reported.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

The present letter to the editor is a commentary on the study titled “Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents”. There is a debate over whether surgical treatment of clavicle shaft fractures improves clinical outcomes in adolescents. The readmission and reoperation rates following surgery should be identified.

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

BACKGROUND

Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines.

AIM

To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.

METHODS

We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively.

RESULTS

There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15.

CONCLUSION

All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

Social media growth of orthopaedic surgery residency programs in response to the COVID-19 pandemic

BACKGROUND

In the Spring of 2020, residency programs across the country experienced rapid and drastic changes to their application process as a result of the coronavirus disease 2019 (COVID-19) pandemic. In response, residency programs shifted to virtual events and began harnessing social media to communicate with applicants.

AIM

To analyze the changes in social media usage by orthopaedic surgery programs in response to the COVID-19 pandemic.

METHODS

Based on the 2019 residency and fellowship electronic database, accredited US orthopaedic surgery programs were reviewed for social media presence on Instagram and Twitter. Approximately 47000 tweets from 2011-2021 were extracted through the Twitter application programming interface. We extracted: Total number of followers, accounts following, tweets, likes, date of account creation, hashtags, and mentions. Natural language processing was utilized for tweet sentiment analysis and classified as positive, neutral, or negative. Instagram data was collected and deemed current as of August 11, 2021. The account foundation date analysis was based on the date recognized as the start of the COVID-19 outbreak in the United States, before or after March 1, 2020.

RESULTS

A total of 85 (42.3%) orthopaedic surgery residency program Twitter handles were identified. Thirty-five (41.2%) programs joined Twitter in the nine months after the 2020 covid outbreak. In 2020, there was a 126.6% increase in volume of tweets by orthopaedic surgery residency accounts as compared to 2019. The median number of followers was 474.5 (interquartile range 205.0-796.5). The account with the highest number of tweets was Hospital for Special Surgery (@HSpecialSurgery) with 13776 tweets followed by University of Virginia (@UVA_Ortho) with 5063 and Yale (@OrthoAtYale) with 899. Sentiment analysis before 2020 revealed 30.4% positive, 60.8% neutral, and 8.8% negative sentiments across tweets. Interestingly, the positive sentiment percentage increased in 2020 from 30.4% to 34.5%. Of the 201 ACGME-accredited orthopaedic residency programs on Fellowship and Residency Electronic Interactive Database, 115 (57.2%) participate on Instagram, with 101 (87.8%) identified as “resident”-managed vs 14 (12.2%) identified as “department”-managed. Over three quarters (77.4%) of Instagram accounts were created after March 1, 2020. The average number of followers per account was 1089.5 with an average of 58.9 total posts.

CONCLUSION

Our study demonstrates a substantial growth of Instagram and Twitter presence by orthopaedic surgery residency programs during the COVID-19 pandemic. These data suggest that orthopaedic residency programs have utilized social media as a new way to communicate with applicants and showcase their programs in light of the challenges presented by the pandemic.

Quantitative alpha-defensin testing: Is synovial fluid dilution important?

BACKGROUND

Alpha-defensin has been widely studied for the diagnosis of periprosthetic joint infection (PJI). However, there is a lack of detailed information regarding the proper laboratory technique of the enzyme-linked immunosorbent assay (ELISA) method, such as sample dilution.

AIM

To assess the influence of dilution in the synovial fluid during ELISA for the diagnosis of knee PJI; and determine which dilution presents a better performance.

METHODS

Forty samples of synovial fluid from arthroplasty knees were included, 17 in the infected group and 23 in the aseptic group, according to Musculoskeletal Infection Society criteria. Initially, five synovial fluid samples from each group were assessed for quantitative analysis of alpha-defensin using ELISA. Different dilution ratios (1:10, 1:100, 1:500, 1:1000 and 1:5000) were tested based on the predetermined cutoff value of 5.2 mg/L. The dilutions that performed better were used to compare the results of all samples.

RESULTS

For infected cases, a gradual increase in the dilution of synovial fluid samples led to an equivalent increase in alpha-defensin level. The same was not observed in the aseptic cases. Both 1:1000 and 1:5000 dilutions presented satisfactory results to differentiate infected and aseptic cases. Further analyses were performed using 1:1000 and 1:5000 for all 40 samples. The 1:1000 dilution resulted in a sensitivity of 88.2% (95%CI, 66%-98%) and specificity of 95.7% (95%CI, 79%-99%), whereas the 1:5000 dilution presented a sensitivity of 94.1% (95%CI, 73%-99%) and a specificity of 100% (95%CI, 86%-100%).

CONCLUSION

The synovial fluid dilution had an important influence on the alpha-defensin ELISA results. Dilutions of 1:5000 showed the best performance for the diagnosis of knee PJI. The results of this study set the basis for a more reliable and reproducible alpha-defensin ELISA during the investigation of PJI, contributing to the expansion of this technique in different treatment centers worldwide.

Risk modeling of femoral neck fracture based on geometric parameters of the proximal epiphysis

BACKGROUND

Fractures of the proximal femur epiphysis are problematic for state health care because they are associated with severe medical and social problems and high morbidity and mortality rates.

AIM

To model the potential risk of hip fracture via femur geometric parameters.

METHODS

Seventy educational cadaveric femurs from people aged 14 to 80 years, 10 X-ray images from the records of the Human Anatomy Department and 10 X-ray images from the Department of Traumatology, Orthopedics and Disaster Surgery of Sechenov University, were evaluated. The parameters of the fractured bone were measured using images captured with a Canon d60 camera. The projection values of the proximal epiphysis of the cadaveric femurs and geometric parameters of the bones shown in the X-ray images were measured with Autodesk software (AutoCAD 2018). Analysis of the video frames showing bone rotation reveal that the greater trochanter can be inscribed in a parallelepiped, where one of the faces is parallel to the plane of view in the frontal standard projection and is rectangular. The angle of bone rotation obtained by turning the cube corresponded to the angle measured with the second technique. This reliable method of calculating the rotation of the bone relative to the anterior projection was employed in subsequent calculations. The geometric parameters of the femur were measured using X-ray images according to the proposed method.

RESULTS

The geometric parameters of 70 femurs were analyzed, and correlation coefficients were calculated. Our measurement results were compared with those reported by other authors. The potential influence of femur geometry on force distribution in the proximal epiphysis of the femur was described, and a 2-dimensional model of the femur epiphysis associated with minimal neck fracture risk was provided. The assessment of the geometric parameters of the femoral epiphysis indicated the greatest risk of a varus fracture of the neck if the angle of the minimal resistance zone (AMRZ) index > 24° and the neck-shaft angle (NSA) < 127.5°. In contrast, the minimum risk was observed at AMRZ < 14° and NSA > 128.87°.

CONCLUSION

The proposed method provides the potential femur neck fracture risk based on geometric parameters.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis

BACKGROUND

The effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient’s ability to mobilize after the fusion is not well understood.

AIM

To see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability.

METHODS

A retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room.

RESULTS

The ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967).

CONCLUSION

Spinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

Higher cost of arthroplasty for hip fractures in patients transferred from outside hospitals vs primary emergency department presentation

BACKGROUND

In 2016 Centers for Medicare and Medicaid Services proposed bundled payments for hip fractures to improve the quality and decrease costs of care. Patients transferred from other facilities may be imposing a financial risk on the hospitals that accept these patients.

AIM

To determine the costs associated with patients that either presented to the emergency department or were transferred from another hospital or skilled nursing facility (SNF) with the diagnosis of a hip fracture requiring operative intervention.

METHODS

A retrospective single institution review was conducted for all arthroplasty patients from 2010 to 2015. Inclusion criteria included a total or partial hip replacement for a hip fracture. Exclusion criteria included pathologic, periprosthetic, and fracture non-union. Data was collected to compare total observed costs for patients from the emergency department, patients from skilled nursing facilities, and patients from an outside hospital.

RESULTS

A total of 223 patients met the inclusion criteria. 135 (60.54%) of these patients presented primarily to the emergency department, 58 patients (26.01%) were transferred from an outside hospital, and 30 patients (13.43%) were transferred from a SNF. Cost data analysis showed that outside hospital patients demonstrated significantly greater total cost for their hospitalization ($43302) compared to emergency department patients ($28875, P = 0.000) and SNF patients ($28282, P = 0.000).

CONCLUSION

Patients transferred from an outside hospital incurred greater costs for their hospitalization than patients presenting from an emergency department or SNF. This is a strong argument for risk-adjustment models when bundling payments for the care of hip fracture patients.

Bilateral hip heterotopic ossification with sciatic nerve compression on a paediatric patient–An individualized surgical approach: A case report

BACKGROUND

Neurogenic heterotopic ossification is an acquired serious complication described in patients with central nervous system disorders and defined by bone formation in non-osseous tissue.

CASE SUMMARY

We present an unusual case of a 13-yr-old boy presenting with hip pain and severe gait impairment 5 mo after the diagnosis of hemiplegia following a spontaneous intracerebral haemorrhage. Computed tomography revealed bilateral heterotopic ossification of both the paretic and the non-paretic limbs, with entrapment of the sciatic nerve. The choice of surgical or nonsurgical management of such patients depends on the timing of diagnosis, the symptoms, and the extent of maturation of the ossified lesions. Surgical resection remains the only treatment with proven, evidence-based effectiveness. The choice of surgical approach largely depends on the location of the ossified lesions.

CONCLUSION

We believe the plane of dissection presented is a satisfactory option for resection of a posteromedial mass and sciatic nerve release.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity.

AIM

To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips.

METHODS

A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1^st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson’s correlation coefficient.

RESULTS

Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips.

CONCLUSION

Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.

Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre

BACKGROUND

Despite motor-vehicle safety advancements and increasingly rigorous workplace safety regulations, trauma/suicide remains the leading cause of death under the age of 45 in the United Kingdom. To promote centralisation of care and optimisation of major trauma outcomes, in 2012 the National Health Service introduced the Trauma Network System. To our knowledge, this is the first study to analyse the epidemiology of pelvic and acetabular trauma over a one-year period at a level-1 trauma centre in the United Kingdom, since nationwide introduction of the Trauma Network System.

AIM

To characterize the epidemiology of high-energy pelvic and acetabular fractures over a one-year period at a level-1 trauma centre, and explore both resources required to care for these patients and opportunities for future research and injury prevention initiatives.

METHODS

227 consecutive patients at a level-1 trauma centre with pelvic and acetabular fractures were analysed between December 2017-December 2018. Paediatric patients (< 18 years) and fragility fractures were excluded, leaving 175 patients for inclusion in the study. Statistical analysis was performed using Fisher’s exact test for categorical variables.

RESULTS

72% of pelvic and acetabular fractures occurred in male patients at a median age of 45 years. 15% were the result of a suicide attempt. 48% of patients required pelvic or acetabular surgery, with 38% undergoing further surgery for additional orthopaedic injuries. 43% of patients were admitted to intensive care. The median inpatient stay was 13 days, and the 30- day mortality was 5%. Pelvic ring trauma was more commonly associated with abdominal injury (P = 0.01) and spine fractures (P < 0.001) than acetabular fractures. Vertical shear pelvic ring fractures were associated with falls (P = 0.03) while lateral compression fractures were associated with road traffic accidents (P = 0.01).

CONCLUSION

High energy pelvic and acetabular fractures are associated with concomitant orthopaedic fractures (most commonly spine and lower limb), intensive care admission and prolonged inpatient stays. Most pelvic ring injuries secondary to road traffic accidents are lateral compression type, demonstrating the need for future research to drive advancements in lateral impact vehicle safety along with mental health surveillance for those deemed to be potential suicide risks.

Does orthotics use improve comfort, speed and injury rate during running? Preliminary analysis of a randomised control trial

BACKGROUND

Evidence regarding the effectiveness of using orthotics in improving comfort, increasing running speed and helping to reduce injury rate during running is limited and mixed. Alongside the increasing popularity of running is the increasing rate of running-related injuries (RRIs). Further research into whether orthotics could be used to help reduce RRIs would be highly beneficial for those affected. Additionally, there is a need to clarify whether orthotics use increases comfort during running and helps improve running speed.

AIM

To investigate whether running with Aetrex Orthotics improves comfort and performance and reduces injury whilst running.

METHODS

Runners were recruited on a voluntary basis if they were 18 or older with no serious health conditions, ongoing foot pain or deformity, previous foot surgery in their lifetime or any surgery in the past 6 mo. Participants were randomly assigned to either an intervention group or a control group. All participants were asked to complete runs and provide quantitative data regarding comfort during running, running time and distance, and any RRIs over an 8-wk study period. Participants in the intervention group ran with Aetrex L700 Speed Orthotics, whilst participants in the control group ran without orthotics. Other than the addition of orthotics for participants in the intervention group, all participants were asked to run as they usually would. This report presents preliminary data from the first 47 participants recruited for this study. Running speed was calculated from running distance and time and given in miles per hour. For each outcome variable, the mean for each group, effect size and 95% confidence interval were calculated, and a t-test was performed to determine if between-group differences were statistically significant.

RESULTS

Data for all three primary outcomes was provided from a total of 254 runs by the 23 participants in the intervention group and a total of 289 runs by the 24 participants in the control group. Participants in the intervention group reported higher comfort scores (8.00 ± 1.41 vs 6.96 ± 2.03, P ≤ 0.0001), faster running speeds (6.27 ± 1.03 vs 6.00 ± 1.54, P = 0.013), and lower RRI rates (0.70 ± 1.01 vs 1.21 ± 1.53, P = 0.18) than those in the control group. These findings were statistically significant for comfort and running speed but not for RRI rate, with statistical significance considered if P < 0.05. No adjustments were made for group differences in age, gender, tendency for RRIs or usual running speed.

CONCLUSION

This preliminary report provides evidence for orthotics use in increasing comfort levels and running speed, but no significant difference in RRI rate.

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis

BACKGROUND

Rotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA.

AIM

To evaluate if a relationship exists between outcomes of RCR in the setting of GHOA.

METHODS

This was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected.

RESULTS

A total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes.

CONCLUSION

Patients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Septic arthritis of the hand: Current issues of etiology, pathogenesis, diagnosis, treatment

Septic arthritis of the hand is a serious disease that often results in dysfunction of the joint or even the need to perform amputation of the finger. They rank second in the frequency of occurrence after lesions of the knee joint. Many points concerning the etiology, the timing of the development of cartilage destruction and the development of osteomyelitis, approaches to surgical treatment, the duration of antibiotic therapy, and the start of rehabilitation measures remain the subject of numerous discussions. Based on a search in the PubMed, Web of Science and Google Scholar databases down to 1990-2021, publications on septic arthritis of the hand were found and analyzed. The following inclusion criteria were used in our review: (1) Septic arthritis of the hand; (2) Published in a peer review journal; (3) Written in English; and (4) Full text version available. Studies were excluded if they met any of the following criteria: (1) Letters; (2) Articles published in abstract form only; and (3) Cadaveric studies. Septic arthritis of the hand was characterized by the most frequent damage to the joints of the index and middle fingers (> 50% of cases). Up to 90% of cases, the infection enters the joint as a result of penetrating trauma, animal bites, etc. Staphylococcus aureus became the most frequently isolated microorganism (30%-55%), and its polyantibiotic-resistant form Methicillin-resistant Staphylococcus aureus was found, according to various sources, from 0% to 73% among all isolated Staphylococcus aureus. In arthritis, Pasteurella multocida (6%-11%) is often isolated as a result of animal bites. Articular cartilage destruction in the experiment developed within 24-48 h after infection. In clinical studies, the development of osteomyelitis was noted when treatment was delayed by more than 10 d. X-ray data during the first two weeks were uninformative. Priority of surgical treatment of septic arthritis. Drainage and surgical treatment, and with the development of osteomyelitis, the implementation of arthrodesis. Antibacterial therapy for 2-4 wk and early start of rehabilitation measures. Timely surgical treatment in combination with antibiotic therapy and rehabilitation makes it possible to obtain a positive result in the treatment of septic arthritis of the hand.

Risk of methicillin-resistant Staphylococcus aureus prosthetic joint infection in elective total hip and knee arthroplasty following eradication therapy

Re-screening following methicillin-resistant Staphylococcus aureus (MRSA) decolonization will be helpful to minimize the development of prosthetic joint infection among MRSA colonizers.

Association between tourniquet use and intraoperative blood loss during below-knee amputation

BACKGROUND

Despite over 150000 amputations of lower limbs annually, there remains a wide variation in tourniquet practice patterns and no consensus on their necessity, especially among orthopedic patient populations. The purpose of this study was to determine whether tourniquet use in orthopedic patients undergoing below knee amputation (BKA) was associated with a difference in calculated blood loss relative to no tourniquet use.

AIM

To determine if tourniquet use in orthopedic patients undergoing BKA was associated with a difference in calculated blood loss relative to no tourniquet use.

METHODS

We performed a retrospective review of consecutive patients undergoing BKA by orthopedic surgeons at a tertiary care hospital from 2008 through 2018. Blood loss was calculated using a combination of the Nadler equation for preoperative blood volume and a novel formula utilizing preoperative and postoperative hemoglobin levels and transfusions. Univariate and forwards step-wise multivariate linear regressions were performed to determine the association between tourniquet use and blood loss. A Wilcoxon was used to determine the univariate relationship between tourniquet use and blood loss for in the restricted subgroups of patients who underwent BKA for trauma, tumor, and infection.

RESULTS

Of 97 eligible patients identified, 67 underwent surgery with a tourniquet and 30 did not. In multivariate regression, tourniquet use was associated with a 488 mL decrease in calculated blood loss (CI 119-857, P = 0.01). In subgroup analysis, no individual group showed a statistically significant decrease in blood loss with tourniquet use. There was no significant association between tourniquet use and either postoperative transfusions or reoperation at one year.

CONCLUSION

We found that tourniquet use during BKA is associated with decreased calculated intraoperative blood loss. We recommend that surgeons performing this procedure use a tourniquet to minimize blood loss.

Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction has been a successful treatment for ACL rupture. However ongoing rotational instability can be an issue. Several surgical techniques have been recommended to overcome this including lateral extra-articular tenodesis (LET) and more recently anterolateral ligament reconstruction (ALLR).

AIM

To compare the clinical outcomes following ACL reconstruction (ACLR) alone or ACLR with either LET or ALLR.

METHODS

A systematic review was conducted by means of four databases (MEDLINE, EMBASE, Cochrane and Clinical.Trials.Gov), and the Reference Citaion Analysis (https://www.referencecitationanalysis.com/) to identify all studies investigating either or both of LET and ALLR. The Critical Appraisal Skills Programme checklist for cohort studies was employed for critical appraisal and evaluation of all twenty-four studies which met the inclusion criteria.

RESULTS

Pooled meta-analyses illustrated that ACLR with additional LET or ALLR results in improved pivot shift test scores, compared to isolated ACLR. There was no statistically significant difference in International Knee Documentation Committee (IKDC) clinical scores with addition of either LET or ALLR. ACL re-rupture rates were compared between LET and ALLR techniques. There was a statistically significant difference between techniques, with a 1.14% rupture rate in ACLR +ALLR, and 4.03% rupture rate in ACLR + LET. Isolated ACLR re-rupture rates were 12.59%, significantly higher than when augmented with either ALLR or LET (P < 0.0001 for both groups). There were no statistical differences in pivot shift test or IKDC scores between LET and ALLR techniques.

CONCLUSION

This meta-analysis has found that use of either LET or ALLR in addition to ACLR results in improved mechanical outcomes suggesting surgeons should consider augmenting ACLR with an extra-articular procedure in patients with rotatory instability. Furthermore, both anterolateral extra articular procedures in addition to ACLR lead to reduced ACL re-rupture rates compared to isolated ACLR. Moreover, ALLR results in reduced ACL re-rupture rates, compared to LET. More research is needed to compare the two respective extra-articular procedures.

Reducing bacterial adhesion to titanium surfaces using low intensity alternating electrical pulses

BACKGROUND

Orthopedic implant-related infection remains one of the most serious complications after orthopedic surgery. In recent years, there has been an increased scientific interest to improve prevention and treatment strategies. However, many of these strategies have focused on chemical measures.

AIM

To analyze the effect of alternating current electrical fields on bacterial adherence to titanium surfaces.

METHODS

Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) were exposed to 6.5 V electrical currents at different frequencies: 0.5 Hz, 0.1 Hz, and 0.05 Hz. After exposure, a bacterial count was then performed and compared to the control model. Other variables registered included the presence of electrocoagulation of the medium, electrode oxidation and/or corrosion, and changes in pH of the medium.

RESULTS

The most effective electrical model for reducing S. aureus adhesion was 6.5 V alternating current at 0.05 Hz achieving a 90% adhesion reduction rate. For E. coli, the 0.05 Hz frequency model also showed the most effective results with a 53% adhesion reduction rate, although these were significantly lower than S. aureus. Notable adhesion reduction rates were observed for S. aureus and E.coli in the studied conditions. However, the presence of electrode oxidation makes us presume these conditions are not optimal for in vivo use.

CONCLUSION

Although our findings suggest electrical currents may be useful in preventing bacterial adhesion to metal surfaces, further research using other electrical conditions must be examined to consider their use for in vivo trials.

Content of blood cell components, inflammatory cytokines and growth factors in autologous platelet-rich plasma obtained by various methods

BACKGROUND

The evaluation of the efficacy of platelet-rich plasma (PRP) in clinical practice yields conflicting results and raises numerous controversies. This may be due to different concentrations of biologically active components in PRP obtained with the use of different methods of gravity separation.

AIM

To compare the content, repeatability and correlations between biologically active components in PRP obtained with four different commercial systems.

METHODS

From a whole blood sample of each of 12 healthy male volunteers, 4 PRP samples were prepared using 4 different commercial kits [Arthrex Autologous Conditioned Plasma (ACP), Mini GPS III, Xerthra, Dr. PRP] in accordance with the instructions provided by the manufacturers. A comparative analysis of blood cell components - 13 selected inflammatory cytokines and 7 growth factors - in the obtained PRP samples was performed using the Kruskal-Wallis test by ranks. The repeatability of results in each method was evaluated by the estimation of the coefficient of variation. The Spearman correlation was used to estimate the relationship between blood cell content and cytokines.

RESULTS

Significantly higher concentrations of platelets (PLT), white blood cells (WBC) and red blood cells (RBC) were found in PRP obtained with the use of Mini GPS III than in PRP obtained using other systems. Significant differences in the content of growth factors and cytokines in PRP were found. A positive correlation of the amount of PLT, RBC and WBC with the concentration of most of the growth factors was found but in only three inflammatory cytokines. The obtained correlations between blood cell components and cytokines differed between the systems in terms of statistical significance, which may be due to insufficient sample size. The repeatability of the obtained PLT concentration also varied between protocols with the lowest in Xerthra and the highest in Arthrex ACP.

CONCLUSION

Significant differences in the content of biologically active components and their repeatability were found in PRP obtained by various methods, providing new data for further research.

Topical use of tranexamic acid: Are there concerns for cytotoxicity?

Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.

Hip prosthetic loosening and periprosthetic osteolysis: A commentary

Prosthetic loosening and periprosthetic osteolysis have been debated for decades, both in terms of the timing and nature of the triggering events. The hypothesis of wear-particle-induced loosening states that wear particles cause a foreign-body response leading to periprosthetic osteolysis and ultimately to late prosthetic loosening, i.e., that the osteolysis precedes the loosening. The theory of early loosening, on the other hand, postulates that the loosening is already initiated during or shortly after surgery, i.e., that the osteolysis is secondary to the loosening. This commentary focuses on the causal relationship between prosthetic loosening and periprosthetic osteolysis.

Management of hip fracture in COVID-19 infected patients

Given that the global population of elderly individuals is expanding and the difficulty of recovery, hip fractures will be a huge challenge and a critical health issue for all of humanity. Although people have spent more time at home during the coronavirus disease 2019 (COVID-19) pandemic, hip fractures show no sign of abating. Extensive studies have shown that patients with hip fracture and COVID-19 have a multifold increase in mortality compared to those uninfected and a more complex clinical condition. At present, no detailed research has systematically analyzed the relationship between these two conditions and proposed a comprehensive solution. This article aims to systematically review the impact of COVID-19 on hip fracture and provide practical suggestions. We found that hip fracture patients with COVID-19 have higher mortality rates and more complicated clinical outcomes. Indirectly, COVID-19 prevents hip fracture patients from receiving regular medical treatment. With regard to the problems we encounter, we provide clinical recommendations based on existing research evidence and a clinical flowchart for the management of hip fracture patients who are COVID-19 positive. Our study will help clinicians adequately prepare in advance when dealing with such patients and optimize treatment decisions.

Managements of osteoporotic vertebral compression fractures: A narrative review

Osteoporotic vertebral compression fractures (OVCFs) are the most common fragility fracture and significantly influence the quality of life in the elderly. Currently, the literature lacks a comprehensive narrative review of the management of OVCFs. The purpose of this study is to review background information, diagnosis, and surgical and non-surgical management of the OVCFs. A comprehensive search of PubMed and Google Scholar for articles in the English language between 1980 and 2021 was performed. Combinations of the following terms were used: compression fractures, vertebral compression fractures, osteoporosis, osteoporotic compression fractures, vertebroplasty, kyphoplasty, bisphosphonates, calcitonin, and osteoporosis treatments. Additional articles were also included by examining the reference list of articles found in the search. OVCFs, especially those that occur over long periods, can be asymptomatic. Symptoms of acute OVCFs include pain localized to the mid-line spine, a loss in height, and decreased mobility. The primary treatment regimens are pain control, medication management, vertebral augmentation, and anterior or posterior decompression and reconstructions. Pain control can be achieved with acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain or opioids and/or calcitonin for moderate to severe pain. Bisphosphonates and denosumab are the first-line treatments for osteoporosis. Vertebroplasty and kyphoplasty are reserved for patients who have not found symptomatic relief through conservative methods and are effective in achieving pain relief. Vertebroplasty is less technical and cheaper than kyphoplasty but could have more complications. Calcium and vitamin D supplementation can have a protective and therapeutic effect. Management of OVCFs must be combined with multiple approaches. Appropriate exercises and activity modification are important in fracture prevention. Medication with different mechanisms of action is a critical long-term causal treatment strategy. The minimally invasive surgical interventions such as vertebroplasty and kyphoplasty are reserved for patients not responsive to conservative therapy and are recognized as efficient stopgap treatment methods. Posterior decompression and fixation or Anterior decompression and reconstruction may be required if neurological deficits are present. The detailed pathogenesis and related targeted treatment options still need to be developed for better clinical outcomes.

Role of joint aspiration before re-implantation in patients with a cement spacer in place

BACKGROUND

The usefulness of a mandatory joint aspiration before re-implantation in patients with a cement spacer already in place is unclear.

AIM

To evaluate the role of culturing synovial fluid obtained by joint aspiration before re-implantation in patients who underwent a two-stage septic revision.

METHODS

A retrospective observational study was conducted, including patients that underwent a two-stage septic revision (hip or knee) from 2010 to 2017. After the first stage revision and according to intraoperative culture results, all patients were treated with an antibiotic protocol for 6-8 wk. Following 2 wk without antibiotics, a culture of synovial fluid was obtained. The results of these cultures were recorded and compared with cultures obtained during re-implantation surgery.

RESULTS

Forty-one patients (20 hip and 21 knee spacers) were included in the final analysis. In 39 cases, the culture of synovial fluid was negative, while in the remaining 2 cases (knee spacers) no analysis was possible due to dry tap. In 5 of the patients, two or more intraoperative cultures taken during the re-implantation surgery were positive.

CONCLUSION

We found no evidence to support mandatory joint aspiration before re-implantation in patients with a cement spacer in place.

Evaluation of artificial intelligence models for osteoarthritis of the knee using deep learning algorithms for orthopedic radiographs

BACKGROUND

Deep learning, a form of artificial intelligence, has shown promising results for interpreting radiographs. In order to develop this niche machine learning (ML) program of interpreting orthopedic radiographs with accuracy, a project named deep learning algorithm for orthopedic radiographs was conceived. In the first phase, the diagnosis of knee osteoarthritis (KOA) as per the standard Kellgren-Lawrence (KL) scale in medical images was conducted using the deep learning algorithm for orthopedic radiographs.

AIM

To compare efficacy and accuracy of eight different transfer learning deep learning models for detecting the grade of KOA from a radiograph and identify the most appropriate ML-based model for the detecting grade of KOA.

METHODS

The study was performed on 2068 radiograph exams conducted at the Department of Orthopedic Surgery, Sir HN Reliance Hospital and Research Centre (Mumbai, India) during 2019-2021. Three orthopedic surgeons reviewed these independently, graded them for the severity of KOA as per the KL scale and settled disagreement through a consensus session. Eight models, namely ResNet50, VGG-16, InceptionV3, MobilnetV2, EfficientnetB7, DenseNet201, Xception and NasNetMobile, were used to evaluate the efficacy of ML in accurately classifying radiographs for KOA as per the KL scale. Out of the 2068 images, 70% were used initially to train the model, 10% were used subsequently to test the model, and 20% were used finally to determine the accuracy of and validate each model. The idea behind transfer learning for KOA grade image classification is that if the existing models are already trained on a large and general dataset, these models will effectively serve as generic models to fulfill the study’s objectives. Finally, in order to benchmark the efficacy, the results of the models were also compared to a first-year orthopedic trainee who independently classified these models according to the KL scale.

RESULTS

Our network yielded an overall high accuracy for detecting KOA, ranging from 54% to 93%. The most successful of these was the DenseNet model, with accuracy up to 93%; interestingly, it even outperformed the human first-year trainee who had an accuracy of 74%.

CONCLUSION

The study paves the way for extrapolating the learning using ML to develop an automated KOA classification tool and enable healthcare professionals with better decision-making.

Insufficient lateral stem contact is an influencing factor for significant subsidence in cementless short stem total hip arthroplasty

BACKGROUND

Subsidence is one of the concerning early complications in cementless femoral stem. Few publications have studied the influencing factors for subsidence in short cementless stems, due to their metaphyseal anchoring without diaphyseal invasion, they might demonstrate different subsidence patterns than with the conventional stems.

AIM

To analyze the factors associated with significant subsidence in short stems, including any radiographic parameters.

METHODS

The digitized radiographs of 274 consecutive short stem total hip arthroplasties were retrospectively reviewed. Subsidence, neck-filling ratio (NFR), seating height and lateral stem contact were evaluated after a minimum of two years follow-up. A threshold of subsidence > 3 mm was considered a clinically significant migration.

RESULTS

For the entire cohort, subsidence occurred in 75 cases (27.4%) with the mean stem subsidence of 0.5 mm. (0-12.7, 1.68). Twelve hips (4.4%) had significant subsidence (> 3 mm). The univariate regression analysis demonstrated that age, diagnosis, BMI, Dorr’s type B, NFR, and seating height had no significant influence on significant subsidence, whereas insufficient lateral stem contact (≥ 1 mm) did have a statistically significant influence [Odds ratio (OR) = 5.02; 95%CI: 1.3-18.9; P = 0.017]. The multivariate regression analysis also demonstrated that insufficient lateral stem contact was a statistically significant influencing factor (OR = 5.5; 95%CI: 1.4-21.4; P = 0.014). There was no femoral stem revision for aseptic loosening in our cohort.

CONCLUSION

This study demonstrated that insufficient lateral stem contact was a statistically significant influencing factor on significant subsidence. Therefore, it is a particularly important step to create proper lateral cortical contact when performing the short stem total hip arthroplasty.

Prophylactic fixation of the unaffected contralateral side in children with slipped capital femoral epiphysis seems favorable: A systematic review

BACKGROUND

Slipped capital femoral epiphysis (SCFE) occurs in adolescents and has an incidence of around 10 per 100000 children. Children presenting with a unilateral SCFE are 2335 times more likely to develop a contralateral SCFE than the general population. Prognostic factors that have been suggested to increase the risk of contralateral slip include a younger patient, an underlying endocrine disorder, growth hormone use and a higher radiographic posterior sloping angle. However, there is still much debate on the advantages and disadvantages of prophylactic fixation of the unaffected side in an otherwise healthy patient.

AIM

To investigate the risk rate of contralateral SCFE and assess the (dis)advantages of prophylactic fixation of the contralateral hip.

METHODS

A systematic literature search was performed in the Embase, Medline, Web of Science Core Collection and Cochrane databases. Search terms included ‘slipped capital femoral epiphysis,’ ‘fixation,’ ‘contralateral,’ and derivatives. The eligibility of the acquired articles was independently assessed by the authors and additional relevant articles were included through cross-referencing. Publications were considered eligible for inclusion if they presented data about otherwise healthy children with primarily unilateral SCFE and the outcomes of prophylactically pinning their unaffected side, or about the rates of contralateral slips and complications thereof. The study quality of the included articles was assessed independently by the authors by means of the methodological index for non-randomized studies criteria.

RESULTS

Of 293 identified unique publications, we included 26 studies with a total of 12897 patients. 1762 patients (14%) developed a subsequent symptomatic contralateral slip. In addition, 38% of patients developed a subsequent slip on the contralateral side without experiencing clinical symptoms. The most outspoken advantage of prophylactic fixation of the contralateral hip in the literature is prevention of an (asymptomatic) slip, thus reducing the increased risk of avascular necrosis (AVN), cam morphology and osteoarthritis. Disadvantages include an increased risk of infection, AVN, peri-implant fractures, loss of fixation as well as migration of hardware and morphologic changes as a consequence of growth guidance. These risks, however, appeared to only occur incidentally and were usually mild compared to the risks involved with an actual SCFE.

CONCLUSION

The advantages of prophylactic pinning of the unaffected side in otherwise healthy patients with unilateral SCFE seem to outweigh the disadvantages. The final decision for treatment remains to be patient-tailored.

Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature

BACKGROUND

Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate. In the case of delayed union after antegrade or retrograde intramedullary nail fixation, fracture dynamization is often attempted first. Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies. We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.

CASE SUMMARY

A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump. Evaluation was consistent with an isolated, closed, left mid-shaft femur fracture. He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain. Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw, and dynamization by distal locking screw removal was performed. The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing. The decision was made to proceed with exchange nailing for aseptic fracture nonunion. During the exchange procedure, an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal. The obstruction required further distal reaming. A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site. Post-operative radiographs showed proper fracture and hardware alignment. There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.

CONCLUSION

The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

Coronal plane deformity around the knee in the skeletally immature population: A review of principles of evaluation and treatment

Coronal plane deformity around the knee, also known as genu varum or genu valgum, is a common finding in clinical practice for pediatricians and orthopedists. These deformities can be physiological or pathological. If untreated, pathological deformities can lead to abnormal joint loading and a consequent risk of premature osteoarthritis. The aim of this review is to provide a framework for the diagnosis and management of genu varum and genu valgum in skeletally immature patients.

Prevalence and factors of work-related musculoskeletal disorders among hand surgeons

BACKGROUND

The nature of tasks required by hand surgeons require both forceful and repetitive maneuvers, thus subjecting these surgeons to the risk of musculoskeletal (MSK) injuries during their years in practice.

AIM

To assess the prevalence, characteristics and impact of MSK disorders among hand surgeons.

METHODS

A modified version of the physical discomfort survey was sent to surgeons who were members of the American Society for Surgery of the Hand via e-mail. The collected data were analyzed using descriptive statistics, one-way analysis of variance, and Fisher's exact test. P values of < 0.05 were considered statistically significant.

RESULTS

Of the 578 respondents, 60.4% reported that they had sustained a work-related MSK injury, of which the most common diagnoses were lateral elbow epicondylitis (18.7%), low back pain (17.1%) and carpal tunnel syndrome (15.6%). Among those that reported an injury, 73.1 % required treatment and 29.2 % needed time off work as a direct result of their injury. The number of work-related injuries incurred by a surgeon increased significantly with increasing age (P < 0.003), increasing years in practice (P < 0.001) and higher case load (P < 0.05).

CONCLUSION

To our knowledge this study is the first of its kind to assess MSK injuries sustained by Hand surgeons with a high incidence. These results should increase awareness on this aspect and fuel future studies directed at preventing these types of work-related injuries, thus minimizing the financial and psychological burden on these surgeons and the healthcare system.

Anterior vertebral body tethering for idiopathic scoliosis in growing children: A systematic review

BACKGROUND

The management of idiopathic scoliosis (IS) in skeletally immature patients should aim at three-dimensional deformity correction, without compromising spinal and chest growth. In 2019, the US Food and Drug Administration approved the first instrumentation system for anterior vertebral body tethering (AVBT), under a Humanitarian Device Exception, for skeletally immature patients with curves having a Cobb angle between 35° and 65°.

AIM

To summarize current evidence about the efficacy and safety of AVBT in the management of IS in skeletally immature patients.

METHODS

From January 2014 to January 2021, Ovid Medline, Embase, Cochrane Library, Scopus, Web of Science, Google Scholar and PubMed were searched to identify relevant studies. The methodological quality of the studies was evaluated and relevant data were extracted.

RESULTS

Seven clinical trials recruiting 163 patients were included in the present review. Five studies out of seven were classified as high quality, whereas the remaining two studies were classified as moderate quality. A total of 151 of 163 AVBT procedures were performed in the thoracic spine, and the remaining 12 tethering in the lumbar spine. Only 117 of 163 (71.8%) patients had a nonprogressive curve at skeletal maturity. Twenty-three of 163 (14.11%) patients required unplanned revision surgery within the follow-up period. Conversion to posterior spinal fusion (PSF) was performed in 18 of 163 (11%) patients.

CONCLUSION

AVBT is a promising growth-friendly technique for treatment of IS in growing patients. However, it has moderate success and perioperative complications, revision and conversion to PSF.

Prosthetic joint infection of the hip and knee due to Mycobacterium species: A systematic review

BACKGROUND

Mycobacterium species (Mycobacterium sp) is an emerging cause of hip and knee prosthetic joint infection (PJI), and different species of this organism may be responsible for the same.

AIM

To evaluate the profile of hip and knee Mycobacterium PJI cases as published in the past 30 years.

METHODS

A literature search was performed in PubMed using the MeSH terms “Prosthesis joint infection” AND “Mycobacterium” for studies with publication dates from January 1, 1990, to May 30, 2021. To avoid missing any study, another search was performed with the terms “Arthroplasty infection” AND “Mycobacterium” in the same period as the previous search. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart was used to evaluate the included studies for further review. In total, 51 studies were included for further evaluation of the cases, type of pathogen, and treatment of PJI caused by Mycobacterium sp.

RESULTS

Seventeen identified Mycobacterium sp were reportedly responsible for hip/knee PJI in 115 hip/knee PJI cases, whereas in two cases there was no mention of any specific Mycobacterium sp. Mycobacterium tuberculosis (M. tuberculosis) was detected in 50/115 (43.3%) of the cases. Nontuberculous mycobacteria (NTM) included M. fortuitum (26/115, 22.6%), M. abscessus (10/115, 8.6%), M. chelonae (8/115, 6.9%), and M. bovis (8/115, 6.9%). Majority of the cases (82/114, 71.9%) had an onset of infection > 3 mo after the index surgery, while in 24.6% (28/114) the disease had an onset in ≤ 3 mo. Incidental intraoperative PJI diagnosis was made in 4 cases (3.5%). Overall, prosthesis removal was needed in 77.8% (84/108) of the cases to treat the infection. Overall infection rate was controlled in 88/102 (86.3%) patients with Mycobacterium PJI. Persistent infection occurred in 10/108 (9.8%) patients, while 4/108 (3.9%) patients died due to the infection.

CONCLUSION

At least 17 Mycobacterium sp can be responsible for hip/knee PJI. Although M. tuberculosis is the most common causal pathogen, NTM should be considered as an emerging cause of hip/knee PJI.

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.

AIM

To assess whether NSAID exposure is a risk factor for fracture nonunion in children.

METHODS

We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.

RESULTS

A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.

CONCLUSION

This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

What factors are important to new patients when selecting an orthopedic oncologist?

BACKGROUND

Understanding how patients choose a provider may improve the overall experience by identifying ways to tailor a clinical practice.

AIM

To identify factors that patients consider important when choosing an orthopedic oncologist.

METHODS

New patients presenting to an orthopedic oncology clinic within a tertiary academic medical center from January 2019 to August 2020 were invited to complete an anonymous survey. The questionnaire consisted of 27 items including a Likert-type assessment of the importance of selection factors.

RESULTS

A total of 101 new patients with a median age of 66 years (range, 14 years to 91 years) responded. Most were referred by another doctor (n = 63, 62.4%), and of the referring providers, the most frequent specialty was orthopedic surgery (n = 32, 51%). Using a Likert-type scale with 1 representing ‘least important’ and 5 representing ‘most important’, the most important factor was the hospital reputation (mean, 4.65; SD, 0.85). Additional factors of importance were the number of years in practice (3.87 ± 1.3) and a primary care provider referral (3.71 ± 1.6). Patients younger than 40 years old found social media (P = 0.016) and internet presence (P = 0.035) of their surgeon to be more important than older patients. In contrast, older patients considered care within an academic center to be of greater importance than younger patients (P = 0.014).

CONCLUSION

This investigation suggests a primary care referral, as well as hospital and physician reputation, are among the most important factors when selecting an orthopedic oncologist. Furthermore, social media utilization appears to be more important for younger patients.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Distal femur complex fractures in elderly patients treated with megaprosthesis: Results in a case series of 11 patients

BACKGROUND

Surgical treatment of complex fractures of the distal femur in the elderly is controversial. Osteoporosis and pre-existent osteoarthritis are common comorbidities in the elderly which add to the need for early walking and rapid restoration of function and also pose significant obstacles to achievement of satisfactory results with standard fixation techniques. Recently, several authors have suggested that primary arthroplasty could be a viable alternative option to standard fixation techniques in selected patients with complex distal femur fractures.

AIM

To present our experience with 11 cases of distal femur fractures treated with knee arthroplasty and large femoral resection in a population of patients over the age of 85.

METHODS

Data from 11 consecutive patients (10 females, 1 male) presenting with acute intra-articular supracondylar or intercondylar distal femur fractures and with pre-existent primary osteoarthritis who were treated with primary knee arthroplasty were recorded. We collected standard demographic data, comorbidities and patient reported outcomes including Visual Analogical Scale (VAS), Oxford Knee Score (OKS) and Barthel's Index. Post-operative joint range of motion (ROM) and standard radiographic data were also collected.

RESULTS

At a mean follow-up of 23.2 mo, all of the implants were well-positioned and osteointegrated. Furthermore, all the patients were alive and walking either independently or with walking aids. There was a marked improvement in pain (VAS 4.5 postop vs 1.9 at the last follow-up), OKS score (29.5 postop vs 36.81 at the last follow-up), ROM (96.2° postop vs 102° at the last follow-up) and restoration of pre-injury ambulatory status (average Barthel Index 77.3). The radiographic evaluations showed good restoration of the articular geometry. No deaths and no complications were recorded.

CONCLUSION

In conclusion, we believe that knee megaprosthesis in the case of complex fractures of the distal femur is a valid surgical choice. This is particularly true in elderly patients with severe osteoporosis and pre-existing osteoarthritis. It is important to note that this surgery should be performed by surgeons with proven experience in prosthetic hip and knee surgery and that a scrupulous selection of the cases is completed.

Extensive adhesion formation in a total knee replacement in the setting of a gastrointestinal stromal tumor: A case report

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare primary neoplasms of the gastrointestinal tract, accounting for 1% to 2% of all gastrointestinal neoplasms worldwide. GISTs are frequently discovered incidentally during workup for other diagnosis or intestinal obstruction, as they can present with few or no symptoms. Simultaneously, GISTs confer a high degree of malignant transformation, with a progression in about 10% to 30% of cases.

CASE SUMMARY

A 63-year-old healthy female presented to our institution with complaints of right knee pain and limited passive and active motion in the setting of a previous right total knee arthroplasty (TKA). One year after TKA, the patient was incidentally diagnosed with a GIST, which was successfully removed. After removal, the patient continued to have limited range of motion of the right knee and subsequently underwent revision TKA. Intraoperatively significant fibrotic adhesions were found encapsulating the femoral and tibial components. The patient’s pain improved postoperatively, however, she continued to have decreased range of motion with difficulty ambulating.

CONCLUSION

We propose that this case may demonstrate a proinflammatory milieu arising from a GIST, which had a direct influence on the outcome of recent total knee arthroplasty. This proposed mechanism between neoplastic cytokinetic activity and adhesion formation could have implications on preoperative and postoperative orthopedic management of total knee arthroplasty.

Comparing complications of outpatient management of slipped capital femoral epiphysis and Blount’s disease: A database study

BACKGROUND

Currents trends in pediatric orthopaedics has seen an increase in surgeries being successfully completed in an outpatient setting. Two recent examples include slipped capital femoral epiphysis (SCFE) and Blount’s disease. Surgical indications are well-studied for each pathology, but to our knowledge, there is an absence in literature analyzing safety and efficacy of inpatient vs outpatient management of either condition. We believed there would be no increase in adverse outcomes associated with outpatient treatment of either conditions.

AIM

To investigate whether outpatient surgery for SCFE and Blount’s disease is associated with increased risk of adverse outcomes.

METHODS

The 2015-2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric Registries were used to compare patient characteristics, rates of complications, and readmissions between outpatient and inpatient surgery for SCFE and Blount’s disease.

RESULTS

Total 1788 SCFE database entries were included, 30% were performed in an outpatient setting. In situ pinning was used in 98.5% of outpatient surgeries and 87.8% of inpatient surgeries (P < 0.0001). Inpatients had a greater percent of total complications than outpatients 2.57% and 1.65% respectively. Regarding Blount’s disease, outpatient surgeries constituted 41.2% of the 189 procedures included in our study. The majority of inpatients were treated with a tibial osteotomy, while the majority of outpatients had a physeal arrest (P < 0.0001). Complications were encountered in 7.4% of patients, with superficial surgical site infections and wound dehiscence being the most common. 1.6% of patients had a readmission. No differences in complication and readmission risks were found between inpatients and outpatients.

CONCLUSION

The current trend is shifting towards earlier discharges and performing procedures in an outpatient setting. This can be safely performed for a large portion of children with SCFE and Blount’s disease without increasing the risk of complications or readmissions. Osteotomies are more commonly performed in an inpatient setting where monitoring is available.

Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy?

BACKGROUND

Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.

AIM

To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.

METHODS

This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.

RESULTS

The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41).

CONCLUSION

Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.

Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion

Jones type fifth metatarsal fractures pose a challenge to the foot and ankle surgeon, given documented high nonunion rates as well as high complication rates including hardware prominence, nerve injury, and screw breakage for existing treatment modalities including screw and plantar plate fixation. We call for the design of innovative Jones-fracture specific implants which contour to the natural curve of the fifth metatarsal. Future research should aim to expand upon existing literature for Jones fracture fixation and evaluate efficacy of novel implants which are designed to address unacceptably high complication rates for existing treatment modalities.