Current Concepts in Assessment and Management of Failed Posterior Labral Repair

Recurrent posterior shoulder instability after primary repair is uncommon, but presents a challenging clinical scenario. Most revisions in failed labral repair were associated with glenoid bone morphology related to critical bone loss, retroversion, or dysplasia. A variety of treatment options exist which include revision labral repair with or without capsular plication, glenoid osteotomy, humeral rotational osteotomy, or glenoid bone augmentation. No single technique has been shown to be superior and each technique has strengths and limitations. Therefore, thoughtful evaluation and planning is critical to address each patient's individual pathology to maximize success after revision surgery.

Proximally positioned femoral grafts decrease passive anterior tibial subluxation in anterior cruciate ligament reconstruction using a posterior trans-septal portal

PURPOSE

To compare the anterior and posterior trans-septal (TS) portal approaches in anterior cruciate ligament reconstruction (ACLR) by evaluating femoral tunnel positioning and passive anterior tibial subluxation (PATS).

METHODS

A total of 205 patients who underwent primary ACLR using the outside-in technique between March 2018 and December 2021 were retrospectively enrolled. Patients were classified into two groups based on the viewing techniques: the anterior group was treated using anteromedial or anterolateral portals (n = 155), and the TS group was treated using posterior TS portal (n = 55). The relative locations of the femoral tunnel were evaluated using the deep-shallow planes (X-axis) and superior-inferior planes (Y-axis) with the quadrant method in the lateral femoral condyle on a 3-dimensional computed tomography image. Anterior tibial subluxation for the lateral and medial compartments relative to the femoral condyles was evaluated as measured on magnetic resonance imaging. Knee laxity was assessed using the pivot-shift test and stress radiography.

RESULTS

In the posterior TS group, the femoral tunnel was usually located deeper on the X-axis and more superior on the Y-axis, which corresponds to a more proximal position, than in the anterior group (deeper on the X-axis and superior on the Y-axis). Moreover, the femoral tunnel locations in this group were more compactly distributed than those in the anterior group. The TS group showed significantly better reduction of postoperative PATS in the lateral compartments than the anterior group (anterior group vs. TS group: lateral compartment, 3.2 ± 3.1 vs. 4.5 ± 3.2 mm; p = .016). Significantly better results were found in the TS group for knee stability as assessed by the pivot-shift grade (p = .044); however, there were no significant differences between the two groups with respect to patient-reported outcome measures (p > .05) and other complications (p = .090).

CONCLUSION

Our results suggest that positioning the femoral tunnel using the posterior TS portal approach may lead to better outcomes in terms of PATS and rotational stability compared to the anterior portal approach in ACLR.

Platelet Rich plasma injection of the vocal folds in benign vocal pathologies

PURPOSE

There are few options for treatment of dysphonia secondary to vocal pathology related to lamina propria scar, atrophy, sulcus, or inflammatory disorders. Platelet rich plasma (PRP) may provide anti-inflammatory and regenerative properties seen with other tissue engineering therapies without the risks associated with these treatments. We evaluated vocal fold (VF) injection of PRP for feasibility, phonatory effects, patient satisfaction and durability.

METHODS

Patients with dysphonia secondary to vocal fold scar, atrophy, sulcus and inflammatory lesions were included. PRP injections were administered in office, to bilateral vocal folds. Patients were followed up at 1 week, 1 month, 3 months and 6 months to assess outcomes (GRBAS scale, maximum phonation time, vocal fatigue index (VFI), voice handicap index (VHI-10) and stroboscopy).

RESULTS

75 intracordal PRP injections were administered to 48 patients. All injections were completed, and no adverse reactions were experienced. Improvements in VHI-10 scores at 1,3,6 months were seen (mean VHI 21.73 at baseline, 15.62 at six months, p < 0.001). 72.3% rated improvement at 7 or above on Likert scale. 95.7% of patients would consider a future PRP injection. Secondary outcomes VFI, MPT, and GRBAS also demonstrated significant improvements over time. Patients receiving a single PRP injection (n = 26) still demonstrated significant VHI-10 improvements at 1,3 and 6 months.

CONCLUSIONS

VF office PRP injections are feasible and safe and can provide phonatory benefit and reduce vocal effort in benign VF disorders. A single PRP injection is sufficient to provide sustained benefit in some cases.

LEVEL OF EVIDENCE

Level III: prospective cohort study.

Smart Glasses in Surgery: The Theatre and Beyond

AIMS & OBJECTIVES

The primary aim of this paper is to determine whether smart glasses or head-mounted displays improve efficiency in a procedural or theatre setting without compromising the quality of the procedure performed. Additionally, this paper aims to qualitatively explore applications in surgical education, whilst on-call, consulting and patient observation.

DESIGN

This paper is a systematic review of the literature available on the topic of smart glasses or head-mounted displays in surgical or procedural settings.

METHODS

A search of Pubmed, Cochrane and the Wiley Online Library was performed in accordance with the PRISMA guidelines. Procedural times and adverse outcomes were compared between the smart glass and non-smart glass groups in each of the quantitative studies. A literature review of studies, including those not satisfying the primary aim was conducted and is included in this paper.

RESULTS

32 studies were identified that complied with the inclusion criteria of this paper. 8 of these studies focused on procedural times and adverse outcomes, with and without smart glass usage. Procedural time was reduced when smart glass technology was used, without an increase in adverse patient outcomes.

CONCLUSIONS

Surgeons should consider whether the relatively short reduction in procedural time is worth the high cost, privacy issues, battery complaints and user discomfort involved with these devices. There are promising applications of this technology in the areas of surgical education and consultation. However, more trials are necessary to assess the value of using smart glasses in these settings.

The variability of MCID, SCB, PASS, and MOI thresholds for PROMs in the reverse total shoulder arthroplasty literature: a systematic review

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is a common procedure utilized to address degenerative pathologies of the glenohumeral joint and rotator cuff. Increased reliance on patient-reported outcome measures (PROMs) have placed emphasis on the utilization of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), and maximal outcome improvement (MOI) thresholds to assess the clinical efficacy of RTSA. In this study, we systematically reviewed the MCID, SCB, PASS, and MOI thresholds reported for PROMs following RTSA.

METHODS

PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar were queried for articles from January 1, 2000 to August 31, 2023 reporting MCID, SCB, PASS, or MOI values for PROMs following RTSA. Patient demographic data, study characteristics, MCID/SCB/PASS/MOI thresholds, and threshold calculation methods were extracted.

RESULTS

One hundred and forty-one articles were screened with 39 ultimately included, comprising 11,984 total patients that underwent RTSA. 34 (87%) studies reported MCID thresholds, 20 (51%) reported SCB, 5 (13%) reported PASS, and 2 (5%) reported MOI. 25/39 (64%) studies referenced a previous study when reporting MCID, SCB, PASS, or MOI values, 11 (28%) used an anchor-based method to calculate threshold values, 1 (3%) used a distribution-based method, and 2 (5%) used both anchor and distribution methods. There were 19 newly calculated MCID (11), SCB (5), PASS (1), and MOI (2) thresholds. For 5 of the 6 most utilized PROMs (ASES, SST, Constant, UCLA, and SPADI), the range of reported MCID values exceeded 50% of the most common threshold. For 3 of 6, the range of SCB values exceeded 25% of the most common threshold.

CONCLUSION

There is substantial variability in the MCID and SCB threshold values reported in the RTSA literature. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs.

The impact of ethnicity on care and outcome after hip fracture in England and Wales

Aims

To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome.

Methods

This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients' odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates.

Results

A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%).

Conclusion

Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates.

Effect of extracorporeal shock wave therapy and ultrasound-guided percutaneous lavage in reducing the pain of rotator cuff calcific tendinopathy; an updated systematic review and meta-analysis

Background

Extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous lavage (UGPL or barbotage) are among those used to treat the pain of rotator cuff calcific tendinopathy (RCCT). This meta-analysis was done to review the effect ESWT and UGPL in reducing the pain of RCCT.

Methods

A comprehensive search was done based on the PRISMA. PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar were reviewed for articles published by Feb 1, 2024, on ESWT vs. UGPL. The main keywords searched are as follows: "rotator cuff calcific tendinopathy", "tendinitis", " ESWT", " ultrasound-guided percutaneous lavage", " RCCT ″, " UGPL", " extracorporeal shock wave therapy" and titles or abstracts may contain one or a mix of these elements. This study was registered at PROSPERO with code" CRD42022385068". STATA version 13 was applied to analyze.

Results

In general, 779 patients from 22 studies were analyzed. The mean age was 51.85 ± 3.41 years. The patients were referred after 18.69 months of suffering from tendinopathy symptoms. Right-sided and supraspinatus locations were affected more. ESWT has been effective in a decrease of calcium deposit (-1.70 SMD after 1 week for ESWT, -0.96 SMD after 12 weeks for ESWT and -1.20 SMD after 12 weeks UPGL). ESWT has been effective in decreasing VAS by -4.32 SMD after 1 week while UPGL showed -0.23 SMD reductions in VAS After 1 week but in time >1 week, UPGL showed better effect by more reduction in VAS. ESWT has been effective in an increase of CMS by 1.60 SMD after 4-6 weeks, by 1.79 SMD after 12 weeks, by 2.44 SMD after 24 weeks, and 2.53 SMD after 48 weeks.

Conclusion

Based on the results, ultrasound-guided lavage is more effective in reducing pain than ESWT, and this effect becomes more evident in the long term. In terms of CMS score, over time, the efficiency of ESWT becomes more visible. In long-term follow-up, UPGL had a better effect on the calcium deposit reduction.

A robust paradigm for studying regeneration after traumatic spinal cord injury in zebrafish

BACKGROUND

Zebrafish are vertebrates with a high potential of regeneration after injury in the central nervous system. Therefore, they have emerged as a useful model system for studying traumatic spinal cord injuries.

NEW METHOD

Using larval zebrafish, we have developed a robust paradigm to model the effects of anterior spinal cord injury, which correspond to the debilitating injuries of the cervical and thoracic regions in humans. Our new paradigm consists of a more anterior injury location compared to previous studies, a modified behavioral assessment using the visual motor response, and a new data analysis code.

RESULTS

Our approach enables a spinal cord injury closer to the hindbrain with more functional impact compared to previous studies using a more posterior injury location. Results reported in this work reveal recovery over seven days following spinal cord injury.

COMPARING WITH EXISTING METHODS

The present work describes a modified paradigm for the in vivo study of spinal cord regeneration after injury using larval zebrafish, including an anterior injury location, a robust behavioral assessment, and a new data analysis software.

CONCLUSIONS

Our findings lay the foundation for applying this paradigm to study the effects of drugs, nutrition, and other treatments to improve the regeneration process.

Bearing-Related Complications of Total Hip Arthroplasty Using Fourth-Generation Ceramic-On-Ceramic Articulations: Does Articular Noise Increase Over Time?

BACKGROUND

We previously reported the mean 6-year outcomes of total hip arthroplasty (THA) using fourth-generation ceramic-on-ceramic (CoC) articulations. With extended observations, this study aimed to report the mean 12-year outcomes focusing on bearing-related complications of CoC THA.

METHODS

We reviewed primary CoC THAs performed between May 2009 and April 2012 at a single institution. Of the 831 hips (739 patients), 716 hips (635 patients) that satisfied a minimum 10-year follow-up were included. The mean age at operation was 54 years (range, 16 to 83). The occurrence of bearing-specific complications, including ceramic fractures and noise generation, was evaluated. The mean follow-up duration was 12 years (range, 10 to 14).

RESULTS

A total of 2 (0.3%) ceramic liner fractures occurred, as previously reported. No additional ceramic fractures were observed during the extended follow-up period. However, the cumulative incidence of audible noise increased from 6.4 (48 of 749) to 8.2% (59 of 716). Of the 59 hips with noise, 26 (44.1%) developed noise within 1 year, whereas 13 (22.0%) presented with noise more than 5 years after THA. The noise was described as clicking in 35 hips (4.9%) and as squeaking in 24 hips (3.4%). No revision surgeries were performed for noise, except in 2 cases of concomitant liner fractures. The implant survivorship free of any revision was 98.1% at 12 years.

CONCLUSIONS

No additional ceramic fractures were identified in this extension study at a minimum follow-up of 10 years. However, the prevalence of articular noise has increased from 6.4 to 8.2% since the previous report. Possible late-onset noise should be considered when performing CoC THA in younger patients.

Influence of base of support on early postural adjustments and fencing lunge performance

The aim of the study was to examine whether the width of the base of support (BOS) has an influence on early postural adjustments (EPA) and armed upper limb and COM kinematics during lunging. Eight elite female fencers participated in the study. The displacement of the centre of foot pressure (COP) and kinematics of centre of mass (COM) were recorded using force platforms. The kinematics of the wrist of the armed upper limb were obtained using a 3D accelerometer. The results show that EPA were characterised by a very small COP displacement (about 0.6 to 1.2 cm). The COP amplitude showed a tendency to decrease with an increase in BOS width under reaction time conditions. In contrast, a greater BOS width was associated with a significant increase in COM acceleration at foot-off and peak COM acceleration during lunging also under reaction time instructions. The kinematics of the wrist were not influenced by BOS. The results show that in elite fencers, the upper limb movement is dissociated from the whole body movement. We suppose that a small COP amplitude is a postural skill which is integrated into the lunging skill and might influence the acceleration of COM.

Outcomes of the "Calcaneo-stop" procedure for treating symptomatic flexible flatfoot in children: A systematic review and meta-analysis of 2394 feet

BACKGROUND

This study evaluates the efficacy of the calcaneo-stop (C-Stop) procedure's effectiveness in treating symptomatic flexible flatfoot (FFF) in children.

METHODS

A systematic review and meta-analysis were conducted using PubMed, Embase, and Cochrane databases to identify studies until 2023 on the outcomes of the C-Stop procedure in children with FFF. The risk of bias was assessed using MINORS criteria.

RESULTS

Of 85 studies screened, 20 involving 2394 feet from 1415 patients (mean age 11.2 ± 1.3 years) were included. Post-procedure, significant improvements were noted in pain reduction (93.5%), heel alignment (95.21%), and radiological measures, including reductions in Kite (7.32º), Meary (11.65º), Costa-Bartani angles (17.11º), talar declination (12.63º) and increase in Calcaneal Pitch Angle (5.92º). AOFAS scores increased by 22.32 points on average, with 94.83% reporting high satisfaction. Complication rate was low (7.8%).

CONCLUSIONS

The C-Stop procedure is effective for treating FFF in children, offering significant clinical, radiological, and functional improvements with high patient satisfaction and a low complication rate.

LEVEL OF EVIDENCE

Level IV, Systematic review of Level-IV studies.

Comparison of Early Postoperative Stress Distribution around Short and Tapered Wedge Stems in Femurs with Different Femoral Marrow Cavity Geometries Using Finite Element Analysis

Backgroud

In total hip arthroplasty (THA), the ideal stem length remains uncertain; different stem lengths are used in different cases or institutions. We aimed to compare the stress distributions of cementless tapered wedges and short stems in femurs with different femoral marrow geometries and determine the appropriate fit.

Methods

Finite element models were created and analyzed using HyperMesh and LS-DYNA R11.1, respectively. The 3-dimensional shape data of the femurs were extracted from computed tomography images using the RETOMO software. Femurs were divided into 3 groups based on the Dorr classification. The computer-aided design data of cementless tapered wedge-type and short stems were used to select the appropriate size. In the finite element analysis, the loading condition of the femur was assumed to be walking. Volumes of interest (VOIs) were placed within the femur model at the internal and external contact points of the stem based on Gruen zones. The average stresses and strain energy density (SED) of the elements included in each VOI were obtained from the preoperative and postoperative models.

Results

The von Mises stress and SED distributions of the cementless tapered wedge and short stems were similar in their respective Dorr classifications. In both stems, the von Mises stress and SED after THA were lower than before THA. The von Mises stress and SED of the cementless tapered wedge stem were higher than those of short stems. Cementless tapered wedge-type stems tended to have lower rates of change than short stems; however, Dorr C exhibited the opposite trend. In the Dorr classification comparison, the von Mises stress and SED were greater for both stems in the order of Dorr C > Dorr B > Dorr A, from Zone 2 to Zone 6.

Conclusions

In Dorr A and B, the short stem exhibited a natural stress distribution closer to the preoperative femur than the tapered wedge stem; however, in Dorr C, the short stem may have a greater effect on stress distribution, suggesting that it may cause greater effects, such as fracture in the early postoperative period, than other Dorr types.

A ten-year experience of musculoskeletal tuberculosis at a tertiary care hospital in South India

Background

The delayed identification and management of musculoskeletal tuberculosis (MSTB) poses substantial health challenges and leads to significant morbidity. This study aimed to collate ten years of hospital data and provide valuable insights into the clinical, diagnostics, and outcomes of the patients diagnosed with MSTB.

Methods

A retrospective study was undertaken to review clinic records from 2013 to 2022 for all individuals diagnosed with MSTB in a tertiary care hospital in South India.

Results

Over a decade, 400 cases of MSTB were diagnosed, revealing 57 % males and 43 % females with a mean age of 43.2 ± 18.9 years. Spinal TB constituted 72 % of cases, with the most common involvement of thoracic vertebrae (50.9 %). Extra-spinal MSTB accounted for 28 %, prevalent more in the pediatric age group (p < 0.05). Surgical intervention was required for 80 % of spinal TB cases and 58 % of extra-spinal MSTB cases. The average follow-up duration was two years, with 73 % completing treatment. Unfortunately, seven patients died, and three experienced relapse.

Conclusion

Spinal TB is the most common type of MSTB and is predominant in young and middle-aged adults, while extra-spinal MSTB is more frequently observed in children. Where use of MRI facilitates early detection of spinal TB; histopathological and microbiological examination confirm the diagnosis. Combining anti-tubercular drugs with modern surgical approaches is essential for obtaining favorable outcomes and improving the quality of life of such patients. It is crucial to have advanced and affordable diagnostic facilities, along with increased public awareness, to reinforce tuberculosis control strategies.

Management of Shoulder Instability in the Overhead Athletes

Overhead athletes with anterior, posterior, and multidirectional shoulder instability present with a wide range of symptoms, especially considering the injury mechanism and affected supportive structures. As such, the management of shoulder instability is widely variable and relies on rehabilitation, operative management, and sport-specific considerations, such as positional and seasonal demands on the athlete. Biomechanical analysis may further aid in the recovery process or serve as a predictive tool to identify an increased risk for injury.

Computer assisted surgical anatomy mapping (CASAM) of the distal Posterior Interosseous Nerve (PIN) and its relation to the wrist arthroscopy portals: A cadaver study

Introduction

The distal Posterior Interosseous Nerve (PIN) plays an important part in the sensory innervation of the wrist joint. Introduction of the arthroscopy portals during wrist arthroscopy might injure the PIN. The anatomic variation in the trajectory of the PIN and the proximity to the dorsal arthroscopy portals have not yet been fully explored.

Materials and methods

Computer assisted surgical anatomy mapping (CASAM) is a technique to digitally compute and merge photographic images using anatomic landmarks and visualize variation in anatomy. A standard wrist arthroscopy procedure was carried out on eight cadaver forearms. CASAM was used to map the trajectory of the distal PIN and measure the distance to bony landmarks and the nearest wrist arthroscopy portals. Descriptive statistics were provided for anatomical measurements.

Results

CASAM illustrated great variation in the PIN trajectories between the specimens. The mean distance from the PIN to Lister's tubercle was 9 ​mm (range 3-14, SD 3.9), the distance to the ulnar styloid was 27 ​mm (range 23-32, SD 3.3). None of the nerves showed signs of iatrogenic injury from placement of the arthroscopy portals. The 3-4 portal and the 6R portal were closest to the PIN with a respective mean distance of 9 ​mm (range 4-15, SD 3.8) and 19 ​mm (range 13-22, SD 3.2).

Conclusion

CASAM demonstrated the importance of understanding nerve anatomy variations and offered insight into which arthroscopy portals are most likely to damage the distal PIN. However, we conclude that the overall risk of PIN injury from wrist arthroscopy is low due to the proximity to the portals.

Injectable bioactive poly(propylene fumarate) and polycaprolactone based click chemistry bone cement for spinal fusion in rabbits

Degenerative spinal pathology is a widespread medical issue, and spine fusion surgeries are frequently performed. In this study, we fabricated an injectable bioactive click chemistry polymer cement for use in spinal fusion and bone regrowth. Taking advantages of the bioorthogonal click reaction, this cement can be crosslinked by itself eliminating the addition of a toxic initiator or catalyst, nor any external energy sources like UV light or heat. Furthermore, nano-hydroxyapatite (nHA) and microspheres carrying recombinant human bone morphogenetic protein-2 (rhBMP-2) and recombinant human vascular endothelial growth factor (rhVEGF) were used to make the cement bioactive for vascular induction and osteointegration. After implantation into a rabbit posterolateral spinal fusion (PLF) model, the cement showed excellent induction of new bone formation and bridging bone, achieving results comparable to autograft control. This is largely due to the osteogenic properties of nano-hydroxyapatite (nHA) and the released rhBMP-2 and rhVEGF growth factors. Since the availability of autograft sources is limited in clinical settings, this injectable bioactive click chemistry cement may be a promising alternative for spine fusion applications in addressing various spinal conditions.

CellKine clinical trial: first report from a phase 1 trial of allogeneic bone marrow-derived mesenchymal stem cells in subjects with painful lumbar facet joint arthropathy

Background

Lumbar facet joint arthropathy (LFJA) is a major cause of low back pain (LBP), with current treatments offering limited long-term benefits. Bone marrow-derived mesenchymal stem cells (BM-MSCs) show promise due to their immunomodulatory and trophic effects, potentially addressing underlying degenerative processes in LFJA.

Objectives

This initial report describes the outcomes of the first treated patient in an ongoing mutidisciplinary phase 1 clinical trial evaluating the safety and feasibility of intra-articular allogeneic BM-MSCs for painful LFJA.

Methods

Following enrollment in our IRB-approved protocol, symptomatic LFJA was confirmed through double blocks on L4 and L5 medial branches. Two 1-mL syringes, each containing 10 million BM-MSCs, were prepared in the cGMP facility and administered bilaterally to the patient's L4-L5 lumbar facet joints. The patient underwent standardized follow-ups, including clinical examinations and functional and imaging assessments for 2 years, utilizing patient-reported outcomes measurement information system-computer adaptive tests (PROMIS CATs), visual analogue scale, Oswestry disability index, work functional status and opioid pain medication use, and MR imaging Fenton-Czervionke score.

Results

The patient tolerated the procedure well, with no drug-related adverse events during the study period. Pain, spine function, and work functional status improved at multiple follow-ups. This patient also reported improvements in mental and social health, along with a notable improvement in the grade of facet synovitis observed at the one-year follow-up MRI evaluation.

Conclusions

This case report suggests the safety and feasibility of administering intra-articular allogeneic BM-MSCs, offering therapeutic benefits for pain management and functional activities.

Patient-Reported Outcomes and Range of Motion Following Knee Arthroplasty Using a Megaprosthesis in Non-Oncological Patients: A Systematic Review

BACKGROUND

This review aimed to determine outcomes following megaprostheses in non-oncological indications for knee arthroplasty, including range of motion (ROM) and patient-reported outcome measures of function, pain, and quality of life (QoL).

METHODS

A search of MEDLINE, Embase, and Cochrane via Ovid and PubMed between January 2003 and June 2023 was conducted. Studies reporting function, pain, ROM, and/or QoL in non-oncological patients who have received knee megaprostheses were included. Studies with sample sizes (n ≤ 5) were excluded. The risk of bias was assessed using the Downs and Black Quality Checklist for Health Care Intervention Studies. Central tendency measures (mean or median) were reported at each time point, and dispersion measures were extracted and reported whenever data were available.

RESULTS

A total of 30 studies (involving 1,294 megaprostheses) were included. Of which, 14 of 30 studies reviewed patients who had mixed indications; 14 of 30 looked at fracture only; 1 of 30 focused on distal femur nonunion; and 1 of 30 focused on patients who had periprosthetic infections. The average patient follow-up time was 40.1 months (range, 1.0 to 93.5). Most studies presented a high risk of bias (27 of 30), while a few (3 of 30) presented a low risk of bias. Improvements from preoperative baseline were observed in 85.7% of studies that reported baseline and follow-up data for function (12 of 14), 100.0% pain (4 of 4), 90.9% ROM (10 of 11), and 66.6% QoL (2 of 3).

CONCLUSIONS

Favorable function, pain, ROM, and QoL outcomes following knee megaprostheses in non-oncological patients were observed. Heterogeneity in outcome measures and follow-up periods prevented the pooling of data. Future comparative studies are warranted to enhance the body of evidence relating to knee megaprostheses in non-oncological patients.

The current standard of the shoulder trauma series in Ireland - A national audit

OBJECTIVES/AIMS

The primary aim of this study was to assess the current standard of shoulder radiographs in Ireland. The secondary aim of this study was to determine whether orthopaedic surgeons in Ireland are of the opinion that a national protocol is required, and what this protocol should consist of.

METHODS

A national audit of shoulder trauma series x-rays performed in emergency departments was conducted. The number and type of views performed was recorded. The anteroposterior (AP) and axillary or Velpeau views were assessed to determine if they met pre-defined audit criteria. Consultant orthopaedic surgeons working in public trauma hospitals were invited to participate in an online survey by email.

RESULTS

The number of shoulder trauma series included in this audit was 789. The majority of patients had two views performed (75.92%, n ​= ​599) and 21.17% (n ​= ​167) had an axillary or Velpeau view. The AP view met the audit criteria in 23.09% (n ​= ​181) of cases. The survey response rate was 70.8% (n ​= ​17). 88.2% (n ​= ​15) of surgeons agreed that three views should be performed for a shoulder trauma series and 94.12% (n ​= ​16) agreed that an axillary or Velpeau view should be included. The majority of surgeons surveyed (94%, n ​= ​16) are in favour of establishing a national protocol.

CONCLUSION

The current standard shoulder trauma series in Irish hospitals consists of two views, most frequently a thoracic AP and a scapular Y view. We propose the introduction of a national protocol consisting of three views: Grashey AP, Scapular Y, and an axillary or Velpeau view.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

Utilization of the pericapsular nerve group block in preoperative rehabilitation of patients with femoral neck fractures -a case series

BACKGROUND

Elderly patients with femoral neck fractures, particularly those with severe comorbidities or living in regions with limited medical resources, may experience delays in surgical treatment. Although the benefits of preoperative rehabilitation (prehabilitation) in hip arthroplasty have been reported, pain management remains a challenge. The pericapsular nerve group (PENG) block, known for its exceptional analgesic effect and motor function preservation, may be a promising intervention during prehabilitation in these patients.

CASE

We enrolled ten patients with Garden classification 3-4 femoral neck fractures scheduled for hip arthroplasty. After receiving a PENG block with 20 ml of 0.375% ropivacaine, all patients underwent initial prehabilitation sessions comprising 9 mobility levels, ranging from bed-sitting to walking. One patient was excluded due to experiencing high blood pressure during prehabilitation. Six of the nine remaining patients (66.7%) were successfully transferred from bed to wheelchair.

CONCLUSIONS

The PENG block enhanced prehabilitation for patients with femoral neck fractures undergoing hip arthroplasty.

Considering occupational performance during recovery of distal radius fracture: A scoping review

INTRODUCTION

Distal radius fracture (DRF) is one of the most common upper extremity fractures treated by hand therapists and can lead to chronic physical impairment and reduced occupational performance. This scoping review aimed to reveal what is currently known about occupational performance following DRF and to explore if and how occupational performance is defined and considered in the research.

METHODS

This review was guided by the PRISMA-Scoping review and the Joanna Briggs Institute (JBI) guidelines. Relevant databases were searched, and studies that addressed occupation performance in adult participants following DRF were included. The findings were summarised according to the components of occupational performance (person, occupation, and environment), and quality was measured using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three articles met the eligibility criteria for inclusion. All of the studies discussed at least two components of occupational performance, while 25 recognised all three. The consideration of occupational performance was dominated by biomechanical issues associated with the person component (i.e. range of motion, strength). There was some acknowledgement of the psychosocial aspects of the person and, to a lesser extent, the environment, as well as the impact of both on return to occupational performance.

CONCLUSION

Despite occupational performance being at the core of occupational therapy theory, its consideration within the context of research on DRF appears to be focussed on the person component of occupational performance and on biomechanical issues. Further research is recommended to determine how much this reflects current clinical practice and if a more comprehensive consideration of occupational performance will improve rates of recovery following DRF.

CONSUMER AND COMMUNITY INVOLVEMENT

As part of the protocol development for this review, consumers and stakeholders were consulted. They provided feedback on clarity and importance of the research questions.

PLAIN LANGUAGE SUMMARY

A distal radius fracture happens when you break the bone on the thumb side of your wrist. This type of injury often occurs when you fall and land on an outstretched hand. It is one of the more common injuries that hand therapists see in their practice. For some people, recovering from this fracture can take a long time and come with a lot of pain, difficulty moving, and emotional stress. These problems can make it hard to do everyday things like driving, cooking, or getting dressed. It can also affect both paid and unpaid work as well as leisure and social activities, making life more difficult for everyone involved. The findings from this review suggest that the current research usually focuses on how the body physically heals from this type of injury, but it does not pay as much attention to the emotional and social impact on healing. Also, it does not always discuss the activities that are important to the person, or the environment where they live, work, and socialise. This may show a gap in the research regarding our full comprehension of recovery from distal radius fractures. Taking a broader view and approach to recovery, considering a person's emotions, social life, environment, and daily activities, could help people recover fully and get back to their previous life routines and roles after this type of injury.

Favourable outcome of severe, unstable grade III slipped capital femoral epiphysis managed by closed reduction percutaneous pinning with mid-term follow up: A case report and literature review

INTRODUCTION AND IMPORTANCE

Slipped capital femoral epiphysis (SCFE) is one of the most common hip pathology in adolescents. Outcome of SCFE management largely depends on the grading of the pathology. Severe, unstable SCFE poses high risk for avascular necrosis (AVN). The objective of this study is to report a good outcome without AVN in an acute, unstable, high grade SCFE managed by closed reduction and percutaneous pinning along with factors that need to be given consideration.

CASE PRESENTATION

A 13 years old boy was unable to bear weight due to severe pain on right hip after trauma since 2 weeks. Patient was diagnosed with acute, unstable high grade SCFE, patient underwent closed reduction and percutaneous pinning (CRPP) using cannulated screw and K wire augmented with spica cast. At 12 weeks patient was already fully active. At 18 month follow up there was no sign of AVN with full hip range of movement.

CLINICAL DISCUSSION

Treatment for unstable, severe SCFE is still challenging. Unreduced severe slippage will deliver serious impingement and end up with early degenerative arthritis. The magnitude of reduction in a severe, unstable SCFE poses high risk for AVN. While some studies claimed reduction is justified only when it is serendipitous, we successfully and purposely performed CRPP.

CONCLUSION

Even after 2 weeks from onset, an acute and severe slippage can still be reduced closely and fixed percutaneously. The hip regain full range of motion with no sign of AVN on x ray at 18 months follow up.

Association between surgical delays for femoral neck fractures and early postoperative complications in young and middle-aged adults: A study based on the national inpatient sample database

BACKGROUND

Femoral neck fractures (FNF) in young and middle-aged adults are primarily caused by high-energy injuries in traffic accidents. Surgical delays often occur due to transportation issues, preoperative evaluations, and economic burdens.

METHODS

A retrospective analysis was conducted on young and middle-aged FNF patients undergoing reduction and internal fixation surgeries from 2010 to 2019 with the use of the National Inpatient Sample database. Logistic regression analysis was used to assess the relationship between surgical delays and complications, and the independent risk factors contributing to delays. Categorical variables were investigated via a chi-square test, while continuous variables including Elixhauser Comorbidity Index (ECI) scores, length of hospital stay (LOS), and total medical costs were analyzed via t-test or rank-sum test.

RESULTS

9,204 patients undergoing reduction and internal fixation surgeries were included. In the delayed group, patients had higher ECI scores, longer hospital stays, higher expenses, and increased inpatient mortality (1.61% vs. 0.28 %, P < 0.0001). Longer surgical delays were associated with higher risks of complications, including femoral head osteonecrosis, internal fixation loosening and breakage, and respiratory complications. Fluid and electrolyte disorders, metastatic cancer, pulmonary circulation disorders, and renal failure were identified as independent risk factors for surgical delays. Except for anemia (OR=2.37, P < 0.0001), no significant differences in early postoperative complications were found between open-reduction and closed-reduction internal fixation (ORIF/CRIF) surgeries.

CONCLUSION

Early surgical intervention, within a 2-days period after injury, seems to be crucial for young adults with FNF. If CRIF is challenging in some cases, ORIF can be another choice.

Microbiological profiles in periprosthetic joint infections after total knee arthroplasty: a comparative analysis of diabetic and non-diabetic patients

AIM OF THE STUDY

The purpose of this study is to conduct a comparative analysis of the microbiological profiles in periprosthetic joint infections (PJIs) after total knee arthroplasty (TKA) between diabetic and non-diabetic patients. The study aims to address what are the variations in microbial colonization and infection patterns between diabetic and non-diabetic patients undergoing total knee arthroplasty.

METHODS

A retrospective analysis of 2,569 culture-positive cases of PJIs post-TKA was conducted, comparing outcomes between diabetic (n = 321) and non-diabetic (n = 2,248) patients. Demographic, clinical, and microbiological data were collected and analyzed using descriptive statistics, chi-squared tests, logistic regression, and other statistical tests.

RESULTS

Diabetic patients exhibited distinct microbial colonization patterns, with a higher prevalence of pathogens such as Staphylococcus aureus (p = 0.033), Pseudomonas aeruginosa (p < 0.001), Streptococcus spp. (Streptococcus agalactiae and Streptococcus dysgalactiae; p = 0.010, 0.016 respectively), Candida spp. (p = 0.010), and Corynebacterium spp. (p = 0.024). Additionally, diabetic patients were at increased risk of polymicrobial infections. Comorbidities associated with diabetes, including chronic pulmonary disease, renal insufficiency, and peripheral artery disease, were significantly more prevalent in diabetic patients and further complicated PJI outcomes.

CONCLUSION

This study underscores the importance of tailored perioperative antimicrobial strategies and vigilant infection control measures in diabetic patients undergoing TKA. Understanding the differential microbial profiles and associated comorbidities can inform targeted interventions to mitigate the risk of PJIs and improve outcomes in this high-risk population. Further research is warranted to elucidate the underlying mechanisms and optimize management strategies for diabetic patients undergoing TKA.

Directional-Specific Modulation of Postural Control and Stepping Kinematics in Multidirectional Gait Initiation

Daily living activities present a diverse array of task and environmental constraints, highlighting the critical role of adapting gait initiation (GI) for an individual's quality of life. This study investigated the effects of GI directions, obstacle negotiation, and leg dominance on anticipatory postural adjustments and stepping kinematics. Fourteen active, young, healthy individuals participated in GI across 4 directions-forward, medial 45°, lateral 45°, and lateral 90°-with variations in obstacle presence and leg dominance. Results revealed a consistent decreasing trend in maximum center of pressure displacement, anticipatory postural adjustment duration, step distance, and swing leg velocity with lateral shifts in GI directions, yet the step duration and swing leg heel trajectory were not affected by GI directions except in lateral 90° GI. Center of pressure displacements were intricately scaled to directional propulsive forces generation, and the stepping kinematics were influenced by the directional modifications in movements. With obstacles, modifications in anticipatory postural adjustment metrics and stepping kinematics reflected the obstacle clearance movements. The dominant leg GI exhibited longer step durations and greater movement variability in medial 45° GI. The current investigation of GI factors expands our existing understanding of GI dynamics and offers valuable insights applicable to fall prevention and gait rehabilitation strategies.

Contralateral Neck-shaft Angle Lower Than 130° Is Associated With Clinical Failure in Nongeriatric Individuals: Analysis of the National Femoral Neck Fracture Database of 1066 Patients

BACKGROUND

Treatment of femoral neck fractures in patients who are nongeriatric (≤ 60 years) is challenging because of high failure rates. Anatomic parameters influence the biomechanical environment for fracture healing, but their associations with clinical prognosis remains unclear.

QUESTIONS/PURPOSES

(1) Which anatomic parameter that is identifiable on pelvic radiographs shows a statistical correlation with a higher risk of clinical failure defined as nonunion, avascular necrosis (AVN), reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference) in the screw fixation of femoral neck fractures among nongeriatric patients? (2) How does the influence of anatomic parameters on clinical prognosis manifest: directly or mediated by additional mechanisms?

METHODS

This retrospective, multicenter study used a nationwide database in China. Between January 2014 and December 2020, we evaluated 1066 patients with femoral neck fractures with a median age of 53 years (interquartile range 46 to 56) and median follow-up period of 62 months. Anatomic parameters including femoral neck-shaft angle (NSA), femoral head radius, femoral neck width, femoral offset, acetabular center-edge angle, and acetabular sharp angle were variables of interest. The primary outcome was clinical failure including nonunion, AVN, reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference). Risk factors for failure were first filtered using the Bayesian information criterion and then assessed with multiple regression adjusting for confounders. The mediation effect was further explored using model-based causal mediation analysis with a quasi-Bayesian Monte Carlo method.

RESULTS

Of all anatomic parameters we assessed, the contralateral NSA was associated with clinical failure, after adjusting for all potential covariates and confounding variables (adjusted odds ratio 0.92 [95% confidence interval 0.89 to 0.95]; p < 0.001). The optimal threshold for the NSA was 130°, with the highest Youden index of 0.27. Patients with an NSA < 130° (41% [441 of 1066]) demonstrated an increased occurrence of nonunion (15% [68 of 441] versus 5% [33 of 625]; p < 0.001), AVN (32% [141 of 441] versus 22% [136 of 625]; p < 0.001), functional failure (25% [110 of 441] versus 15% [93 of 625]), and reoperations (28% [122 of 441] versus 13% [79 of 625]). The impact of an NSA less than 130° on clinical failure was direct and substantially mediated by the type of displaced fracture (mediation proportion: 18.7%).

CONCLUSION

In our study of screw fixations for femoral neck fractures among nongeriatric patients, we identified that a contralateral NSA < 130° correlates with an increased risk of clinical failure including nonunion, AVN, functional failure, and reoperation. The effect is either direct or mediated through displaced fracture types. This is important for surgeons in order to recognize the elevated rate of clinical failure and nature of the challenging biomechanical environment, which should guide them in refining surgical details and selecting appropriate fixation and rehabilitation plans. Approaches to managing these fractures require further validation with large-scale clinical trials.

LEVEL OF EVIDENCE

Level III, prognostic study.

[Arthroplasty and oral health-an overview]

Despite limited evidence for a preoperative dental screening examination and needs-based focal rehabilitation, as well as the need for antibiotic prophylaxis prior to invasive dental procedures, oral health is and remains a relevant topic in arthroplasty. The aspect of oral health should not be neglected in the future in connection with periprosthetic infections and should continue to be the subject of intensive research. The frequency of conspicuous dental findings in middle and old age underlines the importance of this problem. A dental examination prior to arthroplasty implantation can generally contribute to minimizing the risk of arthroplasty infection. It would be desirable for further studies to provide evidence on this topic in order to make recommendations for action. Independently of this, the development of an interdisciplinary guideline (arthroplasty and dentistry) on this topic should be encouraged. This could help to ensure that standardized treatment procedures are integrated into everyday clinical practice across the board.

Prediction model for low bone mass mineral density in type 2 diabetes: an observational cross-sectional study

PURPOSE

Considering the prevalence of type 2 diabetes (T2D), osteoporosis should be considered a serious complication. However, an effective tool for the assessment of low bone mass mineral density (BMD) in T2D patients is not currently available. Therefore, the aim of our study was to establish a simple-to-use risk assessment tool by exploring risk factors for low BMD in T2D patients.

METHODS

This study included 436 patients with a low BMD and 381 patients with a normal BMD. Multiple logistic regression analysis was performed to evaluate risk factors for low BMD in T2D patients. A nomogram was then developed from these results. A receiver operating characteristic (ROC) curve, calibration plot, and goodness-of-fit test were used to validate the nomogram. The clinical utility of the nomogram was also assessed.

RESULTS

Multivariate logistic regression indicated that age, sex, education, body mass index (BMI), fasting C-peptide, high-density cholesterol (HDL), alkaline phosphatase (ALP), estimated glomerular filtration rate (eGFR), and type I collagen carboxy terminal peptide (S-CTX) were independent predictors for low BMD in T2D patients. The nomogram was developed from these variables using both the unadjusted area under the curve (AUC) and the bootstrap-corrected AUC (0.828). Calibration plots and the goodness-of-fit test demonstrated that the nomogram was well calibrated.

CONCLUSIONS

The nomogram-illustrated model can be used by clinicians to easily predict the risk of low BMD in T2D patients. Our study also revealed that common factors are independent predictors of low BMD risk. Our results provide a new strategy for the prediction, investigation, and facilitation of low BMD in T2D patients.

Development of a rocking chair for use by children with spinal cord injuries

PURPOSE

Activity-based locomotor training improves intrinsic trunk control in children with spinal cord injury (SCI). To reinforce these improvements, there is a need to develop community integration activities to allow a patient to apply the retrained nervous system at home. One activity that has been explored is rocking in a rocking chair. This paper describes the design, fabrication, and evaluation of a rocking chair for children with SCI.

MATERIALS AND METHODS

The Quality Function Deployment (QFD) design process was used. Fundamental needs and features for the rocking chair were defined in a focus group with experienced therapists, and needs were then rated for importance. A House of Quality (HOQ) matrix was developed to correlate needs with design features, and a prototype design was generated. Virtual motion studies and finite element analysis (FEA) were utilized to assess the design. The chair was fabricated and physical testing was performed, including tipping and static and dynamic load assessments.

RESULTS AND CONCLUSIONS

The needs identified through the QFD process were categorized into (1) safety, (2) therapeutic, (3) practical and aesthetic, and (4) data to track chair use. Features selected to meet these needs include safety stops, padding, straps, a stable base, armrests, adjustable footrest, and sensors to capture rocking data. FEA showed a factor of safety (FOS) > 5. Physical testing confirmed physical integrity, load-bearing capacity, and stability of the prototype glider rocking chair. The prototype provides a safe tool for further investigation of rocking for promotion of trunk muscle activation in children with SCI.

Incidence of Ipsilateral Femoral Neck and Shaft Fractures in Pediatric and Adolescent Patients

OBJECTIVES

To identify the incidence, patient characteristics, and effectiveness of radiographic screening methods for detecting ipsilateral femoral neck and shaft fractures in pediatric and adolescent trauma patients.

METHODS

DESIGN

Retrospective cohort study.

SETTING

This study was conducted at a tertiary pediatric trauma hospital.

PATIENT SELECTION CRITERIA

Patients younger than 18 years treated for a femoral shaft fracture between 2004 and 2018 were reviewed. Pathologic (metabolic bone disease or bone lesion), periprosthetic, and penetrating traumatic femoral shaft fractures were excluded.

OUTCOME MEASUREMENTS AND COMPARISONS

Patient demographics, mechanisms of injury, treatment methods, and associated injuries were analyzed. Pretreatment x-rays and computed tomography (CT) scans were reviewed for the identification of ipsilateral femoral neck and shaft fractures.

RESULTS

Among the 840 pediatric patients included in this study, 4 patients (0.5%) sustained ipsilateral femoral neck and shaft fractures. All the femoral neck fractures were observed in adolescents (aged 13-17 years) and involved in high-energy traumas. In adolescents involved in high-energy trauma, the incidence increased to 1.7%. Pretreatment sensitivity of both x-rays and CT scans was only 50% for the detection of femoral neck fractures.

CONCLUSIONS

This study reveals that ipsilateral femoral neck and shaft fractures in pediatric patients are rare, occurring in adolescents involved in high-energy trauma. The findings suggest the need for a selective, rather than routine, use of CT scans based on the patient's age and the mechanism of injury. The use of alternative imaging methods such as magnetic resonance imaging should be considered to balance diagnostic accuracy while minimizing radiation exposure.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In silico analysis of the patient-specific acetabular cup anteversion safe zone

INTRODUCTION

Various computer-assisted surgical systems claim to improve the accuracy of cup placement in total hip arthroplasties after assessing spinopelvic mobility to prevent prosthetic impingement. However, no study has yet analyzed the extent of the patient-specific cup anteversion safe zones.

HYPOTHESIS

We hypothesized that most patients have a safe zone >10 °, except those with abnormal spinopelvic mobility, who have a much narrower safe zone.

MATERIALS AND METHODS

We simulated the risks of prosthetic impingement using the planned cup anteversion. The consecutive cohort included 341 patients who underwent total hip arthroplasty. Our primary endpoint was the patient-specific impingement-free zone for cup anteversion, which was then divided into four subgroups: 0 °, 1 ° to 5 °, 6 ° to 10 °, and >10 °. This data was then secondarily analyzed for abnormal spinopelvic mobility (the difference in the spinopelvic tilt [ΔSPT] from a standing to a flexed seated position >20 °).

RESULTS

The mean anteversion safe zone was 22.8 ° with 82.4% (281/341) of patients with a zone strictly >10 °. The mean safe zone was 8.9 ° (+/- 9 °) in patients with an ΔSPT ≥20 ° (18.2%), with 37.1% of these patients having a zone of 0 °, 16.13% a zone between 1 ° and 5 °, 8.06% a zone between 6 ° and 10 ° and 38.71% a zone >10 °. The mean safe zone was 25.9 ° (+/- 9 °) in patients with an ΔSPT <20 ° (81.8%), and the proportion of cases in each zone was 2.51%, 1.08%, 4.3%, and 92.11%, respectively (p < 0.001).

CONCLUSION

The safe zone for anteversion appears to be fairly wide in most patients. However, identifying patients at risk of abnormal spinopelvic mobility seems necessary to identify the two-thirds of patients with a narrow safe zone.

LEVEL OF EVIDENCE

IV; retrospective study.

Higher high-density lipoprotein cholesterol levels increased vertebral osteoporotic fracture, but reduced hip fracture in men based on the National Health Insurance Service-National Health Screening Cohort

BACKGROUND CONTEXT

Lipids are currently known to play an important role in bone metabolism.

PURPOSE

This study aimed to investigate the effect of high-density lipoprotein cholesterol (HDL-C) on osteoporotic fractures beyond its beneficial effects on the cardiovascular system.

STUDY DESIGN/SETTING

This was a retrospective, observational study that used data from the National Health Insurance Service-Health Screening cohort database.

PATIENT SAMPLE

This study included 318,237 participants who were 50 years or older and with HDL-C levels of 10 to 200 mg/dL.

OUTCOMES MEASURES

Physiologic measure-Diagnosis of osteoporotic fracture during the follow-up period.

METHODS

The study participants were categorized into four quartiles according to baseline HDL-C levels. The Cox proportional hazards model was used to assess osteoporotic fracture risk according to HDL-C levels.

RESULTS

After full adjustment and with the Q1 group as the reference group, estimates of hazard ratios (HRs; 95% confidence intervals [CIs]) for any osteoporotic fracture in men were 1.03 (0.94-1.12), 1.02 (0.93-1.11), and 1.07 (0.98-1.18) for the Q2, Q3, and Q4 groups, respectively. After classifying osteoporotic fractures according to the body location, the fully adjusted HRs for vertebral and hip fractures in the men's Q4 groups were 1.16 (1.02-1.31) and 0.74 (0.57-0.96), respectively. In women, fully adjusted HRs (95% CIs) of the female Q4 group for any osteoporotic, vertebral, and hip fractures were 1.03 (0.95-1.11), 0.96 (0.86-1.07), and 1.06 (0.80-1.41), respectively.

CONCLUSION

In this study, HDL-C levels were positively associated with vertebral fractures in both men and women but inversely related to hip fractures in men. Therefore, monitoring the lipid profiles of patients with osteoporosis may be beneficial for the prevention of osteoporotic fractures.

Validation of mediCAD® software for fully digital preoperative planning of total hip arthroplasty: a retrospective study

INTRODUCTION

The planning step that precedes a total hip arthroplasty (THA) procedure is crucial. Digital planning software programs are being increasingly used, although few studies have reported on the reliability of such tools. Furthermore, no studies have been conducted on the mediCAD® software, despite it being widely used in France. This led us to conduct a retrospective study to: (1) assess the accuracy of this planning software, (2) determine the intra- and inter-rater reliability, (3) determine how obesity affects the accuracy of planning.

HYPOTHESIS

THA planning is accurate and reliable when using the mediCAD® software.

PATIENTS AND METHODS

This was a single center, retrospective study. One hundred one consecutive cases performed by a single experienced surgeon were planned retrospectively by two blinded surgeons on two separate occasions. The acetabular cup was cemented in 90 hips (89%), cementless in 11 hips (11%). A dual mobility cup was used in 21 hips (21%). The femoral stem was cemented in 60 hips (59%). The endpoint was the number of exact plans, defined as the same size as the actual implants. An acceptable match was defined as a difference of one size. The match was unacceptable if the planned and implanted size differed by more than 2 for the acetabular cup or by more than 1 size for the femoral stem. The intra-rater and inter-rater reliability were calculated using the intraclass correlation coefficient (ICC) with 95% confidence intervals (CI).

RESULTS

Exact agreement was found by the first rater for 15 planned acetabular cups (15%) and for 45 planned femoral stems (45%) relative to the implants used. The second rater reached exact agreement for 20 planned acetabular cups (20%) and 50 planned femoral stems (50%). The intra-rater reliability for the acetabular cup was average (ICC = 0.57; 95%CI [0.43-0.69]) and poor (ICC = 0.38 95%CI [0.20-054]) for the 1st and 2nd rater, respectively. The intra-rater reliability for the femoral stem was poor for the 1st rater (ICC = 0.47 95%CI [0.30-0.61]) and the 2nd rater (ICC = 0.45 95%CI [0.29-0.60]). The interobserver reliability was low for the planned acetabular cup (ICC = 0.39 95%CI [0.21-0.54]) and the planned femoral stem (ICC = 0.42 95%CI [0.24-0.57]). Overall, when combining the two raters, exact prediction of the acetabular cup was achieved in 31 hips (19%) in non-obese patients and in 7 hips (21%) in obese patients (p = 0.62).

DISCUSSION

This study found acceptable reliability of the mediCAD® software. Experience level, radiograph magnification affected the planning outcome in this study, but obesity did not. We currently do not have the ability to incorporate a reliable radiological scale for two-dimensional templating. Some surgeons prefer using a CT scan, but this costs more than conventional radiographs and exposes the patient to more radiation. This study shows that the mediCAD® software can provide satisfactory output for the preoperative planning of THA.

LEVEL OF EVIDENCE

III; retrospective, diagnostic, comparative study.

Step-cut osteotomy for cubitus varus deformity with application of patient-specific instrument in children: a preliminary report

PURPOSE

The step-cut osteotomy has been recognized as a valuable approach for addressing cubitus varus deformity, albeit one that necessitates technical proficiency. This study aims to evaluate the efficacy of the modified step-cut osteotomy technique in conjunction with patient-specific instruments by clinical and radiological assessment.

METHODS

We conducted a retrospective review of patients who underwent modified step-cut osteotomy with the use of patient-specific instruments in conjunction with Kirschner wires fixation for the correction of cubitus varus deformity between April 2016 and April 2022. Follow-up was performed for a minimum of two years, during which pre-operative and post-operative clinical and radiological parameters were compared.

RESULTS

Fifteen patients were enrolled in this study. The mean pre-operative humeral-elbow-wrist (HEW) of the affected side was -21.7° (ranging from -14° to -34°), while the normal side was 9.4° (ranging from 5° to 15°). The post-operation HEW of affected side was 9° (ranging from 4° to 16°). There was no significant difference between the normal side and affected side after operation (p = 0.74). Pre-operative range of motion in the affected side was 130°, while the post-operative range of motion was 132°. Fourteen patients (93.3%) were pleased with the overall appearance of their elbow. None lazy-S deformity was observed in these cases. There were no major complications.

CONCLUSION

The modified step-cut osteotomy technique, utilizing patient-specific instrument in conjunction with Kirschner wires fixation was found to be a safe, reliable, and technically easy procedure for correcting cubitus varus deformity.

Bodyweight influences the relationship between serum testosterone and bone mineral density in men with spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To examine the association between serum testosterone levels (T levels) and bone mineral density after spinal cord injury (SCI).

SETTING

Medical research center.

METHODS

Body composition assessments were measured in 53 men with chronic SCI. Serum T levels were measured after an overnight fast. Total and regional bone mineral density (BMD) and bone mineral content (BMC) were measured using dual-energy X-ray absorptiometry. Participants were classified into three groups based on their body weight [<65 kg, 65-80 kg, >80 kg] or serum T levels into low (400 ng/dl), mid-normal (401-544 ng/dl) and normal (>545 ng/dl) ranges.

RESULTS

Serum T level was negatively related to body weight (r = -0.33, P = 0.016), fat mass (r = -0.46, P < 0.001) and percentage fat mass (r = -0.48, P < 0.001). There were no significant relationships between serum T levels and any of the bone health measurements. Body weight was related to total, regional (P < 0.01 for both) and knee BMD (P < 0.05). T level was only related to total and regional BMD in the group with body weight of 65-80 kg.

CONCLUSION

Testosterone has no direct relationship with BMD except within a specific weight group. However, body weight or fat mass negatively influences circulating T levels in men with SCI. The relationship between serum T levels and BMD is mediated by body weight in men with SCI.

Enhancing recovery: surgical techniques and rehabilitation strategies after direct anterior hip arthroplasty

Total hip arthroplasty (THA) is a common surgical procedure for hip joint pathologies, with the direct anterior approach (DAA) gaining popularity due to potential benefits in postoperative recovery. This review aims to provide a comprehensive analysis of rehabilitation strategies following DAA THA, focusing on surgical techniques, postoperative care, and outcomes. The evolution of the DAA to THA is discussed, highlighting historical advancements and comparisons with other surgical approaches. Surgical techniques and considerations specific to the DAA are detailed, including outcomes and complications compared to alternative approaches. The role of the surgical technique in influencing postoperative rehabilitation is explored, emphasizing the importance of optimizing surgical procedures for enhanced recovery. Postoperative care and rehabilitation models following DAA THA are examined, with a focus on the impacts of different rehabilitation protocols on patient outcomes. The review underscores the significance of tailored rehabilitation programs in promoting optimal recovery and patient satisfaction. Current evidence from recent studies, meta-analyses, and clinical trials is critically analyzed to provide insights into the effectiveness of postoperative rehabilitation strategies. The review identifies gaps in the existing literature and proposes recommendations for future research to improve rehabilitation protocols and enhance outcomes. In conclusion, this review highlights the importance of postoperative rehabilitation in the context of DAA THA. By synthesizing historical perspectives, current evidence, and future directions, the review offers a comprehensive understanding of rehabilitation strategies following DAA THA. The findings underscore the need for personalized rehabilitation programs and ongoing research to optimize postoperative recovery and improve outcomes in the field of THA.

Evaluation of the efficacy after Total Knee Arthroplasty by Gait analysis in patients with Knee Osteoarthritis: a meta-analysis

BACKGROUND

Total knee replacement (TKA) is a frequent modality performed in patients with knee osteoarthritis (OA). The aim of this study was to perform a meta-analysis and systematic review to evaluate the efficacy after TKA by gait analysis in patients with OA.

METHODS

PubMed, EMBASE, the Cochrane library, and Web of Science were searched for relevant studies from inception to July 2024. STATA SE 14.0 software was used for statistical analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guideline.

RESULTS

A total of 2525 reports were identified with 24 studies meeting pre-designed inclusion criteria. Several gait parameters were investigated. In patients with knee OA after TKA, there existed an increase in the Max knee flexion (WMD, 3.12; 95% CI, 0.93 to 5.32; I2 = 73.9%, P < 0.001), the Cadence (WMD, 4.05; 95% CI, 2.28 to 5.82; I2 = 48.9%, P = 0.068), the stride length (WMD, 0.05; 95% CI, 0.01 to 0.09; I2 = 77.1%, P < 0.001), the walking speed (WMD, 0.08; 95% CI, 0.02 to 0.14; I2 = 93.3%, P < 0.001), and the step length (WMD, 0.04; 95% CI, 0.00 to 0.07; I2 = 89.3%, P < 0.001) while a decrease in the double support time (WMD, -0.04; 95% CI, - 0.08 to -0.01; I2 = 0.0%, P = 0.585). Besides, no statistically significant differences were observed in the Knee range of motion (ROM), the Max knee rotation at stance phase, the Max knee extension, the step width, the stride time and the step time. Sensitivity analysis showed that all the results were robust.

CONCLUSIONS

In summary, the study found that, in patients with knee OA undergoing TKA may have great effects on improving gait parameters. If there are more high-quality studies in the future, we should make a more comprehensive evaluation of walking function by gait analysis together with other evaluation systems such as muscle strength and proprioception measurement.

The evolution and integration of technology in spinal neurosurgery: A scoping review

Spinal disorders pose a significant global health challenge, affecting nearly 5% of the population and incurring substantial socioeconomic costs. Over time, spinal neurosurgery has evolved from basic 19th-century techniques to today's minimally invasive procedures. The recent integration of technologies such as robotic assistance and advanced imaging has not only improved precision but also reshaped treatment paradigms. This review explores key innovations in imaging, biomaterials, and emerging fields such as AI, examining how they address long-standing challenges in spinal care, including enhancing surgical accuracy and promoting tissue regeneration. Are we at the threshold of a new era in healthcare technology, or are these innovations merely enhancements that may not fundamentally advance clinical care? We aim to answer this question by offering a concise introduction to each technology and discussing in depth its status and challenges, providing readers with a clearer understanding of its actual potential to revolutionize surgical practices.

Patient-Reported and Economic Racial and Ethnic Disparities in Patients with Psoriatic Arthritis: Results from the National Health and Wellness Survey

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic, autoimmune form of arthritis that is associated with a substantial humanistic and economic burden. Potential differences in patient-reported outcomes (PROs) and economic outcomes among groups of varying PsA severity and different races/ethnicities have not been well studied.

METHODS

This cross-sectional study assessed sociodemographic data, PROs, and economic outcomes for participants with PsA from the National Health and Wellness Survey (2018-2020). Multivariable analyses were used to assess the association of self-reported PsA severity and race/ethnicity with health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), healthcare resource utilization (HCRU), and medical costs.

RESULTS

This study included 1544 participants with PsA (1073 non-Hispanic white, 114 non-Hispanic Black, 223 Hispanic, and 134 Other). Self-reported moderate/severe PsA was associated with significantly worse HRQoL and WPAI, greater HCRU, and higher costs than self-reported mild PsA. Black participants reported more absenteeism (31.11% vs. 16.69%; P = 0.007) and activity impairment (54.27% vs. 47.96%; P = 0.047) than white participants, and fewer healthcare provider (5.93 vs. 7.42; P = 0.039) and rheumatologist visits (0.29 vs. 0.53; P = 0.028) over the past 6 months. No differences in outcomes were observed between Hispanic and white participants. Race/ethnicity moderated the association of perceived PsA severity and PROs and HCRU, such that white participants with self-reported moderate/severe PsA had a higher likelihood of depression (P < 0.001), lower HRQoL (P < 0.001), and more emergency room visits (P = 0.001) than those with self-reported mild PsA. Race/ethnicity did not moderate the relationship of PROs, HCRU, and economic outcomes among Black or Hispanic participants.

CONCLUSION

Participants with self-reported moderate/severe PsA reported a greater burden than those with self-reported mild PsA. Black participants had a greater humanistic burden than white participants but reported lower HCRU. Moderation results were driven by white participants, suggesting important differences in PROs, HCRU, and perception of PsA severity across race/ethnicity groups. Small sample sizes in Hispanic and non-Hispanic racial/ethnic groups limited ability to discern differences related to disease severity in these groups. Further research is needed to better understand the differential burden of PsA among individuals with varying perceptions of PsA severity across different racial/ethnic groups.

Borderline Hip Dysplasia - Best Treated with Hip Arthroscopy or Periacetabular Osteotomy?

PURPOSE OF REVIEW

As the field of hip preservation evolves, the diagnosis of borderline dysplasia (defined as a lateral center edge angle between 18°-25°) has shown itself to be one of the more challenging diagnoses to treat. As the nuances of acetabular coverage have come to light, the question of whether borderline hip dysplasia is best treated with isolated hip arthroscopy, periacetabular osteotomy, or whether a combined procedure is best, is now top of mind. The goal of these procedures is to not only improve patient symptoms, but to correct underlying pathology and ideally slow the development of hip osteoarthritis. The purpose of this review is to summarize the recent literature and clinical findings regarding both isolated hip arthroscopy and periacetabular osteotomy in the surgical management of borderline hip dysplasia.

RECENT FINDINGS

Current research demonstrates improved postoperative clinical outcome scores for both patients who had isolated hip arthroscopy in the setting of borderline hip dysplasia and for those patients who underwent periacetabular osteotomy. Mid-term outcomes for patients in both groups have showed low rates of conversion to total hip arthroplasty. No gold standard in the surgical management of borderline hip arthroscopy exists. Improved clinical outcomes have been seen postoperatively in patients who undergo hip arthroscopy and in patients who undergo periacetabular osteotomy. Successful clinical outcomes seem to rely on treatment of the underlying clinical pathology and are largely based on the appropriate surgical indications and appropriate surgical techniques. Surgical decision making in this patient population should be individualized based on a comprehensive evaluation of the patient.

Platelet Lysate and Osteoarthritis of the Knee: A Review of Current Clinical Evidence

INTRODUCTION

Osteoarthritis (OA) of the knee affects millions of people with sizable socioeconomic burden. Conventional treatment modalities are prioritized, turning to surgical intervention only when they have failed. However, these traditional modalities have shortcomings, only aiming to reduce pain rather than targeting the underlying pathophysiology. Recently, the use of biologics, including autologous peripheral blood-derived orthobiologics (APBOs), has increased and demonstrated great promise for the management of knee OA. Platelet-rich plasma (PRP) is the most widely used APBO, but its efficacy is still uncertain, attributed to lack of standardized formulation protocols, characterization, and patient variables. To overcome the limitations posed by PRP, the use of other APBOs such as platelet lysate (PL) has been considered. This review summarizes the outcomes of clinical studies involving PL to manage OA of the knee.

METHODS

Multiple databases (Scopus, Embase, PubMed, and Web of Science) were searched employing terms "platelet lysate" and "knee osteoarthritis" for articles published in the English language to August 15, 2024, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Only three clinical studies fulfilled our search and inclusion criteria. Intra-articular injection of three doses of PL injected every 3-4 weeks is safe and efficacious, resulting in statistically significant improvements in different patient-reported outcome measures at 6-12 months follow-up.

CONCLUSION

The existing published peer-reviewed literature suggests that intra-articular injection of PL is safe and can decrease pain and increase function in patients with knee OA. Nonetheless, given the dearth of pertinent literature, more adequately powered, multicenter, prospective, non-randomized and randomized controlled studies with extended follow-up are needed to confirm the effectiveness of PL in knee OA. Further comparative studies to help clinicians in choosing the best APBO for knee OA treatment are also warranted.

MRI findings and classification of brucella spondylitis: a China multicenter study

OBJECTIVES

To propose a magnetic resonance imaging (MRI) classification of brucellosis spondylitis (BS) to determine a standard treatment method and a standard of post-treatment MRI follow-up.

METHODS

This is a multicenter retrospective cohort study. All patients diagnosed with BS at six hospitals for 12 years, were included in the study. Data were collected retrospectively from the medical records of the patients. The classification of the cases was based on MRI. We analyzed MRI features of BS was categorized them into three types.

RESULTS

Six hundred fifteen patients were included in the study, 78.9% of whom were males. The mean age was 53.05 ± 11.06 years. Involvement of single vertebrae occurred in 6.2% of patients, while 72.7% involved two vertebrae and 21.1% involvement of more than two vertebrae. The most common of the lumbar spine was 64.6%. The main findings of MRI were affected vertebral endplate 2/3 above (60.7%), intervertebral space narrow (77.9%), intervertebral disc involvement (83.6%), paravertebral abscess (50.9%), disc abscess (49.6%), epidural abscess (43.3%), vertebra height change (22.1%), psoas abscess (22.0%), and abnormal vertebral accessory (10.2%). MR imaging of BS was categorized into three types. Type I: 57 (9.3%) patients; Type II: 526 (85.5%) patients, including IIa (26.5%), IIb (36.9%), and IIc (22.1%); Type IV: vertebral appendage type, 63 (10.2%) cases; Type III: 32 (5.2%) patients.

CONCLUSIONS

MRI features of multicenter data can provide theoretical support for diagnosing BS. MRI classification of BS can afford better help for clinical treatment and follow-up after clinical treatment.

Pharmacological management of secondary chronic spinal cord injury: a systematic review

INTRODUCTION

Spinal cord injury (SCI) may bring lifelong consequences for affected patients and a high financial burden to the health care system.

SOURCE OF DATA

Published peer-reviewed scientific articles identified from EMBASE, Google Scholar, PubMed and Scopus.

AREAS OF AGREEMENT

Surgery and blood pressure management are the main targets in acute SCI to avoid secondary damage.

AREAS OF CONTROVERSY

The management of secondary chronic SCI is challenging, with unpredictable outcomes.

GROWING POINTS

Given the lack of consensus on pharmacological therapy for acute and secondary chronic SCI, the present study analyses the currently available drugs and treatment options to manage secondary chronic SCI.

AREAS TIMELY FOR DEVELOPING RESEARCH

Different approaches exist for the pharmacological management of secondary chronic SCI. One of the most investigated drugs, 4-aminopyridine, improves central motor conduction and shows improvement in neurological signs. Positive results in different areas have been observed in patients receiving the anti-spastic drugs tizanidine and baclofen or Granulocyte colony-stimulating factor. Growth hormone showed only minimal or no significant effects, and the therapy of secondary chronic SCI with riluzole has been poorly researched to date.

Multiple fractures of the femur: Case report, literature review, and proposal for a shared algorithm of treatment

Multiple fractures of the femur, defined for the purposes of this study as the association of three or more non-contiguous fractures on the same bone segment, is an exceedingly rare condition with an unknown incidence in the literature. A limited number of studies, mainly consisting of case reports or small case series, have addressed this topic, and no shared consensus or guidelines exist on what the ideal timing and sequence of multiple fracture fixation is. The present paper reports the clinical case of a 36 years old man who sustained a blunt chest injury, a non-concussive head injury, a displaced intracapsular fracture of the left femur (AO 31B2), a left diaphyseal multifragmentary fracture (AO 32B3), a supradiacondylar fracture of the distal end of the left femur (AO 33C1.1), a Hoffa fracture of the lateral left femoral condyle (AO 33B3.2 f), and a multifragmentary fracture of the left patella with bone loss (AO 34C3) due to a vehicular high-energy trauma. The patient was surgically treated by open reduction and internal fixation according to a proposed algorithm of treatment and reported excellent clinical and radiological outcomes at 32 months follow-up. The primary aim of this study is to describe our experience in the treatment of such complex fractures, by presenting our clinical and radiological results, and to propose a treatment algorithm. The secondary aim is to provide a comprehensive review of the literature on this topic.

The feasibility and safety of ultrasound-guided puncture for treatment of septic arthritis in children

BACKGROUND

In septic arthritis, joint lavage can be performed using arthrocentesis (articular needle aspiration) or arthrotomy. The use of fluoroscopy to guide the puncture involves radiation. Ultrasound (US) guidance is still little recommended to guide the treatment of septic arthritis in children. We wanted to know whether treating septic arthritis in children was feasible and safe under ultrasound (US) guidance.

METHODS

We retrospectively included 67 children (mean age, 3.0 years; range: 1 month-12 years) treated for septic arthritis of the hip, shoulder, or ankle using arthrocentesis or arthrotomy under US or fluoroscopic guidance (non-US group) with at least two years of follow-up.

RESULTS

We found no significant difference between the groups. After arthrocentesis, patients in the US group remained in hospital for 0.8 days longer than those in the non-US group, but the difference was not significant. After arthrotomy, the arthrotomy-US group required 0.4 more days of hospitalization than the non-US group, but the difference was not significant. Patients in the US group exhibited higher initial CRP and WBC values than patients treated without US, although the differences were not significant. The WBC values of the arthrocentesis-US groups were higher than those of the non-US groups initially and at 72 h, but non significantly so; they became similar on day 5. Three puncture failures required arthrotomy (two under US guidance). Three patients required early revision surgery: one had undergone arthrocentesis with US, one arthrocentesis without US, and one arthrotomy without US. At the last follow-up, there were no clinical sequelae but two hip arthrotomies (one US and one non-US child) showed asymptomatic calcifications.

CONCLUSIONS

US guidance is feasible and safe for treating septic arthritis in children, visualizing structures not shown by X-rays and avoiding radiation exposure during surgery.

LEVEL OF EVIDENCE

IV (case series).

TRIAL REGISTRATION

IRB-MTP_2021_05_202100781.

Psychosocial factors associated with athlete adaptation to spinal cord injury: a systematic review

PURPOSE

To review existing research on psychosocial factors associated with athlete adaptation to acquired spinal cord injury (SCI).

METHODS

A systematic review was conducted in February 2023. MEDLINE (Pubmed), PsycINFO, and SPORTDiscus databases were used, and peer-reviewed academic journal entries fully retrievable from the researcher's institution library or online were considered for inclusion. Publications were identified according to predetermined eligibility criteria, and 18 publications were included in the review.

RESULTS

The results identified many psychosocial factors associated with adaptation to acquired SCI, including self-identity, emotions, coping strategies, sport involvement, social support, narratives, pain, participation, activity, self-efficacy, and sociability.

CONCLUSIONS

This review highlights the need for innovative methodologies and diverse perspectives and sampling in future investigations. Rehabilitation and sport and performance psychology practitioners working with athletes with acquired SCI are encouraged to gain a better understanding of the narratives framing and constraining athletes' life stories and rehabilitation experiences and consider using strategies such as narrative ambushing (Frank, 2010) to help athletes develop new ways of thinking about acquired SCI. Rehabilitation practitioners are also encouraged to discuss and facilitate opportunities to get involved in adaptive sports for athletes with acquired SCI as part of their rehabilitation plan.

Effect of surgical fixation timing on in-hospital mortality and morbidity of distal femur fractures

INTRODUCTION

The literature lacks a large-scale study investigating the effect of surgical fixation timing on early mortality and morbidity outcomes in distal femur fractures. The aims of this study were to determine the effect of fixation timing on in-hospital mortality and morbidity outcomes for operatively treated distal femur fractures retrospectively using large database data.

METHODS

This study is a retrospective analysis using data from the National Trauma Data Bank. Patients were stratified into a fragility cohort (age ≥ 60, ISS < 16) and polytrauma cohort (age < 60, ISS ≥16), with both cohorts analyzed separately. Within each cohort, patients were split into three fixation timing groups: within 24 h, between 24 and 48 h, and greater than 48 h from presentation to the hospital. Fixation-timing groups were compared based on the primary outcome of in-hospital mortality rate. Secondary outcomes included hospital length of stay (LOS), ICU length of stay (ICU LOS), days on a ventilator, and complications.

RESULTS

The fragility and polytrauma cohorts included 22,045 and 5,905 patients, respectively. The in-hospital mortality rate was 1.23 % in the fragility cohort and 2.56 % in the polytrauma cohort. Multivariate analysis of the fragility cohort showed that fixation greater than 48 h from time of presentation was associated with increased mortality compared to fixation within 24 h (OR 1.89, CI: 1.26-2.83, p=0.002) and between 24 and 48 h (OR 1.63, CI: 1.23-2.15, p<0.001). In the polytrauma cohort, multivariate analysis showed no significant mortality differences between fixation timing groups. Multivariate analysis of morbidity outcomes in both cohorts showed that fixation greater than 48 h was associated with increased LOS, ICU LOS, ventilator days, and complications compared to fixation within 24 h. In the polytrauma cohort, fixation between 24 and 48 h was associated with decreased LOS, ICU LOS, and complications compared to the other two timing groups.

CONCLUSIONS

Fixation of distal femur fractures before 48 h from presentation may lead to improved mortality and morbidity in older, lower injury severity patients. No significant mortality benefit was observed in younger, polytrauma fractures. Further prospective work is needed to validate these findings.

High Rate of Return to Sport in Contact and Collision Athletes After Arthroscopic Latarjet With Cortical Button Fixation

BACKGROUND

Contact and collision athletes face a higher risk of recurrent anterior shoulder instability after surgical stabilization. The Latarjet procedure is often preferred given the high incidence of bony lesions. However, this stabilizing procedure, performed either open or arthroscopically, is met with concerns regarding complications and revision surgery rates.

PURPOSE

To evaluate the return to sport (RTS) and assess complication and instability recurrence rates in contact/collision athletes undergoing the arthroscopic Latarjet procedure using a guided technique with suture buttons for coracoid fixations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis was conducted on contact/collision athletes who underwent the arthroscopic Latarjet procedure for recurrent anterior shoulder instability between January 2011 and March 2018. All patients were operated on arthroscopically using glenoid and coracoid guides and suture button fixation of the transferred coracoid. RTS was defined as the patient being able to participate in his or her activity without any restriction postoperatively. Two independent observers assessed patients using postoperative computed tomography (CT) scans to evaluate coracoid positioning and healing. A multivariate analysis was performed to identify predictive factors associated with persistent apprehension. A group comparison was performed to assess RTS failure risk factors.

RESULTS

In 136 contact/collision athletes (mean age, 25 ± 7 years), 93% were satisfied, and 98% achieved shoulder stability at a mean follow-up of 60 months (range, 24-117 months). No suture button-related complications or neurovascular issues were reported. Overall, 82% (112/136) returned to contact/collision sports. The mean time to RTS was 5.3 ± 1.2 months (range, 3-7.3 months). In a CT study performed 2 weeks after surgery, 87% (118/136) of bone grafts were positioned below the equator and 93% (126/136) were flush to the glenoid surface. At the 6-month postoperative CT examination, complete bone block healing was achieved in 84% (114/136). On clinical examination at the latest follow-up, 36 patients (26%) reported some anterior apprehension on testing. On multivariate analysis, patients with severe humeral bone defects (medium to large Hill-Sachs lesions, Calandra grade 2 or 3) had a higher risk of postoperative persistent apprehension. On group comparison, a visual analog scale score >3 and persistent anterior apprehension were found to be associated with failure of RTS.

CONCLUSION

The arthroscopic Latarjet procedure with suture button fixation allowed 82% of athletes with recurrent anterior shoulder instability to return to contact or collision sports. Patients with severe humeral bone defects have a higher risk of persistent anterior apprehension and decreased RTS. The arthroscopic-guided procedure with suture button fixation is safe; accurate, with a high rate of anatomic graft positioning and healing; and reliable, with a low recurrence rate.

Irreversible neurological manifestations in undiagnosed disseminated gonococcal infection

Neisseria gonorrhoeae causes a common sexually transmitted infection with manifestations ranging from asymptomatic to urethritis and pelvic inflammatory disease to disseminated infections including septic arthritis. Serious complications may arise in unrecognised or inappropriately treated infections.We report a young, healthy woman who developed fever and joint pain and was diagnosed with an inflammatory arthritis. After starting immune suppressing treatments, she experienced right wrist drop and progressive muscle atrophy, joint contractures and sensory loss. Electrodiagnostic studies showed patchy, mixed neurogenic and myopathic features. Areas of muscle oedema on extremity MRI led to a right brachioradialis biopsy, which showed only nonspecific changes. Other testing, including lumbar puncture and MRI of the brain/spine was noncontributory. Additional history revealed unprotected intercourse with a new partner prior to symptom onset. Urine gonorrhoeae PCR was positive, and right shoulder arthrocentesis confirmed septic arthritis. After intravenous antibiotic treatment with ceftriaxone, she demonstrated slow, incomplete symptomatic improvement.