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Patel UJ, Holloway MR, Carroll TJ, Soin SP, Ketz JP. No Differences in Clinical, Functional, or Patient-Reported Outcomes Following Trial of Non-operative Management Prior to Open Reduction and Internal Fixation of Humeral Shaft Fractures. J Orthop Trauma 2024:00005131-990000000-00346. [PMID: 38457769 DOI: 10.1097/bot.0000000000002796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 03/04/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management. METHODS DESIGN Retrospective Cohort Review. SETTING Academic Level I Trauma Center. PATIENT SELECTION CRITERIA Adult patients who presented with humeral shaft fractures, and ultimately underwent open reduction and internal fixation (ORIF) from 05/2011 to 05/2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from date of injury were grouped into the trial of nonoperative cohort. OUTCOME MEASURES AND COMPARISONS Post-operative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts.Results: 127 patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial non-operative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of non-operative management cohorts, including age (53±19 vs. 57±18; p=0.25), sex (39% vs. 44% male, 61% vs. 56% female; p=0.70), and BMI (30±6 vs. 32±9; p=0.38) . The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days), and 105 days (28-332 days) in the trial of non-operative treatment group (p<0.01). No differences were found with regards to intra-operative blood loss, total operative time, time to radiographic union (determined using the RUSHu scoring system), or overall complication rates, including primary and secondary radial nerve injuries (P=0.23 and 0.86, respectively). Patients reported similar PROMIS Pain Interference (PI) (P=0.73), Depression (D) (P=0.99), and Physical Function (PF) (P=0.66) scores at their 6-month post-surgical follow up visits. CONCLUSION Patients who attempted a trial of non-operative management for humeral shaft fractures prior to open reduction and internal fixation had similar clinical, functional, and patient reported outcomes as those who underwent primary osteosynthesis. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Urvi J Patel
- University of Rochester Medical Center, Department of Orthopaedic Surgery & Physical Performance, Rochester, New York, USA
| | - Melissa R Holloway
- University of Rochester Medical Center, Department of Orthopaedic Surgery & Physical Performance, Rochester, New York, USA
| | - Thomas J Carroll
- University of Rochester Medical Center, Department of Orthopaedic Surgery & Physical Performance, Rochester, New York, USA
| | - Sandeep P Soin
- OrthoIndy Trauma, St. Vincent Trauma Center, St. Vincent Orthopaedics and Spine Center, Indianapolis, Indiana, USA
| | - John P Ketz
- University of Rochester Medical Center, Department of Orthopaedic Surgery & Physical Performance, Rochester, New York, USA
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Patel UJ, Shaikh HJF, Brodell JD, Coon M, Ketz JP, Soin SP. Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries. J Bone Joint Surg Am 2023; 105:1972-1979. [PMID: 37725686 DOI: 10.2106/jbjs.23.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures. METHODS A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05. RESULTS There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay. CONCLUSIONS Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Urvi J Patel
- Department of Orthopaedic Surgery & Physical Performance, University of Rochester Medical Center, Rochester, New York
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Haws BE, Karnyski S, DiStefano DA, Soin SP, Flemister AS, Ketz JP. Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment. Foot Ankle Orthop 2023; 8:24730114231200485. [PMID: 37786607 PMCID: PMC10541751 DOI: 10.1177/24730114231200485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Background Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Brittany E. Haws
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Steven Karnyski
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - David A. DiStefano
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandeep P. Soin
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Adolph S. Flemister
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - John P. Ketz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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4
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Haws BE, Samborski SA, Karnyski S, Soles G, Gorczyca JT, Nicandri GT, Voloshin I, Ketz JP. Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults. Injury 2023; 54:567-572. [PMID: 36424218 DOI: 10.1016/j.injury.2022.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year. METHODS Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction. RESULTS A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs. CONCLUSIONS Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.
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Affiliation(s)
- Brittany E Haws
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
| | - Steven A Samborski
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Steven Karnyski
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Gillian Soles
- University of California, Davis, Department of Orthopaedic Surgery, Sacramento, CA, USA
| | - John T Gorczyca
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Gregg T Nicandri
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Ilya Voloshin
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - John P Ketz
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
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Bernstein DN, Ramirez G, Thirukumaran CP, Samuel Flemister A, Oh IC, Ketz JP, Baumhauer JF. Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS. Foot Ankle Orthop 2023; 8:24730114221151077. [PMID: 36741681 PMCID: PMC9893091 DOI: 10.1177/24730114221151077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms. Methods From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used. Results A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores. Conclusion Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms. Level of Evidence Level III, case-control study.
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Affiliation(s)
- David N. Bernstein
- Harvard Combined Orthopaedic Residency Program (HCORP), Massachusetts General Hospital, Boston, MA, USA
| | - Gabriel Ramirez
- Harvard Combined Orthopaedic Residency Program (HCORP), Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Caroline P. Thirukumaran
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - A. Samuel Flemister
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Irvin C. Oh
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - John P. Ketz
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Judith F. Baumhauer
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Judith F. Baumhauer, MD, MPH, Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA.
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Neumaier M, Kohring J, Ciufo D, Ketz JP. Technique and Early Outcomes for High-Energy Calcaneus Fractures Treated With Staged External Fixation to Combined Open Reduction Internal Fixation and Subtalar Arthrodesis. J Orthop Trauma 2022; 36:e412-e417. [PMID: 36239617 DOI: 10.1097/bot.0000000000002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE (1) To present an effective surgical technique for the treatment of open and high-energy calcaneal fractures with significant soft tissue injuries. (2) To present complications with this technique and to evaluate patient-reported outcomes of staged external fixation followed by delayed reconstruction with open reduction internal fixation (ORIF) and subtalar arthrodesis. DESIGN Retrospective case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Twelve patients with 13 calcaneus fractures associated with open traumatic wounds (10 patients) or other severe soft tissue injury (ie, fracture blisters) between April 2013 and December 2019. INTERVENTION All patients were treated with staged ankle-spanning external fixation and delayed reconstruction with ORIF with subtalar arthrodesis. MAIN OUTCOME MEASURES Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes are presented via the domains of physical function (PF), pain interference (PI), and depression (D) in addition to visual analog score. Complications with the injury and surgical procedure were reported as well. RESULTS Patients underwent initial stabilization on average 1.3 days (range, 0-12 days) from injury with stage II occurring on average 31.1 days (range, 18-42 days) from external fixation. Mean time to radiographic union was 5.6 months (range, 4-10 months). One-year mean PROMIS outcomes were as follows: PF final average of 37.4 with an average improvement of 12.2 (P < 0.01), PI final average of 62.2 with average improvement of 5.6 (P = 0.01), and D final average of 52.1 with average improvement of 6 (P = 0.12). Mean final visual analog score pain score was 3.6 with an average improvement of 2.25 (P = 0.01). CONCLUSION Staged treatment with initial external fixation followed by ORIF and subtalar arthrodesis in the setting of highly comminuted calcaneus fractures with significant soft tissue compromise effectively addresses both bony and soft tissue concerns while providing for positive outcomes postoperatively with regards to pain and function. There were minimal complications noted for this complex injury. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mackenzie Neumaier
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
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Samborski SA, Haws BE, Karnyski S, Soles G, Gorczyca JT, Nicandri G, Voloshin I, Ketz JP. Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty. JSES Int 2022; 6:755-762. [PMID: 36081702 PMCID: PMC9446248 DOI: 10.1016/j.jseint.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background This study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA). Methods This is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables. Results A total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05). Conclusion The management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group.
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Affiliation(s)
- S. Andrew Samborski
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
- Corresponding author: S. Andrew Samborski, MD, Department of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
| | - Brittany E. Haws
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Steven Karnyski
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Gillian Soles
- Department of Orthopaedics, University of California Davis, Sacramento, CA, USA
| | - John T. Gorczyca
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Gregg Nicandri
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Ilya Voloshin
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - John P. Ketz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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Joo PY, Baumhauer JF, Waldman O, Hoffman S, Houck J, Kohring JM, Flemister AS, Ketz JP, DiGiovanni BF, Oh I. Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery. Foot Ankle Int 2021; 42:1277-1286. [PMID: 34024138 DOI: 10.1177/10711007211007843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests. RESULTS Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points. CONCLUSION The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Judith F Baumhauer
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Olivia Waldman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Samantha Hoffman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Jeffrey Houck
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica M Kohring
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - A Samuel Flemister
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Benedict F DiGiovanni
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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Catheline SE, Bell RD, Oluoch LS, James MN, Escalera-Rivera K, Maynard RD, Chang ME, Dean C, Botto E, Ketz JP, Boyce BF, Zuscik MJ, Jonason JH. IKKβ-NF-κB signaling in adult chondrocytes promotes the onset of age-related osteoarthritis in mice. Sci Signal 2021; 14:eabf3535. [PMID: 34546791 DOI: 10.1126/scisignal.abf3535] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Sarah E Catheline
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Richard D Bell
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Luke S Oluoch
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - M Nick James
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Katherine Escalera-Rivera
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert D Maynard
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Martin E Chang
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher Dean
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Elizabeth Botto
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Brendan F Boyce
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael J Zuscik
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.,Colorado Program for Musculoskeletal Research, Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer H Jonason
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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10
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MacDonald A, Anderson M, Soin S, Brodell JD, Flemister AS, Ketz JP. Single Medial vs 2-Incision Approach for Double Hindfoot Arthrodesis: Is There a Difference in Joint Preparation? Foot Ankle Int 2021; 42:1068-1073. [PMID: 34121477 DOI: 10.1177/10711007211001030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Double hindfoot arthrodesis is a reliable treatment option in lower extremity deformity and arthritis. Single (medial) and 2-incision techniques have been described. The purpose of this study was to evaluate the extent of cartilage debrided in each approach and to evaluate the competency of the deltoid ligament. METHODS Eight matched pairs of cadaveric specimens were acquired. One limb from each pair was randomly assigned to the single medial incision and the other to the 2-incision technique. Stress radiographs were obtained prior to dissection to evaluate for valgus tibiotalar tilt. The talonavicular and subtalar articular surfaces were denuded of cartilage and the joints disarticulated. The percentage of cartilage debrided was determined using ImageJ software. Postoperative tibiotalar tilt was measured with a technique and threshold previously described by our group. The intraclass correlation coefficient was calculated to determine inter- and intraobserver reliability. RESULTS The single medial incision demonstrated significantly less cartilage denuded than the 2-incision technique at the talar head (61.1% ± 20.4% vs 88.1% ± 6.1%, P < .001), and the posterior facets of the talus (53.5% ± 7.6% vs 73.6% ± 7.0%, P < .001) and calcaneus (55.3% ± 16.5% vs 81.0% ± 7.4%, P = .001). Overall, 75% of specimens that underwent a single medial incision approach demonstrated increased valgus tibiotalar tilt postdissection, whereas none that underwent the 2-incision technique developed increased tibiotalar tilt (P < .01). The average tibiotalar tilt among these specimens was 4.6 ± 1.3 degrees (range 2.5-5.7 degrees). For all measurements, the intraclass correlation coefficient was greater than 0.8. CONCLUSION The posterior facet of the subtalar joint and talar head are at risk of subtotal debridement, as well as increased tibiotalar tilt with the single medial incision technique. Adequate debridement may require greater soft tissue dissection, possibly at the expense of medial ankle stability. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Ashlee MacDonald
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA
| | | | - Sandeep Soin
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA
| | - James D Brodell
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Adolph S Flemister
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA
| | - John P Ketz
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA
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11
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Abstract
OBJECTIVES To evaluate and compare femoral neck shortening and varus collapse in stable pertrochanteric femur fractures treated with sliding hip screws (SHSs) or cephalomedullary nails (CMNs). DESIGN Retrospective review. SETTING Academic medical center. PATIENTS A total of 290 patients were included in the study. The average age was 82 years, and most were women. All sustained low-energy pertrochanteric femur fractures (OTA/AO A1.1, 1.2, 1.3, 2.2) treated operatively with SHSs or CMNs. Minimum radiographic follow-up was 3 months, with an average of 28 (range 3-162) months. INTERVENTION CMN or SHS fixation. MAIN OUTCOME MEASURES Varus collapse of the femoral neck-shaft angle and proximal femoral shortening. RESULTS Both implants allowed some varus collapse. Univariate analysis demonstrated a significantly greater portion of patients with SHSs progressed to varus collapse >5 degrees (P = 0.02), mild horizontal shortening >5 mm (P < 0.01), and severe horizontal shortening >10 mm (P < 0.01). There was no statistical difference in vertical shortening (P = 0.3). There was no difference in implant failure (P = 0.5), with failure rates of 3% for cephalomedullary implants and 5% for SHS constructs. CONCLUSIONS The SHS group experienced greater varus collapse and horizontal shortening. There was no difference in overall implant failure. These findings suggest that the CMN is a superior construct for maintenance of reduction in stable pertrochanteric fractures, which may lead to improved functional outcomes as patients recover. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David J Ciufo
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
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12
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D'Amore T, Loewen M, Gorczyca MT, Judd K, Ketz JP, Soles G, Gorczyca JT. Rethinking strategies for blood transfusion in hip fracture patients. OTA Int 2020; 3:e083. [PMID: 33937706 PMCID: PMC8023119 DOI: 10.1097/oi9.0000000000000083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 04/06/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively. DESIGN Retrospective chart review. SETTING Two academic medical centers with Geriatric Fracture Programs. PATIENTS Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017. INTERVENTION Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards. MAIN OUTCOME MEASUREMENTS Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events. RESULTS One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1-6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P < .05). Patients who received transfusions on POD 3 or later had an average length of stay >2.5 days longer than those who received a transfusion earlier (P = 0.005). CONCLUSIONS Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Taylor D'Amore
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | - Michael T Gorczyca
- Department of Biological and Environmental Engineering, Cornell University, Ithaca
| | - Kyle Judd
- Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - John P Ketz
- Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Gillian Soles
- Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - John T Gorczyca
- Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
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13
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MacDonald A, Ciufo D, Vess E, Knapp E, Awad HA, Ketz JP, Flemister AS, Oh I. Peritalar Kinematics With Combined Deltoid-Spring Ligament Reconstruction in Simulated Advanced Adult Acquired Flatfoot Deformity. Foot Ankle Int 2020; 41:1149-1157. [PMID: 32495639 DOI: 10.1177/1071100720929004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model. METHODS Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA). RESULTS Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees (P = .031) and 5.8 ± 2.7 degrees (P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees (P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity (P = .04 and P = .02, respectively). CONCLUSION The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model. CLINICAL RELEVANCE The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.
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Affiliation(s)
- Ashlee MacDonald
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - David Ciufo
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Eric Vess
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Emma Knapp
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY, USA
| | - Hani A Awad
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY, USA
| | - John P Ketz
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Adolph S Flemister
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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14
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Brodell JD, Ayers BC, Baumhauer JF, DiGiovanni BF, Flemister AS, Ketz JP, Oh I. Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection. J Am Acad Orthop Surg 2020; 28:684-691. [PMID: 32769724 DOI: 10.5435/jaaos-d-19-00757] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. METHODS We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. RESULTS Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. DISCUSSION In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
- James D Brodell
- From the Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
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15
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Kohring JM, Houck JR, Oh I, Flemister AS, Ketz JP, Baumhauer JF. Pattern of recovery and outcomes of patient reported physical function and pain interference after ankle fusion: a retrospective cohort study. J Patient Rep Outcomes 2020; 4:40. [PMID: 32462241 PMCID: PMC7253567 DOI: 10.1186/s41687-020-00203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 05/03/2020] [Indexed: 12/26/2022] Open
Abstract
Background Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient’s perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication. Methods This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120–365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points. Results The linear mixed model analysis for PF after the 120–149 days, and for PI, after 90–119 days, indicated recovery plateaued at 39–40 for PF and 57–59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of − 5.4 (95% CI − 7.7 to − 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance. Conclusion Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis. Level of evidence Level II, prospective single cohort study.
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Affiliation(s)
- Jessica M Kohring
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
| | - Jeffrey R Houck
- Department of Physical Therapy, George Fox University, Newberg, OR, USA
| | - Irvin Oh
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
| | - Adolf S Flemister
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
| | - John P Ketz
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
| | - Judith F Baumhauer
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA.
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16
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Catheline SE, Hoak D, Chang M, Ketz JP, Hilton MJ, Zuscik MJ, Jonason JH. Chondrocyte-Specific RUNX2 Overexpression Accelerates Post-traumatic Osteoarthritis Progression in Adult Mice. J Bone Miner Res 2019; 34:1676-1689. [PMID: 31189030 PMCID: PMC7047611 DOI: 10.1002/jbmr.3737] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/18/2019] [Accepted: 04/03/2019] [Indexed: 12/14/2022]
Abstract
RUNX2 is a transcription factor critical for chondrocyte maturation and normal endochondral bone formation. It promotes the expression of factors catabolic to the cartilage extracellular matrix and is upregulated in human osteoarthritic cartilage and in murine articular cartilage following joint injury. To date, in vivo studies of RUNX2 overexpression in cartilage have been limited to forced expression in osteochondroprogenitor cells preventing investigation into the effects of chondrocyte-specific RUNX2 overexpression in postnatal articular cartilage. Here, we used the Rosa26Runx2 allele in combination with the inducible Col2a1CreERT2 transgene or the inducible AcanCreERT2 knock-in allele to achieve chondrocyte-specific RUNX2 overexpression (OE) during embryonic development or in the articular cartilage of adult mice, respectively. RUNX2 OE was induced at embryonic day 13.5 (E13.5) for all developmental studies. Histology and in situ hybridization analyses suggest an early onset of chondrocyte hypertrophy and accelerated terminal maturation in the limbs of the RUNX2 OE embryos compared to control embryos. For all postnatal studies, RUNX2 OE was induced at 2 months of age. Surprisingly, no histopathological signs of cartilage degeneration were observed even 6 months following induction of RUNX2 OE. Using the meniscal/ligamentous injury (MLI), a surgical model of knee joint destabilization and meniscal injury, however, we found that RUNX2 OE accelerates the progression of cartilage degeneration following joint trauma. One month following MLI, the numbers of MMP13-positive and TUNEL-positive chondrocytes were significantly greater in the articular cartilage of the RUNX2 OE joints compared to control joints and 2 months following MLI, histomorphometry and Osteoarthritis Research Society International (OARSI) scoring revealed decreased cartilage area in the RUNX2 OE joints. Collectively, these results suggest that although RUNX2 overexpression alone may not be sufficient to initiate the OA degenerative process, it may predetermine the rate of OA onset and/or progression following traumatic joint injury. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sarah E Catheline
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Donna Hoak
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Martin Chang
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Matthew J Hilton
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Michael J Zuscik
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Orthopedic Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer H Jonason
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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17
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Bernstein DN, Anderson MR, Baumhauer JF, Oh I, Flemister AS, Ketz JP, DiGiovanni BF. A Comparative Analysis of Clinical Outcomes in Noninsertional Versus Insertional Tendinopathy Using PROMIS. Foot Ankle Spec 2019; 12:350-356. [PMID: 30338708 DOI: 10.1177/1938640018806662] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background. Achilles tendinopathy is a common clinical disorder. Utilizing the Patient-Reported Outcomes Measurement Information System, we aim to determine clinical response to nonoperative achilles tendinopathy rehabilitative care of insertional achilles tendinopathy compared to non-insertional achilles tendinopathy. Methods. Prospective Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Depression scores were collected for patients with achilles tendinopathy at presentation and following a standard course of nonoperative care. A distribution-based method was used to determine the minimal clinically important difference. Descriptive statistics were reported and bivariate analysis was used to compare insertional achilles tendinopathy and non-insertional achilles tendinopathy. Receiver operating characteristic curve analysis was used to predict clinical improvement. Results. A total of 102 patients with an average follow-up of 68 days were included. For the non-insertional achilles tendinopathy group: Fifteen (46%), 12 (36%) and 9 (27%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. For the insertional achilles tendinopathy group: Seventeen (25%), 20 (29%) and 22 (32%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. Physical Function scores improved more in non-insertional achilles tendinopathy patients (4.0 vs. -0.046; p = 0.035) and more patients clinically improved (45.5% vs. 24.6%; p = 0.034). Patients with non-insertional and insertional achilles tendinopathy clinically improved functionally when initial Physical Function scores were equal to or lower than 40.25 and 38.08, respectively. Conclusions. Nonoperative care in achilles tendinopathy is often successful. The Patient-Reported Outcomes Measurement Information System can be used to evaluate and help determine clinical success. Levels of Evidence: Level II: Prospective comparative study.
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Affiliation(s)
- David N Bernstein
- Department of Orthopaedics and Rehabilitation, University of Rochester, New York
| | - Michael R Anderson
- Department of Orthopaedics and Rehabilitation, University of Rochester, New York
| | - Judith F Baumhauer
- Department of Orthopaedics and Rehabilitation, University of Rochester, New York
| | - Irvin Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester, New York
| | - A Samuel Flemister
- Department of Orthopaedics and Rehabilitation, University of Rochester, New York
| | - John P Ketz
- Department of Orthopaedics and Rehabilitation, University of Rochester, New York
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18
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Bernstein DN, Kelly M, Houck JR, Ketz JP, Flemister AS, DiGiovanni BF, Baumhauer JF, Oh I. PROMIS Pain Interference Is Superior vs Numeric Pain Rating Scale for Pain Assessment in Foot and Ankle Patients. Foot Ankle Int 2019; 40:139-144. [PMID: 30282475 DOI: 10.1177/1071100718803314] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF). METHODS: Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria. RESULTS: PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = -0.66; postoperative: ρ = -0.69) compared with the NPRS (preoperative: ρ = -0.32; postoperative:ρ = -0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code. CONCLUSION: PROMIS PI was a superior tool to gauge a patient's preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management. LEVEL OF EVIDENCE: Level II, prognostic.
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Affiliation(s)
- David N Bernstein
- 1 Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Meghan Kelly
- 1 Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | | | - John P Ketz
- 1 Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - A Samuel Flemister
- 1 Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | | | - Judith F Baumhauer
- 1 Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Irvin Oh
- 1 Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
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19
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Kelly M, Masqoodi N, Vasconcellos D, Fowler X, Osman WS, Elfar JC, Olles MW, Ketz JP, Flemister AS, Oh I. Spring ligament tear decreases static stability of the ankle joint. Clin Biomech (Bristol, Avon) 2019; 61:79-83. [PMID: 30529505 DOI: 10.1016/j.clinbiomech.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/11/2018] [Accepted: 11/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Spring ligament tear is often found in advanced adult acquired flatfoot deformity and its reconstruction in conjunction with the deltoid ligament has been proposed to restore the tibiotalar and talonavicular joint stability. The aim of the present study is to determine the effect of spring ligament injury and subsequent reconstruction on static joint reactive force using a non-invasive method of measurement. METHODS Ten fresh-frozen human cadaveric lower legs were disarticulated at the knee joint. Static joint reactive force of the tibiotalar and talonavicular joint were measured at baseline, after spring ligament injury, and after ligament reconstruction. Reconstruction consisted of a forked semitendinosis allograft with dual limbs to reconstruct the tibionavicular and tibiocalcaneal ligaments. FINDINGS The mean baseline joint reactive force of the tibiotalar and talonavicular joints were 37.2 N + 8.1 N and 13.4 N + 4.2 N, respectively. The spring ligament injury model resulted in a significant 29% decrease in tibiotalar joint reactive force. Reconstruction of the tibionavicular limb resulted in a significant increase in tibiotalar and talonavicular joint reactive force compared to those seen in the injury state. Furthermore, the addition of the tibiocalcaneal limb significantly increased tibiotalar joint reactive force compared to those results obtained from the injury state and the tibionavicular limb alone. INTERPRETATION This is the first study to demonstrate diminished tibiotalar static joint reactive force in a spring ligament injury model with subsequent joint reactive force restoration using two-limbed reconstruction of the deltoid and spring ligament. LEVEL OF EVIDENCE Biomechanical Study.
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Affiliation(s)
- Meghan Kelly
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Noorullah Masqoodi
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Daniel Vasconcellos
- Department of Mechanical Engineering, Rochester Institute of Technology, Rochester, NY, USA
| | - Xavier Fowler
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Walid S Osman
- Department of Orthopaedic Surgery, Helwan Univesity, Cairo, Egypt
| | - John C Elfar
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Mark W Olles
- Department of Mechanical Engineering, Rochester Institute of Technology, Rochester, NY, USA
| | - John P Ketz
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Adolph S Flemister
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA
| | - Irvin Oh
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA.
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20
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Affiliation(s)
- David J Ciufo
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
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21
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Anderson MR, Baumhauer JF, DiGiovanni BF, Flemister S, Ketz JP, Oh I, Houck JR. Determining Success or Failure After Foot and Ankle Surgery Using Patient Acceptable Symptom State (PASS) and Patient Reported Outcome Information System (PROMIS). Foot Ankle Int 2018; 39:894-902. [PMID: 29791196 DOI: 10.1177/1071100718769666] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As the role of generic patient-reported outcomes (PROs) expands, important questions remain about their interpretation. In particular, how the Patient Reported Outcome Measurement Instrumentation System (PROMIS) t score values correlate with the patients' perception of success or failure (S/F) of their surgery is unknown. The purposes of this study were to characterize the association of PROMIS t scores, the patients' perception of their symptoms (patient acceptable symptom state [PASS]), and determination of S/F after surgery. METHODS This retrospective cohort study contacted patients after the 4 most common foot and ankle surgeries at a tertiary academic medical center (n = 88). Patient outcome as determined by phone interviews included PASS and patients' judgment of whether their surgery was a S/F. Assessment also included PROMIS physical function (PF), pain interference (PI), and depression (D) scales. The association between S/F and PASS outcomes was evaluated by chi-square analysis. A 2-way analysis of variance (ANOVA) evaluated the ability of PROMIS to discriminate PASS and/or S/F outcomes. Receiver operator curve (ROC) analysis was used to evaluate the ability of pre- (n = 63) and postoperative (n = 88) PROMIS scores to predict patient outcomes (S/F and PASS). Finally, the proportion of individuals classified by the identified thresholds were evaluated using chi-square analysis. RESULTS There was a strong association between PASS and S/F after surgery (chi-square <0.01). Two-way ANOVA demonstrated that PROMIS t scores discriminate whether patients experienced positive or negative outcome for PASS ( P < .001) and S/F ( P < .001). The ROC analysis showed significant accuracy (area under the curve > 0.7) for postoperative but not preoperative PROMIS t scores in determining patient outcome for both PASS and S/F. The proportion of patients classified by applying the ROC analysis thresholds using PROMIS varied from 43.0% to 58.8 % for PASS and S/F. CONCLUSIONS Patients who found their symptoms and activity at a satisfactory level (ie, PASS yes) also considered their surgery a success. However, patients who did not consider their symptoms and activity at a satisfactory level did not consistently consider their surgery a failure. PROMIS t scores for physical function and pain demonstrated the ability to discriminate and accurately predict patient outcome after foot and ankle surgery for 43.0% to 58.8% of participants. These data improve the clinical utility of PROMIS scales by suggesting thresholds for positive and negative patient outcomes independent of other factors. LEVEL OF EVIDENCE II, prospective comparative series.
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Affiliation(s)
- Michael R Anderson
- 1 Orthopedic Foot and Ankle Fellow, University of Rochester Medical Center, Rochester, NY, USA.,2 Summit Orthopedics, Woodbury, MN, USA
| | - Judith F Baumhauer
- 3 Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Benedict F DiGiovanni
- 3 Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Sam Flemister
- 3 Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- 3 Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- 3 Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
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22
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Schott EM, Farnsworth CW, Grier A, Lillis JA, Soniwala S, Dadourian GH, Bell RD, Doolittle ML, Villani DA, Awad H, Ketz JP, Kamal F, Ackert-Bicknell C, Ashton JM, Gill SR, Mooney RA, Zuscik MJ. Targeting the gut microbiome to treat the osteoarthritis of obesity. JCI Insight 2018; 3:95997. [PMID: 29669931 DOI: 10.1172/jci.insight.95997] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 03/14/2018] [Indexed: 01/07/2023] Open
Abstract
Obesity is a risk factor for osteoarthritis (OA), the greatest cause of disability in the US. The impact of obesity on OA is driven by systemic inflammation, and increased systemic inflammation is now understood to be caused by gut microbiome dysbiosis. Oligofructose, a nondigestible prebiotic fiber, can restore a lean gut microbial community profile in the context of obesity, suggesting a potentially novel approach to treat the OA of obesity. Here, we report that - compared with the lean murine gut - obesity is associated with loss of beneficial Bifidobacteria, while key proinflammatory species gain in abundance. A downstream systemic inflammatory signature culminates with macrophage migration to the synovium and accelerated knee OA. Oligofructose supplementation restores the lean gut microbiome in obese mice, in part, by supporting key commensal microflora, particularly Bifidobacterium pseudolongum. This is associated with reduced inflammation in the colon, circulation, and knee and protection from OA. This observation of a gut microbiome-OA connection sets the stage for discovery of potentially new OA therapeutics involving strategic manipulation of specific microbial species inhabiting the intestinal space.
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Affiliation(s)
- Eric M Schott
- Center for Musculoskeletal Research.,Department of Pathology & Laboratory Medicine, and
| | | | - Alex Grier
- Genomics Research Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Jacquelyn A Lillis
- Genomics Research Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Sarah Soniwala
- Center for Musculoskeletal Research.,Department of Biology and
| | - Gregory H Dadourian
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
| | - Richard D Bell
- Center for Musculoskeletal Research.,Department of Pathology & Laboratory Medicine, and
| | - Madison L Doolittle
- Center for Musculoskeletal Research.,Department of Pathology & Laboratory Medicine, and
| | - David A Villani
- Center for Musculoskeletal Research.,Department of Pathology & Laboratory Medicine, and
| | - Hani Awad
- Center for Musculoskeletal Research.,Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
| | - John P Ketz
- Center for Musculoskeletal Research.,Department of Orthopaedics & Rehabilitation and
| | - Fadia Kamal
- Center for Musculoskeletal Research.,Department of Orthopaedics & Rehabilitation and
| | | | - John M Ashton
- Genomics Research Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Steven R Gill
- Department of Microbiology & Immunology, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert A Mooney
- Center for Musculoskeletal Research.,Department of Pathology & Laboratory Medicine, and
| | - Michael J Zuscik
- Center for Musculoskeletal Research.,Department of Orthopaedics & Rehabilitation and
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23
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Affiliation(s)
| | - Derek E Bell
- 2 Department of Surgery, Plastic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- 3 Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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Hamada D, Maynard R, Schott E, Drinkwater CJ, Ketz JP, Kates SL, Jonason JH, Hilton MJ, Zuscik MJ, Mooney RA. Suppressive Effects of Insulin on Tumor Necrosis Factor-Dependent Early Osteoarthritic Changes Associated With Obesity and Type 2 Diabetes Mellitus. Arthritis Rheumatol 2017; 68:1392-402. [PMID: 26713606 PMCID: PMC4882234 DOI: 10.1002/art.39561] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 12/17/2015] [Indexed: 12/24/2022]
Abstract
Objective Obesity is a state of chronic inflammation that is associated with insulin resistance and type 2 diabetes mellitus (DM), as well as an increased risk of osteoarthritis (OA). This study was undertaken to define the links between obesity‐associated inflammation, insulin resistance, and OA, by testing the hypotheses that 1) tumor necrosis factor (TNF) is critical in mediating these pathologic changes in OA, and 2) insulin has direct effects on the synovial joint that are compromised by insulin resistance. Methods The effects of TNF and insulin on catabolic gene expression were determined in fibroblast‐like synoviocytes (FLS) isolated from human OA synovium. Synovial TNF expression and OA progression were examined in 2 mouse models, high‐fat (HF) diet–fed obese mice with type 2 DM and TNF‐knockout mice. Insulin resistance was investigated in synovium from patients with type 2 DM. Results Insulin receptors (IRs) were abundant in both mouse and human synovial membranes. Human OA FLS were insulin responsive, as indicated by the dose‐dependent phosphorylation of IRs and Akt. In cultures of human OA FLS with exogenous TNF, the expression and release of MMP1, MMP13, and ADAMTS4 by FLS were markedly increased, whereas after treatment with insulin, these effects were selectively inhibited by >50%. The expression of TNF and its abundance in the synovium were elevated in samples from obese mice with type 2 DM. In TNF‐knockout mice, increases in osteophyte formation and synovial hyperplasia associated with the HF diet were blunted. The synovium from OA patients with type 2 DM contained markedly more macrophages and showed elevated TNF levels as compared to the synovium from OA patients without diabetes. Moreover, insulin‐dependent phosphorylation of IRs and Akt was blunted in cultures of OA FLS from patients with type 2 DM. Conclusion TNF appears to be involved in mediating the advanced progression of OA seen in type 2 DM. While insulin plays a protective, antiinflammatory role in the synovium, insulin resistance in patients with type 2 DM may impair this protective effect and promote the progression of OA.
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Affiliation(s)
- Daisuke Hamada
- University of Rochester Medical Center, Rochester, New York
| | - Robert Maynard
- University of Rochester Medical Center, Rochester, New York
| | - Eric Schott
- University of Rochester Medical Center, Rochester, New York
| | | | - John P Ketz
- University of Rochester Medical Center, Rochester, New York
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25
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Abstract
BACKGROUND The development of valgus tibiotalar tilt following hindfoot arthrodesis is rarely discussed in the literature. The purpose of this study was to determine the incidence of valgus tibiotalar tilt and to evaluate if there were any radiographic predictors for the development of valgus tibiotalar tilt. METHODS Patients who underwent hindfoot fusion between January 1, 2004 and December 31, 2013 were identified. Charts were reviewed for demographic information and operative details. Preoperative and postoperative radiographs were reviewed for the development of tibiotalar tilt, and standardized measurements and angles were calculated. A total of 187 patients were included. There were 106 (56.7%) females and 81 (43.3%) males. The average age was 52 years (range, 11-82 years). The most common indication for surgery was adult-acquired flatfoot deformity (n = 92, 49.2%), followed by arthritis (n = 83, 44.4%). The most common procedure was triple arthrodesis (n = 101, 54%). Twenty-seven patients demonstrated tibiotalar tilt preoperatively. RESULTS A total of 51 patients (27.3%) developed valgus tibiotalar tilt postoperatively at an average of 3.6 months after surgery. We found that an increase in the preoperative Meary (lateral talar-first metatarsal) angle (hazard ratio, 1.039; 95% confidence interval, 1.002-1.077; P < .05) was associated with the development of tibiotalar tilt. An increase in the postoperative Meary angle (hazard ratio, 1.052; 95% confidence interval, 0.999-1.108; P = .0528) approached significance for the development of tibiotalar tilt. CONCLUSION The development of valgus tibiotalar tilt following hindfoot fusion was a notable phenomenon, occurring in 27% of our patient population. The preoperative Meary angle was the only radiographic measurement that was significantly associated with the development of valgus tibiotalar tilt, although the postoperative Meary angle approached significance. These findings should encourage surgeons to be aware of patients with large deformities and of their propensity to develop a valgus deformity about the ankle. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
| | | | - John P Ketz
- 3 Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, New York, USA
| | - A Samuel Flemister
- 3 Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, New York, USA
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26
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Shields E, Sundem L, Childs S, Maceroli M, Humphrey C, Ketz JP, Soles G, Gorczyca JT. The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures. Injury 2016; 47:914-8. [PMID: 26754807 DOI: 10.1016/j.injury.2015.12.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 12/12/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes. METHODS Skeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts. RESULTS Thirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0-18], and 15 ± 7.9° [range 2-27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p=0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all). CONCLUSION Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.
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Affiliation(s)
- Edward Shields
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.
| | - Leigh Sundem
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Sean Childs
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael Maceroli
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Catherine Humphrey
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Gillian Soles
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John T Gorczyca
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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Abstract
OBJECTIVES Medial talar body pins may be inserted to provide points of fixation in the hindfoot when applying external fixators. Because of the proximity to the ankle joint, there is a risk of intracapsular pin placement. We hypothesized that intracapsular placement is common when inserting medial talar body pins. METHODS Medial talar body pins were inserted in 12 fresh frozen cadaver ankles. Arthrography of each ankle was then performed to determine whether the pin was intracapsular. Each pin was then removed, and fluoroscopy was repeated to evaluate for contrast extravasation from the pin insertion site. The distance from the apex of the talar head to the anterior extent of the ankle capsule was measured to determine a safe area for extracapsular pin placement. RESULTS Arthrograms of all 12 ankles demonstrated that the pins were intracapsular. After pin removal, there was contrast extravasation from the pin insertion site in all specimens. Contrast was present in the pin tract in all specimens. Mean distance from the talar head to the anterior ankle capsule was 20.95 ± 4.8 mm (range, 12.2-27.3 mm) on the lateral view and 15.5 ± 1.8 mm (range, 12.4-20.0 mm) on the anteroposterior view of the foot. CONCLUSIONS There is a high rate of intracapsular pin placement when inserting medial talar body pins. Pin placement within the joint capsule risks seeding a sterile joint with bacteria and fistula formation when the pin remains in place for prolonged periods. For this reason, talar body pins should be avoided in temporizing external fixation frames.
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Affiliation(s)
- Michael A Maceroli
- Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY
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28
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Abstract
BACKGROUND Patients who undergo internal fixation of ankle fractures commonly have postoperative imaging performed immediately after surgery. As these patients typically are typically immobilized, radiographs provide limited visualization. The purpose of this study was to evaluate the utility and quality of formal radiographs performed immediately following ankle fracture surgery. METHODS Ankle fractures undergoing open reduction and internal fixation at a single institution from January 1, 2011, to January 1, 2013, were reviewed. Intraoperative and formal postoperative radiographs were evaluated using defined parameters. The postoperative images were compared with the intraoperative fluoroscopic images in terms of quality. Postoperative complications were evaluated in terms of fracture displacement, hardware malpositioning, and need for return to the operating room. A total of 411 patients with 413 ankle fractures underwent surgical fixation, with 271 patients undergoing formal postoperative radiographs. RESULTS Twenty-eight patients (10.3%) had 3 good quality postoperative views of the ankle, with the lateral (35.2%) and mortise (41.3%) views least commonly performed with good technique. None of the patients without radiographs had a complication that could have been detected earlier using postoperative radiographs. No patients required return to the operating room based on immediate postoperative radiographs. Postoperative radiographs cost $191 per patient. CONCLUSION The routine use of formal postoperative radiographs prior to discharge from the hospital did not provide additional value to the patient or orthopedic surgeon. The quality of these images was generally inferior to the quality of those obtained and saved intraoperatively due to malrotation and overlying cast material. To reduce cost and radiation exposure, formal postoperative radiographs should be obtained only in specific circumstances, such as increasing postoperative pain, marginal fixation, or instability. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
| | - Elizabeth A Martin
- Lahey Hospital and Medical Center Orthopaedic Surgery, Burlington, MA, USA
| | - John P Ketz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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29
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Bah I, Kwak ST, Chimenti RL, Richards MS, P Ketz J, Samuel Flemister A, Buckley MR. Mechanical changes in the Achilles tendon due to insertional Achilles tendinopathy. J Mech Behav Biomed Mater 2015; 53:320-328. [PMID: 26386166 DOI: 10.1016/j.jmbbm.2015.08.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 07/31/2015] [Accepted: 08/11/2015] [Indexed: 11/24/2022]
Abstract
Insertional Achilles tendinopathy (IAT) is a painful and debilitating condition that responds poorly to non-surgical interventions. It is thought that this disease may originate from compression of the Achilles tendon due to calcaneal impingement. Thus, compressive mechanical changes associated with IAT may elucidate its etiology and offer clues to guide effective treatment. However, the mechanical properties of IAT tissue have not been characterized. Therefore, the objective of this study was to measure the mechanical properties of excised IAT tissue and compare with healthy cadaveric control tissue. Tissue from the Achilles tendon insertion was acquired from healthy donors and from patients undergoing debridement surgery for IAT. Several tissue specimens from each donor were then mechanically tested under cyclic unconfined compression and the acquired data was analyzed to determine the distribution of mechanical properties for each donor. While the median mechanical properties of tissue excised from IAT tendons were not significantly different than healthy tissue, the distribution of mechanical properties within each donor was dramatically altered. In particular, healthy tendons contained more low modulus (compliant) and high transition strain specimens than IAT tendons, as evidenced by a significantly lower 25th percentile secant modulus and higher 75th percentile transition strain. Furthermore, these parameters were significantly correlated with symptom severity. Finally, it was found that preconditioning and slow loading both reduced the secant modulus of healthy and IAT specimens, suggesting that slow, controlled ankle dorsiflexion prior to activity may help IAT patients manage disease-associated pain.
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Affiliation(s)
- Ibrahima Bah
- University of Rochester, Department of Biomedical Engineering, United States.
| | - Samuel T Kwak
- University of Rochester, Department of Biomedical Engineering, United States
| | - Ruth L Chimenti
- University of Rochester, Department of Biomedical Engineering, United States
| | | | - John P Ketz
- University of Rochester, Department of Orthopaedics, United States
| | | | - Mark R Buckley
- University of Rochester, Department of Biomedical Engineering, United States
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Abstract
The authors report the case of a patient who sustained traumatic two-level noncontiguous ligamentous flexion-distraction injuries in the thoracolumbar spine. To the best of their knowledge, this is the first reported case of this combined injury pattern.
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Affiliation(s)
- John P Ketz
- Department of Orthopaedics, University of Rochester, Strong Memorial Hospital, Rochester, New York 14624, USA
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