3D CT modeling demonstrates the anatomic feasibility of S1AI screw trajectory for spinopelvic fixation in neuromuscular scoliosis

PURPOSE

In patients with neuromuscular scoliosis undergoing posterior spinal fusion, the S2 alar iliac (S2AI) screw trajectory is a safe and effective method of lumbopelvic fixation but can lead to implant prominence. Here we use 3D CT modeling to demonstrate the anatomic feasibility of the S1 alar iliac screw (S1AI) compared to the S2AI trajectory in patients with neuromuscular scoliosis.

METHODS

This retrospective study used CT scans of 14 patients with spinal deformity to create 3D spinal reconstructions and model the insertional anatomy, max length, screw diameter, and potential for implant prominence between 28 S2AI and 28 S1AI screw trajectories.

RESULTS

Patients had a mean age of 14.42 (range 8-21), coronal cobb angle of 85° (range 54-141), and pelvic obliquity of 28° (range 4-51). The maximum length and diameter of both screw trajectories were similar. S1AI screws were, on average, 6.3 ± 5 mm less prominent than S2AI screws relative to the iliac crests. S2AI screws were feasible in all patients, while in two patients, posterior elements of the lumbar spine would interfere with S1AI screw insertion.

CONCLUSION

In this cohort of patients with neuromuscular scoliosis, we demonstrate that the S1AI trajectory offers comparable screw length and diameter to an S2AI screw with less implant prominence. An S1AI screw, however, may not be feasible in some patients due to interference from the posterior elements of the lumbar spine.

Practice Changes Induced by a Traveling Fellowship

The John N. Insall Knee Society Traveling Fellowship selects four international arthroplasty or sports fellowship-trained orthopaedic surgeons to spend 1 month traveling to various Knee Society members' joint replacement and knee surgery centers in North America. The fellowship aims to foster research and education and shares ideas among fellows and Knee Society members. The role of such traveling fellowships on surgeon preferences has yet to be investigated. A 59-question survey encompassing patient selection, preoperative planning, intraoperative techniques, and postoperative protocols was completed by the four 2018 Insall Traveling Fellows before and immediately after the completion of traveling fellowship to assess anticipated practice changes (e.g., initial excitement) related to their participation in a traveling fellowship. The same survey was completed 4 years after the completion of the traveling fellowship to assess the implementation of the anticipated practice changes. Survey questions were divided into two groups based on levels of evidence in the literature. Immediately after fellowship, there was a median of 6.5 (range: 3-12) anticipated changes in consensus topics and a median of 14.5 (range: 5-17) anticipated changes in controversial topics. There was no statistical difference in the excitement to change consensus or controversial topics (p = 0.921). Four years after completing a traveling fellowship, a median of 2.5 (range: 0-3) consensus topics and 4 (range: 2-6) controversial topics were implemented. There was no statistical difference in the implementation of consensus or controversial topics (p = 0.709). There was a statistically significant decline in the implementation of changes in consensus and controversial preferences compared with the initial level of excitement (p = 0.038 and 0.031, respectively). After the John N. Insall Knee Society Traveling Fellowship, there is excitement for practice change in consensus and controversial topics related to total knee arthroplasty. However, few practice changes that had initial excitement were implemented after 4-year follow-up. Ultimately, the effects of time, practice inertia, and institutional friction overcome most of the anticipated changes induced by a traveling fellowship.

Preliminary study on the stabilization of varus proximal femoral osteotomies using pediatric LCP plates in adults undergoing combined correction of proximal femoral and acetabular dysplasia

PURPOSE

Proximal femoral osteotomy (PFO) with periacetabular osteotomy (PAO) improves femoral head coverage in patients with proximal femoral and acetabular dysplasia. Historically, blade plates used in the PFO cause soft-tissue irritation and often lead to implant removal. Here we present a technique using a lower profile pediatric proximal femoral locking compression plate (LCP) for the PFO in a series of adults.

METHODS

The results from 13 hips in 11 patients ≥ 18 years old (age 18-37) with > 10 months of follow-up are presented.

RESULTS

All patients had improved radiographic parameters, pain, and total Merle d'Aubigné-Postel scores postoperatively. Eleven hips (85%) had the LCP removed an average of 15.8 ± 8.6 months postoperatively, often due to pain over the greater trochanter.

CONCLUSION

The pediatric proximal femoral LCP is effective for PFO in combined PAO PFO procedures but has a high rate of lateral hip discomfort leading to implant removal.

Selecting a high-dose antibiotic-laden cement knee spacer

Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.

Management of the posterior wall fracture in associated both column fractures of the acetabulum

PURPOSE

The primary aim of this study was to compare clinical outcomes in patients with associated both column (ABC) acetabular fractures with fracture of the posterior wall (PW), in which the PW underwent reduction and fragment-specific fixation versus those that were treated with column fixation alone. Secondary aims were to assess PW fracture incidence and morphology, as well as to compare radiographic outcomes including fracture healing and interval displacement of the PW in those that did and did not undergo fragment-specific fixation of the PW.

METHODS

This was a retrospective series of ABC acetabular fractures treated at a single Level I trauma center. Separate fractures of the PW were identified, and associated features were assessed. Associated both column fractures that underwent reduction and fragment-specific fixation of the PW where then compared to ABC fractures with PW involvement that underwent column reconstruction alone. Radiographic and clinical outcomes were compared.

RESULTS

Fractures of the PW occurred in 55.7% of ABC fractures and were associated with central displacement of the femoral head. The majority of PW fractures were large and involved the acetabular roof. All PW fractures healed without displacement by 3 months, regardless of whether or not reduction and stabilization was performed. Mid-term outcomes at 1-year were similar regardless of whether or not the PW was reduced and stabilized, with regards to Tönnis grade, Merle d'Aubigné-Postel score, and conversion to total hip arthroplasty.

CONCLUSION

Reduction and fragment-specific fixation of the PW component of ABC acetabular fractures did not improve outcomes in this small comparative study. Posterior wall fractures associated with ABC patterns are frequently large-sized fragments that involve the acetabular roof and are rendered stable after reconstruction of the columns.

Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study

BACKGROUND

Recurrent urinary tract infections (UTI) are an important cause of morbidity and mortality in renal transplant recipients (RTR).

METHODS

In this retrospective study we gathered clinical data from patients prescribed methenamine hippurate to prevent recurrent UTI pre- and post-intervention. Thirty-eight RTR ≥18 years old at Northwestern Memorial Hospital from 2006-2017 were included in the final analysis.

RESULTS

The median and range for follow-up days were 365 (299-365) pre- vs 314 (105-365) post-methenamine. Total UTI frequency (9.16 vs 5.01/1000 patient follow-up days), days of antibiotic therapy to treat UTI (215 vs 132/1000 patient follow-up days), and hospitalization due to UTI (2.64 vs 1.07/1000 patient follow-up days) decreased while patients took methenamine. Escherichia coli and Klebsiella pneumoniae were the most commonly identified cause of UTI both pre- and post-intervention. Drug resistant bacteria (ESBL-producing or VRE) affected 3 patients pre- and recurred in 1 of those patients plus 3 new patients post-methenamine. Methenamine had few adverse side effects for patients. One patient had nausea and 1 was intolerant.

CONCLUSION

We found that methenamine is well tolerated and is useful in reducing UTI, antibiotic prescriptions, and hospitalization in RTR with recurrent UTI. Larger prospective studies are needed to confirm these findings.

The challenge of urinary tract infections in renal transplant recipients

Urinary tract infections (UTI) are an important cause of morbidity and mortality in renal transplant patients. These infections are quite common, and the goal of care is to identify and reduce risk factors while providing effective prophylaxis and treatment. Better understanding of long-term outcomes from these infections has led to the distinctions among UTI, recurrent UTI, and asymptomatic bacteriuria (ASB), and that each requires a different therapeutic approach. Specifically, new research has supported the perspective that asymptomatic bacteriuria should not be treated. Symptomatic UTI, on the other hand, requires intervention and remains an ongoing challenge for infectious disease clinicians. Many bacteria species are responsible for UTI in renal transplant patients, and in recent years there has been a global rise in infection caused by bacteria with newly acquired antibacterial resistance genes. Many renal transplant patients who experience UTI will also have multiple recurring episodes, which likely has a distinct pathophysiological mechanism leading to chronic colonization of the urinary tract. In these cases, long-term management includes bacterial suppression, which aims to reduce rather than eliminate bacteria to levels below the threshold for symptomatic infection. This review will address the current understanding of UTI epidemiology, pathogenesis, and risk factors in the renal transplant community, and also focus on current prevention and treatment strategies for patients who face an environment of increasingly antibiotic-resistant bacteria.

The human cytoplasmic dynein interactome reveals novel activators of motility

In human cells, cytoplasmic dynein-1 is essential for long-distance transport of many cargos, including organelles, RNAs, proteins, and viruses, towards microtubule minus ends. To understand how a single motor achieves cargo specificity, we identified the human dynein interactome by attaching a promiscuous biotin ligase (‘BioID’) to seven components of the dynein machinery, including a subunit of the essential cofactor dynactin. This method reported spatial information about the large cytosolic dynein/dynactin complex in living cells. To achieve maximal motile activity and to bind its cargos, human dynein/dynactin requires ‘activators’, of which only five have been described. We developed methods to identify new activators in our BioID data, and discovered that ninein and ninein-like are a new family of dynein activators. Analysis of the protein interactomes for six activators, including ninein and ninein-like, suggests that each dynein activator has multiple cargos.

DOI:http://dx.doi.org/10.7554/eLife.28257.001