Pub Date : 2019-11-19DOI: 10.1097/CORR.0000000000001064
M. Ghert
Because so many patients with cancer now are living longer as a result of targeted systemic therapies [4], skeletal metastases [7] and the pathological fractures they cause—especially to the hip—should force us to focus on how to improve the care of patients with this problem. In the current study, Varady and colleagues [18] do exactly this; they found that taking the time to medically prepare such complex patients for surgery does not compromise their postoperative outcomes in terms of surgical complications and perioperative mortality. This may be different than what we (think we) know about patients with osteoporotic hip fractures; studies suggest that delayed surgery in those patients is associated with a greater risk of complications and death [11], but whether that delay causes the excess complications remains controversial. However, what is most striking is that Varady and colleagues [18] have shown that the presence of disseminated disease is associated with increased morbidity and mortality. In other words, patients with disseminated disease are high-risk surgical fixation patients and prophylactic fixation is likely to be safer for them. Although one can say this is intuitive, it does bring to light the imperative of identifying patients at risk for fracture, as surgery is safer for those undergoing prophylactic fixation compared to undergoing fixation after a fracture has occurred [15]. Based on this, healthcare systems can introduce policies that prioritize patients with cancer and disseminated disease into screening programs to identify fractures before they occur.
{"title":"CORR Insights®: Is Delayed Time to Surgery Associated with Increased Short-term Complications in Patients with Pathologic Hip Fractures?","authors":"M. Ghert","doi":"10.1097/CORR.0000000000001064","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001064","url":null,"abstract":"Because so many patients with cancer now are living longer as a result of targeted systemic therapies [4], skeletal metastases [7] and the pathological fractures they cause—especially to the hip—should force us to focus on how to improve the care of patients with this problem. In the current study, Varady and colleagues [18] do exactly this; they found that taking the time to medically prepare such complex patients for surgery does not compromise their postoperative outcomes in terms of surgical complications and perioperative mortality. This may be different than what we (think we) know about patients with osteoporotic hip fractures; studies suggest that delayed surgery in those patients is associated with a greater risk of complications and death [11], but whether that delay causes the excess complications remains controversial. However, what is most striking is that Varady and colleagues [18] have shown that the presence of disseminated disease is associated with increased morbidity and mortality. In other words, patients with disseminated disease are high-risk surgical fixation patients and prophylactic fixation is likely to be safer for them. Although one can say this is intuitive, it does bring to light the imperative of identifying patients at risk for fracture, as surgery is safer for those undergoing prophylactic fixation compared to undergoing fixation after a fracture has occurred [15]. Based on this, healthcare systems can introduce policies that prioritize patients with cancer and disseminated disease into screening programs to identify fractures before they occur.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"8 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74254586","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-19DOI: 10.1097/CORR.0000000000001063
R. Dale Blasier
The general public’s awareness of concussive injuries in sports may be at an all-time high. Recent coverage in the lay media [8, 13] has emphasized the risks and long-term sequelae of sports-related concussion in athletes. It is well-known that contact sports, like American football, with its frequent collisions between players, are associated with the highest incidence of concussive injuries [4, 5, 9]. One study found that in a convenience sample of 202 deceased players of American football from a brain donation program, the neurodegenerative disease chronic traumatic encephalopathy was neuropathologically diagnosed in 177 players across all levels of play (87%), including 110 of 111 former National Football League players (99%) [10]. Although women athletes are less likely to incur a head injury caused by contact with another player than are men athletes, women athletes are more likely to incur a concussive injury from a playing surface or an apparatus than men [1]. In the current meta-analysis, Ling and colleagues [7] found that women athletes have a lower risk of playercontact-induced concussions in lacrosse, basketball, ice hockey, and soccer than do men, but are more likely to experience concussions because of ball or equipment contact in lacrosse and soccer compared to men playing those same sports. These results held true in spite of rules differences between the men’s and women’s lacrosse games. Injury is a part of sport, and participating athletes and the supporting public are willing to accept nominal risk. But the prospect of late dementia, accelerated by repetitive microtrauma to the brain, looms over all participants in contact sports, as well as the sports themselves.
{"title":"CORR Insights®: Women Are at Higher Risk for Concussions Due to Ball or Equipment Contact in Soccer and Lacrosse.","authors":"R. Dale Blasier","doi":"10.1097/CORR.0000000000001063","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001063","url":null,"abstract":"The general public’s awareness of concussive injuries in sports may be at an all-time high. Recent coverage in the lay media [8, 13] has emphasized the risks and long-term sequelae of sports-related concussion in athletes. It is well-known that contact sports, like American football, with its frequent collisions between players, are associated with the highest incidence of concussive injuries [4, 5, 9]. One study found that in a convenience sample of 202 deceased players of American football from a brain donation program, the neurodegenerative disease chronic traumatic encephalopathy was neuropathologically diagnosed in 177 players across all levels of play (87%), including 110 of 111 former National Football League players (99%) [10]. Although women athletes are less likely to incur a head injury caused by contact with another player than are men athletes, women athletes are more likely to incur a concussive injury from a playing surface or an apparatus than men [1]. In the current meta-analysis, Ling and colleagues [7] found that women athletes have a lower risk of playercontact-induced concussions in lacrosse, basketball, ice hockey, and soccer than do men, but are more likely to experience concussions because of ball or equipment contact in lacrosse and soccer compared to men playing those same sports. These results held true in spite of rules differences between the men’s and women’s lacrosse games. Injury is a part of sport, and participating athletes and the supporting public are willing to accept nominal risk. But the prospect of late dementia, accelerated by repetitive microtrauma to the brain, looms over all participants in contact sports, as well as the sports themselves.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"53 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76478252","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1097/CORR.0000000000001048
D. Armstrong
Underarm bracing can prevent 25° to 40° curves in patients with adolescent idiopathic scoliosis (AIS) from progressing to the point where surgery may be indicated [2, 7]. While the main goal of bracing for AIS is to prevent the need for surgery, the study by Cheung and colleagues [1] provides the best evidence so far that curve regression can sometimes occur. The authors found that some scoliosis curves may be partially reversed with bracing, and that, in some patients, reversal of vertebral wedging may occur at the apical vertebrae of major curves, which implies that the vertebrae were sufficiently relieved of axial load to allow recovery of their native growth potential. This is an important and rather exciting finding because it definitively demonstrates that bracing may potentially reverse one of the primary elements of the spine deformity which constitutes scoliosis [6]. In the current study, patients wore a brace for mean 3.8 years and SRS 22r scores were better for those who experienced correction. Notably, the authors’ practice setting is a dedicated scoliosis clinic including an orthotist who fits their patients with customized braces, a physical therapist who assists with exercise training and a psychologist [1]. A multidisciplinary team such as theirs could potentially influence patient perceptions and behavior. While many have an orthotist immediately available, few, if any scoliosis practices have immediate access to a psychologist and a therapist. Cheung and colleagues [1] also found that the benefits of bracing were not dependent on sex. This is an important and new finding because no previous studies have unequivocally demonstrated brace efficacy in males. Where Do We Need To Go?
{"title":"CORR Insights®: Does Curve Regression Occur During Underarm Bracing in Patients with Adolescent Idiopathic Scoliosis?","authors":"D. Armstrong","doi":"10.1097/CORR.0000000000001048","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001048","url":null,"abstract":"Underarm bracing can prevent 25° to 40° curves in patients with adolescent idiopathic scoliosis (AIS) from progressing to the point where surgery may be indicated [2, 7]. While the main goal of bracing for AIS is to prevent the need for surgery, the study by Cheung and colleagues [1] provides the best evidence so far that curve regression can sometimes occur. The authors found that some scoliosis curves may be partially reversed with bracing, and that, in some patients, reversal of vertebral wedging may occur at the apical vertebrae of major curves, which implies that the vertebrae were sufficiently relieved of axial load to allow recovery of their native growth potential. This is an important and rather exciting finding because it definitively demonstrates that bracing may potentially reverse one of the primary elements of the spine deformity which constitutes scoliosis [6]. In the current study, patients wore a brace for mean 3.8 years and SRS 22r scores were better for those who experienced correction. Notably, the authors’ practice setting is a dedicated scoliosis clinic including an orthotist who fits their patients with customized braces, a physical therapist who assists with exercise training and a psychologist [1]. A multidisciplinary team such as theirs could potentially influence patient perceptions and behavior. While many have an orthotist immediately available, few, if any scoliosis practices have immediate access to a psychologist and a therapist. Cheung and colleagues [1] also found that the benefits of bracing were not dependent on sex. This is an important and new finding because no previous studies have unequivocally demonstrated brace efficacy in males. Where Do We Need To Go?","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75501940","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1097/CORR.0000000000001055
J. Wegrzyn, M. Malatray, V. Pibarot, G. Anania, J. Béjui-Hugues
BACKGROUND Intraprosthetic dislocation is a specific complication of dual mobility cups, although it occurs less frequently with the latest generations of implants. Intraprosthetic dislocation is related to long-term polyethylene wear of the mobile component chamfer and retentive area, leading to a snap-out of the femoral head. With the increased use of dual mobility cups, even in younger and active patients, the management of intraprosthetic dislocation should be defined according to its type. However, no previous studies, except for case reports, have described the strategy to manage long-term wear-related intraprosthetic dislocation, particularly when a dual mobility cup is not loose. QUESTIONS/PURPOSES This study aimed to (1) determine the prevalence of intraprosthetic dislocation in this patient population and the macroscopic findings at the time of surgical revision and (2) evaluate whether isolated mobile component exchange could be an option to manage intraprosthetic dislocation occurring with a well-fixed dual mobility cup metal shell. METHODS From January 1991 to December 2009, a continuous series of 5274 THAs with dual mobility cups (4546 patients; 2773 women; mean [range] age 58 years [22-87]; bilateral THA = 728) were prospectively enrolled in our institutional total joint registry. A cementless, hemispherical dual mobility cup was systematically implanted, regardless of the patient's age or indication for THA. At the latest follow-up examination, the registry was queried to isolate each occurrence of intraprosthetic dislocation, which was retrospectively analyzed regarding the patient's demographics, indication for THA, radiographs, intraoperative findings (polyethylene wear and lesion patterns on the mobile component, periarticular metallosis, and implant damage because of intraprosthetic impingement of the femoral neck), management of intraprosthetic dislocation (isolated exchange of the mobile component or revision of the dual mobility cup), and outcome. RESULTS At a mean (range) follow-up duration of 14 years (3-26), 3% of intraprosthetic dislocations (169 of 5274) were reported, with a mean (range) time from THA of 18 years (13-22). Intraprosthetic dislocation occurred predominantly in younger men (mean [range] age at THA, 42 years [22-64] versus 61 years [46-87]; p < 0.001, and sex ratio (male to female, 1:32 [96 male and 73 female] versus 0.62 [1677 male and 2700 female]; p < 0.001) in patients with intraprosthetic dislocation and those without, respectively, but was not influenced by the indication for THA (105 patients with intraprosthetic dislocation who underwent THA for primary hip osteoarthritis and 64 with other diagnoses versus 3146 patients without who underwent THA for primary hip osteoarthritis and 1959 for other diagnoses (p = 0.9)). In all patients with intraprosthetic dislocation, a macroscopic analysis of the explanted mobile component revealed circumferential polyethylene wear and damage to the chamfer a
{"title":"Is Isolated Mobile Component Exchange an Option in the Management of Intraprosthetic Dislocation of a Dual Mobility Cup?","authors":"J. Wegrzyn, M. Malatray, V. Pibarot, G. Anania, J. Béjui-Hugues","doi":"10.1097/CORR.0000000000001055","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001055","url":null,"abstract":"BACKGROUND\u0000Intraprosthetic dislocation is a specific complication of dual mobility cups, although it occurs less frequently with the latest generations of implants. Intraprosthetic dislocation is related to long-term polyethylene wear of the mobile component chamfer and retentive area, leading to a snap-out of the femoral head. With the increased use of dual mobility cups, even in younger and active patients, the management of intraprosthetic dislocation should be defined according to its type. However, no previous studies, except for case reports, have described the strategy to manage long-term wear-related intraprosthetic dislocation, particularly when a dual mobility cup is not loose.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000This study aimed to (1) determine the prevalence of intraprosthetic dislocation in this patient population and the macroscopic findings at the time of surgical revision and (2) evaluate whether isolated mobile component exchange could be an option to manage intraprosthetic dislocation occurring with a well-fixed dual mobility cup metal shell.\u0000\u0000\u0000METHODS\u0000From January 1991 to December 2009, a continuous series of 5274 THAs with dual mobility cups (4546 patients; 2773 women; mean [range] age 58 years [22-87]; bilateral THA = 728) were prospectively enrolled in our institutional total joint registry. A cementless, hemispherical dual mobility cup was systematically implanted, regardless of the patient's age or indication for THA. At the latest follow-up examination, the registry was queried to isolate each occurrence of intraprosthetic dislocation, which was retrospectively analyzed regarding the patient's demographics, indication for THA, radiographs, intraoperative findings (polyethylene wear and lesion patterns on the mobile component, periarticular metallosis, and implant damage because of intraprosthetic impingement of the femoral neck), management of intraprosthetic dislocation (isolated exchange of the mobile component or revision of the dual mobility cup), and outcome.\u0000\u0000\u0000RESULTS\u0000At a mean (range) follow-up duration of 14 years (3-26), 3% of intraprosthetic dislocations (169 of 5274) were reported, with a mean (range) time from THA of 18 years (13-22). Intraprosthetic dislocation occurred predominantly in younger men (mean [range] age at THA, 42 years [22-64] versus 61 years [46-87]; p < 0.001, and sex ratio (male to female, 1:32 [96 male and 73 female] versus 0.62 [1677 male and 2700 female]; p < 0.001) in patients with intraprosthetic dislocation and those without, respectively, but was not influenced by the indication for THA (105 patients with intraprosthetic dislocation who underwent THA for primary hip osteoarthritis and 64 with other diagnoses versus 3146 patients without who underwent THA for primary hip osteoarthritis and 1959 for other diagnoses (p = 0.9)). In all patients with intraprosthetic dislocation, a macroscopic analysis of the explanted mobile component revealed circumferential polyethylene wear and damage to the chamfer a","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"104-B 4 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86854111","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1097/CORR.0000000000001053
Audrey N Kobayashi, R. Sterling, S. Tackett, Brant Chee, D. Laporte, C. Humbyrd
BACKGROUND Letters of recommendation are considered one of the most important factors for whether an applicant is selected for an interview for orthopaedic surgery residency programs. Language differences in letters describing men versus women candidates may create differential perceptions by gender. Given the gender imbalance in orthopaedic surgery, we sought to determine whether there are differences in the language of letters of recommendation by applicant gender. QUESTIONS/PURPOSES (1) Are there differences in word count and word categories in letters of recommendation describing women and men applicants, regardless of author gender? (2) Is author gender associated with word category differences in letters of recommendation? (3) Do authors of different academic rank use different words to describe women versus men applicants? METHODS Using a linguistic analysis in a retrospective study, we analyzed all letters of recommendation (2834 letters) written for all 738 applicants with completed Electronic Residency Application Service applications submitted to the Johns Hopkins Orthopaedic Surgery Residency program during the 2018 to 2019 cycle to determine differences in word category use among applicants by gender, authors by gender, and authors by academic rank. Thirty nine validated word categories from the Linguistic Inquiry and Word Count dictionary along with seven additional word categories from previous publications were used in this analysis. The occurrence of words in each word category was divided by the number of words in the letter to obtain a word frequency for each letter. We calculated the mean word category frequency across all letters and analyzed means using non-parametric tests. For comparison of two groups, a p value threshold of 0.05 was used. For comparison of multiple groups, the Bonferroni correction was used to calculate an adjusted p value (p = 0.00058). RESULTS Letters of recommendation for women applicants were slightly longer compared with those for men applicants (366 ± 188 versus 339 ± 199 words; p = 0.003). When comparing word category differences by applicant gender, letters for women applicants had slightly more "achieve" words (0.036 ± 0.015 versus 0.035 ± 0.018; p < 0.0001). Letters for men had more use of their first name (0.016 ± 0.013 versus 0.014 ± 0.009; p < 0.0001), and more "young" words (0.001 ± 0.003 versus 0.000 ± 0.001; p < 0.0001) than letters for women applicants. These differences were very small as each 0.001 difference in mean word frequency was equivalent to one more additional word from the word category appearing when comparing three letters for women to three letters for men. For differences in letters by author gender, there were no word category differences between men and women authors. Finally, when looking at author academic rank, letters for men applicants written by professors had slightly more "research" terms (0.011 ± 0.010) than letters written by associate professors (0.010 ±
{"title":"Are There Gender-based Differences in Language in Letters of Recommendation to an Orthopaedic Surgery Residency Program?","authors":"Audrey N Kobayashi, R. Sterling, S. Tackett, Brant Chee, D. Laporte, C. Humbyrd","doi":"10.1097/CORR.0000000000001053","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001053","url":null,"abstract":"BACKGROUND\u0000Letters of recommendation are considered one of the most important factors for whether an applicant is selected for an interview for orthopaedic surgery residency programs. Language differences in letters describing men versus women candidates may create differential perceptions by gender. Given the gender imbalance in orthopaedic surgery, we sought to determine whether there are differences in the language of letters of recommendation by applicant gender.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Are there differences in word count and word categories in letters of recommendation describing women and men applicants, regardless of author gender? (2) Is author gender associated with word category differences in letters of recommendation? (3) Do authors of different academic rank use different words to describe women versus men applicants?\u0000\u0000\u0000METHODS\u0000Using a linguistic analysis in a retrospective study, we analyzed all letters of recommendation (2834 letters) written for all 738 applicants with completed Electronic Residency Application Service applications submitted to the Johns Hopkins Orthopaedic Surgery Residency program during the 2018 to 2019 cycle to determine differences in word category use among applicants by gender, authors by gender, and authors by academic rank. Thirty nine validated word categories from the Linguistic Inquiry and Word Count dictionary along with seven additional word categories from previous publications were used in this analysis. The occurrence of words in each word category was divided by the number of words in the letter to obtain a word frequency for each letter. We calculated the mean word category frequency across all letters and analyzed means using non-parametric tests. For comparison of two groups, a p value threshold of 0.05 was used. For comparison of multiple groups, the Bonferroni correction was used to calculate an adjusted p value (p = 0.00058).\u0000\u0000\u0000RESULTS\u0000Letters of recommendation for women applicants were slightly longer compared with those for men applicants (366 ± 188 versus 339 ± 199 words; p = 0.003). When comparing word category differences by applicant gender, letters for women applicants had slightly more \"achieve\" words (0.036 ± 0.015 versus 0.035 ± 0.018; p < 0.0001). Letters for men had more use of their first name (0.016 ± 0.013 versus 0.014 ± 0.009; p < 0.0001), and more \"young\" words (0.001 ± 0.003 versus 0.000 ± 0.001; p < 0.0001) than letters for women applicants. These differences were very small as each 0.001 difference in mean word frequency was equivalent to one more additional word from the word category appearing when comparing three letters for women to three letters for men. For differences in letters by author gender, there were no word category differences between men and women authors. Finally, when looking at author academic rank, letters for men applicants written by professors had slightly more \"research\" terms (0.011 ± 0.010) than letters written by associate professors (0.010 ±","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"3 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74237388","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1097/CORR.0000000000001049
Selina R Silva
There is abundant work on brachial plexus birth palsies and I want to highlight current literature on the indications and results of soft-tissue releases and tendon transfers. While the subscapularis is the most commonly released tendon in this setting, other soft-tissue structures that can be released include the anterior capsule, the coracohumeral ligament, and the pectoralis major (usually as a z-plasty); resection of the coracoid sometimes is done to achieve improvement of global abduction and external rotation of the shoulder. A meta-analysis published in 2013 showed open release of the subscapularis was superior to arthroscopic release to improve global abduction of the shoulder, but improvement of external rotation between the two groups was the same [5]. In contrast, another study found that arthroscopic release of the subscapularis was superior to open z-plasty of the pectoralis major when measuring abduction, Mallet scores, active external rotation and hand-to-head motion. All the children in this study also had latissimus dorsi and teres major tendon transfers done at the same time as the soft-tissue release. It is important to note that this study demonstrated improvement in all children, but recommended consideration of arthroscopic soft-tissue release since it is less invasive [9]. Finally, two studies found remodeling of the glenohumeral joint if the mechanics of the shoulder are restored early. They used MRI or CT to demonstrate a more-central position of the humeral head on the glenoid and improvement of the glenoid retroversion [1, 4]. Surgeons need to know that remodeling is possible if these procedures are done early enough and not to delay treatment. Two studies looking specifically at the child’s age at the time of procedure and remodeling potential found that performing soft-tissue releases and tendon transfers on children up to 5 years of age will produce sufficient remodeling over time [3, 4], which tends to decrease the likelihood that humeral osteotomy will be indicated. There is at least agreement that the most helpful tendon transfers include the latissimus dorsi and the teres major [1, 6, 7, 9, 11]. This helps researchers in the field focus on the questions that we do not have answered yet. In the current study, Sarac and colleagues [10] found that young children with obstetric brachial plexus palsies can benefit from soft-tissue release and when there is a lack of active external rotation, a tendon transfer should be added. While these results echo the findings in earlier studies [1, 4, 6, 8], the current study is unique because it had a large number of children and 5-year follow-up. Indeed, the majority of the literature on this topic are small case series or small retrospective reviews.
{"title":"CORR Insights®: What Range of Motion is Achieved Five Years After an External Rotationplasty of the Shoulder in Infants with Obstetric Brachial Plexus Injury?","authors":"Selina R Silva","doi":"10.1097/CORR.0000000000001049","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001049","url":null,"abstract":"There is abundant work on brachial plexus birth palsies and I want to highlight current literature on the indications and results of soft-tissue releases and tendon transfers. While the subscapularis is the most commonly released tendon in this setting, other soft-tissue structures that can be released include the anterior capsule, the coracohumeral ligament, and the pectoralis major (usually as a z-plasty); resection of the coracoid sometimes is done to achieve improvement of global abduction and external rotation of the shoulder. A meta-analysis published in 2013 showed open release of the subscapularis was superior to arthroscopic release to improve global abduction of the shoulder, but improvement of external rotation between the two groups was the same [5]. In contrast, another study found that arthroscopic release of the subscapularis was superior to open z-plasty of the pectoralis major when measuring abduction, Mallet scores, active external rotation and hand-to-head motion. All the children in this study also had latissimus dorsi and teres major tendon transfers done at the same time as the soft-tissue release. It is important to note that this study demonstrated improvement in all children, but recommended consideration of arthroscopic soft-tissue release since it is less invasive [9]. Finally, two studies found remodeling of the glenohumeral joint if the mechanics of the shoulder are restored early. They used MRI or CT to demonstrate a more-central position of the humeral head on the glenoid and improvement of the glenoid retroversion [1, 4]. Surgeons need to know that remodeling is possible if these procedures are done early enough and not to delay treatment. Two studies looking specifically at the child’s age at the time of procedure and remodeling potential found that performing soft-tissue releases and tendon transfers on children up to 5 years of age will produce sufficient remodeling over time [3, 4], which tends to decrease the likelihood that humeral osteotomy will be indicated. There is at least agreement that the most helpful tendon transfers include the latissimus dorsi and the teres major [1, 6, 7, 9, 11]. This helps researchers in the field focus on the questions that we do not have answered yet. In the current study, Sarac and colleagues [10] found that young children with obstetric brachial plexus palsies can benefit from soft-tissue release and when there is a lack of active external rotation, a tendon transfer should be added. While these results echo the findings in earlier studies [1, 4, 6, 8], the current study is unique because it had a large number of children and 5-year follow-up. Indeed, the majority of the literature on this topic are small case series or small retrospective reviews.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"125 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85105220","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1097/CORR.0000000000001047
G. Guyton
The paradox of the lateral ankle sprain is not that so many patients do poorly following this injury, but rather that so many do well. The likelihood of recovery is remarkable given that perceived stability of the ankle requires the contribution of many factors including foot shape, passive mechanics of the ankle in the mortise, peroneal musculature, integrity of the ankle ligaments, and the patient’s chosen activities. If there is a lesson in all this, it is that no single factor entirely determines a pain-free and stable return to full activity. Consider an athlete with completely absent lateral ankle ligaments. When her ankle is suddenly inverted, a protective reflex arc activates the peroneal muscles. No amount of physical strengthening, however vigorous, can alter the speed of nerve conduction. The normal latency for the analogous Achilles reflex arc is 35 milliseconds—more than enough time for mechanical deformation to occur [3]. Some sports and activities may lead to faster andmoreunpredictable loads on the ankle than others. Therefore, no simple mechanical or biologic algorithm by itself will ever determine which patients will benefit from reconstruction. The longdistance runner will always have a different likelihood of rehabilitation success than the basketball player.When physical therapy regimens help despite the presence of mechanical instability, they do so by focusing not only on strength, but also on proprioception. It is likely that the patient who copes with ankle instability does so by activating themuscles prior to ground contact or, as recent evidence suggests, by absorbing the mechanical load through adjacent joints [2]. The key to evaluating interventions and outcomes in such a complex system is agreeing upon common tests that each measure one component of the problem. The Star Excursion Balance Test (SEBT) has been established by our physical therapy colleagues as a reliable and reproducible test of dynamic ankle stability [6]. Think of it as a “model sport” that, in the appropriate research setting, avoids the unthinkable complexity of separately evaluating each individual sport and each individual player position or activity. In the current study, Tsikopoulos and colleagues [12] use the SEBT to answer the common question of the utility of external braces to improve dynamic ankle stability. Surprisingly, the authors did not find a benefit to isolated use of external supports in the setting of the performance laboratory. It is important to remember that this does not necessarily imply that supporting the ankle does not help avoid reinjury. Not only may the demands of any one sport differ from those of the This CORR Insights is a commentary on the article “Do External Supports Improve Dynamic Balance in Patients with Chronic Ankle Instability? A Network Meta-analysis” by Tsikopoulos and colleagues available at: DOI: 10.1097/CORR.0000000000000946. The author certifies that he (GPG) or a member of his immediate family, has re
踝关节外侧扭伤的矛盾之处并不是很多患者在受伤后表现不佳，而是很多患者表现良好。考虑到踝关节的稳定性需要多种因素的共同作用，包括足形、踝关节的被动力学、腓骨肌肉组织、踝关节韧带的完整性和患者选择的活动，恢复的可能性是显著的。如果说这一切能给我们带来什么教训的话，那就是没有一个单一的因素能完全决定一个人能否无痛苦地、稳定地恢复全面活动。考虑一个踝关节外侧韧带完全缺失的运动员。当她的脚踝突然倒立时，一个保护性的反射弧激活了腓肌。再多的体力锻炼，无论多么有力，都不能改变神经传导的速度。类似的跟腱反光弧的正常潜伏期为35毫秒——足够发生机械变形的时间[3]。一些运动和活动可能会导致脚踝承受比其他运动更快和更不可预测的负荷。因此，简单的机械或生物算法本身无法决定哪些患者将从重建中受益。长跑运动员康复成功的可能性总是与篮球运动员不同。尽管存在机械不稳定，但物理治疗方案还是有帮助的，他们不仅注重力量，而且注重本体感觉。应对踝关节不稳定的患者可能是通过在接触地面之前激活肌肉来应对的，或者像最近的证据表明的那样，通过相邻关节吸收机械负荷来应对[2]。在这样一个复杂的系统中，评估干预措施和结果的关键是商定共同的测试，每个测试都测量问题的一个组成部分。星偏移平衡试验(SEBT)已由我们的物理治疗同事建立，作为一种可靠且可重复的动态踝关节稳定性试验[6]。在适当的研究环境下，可以将其视为一种“模式运动”，避免单独评估每项运动和每个运动员的位置或活动所带来的难以想象的复杂性。在目前的研究中，Tsikopoulos及其同事[12]使用SEBT来回答外支架在提高踝关节动态稳定性方面的应用这一常见问题。令人惊讶的是，作者没有发现在性能实验室环境中单独使用外部支架的好处。重要的是要记住，这并不一定意味着支持脚踝不能帮助避免再次受伤。不仅任何一项运动的要求可能与那些不同。这篇CORR见解是对文章“外部支持是否改善慢性踝关节不稳定患者的动态平衡?”的评论。Tsikopoulos及其同事的“网络元分析”可在:DOI: 10.1097/CORR.0000000000000946。提交人证明，他(GPG)或他的直系亲属在研究期间已经或可能收到Paragon28(美国CO . Englewood)提供的1万至10万美元的付款或福利，以及Wright Medical(美国田纳西州孟菲斯)提供的< 1万美元的付款或福利。提交人证明，他(GPG)或他的直系亲属在研究期间已经或可能收到Wright Medical (Memphis, TN, USA)和Arthrex (Naples, FL, USA)的付款或福利金额< 10,000美元。所表达的观点是作者的观点，不反映CORR或骨关节外科医生协会的观点或政策。美国马里兰州巴尔的摩市北卡尔弗特街3333号，MedStar联合纪念医院骨科足部及踝部，G. P. Guyton MD (MD)，邮箱:gpguyton@gmail.com
{"title":"CORR Insights®: Do External Supports Improve Dynamic Balance in Patients with Chronic Ankle Instability? A Network Meta-analysis.","authors":"G. Guyton","doi":"10.1097/CORR.0000000000001047","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001047","url":null,"abstract":"The paradox of the lateral ankle sprain is not that so many patients do poorly following this injury, but rather that so many do well. The likelihood of recovery is remarkable given that perceived stability of the ankle requires the contribution of many factors including foot shape, passive mechanics of the ankle in the mortise, peroneal musculature, integrity of the ankle ligaments, and the patient’s chosen activities. If there is a lesson in all this, it is that no single factor entirely determines a pain-free and stable return to full activity. Consider an athlete with completely absent lateral ankle ligaments. When her ankle is suddenly inverted, a protective reflex arc activates the peroneal muscles. No amount of physical strengthening, however vigorous, can alter the speed of nerve conduction. The normal latency for the analogous Achilles reflex arc is 35 milliseconds—more than enough time for mechanical deformation to occur [3]. Some sports and activities may lead to faster andmoreunpredictable loads on the ankle than others. Therefore, no simple mechanical or biologic algorithm by itself will ever determine which patients will benefit from reconstruction. The longdistance runner will always have a different likelihood of rehabilitation success than the basketball player.When physical therapy regimens help despite the presence of mechanical instability, they do so by focusing not only on strength, but also on proprioception. It is likely that the patient who copes with ankle instability does so by activating themuscles prior to ground contact or, as recent evidence suggests, by absorbing the mechanical load through adjacent joints [2]. The key to evaluating interventions and outcomes in such a complex system is agreeing upon common tests that each measure one component of the problem. The Star Excursion Balance Test (SEBT) has been established by our physical therapy colleagues as a reliable and reproducible test of dynamic ankle stability [6]. Think of it as a “model sport” that, in the appropriate research setting, avoids the unthinkable complexity of separately evaluating each individual sport and each individual player position or activity. In the current study, Tsikopoulos and colleagues [12] use the SEBT to answer the common question of the utility of external braces to improve dynamic ankle stability. Surprisingly, the authors did not find a benefit to isolated use of external supports in the setting of the performance laboratory. It is important to remember that this does not necessarily imply that supporting the ankle does not help avoid reinjury. Not only may the demands of any one sport differ from those of the This CORR Insights is a commentary on the article “Do External Supports Improve Dynamic Balance in Patients with Chronic Ankle Instability? A Network Meta-analysis” by Tsikopoulos and colleagues available at: DOI: 10.1097/CORR.0000000000000946. The author certifies that he (GPG) or a member of his immediate family, has re","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"99 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85903535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1097/CORR.0000000000001045
John A. Walker, T. Walters, M. Parker, J. Wenke
BACKGROUND Muscle injury may result in damage to the vasculature, rendering it unable to meet the metabolic demands of muscle regeneration and healing. Therefore, therapies frequently aim to maintain, restore, or improve blood supply to the injured muscle. Although there are several options to assess the vascular outcomes of these therapies, few are capable of spatially assessing perfusion in large volumes of tissue. QUESTIONS/PURPOSES Can dynamic contrast-enhanced CT (DCE-CT) imaging acquired with a clinical CT scanner be used in a rat model to quantify perfusion in the anterior tibialis muscle at spatially relevant volumes, as assessed by (1) the blood flow rate and tissue blood volume in the muscle after three levels of muscle stimulation (low, medium, and maximum) relative to baseline as determined by the non-stimulated contralateral leg; and (2) how do these measurements compare with those obtained by the more standard approach of microsphere perfusion? METHODS The right anterior tibialis muscles of adult male Sprague Dawley rats were randomized to low- (n = 10), medium- (n = 6), or maximum- (n = 3) level (duty cycles of 2.5%, 5.0%, and 20%, respectively) nerve electrode coupled muscle stimulation directly followed by DCE-CT imaging. Tissue blood flow and blood volume maps were created using commercial software and volumetrically measured using NIH software. Although differences in blood flow were detectable across the studied levels of muscle stimulation, a review of the evidence suggested the absolute blood flow quantified was underestimated. Therefore, at a later date, a separate set of adult male Sprague Dawley rats were randomized for microsphere perfusion (n = 7) to define blood flow in the animal model with an accepted standard. With this technique, intra-arterial particles sized to freely flow in blood but large enough to lodge in tissue capillaries were injected. Simultaneously, blood sampling at a fixed flow rate was simultaneously performed to provide a fixed blood flow rate sample. The tissues of interest were then explanted and assessed for the total number of particles per tissue volume. Tissue blood flow rate was then calculated based on the particle count ratio within the reference sample. Note that a tissue's blood volume cannot be calculated with this method. Comparison analysis to the non-stimulated baseline leg was performed using two-tailed paired student t-test. An ANOVA was used to compare difference between stimulation groups. RESULTS DCE-CT measured (mean ± SD) increasing tissue blood flow differences in stimulated anterior tibialis muscle at 2.5% duty cycle (32 ± 5 cc/100 cc/min), 5.0% duty cycle (46 ± 13 cc/100 cc/min), and 20% duty cycle (73 ± 3 cc/100 cc/min) compared with the paired contralateral non-stimulated anterior tibialis muscle (10 ± 2 cc/100 cc/min, mean difference 21 cc/100 cc/min [95% CI 17.08 to 25.69]; 9 ± 1 cc/100 cc/min, mean difference 37 cc/100 cc/min [95% CI 23.06 to 50.11]; and 11 ± 2 cc
{"title":"Can Dynamic Contrast-Enhanced CT Quantify Perfusion in a Stimulated Muscle of Limited Size? A Rat Model.","authors":"John A. Walker, T. Walters, M. Parker, J. Wenke","doi":"10.1097/CORR.0000000000001045","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001045","url":null,"abstract":"BACKGROUND\u0000Muscle injury may result in damage to the vasculature, rendering it unable to meet the metabolic demands of muscle regeneration and healing. Therefore, therapies frequently aim to maintain, restore, or improve blood supply to the injured muscle. Although there are several options to assess the vascular outcomes of these therapies, few are capable of spatially assessing perfusion in large volumes of tissue.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000Can dynamic contrast-enhanced CT (DCE-CT) imaging acquired with a clinical CT scanner be used in a rat model to quantify perfusion in the anterior tibialis muscle at spatially relevant volumes, as assessed by (1) the blood flow rate and tissue blood volume in the muscle after three levels of muscle stimulation (low, medium, and maximum) relative to baseline as determined by the non-stimulated contralateral leg; and (2) how do these measurements compare with those obtained by the more standard approach of microsphere perfusion?\u0000\u0000\u0000METHODS\u0000The right anterior tibialis muscles of adult male Sprague Dawley rats were randomized to low- (n = 10), medium- (n = 6), or maximum- (n = 3) level (duty cycles of 2.5%, 5.0%, and 20%, respectively) nerve electrode coupled muscle stimulation directly followed by DCE-CT imaging. Tissue blood flow and blood volume maps were created using commercial software and volumetrically measured using NIH software. Although differences in blood flow were detectable across the studied levels of muscle stimulation, a review of the evidence suggested the absolute blood flow quantified was underestimated. Therefore, at a later date, a separate set of adult male Sprague Dawley rats were randomized for microsphere perfusion (n = 7) to define blood flow in the animal model with an accepted standard. With this technique, intra-arterial particles sized to freely flow in blood but large enough to lodge in tissue capillaries were injected. Simultaneously, blood sampling at a fixed flow rate was simultaneously performed to provide a fixed blood flow rate sample. The tissues of interest were then explanted and assessed for the total number of particles per tissue volume. Tissue blood flow rate was then calculated based on the particle count ratio within the reference sample. Note that a tissue's blood volume cannot be calculated with this method. Comparison analysis to the non-stimulated baseline leg was performed using two-tailed paired student t-test. An ANOVA was used to compare difference between stimulation groups.\u0000\u0000\u0000RESULTS\u0000DCE-CT measured (mean ± SD) increasing tissue blood flow differences in stimulated anterior tibialis muscle at 2.5% duty cycle (32 ± 5 cc/100 cc/min), 5.0% duty cycle (46 ± 13 cc/100 cc/min), and 20% duty cycle (73 ± 3 cc/100 cc/min) compared with the paired contralateral non-stimulated anterior tibialis muscle (10 ± 2 cc/100 cc/min, mean difference 21 cc/100 cc/min [95% CI 17.08 to 25.69]; 9 ± 1 cc/100 cc/min, mean difference 37 cc/100 cc/min [95% CI 23.06 to 50.11]; and 11 ± 2 cc","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"23 1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75580505","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-07DOI: 10.1097/CORR.0000000000001052
C. Reitman
Single-level tubular decompressive minimally invasive surgery (MIS) for patients with stenosis is technically demanding, and therefore, the more severe the stenosis, the greater potential for residual symptoms and loss of function because of inadequate decompression. Among spine surgeons, we have seen an increased preference for minimally invasive procedures for spinal disorders [8] because MIS of the spine has been shown to decrease length of stay, offer higher suitability for outpatient procedures, decrease blood loss, lower narcotic requirements, and lower infection rates [5]. Having said that, once outside the early convalescent period, patients-reported outcomes scores following less-invasive surgery are not much different from those after more-conventional open procedures [4, 6]. One concern I have, though, is learning curve associated withMIS [7]. In the last 15 years, I have observed increased interest in MIS, and more publications about these approaches with each passing year. However, in my observation, most of these papers are written by designers, originators of techniques, consultants, or highvolume surgeons who are well outside their learning curves with these new approaches. As these techniques gain traction in the broader practice community, we should not assume that a surgeon just learning a lessinvasive technique will be able to replicate results achieved by a designer, originator, or experienced surgeon who has hundreds or even thousands of these procedures under his or her belt. Believing otherwise (or practicing without consideration of this fact) puts patients at risk. I also am concerned by the fact that many of these studies are selective case series or historically controlled studies, which suffer heavily in some instances from selection bias (the easier procedures being done MIS, and the morechallenging ones decanted into the “control” group, if there is a control group).This is one of the strengths of the current study by Kulkarni and Das [2]; although a small number of patients in this large series were lost to follow-up, it was a genuine all-comers study, with no exclusions. It also focused on some of the more-difficult single-level procedures we see, those with extreme stenosis, and despite this, none underwent conversion to an open procedure and no alternate forms of decompression procedure were used. Having said that, it is clearly the work of surgeons experienced in this technique, and we should not assume their results will generalize to surgeons who are new to this approach, as they probably will not. This CORR Insights is a commentary on the article “Are There Differences Between Patients with Extreme Stenosis and Nonextreme Stenosis in Terms of Pain, Function or Complications After Spinal Decompression Using a Tubular Retractor System?” by Kulkarni and Das available at:DOI: 10.1097/CORR.0000000000001004. The author certifies that neither he, nor any members of his immediate family, have any commercial associat
对狭窄患者进行单节段小管减压微创手术(MIS)在技术上要求很高，因此，狭窄越严重，由于减压不充分导致残留症状和功能丧失的可能性越大。在脊柱外科医生中，我们发现越来越多的人倾向于采用微创手术治疗脊柱疾病[8]，因为脊柱MIS已被证明可以缩短住院时间，更适合门诊手术，减少失血，减少麻醉需求，降低感染率[5]。话虽如此，一旦过了早期恢复期，患者报告的微创手术后的预后评分与更传统的开放手术后的评分没有太大差异[4,6]。不过，我担心的是与管理信息系统相关的学习曲线[7]。在过去的15年里，我观察到人们对管理信息系统的兴趣与日俱增，每年都有更多关于这些方法的出版物。然而，根据我的观察，这些论文大多是由设计师、技术创始者、顾问或高容量外科医生撰写的，他们对这些新方法的学习曲线远远超出了他们的学习曲线。随着这些技术在更广泛的实践社区中获得牵引力，我们不应该假设一个外科医生仅仅学习一种侵入性较小的技术就能复制设计者、创创者或经验丰富的外科医生所取得的结果，这些外科医生在他或她的belt下进行了数百甚至数千次此类手术。否则(或不考虑这一事实的做法)会使患者处于危险之中。我还担心的是，这些研究中有许多是选择性的病例系列或历史对照研究，在某些情况下，这些研究严重受到选择偏差的影响(MIS完成的程序更容易，而更具挑战性的程序则被转移到“对照组”中，如果有对照组的话)。这是Kulkarni和Das当前研究的优势之一[2];虽然在这个大系列中有一小部分患者没有随访，但这是一个真正的所有患者的研究，没有排除。它也集中在我们看到的一些更困难的单节手术，那些极度狭窄的人，尽管如此，没有人接受了开放手术也没有使用其他形式的减压手术。话虽如此，这显然是经验丰富的外科医生的工作，我们不应该假设他们的结果会推广到新的外科医生，因为他们可能不会。这篇CORR Insights文章是对“使用管状牵开系统进行脊柱减压后，极度狭窄和非极度狭窄患者在疼痛、功能或并发症方面是否存在差异?”Kulkarni和Das的文章，可在:DOI: 10.1097/CORR.0000000000001004。提交人证明，他本人及其直系亲属均无任何可能与所提交文章产生利益冲突的商业协会(如咨询公司、股票所有权、股权、专利/许可安排等)。所表达的观点是作者的观点，不反映CORR或骨关节外科医生协会的观点或政策。C. A. Reitman MD (MD)，美国南卡罗来纳州查尔斯顿南卡罗来纳医科大学骨科与物理医学系，Email: reitman@musc.edu
{"title":"CORR Insights®: Are There Differences Between Patients with Extreme Stenosis and Non-extreme Stenosis in Terms of Pain, Function or Complications After Spinal Decompression Using a Tubular Retractor System?","authors":"C. Reitman","doi":"10.1097/CORR.0000000000001052","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001052","url":null,"abstract":"Single-level tubular decompressive minimally invasive surgery (MIS) for patients with stenosis is technically demanding, and therefore, the more severe the stenosis, the greater potential for residual symptoms and loss of function because of inadequate decompression. Among spine surgeons, we have seen an increased preference for minimally invasive procedures for spinal disorders [8] because MIS of the spine has been shown to decrease length of stay, offer higher suitability for outpatient procedures, decrease blood loss, lower narcotic requirements, and lower infection rates [5]. Having said that, once outside the early convalescent period, patients-reported outcomes scores following less-invasive surgery are not much different from those after more-conventional open procedures [4, 6]. One concern I have, though, is learning curve associated withMIS [7]. In the last 15 years, I have observed increased interest in MIS, and more publications about these approaches with each passing year. However, in my observation, most of these papers are written by designers, originators of techniques, consultants, or highvolume surgeons who are well outside their learning curves with these new approaches. As these techniques gain traction in the broader practice community, we should not assume that a surgeon just learning a lessinvasive technique will be able to replicate results achieved by a designer, originator, or experienced surgeon who has hundreds or even thousands of these procedures under his or her belt. Believing otherwise (or practicing without consideration of this fact) puts patients at risk. I also am concerned by the fact that many of these studies are selective case series or historically controlled studies, which suffer heavily in some instances from selection bias (the easier procedures being done MIS, and the morechallenging ones decanted into the “control” group, if there is a control group).This is one of the strengths of the current study by Kulkarni and Das [2]; although a small number of patients in this large series were lost to follow-up, it was a genuine all-comers study, with no exclusions. It also focused on some of the more-difficult single-level procedures we see, those with extreme stenosis, and despite this, none underwent conversion to an open procedure and no alternate forms of decompression procedure were used. Having said that, it is clearly the work of surgeons experienced in this technique, and we should not assume their results will generalize to surgeons who are new to this approach, as they probably will not. This CORR Insights is a commentary on the article “Are There Differences Between Patients with Extreme Stenosis and Nonextreme Stenosis in Terms of Pain, Function or Complications After Spinal Decompression Using a Tubular Retractor System?” by Kulkarni and Das available at:DOI: 10.1097/CORR.0000000000001004. The author certifies that neither he, nor any members of his immediate family, have any commercial associat","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89818443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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