Bulletin of the Hospital for Joint Disease (2013)最新文献

Abstract: Cervical spondylosis is a broad term that describes pathological degeneration of the cervical spine, leading to axial neck pain, cervical myelopathy, and radiculopathy. Surgical treatments have been developed to address cervical radiculopathy and myelopathy, with the gold standard being anterior cervical diskectomy and fusion (ACDF). However, cervical fusion is associated with many well-known complications, such as pseudarthrosis and adjacent segment disease (ASD). As a result, cervical disk arthroplasty (CDA) was developed as an alternative to fusion for addressing cervical pathology without the risk of pseudarthrosis while preserving mobility and theoretically decreasing the risk of ASD. CDA, however, is uniquely associated with heterotopic ossification formation. While ACDF remains the gold standard, newer studies with long-term follow-up extending up to 20 years have begun to demonstrate superiority of CDA over ACDF, with lower rates of ASD. While the success of CDA is leading to a change in practice patterns, there is still a role for fusion in the management of cervical disease.

Background: The purpose of our study was to identify force plate-derived balance metrics that were predictive of multimodal return-to-sport test findings in a sample of anterior cruciate ligament reconstruction patients.

Methods: We conducted a cross-sectional study of anterior cruciate ligament reconstruction patients who were at least 6 months postoperative. Subjects completed our multimodal Institutional RTS testing battery which included testing of hip and knee range of motion (ROM), isokinetic quadriceps strength, and core trunk muscle strength (Bunkie test), as well as balance testing on a force plate. Balance metrics predictive of Institutional RTS test findings for the involved leg were identified using multivariable regression with stepwise selection. Model significance was assessed at α = 0.002.

Results: Sixteen subjects (7M, 9F) were enrolled in our study with a median age of 29 years (range 20-47). Multivariate multiscale entropy (MMSExyz) of the involved leg was predictive of knee flexion active ROM (P = .02) and Bunkie stabilizing test score (P = .03), MMSExyz of the uninvolved leg was predictive of Bunkie lateral and medial test scores (P = .02 and P = .02), and interlimb symmetry of MMSExyz was predictive of triple jump test score (P = .007). Interlimb symmetry of the COPx shift balance metric was predictive of hip internal rotation active and passive ROM (P = .008 and P = .03) and step-down test score (P = .004).

Conclusion: Force plate-based balance testing metrics are predictive of some return-to-sport test findings including knee flexion ROM and Bunkie test scores, but further analysis is needed to identify balance metrics predictive of quadriceps isokinetic testing and muscle flexibility testing results.

Background: Nordic combined (NC) and ski jumping (SJ) athletes have a high prevalence of chronic hip pathology, which may lead to altered knee and ankle biomechanics.

Purpose: The purpose of this study was to determine the relationship among athlete-reported lower extremity outcomes in a proximal-to-distal sequence.

Study design/level of evidence: cross-sectional study, Level IV.

Methods: Elite SJ and NC athletes who competed at the national and international levels were prospectively recruited to complete a survey eliciting information about their Hip Disability and Osteoarthritis Outcome Score (HOOS), International Knee Demographic Committee (IKDC) score, and Foot and Ankle Outcome Score (FAOS). Univariate linear regressions modeling IKDC scores and FAOS subscores were performed for each of the following independent variables: age, sex, body mass index, Nordic event (NC or SJ), HOOS subscore, and FAOS subscore or IKDC score, respectively.

Results: A total of 22 athletes were included in the study. HOOS symptoms subscores were significantly lower (worse) among SJ athletes compared with NC athletes (P = .002). HOOS quality of life subscores were lower for female athletes compared with male athletes (54 ± 21, 73 ± 4.0; P = .029) in the entire cohort. An increase in the HOOS pain subscore (0.54 ± 0.20, P = .016) and HOOS sports subscore (0.40 ± 0.17, P = .042) was associated with a significant increase in the IKDC score. An increase in the HOOS symptoms subscore (0.63 ± 0.21, P = .011) was associated with a significant increase in the FAOS symptoms subscore.

Conclusion: Elite NC and SJ athletes are at high risk of hip pain, which increases their risk of developing knee and ankle pain as well. These findings strongly suggest that training targeted at hip strength and conditioning may optimize knee and ankle outcomes in elite NC and SJ athletes.

Clinical relevance: The results of this study may help guide physicians, allied health personnel, and coaches to alter lower extremity training regimens to decrease the risk of injury.

Background: Children and adolescents are vulnerable to the ongoing opioid overdose epidemic in the United States. To minimize pediatric patients' exposure to opioids, efforts are underway to reduce opioid prescriptions after closed reduction and percutaneous pinning (CRPP) for supracondylar humerus fractures. Standardized pain management protocols preferentially using opioid-free analgesics are reported to be effective in managing postoperative pain and limiting the utilization of opioids. This study compares retrospective data collected before and after the implementation of a standardized postoperative pain management protocol at a large academic children's hospital. The primary aim of this study was to compare opioid prescription patterns during the 2 periods. The secondary aim of the study was to determine the effect of the protocol on minimizing prescription errors.

Methods: This Institutional Review Board-approved study was a retrospective review of pediatric patients who underwent CRPP for supracondylar humerus fractures between January 2019 and December 2021. A control cohort of patients treated before the implementation of a department-approved pain management protocol was compared with a cohort of patients treated after the implementation of a standardized postoperative pain management protocol. We compared the number of opioid prescriptions provided to patients before and after the implementation of the protocol. Descriptive statistics and chi-square analyses were used to evaluate prescribing patterns.

Results: After the implementation of the standardized pain medication control protocol, we observed a successful decrease in pediatric patients receiving postoperative opioids from 49.6% to 13.6% and in opioid prescribing errors from 38.6% to 12.5%. In addition, there was reduced variability in the type of narcotics prescribed. After the protocol's implementation, the most common combination of medication prescribed for postoperative pain control was acetaminophen and ibuprofen (69.5%). The chi-square test demonstrated no significant association between postoperative opioid prescription and fracture classification or length of stay.

Conclusion: Opioid prescription patterns for postoperative pain management after CRPP for supracondylar humerus fractures were highly variable before the introduction of a standardized pain management protocol. The introduction of the standardized guideline effectively decreased the number of opioids prescribed at discharge, resulted in fewer opioid prescribing errors, and reduced variability in prescribing patterns among providers.

Level of evidence: Level IV-retrospective case series.

Introduction: The integration of computer-assisted navigation systems (CASs) in total knee arthroplasty (TKA) procedures has gained popularity in recent years. However, additional validation of the accuracy of CAS feedback is necessary. We used short-length and full-length postoperative radiographs to quantify the differences between alignment parameters measured by a novel imageless CAS and alignment outcomes as evidenced on postoperative radiographs.

Materials and methods: A retrospective analysis was conducted on prospectively collected data from a cohort of patients undergoing navigated primary TKA. Fifty-eight patients had met inclusion criteria, and intraoperative CAS measurements were obtained from device recordings. Alignment parameters were measured digitally and included femorotibial angle on short-length films and hip-knee-ankle axis, mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) on full-length films. These were compared between CAS and radiograph measurements using a 2-tailed t test.

Results: The mean mLDFA measured by the CAS was 0.7° ± 1.1°, compared with 1.3° ± 1.4° as measured on full-body radiographs (P = .1). The mean mMPTA measured by the CAS was 0.2° ± 1.0°, compared with 0.9° ± 1.4° as measured on full-body radiographs (P = .06). On average, radiograph and CAS measurements differed by 0.5° ± 1.5° for mLDFA and 0.7° ± 1.5° for mMPTA. The average postoperative hip-knee-ankle axis was 177.6° ± 2.1°, and the average femorotibial angle was 176.0° ± 9.6° as measured on radiographs.

Conclusion: No significant differences in either average or individual measured values for mLDFA or mMPTA were observed between the intraoperative CAS measurements and alignment outcomes postoperatively. Our data highlight the clinical utility of CASs to accurately achieve intended TKA alignment objectives.

Introduction: Medicare's Bundled Payments for Care Initiative is a risk-sharing, value-based alternative payment model. As such, Medicare providers are financially responsible for poor outcomes, potentially disincentivizing operating on high-risk individuals, including obese patients and smokers. We sought to describe the change in these modifiable risk factors among Medicare, Medicaid, and commercially insured patients in the 6-year period after implementation of Bundled Payments for Care Initiative.

Methods: We analyzed a consecutive series of 11,790 patients who underwent total hip arthroplasty between January 1, 2013, and August 31, 2019. We categorized patients based on smoking status (current, former, or never) and body mass index (BMI; obese if BMI was >30 kg/m2, morbidly obese if BMI was >40 kg/m2, and superobese if BMI was >50 kg/m2). Correlations between each year's proportion of patients in each smoking category and obesity category were evaluated.

Results: We included 11,582 patients with complete demographic and insurance information. There was a statistically significant decrease in the proportion of Medicare patients who were active smokers (7.91% in 2013, 5.99% in 2019, Pearson correlation coefficient = -0.759, P = .048). When looking at patients with BMI >40 kg/m2, commercially insured patients significantly increased (3.64% in 2013, 6.65% in 2019, Pearson correlation coefficient = 0.860, P = .013). Our study also demonstrated a significantly higher rate of active smokers among Medicaid patients compared with other insurance groups (P = .001), which is consistent with the general population.

Discussion: Our results demonstrated that the proportion of Medicare-insured patients who were active smokers decreased significantly over the study period. In addition, the proportion of obese commercially insured patients increased, but the proportion of obese Medicare patients did not. These findings suggest the possibility that surgeons may be disincentivized to operate on both obese patients and those who are actively smoking who are enrolled in risk-sharing, value-based programs. Notably, we found a potential trickle-down effect to Medicare patients with our smoking cessation program. The same was not observed for patients with Medicaid or Commercial insurance or for weight reduction before surgery for any insurance group. A possible explanation is that obesity is not as modifiable as smoking and increased efforts to address obesity in the arthritis population are needed.

Level of evidence: III, retrospective observational analysis.

Abstract: The aim of this study was to provide a review for orthopedic surgeons on the care of para athletes. The article focuses on common patient populations that present to orthopedic surgeons, including individuals with spinal cord injuries and related disorders, limb deficiencies, and neuromuscular conditions. The most common types of injuries affecting these para athletes will be discussed, as well as strategies for injury prevention and treatment. This review article also dives into the historical origins of para sports and discusses how treatment can potentially influence classification levels for para athletes. Orthopedic surgeons should encourage their patients with disabilities to participate in para sports, understand the types of injuries they may be at risk of based on disability and sports-specific factors, and work to help keep para athletes successfully competing in the sports they love.

Background: The purpose of our study was to compare patient-reported outcomes at 6-month follow-up between primary hip arthroscopy patients who were partial weight bearing on crutches for 4 weeks vs. 1 week postoperatively.

Methods: We conducted a pseudorandomized clinical trial involving patients who underwent arthroscopic treatment of femoroacetabular imipingement at a single center from September 2020 to April 2021. Subjects aged 18-65 years old were alternately assigned to one of the 2 rehabilitation regimens involving either 4-week or 1-week partial weight bearing on crutches. Subjects completed the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) surveys before surgery and at 6-month follow-up. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) was assessed using published mHHS cutoff values. Outcomes were compared between groups with the Mann-Whitney U test and analysis of covariance, while MCID, SCB, and PASS rates were compared with the Fisher exact test. P-values < .05 were considered significant.

Results: Fifty patients were included in the study of whom 28 (56.0%) were assigned to 4-week crutch use and 22 (44.0%) to 1-week crutch use. The 4-week crutch use group was significantly older on average (38.4 vs. 32.1 years, P = .03) and had significantly higher mean body mass index (27.6 vs. 24.5, P = .01), but there were no significant baseline differences between the 2 groups (P > .05). After adjusting for age and body mass index, there was no significant difference in preoperative to postoperative improvement in mHHS (P = .43) or NAHS (P = .46) between the 2 groups at 6-month follow-up. Furthermore, there were no significant differences in achievement rates for MCID (P = .50), SCB (P = .51), or PASS (P = .77) between the 2 groups.

Conclusion: We identified no significant differences in improvement of mHHS and NAHS or achievement of the MCID, SCB, or PASS at 6-month follow-up between patients on crutches for 4 weeks vs. 1 week postoperatively.

Level of evidence: II, Pseudorandomized clinical trial.

Abstract: Parkinson disease (PD) is the second most common neurodegenerative disorder in the United States. Despite its rapid increase in prevalence over recent years, there remains a paucity of literature examining the optimal orthopedic management of populations affected by PD and the risk of complications. In this review, we provide insight into the pathophysiology, etiology, manifestations, and orthopedic management of PD, with an emphasis on adult reconstruction. Although limited outcome studies suggest that joint replacement may consistently offer improvement in pain, there is an increased risk of complications and reoperation, with significant functional improvement often being unpredictable.