The Iowa orthopaedic journal最新文献

Background: Complex proximal femoral deformities such as slipped capital femoral epiphyses (SCFE) or residual Perthes disease pose challenging clinical problems due to the severity of pathological femoral head and neck changes from long-standing childhood disease. Utilizing the combination of surgical dislocation (SD) and proximal femoral osteotomy (PFO) is an option to address both the intra-articular pathologies as well as the maximal correction of the proximal femoral deformities. The purpose of this systematic review was to report clinical and radiographical outcomes for patients undergoing these combined procedures.

Methods: A systematic review of the literature was performed utilizing PRISMA guidelines. Databases queried were PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their dates of inception to 7/03/2024. Studies were included if they reported outcomes for patients undergoing combined SDs and PFOs. Each study's data was manually retrieved from the full-text manuscript. The study design, surgical technique, indications, demographic and radiographic data, outcomes, and complications of each study were analyzed.

Results: There were six case series (Evidence Level IV) included in this review. There were 132 patients (46% female) with mean age of 16.5 years (range: 9-30). Etiologies were most commonly SCFE (50.8%) and Perthes (31.8%). Mean follow-up was 40.1 months (range: 3-127). The mHHS improved from 61.9±4.5 to 84.8±6.7. Complication rates were low at 11.4% with the most common complication being instrumentation failure (20%). Lateral slip angles improved from 58.5°±6.5° to 14.4 ±3.6° in 42 patients who underwent combined SD/PFO for SCFE. Alpha angles improved from 86.7°±6.7° to 50.9°±4.8°. Articular-trochanteric distance improved from 0.7±4.5mm to 23.4±3.1mm.

Conclusion: Combined SDs and PFO's should be considered a safe and effective treatment option for patients with severe femoral head and neck pathologies which were more likely from long-standing childhood diseases instead of severe deformities in the setting of SCFE or residual Perthes. This review demonstrated positive radiographic and clinical outcomes when these patients are treated, as well as a low complication and AVN rate. Further research should continue to study the combined approach in larger cohorts and at longer-term follow-up. Level of Evidence: IV.

Background: Patients with large, irreparable rotator cuff tears may develop a compensated cuff arthropathy (CCA) with persistent shoulder pain from contact between the humeral head and acromion. This study reports shoulder pain relief, functional outcomes, and complications in CCA patients treated with greater tuberosity resurfacing (GTR).

Methods: A retrospective case-series review of patients who underwent GTR between 2014 and 2021 by a single community hospital-based surgeon was conducted. Patients who failed nonoperative treatment underwent diagnostic arthroscopy. If the rotator cuff was deemed irreparable intraoperatively, a metallic implant (HemiCAP) was placed at the supraspinatus insertion via a miniopen deltoid splitting approach. Postoperatively, patients followed a standard physiotherapy regimen. Shoulder range of motion, American Shoulder and Elbow Surgeons (ASES) assessment form, Pennsylvania Shoulder Score (PSS), satisfaction scores were collected, and complications recorded.

Results: Of the 33 shoulders, (32 patients), that had a GTR, 29 shoulders (28 patients) were included in the final analysis (two patients were converted to reverse shoulder arthroplasty, one was lost to follow-up, and one was deceased). Mean age was 69 years. Mean follow-up was 48 months. Mean postoperative ASES and PSS were 79 and 74, respectively. Patients were very satisfied with the procedure in 18 (62%) shoulders and satisfied in five (17%) shoulders. Twenty-four patients (86%) with 25 shoulders (86%) stated they would recommend the procedure.

Conclusion: GTR for CCA showed significant pain relief, acceptable functional outcomes, and low revision rates. GTR reduces pain and maintains function in patients with CCA and minimal glenohumeral arthritis. Level of Evidence: IV.

Background: The majority of orthopaedic residents match into fellowship in the subspecialty they are most interested in at the start of residency, however there is a lack of understanding of medical student interest in orthopaedic subspecialties. Our objective was to determine interest in arthroplasty among medical students interested in orthopaedic surgery, and to identify factors contributing to student interest and disinterest..

Methods: An anonymous online survey was developed and distributed to medical students interested in orthopaedic surgery at 23 United States allopathic and osteopathic medical schools through their school administrators. Descriptive statistics were calculated, and a Fisher's exact test was used for categorical variables.

Results: 183 medical students (56% female) completed the survey for an estimated 29% response rate. Significantly fewer female medical students were interested in adult reconstruction compared to their male counterparts (10% versus 29%, p = 0.004). The most commonly identified factors contributing to interest by female students were interest in the subject matter (100%) and patient population (70%), while male students most commonly identified clinical experience (74%) and presence of a mentor (63%). Significantly fewer female medical students received the suggestion to pursue arthroplasty compared to males (0% versus 11%, p = 0.002).

Conclusion: Female medical students are significantly less interested in arthroplasty and receive significantly less encouragement to consider arthroplasty than their male counterparts. Factors influencing both interest and disinterest in orthopaedic subspecialties differ between male and female medical students.Level of Evidence: V.

Background: Conversion total hip arthroplasty (THA) after prior hip surgery is generally associated with higher rates of complications when compared to primary THA. There is a paucity of evidence examining the influence of surgical approach on outcomes of conversion THA. This study compares complication rates between direct anterior approach (DAA) and posterior approach (PA) in patients with prior hip or acetabular fracture fixation undergoing conversion THA.

Methods: Records were reviewed for patients undergoing conversion total hip arthroplasty with prior hip or acetabular fracture fixation from January 1, 2006 to June 30, 2023 at a single institution. Complication rates were assessed at 90 days and at final follow-up. A total of 104 patients were included in the study, with 75 in the PA cohort and 29 in the DAA cohort.

Results: There were no significant differences in complication rates between cohorts at both 90 days and at final follow-up (mean 754 days) including rates of dislocation, intraoperative fracture, postoperative periprosthetic fracture, periprosthetic joint infection, superficial surgical site infection, and wound dehiscence.

Conclusion: Conversion THA on patients with prior hip or acetabular fracture fixation can be successful from either an anterior or posterior approach. Each approach may offer unique benefits and disadvantages depending on patient-specific factors. Further research is needed to evaluate long-term outcomes and complication rates associated with each surgical approach. Level of Evidence: IV.

Hip arthroscopy is a surgical procedure commonly used for hip pathologies including femoroacetabular impingement (FAI). Perioperative considerations in hip arthroscopy have not been explored as thoroughly as more common orthopedic procedures. Preferences vary between surgeons, and there is no current consensus regarding various aspects of perioperative management. Utilization of traction, patient positioning, type of anesthesia, regional nerve blocks, as well as the use of antibiotic prophylaxis and tranexamic acid must be considered. This review will summarize the current literature on this topic, identify recent techniques that have demonstrated promise, and provide suggested direction for future research. Level of Evidence: IV.

Background: To determine the accuracy of preoperative magnetic resonance arthrogram (MRA) in detecting capsulolabral adhesions in patients undergoing revision hip arthroscopy.

Methods: We retrospectively reviewed revision hip arthroscopies performed by a single surgeon between 2019 and 2022. Patients without preoperative MRA were excluded. Musculoskeletal radiologists blinded to surgical variables assessed pre-operative axial T1 FS MRA for adhesions and graded adhesions as mild (length <5 mm), moderate (5-10 mm), or severe (> 10mm). Paralabral sulcus effacement increased the grade one level beyond adhesion length. Intraoperative arthroscopy images were evaluated for the incidence and severity of adhesions. Adhesions were graded intraoperatively as mild (rare, small adhesions), moderate (multiple or large adhesions), or severe (many adhesions disrupting labral function). A grade of 0 was assigned if no adhesions were present. Graders were blinded to each other, and Wilcoxon signed-rank test compared diagnosis methods. Sensitivity, specificity, and predictive values (PPV, NPV) were also calculated.

Results: We identified 42 patients, 45 hips with pre-operative MRA undergoing revision hip arthroscopy. On MRA grading, there were 41 patients with adhesions (93%), of which 14 were considered severe (33%), 22 moderate (52%), and 6 mild (14%). On intraoperative grading (ICC 0.73, Kappa 0.35), there were 32 cases (71%) with 14 considered severe (31%), 10 moderate (22%), and 8 mild (18%). There was no difference in severity assessment between pre-operative MRA and intraoperative findings (P<0.001). Pre-operative MRA was moderately able to predict intra-operative adhesions (sensitivity 90.6%, PPV 69%). Specificity could not be calculated.

Conclusion: Axial T1 FS MRA is a sensitive tool to assess for capsulolabral adhesions in the revision arthroscopy setting. MRA best predicts severe adhesions and is moderately predictive of mild and moderate adhesions. Level of Evidence: IV.

Background: Opioid-related deaths continue to rise annually in the United States, prompting a search for alternative or adjunct pain management strategies. Concurrently, marijuana has become increasingly legal, widely used, and culturally accepted. Within orthopedic surgery, there is growing interest in exploring the potential role of marijuana as a component of multimodal pain control. This study aimed to evaluate the impact of self-reported marijuana use on postoperative opioid prescribing patterns in patients undergoing hip and knee arthroplasty.

Methods: This retrospective study reviewed the medical records of patients treated by a single hip and knee arthroplasty surgeon. Patients were divided into two cohorts based on self-reported marijuana use: those who reported use and those who denied use. The primary outcome was the total morphine milligram equivalents (MME) prescribed within the first 90 days following surgery. Statistical analysis was conducted to compare prescribing patterns between the two groups.

Results: 97 patients were surveyed with a mean age of 64 years old. There were 61 females (62.9%) and 26 (37.1%) males. There were 39 (40.2%) primary total hips and 58 (59.8%) primary total knees. Patients who self-reported marijuana use were prescribed significantly higher MMEs within the 90-day postoperative period compared to those who denied marijuana use (983 MME vs. 501 MME, p=0.019). The difference in opioid prescribing patterns suggests that marijuana use may not mitigate postoperative opioid requirements and could potentially be associated with higher opioid consumption.

Conclusion: Self-reported marijuana use was associated with increased opioid prescribing in the early postoperative period following hip and knee arthroplasty. These findings highlight the need for further investigation into the relationship between marijuana use and postoperative pain management to better inform clinical practice and optimize multimodal analgesic strategies. Level of Evidence: III.

Background: This cadaveric study aims to evaluate the anatomical structures at risk and the amount of joint preparation achieved during percutaneous first metatarsophalangeal joint preparation with a Shannon burr using a direct medial and dorsal-lateral approach.

Methods: Eleven fresh-frozen cadaver foot and ankle specimens underwent first metatarsophalangeal joint preparation with a Shannon burr under fluoroscopy. Following joint preparation, dissection was carried out to locate and evaluate critical soft tissue structures in the vicinity of the first metatarsophalangeal joint, including the extensor hallucis longus tendon, medial dorsal cutaneous nerve, and lateral dorsal digital artery. Measurements from the surgical site to these critical structures were recorded. Image analysis using ImageJ software was conducted to measure the joint surface area prepared on both the distal metatarsal and proximal phalanx articular surfaces.

Results: Contact with the lateral dorsal digital artery and extensor hallucis longus tendon occurred three times each out of the 11 procedures (27%) through the dorsal-lateral approach without macroscopic laceration. The medial dorsal cutaneous nerve was contacted three times (27%) via the medial approach without macroscopic laceration and transected once (9%). The average percentage of joint preparation for the distal first metatarsal was 71.8% (+/- 24.0%), and for the proximal first phalanx was 78.2% (+/- 19.8%). There was no statistically significant difference in joint preparation percentage between both surfaces (p = 0.507). The raw joint surface area prepared on the metatarsal and phalangeal surfaces was 215.24 mm³and 187.98 mm³, respectively.

Conclusion: This study emphasizes the importance of understanding local anatomy and maintaining surgical precision during percutaneous first metatarsophalangeal joint fusion using a Shannon burr. Additionally, this technique offers comparable joint surface preparation to other minimally invasive techniques, however, inferior joint preparation compared to open techniques. Future studies with larger in vivo sample sizes are warranted to further refine the percutaneous approach and enhance patient outcomes. Level of Evidence: V.

Background: The current standard for assessing orthopedic technical skill demonstrated in operating room performance relies primarily on subjective evaluations administered by an expert mentor. This study demonstrates the utility of fluoroscopic image-based analysis as an objective mechanism for assessing technical proficiency for a common wire navigation procedure by comparing it for the first time to the gold standard in orthopedic skills assessment: subjective expert opinion.

Methods: The final pin construct achieved during the closed reduction and percutaneous pinning of pediatric supracondylar humerus fractures was assessed for 23 operating room performances from fluoroscopic imaging to produce an objective ranking. Individual rank-orderings from six experts were independently aggregated into a consensus ranking for the same 23 performances. Inter-rater reliability of expert assessments was measured as Cronbach's α for individual rankings. Spearman correlation coefficients were used to evaluate relationships between individual expert rankings, a consensus ranking, and an algorithm ranking derived from objective scores.

Results: The inter-rater reliability of the experts' individual rankings yielded an α of 0.78, exceeding the 0.70 threshold for acceptable reliability. There was strong agreement between the objective ranking and the expert consensus (R2 = 0.59), with the objective ranking agreement with consensus being superior to all but one individual expert.

Conclusion: These findings suggest that objective fluoroscopic image-based analysis is an effective tool for assessing technical operating room performance and highlight its potential role as a complementary tool to expert assessment in orthopedic skills training.

Clinical relevance: While traditional assessments of intraoperative skill performance based on expert opinion remain important, they can be limited by cognitive biases and variability in feedback. The integration of objective metrics with expert consensus offers a more robust and scalable approach to skill assessment. This hybrid method has potential to complement subjective evaluations by facilitating more consistent and data-driven feedback, which can be particularly useful for training programs with limited mentor availability.