The Iowa orthopaedic journal最新文献

Background: Walking is a vital activity often compromised in individuals with neuropathic conditions. Charcot-Marie-Tooth (CMT) disease and Cerebral Palsy (CP) are two common neurodevelopmental disabilities affecting gait, predisposing to the risk of falls. With guiding scientific evidence limited, there is a critical need to better understand how surgical correction affects mobility, balance confidence, and gait compared to ankle foot orthosis (AFO) bracing. A systematic approach will enable rigorous collaborative research to advance clinical care.

Methods: Key elements of this vision include 1) prospective studies in select patient cohorts to systematically compare conservative vs. surgical management, 2) objective laboratory-based evaluation of patient mobility, balance, and gait using reliable methods, and 3) use of patient-centric outcome measures related to health and mobility.

Results: Valid and reliable standardized tests of physical mobility and balance confidence have been described in the literature. They include 1) the four-square step test, a widely used test of balance and agility that predicts fall risk, 2) the self-selected walking velocity, a measure of general mobility able to detect function change with orthosis use, and 3) the activity specific balance confidence scale, a survey instrument that assesses an individual's level of balance confidence during activity. Additionally, motion capture and ground reaction force data can be used to evaluate whole-body motion and loading, with discriminative biomechanical measures including toe clearance during the swing phase of gait, plantarflexion at 50% of swing, peak ankle plantarflexor moment, and peak ankle push-off power.

Conclusion: The tools needed to support evidence-based practice and inform clinical decision making in these challenging patient populations are all available. Research must now be conducted to better understand the potential benefits and limitations of AFO use in the context of mobility and balance during gait for individuals with neuropathic conditions, particularly relative to those offered by surgical correction.

Clinical relevance: Following this path of research will provide comparative baseline data on mobility, balance confidence, and gait that can be used to inform an objective criterion-based approach to AFO prescription and the impact of surgical intervention.

Background: A 60-year-old female underwent proximal tibial autograft harvest for a Cotton osteotomy. Her postoperative course was complicated by psychogenic non-epileptic seizure (PNES) episodes leading to unintentional weightbearing. Knee radiographs at 6 weeks post-procedure demonstrated a displaced proximal tibia fracture through the autograft harvest site. Further clinical review revealed metabolic derangements consistent with secondary hyperparathyroidism. Initial nonoperative treatment led to atrophic varus nonunion requiring definitive treatment with total knee arthroplasty with revision components.

Conclusion: This case describes a rare complication of proximal tibial autograft harvest and highlights the importance of preoperative metabolic workup and bone health optimization.Level of Evidence: IV.

Background: Bernese periacetabular osteotomy (PAO) improves symptoms and delays degenerative changes in patients with acetabular dysplasia. Yet, eventual total hip arthroplasty (THA) is needed in many of these patients. The impact of PAO on subsequent THA outcomes is not well defined.

The purpose of this study is to define: 1) clinical outcomes, 2) post-operative complications and 3) implant survivorship for patients undergoing THA after prior ipsilateral PAO.

Methods: A retrospective review was conducted at three institutions to identify individuals undergoing THA after ipsilateral PAO surgery with minimum 1 year follow up. Patient reported outcome measures (PROMs) were collected preoperatively and at final follow-up. Surgical details, radiographic and clinical outcomes, and major complications according to the modified Dindo-Clavien classification system were identified through review of the medical record. Regression analysis and student's t-test were used to compare pre- and post-operative outcome scores. Kaplan-Meier analysis was performed to estimate reoperation-free survivorship.

Results: A total of 113 THA in 112 patients were identified with initial review. 103 hips had a minimum of 1-year follow-up and an average follow of 5 ± 4 years (range, 1 to 20). 10 hips (9%) were lost to follow-up leaving 103 (91%) hips available for review with a minimum of 1-year follow-up (mean = 5 years). Mean interval from PAO to THA was 7.7 years (range, 2-15). The average post-operative mHHS improved 37 points (50 to 87, P < 0.001) when compared to pre-operative scores. Eight patients (7.1%) experienced a major grades III-V) surgical complication. These included 2 cases of instability, 2 cases of acetabular loosening, and one case each of periprosthetic fracture, wound dehiscence, periprosthetic infection, acetabular loosening and pneumonia. Failures occurred early at average 3.2 years and survivorship analysis for all-cause revision demonstrated 96% survivorship at both 5 and 10 years.

Conclusion: THA after PAO achieves significant clinical improvement and satisfactory survivorship (96%) at mid-term follow-up, with a major complication rate of 7.1%. Level of Evidence: III.

Background: Hip dysplasia diagnosed after skeletal maturity is distinct from developmental dysplasia of the hip (DDH) in infants and young children. While the natural history of DDH in infants and young children is well-established, the association between hip dysplasia diagnosed after skeletal maturity and osteoarthritis is less clear. This narrative review summarizes existing literature assessing characteristics of hip dysplasia diagnosed after skeletal maturity associated with progression to osteoarthritis.

Methods: Publications were identified from a PubMed search. Three reviewers screened articles for studies that longitudinally assessed progression to osteoarthritis, disability, or arthroplasty for individuals with untreated hip dysplasia identified after skeletal maturity. In total, 13 articles met screening criteria, including 7 prospective cohorts, 2 case-control studies, 1 retrospective case series, 1 cross-sectional analysis, and 2 retrospective cohort studies.

Results: Most studies reported an association between radiographic hip dysplasia and development of osteoarthritis over time,^1-10 though some studies questioned the association between simple radiographic measures of dysplasia and joint degeneration.¹¹ Joint subluxation and incongruity, history of hip pain, and any evidence of radiographic osteoarthritis at the initial time-point were all reliably associated with future joint degeneration. Though many studies confirmed at least an association between the center edge angle of Wiberg and future osteoarthritis development, there was evidence proposed that clinical factors (age, sex, body mass), novel radiographic markers, and pathologic joint mechanics are significant contributors to joint failure.

Conclusion: Hip dysplasia diagnosed after skeletal maturity is associated with development of osteoarthritis beyond 10 years in the majority of published literature, though some studies question the reliability of simple radiographic measures as predictors of osteoarthritis development. Previous literature is limited by small sample size, follow up duration, low diversity in the population, and variable methods characterize severity of hip dysplasia and hip joint failure. Overall, evidence of hip subluxation and incongruity, female sex, more severe dysplasia, and low and high body mass are associated with development of osteoarthritis. Future studies should focus on large, diverse populations with follow up of at least 20 years and consider advanced metrics to quantify pathologic joint mechanics to predict hip joint failure. Level of Evidence: IV.

Background: Septic arthritis is an orthopedic emergency. Diagnosis is difficult in patients with concomitant crystalline arthropathy (gout or pseudogout). The symptomatology of crystal arthritis mimics septic arthritis, clouding clinical diagnosis. Arthrocentesis and synovial fluid analysis are the standard diagnostic tests for both pathologies. Crystals on microscopy are diagnostic of crystal arthritis, however their presence does not rule out septic arthritis. Septic arthritis is diagnosed by positive microbiology culture. Though septic arthritis is associated with elevated synovial total nucleated count (TNC), TNC elevations can also occur with gout. The literature suggests that a TNC count of > 50,000 cells in a crystal-positive joint should raise suspicion for concurrent septic arthritis, however data is limited. Further diagnostic indicators are needed to help clinicians promptly identify crystal positive septic arthritis as the treatments and prognoses are different.

Methods: Patients were retrospectively identified who had arthrocentesis of a native joint positive for monosodium urate (MSU) and/or (CPPD) crystals. Laboratory data was collected including synovial fluid cultures, total nucleated cell count (TNC), percent polymorphic neutrophils (%PMN), and crystal analysis; and serum CRP, ESR, and white blood cell count (WBC). Statistical analysis performed using Spearman correlation, Univariate-Fischer's exact and Wilcoxon tests, and multivariate analysis.

Results: 442 joints identified with positive CPPD and/or MSU crystals, 31% female, 69% male. Of 442 aspirates, 58 had positive cultures. Patients were more likely to have positive cultures if synovial TNC > 50,000 (odds ratio 7.7), CRP > 10 mg/dL (OR 3.2), PMN > 90% (OR 2.17), and if the patient was female (OR 1.9), all were statistically significant with p < 0.05. There were 55 patients who underwent irrigation and debridement based on clinical suspicion or a positive gram stain, 37 of these ultimately had a positive culture (67%), the remaining 18 had negative cultures.

Conclusion: Results are consistent with the literature, a TNC > 50,000 warrants a high suspicion for concurrent septic arthritis and should prompt providers to critically evaluate other patient laboratory data. Results further suggests that a patient with positive crystals, synovial TNC > 50,000 cells, PMN > 90%, and serum CRP > 10mg/dL is at high risk for having a concurrent septic arthritis and may warrant urgent irrigation and debridement and antibiotic therapy. This data serves as a supporting to develop an infection risk calculator for crystal positive septic arthritis. Level of Evidence: III.

Background: A case of chronic osteomyelitis with Brodie's abscess of the cuboid caused by a wooden foreign body penetrating the plantar foot. Total cuboidectomy was carried out with implantation of an anatomically molded antibiotic-impregnated cement spacer with culture-specific postoperative intravenous antibiotics. At six months of follow-up, the patient was completely asymptomatic without evidence of a recurrence of infection. Final radiographs also didn't show spacer migration or surrounding bone erosions. The spacer obviated the need for any foot fusion which preserved foot biomechanics. The patient didn't need to use any braces or insoles.

Conclusion: Osteomyelitis should always be on the differential list of lytic lesions of the tarsal bones, especially if there is a history of prior foot trauma. In this case, cuboid excision and placement of an antibiotic-impregnated cement spacer provided sustained relief of symptoms without evidence of recurrence or complications for six months.Level of Evidence: V.

Background: Fibular hemimelia is the most common congenital long bone deficiency. It is often associated with femoral and tibial deficiencies which result in a clinically evident leg length discrepancy. The primary soft tissue concern is ACL/PCL deficiency. If treatment includes bony lengthening, joint stability is imperative to avoid complications. In this study, we detail a novel technique for long bone lengthening and ACL reconstruction in a single, cohesive surgery. This consolidates the need for multiple procedures and offers improved limb length symmetry and knee stability for this patient population. Clinical outcomes of pediatric patients with hemimelia who underwent either femoral or tibial lengthening with PRECICE® nail and concomitant ACL reconstruction are presented.

Methods: After IRB approval, we identified five patients with complex fibular hemimelia who underwent ACL reconstruction and concomitant lengthening with at least two years of follow-up. Two patients (40%) presented with congenital short femur, and three (60%) with congenital short tibia. In each case, ACL reconstruction and either femoral or tibial guided growth via PRECICE® nail were performed. Operative techniques involving both soft tissue and bony methodology are described in detail.

Results: All patients had objective improvement in knee stability as assessed both intra and post operatively, as well as successful intermedullary lengthening without complications related to joint stability. Three patients had minor complications unrelated to joint stability that did not interfere with overall result.

Conclusion: Fibular hemimelia associated with hypoplasia of bony and soft tissue structures can be successfully addressed with concomitant ligamentous reconstruction at the time of implantation of lengthening devices. This addresses knee instability and reduces both number of operative procedures and potential complications related to joint instability while pursuing bony lengthening. Level of Evidence: V.

Background: Within the realm of orthopedic literature, the determination of statistical significance for outcomes relies on probability analysis and the reporting of P-values. The aim of this study was to employ fragility analysis as a means of evaluating the resilience of randomized controlled trials (RCTs) that assess meniscus surgeries. It was hypothesized that dichotomous outcomes would be statistically fragile and comparable to other orthopedic specialties.

Methods: Included in this study were RCTs reporting dichotomous measures pertaining to meniscus repair, sourced from 14 orthopedic journals indexed on PubMed between 2000 and 2022. The fragility index (FI) for each outcome was determined by iteratively reversing a single outcome event until the significance was reversed. To calculate the fragility quotient (FQ), the FI of each study was divided by its respective sample size. Additionally, the interquartile range (IQR) was calculated for both the FI and FQ.

Results: Out of the 7,844 articles screened, a total of 17 RCTs with 112 dichotomous outcomes were included for analysis. The FI for all the outcomes was 7, with an IQR of 4 to 10. Similarly, the FQ was 0.067, with an IQR of 0.029 to 0.107. However, statistically significant outcomes had a FI and FQ of 4 (IQR 2 to 7) and .057 (IQR 0.03 to 0.108), respectively. The average number of patients lost to follow-up was 2 patients and 17.6% of studies reporting lost to follow up of 7 or greater.

Conclusion: Recent findings suggest that the stability of the literature concerning meniscus repair may not be as robust as previously assumed. Consequently, we strongly advocate for the inclusion of the FI and FQ metrics, alongside the P-value, to enhance the interpretation of clinical findings presented in the meniscus repair literature. Level of Evidence: I.

Background: The COVID-19 pandemic disrupted healthcare systems across the United States resources were consumed caring for COVID-19 patients. Past research on trauma activations during COVID-19 has found changes to hospital length of stay and discharge locations. Subaxial spine fractures are potentially debilitating injuries that require timely surgery and extensive rehabilitation. Accordingly, the objective of this study was to compare the severity of cervical spine injuries, time to surgery, hospital length of stay, and discharge disposition for patients presenting during COVID-19.

Methods: 128 patients with subaxial fractures from a Level One Adult Trauma Center that required surgical intervention were reviewed. The primary outcomes included hospital length of stay, ICU days, time to surgery, complications, and discharge location in patients with subaxial cervical fractures during COVID-19 pandemic versus immediately before the pandemic.

Results: When comparing the pre-COVID-19 period to the COVID-19 group, there was no difference in time to surgery or overall length of stay (2.47 vs. 2.35 days and 12.93 vs. 13.82 days, p>0.05). There was no difference in number of patients discharged home during COVID-19 (41% (32/79) vs. 37% (18/49) p>0.05) or patients discharged to hospital rehab (33%, (26/79) vs. 35% (17/49), p>0.05). A similar percentage of patients had complications within 90 days of discharge (16% (12/75) vs. 22% (10/46), p>0.05).

Conclusion: Despite the burden COVID-19 placed on healthcare systems, it did not affect post-operative hospital course of subaxial fracture patients with potentially debilitating injuries. This vulnerable subset of patients presenting during COVID-19 was still able to undergo timely surgery, have an appropriate hospital length of stay, and be discharged to rehabilitation centers. In future stresses to the healthcare system, deferring elective and non-emergent procedures can allow proper care for emergencies such as subaxial fractures. Level of Evidence: II.