The Iowa orthopaedic journal最新文献

Background: The purpose of this study was to better understand the prevalence and implications of smoking status on patients undergoing shoulder stabilization surgery. In particular, we wanted to test the hypothesis that smokers were more likely to undergo glenoid bone augmentation procedures.

Methods: The present study included all patients 12 to 66 years of age undergoing surgery for anterior shoulder instability in the MOON Shoulder Instability cohort. Analysis was done to determine the prevalence of smokers within the cohort and to determine the relationship of smoking with undergoing a glenoid bone augmentation surgery like the Latarjet.

Results: There were 61 smokers (4.8%) among 1267 patients undergoing anterior shoulder instability surgery in our cohort. Smoking was associated with older age, higher BMI, socioeconomic status as determined by DCI score, and minority status. Smokers were more likely to higher number of dislocation events prior to surgery. Although it did not reach significant smokers had a higher percentage of patients with glenoid bone loss. Logistic regression modeling showed that smoking and higher number of dislocation events were statistically associated with undergoing a glenoid bony augmentation surgery such as Latarjet.

Conclusion: The study determined the prevalence of smoking in a large shoulder instability cohort to be 4.8%. Multi-variate analysis demonstrated that smoking and at least 3 dislocation events were statistically associated with undergoing a glenoid bony augmentation surgery. Level of Evidence: III.

Background: Previous biomechanical studies correlating strength of healing with mRUST are limited to a single mode of intramedullary fixation. This study evaluated the correlation between mRUST and biomechanical strength in a fracture healing model using fixation methods that generated different modes of healing.

Methods: Biomechanical data were sourced from previous ovine osteotomy studies and included 24 sheep, 12 fixed with rigid constructs and 12 fixed with a single relatively stable construct. The sheep were sacrificed at 9 weeks and the tibiae were loaded to failure in torsion. Load to failure was recorded as a percentage of the contralateral intact tibia. Standardized 9 week radiographs were reviewed and the mRUST score was recorded.

Results: A fracture was considered biomechanically healed if it retained 72% of the strength of the contralateral side. In the rigid group, the mRUST score correctly determined the biomechanical healing state in 6/12 fractures. Specifically, it correctly labeled 6 fractures ununited and incorrectly labeled 6 ununited fractures as healed. In the relative stability group, the mRUST correctly determined the biomechanical healing state in 9/12 fractures. Specifically, it correctly labeled 1 fracture ununited and 8 fractures united. The mRUST correctly predicted healing in 9/12 fractures stabilized with a residual fracture gap, but only 4/12 stabilized without a residual fracture gap.

Conclusion: This is the first study to evaluate the biomechanical accuracy of the mRUST score in fracture models using both rigid and relatively stable fractures. The results suggest a disparity in the accuracy of the mRUST to predict biomechanical healing in rigid fixation versus relative fixation constructs and in fractures stabilized with and without residual fracture gaps.

Clinical relevance: Caution should be used when applying the score to fractures stabilized with rigid fixation methods without residual fracture gaps.

Background: Patients' characteristics, both physical and mental, are proven to have relationships to patient-reported outcomes following orthopaedic surgeries. This study aims to elucidate the impact of resilience, using the Brief Resilience Scale, on patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or Achilles tendinopathy with secondary exploratory analysis on factors influencing these outcomes.

Methods: Patients were selected utilizing the current procedural terminology code 27687 between 2013-2020. The electronic medical record was reviewed for basic demographics. Patients were contacted for patient-reported outcome measurement information system (PROMIS) scores, foot function index (FFI) scores, and brief resilience scale survey questionnaires. Pearson correlations were used to assess the association of FFI and PROMIS domains. A linear regression model was constructed to evaluate the independent effect of resilience on each FFI and PROMIS outcome instrument. A significance threshold of P < 0.05 was used to determine significance in the regression model.

Results: Increased resiliency showed a significant correlation with increased PROMIS physical function (r = 0.46, p<0.0001), decreased PROMIS pain interference (r = -0.043, p < 0.0001), and decreased PROMIS depression (r= -0.04, p < 0.0001). Increased resiliency showed a significant correlation with decreased FFI activity limitation (r= -0.047, p < 0.0001), decreased FFI disability (r = -0.53, p < 0.0001), decreased FFI pain (r = -0.36, p < 0.0001), and decreased FFI total (r= -0.52, p < 0.0001).

Conclusion: This study demonstrates the positive impact resilience has on patient-reported outcomes following isolated gastrocnemius recession for patients with a clinical diagnosis of either Achilles tendinopathy or plantar fasciitis. We were able to show a moderate correlation between higher resiliency and improved PROMIS and FFI scores for all domains. Optimizing resiliency preoperatively may help to optimize an individual's own surgical outcomes and aid physicians in managing patient expectations following surgery. Level of Evidence: IV.

Background: Bone mineral density (BMD) warrants attention given its role in secondary fracture prevention and pre-surgical optimization in orthopaedic surgery. While fracture liaison services (FLS) offer expertise in the management of osteoporosis medications that are known to increase BMD, these resources further coordinate the prescription of vitamin D supplementation and provide nutritional counseling to include adequate amounts of dietary calcium and protein, along with recommendations of intentional exercise to improve a patient's overall bone health and decrease fall risk. This case series describes patients who experienced increase in bone mineral density with these non-pharmacologic interventions.

Methods: Retrospective review was performed to identify patients experiencing an increase in BMD on dual-energy x-ray absorptiometry (DXA) scan after presenting to the bone health clinic of a level one academic trauma center since January 2020. Patients prescribed an osteoporosis medication were excluded. Each patient's prior bone health history, comorbidities, prior injuries, DXA data, and laboratory values were recorded. Bone health interventions including nutrition optimization, to include adequate daily dietary intake of calcium and protein, intentional exercise, as well as vitamin D supplementation were noted.

Results: 12 patients experienced an increase in bone mineral density with non-pharmacologic interventions. Average age of the series was 64.8 years (range 51-76 years) and seven were female. 75% were referred by orthopaedic subspecialty services with 50% being referred after sustaining a fracture. All 12 patients experienced an increase in total hip BMD with and average increase of 3.7% (range 1.0-6.8%), while spine BMD was seen to increase in 10 patients for an average increase of 6.0% (range 1.4-10.5%). Increases in femoral neck BMD were only seen in eight patients with an average increase of 1.5% (range 0.6% - 2.8%). Interval time between initial DXA and repeat DXA was 21.7 months (range 12.2-47.4 months).

Conclusion: Incorporation of vitamin D supplementation along with a nutrient dense diet to include adequate dietary intake of calcium and protein, along with exercise counseling may provide a method of improving bone mineral density in orthopaedic patients. These findings highlight the importance providing additional non-pharmacologic interventions for patients treated by the FLS. Level of Evidence: IV.

Background: The aim of this study was too quantify loss of skeletal muscle mass that occurs early after high energy trauma and determine the association with poor nutrition intake.

Methods: This prospective cohort study was completed at a midwest academic level 1 trauma center. Patients aged 18 - 55 years old with acute open fracture of the extremity/pelvis and/or two or more injured extremities treated with operative fixation were enrolled. Body composition was measured with bioelectrical impedance analysis at time of injury, 6 weeks, and 12 weeks after injury (Lean Body Mass (LBM), Skeletal Muscle Mass (SMM), Percent Body Fat (%BF)).Dietary intake was measured with the Vioscreen® survey at time of injury and at 3 months. Baseline to post-operative changes in body composition were evaluated using repeated measures generalized linear models (GLM). To determine whether body composition changes differed according to baseline protein insufficiency, subjects were grouped according to baseline protein insufficiency status (<0.8 g protein/Kg Bodyweight, y/n) and analyses were repeated with addition of a group*time interaction term to GLM models.

Results: Twenty patients (male, n=16 (80%)), mean age 37.7 SD 12.4 years) from June 2021 - June 2022 were enrolled. Subjects lost significant LBM at 6 weeks (mean = -5.2kg SD5.6kg, p=0.0007), 12 weeks (mean = -5.3kg SD5.5 kg, p=0.0017), and 24 weeks (mean = -8.3kg SD 7.3kg, p=0.0037). and significant SMM at 6 weeks (mean= -3.0kg SD 3.3kg, p=0.0009), 12 weeks (mean = -3.1 kg SD 3.2 kg, p=0.0013) and 24 weeks (mean = -4.8kg SD 4.4kg, p= 0.0049). There was also a significant increase in %BF seen at follow-up (0.45% SD 0.16%, p<0.05). Five out of 20 subjects were protein deficient at the time of injury. Protein deficiency was not associated with loss of LBM or SMM.

Conclusion: This study documented significant loss of LBM and SMM and increases in %BF after high energy musculoskeletal trauma. Insufficient protein intake was not associated with greater loss of muscle mass in this small series. Level of Evidence: II.

Background: Roughly 500,000 total hip arthroplasties (THAs) are performed each year in the US, often with participation of resident surgeons. Though previous studies have not established a link between resident involvement in orthopedic surgery and complications, these investigations have lacked data such as number of residents involved, year-in-training, involvement of physician extenders, and level of attending involvement.

Methods: A retrospective study examined all patients who underwent THAs at the Veterans Affairs (VA) Puget Sound from 1999-2016 and had a minimum of 90 days of follow-up. Data was collected on patient and treatment factors as well as postoperative dislocation. Logistic regression analysis was employed to determine the characteristics associated with dislocation.

Results: Twenty-three patients (2.5%) experienced a dislocation. Dislocation was associated with increasing age (p = 0.004) and THA head diameter (p < 0.001), but not with year-in-training of the most senior resident (p=1.00) or number of residents involved (p=1.00), and did not vary significantly by form of attending involvement (p = 0.837). Multivariable analysis demonstrated independent associations of patient age (OR 1.056 per additional year, p = 0.009) and THA head diameter (OR 0.806 per additional millimeter, p = 0.002) with dislocation.

Conclusion: Dislocation was associated with increasing patient age and smaller THA head diameter, but not factors related to surgical training. THA may be safely performed by residents supervised through graduated autonomy, with the degree of attending supervision varying by case complexity and the resident's experience and skill. Level of Evidence: III.

Background: The purpose of this study was to examine the proportion of patients who returned for their previously scheduled knee arthroscopy procedure following state-mandated cancellation of elective procedures during COVID-19 lockdown.

Methods: We reviewed a retrospective cohort of patients who had planned knee arthroscopies, excluding ligament reconstruction and irrigation/ debridement, cancelled for a date between March and June 2020. The cohort was evaluated for scheduling outcome, returned versus did not return for surgery, before March 2022. Cancellation and reschedule dates, reason for not returning for surgery, patient demographics, and planned surgical characteristics were collected. Characteristics between patients who returned versus did not return were compared using statistical tests of independence.

Results: The cohort consisted of 66 patients; 53 (80%) rescheduled and 13 (20%) did not return. For those who rescheduled, the average time between cancellation and surgery was 115 days (sd=16 days). There were various reasons for not rescheduling surgery: eight (62%) had symptom alleviation; two (15%) had logistical barriers; three (23%) were lost to follow-up. Obesity status had a trend towards significance with lower proportion of rescheduled procedures for non-obese patients (68%) compared to obese patients (89%, p=0.057).

Conclusion: Our study highlights a natural experiment in forced delay of elective knee arthroscopies, which may be a surrogate for conservative management. The proportion of patients who did not return for a scheduled knee arthroscopy surgery (20%) is higher than what has been reported previously (11%) and 62% of these patients found symptom relief. However, 80% of the cohort did return for knee arthroscopy in within two years, suggesting delaying surgery will not alleviate symptoms for the majority of patients. Level of Evidence: IV.

Background: This study aims to determine the rate of surgical intervention in children with type IIA supracondylar humerus fractures (SCHF) following routine post-casting radiographic assessment. We hypothesized that no cases would convert to operative management following one-week post-casting alignment assessments.

Methods: This single-center retrospective study focused on pediatric patients diagnosed with type IIA SCHF from 2019 to 2022. Patients were treated with initial long arm cast immobilization, followed by a one-week post-casting radiographic alignment check in cast. Fractures were graded in consensus using the Wilkins-Modified Gartland classification system by three fellowship-trained pediatric orthopaedic surgeons. Demographics, casting details, follow-up dates, and treatment histories were examined. Alignment was considered acceptable or requiring surgery based on the treating surgeons' discretion. The study excluded patients with concomitant ipsilateral upper extremity fractures, flexion-type fractures, lost to follow-up before cast removal, or with type I, IIB or III SCHFs.

Results: Of the 128 patients reviewed in our study, 85 were classified as type IIA SCHF by consensus. The cohort had an average age of 4.2 years (range: 1.1-10.2 years) and was 52% male. The patient population was ethnically diverse, with Hispanic patients constituting the majority (56%), followed by White patients (26%), Black patients (9%), and Asian patients (8%).Patients presented for definitive treatment an average of 2.8 days post-injury and spent an average of 28.8 days in casts. Alignment checks occurred an average of 10.3 days post-injury (SD ±2.5 days). Alignment shifts were noted in 7.1% of cases (n=6). Of these six cases, two were assessed by surgeons as having acceptable alignment, not requiring further intervention. The remaining four cases underwent closed reduction and percutaneous pinning. The rate of conversion to surgical treatment for type IIA supracondylar humerus fractures in our study was 4.7%.

Conclusion: This investigation found that 4.7% of nonoperative type IIA SCHFs converted to operative treatment at the one-week post-casting alignment check. Future studies are warranted to determine specific risk factors for alignment loss in type IIA SCHFs. Level of Evidence: IV.

Background: Posterior cruciate ligament (PCL) tears in young children are rare and optimal treatment is poorly described. Diagnosis may prove challenging as young children may not be able to verbalize a complete history of injury, may be difficult to examine, and plane film radiographs often appear within normal limits. Surgical treatment carries a risk of physeal arrest, but non-operative treatment may lead to recurrent instability and pain.

Methods: We present a case report of a fouryear- old child with a PCL avulsion off the femoral insertion who received an open reduction and internal fixation (ORIF) with combined arthroscopic synovial debridement. We performed a literature review which compared the mechanism, location, concomitant injuries, work up and management of PCL injuries in children under the age of ten compared to adolescents and adults.

Results: Nineteen months following surgery, physical examination revealed full knee range of motion and return to baseline function. Imaging studies confirmed there was no evidence of physeal arrest.

Conclusion: ORIF with arthroscopy can be an effective method to treat PCL avulsions in children under the age of 10 years. This is similar to other case reports which reported positive outcomes with ORIF in this population. Large studies are needed to best understand optimal treatment modalities for PCL injuries in very young children. Level of Evidence: IV.

Background: Periprosthetic joint infection (PJI) in revision arthroplasty presents as a challenging complication that is difficult to manage. Debridement, antibiotics, and implant retention (DAIR) is a recognized treatment option, although few studies have investigated success rates in addition to eventual amputation rates for failed cases.

Methods: A retrospective review of 365 DAIR cases was performed at a single institution from 2008-2020. Patient records were thoroughly reviewed for inclusion and exclusion criteria by multiple members of the research team, discovering 45 cases met criteria for the study cohort. Demographic information, medical history, culture data, and surgical history, were recorded. DAIR's overall survivorship was evaluated with a Kaplan-Meier (KM) survival curve. Additional KM curves were constructed to compare acute postoperative versus acute hematogenous infections as well as DAIR survivorship relative to infecting organism.

Results: DAIR's success rate in revision TKA was 77% at 0.5 years, 56% at 2 years and 46% at 5 years. No significant difference was noted in survivorship when comparing acute postoperative and acute hematogenous cases at 5 years (29 vs 51%, P=0.64). No significance differences in survivorship were noted according to infecting organism (P =0.30). Median follow up duration was significantly lower in the failed DAIR cohort with a median time of 0.5 years in comparison to 1.7 years for the successful DAIR group (P =0.012). There were 20 DAIR cases that failed, 10 of which resulted in eventual amputation.

Conclusion: DAIR's success rate for managing acute PJI in revision arthroplasty cases was 46% at 5 years. Of the 20 failed DAIR cases, 10 resulted in eventual amputation. DAIRs utility in managing these complicated PJI cases in the setting of revision arthroplasty is concerning with low success rates and high rates of amputation in failed cases. Level of Evidence: III.