The Iowa orthopaedic journal最新文献

Background: The aim of this case report is to present a case of chronic cervical ligament tear and instability, which occurred by an unusual work injury with an eversion/hyper-pronation mechanism in contrast to the usual mechanism of inversion. The ligament was reconstructed using an allograft with satisfactory results up to 30 months after surgery. A new magnetic resonance imaging protocol (MRI) was developed to better evaluate the cervical ligament/graft.

Conclusion: In diagnosis of foot sprains, a specific ligament injury should always be sought. In this case, physical examination producing tenderness at the location of the cervical ligament and correlating this with an oblique intercolumn stress test that reproduced pain with apprehension and gross instability supported the diagnosis. Retrospectively applying anatomic knowledge to the earlier MRI findings of bone marrow edema at the insertion points of the cervical ligament on the talus and calcaneus was important in confirming the diagnosis. To better evaluate the cervical ligament allograft tendon reconstruction, a novel volumetric MRI sequence was developed which may prove helpful to also diagnose cervical ligament injuries in future cases. Anatomic reconstruction of the cervical ligament provided satisfactory clinical and radiographic results at 30-month follow-up.Level of Evidence: V.

Background: Postoperative radiographs may be performed on different timelines after shoulder arthroplasty. Radiographs obtained in the post-operative recovery unit (PACU) are often of poorer quality. The purpose of the current study was to explore and compare the quality of PACU radiographs and radiographs performed in the radiology suite on post-operative Day 1 (POD1), as well as determine their impact on changes in post-operative management.

Methods: Our series included 50 consecutive anatomic total shoulder arthroplasties (TSA) for which post-operative radiographs were obtained in the PACU and 50 consecutive TSA for which post-operative radiographs were obtained in the radiology suite on POD 1. TSA radiographs were blinded and reviewed by 3 authors and graded on their quality using criteria described using previously published methods. The weighted kappa was used to describe the intra-rater agreement and inter-rater agreement between two raters.

Results: There was no difference in age, sex, BMI, and comorbidities between cohorts. Intra-observer reliability was moderate to substantial with weighted kappa values of 0.65±0.07 (p<0.001), 0.58±0.09 (p<0.001), and 0.67±0.07 (p<0.001). Inter-observer reliability was moderate to substantial with weighted kappa values of 0.605±0.07 (p<0.001), 0.66±0.07 (p<0.001), and 0.65±0.08 (p<0.001). When assessing quality of radiographs, 30% of radiographs obtained in PACU were deemed quality while 57% of radiographs obtained in the radiology suite were deemed quality (p<0.001).

Conclusion: Post-operative radiographs in the PACU do not alter patient management and are often inadequate to serve as baseline radiographs. Conversely, radiographs obtained in the radiology suite are of higher quality and can serve as a superior baseline radiograph. Level of Evidence: IV.

Background: Quadriceps weakness following total knee arthroplasty (TKA) delays rehabilitation and increases fall risk. The combined impact of tourniquets and adductor canal blocks (ACBs) on postoperative quadriceps strength has not been defined. This study evaluated the early effects of tourniquet and/or ACB usage on quadriceps strength following TKA.

Methods: Primary, elective TKA patients were assigned to one of four groups based on whether they received an ACB and/or tourniquet. We prospectively measured bilateral, isometric knee extension strength preoperatively and within 36 hours postoperatively. Pre/post-change (Δ) and percent strength change were calculated and standardized to the contralateral leg. Strength, postoperative pain, mobility, knee buckling incidence, and falls were compared across groups. Measurements were collected for 203 patients: 68, 45, 45, and 45 in the tourniquet/ACB, tourniquet/ no ACB, ACB/no tourniquet, and no tourniquet/ no ACB groups, respectively.

Results: Tourniquet use was associated with shorter operative time (p=0.004), while ACB use was associated with longer lengths of stay (p=0.005). Average preoperative (p=0.53), postoperative (p=0.12), pre/post-Δ (p=0.60), percent change (p=0.14), and standardized percent change (p=0.85) in strength measures were comparable across groups. Postoperative pain (p=0.67) and knee buckling events (p=0.18) were also comparable across groups. The no tourniquet/no ACB group had decreased postoperative mobility (p=0.004), though it was not clinically significant. No patients sustained inpatient falls.

Conclusion: Combined tourniquet and ACB use during TKA does not lead to additional weakness in postoperative knee extension or buckling events. Concern for impaired early postoperative functionality should not influence arthroplasty surgeons' decision to use a tourniquet or ACB. Level of Evidence: II.

Background: The use of vancomycin powder in spine surgery has been supported in adult populations, however, its efficacy in preventing postoperative surgical site infections in AIS patients is yet to be determined.

Methods: A multi-center review was conducted from June 2010 to February 2019, using ICD and CPT codes to identify AIS patients who underwent primary PSF. The patients were divided into two groups: the vancomycin cohort (receiving local vancomycin powder prior to wound closure) and the non-vancomycin cohort. Demographic and surgical data, microbial data, and SSI rates were compared between the two groups.

Results: A total of 1,917 AIS patients underwent PSF during the study period. There were no significant differences in age at surgery, BMI, sex, or presence of osteotomy between the two groups. The vancomycin cohort had 65.3% patients (n=1,252) with 0.5% (n=6) diagnosed SSIs, while the non-vancomycin cohort had 34.7% patients (n=665) with 0.8% (n=5) SSIs (p=0.451). Four (66.7%) gram-negative bacteria were isolated in the vancomycin cohort, compared to one (20%) in the non-vancomycin cohort.

Conclusion: The results showed no significant reduction in surgical site infections with the use of prophylactic, local vancomycin in AIS patients undergoing PSF (0.5% versus 0.8%). Further studies are needed to fully assess the effectiveness of vancomycin in this population. Level of Evidence: III.

Background: Cementless stems are commonly used in hemiarthroplasty (HA) for femoral neck fractures. Recent studies have reported increased risk of periprosthetic fracture with cementless stems compared to cemented HA. In elective total hip arthroplasty (THA), lower proximal canal fill ratios (CFR) of cementless stems have been associated with worse outcomes. The purpose of this study was to compare CFRs and complications following HA for femoral neck fracture compared to THA for arthritis. We hypothesized that HA would have lower CFRs.

Methods: 130 patients undergoing cementless hemiarthroplasty for femoral neck fracture were identified and matched by age, sex, and BMI to 328 patients undergoing elective cementless THA. Postoperative radiographs were independently evaluated by two investigators to determine Dorr femur type and CFR at four points. Interrater agreement was calculated for CFR and Dorr type. Complication rates were compared between HA and THA groups.

Results: Dorr type and CFR measurements showed strong agreement between investigators. Dorr type was similar between groups. Hemiarthroplasties had significantly lower CFR at each level, with the greatest difference at the lesser trochanter. Dorr C femurs had worse CFR, specifically in the HA group. Complications rates were similar between HA and THA.

Conclusion: Worse CFR in HA compared to THA further suggests that cemented stems should be considered in HA. Suboptimal CFR represents a potential cause of complications including periprosthetic fracture following HA. Level of Evidence: III.

Background: Bicondylar tibial plateau fractures are often associated with significant soft tissue compromise making operative treatment challenging. Dual plating through a two-incision approach following temporary external fixation has been shown to improve complication rates although deep infection rates remain high.The objective was to evaluate early outcomes following a novel technique of percutaneous application of the medial plate superficial to the pes anserinus tendons. Indications for a percutaneous medial plate included local soft tissue conditions, lack of or minimal involvement of medial articular surface with no displaced fragment requiring a posteromedial plate.

Methods: A retrospective chart review at a Level 1 Trauma Center identified twenty-four bicondylar tibial plateaus that were treated from 2015-2017 with standard lateral plate fixation and a medial plate that was percutaneously applied. Fractures were classified according to the AO/OTA classification. Demographic, injury characteristics, and co-morbidities were collected. The primary outcome was presence of a deep infection postoperatively. Secondary outcomes included secondary procedures, range of motion, and maintained radiographic alignment.

Results: The pre-dominant fracture pattern was AO/OTA 41-C3 (75%). The percutaneous medial plate was applied first (71%). The average follow-up was 427 days. Ninety-five percent achieved at least 90 degrees of flexion. All had satisfactory coronal alignment (≤5 degrees) and condylar width (<5mm). Satisfactory articular reductions (≤2mm) were noted in 76% and satisfactory sagittal alignment (≤5 degrees) in 94%. One patient had persistent wound drainage and underwent hardware removal after union. Another patient is pending hardware removal with concerns for deep infection five years post-surgery.

Conclusion: Early results demonstrate that it is safe to place the medial proximal tibia plate above the pes anserinus tendons percutaneously for select fracture patterns with maintained alignment and reduction. This technique may help to minimize deep infection rates. Level of Evidence: IV.

Background: 30-day readmission is an important quality metric evaluated following primary total joint arthroplasty (TJA) that has implications for hospital performance and reimbursement. Differences in how 30-day readmissions are defined between Centers for Medicare and Medicaid Services (CMS) and other quality improvement programs (i.e., National Surgical Quality Improvement Program [NSQIP]) may create discordance in published 30-day readmission rates. The purpose of this study was to evaluate 30-day readmission rates following primary TJA using two different temporal definitions.

Methods: Patients undergoing primary total hip and primary total knee arthroplasty at a single academic institution from 2015-2020 were identified via common procedural terminology (CPT) codes in the electronic medical record (EMR) and institutional NSQIP data. Readmissions that occurred within 30 days of surgery (consistent with definition of 30-day readmission in NSQIP) and readmissions that occurred within 30 days of hospital discharge (consistent with definition of 30-day readmission from CMS) were identified. Rates of 30-day readmission and the prevalence of readmission during immortal time were calculated.

Results: In total, 4,202 primary TJA were included. The mean hospital length of stay (LOS) was 1.79 days. 91% of patients were discharged to home. 30-day readmission rate using the CMS definition was 3.1% (130/4,202). 30-day readmission rate using the NSQIP definition was 2.7% (113/4,202). Eight readmissions captured by the CMS definition (6.1%) occurred during immortal time.

Conclusion: Differences in temporal definitions of 30-day readmission following primary TJA between CMS and NSQIP results in discordant rates of 30-day readmission. Level of Evidence: III.

Background: Determination of need for osteochondroplasty (OCP) during periacetabular osteotomy (PAO) commonly relies on intraoperative assessment of internal rotation at 90° flexion (IRF). Performing an OCP helps decrease the risk of iatrogenic femoroacetabular impingement from PAO reduction. Avoiding impingement helps decrease risks of accelerated secondary osteoarthritis. The literature is limited for factors that predict need for OCPs during PAOs. The purpose of this study was to (1) define the characteristics of patients needing concurrent OCP and provide OCP rate based on IRF and femoral version and (2) identify predictive factors (clinical, radiographic) associated with need for OCP during PAO. As some surgeons determine need for OCP pre-operatively, predictive factors would aid decision making.

Methods: This was a prospective cohort of 224 hips (207 patients) who underwent PAO for symptomatic acetabular dysplasia, of which 154 hips (69%) underwent OCP between years 2013 and 2017. Patients underwent OCP if they had restrictions in motion or impingement intra-operatively. Pre-operative factors such as age, sex, BMI, and CT findings were recorded that underwent univariate and multivariable analyses. Multivariable analysis found predictors that were described using odds ratios and 95% confidence intervals. IRF>30° and femoral version 10°-25° were used as the reference groups during categorical analysis. P-values ≤0.05 were considered significant.

Results: Alpha angles >55° (OR= 2.20, CI: 1.08-4.52, p= 0.03), IRF≤20° (OR: 9.52, CI: 3.87-23.40, p<0.001), IRF >20°-30° (OR: 2.68, CI: 1.08-6.62, p=0.03), and femoral version <10° (OR: 5.26, CI: 1.09-25.30, p=0.04) were associated with increased odds of OCP. On continuous modeling, decreasing femoral version (OR: 1.07, CI: 1.02-1.12, p=0.002) and IRF (OR: 1.06, CI: 1.03-1.09, p<0.001) were associated with increased chance of OCP. For 5° changes, the chance of OCP increased by 40% (OR: 1.40, CI: 1.13-1.73, p=0.002) and 35% (OR: 1.35, IC: 1.16-1.57, p<0.001), respectively.

Conclusion: Awareness of need for OCP may be valuable in peri-operative planning for these patients especially since some surgeons perform this technique arthroscopically before PAO. Factors associated with increased chances of OCP were alpha angles >55°, decreased IRF, and decreased femoral version. More studies in the future would help determine how OCP affects patient outcomes. Level of Evidence: III.

Tarsal tunnel syndrome (TTS) refers to compression of the posterior tibial nerve as it traverses the tarsal tunnel in the ankle. First described by Keck and Lam in 1962, TTS is an underdiagnosed cause of heel pain and foot dysfunction.^1,2 The tarsal tunnel contains the tibial nerve, posterior tibial artery, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles. Compression of the tibial nerve within this tunnel leads to pain, numbness, tingling, and weakness along its distribution. The clinical presentation of TTS can vary due to the numerous etiologies and range of structures involved. Symptoms may develop insidiously over months to years or have a traumatic onset. Lack of definitive clinical tests or imaging often delays diagnosis, which contributes to poor patient outcomes and treatment success. In severe or long-standing cases, permanent nerve damage may occur if left untreated. TTS deserves increased recognition given its potential to significantly impact mobility and quality of life. This review provides a comprehensive overview of the anatomy, etiology, diagnosis, and management of TTS. Optimal strategies to diagnose and treat this condition based on available evidence are discussed to improve patient outcomes and limit disability. Early diagnosis and intervention are key to avoiding permanent nerve injury and maximizing the benefits of treatment, whether conservative or surgical.