The Iowa orthopaedic journal最新文献

Background: Patient provider interactions influence patient treatment adherence, clinical outcomes, patient satisfaction, and an overall patient's engagement in healthcare decisions. The purpose of this study was to examine the effectiveness of patient provider educational interactions and associated variables on patient reported outcomes in the hip dysplasia population.

Methods: A secondary data analysis was completed with 6-month postoperative survey data from participants, who had undergone periacetabular osteotomy. Data analysis including demographic variables, patient reported outcome results, and pre-operative knowledge retention.

Results: A significant difference was found between participants' expectations of crutch use and physical therapy care with actual performance (p<0.001 and p=0.01) and with engagement in pre-operative support based on mental health history (p=0.02).

Conclusion: Pre-operative interactions with a provider team and prior patients (pre-operative support) can influence a patient's educational experience. Providers should review educational interventions and offer pre-operative support to patients. Level of Evidence: VI.

Background: While there have been significant advancements in recent years, complications following fixation for femoral neck fractures remain a concern. This retrospective cohort study aimed to investigate the influence of polytrauma and additional fractures on the occurrence of complications in patients who underwent surgical fixation for femoral neck fractures. The study focused on analyzing patient demographics, comorbidities, fracture classifications, fixation methods, and the likelihood of experiencing post-operative complications, with a specific emphasis on the impact of polytrauma and additional fractures.

Methods: This retrospective cohort study analyzed data from medical records and radiographs of patients who underwent surgical fixation for femoral neck fractures at a tertiary care center between 2007 and 2020. A total of 58 patients met inclusion criteria and were assessed based on their medical history, comorbidities, fracture classification, fixation method, and the occurrence of complications such as osteonecrosis, non-union, limb length discrepancy, and conversion to Total Hip Arthroplasty (THA). Among the patients, 36 received Cancellous Screw (CS) fixation, 12 underwent Sliding Hip Screw (SHS) fixation, while the remaining 10 patients who underwent different fixation methods were excluded from the analysis due to the heterogeneity of the group.

Results: Demographic characteristics and comorbidities were similar between the CS and SHS fixation groups. The overall complication rate for CS fixation was 16.7% (6/36 patients), while the rate for SHS fixation was 33.3% (4/12 patients). However, when considering the presence of polytrauma and additional fractures, a significant association with increased complication rates was observed. Cox proportional regression analysis revealed that the absence of polytrauma/additional fractures significantly reduced the complication rates by more than 90% (Hazard ratio (HRpolytrauma)=0.01, P value = 0.01). This highlights the substantial impact of polytrauma and additional fractures on complications in femoral neck fracture fixation surgeries.

Conclusion: This study emphasizes the need for thorough evaluation and tailored management strategies for patients with femoral neck fractures associated with polytrauma or additional fractures to minimize the complications of femoral neck fracture surgery. Further research is warranted to explore potential preventive measures and optimized treatment approaches for this high-risk patient subset of the femoral neck fracture population. Level of Evidence: III.

Background: Recent literature indicates that COVID-19 infection is a negative predictor of good outcomes following elective orthopedic surgery. However, the ideal timing of surgery after infection is unclear. The purpose of this study was to compare the rates of post-operative complications between those who underwent elective orthopedic surgery <50 days and >50 days after COVID-19 infection.

Methods: This is a pilot study utilizing retrospective review of 28 adult subjects who underwent orthopedic surgery including 17 total-knee arthroplasties, seven total-hip arthroplasties, three posterior spinal fusions, and one common peroneal decompression. These subjects were indicated for an orthopedic surgery that was canceled due to positive pre-operative COVID-19 testing. The subjects were rescheduled for surgery between March 2020-December 2022.There were two cohorts: those who underwent surgery <50 days after COVID-19 infection (n=14) and subjects who underwent surgery >50 days after COVID-19 infection (n=14). Demographics, preoperative comorbid conditions, and post-operative complications were recorded and compared.

Results: There were no significant demographic differences between the two cohorts with respect to age, body mass index, weight, and American Society of Anesthesiologists (ASA) grade. The two cohorts had no significant difference in pre-existing comorbid conditions with hypertension and peripheral vascular disease being the most common comorbidities overall. There were six postoperative complications involving four subjects within 90 days of surgery. One subject developed a postoperative pulmonary embolism (PE), and another subject developed a surgical-site infection, sepsis, and renal failure; both in the >50 days cohort. One patient in each cohort required reoperation. There was no difference in postoperative complications such as deep vein thrombosis (DVT), PE, sepsis, renal failure, and intensive care unit (ICU) admission between the two cohorts.

Conclusion: This pilot cohort study demonstrates that COVID-19 infection within 50 days of orthopedic surgery does not significantly increase the risk of postoperative complications such as DVT, PE, surgical site infection, renal failure, ICU admission, reoperation, or death. Further evaluation of the effects of COVID-19 on surgical outcomes in larger cohorts is warranted. Level of Evidence: III.

Background: Optimal management of post-operative pain is a critical component of orthopedic surgical care. There is a heightened awareness of narcotic prescribing habits given the current "opioid epidemic." The lack of standardized protocols has led to increased errors, delayed access to prescribed medications, and excessive narcotic prescribing.The purpose of this study is to assess the current trends in opioid use and document the prescribing patterns in the pediatric population before and after the implementation of a standardized protocol at our Institution.

Methods: A multimodal postoperative pain pathway was developed and implemented throughout a large, academic, pediatric orthopedic division. The pathway utilized opioid and non-opioid pain medications and educational handouts with descriptions of the different classes of pain medication and specific dosing regimens.A query of electronic medical records was completed to identify all patients under the age of 18 that underwent inpatient orthopedic surgery from January 2016 to June 2018. Based on surgical dissection and anticipated postoperative pain, procedures were grouped into low complexity and high complexity. The average amount of opioids administered to the patients during their stay in the hospital was converted to morphine milligram equivalents (MME). The average MME was plotted, and the trends were analyzed.

Results: 455 inpatients met the inclusion criteria. Opioid pain medication administration was significantly higher in the high-complexity group compared to the low-complexity group. Implementing the multimodal pain pathway significantly reduces opioid administration in both groups without an increase in length of stay.

Conclusion: Implementation of a standardized, post-operative, multimodal pain regimen lead to a significant decrease in the amount of administered narcotics following inpatient orthopedic surgery without an increase in length of stay. Level of Evidence: IV.

Background: Early post-operative pain control is essential to facilitate rapid recovery after orthopaedic surgery. Despite periacetabular osteotomy (PAO) being the gold standard treatment of prearthritic hip dysplasia, there is limited evidence assessing efficacy of early post-operative pain management strategies. Recent literature has focused on non-opioid supplemental treatments such as nerve blocks or local wound infiltration. The purpose of this systematic review was to assess efficacy of these interventions to reduce pain, facilitate mobilization, reduce length of stay after PAO surgery.

Methods: A systematic review was created under the guidance of PRISMA from databases that included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their creation dates to 12/21/23. These studies were screen based on predetermined inclusion and exclusion criteria.

Results: A total of six studies were included in this analysis from independent institutions. Three investigated nerve blocks (fascia iliaca, pericapsular, transversus abdominis), one investigated local wound infiltration with ropivacaine, one investigated high-dose dexamethasone, and the last investigated removal of the epidural catheter on postoperative (POD) 1 compared to POD 2. There were heterogeneous outcomes that were measured from these studies. In general, nerve blocks decreased opioid use, pain, and length of hospital stay. The local wound infiltration decreased pain on POD 3 and 4. Removing the epidural catheter on POD1 compared to POD 2 decreased pain and length of stay. High-dose dexamethasone use decreased opioid use on POD 1, otherwise, there was no difference in pain.

Conclusion: In summary, supplemental pain management strategies peri-operatively for PAO surgery can decrease pain, opioid use, and length of hospital stay, though there are few studies assessing these interventions. Limiting opioid use after surgery reduces known negative consequences of the medication and facilitates rapid recovery. Clinical trials are needed that assess efficacy of supplemental pain management strategies after PAO surgery. Level of Evidence: II.

Background: This study aimed to demonstrate the feasibility of lag screw exchange for painful lateral soft tissue impingement in patients initially treated with cephalomedullary nailing (CMN) for an intertrochanteric hip fracture.

Methods: Ten patients initially treated with CMN for unstable intertrochanteric fractures presenting with persistent pain and radiographic evidence of lag screw lateral migration were treated with exchange of original screw with shorter lag screw buried in the lateral cortex to prevent impingement. Patients were evaluated for resolution of pain and achievement of pre-fracture ambulatory status at 6 months post-operatively.

Results: Average age was 71.5 years (range: 62-88). Average length of follow-up was 24.9 months. All patients were female, with an average Charlson Comorbidity Index of 1.0 (0-3) and average Body Mass Index of 22.2 (16.0-31.1). Five of ten patients (50.0%) were treated with a cortisone injection in the trochanteric bursa prior to screw exchange with temporary pain relief. Five (50.0%) patients presented with limited range of hip motion. Five (50.0%) had history of prior or current bisphosphonate use. Average lag screw prominence was noted to be 12.2mm (7.9-17.6mm) on radiographic evaluation. Screw exchange was performed at an average of 18.6 months (5.4-44.9 months) following the index procedure. Average operating time of the screw exchange procedure was 45.3 minutes (34-69 minutes) and blood loss was <50mL in all cases. Replacement lag screws were an average of 16.0mm (10-25mm) shorter than the initial screw. All patients achieved complete or significant resolution of lateral thigh pain, and nine (90%) returned to pre-fracture ambulatory status by eight weeks after screw exchange. All patients remained pain free at six months after screw exchange.

Conclusion: Lag screw exchange is a efficacious method to address the mechanical irritation of laterally protruding lag screws following IT hip fracture, while also prophylaxing against subsequent femoral neck fractures. Level of Evidence: IV.

Background: Provisional stabilization of high-energy tibia fractures using temporary plate fixation (TPF) or external fixation (ex-fix) prior to definitive medullary nailing (MN) is a strategy common in damage control orthopaedics. There is a lack of comprehensive data evaluating outcomes between these methods. This study compares outcomes of patients stabilized with either TPF or ex-fix, and with early definitive MN only, assessing complications including nonunion and deep infection.

Methods: A retrospective review was performed on adult patients with tibia fractures treated with MN followed until fracture union (≥3 months) at a single level-1 trauma center from 2014 to 2022. Medical records were evaluated for nonunion and deep infection. Demographics, injury characteristics, and fixation methods were recorded. Significance between patients who underwent TPF and ex-fix was compared with a matched cohort of early MN using Pearson's exact tests, independent t-tests, and one-way ANOVA, depending on the appropriate variable.

Results: 81 patients were included; 27 were temporized with TPF (n = 12) or ex-fix (n = 15). 54 early MN cases defined the matched cohort. All groups had similar patient and fracture characteristics. The difference in rates of nonunion between groups was significant, with TPF, ex-fix, and early MN groups at 17, 40, and 11% respectively (p = 0.027). Early MN had lower rates of nonunion (11% vs. 40%, p = 0.017) and deep infection (13% vs. 40%, p = 0.028) compared to ex-fix.

Conclusion: Temporary ex-fix followed by staged MN was associated with higher rates of nonunion and deep infection. There was no difference in complication rates between TPF and early definitive MN. These data suggest that ex-fix followed by MN of tibia fractures should be avoided in favor of early definitive MN when possible. If temporization is needed, TPF may be a better option than ex-fix. Level of Evidence: IV.

Background: The use of intraoperative intra-articular morphine has been suggested to lower postoperative pain scores and opioid use. We sought to evaluate the effectiveness of intra-articular morphine with 0.75% ropivacaine when compared to the use of ropivacaine alone. Our study's purpose was to determine the efficacy of intra-articular morphine on pain control, opioid consumption, and discharge times in the immediate post-operative period.

Methods: We retrospectively reviewed the charts of 100 patients who underwent hip arthroscopy with repair for femoroacetabular impingement (FAI) between 2021 to 2023. 50 patients who received 5 mg of intra-articular morphine injections intraoperatively were identified, and 50 who did not. Patients undergoing hip arthroscopy without repair, revision surgery, or combined hip arthroscopy and femoral osteotomy or periacetabular osteotomy were excluded. Demographics including age, sex, race, ethnicity, BMI, and tobacco use were recorded. Procedural factors included total operative time, traction time, and time to discharge. Pain scores were assessed using the Visual Analog Scale (VAS), and the initial Post-Anesthesia Care Unit (PACU) and final VAS score prior to discharge were recorded. Total acute opioid use was recorded using morphine milligram equivalents (MME) during post-operation to discharge. We used the Wilcoxon rank sum test and chi-square statistics on continuous and categorical variables, respectively. Statistically significant level was set as p<0.05.

Results: No significant differences were found between demographics, operative time, traction time, or discharge time. The median age of patients in the non-morphine group was 29 (48% M, 52% F) and 24.5 (34% M, 66% F) in the morphine group. Differences between the morphine and non-morphine group in postoperative VAS scores were insignificant, with the mean initial PACU VAS scores (4.6 ± 3.0 vs 5.5 ± 3.0) and mean final PACU VAS scores (3.5 ± 1.9 vs 3.7 ± 1.4) respectively. Postoperative MME consumption difference was also insignificant (17.1 ± 7.4 vs 17.9 ± 7.3).

Conclusion: Intraoperative intra-articular morphine injection with ropivacaine does not provide a significant reduction in acute postoperative pain scores or opioid use when compared to ropivacaine use alone. Further investigation into the efficacy of intra-articular morphine is warranted. Level of Evidence: III.

Background: Little empirical research has been done on factors evaluated in the fellowship matching process, this study intends to evaluate the impact of research productivity.

Objective: The purpose of this study is to identify research trends and characterize the academic profiles of recent Foot and Ankle (F&A) fellows in the United States when they applied for fellowship.

Methods: The American Orthopedic F&A Society website was used to identify accepted fellows between the years 2017-2023. A retrospective bibliometric analysis was performed using the total number of publications up to December 31st of the year prior to the start of fellowship, collected from each fellow's Scopus profiles. Recorded data included total number of publications, citations, authorship position, and publications with a F&A focus. Data was compared between academic versus community fellowship programs, and by years, fellowship and residency program region, medical degree, and sex.

Results: A total of 444 F&A fellows from 2017 to 2023 were identified, and 404 (90.99%) were verified. Fellows averaged 5.288±10.075 publications and 60.646±232.297 citations. Fellows were listed as first author in 31.35% publications and middle author in 65.08% publications, while 93.81% of fellows had at least 1 publication, and 54.95% percent had at least 1 first author publication (Table 1). A statistically significant increase in average number of publications was identified between the years 2017 and 2018 and the years 2020-2023 (Table 2).

Conclusion: There exists a statistically significant, increasing trend in research productivity of F&A fellows across the years 2017-2023. Over half of fellows published at least one first authorship article, and just under half had a publication focused on F&A. Level of Evidence: II.