The Iowa orthopaedic journal最新文献

Background: Wound healing is particularly important for sarcoma patients who undergo neoadjuvant radiation therapy. Previous studies have demonstrated wound complications in this population approaching 35%. With this high rate of wound healing issues, identifying treatment modalities to minimize these complications is of paramount importance.

Methods: All patients with high grade bone and soft tissue sarcoma received 15 days of twice daily amino acid supplementation starting in the immediate post-operative period. We documented the healing status of the surgical wound, the primary outcome, at all follow up appointments until six months after surgery. Non-healing wounds were defined as any wound requiring 1) a return visit to the OR for debridement, 2) IV antibiotics (ABX), and 3) unhealed wounds at 6 months post-operatively.¹ For each patient, we collected biometrics with lean body mass analysis at preoperative appointment, and two and six weeks postoperatively. The proportion with non-healing wounds was compared with a historical patient cohort using the chi-square test. In a subgroup of participants with body composition measurements, we also compared changes in mean fat mass, lean mass, and psoas index from pre-operative baseline to 6 months post-operative using generalized linear models.

Results: A total of 33 consecutive patients were supplemented with a branched chain amino acid (BCAA) formulation. The historical cohort included 146 participants from the previous 7 years (2010-2017). 26% of patients in the historical cohort experienced wound complications compared to 30% in the supplemented group. (p=0.72) When focusing specifically on lower extremity sarcomas treated with neoadjuvant radiation therapy, 46% of patients in the supplemented group experienced wound healing complications compared to 39% in the non-supplemented group (p=0.68). BCAA supplementation was found to be protective with regards to decreasing muscle wasting with no difference in psoas index measurements throughout the study period compared to a 20% muscle loss in the historical cohort (p=0.02).

Conclusion: In our limited sample size, there was no difference in wound healing complications between sarcoma patients who received postoperative BCAA supplementation compared to a historical cohort who were not supplemented. Patients who did not receive supplementation had a significant decline in post-operative psoas index following operative sarcoma removal. Level of Evidence: III.

Background: Psychiatric disorders are known to have a negative impact on outcomes attained from hip-preservation surgery. Psychosocial traits such as resiliency and pain avoidance likely also affect treatment outcomes, however these characteristics are less easily identified, and data is lacking supporting their presence and impact on related outcomes within the hip preservation population. We therefore evaluated hip preservation patients for a variety of maladaptive psychosocial traits and assessed patient-reported outcomes (PROs) in order to ascertain which specific traits were most associated with hip pain and dysfunction.

Methods: 62 subjects aged 15-49 years presenting for evaluation of a nonarthritic hip condition completed psychosocial questionnaires and patient reported outcome measures via electronic survey as listed in table one. Participants were tested again eight weeks later to evaluate the relationship between changes in physical function, pain, and mental health behaviors. Pearson correlation coefficients assessed association between hip PROs and psychosocial tests and analyses were corrected for multiple comparisons.

Results: Pain Catastrophizing (PCS), Kinesiophobia (TSK), Stress, and PROMIS-Global Mental Health (GMH) scores correlated with poor physical function and high pain scores at zero and eight weeks. Low resiliency (BRS) and depression were also associated with elevated pain on PRO tests as well as HOOS-Physical Function. There was a moderately strong correlation between improvement in PROMIS-Physical Function (PF) from zero to eight weeks and subjects initial scores for kinesiophobia, anxiety, and stress (r= -0.45, -0.41, -0.44, all p<0.05).

Conclusion: PCS, TSK, Stress, Depression, and low BRS are associated with pain and disability in hip preservation subjects. Elevated TSK, Anxiety and Stress may be predictors of failure to improve with nonoperative treatment. These psychosocial characteristics should be investigated further as predictors of clinical outcomes in the hip preservation population. Level of Evidence: II.

Background: Female patients undergoing hip preservation surgery often have inferior patient-reported outcome scores (PROs), raising concerns about the clinical benefit of hip preservation surgery in women. Comparison of preoperative and postoperative PROs, and change in PROs, for female versus (vs.) male hip preservation patients was completed via systematic review.

Methods: In accordance with PRISMA guidelines, the MEDLINE, Cochrane Central, and Em-base databases were searched. Level I-IV studies of patients undergoing surgical intervention for femoroacetabular impingement (FAI) and/or developmental dysplasia of the hip (DDH) with at least two years of postoperative follow-up were included. Sex-stratified PRO scores or outcome information had to be included.

Results: We identified 32 hip preservation studies evaluating sex-related PRO differences, and/or providing sex-specific PRO data. The quantitative analysis of 24 studies (1843 patients) was stratified by DDH status. The modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL), and Hip Outcome Score-Sport-Specific subscale (HOS-SSS) were assessed. Patients undergoing surgery for FAI only were 52.1% female (n= 806/1546). As predicted, women had lower preoperative PRO scores, however, they had significantly greater improvements in HOS-ADL (20.14±4.41 vs. 26.00±0.35, p<0.05) and HOS-SSS (33.21± 0.71 vs. 38.33± 0.46, p<0.05) compared to males. Similar results were found in the DDH cohort of 330 patients (72.1% female): females had lower preoperative PRO scores, but significantly greater improvement of mHHS (22.68±0.45 vs. 10.60±1.46, p<0.01).

Conclusion: The present review suggests that men undergoing surgery for FAI and/or DDH tend to have higher preoperative and postoperative PRO scores. However, it appears that women often have greater preoperative to postoperative improvement in PRO scores. This finding is strongest in surgical treatment of DDH. Level of Evidence: III.

Cast application is a critical portion of pediatric orthopaedic surgery training and is being performed by a growing number of non-orthopaedic clinicians including primary care physicians and advanced practice providers (APPs). Given the tremendous remodeling potential of pediatric fractures, correct cast placement often serves as the definitive treatment in this age population as long as alignment is maintained. Proper cast application technique is typically taught through direct supervision from more senior clinicians, with little literature and few resources available for providers to review during the learning process. Given the myriad complications that can result from cast application or removal, including pressure sores and cast saw burns, a thorough review of proper cast technique is warranted. This review and technique guide attempts to illustrate appropriate upper and lower extremity fiberglass cast application (and waterproof casts), including pearls and pitfalls of cast placement. This basic guide may serve as a resource for all orthopaedic and non-orthopaedicproviders, including residents, APPs, and medical students in training. Level of Evidence: IV.

Background: Atlantoaxial rotatory fixation (AARF) is extremely rare in adults, and there is no consensus on the ideal treatment of adult AARF because of its rarity. We presented a case series of three adult AARFs and reviewed the literature on adult AARFs. We suggest treatment guidelines for the injury based on the literature review.

Methods: We compiled a series of three adult AARFs seen in our hospital. We also utilized the NCBI library to retrieve literature on adult AARF from 2000 to 2021. We included articles on adult AARF, which described the number of days from injury to diagnosis, Fielding classification, occurrence of associated cervical injuries, and details of treatment and the results.

Results: Thirty adult AARFs reports fulfilled the criteria and 32 patients were analyzed. Eighteen patients had Fielding Type 1 AARF and were diagnosed within 1 month of injury. Among them, 13 cases healed with conservative treatment. Patients with acute AARF of Fielding Type 1 who underwent manual reduction healed successfully. All patients that required more than 1 month from injury to diagnosis underwent surgery. All cases with AARF Fielding Types 2, 3, and 4 failed conservative treatment.

Conclusion: The case series and literature review suggest that early diagnosis of adult AARF is essential for successful closed reduction, and the Fielding classification may help determine treatment strategy. Furthermore, this study showed that not only traction but also manual reduction may be a useful treatment for early diagnosed AARF Fielding Type 1 without complications. Level of Evidence: III.

Background: Extremity soft-tissue sarcomas (STS) are commonly treated with neoadjuvant radiation therapy followed by surgical resection. However, the pathological near-complete response rate is low (9-25%). Noninvasive imaging assessment that predicts treatment response before and during treatment is desirable to optimize treatment regimens. This pilot study aimed to investigate the application of a quantitative MRI parameter, T₂*, in assessing neoadjuvant radiation therapy combined with pharmacological ascorbate in extremity STS.

Methods: This prospective cohort study included seven patients diagnosed with extremity STS and scheduled to receive neoadjuvant radiation therapy combined with pharmacological ascorbate. T₂* maps were obtained from each patient before treatment (baseline MRI), two weeks after initiating treatment (on-treatment MRI), and before surgery (pre-surgery MRI). The T₂* values within the tumor region were transformed into z-scores with respect to the normal- appearing tissue region. The voxel-wise z-scores within the tumor region were thresholded to generate masks representing significantly high (z-score>1.96) and low z-score (z-score<-1.96) voxels. The means of the total z-scores and within each of the significantly high and low z-score mask were computed. Their correlations with percent necrosis from pathological examination were evaluated using Spearman's rank correlation coefficient r. A correlation was considered as moderate or strong when r is higher than 0.6 and 0.8, respectively. A correlation was considered as fair or weak when r is below 0.6.

Results: For the baseline and on-treatment MRIs, the means of the significantly high z-scores of the T₂* measurements showed moderate correlations with percent necrosis (r = 0.68 and 0.6; p = 0.11 and 0.24). For the pre-surgery MRI, the means of the total and significantly high z-scores showed strong correlations with percent necrosis (r = 0.8 and 0.9; p = 0.13 and 0.08). Tumor volume and baseline MRI-based percent necrosis showed fair or weak correlations (r = 0.3-0.54; p = 0.24-0.68).

Conclusion: T₂* measurements prior to treatment, two weeks after initiating treatment, and before surgery showed moderate to strong correlations with percent necrosis. These results support the potential for using T₂* mapping to predict and assess response to neoadjuvant radiation therapy combined with pharmacological ascorbate in extremity STS. Level of Evidence: IV.

Background: Studies demonstrate an increase incidence of intertrochanteric fractures within the United States. Matched studies evaluating intertrochanteric fractures managed with either sliding hip screw (SHS) or intramedullary nail (IMN) within the Medicare population are limited. The purpose of this study was to investigate: 1) annual utilization trends; 2) patient demographics; and 3) complications including mortality.

Methods: A retrospective query using a nationwide database was performed. Patients undergoing SHS or IMN for intertrochanteric fractures were identified. The query yielded a total of 37,929 patients utilizing SHS (n = 11,665) or IMN (n = 26,264). Patients were matched 1:1 based on comorbidities. Primary outcomes included: utilization trends, patient demographics, 90-day complications, and 90-day readmission rates. Linear regression analyses were used to compare utilization trends. Pearson's c2 analyses were used to compare patient-demographics, medical complications, and 90-day readmission rates. A p-value less than 0.05 was considered statistically significant.

Results: Linear regression analysis demonstrated a statistically significant decrease in utilization of SHS for IT fractures (p<0.0001); whereas utilization for IMN stayed consistent (p=0.36). IMN had significantly higher prevalence of comorbidities compared to SHS, notably, hyperlipidemia (70.6 vs. 62.6%; p<0.0001). Based on 1:1 match, IMN patients had significantly higher rates of 90-day medical complications, such as respiratory failure (11.0 vs. 8.1%; p<0.0001) and VTE (4.2 vs. 3.2%; p<0.001; however, there was not a statistical difference in postoperative infection (1.4 vs. 1.5%, p=0.06). There was no statistical difference in 90-day mortality between IMN and SHS cohorts (0.19 vs .13%, p = 0.249).

Conclusion: This analysis demonstrates a difference in utilization of SHS and IMN for patients with IT fractures. Patients with IMN had significantly higher prevalence of comorbid conditions and incidence of 90-day postoperative complications compared to SHS patients. The study can be utilized by orthopaedic surgeons to potentially anticipate healthcare utilization depending on implant selection. Level of Evidence: III.

Background: Irreducible radial head dislocations are uncommon injuries and blocks to reduction typically result from interposed soft tissue. We report the case of a pediatric patient who sustained an irreducible radial head dislocation with a concomitant posterior elbow dislocation and coronoid process fracture. To the author's knowledge, irreducible radial head dislocations presenting as part of a terrible triad like constellation of injuries have not been previously reported. A case-based review of the literature was also performed.

Case description: A 7-year-old male presents to our pediatric hospital as a transfer from an outside hospital after sustaining a posterolateral radial head and posterior elbow dislocation secondary to a fall. CT imaging and 3D reconstruction revealed a Type 1 coronoid process fracture. At our institution, closed attempts at reduction in the operating room under fluoroscopy with general anesthesia were also unsuccessful. Open reduction of the radial head and repair of the soft tissue structures was ultimately required to stabilize the patient's elbow injury.

Conclusion: Irreducible pediatric radial head dislocations are rare and inherently unstable injuries. To the authors' knowledge, there are no prior reports of irreducible radial head dislocations that present in a terrible triad like fashion with a coronoid process fracture and posterior elbow dislocation. In the present report, successful treatment of this injury required open reduction and soft tissue repair. Level of Evidence: IV.

Background: Perilunate injuries are complex injuries typically arising from high-energy injuries to the wrist. Standard treatment involves open reduction and internal fixation with ligamentous reconstruction; however, outcomes are fraught with complications including pain, stiffness, and arthrosis. Several case reports have demonstrated the role of proximal row carpectomy as a salvage procedure for complex carpal trauma in the setting of significant cartilage injury or bone loss. The authors believe that proximal row carpectomy may be an appropriate acute treatment in certain patient populations, with functional results similar to those obtained with ligamentous reconstruction.

Methods: A retrospective review of two cases with perilunate dislocations managed with primary proximal row carpectomy are presented.

Results: At greater than 1-year follow-up, both patients had stable radiocarpal alignment. Quick-DASH scores were 22.7 and 27.3.

Conclusion: Primary proximal row carpectomy is a treatment option in the acute setting for perilunate injuries in elderly, lower-demand patients. Functional results are similar to those obtained with ligamentous reconstruction, with a shorter recovery period. Level of Evidence: IV.

Background: Negative wound pressure therapy (NWPT) may reduce the wound complication (WC) risk in soft tissue sarcoma (STS) and is often utilized for large and/or irradiated wounds, extensive dissections, or wounds at risk of impaired drainage. However, data on WCs after NWPT in STS are lacking. This study systematically reviewed the available literature on NWPT in STS.

Methods: A query of the Cochrane Central Register of Controlled Trials (1976-2022), Cochrane Database of Systematic Reviews, MEDLINE (1946-2022), Scopus, and PubMed (1964-2022) was performed. Eight studies met inclusion.

Results: One-hundred eighty-six cases were analyzed. Among studies with available data, myxofibrosarcoma (n=32/131; 24.4%) and undifferentiated pleomorphic sarcoma (n=29/131; 22.1%) were the most common subtypes, 83.3% (n=90/108) were lower extremity STS, and 51.9% (n=82/158) were preoperatively irradiated. The overall WC rate was 10.8% (n=20/186). Pooled-analysis (three studies) demonstrated a lower WC risk with NWPT versus conventional dressings (OR, 0.133; 95% CI, 0.050-0.351; p<0.001; I²=0%). Subsequent analysis (two studies) found no increased local recurrence risk versus conventional dressings (OR, 1.019; 95% CI, 0.125-8.321; p=0.99), with high heterogeneity.

Conclusion: NWPT appears to lower the WC risk in STS without increasing the recurrence risk, and may be suitable for primary, recurrent, or positive margin resections, staged reconstructions, and while awaiting histologic margin assessment. However, larger, randomized-controlled trials of NWPT in STS are warranted. Level of Evidence: III.