The Iowa orthopaedic journal最新文献

Background: Acetabular dysplasia has a wide range of prevalence reported in the literature. This variation is likely due to differences in the population under investigation and studies focusing on cohorts with hip pain and osteoarthritis. There are reports of radiographic hip dysplasia prevalence for adults without hip pain but there is no systematic review of these studies to document the incidence in the general population. The purpose of this systematic review was to provide a full summary of all studies that report prevalence of hip dysplasia in adults without hip pain.

Methods: PRISMA guidelines were utilized as an outline for this systematic review. Articles were pulled from PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their inception dates to 1/7/24. Studies were included if participants were asymptomatic and reported rates of prevalence.

Results: Fourteen studies were included in this systematic review. There were 10,998 hips from 5,506 participants included in this analysis. The overall prevalence of radiographic hip dysplasia was 2.3%. Eight studies of 5,930 hips reported the prevalence of hip dysplasia by sex. The prevalence rate in these studies was 3.8% in females and 2.7% in males.

Conclusion: Acetabular dysplasia based on radiographic measurements is relatively common in the general adult population. Furthermore, females have a higher prevalence rate when compared to males. It is important to recognize the incidence of hip dysplasia in the asymptomatic adult population as we recommend surgical treatment for patients who present with hip pain and dysplasia. Further studies should investigate the natural history of untreated and treated hip dysplasia. Level of Evidence: III.

Background: Patients often access online resources to educate themselves prior to undergoing elective surgery such as carpal tunnel release (CTR). The purpose of this study was to evaluate available online resources regarding CTR on objective measures of readability (syntax reading grade-level), understandability (ability to convey key messages in a comprehensible manner), and actionability (providing actions the reader may take).

Methods: The study conducted two independent Google searches for "Carpal Tunnel Surgery" and among the top 50 results, analyzed articles aimed at educating patients about CTR. Readability was assessed using six different indices: Flesch-Kincaid Grade Level Index, Flesch Reading Ease, Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) Index, Coleman Liau Index, Automated Readability Index. The Patient Education Materials Assessment Tool evaluated understandability and actionability on a 0-100% scale. Spearman's correlation assessed relationships between these metrics and Google search ranks, with p<0.05 indicating statistical significance.

Results: Of the 39 websites meeting the inclusion criteria, the mean readability grade level exceeded 9, with the lowest being 9.4 ± 1.5 (SMOG index). Readability did not correlate with Google search ranking (lowest p=0.25). Mean understandability and actionability were 59% ± 15 and 26% ± 24, respectively. Only 28% of the articles used visual aids, and few provided concise summaries or clear, actionable steps. Notably, lower grade reading levels were linked to higher actionability scores (p ≤ 0.02 in several indices), but no readability metrics significantly correlated with understandability. Google search rankings showed no significant association with either understandability or actionability scores.

Conclusion: Online educational materials for CTR score poorly in readability, understandability, and actionability. Quality metrics do not appear to affect Google search rankings. The poor quality metric scores found in our study highlight a need for hand specialists to improve online patient resources, especially in an era emphasizing shared decision-making in healthcare. Level of Evidence: IV.

Background: Posterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively.

Methods: Adult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained.

Results: 288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don't routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus.

Conclusion: Although preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.

Background: The institutional standard follow-up schedule for patients undergoing spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS) is return to clinic at 6-weeks and 3 months post-procedure for radiographs. COVID-19 prompted a change in this practice and most routine post-op visits were performed virtually during that time. The purpose of this study is to estimate the cost and benefit of in-person visits to inform the relative value of in-person follow-up using data from the year prior to COVID changes.

Methods: This was a retrospective study including all patients with AIS who underwent spinal instrumentation and fusion in 2019 by a single surgeon at a tertiary medical center. The cost of radiographs, travel, and parental lost wages associated with follow-up visits at 6-weeks and 3-months were estimated. Transportation costs were estimated by multiplying the distance between home and clinic by the standard IRS travel reimbursement rate ($0.58/mile). Parental lost wages were estimated using the average 2019 US census income for men and women. Each patient's electronic medical record was reviewed to see whether radiographs and physical assessment resulted in any changes in orthopaedic management at each visit.

Results: The sample included 63 patients (75% female, 94% Caucasian) with an average age of 15.22 years. The average round-trip distance traveled was 94.4 miles (range 3.2-476), resulting in an average travel cost of $109.47. The total time spent for a visit (travel, wayfinding and the clinic visit itself) averaged 330 minutes, resulting in an estimated lost parental wage of $125.47. Estimated cost of radiographs at each visit was $693. This combined cost burden totaled $927.94 for each visit, and no changes in management were prompted by clinical or radiographic findings at any of the 126 visits.

Conclusion: COVID-19 presented many new challenges to healthcare, including a necessary increase in virtual healthcare delivery. This study estimated the cost of in-person follow-up visits the year prior to COVID-19. Patients and their families traveled hundreds of miles and spent hundreds of dollars to attend these visits. No changes in clinical management were prompted by findings at these in-person follow-up visits, and implementation of virtual post-operative visits could potentially lead to cost savings for families in these instances. Level of Evidence: III.

Background: There is a currently limited data regarding cancer risk in Orthopaedic Surgeons. This study summarizes a survey on cancer prevalence in orthopaedic surgeons.

Methods: A cancer prevalence survey was emailed to all 23,370 members of the American Academy of Orthopaedic Surgeons (AAOS).

Results: 1826 (7.8%) AAOS members responded to the survey. 291 respondents (15.9%) have been diagnosed with cancer. The average age of those with cancer was 66 years, while the average age of those without cancer was 56 years (p<0.001). The most common cancers were skin cancer (9.58%), prostate cancer (5.11% of men), and breast cancer (2.4% of women). Screening colonoscopy had been performed in 129/203 (63.5%) surgeons between the ages of 50 and 55 years. We were unable to demonstrate an association between specific types of cancer and orthopaedic specialty. 36% of those aged 50-55 years had not undergone screening colonoscopy.

Conclusion: This study highlights the overall 15.9% prevalence of cancer and 9.58% prevalence of skin cancer in all orthopaedic surgeons; the 5.11% prevalence of prostate cancer in male orthopaedic surgeons; and the 2.4% prevalence of breast cancer in female orthopaedic surgeons who responded to the survey. There is room for improvement in routine screening for prostate cancer (men), breast cancer (women) and colon cancer (both). Level of Evidence: IV.

Background: Trochleoplasty is a surgical consideration for the treatment of high-grade trochlear dysplasia. The safety profile of this procedure remains particularly unclear in the skeletally immature population where concerns exist regarding physeal arrest and the development of premature patellofemoral arthritis. The purpose of this study was to systematically review the literature to evaluate trochleoplasty use, outcomes and complications observed among pediatric patients.

Methods: A systematic review was performed in accordance with PRISMA guidelines reviewing PubMed, SCOPUS, and Embase databases. Inclusion criteria were studies with a mean cohort age ≤ 18 in which individualized patient characteristics and resultant outcomes were reported after trochleoplasty. Patient demographics, dysplasia type, procedure type and patient outcomes were abstracted when available and summarized with descriptive statistics.

Results: Our search strategy identified 7 studies published from 2006-2020 that included 108 patients (mean age = 14.3) with a mean follow up of 27.6 months (range 12-60 months). All but one were classified as Level IV evidence (mean MINORS score of 10.5 [6-13]). Most patients were classified according to Dejour (107/108). The Bereiter technique was used most often (83/108). In studies including patient-reported outcome measures, mean Kujala and Lysholm scores increased postoperatively. Recurrent instability occurred in 1 patient (1%) following trochleoplasty. Postoperative complications, most commonly arthrofibrosis, were observed in 13% of patients (14/108). Premature radiographic osteoarthritic changes were identified in a single study using the Albee lateral wedge augmentation and observed in 4 of 23 (17.4%) of patients. No study identified premature physeal arrest or growth disturbance.

Conclusion: There remains a limited evidence base regarding trochleoplasty use in pediatric patients. Overall, favorable outcomes have been observed with infrequent recurrent instability and no reported growth disturbance from physeal arrest. Patellofemoral arthritic changes were observed radiographically in a small subgroup of patients undergoing a single trochleoplasty technique. Further work is necessary to determine if this is a result of the procedure itself or the underlying pathology being treated. As interest grows in implementing trochleoplasty in the pediatric population and among skeletally immature individuals, further work is necessary to clarify the complication profile in this population to appropriately counsel patients and inform surgical decision-making. Level of Evidence: III.

Background: Pelvic fractures often result in traumatic and intraoperative blood loss. Cell salvage (CS) is a tool where autologous blood lost during surgery is collected and recycled with anticoagulation, centrifugation to separate red blood cells, and washing to be reinfused back to the patient. The purpose of this study was to investigate our experience with CS in pelvic and acetabular surgery and its relationship to perioperative transfusion requirements.

Methods: After institutional review board approval, adult patients who underwent pelvic ring or acetabular open reduction internal fixation between 01/2014-11/2021 at a tertiary care level-one trauma center were retrospectively reviewed. Peri-operative outcomes including pre-/post-operative hemoglobin and hematocrit, estimated blood loss, use of CS, and perioperative blood transfusions were collected. Pooled two-sample t-tests were used to compare parametric populations while Fischer's exact test or Pearson's Chi squared test were used for nonparametric data.

Results: 402 patients were included (85 in the CS group and 317 in the non-CS group). Patients had a higher proportion of acetabular fractures. The use of CS was associated with longer operative time (366 mins vs. 269 mins, p<0.0001), EBL (911 mL vs. 473 mL, p<0.0001), and allogenic transfusion of RBC units intraoperatively (1.75 u vs. 1.28 u, p=0.0442) and postoperatively (1.38 u vs. 0.66 u, p<0.0012).

Conclusion: The use of CS was associated with higher total and postoperative allogenic units transfused. Future prospective randomized trials would help to further delineate the risks and benefits of CS utilization in surgical treatment of these fractures. Level of Evidence: III.

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.