The Iowa orthopaedic journal最新文献

Background: Walking is a vital activity often compromised in individuals with neuropathic conditions. Charcot-Marie-Tooth (CMT) disease and Cerebral Palsy (CP) are two common neurodevelopmental disabilities affecting gait, predisposing to the risk of falls. With guiding scientific evidence limited, there is a critical need to better understand how surgical correction affects mobility, balance confidence, and gait compared to ankle foot orthosis (AFO) bracing. A systematic approach will enable rigorous collaborative research to advance clinical care.

Methods: Key elements of this vision include 1) prospective studies in select patient cohorts to systematically compare conservative vs. surgical management, 2) objective laboratory-based evaluation of patient mobility, balance, and gait using reliable methods, and 3) use of patient-centric outcome measures related to health and mobility.

Results: Valid and reliable standardized tests of physical mobility and balance confidence have been described in the literature. They include 1) the four-square step test, a widely used test of balance and agility that predicts fall risk, 2) the self-selected walking velocity, a measure of general mobility able to detect function change with orthosis use, and 3) the activity specific balance confidence scale, a survey instrument that assesses an individual's level of balance confidence during activity. Additionally, motion capture and ground reaction force data can be used to evaluate whole-body motion and loading, with discriminative biomechanical measures including toe clearance during the swing phase of gait, plantarflexion at 50% of swing, peak ankle plantarflexor moment, and peak ankle push-off power.

Conclusion: The tools needed to support evidence-based practice and inform clinical decision making in these challenging patient populations are all available. Research must now be conducted to better understand the potential benefits and limitations of AFO use in the context of mobility and balance during gait for individuals with neuropathic conditions, particularly relative to those offered by surgical correction.

Clinical relevance: Following this path of research will provide comparative baseline data on mobility, balance confidence, and gait that can be used to inform an objective criterion-based approach to AFO prescription and the impact of surgical intervention.

Background: A 60-year-old female underwent proximal tibial autograft harvest for a Cotton osteotomy. Her postoperative course was complicated by psychogenic non-epileptic seizure (PNES) episodes leading to unintentional weightbearing. Knee radiographs at 6 weeks post-procedure demonstrated a displaced proximal tibia fracture through the autograft harvest site. Further clinical review revealed metabolic derangements consistent with secondary hyperparathyroidism. Initial nonoperative treatment led to atrophic varus nonunion requiring definitive treatment with total knee arthroplasty with revision components.

Conclusion: This case describes a rare complication of proximal tibial autograft harvest and highlights the importance of preoperative metabolic workup and bone health optimization.Level of Evidence: IV.

Background: Septic arthritis is an orthopedic emergency. Diagnosis is difficult in patients with concomitant crystalline arthropathy (gout or pseudogout). The symptomatology of crystal arthritis mimics septic arthritis, clouding clinical diagnosis. Arthrocentesis and synovial fluid analysis are the standard diagnostic tests for both pathologies. Crystals on microscopy are diagnostic of crystal arthritis, however their presence does not rule out septic arthritis. Septic arthritis is diagnosed by positive microbiology culture. Though septic arthritis is associated with elevated synovial total nucleated count (TNC), TNC elevations can also occur with gout. The literature suggests that a TNC count of > 50,000 cells in a crystal-positive joint should raise suspicion for concurrent septic arthritis, however data is limited. Further diagnostic indicators are needed to help clinicians promptly identify crystal positive septic arthritis as the treatments and prognoses are different.

Methods: Patients were retrospectively identified who had arthrocentesis of a native joint positive for monosodium urate (MSU) and/or (CPPD) crystals. Laboratory data was collected including synovial fluid cultures, total nucleated cell count (TNC), percent polymorphic neutrophils (%PMN), and crystal analysis; and serum CRP, ESR, and white blood cell count (WBC). Statistical analysis performed using Spearman correlation, Univariate-Fischer's exact and Wilcoxon tests, and multivariate analysis.

Results: 442 joints identified with positive CPPD and/or MSU crystals, 31% female, 69% male. Of 442 aspirates, 58 had positive cultures. Patients were more likely to have positive cultures if synovial TNC > 50,000 (odds ratio 7.7), CRP > 10 mg/dL (OR 3.2), PMN > 90% (OR 2.17), and if the patient was female (OR 1.9), all were statistically significant with p < 0.05. There were 55 patients who underwent irrigation and debridement based on clinical suspicion or a positive gram stain, 37 of these ultimately had a positive culture (67%), the remaining 18 had negative cultures.

Conclusion: Results are consistent with the literature, a TNC > 50,000 warrants a high suspicion for concurrent septic arthritis and should prompt providers to critically evaluate other patient laboratory data. Results further suggests that a patient with positive crystals, synovial TNC > 50,000 cells, PMN > 90%, and serum CRP > 10mg/dL is at high risk for having a concurrent septic arthritis and may warrant urgent irrigation and debridement and antibiotic therapy. This data serves as a supporting to develop an infection risk calculator for crystal positive septic arthritis. Level of Evidence: III.

Background: A case of chronic osteomyelitis with Brodie's abscess of the cuboid caused by a wooden foreign body penetrating the plantar foot. Total cuboidectomy was carried out with implantation of an anatomically molded antibiotic-impregnated cement spacer with culture-specific postoperative intravenous antibiotics. At six months of follow-up, the patient was completely asymptomatic without evidence of a recurrence of infection. Final radiographs also didn't show spacer migration or surrounding bone erosions. The spacer obviated the need for any foot fusion which preserved foot biomechanics. The patient didn't need to use any braces or insoles.

Conclusion: Osteomyelitis should always be on the differential list of lytic lesions of the tarsal bones, especially if there is a history of prior foot trauma. In this case, cuboid excision and placement of an antibiotic-impregnated cement spacer provided sustained relief of symptoms without evidence of recurrence or complications for six months.Level of Evidence: V.

Background: Fibular hemimelia is the most common congenital long bone deficiency. It is often associated with femoral and tibial deficiencies which result in a clinically evident leg length discrepancy. The primary soft tissue concern is ACL/PCL deficiency. If treatment includes bony lengthening, joint stability is imperative to avoid complications. In this study, we detail a novel technique for long bone lengthening and ACL reconstruction in a single, cohesive surgery. This consolidates the need for multiple procedures and offers improved limb length symmetry and knee stability for this patient population. Clinical outcomes of pediatric patients with hemimelia who underwent either femoral or tibial lengthening with PRECICE® nail and concomitant ACL reconstruction are presented.

Methods: After IRB approval, we identified five patients with complex fibular hemimelia who underwent ACL reconstruction and concomitant lengthening with at least two years of follow-up. Two patients (40%) presented with congenital short femur, and three (60%) with congenital short tibia. In each case, ACL reconstruction and either femoral or tibial guided growth via PRECICE® nail were performed. Operative techniques involving both soft tissue and bony methodology are described in detail.

Results: All patients had objective improvement in knee stability as assessed both intra and post operatively, as well as successful intermedullary lengthening without complications related to joint stability. Three patients had minor complications unrelated to joint stability that did not interfere with overall result.

Conclusion: Fibular hemimelia associated with hypoplasia of bony and soft tissue structures can be successfully addressed with concomitant ligamentous reconstruction at the time of implantation of lengthening devices. This addresses knee instability and reduces both number of operative procedures and potential complications related to joint instability while pursuing bony lengthening. Level of Evidence: V.

Background: Within the realm of orthopedic literature, the determination of statistical significance for outcomes relies on probability analysis and the reporting of P-values. The aim of this study was to employ fragility analysis as a means of evaluating the resilience of randomized controlled trials (RCTs) that assess meniscus surgeries. It was hypothesized that dichotomous outcomes would be statistically fragile and comparable to other orthopedic specialties.

Methods: Included in this study were RCTs reporting dichotomous measures pertaining to meniscus repair, sourced from 14 orthopedic journals indexed on PubMed between 2000 and 2022. The fragility index (FI) for each outcome was determined by iteratively reversing a single outcome event until the significance was reversed. To calculate the fragility quotient (FQ), the FI of each study was divided by its respective sample size. Additionally, the interquartile range (IQR) was calculated for both the FI and FQ.

Results: Out of the 7,844 articles screened, a total of 17 RCTs with 112 dichotomous outcomes were included for analysis. The FI for all the outcomes was 7, with an IQR of 4 to 10. Similarly, the FQ was 0.067, with an IQR of 0.029 to 0.107. However, statistically significant outcomes had a FI and FQ of 4 (IQR 2 to 7) and .057 (IQR 0.03 to 0.108), respectively. The average number of patients lost to follow-up was 2 patients and 17.6% of studies reporting lost to follow up of 7 or greater.

Conclusion: Recent findings suggest that the stability of the literature concerning meniscus repair may not be as robust as previously assumed. Consequently, we strongly advocate for the inclusion of the FI and FQ metrics, alongside the P-value, to enhance the interpretation of clinical findings presented in the meniscus repair literature. Level of Evidence: I.

Background: The COVID-19 pandemic disrupted healthcare systems across the United States resources were consumed caring for COVID-19 patients. Past research on trauma activations during COVID-19 has found changes to hospital length of stay and discharge locations. Subaxial spine fractures are potentially debilitating injuries that require timely surgery and extensive rehabilitation. Accordingly, the objective of this study was to compare the severity of cervical spine injuries, time to surgery, hospital length of stay, and discharge disposition for patients presenting during COVID-19.

Methods: 128 patients with subaxial fractures from a Level One Adult Trauma Center that required surgical intervention were reviewed. The primary outcomes included hospital length of stay, ICU days, time to surgery, complications, and discharge location in patients with subaxial cervical fractures during COVID-19 pandemic versus immediately before the pandemic.

Results: When comparing the pre-COVID-19 period to the COVID-19 group, there was no difference in time to surgery or overall length of stay (2.47 vs. 2.35 days and 12.93 vs. 13.82 days, p>0.05). There was no difference in number of patients discharged home during COVID-19 (41% (32/79) vs. 37% (18/49) p>0.05) or patients discharged to hospital rehab (33%, (26/79) vs. 35% (17/49), p>0.05). A similar percentage of patients had complications within 90 days of discharge (16% (12/75) vs. 22% (10/46), p>0.05).

Conclusion: Despite the burden COVID-19 placed on healthcare systems, it did not affect post-operative hospital course of subaxial fracture patients with potentially debilitating injuries. This vulnerable subset of patients presenting during COVID-19 was still able to undergo timely surgery, have an appropriate hospital length of stay, and be discharged to rehabilitation centers. In future stresses to the healthcare system, deferring elective and non-emergent procedures can allow proper care for emergencies such as subaxial fractures. Level of Evidence: II.

Background: Per the American Academy of Orthopaedic Surgeons, 6.5% of practicing orthopedic surgeons are female and a majority subspecialize in pediatrics, hand, and foot and ankle surgery. The study purpose is to evaluate influences of orthopedic subspecialty selection, specifically factors such as perceived strength, lifestyle, and mentorship influence on subspecialty decisions and to identify if gender plays a role in these perceptions.

Methods: An IRB approved cross-sectional study was conducted via email distribution of a REDCap^TM survey to U.S. licensed orthopedic surgeons. Data regarding demographics, professional degree, training and current practice location, and perceptions regarding orthopedic surgery was obtained using Likert rating scales. Data was analyzed using descriptive statistics with two-tailed student's t-tests (α=0.05).

Results: The survey yielded 282 responses (182 females and 100 males). Overall, the distribution of residents (28%), fellows (6%), and attendings (66%) correlates well with the prevalence of each respective physician category in the field of orthopedic surgery. The study demonstrated no difference in subspecialty choice based on mentorship, work-life-balance, career advancement, subspecialty culture, salary potential, family planning, or schedule. However, a statistically significant difference exists regarding stereotypes, perceived strength required, and perception of discrimination from pursuing a specific orthopedic subspecialty. 27% of females and 10% of males reported discouragement from any subspecialty (p<0.05). Adult reconstructive and oncology were most frequently discouraged. Women reported not choosing a subspecialty because of perceived physical demands more often than men (p<0.001). Women reported an increased use of adaptive strategies in the operating room (p<0.001). Women were also more likely to report feeling discouraged from pursuing a subspecialty due to their gender (p<0.001). Both men and women reported mentorship as the most influential factor in subspecialty selection.

Conclusion: Women and men reported different factors were important in their decision of subspecialty. Women were more likely to be discouraged from a subspecialty and experience discrimination based on their perceived strength compared to male peers. Residents, fellows, and attending surgeons valued mentorship as the most influential in their subspeciality choice. This study suggests intrinsic and extrinsic influences that may differentially affect male and female orthopedic surgeons when they choose a subspecialty. Level of Evidence: III.

Background: The specific aim of this study was to evaluate the mechanical properties of cement prepared with the advanced one-step mixing system and whether the addition of vacuum conditions yielded an appreciable improvement in the biomechanical strength or overall quality of bone cement.

Methods: The advanced one-step mixing system was used. Twelve specimens were prepared by mixing under vacuum conditions and 12 specimens were prepared by mixing without a vacuum. Radiographs of cement specimens were analyzed to determine the porosity of the test region. Tensile testing of the specimens was performed with a loading rate of 2.54mm/min at room temperature. The ultimate tensile strength (UTS) and the tensile elastic modulus (E) were determined for each sample.

Results: The UTS of the bone cement samples mixed under vacuum conditions were not significantly different than those mixed without vacuum (vacuum: 39±6MPa; non-vacuum: 35±6MPa; p=0.637). The E of samples mixed under vacuum conditions was significantly higher than the bone cement mixed without vacuum (vacuum: 2.78±0.06GPa; non-vacuum: 2.63±0.15GPa; p=0.019). Radiographic images showed samples mixed under vacuum conditions contained fewer defects than the samples mixed without vacuum (vacuum: 3.5%±3.3% (range: 0.0%-9.0%); non-vacuum: 6.9%±1.0% (range: 4.6%-8.2%)).

Conclusion: Mixing bone cement with the advanced one-step mixing system under vacuum conditions does not produce an appreciable difference in the UTS of the bone cement in a bench biomechanical testing model compared to the bone cement mixed without vacuum. It does, however, create a less porous cement mixture with a higher E compared to cement mixed without vacuum. Level of Evidence: V.

Background: Myxofibrosarcoma (MFS) is a rare type of soft tissue sarcoma that is locally aggressive and has a high risk of recurrence. The effectiveness of perioperative radiotherapy (RT) in preventing local recurrence (LR) of MFS remains uncertain. This retrospective study aimed to evaluate the impact of perioperative radiotherapy on local recurrence in patients with MFS.

Methods: A total of 75 patients diagnosed with MFS and treated at a single institution were included in the study. Patient data, including demographics, tumor characteristics, and treatment variables, were collected from electronic medical records. The primary endpoint was the occurrence of local recurrence.

Results: Among the patients, 25/75 (33.3%) received radiation therapy, while 50/75 (66.7%) did not. Local recurrence in the radiated group was 28% (7/25) compared to 36% (18/50) in the non-irradiated group (p = 0.20). The LR rate trended higher in patients who received RT postoperatively (adjuvant) (6/12, 50%) than preoperatively (neoadjuvant) (1/13, 7.6%) (p = 0.124). Of the 54 patients with negative margins, the local recurrence rate was lower in the radiated group (1/12, 8.33) than the non-irradiated group (9/36, 25%) (p = 0.034). A subgroup analysis based on tumor grade did not reveal any significant differences in recurrence rates between the radiated and non-irradiated groups. Furthermore, there was no significant difference in recurrence rates between the irradiated and non-irradiated groups at the one-year (p = 0.32), two-year (p = 0.24), and five-year (p = 0.32) follow-up marks.

Conclusion: Although radiotherapy demonstrated a trend toward reduction in recurrence rates in patients with MFS in this study, the observed difference did not reach statistical significance. Neoadjuvant radiation appears to be more effective than adjuvant radiation. However, there was a significant reduction in recurrence in patients with negative margins who received radiation demonstrating that effective surgical resection continues to be the most important intervention in patients with myxofibrosarcoma. Level of Evidence: III.