The Iowa orthopaedic journal最新文献

Background: Coronal lower extremity malalignment and improper implant position have been described as risk factors for aseptic tibial loosening following primary total knee arthroplasty (TKA). However, several prior studies have shown no association between alignment and implant loosening. Meanwhile, there is increasing interest in kinematic alignment. Therefore, we sought to determine the incidence of coronal malalignment of the limb and tibial component in patients that were revised secondary to aseptic tibial loosening.

Methods: A cohort of 73 patients that were revised for aseptic tibial loosening was identified. Patient demographics were recorded. Radiographs from the primary procedure (preoperative and postoperative) were reviewed to determine the index coronal alignment of the knee and tibial component. Adequate alignment was noted if limb alignment was in neutral or appropriate valgus alignment and tibial implant position was within 3° of the neutral mechanical axis.

Results: Four (5.5%) patients had varus alignment of the tibial component >3°. Therefore, 69/73 (94.5%) patients had well-aligned tibial implants. The average coronal alignment of the limb was 3° of valgus and six (8.2%) patients had coronal varus limb alignment (all >0° anatomic varus).

Conclusion: Limb and tibial implant malalignment were infrequently seen in patients revised secondary to aseptic tibial loosening. Most patients fell within previously described "safe" alignment parameters (<3° varus for the tibial component and neutral or valgus limb alignment). Specifically, malalignment was only present in approximately six to eight percent of patients. Therefore, factors other than alignment appear to contribute most to the development of aseptic tibial loosening. Level of Evidence: III.

Background: Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia, but very few studies report the impact of peri-operative management strategies on early pain and function. The purpose of this study is to describe peri-operative management variability among a group of experienced surgeons and review the literature supporting these practice patterns.

Methods: We surveyed 16 surgeons that perform PAO to document various aspects of peri-operative management at four stages: pre-operative, intra-operative, post-operative in the hospital, and at discharge. Our goal was to report current surgical pain management strategies, adjunct medications, type of anesthesia, deep venous thrombosis and heterotopic ossification prophylaxis strategies, initiation of physical therapy, and use of continuous passive motion (CPM). We reviewed current literature to identify studies supporting these perioperative strategies and identify knowledge gaps that would benefit from further investigation.

Results: Of the 16 surgeons surveyed, 75% had been in practice greater than 10 years and most had not altered their post-operative protocol for more than 3 years. 15/16 surgeons felt that length of stay could be reduced at their institution with improved peri-operative pain management. 6/16 were considering or had already implemented outpatient PAO as a part of their practice. We found significant variability in the pain medications provided at all peri-operative stages. 14/16 utilized general anesthesia, and many utilized epidural or peripheral nerve blocks. 6/16 surgeons utilized surgical field block (also referred to as periarticular block). These surgeons advocated that surgical field block was an effective intervention with no/minimal complication risk. There is very little literature critically evaluating efficacy of these perioperative management strategies for PAO.

Conclusion: There is significant practice variability in peri-operative management of PAO surgery. We report various strategies utilized by a group of experienced surgeons and review supporting literature. There are significant knowledge gaps in best surgical pain management strategies, adjunct medications, surgical field blocks, and use of CPM that need further investigation. Level of Evidence: IV.

Background: The National Institutes of Health (NIH) and American Medical Association (AMA) recommend that online health information be written at a maximum 6th grade reading level. The aim was to evaluate online resources regarding shoulder arthroscopy utilizing measures of readability, understandability, and actionability, using syntax reading grade level and the Patient Education Materials Assessment Tool (PEMAT-P).

Methods: An online Google™ search utilizing "shoulder arthroscopy" was performed. From the top 50 results, websites directed at educating patients were included. News and scientific articles, audiovisual materials, industry websites, and unrelated materials were excluded. Readability was calculated using objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). The PEMAT-P was used to assess understandability and actionability, with a 70% score threshold. Scores were compared across academic institutions, private practices, and commercial health publishers. The correlation between search rank and readability, understandability, and actionability was calculated.

Results: Two independent searches yielded 53 websites, with 44 (83.02%) meeting inclusion criteria. No mean readability score performed below a 10th grade reading level. Only one website scored at or below 6th grade reading level. Mean understandability and actionability scores were 63.02%±12.09 and 29.77%±20.63, neither of which met the PEMAT threshold. Twelve (27.27%) websites met the understandability threshold, while none met the actionability threshold. Institution categories scored similarly in understandability (61.71%, 62.68%, 63.67%) among academic, private practice, and commercial health publishers respectively (p=0.9536). No readability or PEMAT score correlated with search rank.

Conclusion: Online shoulder arthroscopy patient education materials score poorly in readability, understandability, and actionability. One website scored at the NIH and AMA recommended reading level, and 27.27% of websites scored above the 70% PEMAT score for understandability. None met the actionability threshold. Future efforts should improve online resources to optimize patient education and facilitate informed decision-making. Level of Evidence: IV.

Background: Hip dysplasia is a leading cause of hip osteoarthritis. While periacetabular osteotomy (PAO) is effective for relieving pain and dysfunction caused by hip dysplasia in adolescents and young adults, there is concern that patients over 40 years of age will have an increased risk of persistent dysfunction and need for total hip arthroplasty. Current available evidence for PAO in older adults is limited and there is no systematic review in the literature focusing on this topic. The current systematic review offers insight into the demographics, patient-reported outcome measure (PROM) scores, and hip survivorship from total hip arthroplasty in patients over 40 years older treated for hip dysplasia with PAO.

Methods: The review was conducted under the guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Databases that were searched included PubMed, OVID Medline, SCOPUS, Embase, Cochrane Library, and clinicaltrials.gov. Studies were screened based on predetermined inclusion and exclusion criteria.

Results: Five studies were included in this systematic review. Enrollment years were 1990-2013. In total, there were 335 hips with mean ages between 43.5-47.2 years. Mean follow up was 4-10.8 years. Most patients that underwent hip preservation had Tonnis osteoarthritis grade 0-1. There was contradicting evidence whether patients >40 years did better or worse compared to <40 years; although, most patients in the >40 years group had good outcomes after PAO. PAO survivorship ranged from 67-100% depending on the study. Complications ranged from 2-36% of cases depending on the study; although, none of these complications had lasting effects.

Conclusion: Patients over 40 years old appear to have positive outcomes when treated for hip dysplasia with PAO, though these patients were likely selected for no to minimal osteoarthritis, high functional status, and good health. PAO should be considered for patients with hip dysplasia over 40 years old without hip arthritis, though we recommend very selective indications. Level of Evidence: II.

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: 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: 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.