Prospective, Randomized Study of Direct Anterior Approach vs Posterolateral Approach Total Hip Arthroplasty: A Concise 5-Year Follow-Up Evaluation.

BACKGROUND: Interest in direct anterior approach (DAA) has increased over the last decade. In our previously published study comparing DAA to posterolateral approach (PA), early 3-month benefits were noted in terms of pain and function. There was no difference noted at 6 or 12 months. This study reports average 5-year follow-up of our original study. METHODS: Originally there were 43 DAA patients and 44 PA patients. At an average 5-year follow-up, patients were evaluated clinically with a University of California at Los Angeles activity score, Harris hip score, and Hip Disability and Osteoarthritis Outcome Score Jr Survivorship analysis was calculated. Radiographs were evaluated for loosening and evidence of radiolucent lines. RESULTS: There were 2 deaths 1 in each group, neither was related to the implant or procedure. Four patients were lost to follow-up: 2 in the DAA group and 2 in the PA group. There was no statistical difference between surgical approaches in terms of Harris hip score, University of California at Los Angeles activity score, and Hip Disability and Osteoarthritis Outcome Score Jr. The 7-year survivorship was not significantly different. There were no loose implants at average 5-year follow-up. CONCLUSION: Both DAA and PA yield good results at an average 5-year follow-up in terms of survivorship, function, rate of complications, and radiographic analysis.

Effects of age and insulin-like growth factor-1 on rat neurotrophin receptor expression after nerve injury.

INTRODUCTION: Neurotrophin receptors, such as p75(NTR) , direct neuronal response to injury. Insulin-like growth factor-1 receptor (IGF-1R) mediates the increase in p75(NTR) during aging. The aim of this study was to examine the effect of aging and insulin-like growth factor-1 (IGF-1) treatment on recovery after peripheral nerve injury. METHODS: Young and aged rats underwent tibial nerve transection with either local saline or IGF-1 treatment. Neurotrophin receptor mRNA and protein expression were quantified. RESULTS: Aged rats expressed elevated baseline IGF-1R (34% higher, P = 0.01) and p75(NTR) (68% higher, P < 0.01) compared with young rats. Post-injury, aged animals expressed significantly higher p75(NTR) levels (68.5% above baseline at 4 weeks). IGF-1 treatment suppressed p75(NTR) gene expression at 4 weeks (17.2% above baseline, P = 0.002) post-injury. CONCLUSIONS: Local IGF-1 treatment reverses age-related declines in recovery after peripheral nerve injuries by suppressing p75(NTR) upregulation and pro-apoptotic complexes. IGF-1 may be considered a viable adjuvant therapy to current treatment modalities. Muscle Nerve 54: 769-775, 2016.

Resource utilization and costs for robotic-assisted and manual total knee arthroplasty - a premier healthcare database study.

INTRODUCTION: The impact of robotic-assisted total knee arthroplasty (rTKA) vs. traditional, manual TKA (mTKA) on hospital costs is not well documented and is analyzed herein. RESEARCH DESIGN AND METHODS: Patients in the Premier billing Healthcare Database undergoing elective rTKA or mTKA ("index') in the in- or outpatient setting for knee osteoarthritis between Oct 1st, 2015, to September 30th, 2021, were identified. Variables included patient demographics and comorbidities and hospital characteristics. Matched rTKA vs. mTKA cohorts were created using direct (on provider characteristics, age, gender, race and Elixhauser index) and propensity score matching (fixation type, comorbidities). Index and 90-day inflation-adjusted costs and healthcare utilization (HCU) were analyzed for both cohorts, using generalized linear models. RESULTS: 16,714 rTKA patients were matched to 51,199 mTKA patients. Average 90-day hospital cost reached $17,932 and were equivalent for both cohorts (rTKA vs. mTKA: $132 (95% confidence interval; -$19 to $284). There was a 2.7% (95%CI: 2.2%-3.3%) increase in home or home health discharge, and a 0.4% (95%CI: 0%-0.8%) decrease in 90-day hospital knee related re-visit in the rTKA vs. mTKA group. CONCLUSIONS: Cost-neutrality of rTKA vs. mTKA was observed, with a potential for lowered immediate post-operative HCU in the rTKA vs. mTKA cohorts.

Open Ankle Fractures: What Predicts Infection? A Multicenter Study.

OBJECTIVE: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN: Multicenter retrospective review. SETTING: Sixteen trauma centers. PATIENTS: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES: Fracture-related infection (FRI) in open ankle fractures. RESULTS: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01). CONCLUSIONS: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Modified Technique for Applying Closed Incision Negative Pressure Therapy Dressing Following Total Joint Arthroplasty.

Postoperative incisional management subsequent to total joint replacement arthroplasty is of importance to the orthopedic surgical team. The application of closed incision negative pressure therapy (ciNPT) to surgical incisions following replacement arthroplasty has demonstrated positive outcomes in orthopedics. This paper describes a technique involving the postoperative application of ciNPT over closed incisions originating from joint arthroplasty to facilitate a reduction in the incidence of surgical site complications (SSCs). To address any potential challenges that may be associated with ciNPT application and removal, the ciNPT dressing was applied to the knee incision with approximately 15 degrees of flexion utilizing the total knee bump to allow the knee to rest with flexion at that angle. For posterior hip replacements or revisions, the readily adjustable ciNPT dressing was enlisted for use to cover curvilinear incisions. The adhesive drape over the foam ciNPT dressing would be blocked to ensure that drain placement, if used, would not be incorporated with the hydrocolloid portion of the dressing. In order to properly apply the dressing, it was imperative that the hydrocolloid portion was not subject to any buckling. The dressing was walked over the foam ciNPT dressing to ensure that there was an absence of tension on the dressing. The manufacturer's instructions support dressing use for a maximum of seven days with continuous subatmospheric pressure (-125 mmHg) applied to the closed incision. Applying the adhesive ciNPT drape over the ciNPT foam dressing with a minimal amount of tension is integral to attaining positive outcomes using ciNPT. Employing ciNPT may reduce the risk of delayed incisional healing and SSCs, which may alleviate providers from extra postoperative global visits.

Effect of locally delivered IGF-1 on nerve regeneration during aging: an experimental study in rats.

Age is an important predictor of neuromuscular recovery after peripheral nerve injury. Insulin-like growth factor 1 (IGF-1) is a potent neurotrophic factor that is known to decline with increasing age. The purpose of this study was to determine if locally delivered IGF-1 would improve nerve regeneration and neuromuscular recovery in aged animals. Young and aged rats underwent nerve transection and repair with either saline or IGF-1 continuously delivered to the site of the nerve repair. After 3 months, nerve regeneration and neuromuscular junction morphology were assessed. In both young and aged animals, IGF-1 significantly improved axon number, diameter, and density. IGF-1 also significantly increased myelination and Schwann cell activity and preserved the morphology of the postsynaptic neuromuscular junction (NMJ). These results show that aged regenerating nerve is sensitive to IGF-1 treatment.

Occult Cranial Cervical Dislocation: A Case Report and Brief Literature Review.

Study Design. Retrospective case report and review. Objective. Cranial cervical dislocation (CCD) is commonly a devastating injury. Delay in diagnosis has been found to lead to worse outcomes. Our purpose is to describe a rare case of occult cranial cervical dislocation (CCD) and use it to highlight key clinical and radiographic findings to ensure expedited diagnosis and proper management avoiding delays and subsequent neurologic deterioration. Method. Case report with literature review. Results. We describe a unique case of occult cranial cervical dislocation where initial imaging of the cervical spine failed to illustrate displacement of the occipital-cervical (O-C1) articulation or C1-C2 articulation. Careful evaluation of subtle radiographic clues suggested a more severe injury than initial review. Additional imaging was obtained due to these subtle clues confirming true cranial cervical dislocation allowing subsequent treatment with no neurologic sequelae. Conclusion. A high index of suspicion of CCD may prevent injury in select patients who present without gross cord compromise. Careful consideration of associated fractures, soft tissue injuries, and mechanism of injury are essential clues to the correct diagnosis and management of injuries to the craniocervical junction (CCJ).

Intraoperative Distal Femoral Fine Wire Traction to Facilitate Intramedullary Nailing of the Femur.

Many techniques have been employed to facilitate intramedullary nailing of femur fractures. Maintaining limb length during the operation can be difficult. The authors describe the use of distal femoral fine wire skeletal traction as a technique to maintain reduction while allowing intramedullary nailing of femur fractures. This technique is safe, is effective, and negates the need for a fracture table or an assistant.

Single provider reduction and splinting of displaced ankle fractures: a modification of Quigley's classic technique.

Ankle fractures are commonly treated by orthopaedic surgeons and often require manipulative reduction. This can be painful for the patient and frequently uses 2 or more providers. Intra-articular injection of local anesthetic into the ankle joint precludes the need for conscious sedation (intravenous narcotics and benzodiazepines, propofol, or ketamine). By combining an ankle block with a modification of the classic ankle fracture reduction technique described by Quigley 1959, a single provider can effectively perform a manipulative reduction and splinting of an ankle fracture without conscious sedation.

Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses?

BACKGROUND CONTEXT: The ideal management of cervical spine epidural abscess (CSEA), medical versus surgical, is controversial. The medical failure rate and neurologic consequences of delayed surgery are not known. PURPOSE: The purpose of this study is to assess the neurologic outcome of patients with CSEA managed medically or with early surgical intervention and to identify the risk factors for medical failure and the consequences of delayed surgery. STUDY DESIGN/SETTING: Retrospective electronic medical record (EMR) review. PATIENT SAMPLE: Sixty-two patients with spontaneous CSEA, confirmed with advanced imaging, from a single tertiary medical center from January 5 to September 11. OUTCOME MEASURES: Patient data were collected from the EMR with motor scores (MS) (American Spinal Injury Association 0-100) recorded pre/posttreatment. Three treatment groups emerged: medical without surgery, early surgery, and those initially managed medically but failed requiring delayed surgery. METHODS: Inclusion criteria: spontaneous CSEA based on imaging and intraoperative findings when available, age >18 years, and adequate EMR documentation of the medical decision-making process. Exclusion criteria: postoperative infections, Pott disease, isolated discitis/osteomyelitis, and patients with imaging findings suggestive of CSEA but negative intraoperative findings and cultures. RESULTS: Of the 62 patients included, 6 were successfully managed medically (Group 1) with MS increase of 2.3 points (standard deviation [SD] 4.4). Thirty-eight patients were treated with early surgery (Group 2) (average time to operating room 24.4 hours [SD 19.2] with average MS increase 11.89 points [SD 19.5]). Eighteen failed medical management (Group 3) requiring delayed surgery (time to OR 7.02 days [SD 5.33]) with a net MS drop of 15.89 (SD 24.9). The medical failure rate was 75%. MS change between early and delayed surgery was significant (p<.001) favoring early surgery. Risk factors and laboratory data did not predict medical failure or posttreatment MS because of the high number of medical failures when abscess involves the cervical epidural space. CONCLUSIONS: Early surgery results in improved posttreatment MS compared with medical failure and delayed surgery. In our patients, the failure rate of medical management was high, 75%. Based on our results, we recommend early surgical decompression for all CSEA.

Do anchor density or pedicle screw density correlate with short-term outcome measures in adolescent idiopathic scoliosis surgery?

STUDY DESIGN: Retrospective review. OBJECTIVE: Determine if factors under surgeon control (anchor density or pedicle screw density) or those not under surgeon control (curve magnitude, levels requiring fusion, and curve flexibility) correlate with standard, short-term quality and outcome measures for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Pedicle screw fixation has revolutionized posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis and seems to provide greater radiographical coronal plane curve correction than less expensive constructs. Other clinically relevant improvements in outcome have been difficult to demonstrate. METHODS: Retrospective review of 119 posterior spinal instrumentation and fusion cases for adolescent idiopathic scoliosis by 4 surgeons at 1 institution. Average follow-up was 586.7 days. Outcome measures were main thoracic curve correction, complications, reoperations, infection, intensive care unit days, length of stay, estimated blood loss, transfusion, procedure time, implant charges, and total hospital charges. "Surgeon-dependent" variables were implant density (fixation/instrumented level) and pedicle coefficient (implant density × percentage of anchors that are pedicle screws). "Surgeon-independent" variables were main thoracic curve magnitude, main thoracic curve flexibility, and levels fused. Correlations were estimated using Pearson correlation coefficients. One-way analysis of variance was used to estimate the effect of "type of surgeon" or "surgeon" on surgeon-dependent variables. RESULTS: Complications, reoperations, and infections did not correlate with surgeon-dependent or surgeon-independent variables. Main thoracic curve correction correlated strongly with curve flexibility (correlation coefficient [cc] = 0.4089, P < 0.0001). Surgeon-independent variables were levels fused correlated significantly with procedure time (cc = 0.610, P < 0.001), hospital charges (cc = 0.309, P < 0.001), hospital length of stay (cc = 0.366 [P < 0.001]), implant charges (cc = 0.199, P < 0.047), and estimated blood loss (cc = 0.243, P < 0.013). Surgeon-dependent variables were implant density significantly correlated with implant charges (cc = 0.243, P < 0.015) and inversely with length of stay (cc = -0.236, P < 0.015). Pedicle coefficient was not significantly correlated with any outcome measure. CONCLUSION: Levels fused, a surgeon-independent variable, had the most consistently strong correlations with standard short-term quality indicators. With physician grading by payers largely dependent on easily measured outcomes from medical records, hospital and billing records, physicians need to be aware of the surgeon-dependent and surgeon-independent variables that may affect their outcomes and cost-effectiveness profile. LEVEL OF EVIDENCE: 3.

Upper cervical spine trauma.

Injuries to the upper cervical spine are potentially lethal; thus, full characterization of the injuries requires an accurate history and physical examination, and management requires an in-depth understanding of the radiographic projection of the craniocervical complex. Occipital condyle fractures may represent major ligament avulsions and may be highly unstable, requiring surgery. Craniocervical dissociation results from disruption of the primary osseoligamentous stabilizers between the occiput and C2. Dynamic fluoroscopy can differentiate the subtypes of craniocervical dissociation and help guide treatment. Management of atlas fractures is dictated by transverse alar ligament integrity. Atlantoaxial dislocations are rotated, translated, or distracted and are treated with a rigid cervical orthosis or fusion. Treatment of odontoid fractures is controversial and dictated by fracture characteristics, patient comorbidities, and radiographic findings. Hangman's fractures of the axis are rarely treated surgically, but atypical patterns and displaced fractures may cause neurologic injury and should be reduced and fused. Management of injuries to the craniocervical junction remains challenging, but good outcomes can be achieved with a comprehensive plan that consists of accurate and timely diagnosis and stabilization of the craniocervical junction.

Pediatric cervical spondylolysis and American football.

BACKGROUND CONTEXT: Cervical spondylolysis (CS) is a rare condition and is even more uncommon in pediatric patients. It is characterized by a disruption of the articular mass at the junction of the superior and inferior facet joints and often is diagnosed incidentally. The C6 level is most commonly involved, and the cause of CS remains unknown. There are no recommendations in the literature regarding activity modification in patients with CS and no discussion as to risks of participation in American football or other contact sports. PURPOSE: To report a case of C6 bilateral cervical spondylolysis with bicuspid spinous process and to discuss radiographic/clinical findings and issues related to participation in contact sports and minimizing the risk of spinal cord injury. STUDY DESIGN/SETTING: Case report with 6 months clinical/radiographic follow-up METHODS: Radiographic description, clinical findings, and current review of the literature. RESULTS: A pediatric patient presented with a bilateral C6 cervical spondylolysis and bicuspid spinous process after an American football-related minor cervical spine trauma. Findings on radiographs indicated that the spondylolysis appeared to be chronic in nature, without evidence of instability. The patient and his family were educated on ways to decrease the risk of spinal cord injury with contact sports, after which the patient was allowed to participate fully in sports without restrictions or adverse events. CONCLUSION: Pediatric cervical spondylolysis is a rare condition, the cause of which remains debated. Although there is theoretical risk, more than 1.5 million youth participate in American football annually, and there have been no reported cases of significant spinal cord injury in patients with CS from football or other contact sports.

Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases.

BACKGROUND CONTEXT: Spinal epidural abscess (SEA) is a rare, serious and increasingly frequent diagnosis. Ideal management (medical vs. surgical) remains controversial. PURPOSE: The purpose of this study is to assess the impact of risk factors, organisms, location and extent of SEA on neurologic outcome after medical management or surgery in combination with medical management. STUDY DESIGN: Retrospective electronic medical record (EMR) review. PATIENT SAMPLE: We included 128 consecutive, spontaneous SEA from a single tertiary medical center, from January 2005 to September 11. There were 79 male and 49 female with a mean age of 52.9 years (range, 22-83). OUTCOME MEASURES: Patient demographics, presenting complaints, radiographic features, pre/post-treatment neurologic status (ASIA motor score [MS] 0-100), treatment (medical vs. surgical) and clinical follow-up were recorded. Neurologic status was determined before treatment and at last available clinical encounter. Imaging studies reviewed location/extent of pathology. METHODS: Inclusion criteria were a diagnosis of a bacterial SEA based on radiographs and/or intraoperative findings, age greater than 18 years, and adequate EMR. Exclusion criteria were postinterventional infections, Pott's disease, isolated discitis/osteomyelitis, treatment initiated at an outside facility, and imaging suggestive of a SEA but negative intraoperative findings/cultures. RESULTS: The mean follow-up was 241 days. The presenting chief complaint was site-specific pain (100%), subjective fevers (50%), and weakness (47%). In this cohort, 54.7% had lumbar, 39.1% thoracic, 35.9% cervical, and 23.4% sacral involvement spanning an average of 3.85 disc levels. There were 36% ventral, 41% dorsal, and 23% circumferential infections. Risk factors included a history of IV drug abuse (39.1%), diabetes mellitus (21.9%), and no risk factors (22.7%). Pathogens were methicillin-sensitive Staphylococcus aureus (40%) and methicillin-resistance S aureus (30%). Location, SEA extent, and pathogen did not impact MS recovery. Fifty-one patients were treated with antibiotics alone (group 1), 77 with surgery and antibiotics (group 2). Within group 1, 21 patients (41%) failed medical management (progressive MS loss or worsening pain) requiring delayed surgery (group 3). Irrespective of treatment, MS improved by 3.37 points. Thirty patients had successful medical management (MS: pretreatment, 96.5; post-treatment, 96.8). Twenty-one patients failed medical therapy (41%; MS: pretreatment, 99.86, decreasing to 76.2 [mean change, -23.67 points], postoperative improvement to 85.0; net deterioration, -14.86 points). This is significantly worse than the mean improvement of immediate surgery (group 2; MS: pretreatment, 80.32; post-treatment, 89.84; recovery, 9.52 points). Diabetes mellitus, C-reactive protein greater than 115, white blood count greater than 12.5, and positive blood cultures predict medical failure: None of four parameters, 8.3% failure; one parameter, 35.4% failure; two parameters, 40.2% failure; and three or more parameters, 76.9% failure. CONCLUSION: Early surgery improves neurologic outcomes compared with surgical treatment delayed by a trial of medical management. More than 41% of patients treated medically failed management and required surgical decompression. Diabetes, C-reactive protein greater than 115, white blood count greater than 12.5, and bacteremia predict failure of medical management. If a SEA is to be treated medically, great caution and vigilance must be maintained. Otherwise, early surgical decompression, irrigation, and debridement should be the mainstay of treatment.

Prognostic value of computed tomography classification systems for intra-articular calcaneus fractures.

BACKGROUND: There are several published computed tomography (CT) classification systems for calcaneus fractures, each validated by a different standard. The goal of this study was to measure which system would best predict clinical outcomes as measured by a widely used and validated musculoskeletal health status questionnaire. METHODS: Forty-nine patients with isolated intra-articular joint depression calcaneus fractures more than 2 years after treatment were identified. All had preoperative CT studies and were treated with open reduction and plate fixation using a lateral extensile approach. Four different blinded reviewers classified injuries according to the CT classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders. Functional outcomes evaluated with a Musculoskeletal Functional Assessment (MFA). The mean follow-up was 4.3 years. RESULTS: The mean MFA score was 15.7 (SD = 11.6), which is not significantly different from published values for midfoot injuries, hindfoot injuries, or both, 1 year after injury (mean = 22.1, SD = 18.4). The classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders, the number of fragments of the posterior facet, and payer status were not significantly associated with outcome as determined by the MFA. The Sanders classification trended toward significance. Anterior process comminution and surgeon's overall impression of severity were significantly associated with functional outcome. CONCLUSIONS: The amount of anterior process comminution was an important determinant of functional outcome with increasing anterior process comminution significantly associated with worsened functional outcome (P = .04). In addition, the surgeon's overall impression of severity of injury was predictive of functional outcome (P = .02), as determined by MFA. LEVEL OF EVIDENCE: Level III, comparative series.

Association of atypical femoral fractures with bisphosphonate use by patients with varus hip geometry.

BACKGROUND: There is increasing evidence associating "atypical" femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture. METHODS: The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group. RESULTS: The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5° versus 133.8°; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128°). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs. CONCLUSIONS: Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use.