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The purpose of this systematic review is to (i) compare post-operative activity levels after periacetabular osteotomy (PAO) versus PAO + HA (concomitant PAO and hip arthroscopy) using patient-reported outcomes that specifically assess activity and sports participation [Hip Disability and Osteoarthritis Outcome Score-Sport and Recreation subscale (HOOS-SR), University of California Los Angeles (UCLA) activity score, Hip Outcome Score-Sport-Specific Subscale (HOS-SSS)] and (ii) compare post-operative return to sport (RTS) data between PAO and PAO + HA groups. A systematic review of literature was conducted on 1 June 2023, utilizing PubMed, Cochrane and Embase (OVID). Articles were screened for inclusion using specific inclusion and exclusion criteria. Twenty-six out of 1610 articles met all inclusion criteria, without meeting any exclusion criteria. In the 12 studies containing only subjects who underwent PAO alone, 11 demonstrated an average score improvement in UCLA, HOOS-SR or HOS-SSS post-operatively (P < 0.05). In the three studies containing subjects who underwent PAO with concomitant HA, significant improvements were seen in the HOS-SS and UCLA scores (P < 0.05). In the five studies that directly compared UCLA, HOS-SSS and HOOS-SSS scores between PAO groups and PAO + HA groups, all demonstrated statistically significant improvement post-operatively (P < 0.05). The rate of RTS ranged from 63% to 90.8% among PAO studies and was found to be 81% in the single PAO + HA study that assessed RTS. When performed in patients with intra-articular pathology, concomitant PAO + HA may provide similar sport-related outcomes to PAO alone in patients without intra-articular pathology.
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Introduction: Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors. Methods: Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared. Results: A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P < .001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 - 34.199, P = .020). There were no significant differences in any adverse event (AAE) between procedures (P = .259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 - 1.128, P = .018). Conclusion: The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures.
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BACKGROUND: Although elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aimed to identify the elective orthopaedic procedures with the highest rate of unplanned reoperation and the reasons for these procedures having such high reoperation rates. METHODS: Patients in the NSQIP database were identified using CPT and ICD-10 codes. We isolated 612,815 orthopaedics procedures from 2018 to 2020 and identified the 10 CPT codes with the greatest rate of unplanned return to the operating room. For each index procedure, we identified the ICD-10 codes for the reoperation procedure and categorized them into infection, mechanical failure, fracture, wound disruption, hematoma or seroma, nerve pathology, other, and unspecified. RESULTS: Below knee amputation (BKA) (CPT 27880) had the highest reoperation rate of 6.92% (37 of 535 patients). Posterior-approach thoracic (5.86%) or cervical (4.14%) arthrodesis and cervical laminectomy (3.85%), revision total hip arthroplasty (5.23%), conversion to total hip arthroplasty (4.33%), and revision shoulder arthroplasty (4.22%) were among the remaining highest reoperation rates. The overall leading causes of reoperation were infection (30.1%), mechanical failure (21.1%), and hematoma or seroma (9.4%) for the 10 procedures with the highest reoperation rates. CONCLUSIONS: This study successfully identified the elective orthopaedic procedures with the highest 30-day return to OR rates. These include BKA, posterior thoracic and cervical spinal arthrodesis, revision hip arthroplasty, revision total shoulder arthroplasty, and cervical laminectomy. With this data, we can identify areas across orthopaedics in which revising protocols may improve patient outcomes and limit the burden of reoperations on patients and the healthcare system. Future studies should focus on the long-term physical and financial impact that these reoperations may have on patients and hospital systems. LEVEL OF CLINICAL EVIDENCE: IV.
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Procedimentos Cirúrgicos Eletivos , Salas Cirúrgicas , Procedimentos Ortopédicos , Reoperação , Humanos , Reoperação/estatística & dados numéricos , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/estatística & dados numéricos , Feminino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Bases de Dados Factuais , IdosoRESUMO
BACKGROUND: Anatomical total shoulder arthroplasty (TSA) and shoulder hemiarthroplasty (HA) have both been shown to have good outcomes in patients with osteoarthritis of the glenohumeral joint. However, evidence comparing perioperative complications between these procedures in this population is heterogeneous. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried between the years 2012 and 2021 (10 years in total) for records of patients who underwent either TSA or HA for osteoarthritis of the glenohumeral joint. Patients in each group underwent a 1:1 propensity match for demographic variables. Bivariate and multivariate analyses were performed to compare complications and risk factors between these cohorts. RESULTS: A total of 4376 propensity-matched patients, with 2188 receiving TSA and 2188 receiving HA, were included in the primary analyses. The HA cohort had a higher rate of any adverse event (7.18% vs 4.8%, P=.001), death (0.69% vs 0.1%, P=.004), sepsis (0.46% vs 0.1%, P=.043), postoperative transfusion (4.62% vs 2.2%, P<.001), postoperative intubation (0.5% vs 0.1%, P=.026), and extended length of stay (23.77% vs 13.1%, P<.001). HA was found to increase the odds of developing these complications when baseline demographics were controlled. Older age (odds ratio, 1.040; 95% CI, 1.021-1.059; P<.001) and lower body mass index (odds ratio, 0.949; 95% CI, 0.923-0.975; P<.001) increased the odds of having any adverse event in the HA cohort but not in the TSA cohort. CONCLUSION: Compared with TSA, HA appears to be associated with significantly higher rates of 30-day postoperative complications when performed for glenohumeral osteoarthritis. [Orthopedics. 2024;47(4):217-224.].
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Artroplastia do Ombro , Hemiartroplastia , Osteoartrite , Complicações Pós-Operatórias , Pontuação de Propensão , Articulação do Ombro , Humanos , Artroplastia do Ombro/efeitos adversos , Artroplastia do Ombro/métodos , Masculino , Feminino , Complicações Pós-Operatórias/epidemiologia , Osteoartrite/cirurgia , Idoso , Hemiartroplastia/efeitos adversos , Hemiartroplastia/métodos , Pessoa de Meia-Idade , Articulação do Ombro/cirurgia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Background: Traditionally, postoperative rehabilitation protocols after proximal hamstring repair (PHR) for avulsion of the proximal hamstring tendon from its ischial insertion recommend bracing the hip and/or knee to protect the fixation. However, because of the cumbersome nature of these orthoses, recent studies have investigated outcomes in patients with postoperative protocols that do not include any form of postoperative bracing. Purpose: To synthesize the current body of evidence concerning bracing versus nonbracing postoperative management of PHR. Study Design: Systematic review; level of evidence, 4. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a thorough search of the PubMed/Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase (OVID) databases on March 24, 2023. We analyzed complication rates, reoperation rates, patient satisfaction, return to sport, and patient-reported outcomes of studies that used postoperative bracing versus studies that used no postoperative bracing after PHR with at least 12 months of follow-up. A total of 308 articles were identified after initial search. Results: In total, 25 studies were included in this review: 18 studies (905 patients) on bracing and 7 studies (291 patients) on nonbracing after PHR. The overall complication rate in the braced patients was found to be 10.9%, compared with 12.7% in nonbraced patients. The rate of reoperation due to retear of the proximal hamstring was found to be 0.05% in braced patients and 3.1% in nonbraced patients. Patient-reported outcome measures were found to be higher at the final follow-up in braced versus nonbraced patients, and patient satisfaction was found to be 94.7% in braced studies compared with 88.9% in nonbraced studies. The rate of 12-month return to sport in athletic patients was 88.4% with bracing and 82.7% without bracing. Conclusion: The findings of this review demonstrated lower complication and reoperation rates, higher patient-reported outcome scores, higher patient satisfaction, and a higher rate of return to sport in braced patients compared with nonbraced patients.
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Background: Deficiency in vitamin D has been shown to increase the risk of injury. Purpose: To synthesize current placebo-controlled randomized trials investigating the effect of vitamin D supplementation in elite athletes on (1) aerobic capacity; (2) anaerobic measures, such as strength, speed, and anaerobic power; (3) serum biomarkers of inflammation; and (4) bone health. Study Design: Systematic review; Level of evidence, 1. Methods: A literature search was conducted on November 30, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included were randomized, placebo-controlled studies of longer than 2 weeks on subjects with active participation in organized sport. Excluded were nonrandomized controlled trial study designs, vitamin D administration routes other than oral, studies that did not use vitamin D supplementation as the sole intervention, and studies with nonathletic or military populations. Results: Out of 2331 initial studies, 14 studies (482 athletes) were included. Of the 3 studies that assessed aerobic capacity, 2 demonstrated significantly greater improvements in maximal oxygen uptake and physical working capacity-170 (P < .05) in supplemented versus nonsupplemented athletes. Measurements of anaerobic power and strength were consistently increased in supplemented groups compared with nonsupplemented groups in 5 out of the 7 studies that assessed this. Of the 6 studies that assessed sprint speed, 4 found no significant difference between supplemented and nonsupplemented groups. Aside from 1 study that found significantly lower interleukin-6 levels in supplemented athletes, measures of other inflammatory cytokines were not affected consistently by supplementation. The 4 studies that assessed markers of bone health were conflicting regarding benefits of supplementation. One study found demonstrated improvements in bone mineral density in response to supplementation (P = .02) compared with control whereas another found no significant difference between supplemented and nonsupplemented groups. However, in 3 other studies, serum biomarkers of bone turnover such as bone-specific alkaline phosphatase, parathyroid hormone, and N-terminal telopeptide appeared to be higher in subjects with lower serum vitamin D levels (P < .05). Conclusion: Results of this systematic review indicated that the greatest benefit of vitamin D supplementation in elite athletes may be improving aerobic endurance, anaerobic power, and strength. More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in this population.
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PURPOSE: To use the National Surgical Quality Improvement Program (NSQIP) database to identify risk factors for 30-day adverse events and hospital readmission following isolated and unilateral meniscectomy or meniscus repair. METHODS: A retrospective review of the NSQIP database from the years 2012 to 2021 identified all patients undergoing isolated, unilateral meniscectomy or meniscus repair. Multivariable analyses were performed for each procedure to identify patient characteristics associated with any adverse event (AAE) or unplanned hospital readmission within 30 days of surgery. RESULTS: From 2012 to 2021, 59,450 (93%) patients underwent meniscectomy, and 4,773 (7%) patients underwent meniscus repair. Overall adverse event rate was 0.95% after meniscectomy and 1.40% after repair. Risk factors for AAE after meniscectomy included increased age (odds ratio [OR] = 1.010; P = .009), increased operative time (OR = 1.003; P = 0.011), American Society of Anesthesiologists (ASA) class IV (OR = 2.048; P = .045), functional dependency (OR = 3.527; P = .001), and current smoking (OR = 1.308; P = .018). Risk factors for AAE after meniscus repair included age (OR = 1.024; P = .016), operative time (OR = 1.004; P = .038), and bleeding disorders (OR = 7.000; P = .014). ASA class III increased risk of hospital readmission after both procedures (OR = 1.906; P = .008; OR = 4.101; P = .038), and medical comorbidities of heart failure (OR = 3.924; P = .016), hypertension (OR = 1.412; P = .011), and chronic obstructive pulmonary disease (OR = 2.350; P < .001) increased readmission risk after meniscectomy only. CONCLUSIONS: Per analysis of the ACS-NSQIP database, surgical treatment of meniscal tears in the knee has been performed frequently over the past 10 years, with meniscectomies comprising over 90% of cases. Increased age and operative time were associated with a modest risk of adverse events after both meniscectomy and meniscus repair. Increased comorbidity burden, evidenced by ASA class, dependent functional status, current smoking, and systemic medical conditions, such as heart failure, hypertension, chronic obstructive pulmonary disease, and bleeding disorders, greatly increased rates of unfavorable outcomes within 30 days of meniscus surgery. LEVEL OF EVIDENCE: Level III, retrospective prognostic comparative investigation.
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CASE: A 22-year-old athlete sustained a traumatic posterior tibial tendon (PTT) rupture with medial malleolus fracture and anterior tibial plafond chondral lesion during practice. He underwent PTT repair, ankle arthroscopy with microfracture, and medial malleolus open reduction and internal fixation with deltoid ligament repair. At 1 year postoperatively, the patient returned to activity excluding high-level competition. CONCLUSION: Anterior tibial chondral impaction injury with an avulsion fracture of the medial malleolus and PTT tear is effectively treated with a combined arthroscopic and open approach.
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Fraturas do Tornozelo , Traumatismos dos Tendões , Masculino , Humanos , Adulto Jovem , Adulto , Traumatismos dos Tendões/diagnóstico por imagem , Traumatismos dos Tendões/etiologia , Traumatismos dos Tendões/cirurgia , Tendões , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Artroscopia , AtletasRESUMO
BACKGROUND: Previous research shows conflicting evidence regarding the postoperative role of cryotherapy after total knee arthroplasty (TKA). This systematic review aims to further investigate the effect of various methods of cryotherapy on the following: (1) pain; (2) swelling; (3) postoperative opioid use; and (4) range of motion (ROM). METHODS: A strategic keyword search of Medline, Cochrane, Embase, and CINAHL retrieved randomized controlled trials examining cryotherapy following TKA published between February 1, 2017, and February 24, 2022. The studied outcomes included pain ratings, knee/limb swelling, opioid use, and ROM. Six studies were selected for inclusion in this review. RESULTS: Opioid use was significantly decreased in cryotherapy groups compared to noncryotherapy groups within the first postoperative week only (P < .05). This effect may be augmented by the use of computer-assisted (temperature regulated) cryotherapy devices, compared to other modalities including ice packs. Pain ratings also decrease, but this decrease may not be clinically relevant. Cryotherapy appears to confer no consistent benefit to ROM and swelling at any time point. Computer-assisted cryotherapy may be associated with decreased opioid consumption after TKA compared to traditional ice packs. CONCLUSION: Cryotherapy's role after TKA appears to be in decreasing opioid consumption primarily in the first postoperative week. Pain ratings also decrease consistently with cryotherapy use, but this decrease may not be clinically relevant. Study heterogeneity requires further research focusing on optimizing cryotherapy modalities within the first postoperative week, and analyzing cost associated with modern outpatient postoperative TKA protocols.
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Artroplastia do Joelho , Artropatias , Transtornos Relacionados ao Uso de Opioides , Humanos , Artroplastia do Joelho/efeitos adversos , Analgésicos Opioides/uso terapêutico , Gelo , Dor Pós-Operatória/terapia , Dor Pós-Operatória/cirurgia , Articulação do Joelho/cirurgia , Artropatias/cirurgia , Crioterapia/métodos , Amplitude de Movimento Articular , EdemaRESUMO
Introduction: Postsurgical knee arthrofibrosis is a common complication associated with pain and limited range of motion. Although the mechanism is unclear, many biochemical and genetic markers have been identified within arthrofibrotic knees. The purpose of this systematic review is to synthesize the many biochemical and genetic markers that have been associated with surgery-induced knee arthrofibrosis in order to better guide future therapeutic endeavors. Methods: A thorough search of literature was conducted on April 27, 2022. Seventeen studies met inclusion criteria for this systematic review. Inclusion criteria for this study were as follows: title or abstract discussed biochemical and genetic markers associated with postoperative knee arthrofibrosis, study design included human and/or animal subjects. Results: A wide variety of genetic biomarkers (mRNA), proteins/enzymes, and cytokines were identified in both animal models and human subjects with postsurgical knee arthrofibrosis. These included various extracellular matrix-encoding mRNA sequences, matrix metalloproteinases, proteins and mRNA sequences involved in Transforming Growth Factor-ß signaling, and interleukin-family cytokines to name just a few. Conclusion: There are many biomarkers found in postsurgical arthrofibrotic knees. TGF-ß, and mRNA/proteins that participate in TGF-ß signaling (i.e., LOX, SERPINE1, PAI-1/Akt/mTOR, BMP-2), appear to be particularly common. Future comparative studies should aim to determine which of these are most relevant, and therefore, worthwhile therapeutic targets.
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Introduction: The etiology of patellofemoral (PF) instability is multifactorial. Excessive external tibial torsion has been associated with recurrent patellar subluxation and persistent anterior knee pain. Several surgical techniques have been historically used to correct this, including medial patellofemoral ligament reconstruction, tibial tuberosity transfer (TTT), trochleoplasty, and tibial derotation osteotomy (TDO). The purpose of this systematic review is to investigate the safety and efficacy of TDO for PF instability and pain. Methods: A thorough search of the literature was conducted on July 15, 2022. Seven studies met the inclusion criteria for this systematic review. Results: Among the included studies, there were 179 total subjects and 204 operative knees. Mean follow-up time was 66.31 months (range 11-192). Complication rate was low (12.8%) in studies that reported complications. Average degree of anatomical correction in the transverse plane was 19.9 degrees with TDO. This increased to 34 degrees when combined with TTT. All PROMs assessed were significantly increased postoperatively (p < 0.05). Age greater than 25 years and advanced PF chondromalacia may negatively affect postoperative outcomes. Conclusion: The primary findings of this review were as follows: (1) TDO results in significantly improved pain and PROM ratings in patients with PF pain and/or instability, (2) the likelihood of complication, including recurrent patella subluxation after TDO, is low but may be increased by aging, and (3) the successful anatomical correction of TDO may be augmented by concurrent TTT in some cases.
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Introduction: While the body of research investigating anterior cervical disk fusion (ACDF) for symptomatic cervical disk herniations in high-level athletes is large, evidence for cervical disk replacement (CDR) is sparse. The amount of patients able to return to sport after an ACDF is estimated to be 73.5%, causing surgeons to search for alternatives with better outcomes in this population. This case report describes the successful treatment of a symptomatic collegiate American football player with C6-C7 disk herniation and C5-C6 central canal stenosis. Case Report: This is a 21-year-old American football safety who underwent a C5-6 and C6-7 cervical disk arthroplasty. Three weeks postoperatively, the patient demonstrated nearly complete resolution of weakness, full resolution of radiculopathy, and normal cervical range of motion in all planes. Conclusion: The CDR may be considered as an alternative to the ACDF in the treatment of high-level contact athletes. Compared to the ACDF, CDR has been shown in prior studies to decrease the long-term risk of adjacent segment degeneration. Future studies comparing ACDF to CDR in the high-level contact sport athlete population are needed. CDR appears to be a promising surgical intervention for symptomatic patients in this population.
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KEY CLINICAL MESSAGE: Maternal serum screening-positive patient had prenatal diagnosis with amniotic fluid, which showed inconsistent results between interphase fluorescence in situ hybridization (three signals of 21q22.13-21q22.2) and G-banding analysis (46,XY). Further analyses proved that the fetus had extremely complex rearrangements of chromosome 21, including the interstitial duplication of Down syndrome critical region.