Manipulation Under Anesthesia is Safe and Effective for Management of Early Postoperative Knee Arthrofibrosis in Adolescent Patients.

BACKGROUND: Management of postoperative knee arthrofibrosis can be challenging and the preferred time for intervention remains controversial. The purpose of this study is to evaluate the safety and efficacy of early (<3 mo postoperatively) manipulation under anesthesia (MUA) for the treatment of knee arthrofibrosis in adolescent patients. We hypothesized that early MUA could restore normal knee motion with a low complication rate and without the need for more invasive intervention. METHODS: In a retrospective review, 57 patients who underwent MUA for postoperative knee arthrofibrosis were identified. The time between the index surgery and MUA as well as changes in range of motion (ROM) before and after MUA were analyzed. Descriptive statistics with median and interquartile range were used to analyze this non-parametric study cohort. Repeated measures ANOVA was performed to assess improvement in ROM over time. A P value <0.05 denoted statistical significance. RESULTS: The median age of the cohort at time of MUA was 14.5 years [interquartile range (IQR) 12.9 to 17.6)]. 54.4% were male. Median time to MUA was 64 days (IQR 52 to 79) after index surgery. ROM before MUA was 90.0 degrees (IQR 75 to 100), which improved to 130 degrees (120 to 135) after MUA. At final median follow-up of 8.9 months (IQR 5.1 to 16.1), mean ROM was 133 degrees (130 to 140). There were no iatrogenic fractures or physeal separations associated with MUA. 12.3% (n=7/57) failed MUA either due to the need for subsequent repeat MUA (n=2), need for lysis of adhesions (n=3) or need for surgery after MUA (n=2). Those who failed early MUA and required subsequent procedures had ROM >120 degrees at final follow-up. CONCLUSIONS: Postoperative knee arthrofibrosis can be safely and effectively treated with early (<3 mo postoperative) MUA. There were no iatrogenic fractures or physeal separations during MUA. Patients who had recurrence of motion deficits after early MUA and required further intervention, regained satisfactory knee motion at final follow-up. Although further research is warranted to better characterize risk factors for knee arthrofibrosis in adolescent patients, early recognition and MUA is a safe and effective treatment for arthrofibrosis to help patients regain full ROM without invasive intervention. LEVEL OF EVIDENCE: Therapeutic Study - Level IV.

Incidence of Urinary Retention Following Posterior Spinal Fusion for Adolescent and Pediatric Scoliosis at a Single Academic Center: Is There a Role for Prophylactic Tamsulosin?

The purpose of this study is to better characterize patient- and surgery-specific parameters associated with postoperative urinary retention (POUR) and assess the impact of prophylactic Tamsulosin following posterior spinal fusion (PSF) for the management of scoliosis in pediatric and adolescent patients. All patients who underwent PSF for surgical correction of adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS) between 2015 and 2019 were retrospectively reviewed. Patients were stratified based on whether they received prophylactic Tamsulosin. Overall, POUR was reported in 3.7% (n = 10) of all patients in the study, although Tamsulosin was associated with a lower rate of POUR, and this did not reach statistical significance. Longer fusion constructs were identified as a risk factor for POUR and could help surgeons counsel families prior to surgery. This is the first study to assess the rate of POUR on AIS and NMS patients following PSF without epidural analgesia. (Journal of Surgical Orthopaedic Advances 33(1):010-013, 2024).

Editorial Commentary: Microfracture Remains a Foundational Tool for Cartilage Restoration During Hip-Preservation Procedures: Defying the Odds.

A comprehensive approach to arthroscopic hip preservation in patients whose pathology includes cartilage defects may include microfracture; microfracture has been shown to have long-lasting positive effects in most patients treated for femoroacetabular impingement plus full-thickness chondral pathology. Although modern cartilage treatment alternatives such as autologous chondrocyte implantation, autologous matrix-induced chondrogenesis scaffolds, allograft or autograft particulate cartilage graft, and others have been described for the treatment of high-degree cartilage acetabular lesions, microfracture remains a foundational tool in cartilage restoration procedures. That said, when determining outcome, comorbidity must be considered, and, moreover, it is difficult to determine whether outcomes are only attributable to the microfracture versus concomitant procedures or changes in postoperative activity of operated patients.

Hip Arthroscopic Microfracture Augmented With Platelet-Rich Plasma-Infused Micronized Cartilage Allograft Significantly Improves Functional Outcomes.

PURPOSE: To evaluate functional outcomes and survivorship in patients at 1 year after undergoing arthroscopic microfracture augmented with hyaline allograft for symptomatic chondral defects of the hip. METHODS: Consecutive patients with and without prior hip procedures presenting with Outerbridge grade IV chondral lesion of the acetabulum or femoral head were prospectively followed. Patients underwent hip microfracture augmented with hyaline allograft suspended in autologous platelet-rich plasma between October 2016 and April 2018. Extent of cartilage degeneration was quantified using the chondromalacia severity index (CMI). Patient functional scores, including Tegner, Hip Outcome Score-Activities of Daily Living (HOS-ADL), Sport-Specific Subscale (HOS-SSS), modified Harris Hip Score (mHHS), and Nonarthritic Hip Score (NAHS) were collected preoperatively and at minimum 1-year postoperatively. Minimal clinically important difference (MCID) was analyzed. Statistical significance was established at P < .05. Pearson's coefficient analysis was performed to identify preoperative variables correlated with clinical outcomes. RESULTS: Fifty-seven patients (86.4%) had minimum 1-year follow-up and were included in the final analysis, with a mean age and body mass index (BMI) of 38.3 ± 9.1 years and 27.7 ± 4.9 kg/m2, respectively. Comparison of baseline and postoperative score averages demonstrated significant improvements in Tegner scores (3.7 ± 2.9 vs 5.1 ± 2.6; P = .003), HOS-ADL (63.3 ± 16.4 vs 89.1 ± 14.5; P < .001), HOS-SSS (40.8 ± 20.4 vs 79.5 ± 21.6; P < .001), mHHS (61.5 ± 16.2 vs 87.0 ± 17.7; P < .001), and NAHS (56.6 ± 14.9 vs 78.7 ± 18.3; P < .001). The percentage of patients who achieved MCID for HOS-ADL, HOS-SSS, mHHS, and NAHS were 89.8%, 83.0%, 75.6%, and 81.6%, respectively. Overall, 91.8% of patients met the threshold for achieving MCID in at least one outcome score. Of the 57 patients, 5 (8.8%) failed clinically, with 1 (1.8%) undergoing revision surgery and 4 (6.9%) undergoing conversion to total hip arthroplasty. There was a direct correlation between preoperative alpha angle and postoperative HOS-ADL. Femoral chondral lesion size and CMI inversely correlated with postoperative HOS-ADL. CONCLUSIONS: Treatment of hip chondral defects with microfracture and hyaline allograft augmentation demonstrated excellent survivorship and significantly improved patient report outcomes at 1 year. LEVEL OF EVIDENCE: IV, retrospective case series.

An Innovative Seven-year Physician Scientist Residency Training Program That Addresses the Shortage of Academic Surgeons.

Due to the declining number of scientifically trained physicians and increasing demand for high-quality literature, our institution pioneered a seven-year Physician Scientist Training Program (PSTP) to provide research-oriented residents the knowledge and skills for a successful academic career. The present study sought to identify orthopaedic surgeons with MD/PhD degrees, residency programs with dedicated research tracks, and to assess the effectiveness of the novel seven-year program in training prospective academic orthopaedic surgeons. Surgeons with MD/PhD degrees account for 2.3% of all 3,408 orthopaedic faculty positions in U.S. residency programs. During the last 23 years, our PSTP residents produced 752 peer-reviewed publications and received $349,354 from 23 resident-authored extramural grants. Eleven of our seven-year alumni practice orthopaedic surgery in an academic setting. The seven-year PSTP successfully develops clinically trained surgeon scientists with refined skills in basic science and clinical experimental design, grant proposals, scientific presentations, and manuscript preparation. (Journal of Surgical Orthopaedic Advances 31(3):144-149, 2022).

History of Breast Cancer Increases 90-Day Pulmonary Embolism Rates and Reimbursements After Total Hip Arthroplasty: A National Matched-Pair Analysis.

BACKGROUND: Rates of total hip arthroplasty (THA) are projected to increase in the coming decades. Multiple studies have focused on identifying risk factors for adverse events after joint arthroplasty, and recent attention has been directed toward cancer. Very limited data have been published examining the effects of history of malignancy on outcomes after THA. With a concomitant increase in breast cancer diagnosis and treatments in recent years, it is expected that orthopedic surgeons will likely see more breast cancer survivors in clinic. The purpose of this study is to examine the effects of a personal history of breast cancer on 90-day outcomes after THA. METHODS: We conducted a retrospective case-control study of the entire Medicare records. The endpoints of this study included length of stay, medical complications, surgical complications, and costs (examined here as reimbursements). Patients were matched by age and gender in order to decrease confounding. A 1:1 matching was performed. RESULTS: After age and demographics matching, our findings demonstrated that patients with a history of breast cancer have increased rates of pulmonary embolism (0.59% vs 0.45%, P = .003), increased use of chest computed tomography (1.72% vs 1.18%, P < .001), and higher mean 90-day reimbursements (mean $15,432 vs mean $14,701, P = .011) in the 90 days following surgery. Other medical and surgical complications were equally distributed in both cohorts. CONCLUSION: Surgeons should be aware of the increased rate of pulmonary embolism and have a more aggressive thromboprophylaxis protocol in these patients.

Variability in Patellofemoral Alignment Measurements on MRI: Influence of Knee Position.

OBJECTIVE: The purpose of this study was to determine the variability of distances between four distinct anatomic landmarks used for the evaluation of patellofemoral alignment while implementing controlled changes in patient positioning during MRI. MATERIALS AND METHODS: Limited MRI was performed of 12 knees in healthy volunteers (10 men, two women; mean age, 28 years) with the knees in four different positions. The four landmarks used were TT (the most anterior point of the osseous tibial tubercle), TG (the nadir of the cartilaginous trochlear groove), PT (the center of the patellar tendon insertion on the tibia), and PCL (the medial border of the posterior cruciate ligament at its insertion along the posterior tibia). TT-TG, PT-TG, TT-PCL, and PT-PCL distances were measured on the MR images. Each distance was measured with the knee at maximum patient comfort (rest), full extension, 15° of flexion, and 30° of flexion. Linear mixed models with random intercepts were implemented to determine variability between measurements and knee position. RESULTS: In general, measurements based on anatomic landmark and knee position varied greatly. The greatest variability in different knee positions was seen in mean TT-TG and PT-TG distances ± SD (TT-TG: rest, 18.1 ± 7.9 mm; full extension, 17.3 ± 5.3 mm; 15° of flexion, 11.4 ± 5.7 mm; 30° of flexion, 11.7 ± 6.0 mm; intraclass correlation coefficient [ICC] = 0.539; PT-TG: rest, 18.1 ± 6.3 mm; full extension, 17.9 ± 4.7 mm; 15° of flexion, 13.2 ± 5.2 mm; 30° of flexion, 11.8 ± 4.3 mm; ICC = 0.633). In contrast, knee position did not significantly affect distances for TT-PCL and PT-PCL (TT-PCL: rest, 23.5 ± 6.8 mm; full extension, 20.5 ± 5.5 mm; 15° of flexion, 22.8 ± 6.2 mm; 30° of flexion, 22.8 ± 6.7 mm; ICC = 0.484; PTPCL: rest, 23.4 ± 5.3 mm; full extension, 21.5 ± 4.5 mm; 15° of flexion, 22.3 ± 4.3 mm; 30° of flexion, 23.1 ± 4.8 mm; ICC = 0.509). CONCLUSION: On MRI, TT-PCL and PT-PCL measurements have significantly less variability compared with TT-TG and PT-TG measurements, regardless of knee position. Although further studies are warranted, the use of TT-PCL and PT-PCL measurements may offer more reliable assessment of tibial tubercle lateralization and patellofemoral alignment.

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study.

PURPOSE: To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome. METHODS: We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n = 14) or diaphyseal (n = 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed. RESULTS: There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group. CONCLUSIONS: Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Hemiarthroplasty for Fractures of Metastatic Bone Disease Have Different Outcomes Compared to Fractures Without Metastasis: A Matched-Pair Analysis.

INTRODUCTION: Hemiarthropalsty (HA) for proximal femur fractures (PFF) has shown good results in the elderly patient population. It has also been used to treat fractures of the proximal femur in patients with metastatic bone disease (MBD). Nonetheless, complications still occur in both patient populations and their effect on 90-day costs can be a great burden to the healthcare system. Thus, the purpose of this study was to evaluate and compare the outcomes and costs of HA for PFF in patients with bone metastasis versus those without it. MATERIALS AND METHODS: The Medicare standard analytical files were queried through International Classification of Diseases and Related Health Problems, ninth edition (ICD-9) codes. A case-control study comparing PFF in patients with and without MBD treated with HA was performed. Medical and surgical complications, mortality, discharge disposition, and length of stay were analyzed and compared. Outcomes were tracked for the 90-day period after surgery. Statistical analysis was performed through odds ratios, unpaired t-tests, and chi-squares. RESULTS: Patients treated with HA for fractures with MBD have higher rates of medical complications compared to fracture patients without MBD. Mortality was found to be significantly greater in the MBD cohort (8.8% vs. 2.3%), as were medical complications and length of stay. Both charges and reimbursements were also significantly greater in the MBD cohort. CONCLUSION: Patients who undergo hip HA for MBD are at increased risks of medical complications compared to patients who undergo HA for fractures without metastasis, and surgeons should be aware of these increased risks.

Arthroscopic Management of Hip Chondral Defects: A Systematic Review of the Literature.

PURPOSE: To critically evaluate the evidence for arthroscopic management of chondral defects in the hip through a systematic literature review. METHODS: A systematic literature review was performed to identify all articles addressing the arthroscopic management of chondral defects about the hip. Case reports, open techniques, and those associated with osteonecrosis were excluded. Articles were assessed for sample size, location, severity, and size of chondral defects, and the surgical technique. Associated injuries, follow-up duration (months), and functional outcomes were recorded. Study cohorts were defined by a surgical technique (debridement v microfracture v autologous chondrocyte transplantation [ACT]). Statistical analysis was performed with a χ(2) test and analysis of variance with post hoc pairwise analysis for categorical and continuous data, respectively, with significance defined as P < .05. RESULTS: The literature search identified 269 articles, of which 12 clinical studies met inclusion criteria for this analysis. After pooling the data, there were 579 (64.7%) debridements, 279 (31.2%) microfracture, and 37 (4.1%) ACT performed. Patients were followed for an average of 27.1 months (range: 5 to 72 months). All lesions treated with either a microfracture or ACT were high grade (Outerbridge 3 to 4). However, lesion size was significantly larger in ACT-treated patients compared with those who underwent microfracture (357.3 ± 96.0 mm(2)v 149.5 ± 20.7 mm(2); P = .020). All cohorts showed significant improvement in functional outcomes after hip arthroscopy (P < .001). CONCLUSIONS: This systematic review showed that arthroscopic debridement, microfracture, and ACT are associated with equivalent improvement in clinical outcomes in patients with high-grade chondral defects in the hip in the short- and midterm follow-up. In addition, although there were no differences in patient characteristics and demographics based on the surgical technique, we confirmed the hypothesis that lesion size varied significantly between arthroscopic techniques, and that the decision to use one technique over another may be determined by the size of the defect. Therefore, lesion size is likely to influence the development of hip- and technique-specific indications, and may also represent a useful metric for success of surgical intervention. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Maintenance of curve correction and unplanned return to the operating room with magnetically controlled growing rods: a cohort of 24 patients with follow-up between 2 and 7 years.

PURPOSE: Early onset scoliosis (EOS) is defined as spinal curvature affecting children below 10 years of age. Non-operative treatment can consist of casting and bracing. When curvature progresses despite these treatments, operative intervention is indicated. Traditional growing rods (TGR) have been a mainstay of treatment. Unfortunately, TGR's require planned return to the operating room every 6-9 months. Magnetic controlled growing rods (MCGR) ideally provide curve correction and allow the spine to grow without frequent surgeries. However, the ability to correct and maintain correction after MCGR has not been well-characterized. The purpose of this study is to evaluate maintenance of curve correction in patients treated primarily with MCGR and analyze the rate of complications including unplanned return to the operating room (UPROR). METHODS: 24 patients with EOS were retrospectively reviewed. These patients were subdivided into 4 subcategories: congenital, idiopathic, neuromuscular (NMS), and syndromic. The major curve correction (%) and T1-S1 distance were assessed utilizing scoliosis plain film radiographs over time. Complications and return to the operating room for any reason were recorded. Patients were followed until conversion to posterior spinal fusion (PSF) or most recent lengthening of MCGR. RESULTS: There were 11 male and 13 female patients averaging 8 years at the time of index surgery. The average preoperative curve angle was 61.1°. Initial curve correction with MCGR obtained at the index procedure was 46.2%, reducing the mean curve angle to 32.7° (p < 0.05). Curve correction at a mean 6.2 years (2.4-7.4) follow-up was 36.1°, 40.9% curve correction. 75% of patients underwent conversion to PSF during the study period 4.8 years (2.4-7.0) after initial MCGR surgery. 15% of patients were still undergoing MCGR lengthening after 6.1 years. 54.2% of patients had at least one UPROR. CONCLUSIONS: For patients with EOS with curve progression, MCGRs can maintain curve correction well after 2 years. Furthermore, MCGR allowed patients to grow over time to safely delay timing to definitive fusion. On average, patients underwent conversion to PSF after 4.7 years at an average age of 13.5. Although the complication rate in the first 2 years is relatively low, 54.2% of patients underwent an UPROR. As the use of MCGR increases, surgeons should be aware of possible complications associated with this technology and counsel patients accordingly. Further research is needed to continue to evaluate the efficacy and safety of MCGR in this challenging patient population.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study.

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

Keratin Biomaterials Improve Functional Recovery in a Rat Spinal Cord Injury Model.

STUDY DESIGN: Laboratory study using a rat T9 contusion model of spinal cord injury (SCI). OBJECTIVE: The purpose of this study was to evaluate which method of delivery of soluble keratin biomaterials would best support functional restoration through the macrophage polarization paradigm. SUMMARY OF BACKGROUND DATA: SCI is a devastating neurologic event with complex pathophysiological mechanisms that currently has no cure. After injury, macrophages and resident microglia are key regulators of inflammation and tissue repair exhibiting phenotypic and functional plasticity. Keratin biomaterials have been demonstrated to influence macrophage polarization and promote the M2 anti-inflammatory phenotype that attenuates inflammatory responses. METHODS: Anesthetized female Lewis rats were subjected to moderate T9 contusion SCI and randomly divided into: no therapy (control group), an intrathecally injected keratin group, and a keratin-soaked sponge group (n = 11 in all groups). Functional recovery assessments were obtained at 3- and 6-weeks post-injury (WPI) using gait analysis performed with the DigiGait Imaging System treadmill and at 1, 3, 7, 14, 21, 28, 35, and 42 days post-injury by the Basso, Beattie, Bresnahan (BBB) locomotor rating scale. Histology and immunohistochemistry of serial spinal cord sections were performed to assess injury severity and treatment efficacy. RESULTS: Compared to control rats, applying keratin materials after injury improved functional recovery in certain gait parameters and overall trended toward significance in BBB scores; however, no significant differences were observed with tissue analysis between groups at 6 WPI. CONCLUSION: Results suggest that keratin biomaterials support some locomotor functional recovery and may alter the acute inflammatory response by inducing macrophage polarization following SCI. This therapy warrants further investigation into treatment of SCI.Level of Evidence: N/A.

Clinical presentation, imaging findings, and arthroscopic features in skeletally immature and mature adolescent hip patients: a comparative double-cohort retrospective study.

The purpose of this study was to evaluate differences in clinical presentation and extent of surgery required based on skeletal maturity between two cohorts of adolescent hip arthroscopy patients. We hypothesized that skeletal immaturity would be associated with a lower frequency of pincer impingement and a decreased need for surgical acetabuloplasty. A database of 1481 hip arthroscopies performed by a single orthopaedic surgeon between 2008 and 2016 was queried. Patients ≤18 years of age with femoroacetabular impingement were divided into two groups based on Risser score: Risser 1-4 (skeletally immature) or Risser 5 (skeletally mature). Groups were compared with respect to presentation, diagnosis, and arthroscopic procedures performed. Eighty-eight skeletally immature and 49 skeletally mature patients were included. Mixed impingement was more common in skeletally mature patients than immature (67.3% vs. 48.9%, P = 0.037). Skeletal maturity was associated with a significantly increased probability of undergoing acetabuloplasty (odds ratio = 4.6, 95% confidence interval 1.4-15.5; P = 0.014). Extent of chondral degeneration was similar between groups. Our findings support the hypothesis that skeletally immature hips undergo acetabuloplasty less frequently and demonstrate similar chondromalacia compared with a skeletally mature cohort. These results suggest that arthroscopic treatment for impingement-associated hip pain may be a reasonable option to consider for symptomatic skeletally immature patients who have completed a structured course of nonoperative treatment. Additional longitudinal outcomes data are needed to clarify the natural history of impingement-associated hip pain in younger populations and whether hip arthroscopy delays progression of osteoarthritis in these patients.

Pelvic osteotomies for acetabular dysplasia: Are there outcomes, survivorship and complication differences between different osteotomy techniques?

The purpose of this study was to evaluate the safety and efficacy of Periacetabular osteotomy (PAO), rotational acetabular osteotomy (RAO), and eccentric rotational acetabular osteotomy (ERAO) for treating hip dysplasia by comparing complication rates, survivorship, and functional outcomes after treatment. A systematic review in the MEDLINE and CINAHL databases was performed, and studies reporting outcomes after pelvic osteotomy for hip dysplasia with a minimum of 1-year follow-up or reported postoperative complications was included. Patient demographics, radiographic measurements, patient reported outcomes including the modified Harris hip score (mHHS), complications using the modified Clavien-Dindo classification, and reoperations were extracted from each study. A meta-analysis of outcome scores, complications, change in acetabular coverage, and revision rates for the 3 pelvic osteotomies was performed. A total of 47 articles detailing outcomes of 6,107 patients undergoing pelvic osteotomies were included in the final analysis. When stratified by procedure, RAO had a statistically greater change in LCEA when compared to PAO (33.9° vs 18.0°; P <0.001). The average pooled mHHS improvement was 15.6 (95% CI: 8.3-22.8, I 2= 99.4%). Although ERAO had higher mean score improvements when compared to RAO and PAO, the difference was not statistically significant (P >0.05). Lastly, patients undergoing PAO had a statistically greater complication rate than those undergoing ERAO and RAO (P <0.001 for both), while revision rate was not statistically different between the 3 techniques. In summary, there are many more publications on PAO surgery with a wide range of reported complications. Complications after ERAO and RAO surgery are lower than PAO surgery in the literature, but it is unclear whether this represents an actual difference or a reporting bias. Lastly, there are no significant differences between revisions, or postoperative reported outcomes between the 3 techniques.

Comparing the Efficiency, Radiation Exposure, and Accuracy Using C-Arm versus O-Arm With 3D Navigation in Placement of Transiliac-Transsacral and Iliosacral Screws: A Cadaveric Study Evaluating an Early Career Surgeon.

OBJECTIVES: To compare the efficiency, radiation exposure to surgeon and patient, and accuracy of C-arm versus O-arm with navigation in the placement of transiliac-transsacral and iliosacral screws by an orthopaedic trauma fellow, for a surgeon early in practice. METHODS: Twelve fresh frozen cadavers were obtained. Preoperative computed tomography scans were reviewed to assess for safe corridors in the S1 and S2 segments. Iliosacral screws were assigned to the S1 segment in dysmorphic pelvises. Screws were randomized to modality and laterality. An orthopaedic trauma fellow placed all screws. Time of procedure and radiation exposure to the cadaver and surgeon were recorded. Three fellowship-trained orthopaedic trauma surgeons rated the safety of each screw on postoperative computed tomography scan. RESULTS: Six normal and 6 dysmorphic pelvises were identified. Eighteen transiliac-transsacral screws and 6 iliosacral screws were distributed evenly between C-arm and O-arm. Average operative duration per screw was significantly shorter using C-arm compared with O-arm (15.7 minutes ± 6.1 vs. 23.7 ± 8.5, P = 0.014). Screw placement with C-arm exposed the surgeon to a significantly greater amount of radiation (3.87 × 10 rads vs. 0.32 × 10, P < 0.001) while O-arm exposed the cadaver to a significantly greater amount of radiation (0.03 vs. 2.76 rads, P < 0.001). Two S2 transiliac-transsacral screws (1 C-arm and 1 O-arm) were categorized as unsafe based on scoring. There was no difference in screw accuracy between modalities. CONCLUSIONS: A difference in accuracy between modalities could not be elucidated, whereas efficiency was improved with utilization of C-arm, with statistical significance. A statistically significant increase in radiation exposure to the surgeon using C-arm was found, which may be clinically significant over a career. The results of this study can be extrapolated to a fellow or surgeon early in practice. The decision between use of these modalities will vary depending on surgeon preference and hospital resources.

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome.

Background The purpose of this study is to characterize patient- and surgery-specific factors associated with perioperative pain level in patients undergoing ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS). We hypothesize that preoperative opiate consumption, tobacco utilization, and severity of ulnar variance will be associated with less postoperative pain relief. Methods All cases of USO between January 2010 and December 2016 for management of UIS were retrospectively reviewed. Patient demographics, smoking status, type of labor, and opioid utilization before surgery were recorded. Radiographic measurements for ulnar variance, radial tilt and inclination, as well as triangular fibrocartilage complex and distal radial-ulnar joint (DRUJ) morphology were assessed. Pre- and postoperative pain score were recorded. Regression analysis was performed to determine predictors of pain scores. Results A total of 69 patients were included for the final analysis with a mean age of 44 years (range 17-73 years). Seventeen patients reported use of daily opioid medications at the time of surgery (25%). Patients who used opioid analgesics daily, active laborers, smokers, and patients involved in worker compensation claims had significantly less pain relief after surgery. Patients with osteotomy performed at the metaphysis had significantly more pain relief than patients that had diaphyseal osteotomy. Regression analysis identified tobacco utilization and anatomic site of osteotomy as independent predictors of postoperative pain. Conclusion The results from this study identified smoking and location of osteotomy as independent predictors of postoperative pain relief. While smoking cessation is paramount to prevent delayed/nonunion it may also help improve pain relief following USO. The potential to achieve greater shortening with a metaphyseal osteotomy suggests that in addition to the mechanical unloading the carpus, pain relief after USO may also stem from tensioning the ulnar collateral ligaments of the wrist, the ECU subsheath, and the radioulnar ligaments. Level of Evidence This is a Level III, therapeutic study.

Uniplanar Osteotomy for Multiplanar Femoral Deformity Correction.

Long-bone deformity may be significantly symptomatic. A uniplanar corrective osteotomy uses a single cut to correct coronal, sagittal, and axial plane deformity simultaneously. Careful preoperative planning is required in addition to a comprehensive understanding of the magnitude and plane of the true deformity of the bone. With precise operative technique and intraoperative assessment of correction, good results can be achieved.

Previous History of Breast Cancer Increases Rates of Pulmonary Embolism and Costs after Total Knee Arthroplasty: An Evaluation of 185,114 Matched Patients.

Risk factors for adverse events after total knee arthroplasty (TKA) relating to malignancy have not been well studied. Thus, the purpose of this study was to conduct a retrospective case-control outcome and cost analysis after TKA in this population. Patients with a history of breast cancer (BrCa) were identified based on the International Classification of Disease 9th revision codes. An age- and sex-matched cohort was also identified of patients without a history of BrCa. Complications, length of stay, comorbidity burden, and reimbursements were tracked at 90 days. Each cohort comprised 92,557 patients. Length of stay was similar between cohorts (p = 0.627). Comorbidity status and incidence of pulmonary embolism (PE), lower extremity ultrasound, and chest computed tomography (CT) use were higher in patients with a history of BrCa (p < 0.05 for all). Control patients had a lower incidence of acute myocardial infarction (0.14 vs. 0.21%; p < 0.001). Surgical complications were similar. The 90-day reimbursements were greater in patients with a history of BrCa (US$13,990 vs. US$13,033 for controls; p = 0.021). Surgeons should be aware of the increased risk of PE after TKA in patients with a history of BrCa as well as increased 90-day costs, which warrant great attention.

Treatment of Peritrochanteric Femur Fractures With Proximal Femur Locked Plating.

OBJECTIVES: To report on our results using a proximal femoral locking plate for the treatment of peritrochanteric femur fractures. DESIGN: Retrospective study. SETTING: Level I Academic Medical Center. PATIENTS: Sixty-eight patients with 68 fractures. INTERVENTION: Demographics, fracture morphology, preoperative imaging, rationale against nailing, and outcomes were collected. MAIN OUTCOME MEASUREMENTS: Outcomes were grouped into no complication, minor complication, or major complication. Minor complications included healed fractures with implant failure or change in alignment from immediate postoperative radiographs, which did not require intervention or elective implant removal. Major complications included any case that required revision for nonunion or implant failure. RESULTS: Nine patients were lost to follow-up. Of the 59 fractures, 16 had complications (27%): 9 minor and 7 major. Active tobacco use (P = 0.020) and fractures with an associated intracapsular femoral neck component (P = 0.006) correlated with complications. CONCLUSIONS: Proximal femoral locking plates continue to be associated with a high complication rate. However, based on our experience, proximal femoral locking plates may be considered in highly selected cases when absolutely no other implant is deemed appropriate, based on the degree of comminution and the complexity of the fracture pattern. Patients must be informed about the possibility of revision surgery based on the inherent limitations of these devices. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.