Intramedullary Plate Fixation and Viable Bone Allografting in a Complex Intra-articular Distal Radius Fracture Nonunion: A Case Report.

In this report, we detail a 69-year-old female who sustained a comminuted intra-articular left distal radius fracture that failed to heal with bridge plate fixation. Given the patient's poor subchondral bone stock and refusal of bone autograft, we designed a construct using a dorsal spanning plate and an intramedullary fragment-specific plate as a volarly placed strut in combination with viable bone allograft and cancellous bone chips to treat this nonunion. This case demonstrates an option for distal radius non-union treatment and highlights the importance of ingenuity that orthopedic surgeons should demonstrate when trying to accommodate patients' wishes.

Total Humeral Endoprosthetic Reconstruction: A Systematic Review.

BACKGROUND: Total humeral endoprosthetic reconstruction (THER) is a rare reconstruction option for limb salvage surgery for large humeral neoplasms or bone destruction. MATERIALS AND METHODS: Because of the limited data and need for this procedure, we reviewed the literature surrounding THER and assessed functionality, complications, and revisions using the PubMed, Embase, Ovid, and Scopus databases. RESULTS: Among 29 articles and 175 patients, the most common indication was neoplasm (n=25, 86%), mean follow-up was 61.98 months (SD=55.25 months), and mean Musculoskeletal Tumor Society score was 73.64% (SD=10.69%). Reported complications included 26 (23%) revisions in 7 studies, 35 (36%) cases of shoulder instability in 7 studies, and 13 (13.54%) cases of deep infection in 4 studies. CONCLUSION: THER should be considered with a thorough knowledge of outcomes and potential complications to guide patient and clinician expectations. [Orthopedics. 2024;47(3):e106-e113.].

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060.

INTRODUCTION: The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060. METHODS: A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI). RESULTS: The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%). CONCLUSION: Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

A Current Review in the Orthopedic Management of Osteonecrosis of the knee Secondary to Treatment of Pediatric Hematologic Malignancy.

Acute Lymphoblastic Leukemia is the most prevalent pediatric hematologic malignancy. The treatment for this illness has advanced significantly, now touting a 90% cure rate. Although these patients often become disease free, treatment can leave devastating effects that last long after their disease burden is alleviated. A commonly experienced result of treatment is osteonecrosis (ON), often occurring in weight bearing joints. Uncertainty exists in the optimal treatment of this cohort of patients. In this review, we describe the etiology and suspected pathogenesis of ON, as well as treatment options described in the literature.

Dorsal spanning plate fixation in perilunate injuries: a case report.

A 63-year-old male presented with a trans-scaphoid lunate dislocation after a ten-foot fall. Internal fixation included placement of a dorsal spanning plate (DSP). One-year follow-up yielded a satisfactory outcome. A rigid DSP is a useful tool in acute perilunate injuries to protect internal fixation constructs and help with injury rehabilitation.

Spontaneous Resolution of Pediatric Varus Ankle Deformity: A Case Report.

Introduction: Distal tibia fractures are a common cause of physeal injuries that can subsequently cause deformity in pediatric populations. Limited literature exists supporting treatment strategies for varus deformities. In this study, we illustrate a unique case of premature physeal closure complicated by development of a varus ankle deformity treated with navigation guided physeal bar resection that spontaneously resolved without the requirement for guided growth. Case Report: A 6-year-old female presented to our clinic after development of a right ankle varus deformity measuring 14°. She had sustained a right Salter Harris type 3 distal tibia fracture 10 months prior and underwent fixation at an external facility. After undergoing navigation guided physeal bar resection, resolution of her deformity occurred without the use of guided growth. Conclusion: Spontaneous resolution of an ankle deformity is possible after a physeal bar resection. However, in these technically demanding procedures, it is important to optimize accuracy and results using preoperative bar mapping and intraoperative three-dimensional navigation.

Dorsal lunate dislocation and en bloc proximal row carpectomy: a case report.

An unhelmeted 59-year-old male involved in a motorcycle accident presented with a right dorsal lunate dislocation in the context of a polytrauma evaluation. Soft-tissue attachments were minimal across the carpus, which allowed for an en bloc proximal row carpectomy. Two-year follow-up yielded a satisfactory outcome given the high energy injury mechanism. Proximal row carpectomy is a useful tool which preserves wrist range of motion in the acute trauma setting and is durable, as demonstrated by our patient's postoperative mobilization using a wheelchair.

Assessing ChatGPT's orthopedic in-service training exam performance and applicability in the field.

BACKGROUND: ChatGPT has gained widespread attention for its ability to understand and provide human-like responses to inputs. However, few works have focused on its use in Orthopedics. This study assessed ChatGPT's performance on the Orthopedic In-Service Training Exam (OITE) and evaluated its decision-making process to determine whether adoption as a resource in the field is practical. METHODS: ChatGPT's performance on three OITE exams was evaluated through inputting multiple choice questions. Questions were classified by their orthopedic subject area. Yearly, OITE technical reports were used to gauge scores against resident physicians. ChatGPT's rationales were compared with testmaker explanations using six different groups denoting answer accuracy and logic consistency. Variables were analyzed using contingency table construction and Chi-squared analyses. RESULTS: Of 635 questions, 360 were useable as inputs (56.7%). ChatGPT-3.5 scored 55.8%, 47.7%, and 54% for the years 2020, 2021, and 2022, respectively. Of 190 correct outputs, 179 provided a consistent logic (94.2%). Of 170 incorrect outputs, 133 provided an inconsistent logic (78.2%). Significant associations were found between test topic and correct answer (p = 0.011), and type of logic used and tested topic (p = < 0.001). Basic Science and Sports had adjusted residuals greater than 1.96. Basic Science and correct, no logic; Basic Science and incorrect, inconsistent logic; Sports and correct, no logic; and Sports and incorrect, inconsistent logic; had adjusted residuals greater than 1.96. CONCLUSIONS: Based on annual OITE technical reports for resident physicians, ChatGPT-3.5 performed around the PGY-1 level. When answering correctly, it displayed congruent reasoning with testmakers. When answering incorrectly, it exhibited some understanding of the correct answer. It outperformed in Basic Science and Sports, likely due to its ability to output rote facts. These findings suggest that it lacks the fundamental capabilities to be a comprehensive tool in Orthopedic Surgery in its current form. LEVEL OF EVIDENCE: II.

Use of botulinum toxin as a non-surgical treatment option for idiopathic hallux varus: a case report.

Hallux varus presents with midline deviation of the hallux at the first metatarsophalangeal joint. If left untreated, it may lead to pain and difficulty with normal daily activities. Here, we present a case of spontaneous hallux varus in an 84-year-old female treated non-operatively with injection of botulinum toxin in the Abductor Hallucis Brevis. Ultrasound guidance with electromyography was used to assist in all injections. Near total symptomatic relief and resumption of daily activities was obtained for up to 12 weeks at a time. Radiographic correction seen was improvement from 14° to 7° on weight bearing radiographs. After five rounds of treatment, no adverse reactions had been observed.

Management of Calcaneal Cysts in the Pediatric Population: A Review.

Cysts of the bone are a common pathology that, although benign, are frequently treated because of their tendency to compromise the integrity of affected bone. Two common entities are unicameral bone cysts and aneurysmal bone cysts. Although these are two distinct pathologies, they are treated similarly and thus will be discussed in tandem. The optimal treatment of calcaneal bone cysts in pediatric patients has long been debated among orthopaedic surgeons because of the relatively small number of cases and varied results within the literature. Currently, there are three lines of thought regarding treatment: observation, injection, and surgical intervention. When considering which course of treatment is best for an individual patient, the surgeon must consider the fracture risk without treatment, the risk of complications with treatment, and the recurrence rate with each treatment approach. There are limited data on pediatric calcaneal cysts specifically. Still, there are much data concerning simple bone cysts of long bones in the pediatric population and calcaneal cysts in the adult population. Because of the lack of literature on the subject, there is a need for a review of the available literature and a consensus on the approach to treating calcaneal cysts in the pediatric population.

Septic Arthritis Among Users of Injection Drugs: Clinical Course and Microbial Characteristics.

Injection drug use (IDU) is a risk factor for septic arthritis (SA) of native joints. Amid the opioid crisis, IDU rates have increased. This study assessed differences in pre-operative characteristics, microbial characteristics, and postoperative outcomes of 177 cases of SA treated operatively from 2015 to 2019 at 3 US hospitals, by self-reported IDU status. Forty cases (23%) involved patients who reported IDU. Patient characteristics, comorbidities, microbial characteristics, duration of hospital stay, discharge destination, follow-up rates, and rates of persistent/secondary infection were compared by self-reported IDU status. Compared with non-IDU-associated SA (non-IDU-SA), IDU-associated SA (IDU-SA) was associated with female sex (P=.001), younger age (P<.001), lower body mass index (P<.001), tobacco use (P<.001), and psychiatric diagnosis (P=.04) and was more likely to involve methicillin-resistant Staphylococcus aureus (P<.001). The IDU-SA was associated with discharge to a skilled nursing facility or against medical advice (P<.001) and with loss to follow-up (P=.01). The 2 groups did not differ in terms of American Society of Anesthesiologists classification, joint involved, Gram stain positivity, presence of bacteremia, peripherally inserted central catheter placement, return to hospital within 3 months, or persistent/secondary positive results on culture within 3 months. Patients with IDU-SA were younger, were more likely to be female, had lower body mass index, and had fewer medical comorbidities but were more likely to use tobacco and to have a psychiatric diagnosis compared with patients with non-IDU-SA. Methicillin-resistant S aureus was more common in the IDU-SA group, as was discharge to a skilled nursing facility or against medical advice. Patients with IDU-SA were less likely to return for follow-up than patients with non-IDU-SA. [Orthopedics. 2021;44(6):e747-e752.].

Orthopaedic Problems in 35 Patients With Organic Acid Disorders.

INTRODUCTION: Organic acid disorders (OADs) are a subset of inborn errors of metabolism that result in a toxic accumulation of organic acids in the body, which can lead to metabolic derangements and encephalopathy. Patients with these disorders are managed by a team of biochemical geneticists and metabolic nutritionists. However, subspecialists such as neurologists and orthopaedic surgeons are often needed to help manage the sequelae of the metabolic derangements. The breadth of orthopaedic sequelae of these disease states is poorly understood. Herein, we describe orthopaedic problems associated with 5 types of OAD most commonly seen at our institution: maple syrup urine disease, methylmalonic aciduria, propionic aciduria, pyruvate dehydrogenase deficiency, and glutaric aciduria type 1. METHODS: We retrospectively reviewed medical records of 35 patients with an OAD who were seen at our academic tertiary care center from May 1999 to May 2020. Patients were grouped into cohorts according to OAD type and analyzed for orthopaedic presentations of hip, knee, or foot disorders, presence and severity of scoliosis, history of fracture, movement disorders, and osteopenia/osteoporosis. RESULTS: Of the 35 patients, 13 had maple syrup urine disease, 12 had methylmalonic aciduria, 4 had propionic aciduria, 4 had pyruvate dehydrogenase deficiency, and 2 had glutaric aciduria type 1. Associated orthopaedic problems included spasticity causing neuromuscular scoliosis and/or hip subluxation or dislocation (10 patients), fractures (7 patients), and osteopenia/osteoporosis (7 patients). Overall, 22 of 35 patients had some orthopaedic condition. CONCLUSIONS: Most in this cohort of patients with OAD also had an orthopaedic abnormality. It is important for physicians treating these patients to understand their propensity for musculoskeletal problems. When treating patients with OAD, it is important to initiate and maintain communication with specialists in several disciplines and to develop collaborative treatments for this unique population. LEVEL OF EVIDENCE: Level IV-prognostic study.

Radiographic assessments of pediatric supracondylar fractures and mid-term patient-reported outcomes.

Radiographic parameters are commonly used to determine the need for surgical supracondylar humeral (SCH) fracture reduction and the postoperative quality of reduction. We studied whether such parameters are correlated with mid-term patient-reported outcome (PRO) scores in pediatric patients.We retrospectively reviewed data from 213 patients (104 girls) treated surgically for Gartland type-II (n = 84) or type-III (n = 129) SCH fractures from 2008-2016. Mean (± standard deviation) age at surgery was 5.1 ±â€Š2.1 years. Mean time from initial treatment to outcome survey completion was 5.0 ±â€Š2.1 years (range, 2.0-10 years). We evaluated preoperative radiographs for coronal/sagittal fracture displacement, presence of impaction/comminution, Gartland classification, and rotation. Patients, parents were asked via telephone to complete the QuickDASH (Quick Disability of the Arm, Shoulder, and Hand) and PROMIS (Patient-Reported Outcomes Measurement Information System) Strength Impact, Upper Extremity, and Pain Interference questionnaires. Parents were also asked whether the previously fractured arm appeared normal or abnormal. We evaluated postoperative radiographs for coronal/sagittal deformity, Baumann angle, and rotation and classified reductions as near complete/complete or incomplete. Anterior humeral line through the capitellum, Baumann angle in the 7.5th to 92.5th percentile of the sample, or rotation ratio between 0.85 and 1.15 were considered near complete/complete reductions; all others were considered incomplete. Bivariate analysis was used to determine whether radiographic parameters and arm appearance were associated with QuickDASH and PROMIS scores.Patients with Gartland type-III fractures had significantly greater disability on the QuickDASH at follow-up compared with those with Gartland type-II fractures (P < .01). It is unknown if this statistical difference translates to clinical relevance. No other preoperative or postoperative radiographic parameter was significantly associated with PRO scores. There was no association between fractured arm appearance at follow-up and PRO scores.Radiographic parameters that are used to evaluate the need for and quality of pediatric SCH fracture reduction are not significantly associated with mid-term PROMIS and QuickDASH scores.LOE: Prognostic Level III.

Ponte Osteotomy in Pediatric Spine Surgery.

First utilized in spine surgery in the late 1980s, the Ponte osteotomy is a method of surgically shortening the posterior column in order to obtain greater corrective power in the management of kyphosis or kyphoscoliosis. It is accomplished by removal of bone around the articulation of spinal facet joints, which alters the mechanical axis of rotation and enables greater deformity correction potential. This procedure is performed in the following steps: (1) a posterior midline incision is made in order to expose and clear soft tissues from the desired surgical site; (2) the spinous process and base of the lamina are removed to allow for better visualization and working space; (3) the inferior facet is excised, followed by (4) removal of the superior facet and the (5) ligamentum flavum. If performed correctly, this procedure should allow for appropriate deformity correction and the ability to place desired instrumentation without problems.

Correction to: Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis.

The original version of this article unfortunately contained a mistake.

Intralaminar Screw Fixation of Spondylolysis.

Spondylolysis, defined as injury to the pars interarticularis, is the most common identifiable cause of back pain in children. Historically, treatment has primarily been nonoperative, including physical therapy, activity modification, and occasionally bracing1. In instances in which the condition is refractory to nonoperative management, however, surgical treatment may be an efficacious alternative. Persistent pain following nonoperative management is described as occurring in 6% of the general population, but is reported to be as high as 15% to 47% in the pediatric population who participate in sports2,3. There have been several proposed methods of surgical intervention, such as screws, hooks, wires, and combinations of the aforementioned, none of which have garnered unanimous support as being most effective. The report by Buck3 served to popularize the use of intralaminar screwing for fixation, and the 93% success rate reported in that study has since been corroborated, with several studies reporting rates from 82% to 100%1,3,4. This technique offers a low-profile solution that is motion-sparing with demonstrable stability and mechanical advantage compared with other techniques5 and has been shown to be a more stable method of fixation that can correct relatively large defects, showing efficacy with defects 4 mm and larger5. This procedure is performed by (1) placing the patient in a prone position with minimization of lordosis on the operating table and use of fluoroscopy to localize the defect. (2) A midline incision (approximately 5 cm) is made just lateral to the corresponding spinous process in order to expose the lamina and the defect. (3) A curet is used to clean the defect. (4) Under fluoroscopy, and alternating between anteroposterior and lateral views, a percutaneous stab is made if needed using a 4.5-mm cannulated screw guidewire, and the wire is drilled through the caudal laminar surface, bisecting the pedicle to the superior cortex of the pedicle. (5) A 3.2-mm cannulated drill is then used to drill over the guidewire. (6) The wire is removed, and a ball-tip probe is used to feel the cortices. The screw length is measured and tapped. (7) The lamina is distally overdrilled if it is large enough. (8) A solid (rather than cannulated) screw of appropriate size (usually 4.5-mm diameter) is inserted with compression as needed. (9) If necessary, autologous posterior iliac crest bone graft is obtained from the same incision, and cancellous graft is placed in the defect. (10) A corticocancellous strip is overlaid from the lamina to the transverse process.

Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective review. OBJECTIVE: To identify national trends in postoperative opioid prescribing practices after posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). Opioids are an important component of pain management after PSF for AIS. Given the national opioid crisis, it is important to understand opioid prescribing practices in these patients. METHODS: Using a commercial prescription drug claims database, we identified AIS patients who underwent PSF from 2010 to 2016 and who were prescribed opioids postoperatively. An initial prescription at hospital discharge of ≥ 90 morphine milligram equivalents daily (MMED) was used to identify patients at risk of overdose according to the US Centers for Disease Control and Prevention (CDC) guidelines. Prescriptions for skeletal muscle relaxants were also identified. α = 0.05. RESULTS: We included 3762 patients (75% female) with a mean (± standard deviation) age of 15 ± 2.1 years. 56% of patients filled only 1 opioid prescription after discharge, and 44% had ≥ 1 refills. 91% of opioid prescriptions were for hydrocodone (median strength, 43 MMED; mean strength, 65 ± 270 MMED) or oxycodone formulations (median strength, 60 MMED; mean strength, 79 ± 174 MMED). 82% of prescriptions complied with CDC guidelines (< 90 MMED). Overall, 612 patients (16%) filled ≥ 1 prescription for skeletal muscle relaxants, the most common being cyclobenzaprine (45%) and methocarbamol (29%). The percentage of patients filling > 1 prescription declined from 54% in 2010 to 31% in 2016 (p < 0.001). The proportion of patients receiving prescriptions for ≥ 90 MMED was highest in the West (29%) and lowest in the South (16%) (p < 0.001). CONCLUSION: Most opioid prescriptions after PSF in patients with AIS comply with CDC guidelines. Temporal and geographic variations show an opportunity for standardizing opioid prescribing practices in these patients. LEVEL OF EVIDENCE: III.

Mid-term Patient-reported Outcomes After Lateral Versus Crossed Pinning of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning. METHODS: We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05). RESULTS: The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05). CONCLUSION: We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up. LEVEL OF EVIDENCE: Level III.

Brachial Artery Pseudoaneurysm After Supracondylar Humerus Fracture: A Case Report.

CASE: A 9-year-old boy with a widely displaced Type-III supracondylar humerus fracture presented with a painful mass at the antecubital fossa after pin fixation. Exploration of the mass caused bleeding from a brachial artery pseudoaneurysm that necessitated repair with a saphenous vein graft. Six weeks later, the fracture had healed without complications. CONCLUSION: We describe an unusual presentation of a pediatric supracondylar humerus fracture that highlights the importance of including vascular injury in the differential diagnosis for similar presentations.

Factors associated with extended length of stay in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To investigate whether certain patient, surgical, and recovery-related factors may be associated with extended LOS following posterior spinal fusion for Adolescent Idiopathic Scoliosis (AIS). Understanding determinants of hospital length of stay (LOS) following surgical procedures is important for perioperative planning and improvements in quality of care. METHODS: Using a private insurance claims database, AIS patients ages 10-21 that underwent posterior spinal fusion from 2010 to 2016 in the United States were identified. Extended LOS was defined as > 7.2 days (+ 1 standard deviation from the mean). Univariate and multivariate analyses were performed to identify factors associated with extended LOS. Significance was set at p < 0.05. RESULTS: 5864 patients met the inclusion criteria (mean age 14.4 ± 2.2 years; 75% girls). Mean LOS was 4.7 ± 2.5 days (median 4 days). 69% patients had 7-12 levels fused, and 25% had 13+ levels fused. On multivariate analysis, factors associated with extended LOS were: longer fusion construct (13+ levels fused) (OR 2.1, p = 0.020), thoracoplasty (OR 3.8, p < 0.001), and postoperative complications: wound problems (OR 13, p < 0.001), respiratory problems (OR 7.9, p < 0.001), urinary tract infection (OR 6.0, p < 0.001), and constipation (OR 2.4, p < 0.001). Postoperative ICU admission, female gender, and surgery performed on Wednesday were significant on univariate analysis but not on multivariate analysis. Extended LOS was associated with an increase of $50,494 in net hospital payments (p < 0.001). CONCLUSION: Patient, surgical and recovery factors are associated with extended LOS in AIS patients who undergo posterior spinal fusion surgery. Extended LOS significantly increases healthcare spending. LEVEL OF EVIDENCE: Level III.