Curve Characteristics and Surgical Outcomes in Scoliosis Associated With Childhood Sternotomy or Thoracotomy.

BACKGROUND: The purpose of this study is to describe curve characteristics and postoperative outcomes in patients undergoing spinal fusion (SF) to treat thoracogenic scoliosis related to sternotomy and/or thoracotomy as a growing child. METHODS: A retrospective review of electronic medical records of all patients with Post-Chest Incision scoliosis treated with SF was performed at 2 tertiary care pediatric institutions over a 19-year period. Curve characteristics, inpatient, and outpatient postoperative outcomes are reported. RESULTS: Thirty-nine patients (62% female) were identified. Eighteen had sternotomy alone, 14 had thoracotomy alone, and 7 had both. Mean age at the time of first chest wall surgery was 2.5 years (range: 1.0 d to 14.2 y). Eighty-five percent of patients had a main thoracic curve (mean major curve angle 72 degrees, range: 40 to 116 degrees) and 15% had a main lumbar curve (mean major curve angle 76 degrees, range: 59 to 83 degrees). Mean thoracic kyphosis was 40 degrees (range: 4 to 84 degrees). Mean age at the time of SF was 14 years (range: 8.2 to 19.9 y). Thirty-six patients had posterior fusions and 3 had combined anterior/posterior. Mean coronal curve correction measured at the first postoperative encounter was 53% (range: 9% to 78%). There were 5 (13%) neuromonitoring alerts and 2 (5%) patients with transient neurological deficits. Mean length of hospital stay was 9±13 days. At an average follow-up time of 3.1±2.4 years, 17 complications (10 medical and 7 surgical) were noted in 9 patients for an overall complication rate of 23%. There was 1 spinal reoperation in the cohort. 2/17 (12%) complications were Clavien-Dindo-Sink class III and 5/17 (29%) were class IV. CONCLUSION: Kyphotic thoracic curves predominate in patients with Post-Chest Incision scoliosis undergoing SF. Although good coronal and sagittal plane deformity can be expected after a fusion procedure, postoperative complications are not uncommon in medically complex patients, often necessitating longer postoperative stays. LEVEL OF EVIDENCE: Level III.

Femoral acetabular impingement labral pathology on MRI is correlated with greater hip flexion and decreased abduction in collegiate water polo players: A pilot study.

OBJECTIVES: Femoroacetabular impingement (FAI) morphology is associated with hip pain and disability. Water polo players utilise the egg beater motion (method of treading water with legs rotating like an "egg beater"), and it is currently unclear what the relationship is between an egg beater and FAI morphology. Our objective was to associate hip range of motion during egg beater motion to MRI findings. METHODS: Eight National Collegiate Athletic Association (NCAA) Division 1 varsity water polo athletes (5 females and 3 males) were filmed at orthogonal views performing the egg beater motion using two waterproof cameras in synchrony. A model-based image-matching technique was used to determine hip joint angles which were recorded from the software. These athletes also underwent noncontrast MRI scans of both hips using a 3T MRI scanner and completed an 33-item International Hip Outcome Tool (iHOT-33) hip pain outcomes questionnaire. Descriptive statistics are reported as counts and percentages for categorical variables and as means, standard deviations, and a five-number summary for continuous variables. Relationships between the range of motion measures with MRI measures and with iHOT33 scores were analysed using linear regression models. All statistical analyses were completes using a two-sided level of significance of 0.05. RESULTS: The average alpha angles for the right and left hips were 71.80 ±7.50 and 74.10 ±8.40, respectively. There was no statistically significant correlation between hip range of motion in any plane and alpha angle or lateral centre edge angle (CEA) on MRI. The average iHOT33 was 85.9 ± 18.9. Participants who had a labral tear had significantly smaller hip abduction ranges than participants who did not have a labral tear (29° ± 4.1 vs. 35.3° ± 0.6, p = 0.02), and those who had a labral tear had significantly increased hip flexion during egg beater kicking as compared with participants who did not have a labral tear (28.2° ± 6.1 vs. 16.3° ± 4, p = 0.02). There were no differences between right and left alpha angles or between right and left CEA. CONCLUSION: There were no significant correlations between hip range of motion and alpha angle or CEA, but hips with labral pathology had greater hip flexion and more limited hip abduction ranges.

The prevalence of femoroacetabular impingement anatomy in Division 1 aquatic athletes who tread water.

Femoroacetabular impingement (FAI) is a disorder that causes hip pain and disability in young patients, particularly athletes. Increased stress on the hip during development has been associated with increased risk of cam morphology. The specific forces involved are unclear, but may be due to continued rotational motion, like the eggbeater kick. The goal of this prospective cohort study was to use magnetic resonance imaging (MRI) to identify the prevalence of FAI anatomy in athletes who tread water and compare it to the literature on other sports. With university IRB approval, 20 Division 1 water polo players and synchronized swimmers (15 female, 5 male), ages 18-23 years (mean age 20.7 ± 1.4), completed the 33-item International Hip Outcome Tool and underwent non-contrast MRI scans of both hips using a 3 Tesla scanner. Recruitment was based on sport, with both symptomatic and asymptomatic individuals included. Cam and pincer morphology were identified. The Wilcoxon Signed-Rank/Rank Sum tests were used to assess outcomes. Seventy per cent (14/20) of subjects reported pain in their hips yet only 15% (3/20) sought clinical evaluation. Cam morphology was present in 67.5% (27/40) of hips, while 22.5% (9/40) demonstrated pincer morphology. The prevalence of cam morphology in water polo players and synchronized swimmers is greater than that reported for the general population and at a similar level as some other sports. From a clinical perspective, acknowledgment of the high prevalence of cam morphology in water polo players and synchronized swimmers should be considered when these athletes present with hip pain.

Effect of polyethylene conformity on total knee arthroplasty early clinical outcomes.

PURPOSE: Total knee arthroplasty is a successful procedure in treating subjects with end-stage knee osteoarthritis. The objective of this matched study was to evaluate subjective patient satisfaction and clinical and radiological outcomes in two groups of patients undergoing primary TKA using an identical third-generation design with different conformity in the polyethylene insert. METHODS: One hundred consecutive patients undergoing TKA because of knee osteoarthritis were randomized in two matched groups. Group A included 50 Posterior-Stabilized (PS) implants, while group B included 50 Medially Congruent (MC) implants. The surgical technique was identical: gap balancing in extension and measured resection in flexion; cruciate ligaments were always removed; the coronal alignment followed the mechanical axis and the tibial slope was set at 3° in the PS group and 5° in the MC. Oxford Knee Score (OKS) and Knee Society Score (KSS) were assessed preoperatively and at 2 year minimum follow-up. Two-sample T test statistical analysis was performed. RESULTS: All patients were available at final follow-up: there were no preoperative statistical differences between the two groups in the average preoperative ROM (PS 112°, MC 108°; n.s.), average preoperative KSS (PS 64.4, MC 63.7; n.s.), average preoperative OKS (PS 19.6; MC 19.0; n.s.), and average BMI (PS 34.40, MC 34.60; n.s.). At final follow-up, there were no statistical differences between the two groups in the average OKS (PS 40,5; MC 41.1; n.s.) and in the average KSS (PS 161,5, MC 165,7; n.s.). We found a statistically but not clinically significant difference at final ROM: the average maximum active flexion was 120° in the PS group and 123° in the MC group (s.s.). CONCLUSION: This study evaluated two biomechanically different polyethylene inserts in the same TKA design, showing that reducing the level of intra-articular conformity had minimal effects on PROMs and objective short-term clinical results but a potentially beneficial effect on ROM. This study suggests that, once a satisfactory intra-operative stability is obtained, the minimal level of constraint should be used. LEVEL OF EVIDENCE: III.

The effects of perceived racism on psychological distress mediated by venting and disengagement coping in Native Hawaiians.

BACKGROUND: Studies have linked perceived racism to psychological distress via certain coping strategies in several different racial and ethnic groups, but few of these studies included indigenous populations. Elucidating modifiable factors for intervention to reduce the adverse effects of racism on psychological well-being is another avenue to addressing health inequities. METHODS: We examined the potential mediating effects of 14 distinct coping strategies on the relationship between perceived racism and psychological distress in a community-based sample of 145 Native Hawaiians using structural equation modeling. RESULTS: Perceived racism had a significant indirect effect on psychological distress, mediated through venting and behavioral disengagement coping strategies, with control for age, gender, educational level, and marital status. DISCUSSION: The findings suggest that certain coping strategies may exacerbate the deleterious effects of racism on a person's psychological well-being. CONCLUSION: Our study adds Native Hawaiians to the list of U.S. racial and ethnic minorities whose psychological well-being is adversely affected by racism.

Rate of Transfusions After Total Knee Arthroplasty in Patients Receiving Lovenox or High-Dose Aspirin.

BACKGROUND: Controversy continues regarding the use of powerful anticoagulants for venous thromboembolism prophylaxis in patients undergoing total knee arthroplasty (TKA). To comply with institution-mandated guidelines and pressure from hospitalist intent on complying with conventionally recommended anticoagulation guidelines, we singularly changed our chemoprophylaxis practice from using aspirin to Lovenox and noted that transfusion rates increased substantially. METHODS: A retrospective case review was performed to evaluate transfusion requirement differences in primary TKA patients receiving Lovenox (unilateral TKA: n = 135, bilateral TKA: n = 44) or aspirin (unilateral TKA: n = 153, bilateral TKA: n = 45) for venous thromboembolism prophylaxis. Pearson's chi-square tests were used to evaluate surgical complications and the rate of transfusions between aspirin and Lovenox groups. Independent t tests were used to evaluate the units of packed red blood cells transfused, hemoglobin drop, and hematocrit drop between aspirin and Lovenox groups. RESULTS: Lovenox was found to significantly increase (P < .01) the rate of transfusion, units of packed red blood cells, hemoglobin drop, and hematocrit drop compared to aspirin in both unilateral and bilateral TKA patients, without significantly decreasing venous thromboembolism events (aspirin: 3 pulmonary embolisms and 4 deep venous thrombosis; Lovenox: 3 pulmonary embolisms and 2 deep venous thrombosis). CONCLUSION: Our findings suggest that aspirin is as effective as Lovenox in preventing venous thromboembolism and that the use of Lovenox significantly increases the likelihood of requiring transfusions after surgery.

Dynamic Parathyroid Computed Tomography (4DCT) Facilitates Reoperative Parathyroidectomy and Enables Cure of Missed Hyperplasia.

BACKGROUND: Four-dimensional computed tomography (4DCT) is an emerging imaging modality in the evaluation of primary hyperparathyroidism (PHPT). We assessed the role of 4DCT in patients presenting for reoperative parathyroidectomy. METHODS: A prospective database of patients with persistent or recurrent PHPT undergoing reoperative parathyroidectomy during the years 2006-2014 was analyzed. Patients treated before versus after the advent of 4DCT were compared for operative eligibility, operative success, operative time, and concordance of imaging results with surgical findings. RESULTS: Ninety patients were included in the study (61 before 4DCT, 29 after 4DCT). The post-4DCT group had a higher rate of surgical concordance with imaging results (63 vs. 90 %, p < 0.01) and shorter operative time (114 vs. 76 min, p < 0.05). The operative success rate was not different (87 vs. 86 %). A similar pattern was observed in the subset of sestamibi-negative patients, with post-4DCT patients having a higher rate of surgical concordance (12 vs. 83 %, p < 0.0001) and shorter operative time (181 vs. 89 min, p < 0.05). Among patients ultimately found to have parathyroid hyperplasia, 4DCT correctly identified multiple enlarged glands in 80 % (4 of 5) and correctly lateralized one or more glands in 100 % (5 of 5) of cases, facilitating successful subtotal parathyroidectomy in the reoperative setting. CONCLUSIONS: 4DCT enables successful and efficient reoperative parathyroidectomy. These benefits extend to difficult cases, including sestamibi-negative patients and those with missed hyperplasia.