Intradural cervical herniated nucleus pulposus presentation and management: a case report.

Background: Intradural disc herniations (IDH) are uncommon and can be found in the cervical spine. It is commonly associated with Brown-Sequard syndrome (BSS). The case report describes cervical spine magnetic resonance imaging (MRI) findings that assists in identifying IDH pre-operatively and discusses surgical management. Case Description: This is a case report regarding a 42-year-old obese male who developed atraumatic spontaneous bilateral upper extremity numbness, right upper extremity weakness and right lower extremity weakness. MRI showed a C6-7 herniated nucleus pulposus that focally protruded through the posterior longitudinal ligament with a beak-like projection similar to what has been described in previous reports. Clinical exam revealed an incomplete spinal cord injury (SCI) most consistent with BSS. He underwent anterior cervical discectomy and fusion at the level of C6-7. Intra-operatively, a disc fragment was found to be embedded in the dura. Three months post-operatively, the patient had persistent weakness in his right lower extremity but no longer had any bilateral upper extremity weakness. Conclusions: An anterior cervical decompression and fusion was performed shortly after the patient presented, with adequate neurological recovery after 3 months. Advanced imaging with an MRI could lead to the diagnosis of an IDH and surgical intervention via the anterior approach could facilitate removal of the disc and adequate dura repair.

Medial Patellofemoral Ligament Reconstruction in Obese Patients Results in Low Complication Rates and Improved Subjective Outcomes.

Purpose: To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. Methods: A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. Results: A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P = .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P = .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P = .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P = .68). Conclusions: In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level of Evidence: Level III, retrospective cohort study.

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury.

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.

A preliminary assessment of intervertebral disc health and pathoanatomy changes observed two years following anterior vertebral body tethering.

PURPOSE: Vertebral body tethering (VBT) has been reported as a safe and effective non-fusion surgical technique for the treatment of adolescent idiopathic scoliosis, but the postoperative health of the bone and soft tissues of the spine following instrumentation remains unknown. We aimed to evaluate pathoanatomy and degenerative changes of the spine in adolescent idiopathic scoliosis patients both prior to and two years following VBT. METHODS: We prospectively enrolled nine patients who underwent VBT for the treatment of progressive adolescent idiopathic scoliosis. All patients received preoperative and two-year postoperative magnetic resonance imaging of their spine; images were assessed for pathoanatomy (e.g. nucleus pulposus positioning and muscle atrophy) and degenerative changes (e.g. Schmorl nodes, endplate oedema, disc degeneration, and osteoarthritis) at each vertebral level between T1 and S1. RESULTS: Four patients (44%) exhibited a shift of the nucleus pulposus from an eccentric position at baseline towards midline at three or more levels, most of which were in the tethered region. Tethering did not affect preexisting fatty atrophy of multifidus. No patients exhibited postoperative Schmorl nodes, endplate oedema, or disc degeneration in either the tethered or untethered regions. Four patients (44%) presented with mild facet osteoarthritis in the lower lumbar spine, which did not change postoperatively. One patient developed moderate facet osteoarthritis at L5-S1. CONCLUSIONS: These preliminary data indicate that VBT may not result in significant degenerative changes in either the intervertebral discs or the posterior facets two years following instrumentation.

Patient-Reported Outcomes for Large Bipolar Osteochondral Allograft Transplantation in Combination with Realignment Osteotomies for the Knee.

Effective treatment for bipolar articular cartilage lesions in the knee remains a clinical challenge. Lower extremity malalignment is a risk factor for treatment failures, which can be addressed by tibial or femoral osteotomy. The purpose of this study was to compare outcomes among patients who underwent knee joint restoration by osteochondral allograft (OCA) transplantation with concurrent or staged realignment osteotomy. With Institutional Review Board approval, patients undergoing bipolar OCA transplantation with concurrent or staged distal femoral osteotomy (DFO) or high tibial osteotomy (HTO) were analyzed. Patients were categorized by osteotomy type (DFO and HTO) and timing (concurrent and staged). Patient-reported outcome measures (PROMs), revisions, failures, and complications were examined preoperatively (baseline), 3, 6, 12, and 24 months after OCA transplantation; change scores from preoperative values were used for analysis. A total of 23 patients met inclusion criteria (15 males); 13 (56.5%) received HTO (5 concurrent), while 10 (43.5%) received DFO (5 concurrent). There were no significant differences in complication rates between concurrent and staged osteotomies. Primary bipolar OCA transplantation with osteotomy was associated with successful outcomes in 70% of patients; four patients underwent revision (17.4%) and three (13.0%) failed and were treated by total knee arthroplasty. Further, the four patients undergoing revision met functional criteria for success at final follow-up, resulting in a 2-year functional survival rate of 87.4%. Aside from Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, all PROMs for concurrent and staged osteotomies improved from baseline to 2 years postoperatively. Concurrent osteotomies of both types were associated with significantly lower pain scores at 12 months (p = 0.04), compared with staged osteotomies. Apart from Single Assessment Numerical Evaluation (SANE), more PROM improvement was observed for concurrent osteotomies at 2 years. Improvements in PROMs for patients undergoing OCA transplantation combined with osteotomy were observed at 2-year follow-up. PROMs for concurrent osteotomy were consistently greater than staged osteotomy, lending support to addressing lower extremity malalignment with bipolar OCA transplantation in the knee during a single surgery when possible.

Anterior Vertebral Body Tethering for Adolescent Scoliosis with Growth Remaining: A Retrospective Review of 2 to 5-Year Postoperative Results.

BACKGROUND: Anterior vertebral body tethering (VBT) is an early treatment option for progressive scoliosis in pediatric patients, allowing for continued deformity correction during normal growth. We report postoperative radiographic and clinical outcomes for patients treated with VBT. METHODS: This clinical and radiographic retrospective review of 31 consecutive patients included an analysis of preoperative, perioperative, and postoperative details, including the Lenke classification; Cobb angle measurements of the proximal thoracic, main thoracic, and lumbar curves; the sagittal profile; and skeletal maturity. Successful outcomes were defined by a residual curve of ≤30° in skeletally mature patients who did not undergo a posterior spinal fusion (PSF). RESULTS: Of the 31 patients treated, 29 met the inclusion criteria, and 2 were lost to follow-up. The mean patient age (and standard deviation) at the time of the surgical procedure was 12.7 ± 1.5 years (range, 10.2 to 16.7 years), with most patients classified as Risser grade 0 or 1 (52%) and Sanders stage 3 (32%). A mean of 7.2 ± 1.4 vertebral levels were instrumented, with a minimum preoperative Cobb angle of 42°. At the latest follow-up, 27 patients had reached skeletal maturity (Sanders stage ≥7) and 20 patients exhibited a curve magnitude ≤30°, for a success rate of 74%. A suspected broken tether occurred at ≥1 level in 14 patients (48%). Two patients underwent PSF and 4 had tether revision. The overall revision rate was 21% (6 of 29). CONCLUSIONS: This study shows the success and revision rates as well as the impact of a suspected broken tether on the procedural success of VBT. Despite our patient population being slightly more mature at the time of the surgical procedure compared with previous studies, we had a higher success rate and a lower revision rate. A PSF was avoided in 93% of patients, indicating that VBT may be a reliable treatment option for adolescent scoliosis in skeletally immature individuals. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Age-Related Variances in Patients with Tibial Plateau Fractures.

Tibial plateau fractures account for approximately 8% of fractures in the elderly population. Treatment strategies in the elderly are similar to those for younger patients; however, practitioners must account for the elevated comorbidity burden in this population. To date, few studies have analyzed age-based outcomes in patients with tibial plateau fractures. Therefore, the purpose of this study was to determine age-related variances in demographics, fracture characteristics, mechanism of injury, and complications. A 10-year retrospective review was conducted to identify patients who received treatment for a tibial plateau fracture. There were 351 patients (360 tibial plateau fractures) who were identified and subsequently stratified according to their age at the time of injury. Patients were classified as elderly if they were 65 years of age or older at the time of injury; all other patients were included in the control cohort. These two cohorts were analyzed using bivariate analysis to isolate for age-related variations with respect to risk factors, mechanism of injury, and complications. There were 351 patients (360 tibial plateau fractures) with a median follow-up of 1.84 ± 2.44 years who met inclusion criteria. There were a greater proportion of women in the elderly cohort as compared with the younger cohort (60.0 vs. 43.4%, p = 0.06). Elderly patients were significantly more likely to present with diabetes (33.3 vs. 16.1%, p = 0.01) or osteoporosis (14.3 vs. 1.6%, p = 0.001). Younger patients were significantly more likely to require further surgery to address ligament (12.6 vs. 0%, p = 0.008), meniscus (20.9 vs. 7.1%, p = 0.036), or cartilage pathology (13.6 vs. 0%, p = 0.005). There was no difference in the arthroplasty conversion rate (4.8% elderly vs. 7.9% control, p = 0.755). While elderly patients presented with a greater comorbidity burden, they had equivalent or better short-term outcomes when compared with their younger peers when treated with open reduction and internal fixation (ORIF). Despite the recent interest in primary total knee arthroplasty for elderly patients with tibial plateau fractures, the results of this study suggest that elderly patients may respond well when treated with ORIF following a tibial plateau fracture.

Incidence of Concurrent Peroneal Nerve Injury in Multiligament Knee Injuries and Outcomes after Knee Reconstruction.

The purpose of this study was to determine incidence of concurrent peroneal nerve injury and to compare outcomes in patients with and without peroneal nerve injury after surgical treatment for multiligament knee injuries (MLKIs). A retrospective study of 357 MLKIs was conducted. Patients with two or more knee ligaments requiring surgical reconstruction were included. Mean follow-up was 35 months (0-117). Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full duty (p = 0.06). In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity (p = 0.41). At final follow-up, there were no significant differences in level of pain (mean visual analog scale 1.6 vs. 2; p = 0.17), Lysholm score (mean 88.6 vs. 88.8; p = 0.94), or International Knee Documentation Committee score (mean 46.2 vs. 47.8; p = 0.67) for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121 degrees) was significantly lower (p = 0.02) for patients with nerve injury compared with patients without nerve injury (mean 127 degrees). Concurrent peroneal nerve injury occurred in 19% of patients in this large cohort suffering MLKIs. After knee reconstruction surgery, patients with concurrent peroneal nerve injuries had significantly lower knee ROM and trended toward a lower rate of return to work. However, outcomes with respect to activity level, pain, and function were not significantly different between the two groups. This study contributes to our understanding of patient outcomes in patients with concurrent MLKI and peroneal nerve injury, with a focus on the patient's ability to return to work and sporting activity.

Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference?

OBJECTIVE: To assess the "Dedicated Orthopaedic Trauma Operating Room" (DOTOR) effect on management and outcomes of open tibia and femur fractures. DESIGN: Retrospective chart review. LOCATION: University Level I Trauma Center. METHODS: Patients categorized into those managed in the DOTOR versus those managed in a standard on-call operating room (OCOR). Data collected include patient and injury characteristics, time to debridement, and patient outcomes. RESULTS: A total of 297 patients with 347 open tibia and femur fractures were included; 154 patients (174 fractures) were managed in the DOTOR group and 143 patients (170 fractures) were managed in the OCOR group. The average time to debridement was significantly longer for DOTOR (12.9 hours) versus OCOR (5.4 hours). The DOTOR group was 9 times less likely to undergo debridement within 6 hours. The number of patients debrided within 24 hours was similar (90% for DOTOR vs. 96% OCOR). The rate of primary fracture union was significantly higher in the DOTOR (73.2% vs. 56.6%). OCOR patients were twice as likely to have an unplanned surgery. Rates of infection, nonunion, and amputation were similar. CONCLUSION: Despite earlier access to the Operating room for debridement in the OCOR group, there was no difference in the infection rate compared with the DOTOR group. However, patients managed in the DOTOR group were more likely to go on to uncomplicated fracture union and less likely to have an unplanned surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mentorship in Orthopedics: A National Survey of Orthopedic Surgery Residents.

OBJECTIVE: Mentorship is an important component of graduate medical education. It has been associated with numerous benefits including personal development, increased career satisfaction, and reduced stress and burnout. The purpose of this study was to assess orthopedic resident attitudes regarding mentorship and to determine if there were sociodemographic differences. DESIGN: A total of 243 orthopedic surgery residents completed this 25-item mixed response questionnaire. RESULTS: Nearly two-thirds of residents conveyed that their training program either had a formal or informal mentorship program, and 95.8% of residents indicated that they believed mentorship played an important role with respect to their development as an orthopedic resident. Minorities were more likely to have a mentor that was obtained while they were in medical school, less likely to have multiple mentors, and more likely to be dissatisfied with the quality of mentorship in residency. Females were more likely to pursue a mentor on their own. Overall, 31% of orthopedic residents were classified as experiencing burnout. There was no difference in the prevalence of mentorship in respondents experiencing burnout, but they were more likely to be unsatisfied with the quality of mentorship in residency. Finally, only two-thirds of residency programs have mentorship programs despite the fact that the vast majority of orthopedic residents believe that the mentorship plays an important role in their development as surgeons. RESULTS: Given these findings, future work should focus on identifying and addressing race and sex-based mentorship disparities while simultaneously working to improve access to mentorship for all residents.

The Effectiveness of Osteoporosis Screening and Treatment in the Midwest.

INTRODUCTION: With osteoporosis on the rise across the United States, the goal of this prospective study is to determine the effectiveness of our Midwest level-1 trauma center in diagnosing, treating, and educating osteoporosis patients after fracture with the use of questionnaires. Secondarily, we aimed to identify barriers that prevent our patients from complying with bone health recommendations. METHODS: One hundred participants (≥55 years) were given 2 questionnaires (Fracture Risk Assessment Tool and a study-specific questionnaire) that were administered during the patient's visit to the orthopedic trauma clinic. A group of patients diagnosed with osteoporosis was compared to a group of patients not diagnosed with osteoporosis. Statistical analyses were performed using SPSS 24 (IBM Corp, Chicago, Illinois). RESULTS: Patients who had been diagnosed with osteoporosis were significantly older (72.7 vs 66.5, P = .009) and more were women (86.2% vs 66.2%, P = .043). Significantly, fewer patients without the diagnosis of osteoporosis had a history of fragility fracture (56.3%) compared to 92.9% of those diagnosed with osteoporosis (P < .001). Of those with dual-energy X-ray absorptiometry (DXA) recommended by a healthcare provider, 20 (55.6%) of those without the diagnosis of osteoporosis and 13 (52%) of those with the diagnosis of osteoporosis had DXA screening before their fragility fracture (P = .499). More patients diagnosed with osteoporosis (93.1%) were taking calcium and vitamin D supplementation compared to 66.2% of those without the diagnosis of osteoporosis (P = .005). Only 37.9% of patients with the diagnosis of osteoporosis were receiving US Food and Drug Administration-approved medications for the management of their disease. DISCUSSION: In patients without previous osteoporosis diagnosis, 59 (83.1%) of the 71 claimed that they did not receive any preventative education about osteoporosis, while 21 (72.4%) of the 29 patients with the diagnosis of osteoporosis claimed that they did not receive a preventative education (P = .165). Both groups lacked optimum diagnosis, treatment, and education of osteoporosis. CONCLUSION: Our study highlights the need for a deliberate effort of a multidisciplinary team to focus efforts in all stages of osteoporosis management.