Elbow Uncemented Hemiarthroplasty: Surgical Technique.

Management of elbow arthritis in younger and higher demand patients is challenging and may benefit from a distal humerus hemiarthroplasty that employs a noncemented method of implant fixation and stabilizes the elbow through ligament reconstruction. By not replacing both articulating surfaces, hardware longevity may be improved. We describe a novel system that may be indicated for the treatment of posttraumatic or primary osteoarthritis of the distal humerus. The step-by-step technique for surgical implantation of this uncemented distal humerus hemiarthroplasty is described and illustrated.

Static stability of novel uncemented elbow hemiarthroplasty stabilized with ligament reconstruction.

BACKGROUND: The purpose of this study was to create a model to simulate treatment of unreconstructable distal humerus fractures with hemiarthroplasty. Stability was restored with a latest plate-system that simultaneously tensions medial and lateral collateral ligament grafts. MATERIALS AND METHODS: Static varus and valgus elbow stability was tested in 11 cadaver elbows with intact ligaments and capsule at 5 flexion angles (0°, 30°, 60°, 90°, 120°). The elbows were then destabilized via release of all ligaments and capsular attachments. The distal humerus articular cartilage was excised and replaced with an uncemented hemiarthroplasty. Ligament reconstruction was subsequently performed, and elbow stability was measured and compared to the native state. Dimensions of the hemiarthroplasty component were compared to native elbow dimensions to assess and quantify any existing relationship to elbow stability. RESULTS: A hemiarthroplasty was implanted in all specimens. A size mismatch occurred between the distal humerus trochlea and the olecranon fossa in all specimens and averaged 6.3 mm. Following ligament reconstruction, specimens reproduced the flexion angle-dependent stability of native elbows to both varus and valgus stress. On the medial side, elbow joint stability in mid-flexion was approximately 7% tighter after hemiarthroplasty. Laterally, the elbow was approximately 15% tighter after hemiarthroplasty and demonstrated peak stability in full flexion. The 3 assessed hemiarthroplasty components and bony dimensions did not exhibit any relationship between implant-bone mismatch and elbow stability after ligamentous reconstruction. CONCLUSION: Cadaveric elbow specimens underwent uncemented hemiarthroplasty with soft tissue stabilization with a novel technique for ligament reconstruction. Following hemiarthroplasty and ligament reconstruction, these specimens maintained secure fixation between ligament and bone. Static stability was maintained at varying degrees of elbow flexion regardless of variable mismatch between the hemiarthroplasty component and the native olecranon fossa.

Association Between Industry Sponsorship of Spine-Related Clinical Trials, Publication Status, and Research Outcomes.

STUDY DESIGN: Observational Database Study. OBJECTIVES: Prospective clinical trials in spinal surgery are expensive to conduct, especially when randomized, appropriately powered, and/or multicentered. Industry collaborations generate symbiotic relationships promoting technological advancement; however, they also allow for bias. To the authors' knowledge, there is no known analysis of correlations between industry sponsorship and publication rates of spine-related clinical trials. This observational work evaluates such potential associations. METHODS: The ClinicalTrials.gov database was queried with terms spine, spinal, spondylosis, spondylolysis, cervical, lumbar, and compression fracture over an 11-year period. Design characteristics and outcomes were recorded from 822 spine surgery-related trials. Trials were stratified based on funding source and intervention class. Groups were compared via two-tailed chi-square test of independence or Fisher's exact test (α = .05), based on completion status and publication rates of positive vs negative results. RESULTS: Industry-sponsored spine-related clinical trials were more likely to be terminated than their non-industry-sponsored counterparts (P < .001). Of the trials achieving publication, industry-sponsored trials reported positive results at a higher rate than did trials without industry funding (P = .037). Clinical trials examining devices were more likely to be terminated than those studying other intervention classes (P = .001). CONCLUSIONS: High termination rates and positive result publication rates among industry-sponsored clinical trials in spinal surgery likely reflect industry's influence on the research community. Such partnership alleviates financial burden and provides accessibility to cutting-edge innovation. It is essential that all parties remain mindful of the significant bias that funding source may impart on study outcome.

Prospective Cohort Study Comparing Ligament Reconstruction with Tendon Interposition and Suture-Only Suspension Arthroplasty.

BACKGROUND: Basal joint arthritis is a common form of osteoarthritis. There is no consensus procedure for maintenance of trapezial height following trapeziectomy. Suture-only suspension arthroplasty (SSA) is a simple method for stabilizing the thumb metacarpal following trapeziectomy. METHODS: This single-institution, prospective, cohort study compares trapeziectomy followed by either ligament reconstruction with tendon interposition (LRTI) or SSA for the treatment of basal joint arthritis. Patients underwent LRTI or SSA from May of 2018 to December of 2019. Visual analogue scale pain scores; Disabilities of the Arm, Shoulder and Hand questionnaire functional scores; clinical thumb range of motion, pinch, and grip strength data; and patient-reported outcomes were recorded and analyzed preoperatively and at 6 weeks and 6 months postoperatively. RESULTS: Total number of study participants was 45 (LRTI, n = 26; SSA, n = 19). Mean ± SE age was 62.4 ± 1.5 years; 71% were female patients; and 51% underwent surgery on the dominant side. Visual analogue scale scores improved for LRTI and SSA ( P < 0.0001) over 6 months, with no differences between groups at any time point ( P > 0.3). Disabilities of the Arm, Shoulder and Hand questionnaire scores improved for LRTI and SSA over 6 months ( P < 0.0001), with no differences between groups at any time point ( P > 0.3). Following SSA, opposition improved ( P = 0.02), but not as well for LRTI ( P = 0.16). Grip and pinch strength decreased following LRTI and SSA at 6 weeks but recovered similarly for both groups over 6 months. Patient-reported outcomes were generally no different between groups at all time points. CONCLUSION: LRTI and SSA are similar procedures following trapeziectomy relative to pain, function, and strength recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Spine Fractures of Patients with Ankylosing Spondylitis and Diffuse Idiopathic Skeletal Hyperostosis: Fracture Severity and Injury-Related Mortality at a Level I Trauma Center.

STUDY DESIGN: Retrospective review of prospectively collected cohort. PURPOSE: To identify differences in treatment and mortality of spine fractures in patients with ankylosing conditions of the spine. OVERVIEW OF LITERATURE: Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are the two most common etiologies of ankylosing spinal disorder (ASD). However, studies on the treatment and outcomes of spine fractures in AS and DISH patients remain few. METHODS: Patients presenting with a spine fracture were diagnosed with AS or DISH at a single tertiary care center between 2010 and 2019. We excluded those who lacked cross-sectional imaging or fractures occurring at spinal segments affected by ankylosis, as well as polytraumatized patients. Patient demographics, injury mechanism, fracture level, neurologic status, treatment, and 1-year mortality were recorded. Computed tomography imaging was reviewed by two independent readers and graded according to the indicated AO Spine Injury Classification System. Differences in fracture severity, treatment method, and mortality were examined using Student t -tests, chi-square tests, and two-proportion Z-tests with significance set to p <0.05. RESULTS: We identified 167 patients with spine fracture diagnosed with AS or DISH. Patients with AS had more severe fractures and more commonly had surgery than patients with DISH (p <0.001). Despite these differences, 1-year mortality did not significantly differ between AS and DISH patients (p =0.14). CONCLUSIONS: Although patients with AS suffered more severe fractures compared to DISH and more frequently underwent surgery for these injuries, outcomes and 1-year mortality did not differ significantly between the two groups. For patients with ASDs and fractures, outcomes appear similar regardless of treatment modality. Consequently, there may be an opportunity for critical reappraisal of operative indications in ASD and a larger role for nonoperative management in these challenging patients.

In Vivo Evidence of Early Instability and Late Stabilization in Motion Segments Immediately Superior to Anterior Cervical Arthrodesis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The aim was to identify patient factors that affect adjacent segment kinematics after anterior cervical discectomy and fusion (ACDF) as measured by biplane radiography. SUMMARY OF BACKGROUND DATA: The etiology of adjacent segment disease (ASD) may be multifactorial. Previous studies have investigated associations between patient factors and ASD, although few attempted to link patient factors with mechanical changes in the spine that may explain ASD development. Previous studies manually measured intervertebral motion from static flexion/extension radiographs, however, manual measurements are unreliable, and those studies failed to measure intervertebral motion during rotation. METHODS: Patients had continuous cervical spine flexion/extension and axial rotation movements captured at 30 images per second in a dynamic biplane radiography system preoperatively and 1 year after ACDF. Digitally reconstructed radiographs generated from subject-specific computed tomography scans were matched to the biplane radiographs using a validated tracking process. Dynamic kinematics and preoperative disc height were calculated from this tracking process. Preoperative magnetic resonance imagings were evaluated for disc bulge. Patient age, sex, body mass index, smoking status, diabetes, psychiatric history, presence of an inciting event, and length of symptoms were collected. Multivariate linear regression was performed to identify patient factors associated with 1-year postoperative changes in adjacent segment kinematics. RESULTS: Sixty-three patients completed preoperative and postoperative testing. Superior adjacent segment disc height and disc bulge predicted the change in superior adjacent segment range of motion after surgery. Inferior adjacent segment disc bulge, smoking history, and the use of psychiatric medications predicted the change in inferior adjacent segment flexion/extension range of motion after surgery. CONCLUSIONS: Preexisting adjacent segment disc degeneration, as indicated by disc height and disc bulge, was associated with reduced adjacent segment motion after ACDF, while lack of preexisting adjacent disc degeneration was associated with increased adjacent segment motion after ACDF. These findings provide in vivo evidence supporting early instability and late stabilization in the pathophysiology of disc degeneration.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome.

Background: We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy. Methods: 104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length. Results: The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed. Conclusion: Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system. Level of evidence: III, retrospective cohort study.

Use of continuous passive motion device after arthroscopic hip surgery decreases post-operative pain: A randomized controlled trial.

BACKGROUND: We sought to determine whether continuous passive motion (CPM) usage improves outcomes following arthroscopic hip surgery involving acetabular labral repair. Our hypothesis is that CPM usage reduces pain and pain medication use and improves quality of life in individuals who undergo hip arthroscopy. METHODS: We created a randomized controlled trial consisting of 54 patients who underwent arthroscopic acetabular labral repair. Patients were randomized to two groups, one with CPM use post-operatively and one without. Primary outcomes measured were pain level, patient satisfaction, and quality of life. Parameters used to measure these outcomes were self-reported pain scores on Likert scale, frequency of analgesic medication use, and self-reported scores on Hip Outcome Score Activity of Daily Living (HOS ADL). These parameters were compared between the two randomized groups using t-test for statistical analysis. RESULTS: There was no statistical difference between the treatment and control groups in terms of patient characteristics. There was no statistical difference between the two groups in terms of HOS ADL scores, although the patients in the control group demonstrated a trend toward higher HOS ADL scores. The patients in the CPM group had a statistically significant decrease in pain levels after surgery compared to patients in the control group. The total morphine equivalent dose consumed in the first two post-operative weeks was higher in the control group compared to the CPM group, although this difference was not statistically significant. CONCLUSIONS: Use of CPM resulted in lower pain level scores in patients after hip arthroscopy. Although there is no statistical difference in quality of life or quantity of analgesics consumed post-operatively, patients who used CPM tended to have lower HOS ADL scores (which is desirable) and less consumption of pain medication. A study with a larger sample of patients might elucidate more differences between the two groups. LEVEL OF EVIDENCE: II, therapeutic.

Inpatient and outpatient opioid requirements after total joint replacement are strongly influenced by patient and surgical factors.

AIMS: Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. METHODS: Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. RESULTS: TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. CONCLUSION: Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements.Cite this article: Bone Joint Open 2020;1-7:398-404.

Bone marrow lesions: etiology and pathogenesis at the hip.

Bone marrow lesions (BML) are painful changes in subchondral bone which can be reliably identified on magnetic resonance imaging and have been identified in patients suffering from hip osteoarthritis (OA) and related conditions. Created via repetitive microdamage at the articular surface and dysregulated subchondral healing, BML have been linked to traumatic, inflammatory, degenerative, metabolic and neoplastic processes. While BML are known to be a common pathology throughout the body, BML at the hip have not been extensively studied in comparison to those at the knee. Due to the hip's unique biomechanical architecture, function and loading, and independent risk factors leading to hip OA, hip BMLs must be independently understood. The identification of BML in the setting of a pre-osteoarthritic condition may provide a target for treatment and prevention of joint degeneration. By continuing to define and refine the relationships between BML, subchondral bone cysts and OA, prevention, diagnosis and treatment of OA could shift, leading to an improved quality of life and increased longevity of individuals' native hips.

Comparison of ultrasound and electrodiagnostic testing for diagnosis of carpal tunnel syndrome: study using a validated clinical tool as the reference standard.

BACKGROUND: Ultrasound examination is both accurate and cost-effective for the confirmation of a clinical diagnosis of carpal tunnel syndrome. Previous studies have shown electrodiagnostic testing and ultrasound to be similar with regard to sensitivity and specificity. The purpose of this study was to compare the sensitivity and specificity of ultrasound and electrodiagnostic testing by using a validated clinical diagnostic tool as the reference standard. METHODS: All consecutive patients referred to an upper-extremity practice for electrodiagnostic testing for any reason over a three-month period were recruited to participate in this study. All patients were evaluated with the use of the Carpal Tunnel Syndrome 6 (CTS-6) clinical diagnostic tool, and a score of ≥12 was considered positive for carpal tunnel syndrome. A positive finding on ultrasound was considered to be a cross-sectional area of the median nerve, measured just proximal to the level of the pisiform, of ≥10 mm(2). A positive finding on electrodiagnostic testing was a distal motor latency of ≥4.2 ms and/or a distal sensory latency of ≥3.2 ms. Sensitivity, specificity, and accuracy were calculated for ultrasound and electrodiagnostic testing with use of the CTS-6 as the reference standard. RESULTS: With use of the CTS-6 as the reference standard, ultrasound had a sensitivity of 89% and a specificity of 90% in our series of eighty-five patients. Electrodiagnostic testing had a sensitivity of 89% and a specificity of 80%. The positive predictive value of ultrasound was 94% compared with 89% for electrodiagnostic testing. The negative predictive value of ultrasound was 82% compared with 80% for electrodiagnostic testing. Ultrasound was accurate in seventy-six (89%) of the eighty-five cases whereas electrodiagnostic testing was accurate in seventy-three (86%) of the eighty-five cases (p = 0.5). CONCLUSIONS: While ultrasound will not replace electrodiagnostic testing in complicated or unclear cases, in a select group of patients with a positive CTS-6, ultrasound can be used to confirm the diagnosis of carpal tunnel syndrome with better specificity and equal sensitivity as compared with those of electrodiagnostic testing. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.