Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study.

BACKGROUND: Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared. METHODS: Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs. RESULTS: When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting. CONCLUSION: While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear. LEVEL OF EVIDENCE: III, retrospective cohort study.

A New Test for Trigger Finger: The Lenox Independent Flexion Test.

Background: The diagnosis of trigger finger (TF) in patients who do not demonstrate triggering at presentation can be challenging. We have been using a new test for TF - the Lenox Independent Flexion Test (LIFT). The aim of this study is to determine the sensitivity of LIFT in diagnosing TF. We hypothesise that LIFT will be more sensitive compared to the classic physical exam finding of triggering or locking with active range of motion (AROM). Methods: This is a prospective study of consecutive patients with TF over a 5-month period. Patients with the onset of trigger following trauma and trigger of the thumb were excluded. Patients were examined for tenderness over the first annular (A1) pulley, triggering or locking with AROM, and the LIFT was performed. A two-proportion test was used to determine whether the LIFT was more sensitive than triggering with AROM. Results: The study included 85 patients with 118 TFs. The average age of patients was 63 years and the study included 49 women. There were 69, 49, 0 and 0 grade I, II, III and IV TF, respectively. 108 fingers (92%) had a history of catching or locking of the affected digit, 110 (93%) had tenderness over the A1 pulley, 49 (44%) had triggering or locking with AROM and 102 (91%) had a positive LIFT. The LIFT was found to be more sensitive when compared to triggering with AROM (p < .001). Conclusion: The LIFT is more sensitive than triggering with AROM in the diagnosis of trigger digits. This test is especially useful in the diagnosis of TF in patients who do not have triggering at presentation. Level of Evidence: Level III (Diagnostic).

The top 100 classic papers on adolescent idiopathic scoliosis in the past 25 years: a bibliometric analysis of the orthopaedic literature.

STUDY DESIGN: Bibliometric analysis. OBJECTIVES: To identify the 100 most cited orthopedic papers in adolescent idiopathic scoliosis (AIS) over the past 25 years and characterize them by study type, topic, and country and assess study quality (design, level of evidence, and impact factor) to provide an updated account of the most impactful AIS evidence. AIS represents a three-dimensional deformity that drives a significant number of investigations. Although available evidence continues to grow, recent impactful studies pertaining to AIS have not been identified; their quality has not been thoroughly assessed. METHODS: Web of Science was reviewed to identify the top 1000 cited AIS studies published from 1992 to 2017. Articles were organized by number of citations. Titles and abstracts were screened for inclusion/relevance, and the top 100 articles by citation count were identified, and study and publication characteristics were extracted. RESULTS: Among the top 100 articles, 42 were cited ≥ 100 times. Mean number of authors and citations of these studies was 5.6 and 118.3, respectively. Study types were predominantly retrospective (n = 53), followed by prospective (n = 18), cross-sectional (n = 13), and systematic review/meta-analysis (n = 7). Topics covered in these studies included clinical/patient outcomes (n = 47), methodology/validation (n = 22), basic science (n = 15), radiographic analyses (n = 12), and gait/biomechanics (n = 4). Most studies originated in the United States of America (n = 65) and were published in Spine (n = 76), with 8266 total citations. Most studies were of Level III (n = 55) or Level II (n = 23) evidence. Mean impact factor was 3.47. CONCLUSIONS: Despite recent studies' shorter time frames for impact, citations of AIS research have progressively increased during the past 25 years. The top 100 cited orthopedic studies were predominantly Level III, retrospective, nonrandomized studies, and therefore, were subject to biases. The low proportion of prospective studies (18%) reflects an area of future improvement, underscoring the need for higher-quality studies to support our practice. LEVEL OF EVIDENCE: N/A.

The Dubousset Functional Test is a Novel Assessment of Physical Function and Balance.

BACKGROUND: Currently, the functional status of patients undergoing spine surgery is assessed with quality-of-life questionnaires, and a more objective and quantifiable assessment method is lacking. Dr. Jean Dubousset conceptually proposed a four-component functional test, but to our knowledge, reference values derived from asymptomatic individuals have not yet been reported, and these are needed to assess the test's clinical utility in patients with spinal deformities. QUESTIONS/PURPOSES: (1) What are the reference values for the Dubousset Functional Test (DFT) in asymptomatic people? (2) Is there a correlation between demographic variables such as age and BMI and performance of the DFT among asymptomatic people? METHODS: This single-institution prospective study was performed from January 1, 2018 to May 31, 2018. Asymptomatic volunteers were recruited from our college of medicine and hospital staff to participate in the DFT. Included participants did not report any musculoskeletal problems or trauma within 5 years. Additionally, they did not report any history of lower limb fracture, THA, TKA, or patellofemoral arthroplasty. Patients were also excluded if they reported any active medical comorbidities. Demographic data collected included age, sex, BMI, and self-reported race. Sixty-five asymptomatic volunteers were included in this study. Their mean age was 42 ± 15 years; 27 of the 65 participants (42%) were women. Their mean BMI was 26 ± 5 kg/m. The racial distribution of the participants was 34% white (22 of 65 participants), 25% black (16 of 65 participants), 15% Asian (10 of 65 participants), 9% subcontinental Indian (six of 65 participants), 6% Latino (four of 65 participants), and 10% other (seven of 65 participants). In a controlled setting, participants completed the DFT after verbal instruction and demonstration of each test, and all participants were video recorded. The four test components included the Up and Walking Test (unassisted sit-to-stand from a chair, walk forward/backward 5 meters [no turn], then unassisted stand-to-sit), Steps Test (ascend three steps, turn, descend three steps), Down and Sitting Test (stand-to-ground, followed by ground-to-stand, with assistance as needed), and Dual-Tasking Test (walk 5 meters forwards and back while counting down from 50 by 2). Tests were timed, and data were collected from video recordings to ensure consistency. Reference values for the DFT were determined via a descriptive analysis, and we calculated the mean, SD, 95% CI, median, and range of time taken to complete each test component, with univariate comparisons between men and women for each component. Linear correlations between age and BMI and test components were studied, and the frequency of verbal and physical pausing and adverse events was noted. RESULTS: The Up and Walking Test was completed in a mean of 15 seconds (95% CI, 14-16), the Steps Test was completed in 6.3 seconds (95% CI, 6.0-6.6), the Down and Sitting Test was completed in 6.0 seconds (95% CI, 5.4-6.6), and the Dual-Tasking Test was performed in 13 seconds (95% CI, 12-14). The length of time it took to complete the Down and Sitting (r = 0.529; p = 0.001), Up and Walking (r = 0.429; p = 0.001), and Steps (r = 0.356; p = 0.014) components increased with as the volunteer's age increased. No correlation was found between age and the time taken to complete the Dual-Tasking Test (r = 0.134; p = 0.289). Similarly, the length of time it took to complete the Down and Sitting (r = 0.372; p = 0.005), Up and Walking (r = 0.289; p = 0.032), and Steps (r = 0.366; p = 0.013) components increased with increasing BMI; no correlation was found between the Dual-Tasking Test's time and BMI (r = 0.078; p = 0.539). CONCLUSIONS: We found that the DFT could be completed by asymptomatic volunteers in approximately 1 minute, although it took longer for older patients and patients with higher BMI. CLINICAL RELEVANCE: We believe, but did not show, that the DFT might be useful in assessing patients with spinal deformities. The normal values we calculated should be compared in future studies with those of patients before and after undergoing spine surgery to determine whether this test has practical clinical utility. The DFT provides objective metrics to assess function and balance that are easy to obtain, and the test requires no special equipment.

Robotic-Assisted and Computer-Navigated Unicompartmental Knee Arthroplasties: A Systematic Review.

INTRODUCTION: Unicompartmental knee arthroplasty (UKA) effectively improves pain and function associated with isolated compartmental knee arthritis. The developments of computer-navigated and robotic-assisted UKA are among the most significant changes that have improved patient outcomes. This study aimed to systematically review the literature to identify differences between computer-navigated and robotic-assisted UKAs. MATERIALS AND METHODS: Twenty total articles were identified. Data pertaining to demographics, outcomes, and complications/failures were extracted from each study. Reoperation/revision rates, indications for reoperation/revision, type of procedure, and number of patients who underwent conversion to TKA (when available) were recorded. RESULTS: Nine studies reported 451 computer-navigated medial UKAs, with 19 (3.9%) reportedly requiring reoperation: primary revision (n=8; 42.1%), conversion to TKA (n=6), and manipulation under anesthesia (n=5). Eleven studies reported 2,311 robotic-assisted UKAs (74 lateral UKAs), with 106 (5.0%) requiring reoperation: conversion to TKA (n=46; 43.4%), primary revision (n=43), reoperations without component-removal (n=15), subchondroplasty, and partial meniscectomy/synovectomy (both n=1). Reoperation rate discrepancy between computer-navigated and robotic-assisted UKA was not statistically significant (p=0.495); age and BMI differed between both groups (p<0.0001). DISCUSSION: This study represents the first known comparison of revision rates of computer-navigated and robotic-assisted UKA, suggesting that these methods can benefit orthopaedic surgeons, especially those new to UKA or in a low-volume practice.

A Systematic Review and Meta-Analysis of Procalcitonin as a Marker of Postoperative Orthopedic Infections.

Procalcitonin is a serologic marker that increases in response to inflammatory stimuli, especially those of bacterial origin. Postoperative orthopedic periprosthetic infections are often difficult to diagnose. This study systematically reviewed the literature to evaluate the statistical measures of performance of procalcitonin as a marker of postoperative orthopedic infection. This study showed that procalcitonin has a weighted pooled sensitivity of 67.3%, specificity of 69.4%, positive likelihood ratio of 1.778, negative likelihood ratio of 0.423, and diagnostic odds ratio of 5.770. These results illustrate that procalcitonin is an effective serologic marker for postoperative bacterial infections. [Orthopedics. 2018; 41(3):e303-e309.].

The Impact of Comorbid Mental Health Disorders on Complications Following Cervical Spine Surgery With Minimum 2-Year Surveillance.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To improve understanding of the impact of comorbid mental health disorders (MHDs) on long-term outcomes following cervical spinal fusion in cervical radiculopathy (CR) or cervical myelopathy (CM) patients. SUMMARY OF BACKGROUND DATA: Subsets of patients with CR and CM have MHDs, and their impact on surgical complications is poorly understood. METHODS: Patients admitted from 2009 to 2013 with CR or CM diagnoses who underwent cervical surgery with minimum 2-year surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. Patients with a comorbid MHD were compared against those without (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between MHD and no-MHD cohorts. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: age, sex, Charlson/Deyo score, and surgical approach). RESULTS: A total of 20,342 patients (MHD: n = 4819; no-MHD: n = 15,523) were included. MHDs identified: depressive (57.8%), anxiety (28.1%), sleep (25.2%), and stress (2.9%). CR patients had greater prevalence of comorbid MHD than CM patients (P = 0.015). Two years postoperatively, all patients with MHD had significantly higher rates of complications (specifically: device-related, infection), readmission for any indication, and revision surgery (all P < 0.05); regression modeling corroborated these findings and revealed combined surgical approach as the strongest predictor for any complication (CR, odds ratio [OR]: 3.945, P < 0.001; CM, OR: 2.828, P < 0.001) and MHD as the strongest predictor for future revision (CR, OR: 1.269, P = 0.001; CM, OR: 1.248, P = 0.008) in both CR and CM cohorts. CONCLUSION: Nearly 25% of patients admitted for CR and CM carried comorbid MHD and experienced greater rates of any complication, readmission, or revision, at minimum, 2 years after cervical spine surgery. Results must be confirmed with retrospective studies utilizing larger national databases and with prospective cohort studies. Patient counseling and psychological screening/support are recommended to complement surgical treatment. LEVEL OF EVIDENCE: 3.

The Impact of Comorbid Mental Health Disorders on Complications Following Adult Spinal Deformity Surgery With Minimum 2-Year Surveillance.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To compare long-term outcomes between patients with and without mental health comorbidities who are undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Recent literature reveals that one in three patients admitted for surgical treatment for ASD has comorbid mental health disorder. Currently, impacts of baseline mental health status on long-term outcomes following ASD surgery have not been thoroughly investigated. METHODS: Patients admitted from 2009 to 2013 with diagnoses of ASD who underwent more than or equal to 4-level thoracolumbar fusion with minimum 2-year follow-up were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System (SPARCS). Patients were stratified by fusion length (short: 4-8-level; long: ≥9 level). Patients with comorbid mental health disorder (MHD) at time of admission were selected for analysis (MHD) and compared against those without MHD (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between cohorts for each fusion length. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: fusion length, age, female sex, and Deyo score). RESULTS: Six thousand twenty patients (MHD: n = 1631; no-MHD: n = 4389) met inclusion criteria. Mental health diagnoses included disorders of depression (59.0%), sleep (28.0%), anxiety (24.0%), and stress (2.3%). At 2-year follow-up, MHD patients with short fusion had significantly higher complication rates (P = 0.001). MHD patients with short or long fusion also had significantly higher rates of any readmission and revision (all P ≤ 0.002). Regression modeling revealed that comorbid MHD was a significant predictor of any complication (odds ratio [OR]: 1.17, P = 0.01) and readmission (OR: 1.32, P < 0.001). MHD was the strongest predictor of any revision (OR: 1.56, P < 0.001). Long fusion most strongly predicted any complication (OR: 1.87, P < 0.001). CONCLUSION: ASD patients with comorbid depressive, sleep, anxiety, and stress disorders were more likely to experience surgical complications and revision at minimum of 2 years following spinal fusion surgery. Proper patient counseling and psychological screening/support is recommended to complement ASD treatment. LEVEL OF EVIDENCE: 3.

The Risks of Hepatitis C in Association With Cervical Spinal Surgery: Analysis of Radiculopathy and Myelopathy Patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: To investigate rates of in-hospital postsurgical complications among hepatitis C-infected patients after cervical spinal surgery in comparison with uninfected patients and determine independent risk factors. SUMMARY OF BACKGROUND DATA: Studying hepatitis C virus (HCV) as a possible risk factor for cervical spine postoperative complications is prudent, given the high prevalence of cervical spondylosis and HCV in older patients. Spine literature is limited with respect to the impact of chronic HCV upon complications after surgery. MATERIALS AND METHODS: Patients who underwent cervical spine surgery for cervical radiculopathy (CR) or cervical myelopathy (CM) from 2005 to 2013 were retrospectively reviewed using the Nationwide Inpatient Sample database. Patients were divided into CR and CM groups, with comparative subgroup analysis of HCV and no-HCV patients. Univariate analysis compared demographics and complications. Binary logistic stepwise regression modeling identified any independent outcome predictors (covariates: age, sex, Deyo score, and surgical approach). RESULTS: In total, 227,310 patients (HCV: n=2542; no-HCV: n=224,764) were included. From 2005 to 2013, HCV infection prevalence among all cervical spinal fusion cases increased from 0.8% to 1.2%. HCV patients were more likely to be African American or Hispanic and have Medicare and/or Medicaid (all P<0.001). Overall complication rates among HCV patients with CR or CM increased, specifically related to device (CR: 3.1% vs. 1.9%; CM: 2.9% vs. 1.3%), hematoma/seroma (CR: 1.1% vs. 0.4%; CM: 1.8% vs. 0.8%), and sepsis (CR: 0.4% vs. 0.1%; CM: 1.1% vs. 0.5%) (all P≤0.001). Among CR and CM patients, HCV significantly predicted increased complication rates [odds ratio (OR): 1.268; OR: 1.194], hospital stay (OR: 1.738; OR: 1.861), and hospital charges (OR: 1.516; OR: 1.732; all P≤0.044). CONCLUSIONS: HCV patients undergoing cervical spinal surgery were found to have increased risks of postoperative complications and increased risk associated with surgical approach. These findings should augment preoperative risk stratification and counseling for HCV patients and their spine surgeons. LEVEL OF EVIDENCE: Level III.

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Hip Arthroplasty?

BACKGROUND: Periprosthetic hip infections are among the most catastrophic complications after total hip arthroplasty (THA). We had previously proven that the use of chlorhexidine cloths before surgery may help decrease these infections; hence, we increased the size of the previously reported cohort. QUESTIONS/PURPOSES: (1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing THA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol? METHODS: Between 2007 and 2013, a group of 998 patients used chlorhexidine cloths before surgery, whereas a group of 2846 patients did not use them and underwent standard perioperative disinfection only. Patient records were reviewed to determine the development of periprosthetic infection in both groups of patients. RESULTS: Patients without the preoperative chlorhexidine gluconate disinfection protocol had a higher risk of infections (infections with protocol: six of 995 [0.6%]; infections in control: 46 of 2846 [1.62%]; relative risk: 2.68 [95% confidence interval {CI}, 1.15-0.26]; p = 0.0226). When stratified based on risk category, no differences were detected; preadmission chlorhexidine preparation was not associated with reduced infection risk for low, medium, and high NHSN risk categories (p = 0.386, 0.153, and 0.196, respectively). CONCLUSIONS: The results of our study suggest that this cloth application appears to reduce the risk of infection in patients undergoing THA. When stratified by risk categories, we found no difference in the infection rate, but these findings were underpowered. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and so might be considered on the basis of this retrospective, comparative study. LEVEL OF EVIDENCE: Level III, therapeutic study.