Time to surgery and outcomes following open reduction and internal fixation of both-bone forearm fractures.

PURPOSE: To determine the effect of time to surgery on outcomes following open reduction and internal fixation (ORIF) of both-bone forearm fractures (BBFFs). METHODS: Ninety-nine patients who underwent ORIF of BBFFs in a single academic medical center over a 16-year time period were retrospectively reviewed. Demographic and clinical data including age, sex, current smoking status, time from injury to surgery (tsurg), presence of open injury, polytrauma status, and complications were obtained. Radiographs of the affected extremity were reviewed for fracture morphology, reduction quality, and time to union (or presence of nonunion). In addition to descriptive statistics, Chi-square and Wilcoxon-Mann-Whitney tests were used to compare categorical and interval, respectively, with a significance level of 0.05. RESULTS: A tsurg > 48 h was associated with increased rate of delayed unions (tsurg < 48 h: 25% vs tsurg > 48 h: 59%, p = 0.03), but not complications (tsurg < 48 h: 44% vs tsurg > 48 h: 47%, p = 0.79). Open BBFFs were not associated with increased rates of delayed unions (closed: 16% vs open: 19%, p = 0.77) or complications (closed: 42% vs open: 53%, p = 0.29). A trend toward increased time to union with tsurg > 48 h was also seen, but did not reach significance (tsurg < 48 h: 13.5 weeks vs tsurg > 48 h: 15.7 weeks, p = 0.11). CONCLUSION: A tsurg > 48 h is associated with an increased rate of delayed union, but not complications, after ORIF of BBFFs. LEVEL OF EVIDENCE: Therapeutic Level III (Retrospective Cohort).

Return to Sport After Articular Cartilage Repair in Athletes' Knees: A Systematic Review.

PURPOSE: To perform a systematic review of cartilage repair in athletes' knees to (1) determine which (if any) of the most commonly implemented surgical techniques help athletes return to competition, (2) identify which patient- or defect-specific characteristics significantly affect return to sport, and (3) evaluate the methodologic quality of available literature. METHODS: A systematic review of multiple databases was performed. Return to preinjury level of sport was defined as the ability to play in the same or greater level (i.e., league or division) of competition after surgery. Study methodologic quality for all studies analyzed in this review was evaluated with the Coleman Methodology Score. RESULTS: Systematic review of 1,278 abstracts identified 20 level I-IV studies for inclusion but only 1 randomized controlled trial. Twenty studies (1,117 subjects) were included. Subjects (n = 970) underwent 1 of 4 surgeries (microfracture [n = 529], autologous chondrocyte implantation [ACI, n = 259], osteochondral autograft [n = 139], or osteochondral allograft [n = 43]), and 147 were control patients. The rate of return to sports was greatest after osteochondral autograft transplantation (89%) followed by osteochondral allograft, ACI, and microfracture (88%, 84%, and 75%, respectively). Osteochondral autograft transplantation and ACI had statistically significantly greater rates of return to sports compared with microfracture (P < .001, P < .01; Fisher exact test). CONCLUSIONS: Athletes may return to sports participation after microfracture, ACI, osteochondral autograft, or osteochondral allograft, but microfracture patients were least likely to return to sports. The athletes who had a better prognosis after surgery were younger, had a shorter preoperative duration of symptoms, underwent no previous surgical interventions, participated in a more rigorous rehabilitation protocol, and had smaller cartilage defects. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Is magnetic resonance imaging assessment of the size of articular cartilage defects accurate?

The purpose of this study was to systematically review the literature relative to the following question: Is preoperative magnetic resonance imaging (MRI) an accurate instrument for the assessment of the size of knee articular cartilage defects compared with arthroscopy? A systematic search was performed in September 2011 using PubMed MEDLINE (from 1966), CINAHL (from 1982), SPORTDiscus (from 1985), SCOPUS (from 1996), and EMBASE (from 1974) databases. Four studies (one study of Level II and three studies of Level III) were identified that met the predetermined inclusion and exclusion criteria. The ability of MRI to preoperatively assess the size of cartilage lesions was highly variable. As a result of inconsistencies between imaging techniques, the methodological variability and shortcomings of the studies, and the limited amount of data available, a meta-analysis was not performed. There is some evidence that MRI is an accurate tool for preoperatively assessing the dimensions of articular cartilage defects. However, because of the heterogeneity of MRI sequences and the paucity of literature related to preoperative sizing, it is not possible to make definitive conclusions regarding the global clinical utility of MRI for guiding the selection of therapeutic strategies.

Total Wrist Fusion with an Intramedullary Device: A Single-Institution Series with a Minimum of One Year Follow-Up.

Objective The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods A single institution study was performed, which entailed in-person reexamination of 18 patients ( n = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n I = 38 wrists) were noted. Results In the 18 patients, age was 47.6 ± 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74-294). The VAS score was 0 ± 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 ± 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF. Level of Evidence This is a Level IV, therapeutic study.

Cost-efficacy of Knee Cartilage Defect Treatments in the United States.

BACKGROUND: Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. PURPOSE/HYPOTHESIS: The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years. STUDY DESIGN: Systematic review. METHODS: A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure. RESULTS: Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm2 to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm2 ($127,782) became cost-ineffective over 10 years. CONCLUSION: Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm2. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously.

Preoperative MRI underestimates articular cartilage defect size compared with findings at arthroscopic knee surgery.

BACKGROUND: Magnetic resonance imaging (MRI) is widely used as a preoperative tool to estimate the size of articular cartilage defects to optimize treatment selection. However, the reliability of MRI sizing of cartilage defects is not well understood. Hypothesis/ PURPOSE: The purpose of this investigation was to compare the size of knee articular cartilage defects on MRI to arthroscopic visualization after debridement. It was hypothesized that MRI sizing would produce measurements that were no different than those made during arthroscopic knee surgery. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Seventy-seven patients (age [mean ± SD], 38 ± 10.7 years) who met inclusion criteria underwent preoperative knee MRI of at least 1.5 T within 1 year of arthroscopic knee surgery for a high-grade cartilage defect. Postdebridement defect sizes were obtained from intraoperative surgery notes and compared with retrospective MRI estimates. RESULTS: Ninety-two total cartilage defects were analyzed with an average of 1.2 high-grade defects per knee and average postdebridement defect area of 2.99 cm(2) per lesion (95% CI, 1.63-2.26 cm(2)). Preoperative MRI analysis estimated a lesion area that was an average of 1.04 cm(2) smaller (95% CI, 0.70-1.39 cm(2); P < .0001). In 74% of the lesions analyzed, defect size was larger on arthroscopic visualization than was estimated by MRI sizing. On average, MRI underestimated the defect area by 70% compared with arthroscopic visualization. CONCLUSION: Magnetic resonance imaging underestimates the size of articular cartilage defects compared with final postdebridement size as measured during arthroscopic knee surgery. Thus, before arthroscopic surgery, orthopaedic surgeons should consider treatment strategies that are appropriate for a larger defect than predicted by preoperative MRI.

Inflammatory markers in intrauterine and fetal blood and cerebrospinal fluid compartments are associated with adverse pulmonary and neurologic outcomes in preterm infants.

Recent evidence strongly implicates the inflammatory response to intrauterine infection in the pathogenesis of neonatal brain and lung injury. We hypothesized that lung and brain injury in preterm infants occurs during a common developmental window of vulnerability as the result of an inflammatory response in different compartments. To determine whether inflammatory markers in these compartments are associated with bronchopulmonary dysplasia (BPD) or cranial ultrasound (CUS) abnormalities in infants <33 wk gestation age (GA) and <1501 g birth weight, we analyzed placental pathology and serum and cerebrospinal fluid (CSF) IL-6, IL-1beta, and tumor necrosis factor-alpha (TNF-alpha) concentrations in 276 infants. Logistic regressions were performed stratified by GA. Histologic chorioamnionitis was significantly associated with BPD in infants /=17 pg/mL was associated with an abnormal CUS in infants >28 wk GA (OR 3.36, p = 0.023) but not /=6.5 pg/mL and TNF-alpha >/=3 pg/mL were associated with abnormal CUS in infants /=28 wk GA. These data suggest that in infants