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STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery. SUMMARY OF BACKGROUND DATA: Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery. METHODS: We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT). RESULTS: We found that the use of TXA statistically significantly reduced total perioperative blood loss ( P =0.04) and postoperative drain output ( P =0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative ( P =0.02) and postoperative ( P <0.01) blood loss. CONCLUSIONS: This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors. LEVEL OF EVIDENCE: Level III.
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Pérdida de Sangre Quirúrgica , Vértebras Cervicales , Ácido Tranexámico , Humanos , Ácido Tranexámico/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Estudios Retrospectivos , Vértebras Cervicales/cirugía , Masculino , Femenino , Persona de Mediana Edad , Antifibrinolíticos/uso terapéutico , Anciano , AdultoRESUMEN
Purpose: To determine the prevalence of 4 different types of acetabular rim ossifications, including partial labral ossification or punctate calcification, true os acetabuli, acetabular rim stress fracture, and complete labral ossification, and to determine whether different types of periacetabular ossifications are linked to demographic or radiological factors. Methods: We retrospectively reviewed the medial records of patients presenting for hip-related complaints at 2 sports medicine practices from September 2007 to December 2009. An anteroposterior radiograph of both hips and a lateral radiograph of each hip was obtained for all patients and reviewed for findings of cam and pincer femoroacetabular impingement, degenerative changes (Tönnis grade), and periacetabular calcifications for both hips. These parameters were also evaluated with respect to symptoms, sex, and age. Results: Four hundred ninety-one consecutive patients (982 hips) presented to 2 orthopaedic surgeons at 2 centers for "hip"-related complaints. There were 223 males and 268 females (age 39 ± 14 years). The overall prevalence of periacetabular calcifications in hips was 17.6%, with 56.6% of calcifications in the symptomatic hip and 43.4% in the contralateral hip. Four basic patterns of calcification were identified: punctuate calcifications within the labrum (8.0% hips), large rounded calcifications (os acetabuli) (4.2% hip), large fragments with a vertical line of the superior-lateral acetabular rim, consistent with healed or non-healed stress fracture (2.0% hips), and complete ossification of the labrum (3.4% hips). Overall, male sex (P = .002), increased lateral center-edge angle (P = .046), and higher Tönnis grade (P < .001) statistically predicted the presence of periacetabular ossification. Punctate calcifications were more prevalent in males (P = .002). Higher Tönnis grade (P = .029) and increased alpha angle (P = .046) were more prevalent with os acetabuli. Younger age (P = .001), male sex (P = .048), increased alpha angle (P = .012), and increased lateral center-edge angle (P < .001) were more prevalent in acetabular rim fractures. No factors were statistically significant at predicting the presence of an ossified labrum. Conclusions: Periacetabular calcifications are not uncommon. Four particular patterns of calcification are identified: punctate labral calcifications (8%), larger rounded calcifications (i.e., os acetabuli) (4.2%), acetabular rim stress fractures (2%), and complete ossification of the labrum (3.4%) for a combined prevalence of 17.6% in patients presenting to an orthopaedic surgeon with "hip"-related complaints. Nearly half were in the asymptomatic hip. Male sex had a higher prevalence of periacetabular calcifications. An increased lateral center edge angle and higher Tönnis grade also had a higher prevalence of periacetabular calcifications. Younger male patients are more likely to have acetabular rim stress fractures. Patients with an increased alpha angle have a higher prevalence of os acetabuli and rim stress fractures. Clinical Relevance: This study aims to identify, quantify, and categorize periacetabular calcifications about the hip. Their clinical relationships and relevance have been discussed, but no study has distinctly categorized the various types and their prevalence. This study provides a framework for identification and categorization.
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Background: Hip microinstability is an increasingly recognized cause of pain and disability in young adults. It is unknown whether differences in passive hip range of motion (ROM) exist between patients with versus without hip microinstability. Hypothesis: Underlying ligamentous and capsular laxity will result in differences in clinically detectable passive ROM between patients with femoroacetabular impingement (FAI), patients with microinstability, and asymptomatic controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of all patients undergoing hip arthroscopy between 2012 and 2018 was conducted. Patients with a diagnosis of isolated microinstability based on intraoperative findings were identified and classified as having isolated FAI, instability, or FAI + instability. Patients without a history of hip injury were included as controls. Range of motion was recorded in the supine position for flexion, internal rotation, and external rotation. Univariate and multivariate analysis was performed on each measurement in isolation as well as combinations of motion to include total rotation arc, flexion + rotation arc, and flexion + 2× rotation arc Models were then created and tested to predict instability status. Results: In total, 263 hips were included: 69 with isolated instability, 50 with FAI, 50 with FAI + instability, and 94 control hips. A higher proportion of patients in the instability and FAI + instability groups were female compared with the FAI and control groups (P < .001). On univariate analysis, differences were found in all groups in all planes of motion (P < .001). Multivariable analysis demonstrated differences in all groups in flexion and flexion + rotation arc. In symptomatic patients, the best performing predictive model for hip microinstability was flexion + rotation arc ≥200° (Akaike information criterion, 132.3; P < .001) with a sensitivity of 68.9%, specificity of 80.0%, positive predictive value of 89.1%, and negative predictive value of 51.9%. Conclusion: Patients with hip microinstability had significantly greater ROM than symptomatic and asymptomatic cohorts without hip microinstability. Symptomatic patients with hip flexion + rotation arc ≥200° were highly likely to have positive intraoperative findings for hip microinstability, whereas instability status was difficult to predict in patients with a flexion + rotation arc of <200°.
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PURPOSE: Hip microinstability has emerged as a contributor to young adult, non-arthritic hip pain. There is a paucity of objective clinical data to identify patients with hip microinstability and guide surgical treatment. The purpose of this study was to identify the degree of distractibility in patients with and without microinstability undergoing hip arthroscopy. METHODS: A single-surgeon series of hip arthroscopies were retrospectively reviewed from 2014-2020. All procedures were performed with paralysis on a fracture table with a perineal post where 1 turn of fine traction equates to 4 mm of axial traction. Diagnosis was recorded as isolated instability, instability plus femoroacetabular impingement (FAI), and isolated FAI. Operative reports were reviewed to collect patient demographic data, number of turns of traction required for adequate distraction of the femoral head relative to the acetabulum (10 mm), and the presence of residual subluxation after initial traction was released. RESULTS: A total of 464 patients were identified, 26 (5.6%) with isolated microinstability, 183 (39.4%) with microinstability with FAI anatomy, and 255 (55.0%) with FAI. The concurrent diagnosis of microinstability was associated with decreased turns required to adequately distract the hip. Isolated microinstability patients required 6.9 turns (IQR 4.6-8.8) while those with instability plus FAI required 8.8 turns (IQR 6.5-11) and isolated FAI required 19.1 turns (IQR 15-22). Residual subluxation after removal of negative intra-articular pressure but before performing the hip arthroscopy was more commonly associated with instability, occurring in 84.6% of isolated instability and 86.9% of instability plus FAI as compared with 29.8% in the isolated FAI cohort. CONCLUSION: A diagnosis of hip microinstability, with or without features of FAI, is associated with decreased axial traction required to distract the hip. These data support the use of intra-operative ease of distraction as a method of identifying patients with hip microinstability. LEVEL OF EVIDENCE: Level III.
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Pinzamiento Femoroacetabular , Articulación de la Cadera , Adulto Joven , Humanos , Articulación de la Cadera/cirugía , Estudios Retrospectivos , Acetábulo/cirugía , Pinzamiento Femoroacetabular/diagnóstico , Pinzamiento Femoroacetabular/cirugía , Tracción , Artroscopía/métodosRESUMEN
PURPOSE: To identify factors associated with ease of hip distraction at the time of hip arthroscopy. METHODS: A retrospective review of patients 17-50 years old undergoing hip arthroscopy with a single high-volume hip arthroscopist was performed from 2014 to 2020. Demographics, clinical history, examination, and imaging findings were collected. Distractibility was quantified using turns of fine traction (1 turn = 4 mm axial distraction) with the patient paralyzed on a fracture table with a well-padded perineal post Fine axial traction was applied after the patient's perineum contacted the post. Demographic and clinical predictors of ease of distractibility were analyzed with simple linear regression models. Significant predictors were subsequently added to a multivariable linear regression model, estimating the effect of each variable. RESULTS: In total, 453 patients were included, with an average age of 31.6 years (± 9.2) and 45.9% females. In univariate analysis, gender, race, BMI, range of motion, hyperextension-external rotation (HEER) test, the abduction-extension-external rotation test, and lateral center edge angle (LCEA) were associated with the number of fine traction turns required to distract the hip. On multivariable analysis, lower LCEA (p = 0.002), female gender (p < 0.001), and a positive HEER test (p = 0.045) were associated with decreased turns required for adequate hip distraction. CONCLUSION: Female gender, decreased LCEA, and a positive HEER test are associated with decreased axial traction required for adequate hip distraction at the time of hip arthroscopy. As ease of distractibility has been associated with hip microinstability, these findings may allow pre-operative identification of hip instability patients and aid in pre-operative counseling, risk stratification and capsular management planning. LEVEL OF EVIDENCE: IV. CLINICAL RELEVANCE: Preoperative identification of risk factors for ease of hip distraction may raise pre-surgical suspicion and, when coupled with other intraoperative findings, may aid in the diagnosis and management of hip microinstability.
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Artroscopía , Pinzamiento Femoroacetabular , Adolescente , Adulto , Artroscopía/métodos , Femenino , Pinzamiento Femoroacetabular/cirugía , Articulación de la Cadera/cirugía , Humanos , Masculino , Persona de Mediana Edad , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.
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Enfermedades Transmisibles , Medicina Deportiva , Cirujanos , Desbridamiento , Humanos , Complicaciones PosoperatoriasRESUMEN
Microinstability is an increasingly recognized diagnosis in young athletes presenting with hip pain. Causes of microinstability may include abnormality of the hip bony anatomy, acetabular labral tears, joint capsule laxity or injury, and muscle dysfunction. Borderline hip dysplasia is an increasingly recognized factor predisposing to microinstability. The capsuloligamentous structures of the hip, particularly the iliofemoral ligament, provide important restraints to femoral head motion, and iatrogenic defects can predispose patients to instability after surgery. Injury to the acetabular labrum may disrupt its important hip-stabilizing properties including the suction seal and improved acetabular depth. Hip muscle weakness or imbalance may result in increased femoral head motion within the acetabulum. The diagnosis of hip microinstability can be challenging, and the history is often nonspecific. Physical examination maneuvers include the anterior apprehension, prone instability, axial distraction, and abduction-hyperextension-external rotation tests. Radiographic features may include borderline hip dysplasia, femoral head-neck junction cliff sign, and an elevated femoral-epiphyseal acetabular roof index. Magnetic resonance arthrography may demonstrate a capsular defect, capsular thinning, or labral pathology. Diagnostic intra-articular injection of anesthetic can confirm the intra-articular nature of the pathology. Management of hip microinstability focuses on strengthening the dynamic stabilizers of the hip through focused physical therapy. Surgery may be considered in recalcitrant cases where symptoms persist despite optimization of hip stabilizer strength. In such cases, addressing the primary source of instability through labral repair or reconstruction and capsular repair or plication can be considered. In highly selected cases, surgery can result in excellent outcomes.
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Luxación de la Cadera , Articulación de la Cadera , Acetábulo/cirugía , Atletas , Cabeza Femoral , Luxación de la Cadera/cirugía , Articulación de la Cadera/diagnóstico por imagen , Articulación de la Cadera/cirugía , HumanosRESUMEN
BACKGROUND: Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of .05 was set as significant. RESULTS: The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001). CONCLUSION: When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.
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Artroplastía de Reemplazo de Hombro , Infecciones Relacionadas con Prótesis , Articulación del Hombro , Adulto , Anciano , Antibacterianos/uso terapéutico , Artroplastia/efectos adversos , Artroplastía de Reemplazo de Hombro/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Rango del Movimiento Articular , Reoperación/métodos , Estudios Retrospectivos , Terapia Recuperativa , Hombro/cirugía , Articulación del Hombro/cirugía , Resultado del TratamientoRESUMEN
PURPOSE: The purpose of this study was to evaluate the relationship between patient-specific factors, preoperative radiographic findings, and the presence and severity of chondrolabral damage identified during hip arthroscopy for femoroacetabular impingement. METHODS: Between 2014 and 2017, patients who underwent hip arthroscopy for FAI and labral tear were retrospectively reviewed. Patient-specific variables including age, gender, BMI, LCEA, and alpha angle were collected. Surgical reports were reviewed for labral tear position and size, as well as severity of acetabular and femoral chondromalacia. RESULTS: There were 205 patients who met inclusion criteria with a mean age of 33 years (range 15-66), BMI 26.5 (range 15.9-44.5), LCEA 32.2° (range 21.0°-56.0°) and alpha angle 59.1° (range 33.0°-86.0°). Greater age (p = 0.023), alpha angle (p = 0.011) and male gender (p < 0.001) significantly correlated with high-grade acetabular chondral damage. Increased LCEA (p < 0.001), increased alpha angle (p = 0.012), and greater age (p = 0.002) were significantly associated with increased labral tear size. CONCLUSIONS: Greater age, male gender, increased BMI and increased alpha angle were associated with more advanced acetabular chondromalacia. Additionally, greater age, increased LCEA, and increased alpha angle was associated with larger labral tear size. LEVEL OF EVIDENCE: IV.
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Acetábulo/patología , Enfermedades de los Cartílagos/patología , Pinzamiento Femoroacetabular/patología , Fémur/patología , Acetábulo/diagnóstico por imagen , Adolescente , Adulto , Factores de Edad , Anciano , Artroscopía , Índice de Masa Corporal , Enfermedades de los Cartílagos/diagnóstico por imagen , Femenino , Pinzamiento Femoroacetabular/diagnóstico por imagen , Pinzamiento Femoroacetabular/cirugía , Fémur/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores Sexuales , Adulto JovenRESUMEN
BACKGROUND: Femoroacetabular impingement (FAI) syndrome is a common source of hip pain associated with chondrolabral injury. There is a subset of patients with FAI syndrome who present with radiopaque densities (RODs) adjacent to the acetabular rim. PURPOSE: To evaluate the prevalence, characteristics, and patient-specific factors associated with RODs adjacent to the acetabulum in patients treated with hip arthroscopy for symptomatic FAI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between November 2014 and March 2018, a total of 296 patients who underwent hip arthroscopy for FAI with a labral tear were reviewed retrospectively. Patient-specific variables were collected, including age, sex, lateral center-edge angle (LCEA), and alpha angle. Imaging (computed tomography) and surgical reports were reviewed for the location and characteristics of RODs, as well as subsequent labral treatment technique. Patients were excluded if they were treated for extra-articular hip pathology, had a revision procedure, or had a diagnosis other than FAI with a labral tear. No patient was excluded for any history of systemic inflammatory disease. Binary logistic regression was used to compare age, LCEA, and alpha angle for patients with or without radiopaque fragments. An alpha level of 0.05 was used to indicate statistical significance. RESULTS: A total of 204 patients met inclusion criteria; 33 patients (16.2%; 16 males, 17 females) had para-acetabular RODs. There were no statistically significant differences in age (P = .82), sex (P = .92), LCEA (P = .24), or alpha angle (P = .10) among patients with or without an ROD. Of the 33 patients, 29 (87.9%) had fragments in the anterosuperior quadrant. Overall, 31 patients (93.9%) were treated with labral repair in addition to correction of the underlying bony impingement, while 2 patients (6.1%) underwent focal labral debridement owing to poor labral tissue quality around the RODs. Twenty-five patients (76%) had identifiable RODs, which were excised at the time of surgery. The mean (± SD) ROD size measured on axial and coronal computed tomography imaging was 6.3 ± 5.5 mm and 4 ± 4.5 mm, respectively. CONCLUSION: Age, sex, LCEA, and alpha angle were not predictive of the presence of para-acetabular RODs. Approximately one-sixth of all patients with FAI had RODs identified on computed tomography, which were typically located at the anterosuperior acetabulum. The majority of hips with para-acetabular RODs were amenable to labral repair. The relative prevalence and lack of predictive patient-specific indicators for these fragments suggest that a high degree of suspicion is necessary when evaluating patients with FAI.
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CASE: Few cases have reported Clostridium species of bacteria as a source for vertebral osteomyelitis and epidural abscesses. The subspecies of Clostridium septicum has not been described as a cause. This case describes a 69-year-old man who hematogenously spread C. septicum without associated malignancy, subsequently failed conservative management in the form of intravenous antibiotics, and was definitively treated with surgical intervention through a minimally invasive approach. CONCLUSIONS: An epidural abscess occurring in a surgically naive patient is a rare phenomenon. An epidural abscess caused by C. septicum is even rarer. Appropriate imaging, early recognition, and surgical debridement can lead to a favorable outcome.
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Infecciones por Clostridium/complicaciones , Clostridium septicum/aislamiento & purificación , Absceso Epidural/microbiología , Anciano , Infecciones por Clostridium/diagnóstico por imagen , Absceso Epidural/diagnóstico por imagen , Humanos , Dolor de la Región Lumbar/etiología , Imagen por Resonancia Magnética , MasculinoRESUMEN
PURPOSE: To evaluate the impact of the portal used for drilling, the position of the drill guide on the acetabular rim, and the use of straight versus curved drill guides on drill perforation of the acetabular subchondral bone and the outer cortex of the acetabulum. METHODS: Sixty acetabular models were marked at the 3-, 2-, 1-, 12-, and 11-o'clock positions. Simulated anterior, anterolateral, and distal anterolateral accessory (DALA) portals were created. Twelve groups of 5 acetabula were drilled at each clock-face position using all combinations of variables. RESULTS: A total of 38 of 300 drillings (12.7%) perforated the subchondral bone, and 45 of 300 (15%) breached the outer cortex. Drilling from the anterior, anterolateral, and DALA portals perforated the acetabular subchondral bone on 21 of 100 attempts (21%), 17 of 100 attempts (17%), and 0 of 100 attempts (0%), respectively (P < .001), and perforated the outer acetabular cortex on 36 of 100 attempts (36%), 1 of 100 attempts (1%), and 8 of 100 attempts (8%), respectively (P < .001). The use of a curved or straight drill guide did not make a statistically significant difference. Drilling with a starting point on the acetabular rim perforated the acetabular subchondral bone on 29 of 150 attempts (19.3%) compared with 9 of 150 attempts (6%) when the starting point was 2 mm removed from the acetabular rim (P < .001). CONCLUSIONS: The use of the DALA portal and a drill starting point slightly off the acetabular rim was associated with the lowest rate of acetabular subchondral perforation and is recommended to reduce the risk of iatrogenic chondral injury. CLINICAL RELEVANCE: Iatrogenic chondral injury is a relatively common complication of hip arthroscopy. Increased awareness of factors associated with drill perforation during suture anchor placement can help surgeons mitigate this risk.