The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study.

INTRODUCTION: Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients. METHODS: This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs. RESULTS: A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score. CONCLUSIONS: The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

The increased utilization of operating room time in patients with increased BMI during primary total hip arthroplasty.

While obesity is associated with increased need for total hip arthroplasty (THA), the relationship between body mass index (BMI) and operative duration is unknown. We reviewed a series of 425 primary THAs implanted by one surgeon from 2004 to 2010. Patients were grouped by BMI based on the World Health Organization's categorization. Intraoperative time measurements (Total Room Time, Anesthesia Induction Time, Surgery Time) were compared across groups. Mean times were analyzed using a one-way ANOVA with post-hoc least squares difference test. Operating time increased progressively with increasing BMI category. Significant differences were found between normal weight patients and all 3 obesity groups in total room and surgery times. Obese patients spend more time in the OR during THA, reflecting the burden obesity poses to surgeons and hospitals.

Rates of Operative Management for Achilles Tendon Rupture Over the Last Decade and the Influence of Gender and Age.

BACKGROUND: With emerging evidence supporting functional rehabilitation for Achilles tendon ruptures (ATRs), this study sought to evaluate the treatment trends for patients sustaining an acute ATR and whether gender and age may influence the rates of operative repair. METHODS: A retrospective database review identified ATRs from 2010 through 2019. Patients were then stratified into three cohorts based on age (18-30, 30-45, and 46 and older), separated by gender, and then assessed whether patients were treated operatively or not. Cochran-Armitage Trend test was performed to analyze the trends of operative management. Chi-square analyses were performed to assess whether the proportion of patients who received operative management in each age cohort differed from 2010 to 2019. Logistic regression analyses were performed to assess whether gender influenced treatment. RESULTS: Over the previous decade, the total rates of operative treatment for ATR significantly decreased (18.3%-12.3%, P < .0001). Each individual age cohort experienced a proportional decrease in operative management when comparing 2010 with 2019 (all P < .0001). Within all age cohorts, males were significantly more likely to receive operative treatment for an ATR over the previous decade (odds ratios: 2.63-3.22). Conclusion. Overall rates of operative management for ATR decreased across all cohorts likely due to previous studies providing evidence of similar results between operative and nonoperative managements. Over the previous decade, males were demonstrated to be far more likely than females to undergo operative management. Why females are less likely to receive an operation for ATR is likely multi-factorial and requires further exploration. LEVEL OF EVIDENCE: Level III: Retrospective comparative study.

A Rare Case of a Lisfranc Ligament Transection.

Ligamentous Lisfranc injuries, which mimic a surgical transection are rare. Left untreated or missed, these injuries may result in severe complications including long-term disability. The present case describes a unique mechanism of injury via a sharp object puncture through the plantar surface of the midfoot. It highlights the utility of planning staged procedures to remove a large foreign body object, reports notable intraoperative techniques, and provides a decision management guide for treating this type of injury. Extensive surgical planning may be required when encountering similar cases and knowledge of this may be useful to providers.

Increased operating room time in patients with obesity during primary total knee arthroplasty: conflicts for scheduling.

Obesity is associated with increased complications related to total knee arthroplasty (TKA), but the relationship between body mass index (BMI) and operating room time during TKA is unknown. A total of 454 unilateral primary TKAs (2005-2009) were reviewed and categorized by BMI (normal weight, 18.5-25 kg/m(2); overweight, 25-30 kg/m(2); obese class I, 30-<35 kg/m(2); class II, 35-40 kg/m(2); class III, >40 kg/m(2)). Intraoperative time measurements (total room time, anesthesia induction time, tourniquet time, closing time, surgery time) were compared across the BMI groups. Comparing normal weight to obese class III, time differences were significant in total room time (24 minutes, P < .01), surgery time (16 minutes, P < .01), tourniquet time (7.5 minutes, P < .01), and closure time (8 minutes, P < .01). Armed with this information, BMI can be used to better allocate operating room time for TKA.

Vascularity of the early post-natal human distal femoral chondroepiphysis: Quantitative MRI analysis.

Purpose: Injury to or abnormality of developing distal femoral chondroepiphysis blood supply has been implicated in osteochondritis dissecans development. Progressive decrease in epiphyseal cartilage blood supply occurs in normal development; however, based on animal studies, it is hypothesized that there is greater decrease in regions more prone to osteochondritis dissecans lesions. We aimed to quantify differential regional perfusion of the immature distal femoral chondroepiphysis. We hypothesized there is decreased perfusion in the lateral aspect of the medial femoral condyle, the classic osteochondritis dissecans lesion location. Methods: Five fresh-frozen human cadaveric knees (0-6 months old) were utilized. The superficial femoral artery was cannulated proximally and contrast-enhanced magnetic resonance imaging performed using a previously reported protocol for quantifying osseous and soft tissue perfusion. Regions of interest were defined, and signal enhancement changes between pre- and post-contrast images, normalized to background muscle, were compared. Results: When comparing average normalized post-contrast signal enhancement of whole condyles, as well as distal, posterior, and inner (toward the notch) aspects of the medial and lateral condyles, no significant perfusion differences between condyles were found. In the medial condyle, no significant perfusion difference was found between the medial and lateral aspects. Conclusion: We quantified immature distal femoral chondroepiphysis regional vascularity in the early post-natal knee. In specimens aged 0-6 months, no distinct watershed region was detected. Despite possible limitations, given small sample size, as well as resolution of magnetic resonance imaging and analysis, our results suggest the hypothesized vascular abnormality predisposing osteochondritis dissecans either does not occur universally or occurs after this developmental age.

Effect of body mass index on range of motion and manipulation after total knee arthroplasty.

This study evaluates the effects of increased body mass index (BMI) on postoperative range of motion (ROM) and rate of manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) in 391 primary TKAs. Range of motion and incidence of MUA were retrospectively collected and compared between 4 BMI groups (I, BMI <25; II, BMI 25-29.9; III, BMI 30-34.9; IV, BMI >35) using χ(2) or Fisher exact tests. Patients with higher BMIs had a greater incidence of MUA (I, 9.7%; II, 19%; III, 20%; IV, 15%) and lower preoperative and postoperative ROM. Women had lower ROM and a higher rate of MUA. Age was not a significant predictor of ROM or rate of MUA. Patients at greater risk of complications after TKA should be counseled about realistic surgical outcomes.

Arthroscopic-Assisted Removal of Proximal Humerus Locking Plates With Capsular Release Significantly Improves Range of Motion and Function.

PURPOSE: To investigate the clinical outcomes following the arthroscopic removal of proximal humerus locking plates for symptomatic hardware after open reduction and internal fixation (ORIF) of proximal humerus fractures. METHODS: Patients who underwent arthroscopic removal of hardware (ROH) with capsular release due to pain and/or immobility after receiving locking plates to treat proximal humerus fractures from 2009 to 2016 were identified. Operative and clinic records were reviewed to obtain demographic information, concomitant procedures during ROH, and pre- and postoperative active shoulder range of motion. Postoperative patient-reported outcomes included the QuickDASH, PROMIS Pain Intensity, Constant, and University of California, Los Angeles shoulder rating scale. RESULTS: In total, 88 patients were included. Patients were evaluated at a minimum of 6 weeks postoperatively after ROH. Patients with pre- and postoperative active range of motion values demonstrated significant improvements in mean forward elevation (n = 69; 78.4%; 115.1° to 152.1°, P < .001), abduction (n = 29; 33.0%; 70.9° to 138.7°, P < .001), external rotation (n = 49; 55.7%; 43.7° to 58.6°, P = .012), and internal rotation (n = 45; 51.1%; 25.7° to 61.9°, P < .001). Patients also reported positive patient-reported scores, including the QuickDASH (4.1 ± 7.8), PROMIS Pain Intensity (3.5 ± 0.9), Constant (84.6 ± 10.7), and University of California, Los Angeles shoulder rating scale (33 ± 2.9), which were measured 70.6 ± 26.6 months postoperatively. There were no surgical complications, no arthroscopic cases were converted to open, but 2 reported refractures (2.3%). CONCLUSIONS: Arthroscopic-assisted removal of proximal humerus locking plates significantly improves motion and function while allowing for management of concomitant shoulder pathology and potentially avoiding open surgery complications. Given that patients undergoing this procedure frequently have multiple comorbidities, arthroscopic-assisted removal with smaller incisions may minimize risks while restoring shoulder mobility. Therefore, arthroscopic ROH for patients experiencing symptomatic hardware after ORIF is recommended. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Increased Vascularity in the Neonatal versus Adult Meniscus: Evaluation with Magnetic Resonance Imaging.

Objective. Quantification of meniscus vascularity has been limited with previous techniques, and minimal data exist describing differential vascular zones in the skeletally immature meniscus. The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in neonatal specimens with adults. We hypothesized that the developing meniscus has greater and more uniform vascularity throughout all zones. Design. Ten fresh-frozen human cadaveric knees (5 neonatal, age 0-6 months; 5 adult, 34-67 years) underwent gadolinium-enhanced MRI using an established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement within the same regions (normalized against background tissue) was compared between pre- and post-contrast images. Results. The medial and lateral menisci had similar distribution of perfusion (45.8% ± 8.1% medial vs. 54.2% ± 8.1% lateral in neonatal knees; 50.6% ± 11.3% medial vs. 49.4% ± 11.3% lateral in adult knees, P = 0.47). Increased perfusion was demonstrated in the periphery compared with the central zone (2.3:1 in neonatal knees and 3.25:1 in adult knees, P = 0.31). Neonatal specimens demonstrated 6.0-fold greater overall post-contrast meniscal signal enhancement compared with adults (P < 0.0001), with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusions. While blood flow to the periphery is greater than to central zones in all menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including to the central zone, suggesting that the immature meniscus is a more biologically active tissue than its adult counterpart.

Quantitative assessment of the vascularity of the skeletally immature patella: a cadaveric study using MRI.

PURPOSE: While predominant blood supply to the adult patella enters inferomedially, little is known about skeletally immature patellar perfusion. Improved knowledge of immature patella vascularity can further understanding of osteochondritis dissecans, dorsal defects of the patella and bipartite patella, and help ensure safe surgical approaches. We hypothesized that the immature patella would exhibit more uniform blood flow. The study purpose was to quantify immature patella regional perfusion in comparison with adults. METHODS: Ten cadaveric knees were utilized (five immature, five mature). The superficial femoral artery was cannulated proximally. Signal enhancement increases were compared from pre- to post-contrast MRI to assess relative arterial contributions to patella regions (quadrants, anterior/posterior, superior/inferior, medial/lateral, and outer/inner). RESULTS: Quantitative-MRI analysis revealed similar distribution of enhancement between the immature and mature patella. The inferior pole exhibited significantly higher arterial contribution versus superior pole in both immature and mature groups (p = 0.009; both groups), while the inferomedial quadrant had the highest arterial contribution of all quadrants in both groups. The superolateral quadrant demonstrated the lowest arterial contribution in the immature group and second lowest in the adult group. The patella outer periphery had significantly greater arterial contribution than the inner central region in both immature (p = 0.009) and mature (p = 0.009) groups. CONCLUSION: Distribution of arterial contributions between the immature and mature patella was similar. Our results highlight the importance of inferior and inferomedial blood supply in both immature and mature patellas. These findings have implications for paediatric and adult patients; surgical damage to inferior patellar vessels should be avoided to prevent associated complications.

Endosteal Vasculature Dominates Along the Tibial Cortical Diaphysis: A Quantitative Magnetic Resonance Imaging Analysis.

OBJECTIVE: Disrupted blood supply has been proposed as an underlying cause for delayed union in tibial shaft fractures (OTA/AO 42). Although tibial blood supply has been qualitatively evaluated, quantitative studies are lacking. The purpose of this project was to quantify the relative contribution of the endosteal supply to the tibial diaphysis. METHODS: The superficial femoral artery of 8 fresh frozen cadaveric matched pair lower extremities was cannulated. The nutrient artery was ligated at its proximal branch point in experimental limbs. Pregadolinium and postgadolinium enhanced magnetic resonance imaging was performed with high resolution fat-suppressed ultrashort echo time magnetic resonance imaging sequences. Perfusion was assessed in 3 zones (outer, central, and inner cortex) for the proximal, middle, and distal diaphysis, respectively, using custom software to quantify and compare signal intensity between experimental and control limbs. RESULTS: On average, the endosteal system supplied 91.4% (±3.9%) of the cortex and was the predominant blood supply for the inner, central, and outer thirds. The dominance of the endosteal contribution was most pronounced in the inner two-third of the cortex, with more than 97% loss of perfusion. Disruption of the nutrient artery also resulted in 76.3% (±11.2%) loss of perfusion of the outer one-third of the cortex. CONCLUSION: This quantitative study revealed a predominance of endosteal blood supply to all areas (inner, middle, and outer thirds) of the tibial diaphyseal cortex. To prevent delayed bone healing, surgeons should take care to preserve the remaining periosteal vascular network in fracture patterns in which the nutrient artery has likely been disrupted.

The effects of dual plating on the vascularity of the distal femur.

AIMS: Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. METHODS: A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. RESULTS: Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. CONCLUSION: Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530-538.

Femoral Head Vascularity: Implications Following Trauma and Surgery About the Hip.

Traumatic injury and surgical intervention about the hip joint place the arterial supply to the femoral head (FH) at risk. Compromised perfusion may lead to FH ischemia, cell death, and osteonecrosis. Progression to FH collapse may lead to pain, functional impairment, and decreased quality of life, especially in younger patients. This review describes the arterial supply to the FH, analyzes the impact of femoral neck fractures on FH vascularity, and explores the vascular implications of various surgical interventions about the hip, offering specific techniques to minimize iatrogenic damage to the vessels supplying the FH. [Orthopedics. 2019; 42(5):250-257.].

Two cases of brachial plexus compression secondary to displaced clavicle fractures.

Brachial plexus compression is a rare complication of displaced clavicle fractures, with few reports existing in the literature. Neurologic symptoms can present immediately after the injury or in a delayed fashion months later. Following polytrauma, two patients presented with displaced middle-third left clavicle fractures initially treated conservatively at other institutions. Both patients developed neurologic symptoms in the left upper extremity consistent with brachial plexus compression. Magnetic resonance imaging and electrodiagnostic testing were used to help confirm the diagnosis of thoracic outlet syndrome/brachial plexopathy, and both patients underwent open reduction internal fixation with dual plating, local bone grafting and brachial plexus decompression. Both patients experienced successful relief of neurologic symptoms postoperatively. The purpose of this case series is to report on a rare complication of delayed- and non-united clavicle fractures and describe successful treatment with a novel fracture fixation construct.

Outcomes of Surgical Treatment of Periprosthetic Acetabular Fractures.

Periprosthetic acetabular fractures sustained following acute trauma after total hip arthroplasty are rare and historically have poor outcomes. This article reviews 5 cases and the treatment algorithm used by a single orthopaedic surgeon specializing in acetabular fracture care with a co-surgeon specializing in arthroplasty. Team-based surgical management with arthroplasty- and fracture-trained surgeon(s) is paramount for optimal outcome. The following approach resulted in satisfactory outcomes without need for revision implants. In fracture patterns with columnar involvement, the columns were restored with plates and screws. In fracture patterns with wall involvement, the acetabular component functioned as a template for wall reconstruction with use of a buttress plate. The acetabular component was revised when deemed loose during stress of the component through the surgical approach used for fracture fixation.