Total Hip Arthroplasty in Patients With Sickle Cell Disease: A Comprehensive Systematic Review.

BACKGROUND: Total hip arthroplasty (THA) is a common treatment for end-stage osteonecrosis of the hip in patients with sickle cell disease (SCD). This patient population presents unique challenges in the perioperative period. This systematic review aims to investigate the existing literature on the outcomes, complications, and survivorship of primary THA in SCD patients. METHODS: A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed of PubMed, MEDLINE, EMBASE, and Cochrane databases for clinical studies on THA in SCD patients. Studies on primary THA in SCD patients with a mean follow-up greater than 90 days were included. RESULTS: Sixteen studies containing 5193 SCD patients met criteria for inclusion. The Coleman Quality of Evidence score ranged from poor to moderate. SCD patients had a significant increase in Harris Hip Scores and Merle d'Aubigne Scores after undergoing THA. Compared to non-SCD patients, SCD patients had increased hospital length-of-stay, 30-day and 90-day readmission rates, and rates of medical complications, including pain crises, acute chest syndrome, cardiac complications, sepsis, and mortality. SCD patients also had increased rates of surgical complications, including wound complications, infection, periprosthetic fracture, and aseptic loosening. Overall, THA revision rates were higher in SCD patients relative to those with primary osteoarthritis. CONCLUSION: THA remains an effective treatment modality for osteonecrosis of the hip in SCD patients. However, these patients are at increased risk of medical and surgical complications. Surgeons should be aware of the unique challenges in this patient population when counseling and managing these patients in the perioperative period.

The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review.

PURPOSE: There is a wide array of device modalities available for post-operative treatment following arthroscopic knee surgery; however, it remains unclear which types and duration of modality are the most effective. This systematic review aimed to investigate the efficacy of device modalities used following arthroscopic knee surgery. METHODS: A systematic search of the literature was performed on: PubMed; Scopus; MEDLINE; EMBASE; PEDro; SportDiscus; and CINAHL databases (1995-2015) for clinical trials using device modalities following arthroscopic knee surgery: cryotherapy, continuous passive motion (CPM), neuromuscular electrical stimulation (NMES), surface electromyographic (sEMG) biofeedback and shockwave therapy (ESWT). Only level 1 and 2 studies were included and the methodological quality of studies was evaluated using Physiotherapy Evidence Database (PEDro) scores. Outcome measures included: muscle strength, range of motion, swelling, blood loss, pain relief, narcotic use, knee function evaluation and scores, patient satisfaction and length of hospital stay. RESULTS: Twenty-five studies were included in this systematic review, nineteen of which found a significant difference in outcomes. For alleviating pain and decreasing narcotic consumption following arthroscopic knee surgery, cryocompression devices are more effective than traditional icing alone, though not more than compression alone. CPM does not affect post-operative outcomes. sEMG biofeedback and NMES improve quadriceps strength and overall knee functional outcomes following knee surgery. There is limited evidence regarding the effects of ESWT. CONCLUSION: Cryotherapy, NMES and sEMG are recommended for inclusion into rehabilitation protocols following arthroscopic knee surgery to assist with pain relief, recovery of muscle strength and knee function, which are all essential to accelerate recovery. CPM is not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee range of motion, and additional studies are required to investigate the effects of ESWT. LEVEL OF EVIDENCE: II.

Erratum to 'Total Hip Arthroplasty in An Adult Patient With Pelvic Dysmorphism, Unilateral Sacroiliac Joint Autofusion, and Developmental Hip Dysplasia' [Arthroplasty Today 6 (2020) 41-47].

[This corrects the article DOI: 10.1016/j.artd.2019.10.006.].

A systematic review of the effect of regional anesthesia on diagnosis and management of acute compartment syndrome in long bone fractures.

PURPOSE: Peripheral nerve blockade (PNB) is a useful tool for pain control in the perioperative period. However, there are significant concerns about the use of PNBs following acute orthopaedic trauma due to the theoretical risk of masking acute compartment syndrome (ACS). This study aims to systematically review the effects of PNBs on diagnosis of ACS following long bone fractures. METHODS: A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Six studies, all of which were single-patient case reports, met criteria for inclusion in this review. Two studies reported a delay in diagnosis of ACS in the setting of PNB use, while four studies did not. CONCLUSIONS: Due to the low incidence of ACS, there is a paucity of literature available on ACS following PNB use in the setting of orthopedic trauma. There is no consensus in the literature about the safety of PNB use in the setting of acute long bone fractures, and this review could draw no conclusions from the literature, as the level of evidence is limited to case reports. PNBs should be administered to orthopedic trauma patients only in strictly controlled research environments, and surgeons should be highly cautious about using PNBs for orthopedic long bone fractures, particularly in cases at increased risk for developing ACS.

A comparison of the Functional Movement ScreenTM and the Landing Error Scoring System: A cohort study.

The Functional Movement Screen (FMSTM) is a nonspecific movement pattern assessment while the Landing Error Scoring System (LESS) is a screen for movement patterns associated with lower extremity injury. The purpose of this study was to determine if the LESS and FMSTM are correlated or if they can be used as complementary assessments of preseason injury risk for anterior cruciate ligament injury. METHODS: FMSTM and LESS were used to conduct a cohort study of 126 male National Collegiate Athletic Association Division IA football players. One hundred and eleven players met the criteria for inclusion during data review. At risk and not at risk LESS scores of players and FMSTM exercise score status were compared using Welch's t-test. Associations between FMSTM composites and LESS scores were evaluated using linear regression. RESULTS: The average LESS score was 5.51±1.34, and the average composite FMSTM score was 11.77±2.13 (max=15). A poor FMSTM squat score (≤1 or asymmetry present) was associated with a higher LESS score (P<0.001). No other FMSTM individual exercise score was associated with an at-risk LESS score (P>0.05). Composite FMSTM score was loosely associated with the LESS score (R-squared=0.0677, P=0.006). Prior history of an ACL injury and player position were not associated with LESS score on multivariate regression (P>0.05). CONCLUSIONS: The LESS and FMSTM are not well correlated and may serve as complementary assessments for preseason injury risk. LEVEL OF EVIDENCE: Level III.

Total hip arthroplasty in an adult patient with pelvic dysmorphism, unilateral sacroiliac joint autofusion, and developmental hip dysplasia.

This case describes the challenges associated with total hip arthroplasty in a patient with unique anatomy, including developmental dysplasia of the hip, pelvic dysmorphism, and unilateral sacroiliac joint autofusion. A 30-year-old female, with a history of developmental dysplasia of the hip treated with presumed pelvic osteotomy complicated by postoperative infection, presented with hip pain refractory to conservative management. Radiographic studies demonstrated a 10-cm leg length discrepancy, 20° of acetabular retroversion, severe hemipelvic dysmorphism, ipsilateral sacroiliac joint autofusion, and significant femoral head dysplasia. Total hip arthroplasty was performed using a revision acetabular component and modular femoral component, resulting in improvement in the postoperative leg length discrepancy. There were no neurovascular or other perioperative complications, and the patient was ambulating without pain or assistive devices at 1-year follow-up.

Age Influences Biomechanical Changes After Participation in an Anterior Cruciate Ligament Injury Prevention Program.

BACKGROUND: The prevalence of anterior cruciate ligament (ACL) injuries increases during maturation and peaks during late adolescence. Previous studies suggested an age-related association between participation in injury prevention programs and reduction of ACL injury. However, few studies have investigated differences in biomechanical changes after injury prevention programs between preadolescent and adolescent athletes. Purpose/Hypothesis: The purpose was to investigate the influence of age on the effects of the FIFA Medical and Research Centre (F-MARC) 11+ injury prevention warm-up program on differences in biomechanical risk factors for ACL injury between preadolescent and adolescent female soccer players. It was hypothesized that the ACL injury risk factors of knee valgus angle and moment would be greater at baseline but would improve more after training for preadolescent athletes than adolescent athletes. It was further hypothesized that flexor-extensor muscle co-contraction would increase after training for both preadolescent and adolescent athletes. STUDY DESIGN: Controlled laboratory study. METHODS: Institutional Review Board-approved written consent was obtained for 51 preadolescent female athletes aged 10 to 12 years (intervention: n = 28, 11.8 ± 0.8 years; control: n = 23, 11.2 ± 0.6 years) and 43 adolescent female athletes aged 14 to 18 years (intervention: n = 22, 15.9 ± 0.9 years; control: n = 21, 15.7 ± 1.1 years). The intervention groups participated in 15 in-season sessions of the F-MARC 11+ program 2 times per week. Pre- and postseason motion capture data were collected during 4 tasks: preplanned cutting, unanticipated cutting, double-legged jump, and single-legged jump. Lower extremity joint angles and moments were estimated through biomechanical modeling. Knee flexor-extensor muscle co-contraction was estimated from surface electromyography. RESULTS: At baseline, preadolescent athletes displayed greater initial contact and peak knee valgus angles during all activities when compared with the adolescent athletes, but knee valgus moment was not significantly different between age groups. After intervention training, preadolescent athletes improved and decreased their initial contact knee valgus angle (-1.24° ± 0.36°; P = .036) as well as their peak knee valgus moment (-0.57 ± 0.27 percentage body weight × height; P = .033) during the double-legged jump task, as compared with adolescent athletes in the intervention. Compared with adolescent athletes, preadolescent athletes displayed higher weight acceptance flexor-extensor muscle co-contraction at baseline during all activities ( P < .05). After intervention training, preadolescent athletes displayed an increase in precontact flexor-extensor muscle co-contraction during preplanned cutting as compared with adolescent intervention athletes (0.07 ± 0.02 vs -0.30 ± 0.27, respectively; P = .002). CONCLUSION: The F-MARC 11+ program may be more effective at improving some risk factors for ACL injury among preadolescent female athletes than adolescent athletes, notably by reducing knee valgus angle and moment during a double-legged jump landing. CLINICAL RELEVANCE: ACL prevention programs may be more effective if administered early in an athlete's career, as younger athletes may be more likely to adapt new biomechanical movement patterns.

Administering Blood Products Before Selected Interventional Radiology Procedures: Developing, Applying, and Monitoring a Standardized Protocol.

PURPOSE: To apply and monitor a single institution's adherence to internally established guidelines for the preoperative administration of platelets and/or fresh frozen plasma (FFP) before a specified subset of minimally invasive interventional radiology (IR) procedures. MATERIALS AND METHODS: Beginning in December 2008, we implemented a set of restrictive guidelines for preoperative platelet and/or FFP administration before IR procedures at a single academic hospital. Basing our program on the methodology of Lean Six Sigma, we compared the number and appropriateness of transfusions between the months of January and October in 2008 (prepolicy), again in 2010 (postpolicy), and finally in 2015 (follow-up). Patients with a platelet count less than or equal to 50,000 or an international normalized ratio greater than or equal to 1.7 met criteria for receiving platelets or FFP, respectively, before their IR procedure. For all three periods, we compared the rates of transfusion, hemorrhagic complications, and proportion of appropriate versus inappropriate blood product administration (BPA) per our guidelines. RESULTS: There was a significant increase in the number of appropriate BPAs between 2008 and 2010 from 58% to 76% (P = .021). Between 2010 and 2015, the rate trended up further, from 76% to 88% (P = .051). Overall, between 2008 and 2015, the improvement from 58% to 88% was significant (P < .001). The rate of hemorrhagic complications was extremely low in all three groups. CONCLUSION: Restrictive guidelines for receiving platelets and FFP administrations before IR procedures can sustainably decrease the rate of overall BPA while increasing the proportion of appropriate BPA without impacting the rate of hemorrhagic complications.

Biomechanical Effects of an Injury Prevention Program in Preadolescent Female Soccer Athletes.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common, and children as young as 10 years of age exhibit movement patterns associated with an ACL injury risk. Prevention programs have been shown to reduce injury rates, but the mechanisms behind these programs are largely unknown. Few studies have investigated biomechanical changes after injury prevention programs in children. Purpose/Hypothesis: To investigate the effects of the F-MARC 11+ injury prevention warm-up program on changes to biomechanical risk factors for an ACL injury in preadolescent female soccer players. We hypothesized that the primary ACL injury risk factor of peak knee valgus moment would improve after training. In addition, we explored other kinematic and kinetic variables associated with ACL injuries. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 51 female athletes aged 10 to 12 years were recruited from soccer clubs and were placed into an intervention group (n = 28; mean [±SD] age, 11.8 ± 0.8 years) and a control group (n = 23; mean age, 11.2 ± 0.6 years). The intervention group participated in 15 in-season sessions of the F-MARC 11+ program (2 times/wk). Pre- and postseason motion capture data were collected during preplanned cutting, unanticipated cutting, double-leg jump, and single-leg jump tasks. Lower extremity joint angles and moments were estimated using OpenSim, a biomechanical modeling system. RESULTS: Athletes in the intervention group reduced their peak knee valgus moment compared with the control group during the double-leg jump (mean [±standard error of the mean] pre- to posttest change, -0.57 ± 0.27 %BW×HT vs 0.25 ± 0.25 %BW×HT, respectively; P = .034). No significant differences in the change in peak knee valgus moment were found between the groups for any other activity; however, the intervention group displayed a significant pre- to posttest increase in peak knee valgus moment during unanticipated cutting ( P = .044). Additional analyses revealed an improvement in peak ankle eversion moment after training during preplanned cutting ( P = .015), unanticipated cutting ( P = .004), and the double-leg jump ( P = .016) compared with the control group. Other secondary risk factors did not significantly improve after training, although the peak knee valgus angle improved in the control group compared with the intervention group during unanticipated cutting ( P = .018). CONCLUSION: The F-MARC 11+ program may be effective in improving some risk factors for an ACL injury during a double-leg jump in preadolescent athletes, most notably by reducing peak knee valgus moment. CLINICAL RELEVANCE: This study provides motivation for enhancing injury prevention programs to produce improvement in other ACL risk factors, particularly during cutting and single-leg tasks.

The effect of foot landing position on biomechanical risk factors associated with anterior cruciate ligament injury.

BACKGROUND: Identification of biomechanical risk factors associated with anterior cruciate ligament (ACL) injury can facilitate injury prevention. The purpose of this study is to investigate the effects of three foot landing positions, "toe-in", "toe-out" and "neutral", on biomechanical risk factors for ACL injury in males and females. The authors hypothesize that 1) relative to neutral, the toe-in position increases the biomechanical risk factors for ACL injury, 2) the toe-out position decreases these biomechanical risk factors, and 3) compared to males, females demonstrate greater changes in lower extremity biomechanics with changes in foot landing position. METHODS: Motion capture data on ten male and ten female volunteers aged 20-30 years (26.4 ± 2.50) were collected during double-leg jump landing activities. Subjects were asked to land on force plates and target one of three pre-templated foot landing positions: 0° ("neutral"), 30° internal rotation ("toe-in"), and 30° external rotation ("toe-out") along the axis of the anatomical sagittal plane. A mixed-effects ANOVA and pairwise Tukey post-hoc comparison were used to detect differences in kinematic and kinetic variables associated with biomechanical risk factors of ACL injury between the three foot landing positions. RESULTS: Relative to neutral, landing in the toe-in position increased peak hip adduction, knee internal rotation angles and moments (p < 0.01), and peak knee abduction angle (p < 0.001). Landing in the toe-in position also decreased peak hip flexion angle (p < 0.001) and knee flexion angle (p = 0.023). Landing in the toe-out position decreased peak hip adduction, knee abduction, and knee internal rotation angles (all p < 0.001). Male sex was associated with a smaller increase in hip adduction moment (p = 0.043) and knee internal rotation moment (p = 0.032) with toe-in landing position compared with female sex. CONCLUSIONS: Toe-in landing position exacerbates biomechanical risk factors associated with ACL injury, while toe-out landing position decreases these factors.

Can We Improve Workflows in the OR? A Comparison of Quality Perceptions and Preoperative Efficiency across Institutions in Spine Surgery.

INTRODUCTION: Cost containment and surgical inefficiencies are major concerns for hospitals in this era of declining resources. The primary aim of this investigation was to understand subjective perceptions of perioperative spine surgical quality across three practice settings and to identify potential factors contributing to these perceptions. Subsequently, we objectively evaluated factors that influence the duration of time in which the patient is in the operating room (OR) prior to the surgical incision and assessed the influence of fluoroscopy technician expertise on radiation dose and imaging efficiency. METHODS: One hundred and eight medical device representatives with at least 1 year of OR experience were surveyed at a national conference. Three distinct healthcare facilities were identified: university, small volume, and large volume private hospitals. Respondents rated facilities on a five-point scale for staff quality; size and consistency of surgical teams; and overall likelihood of recommending the facility. Separately, 140 posterior lumbar procedures from two institutions were retrospectively reviewed. Two time periods were quantified for each surgical case: patient arrival in the OR to induction of anesthesia (T1) and induction to surgical incision (T2). T1 and T2 were compared between university and large private hospital settings using t tests and multivariate analysis. For 44 separate lumbar spine surgical procedures, practice setting, patient BMI, number of vertebral levels requiring imaging, number of localizing fluoroscopy images taken, total fluoroscopy time, total radiation dose, fluoroscopy machine, and whether the fluoroscopist could correctly state his or her role, which was to obtain a lateral lumbar localizing image, were recorded. T-tests were used to compare cases in which the fluoroscopist could and could not correctly state the task. RESULTS: Survey ratings for surgeons were not significantly different across university, large private, and small private hospitals. Fewer circulating nurses were rated as excellent or good in university versus private hospitals (p < 0.001). Small volume private hospital surgical teams were more likely to have worked together before than university teams (p < 0.05), and university teams were larger (p < 0.05). Respondents were more likely to recommend a university or large private hospital for complex instrumentation cases (p < 0.001). On objective measures, university patients were older, less obese, and had higher mean ASA scores (2.5 versus 2.2, p < 0.001). Compared to the university setting, private hospital cases had significantly shorter Time 1 (8 versus 37 min, p < 0.001) and Time 2 (23 versus 30 min, p < 0.001), even after adjusting for ASA score, BMI, and age. Cases in which the fluoroscopist knew the imaging purpose were associated with significantly fewer images (mean 1.8 versus 3.4 images, p < 0.0001) and shorter total exposure times (2.3 versus 4.0 sec, p < 0.001). Operations performed in the university setting were associated with significantly more images (2.7 versus 1.8 images, p < 0.001), longer total exposure times (3.2 versus 2.3 sec, p = 0.0027), and total radiation dose (27.8 versus 53.3 rad, p < 0.001) when compared with those performed in the private setting. The university practice setting was associated with significantly more images (2.7 versus 1.8 images, p < 0.001), longer total exposure times (3.2 versus 2.3 sec, p = 0.003), and total radiation dose (27.8 versus 53.3 rad, p < 0.001) when compared with non-university settings. CONCLUSION: Large private and university hospitals had higher surgeon ratings. The university setting was associated with larger and less consistent surgical teams and lower nurse ratings. Surgical staff awareness of the procedure and attention to preoperative tasks specific to the procedure reduced pre-operative time spent in the OR as well as fluoroscopy radiation. These data suggest that nurses and support staff make substantial contributions to overall quality of care, and that leadership and interpersonal coordination are especially important within large teams at teaching hospitals.

Tract embolization with gelatin sponge slurry for prevention of pneumothorax after percutaneous computed tomography-guided lung biopsy.

PURPOSE: To determine the effect of embolization with absorbable gelatin sponge slurry on the incidence of pneumothorax (PTX) and need for chest tube placement after percutaneous lung biopsy. MATERIALS AND METHODS: Seven hundred fifty-two percutaneous lung biopsy procedures and fiducial seed placements were performed using computed tomography (CT)-guidance at a single institution. A retrospective review was performed including 145 patients with embolization (19.28%) of the tract with gelatin sponge slurry during needle withdrawal and 607 patients who did not undergo tract embolization. Patient- and lesion-related characteristics were collected through the electronic health record and PACS. Outcome measures included the occurrence of PTX during or after the biopsy procedure and the need for chest tube placement. Analysis was performed by multivariate logistic regression. RESULTS: Although tract embolization did not significantly decrease the chances of developing PTX (p = 0.06), it did decrease the likelihood of progressing to requiring chest tube insertion. Without tract embolization, 10.7% of cases required a chest tube, whereas only 6.9% of the patients whose tract was embolized needed a chest tube (p = 0.01). A history of emphysema was associated with 151% increased odds of PTX requiring chest tube placement after lung biopsy (p = 0.009). Tract length >24 mm was associated with a 262% increase in the odds of requiring chest tube placement (p = 0.003). CONCLUSION: Embolization of the needle tract during percutaneous lung biopsy with gelfoam slurry significantly decreased the odds of requiring a chest tube for PTX and should be considered for all patients, particularly those with emphysema and deep lesions.