Total Knee Arthroplasty following Knee Arthroscopy in Patients over 50.

The purpose of this study was to evaluate the conversion rate of knee arthroscopy to ipsilateral total knee arthroplasty (TKA) within 2 years in patients aged 50 or older at the time of arthroscopy. The administrative database from a large, physician-owned orthopaedic practice (>100 surgeons) was queried to identify patients over the age of 50 who had undergone arthroscopic knee surgery between January 1, 2006 and January 2, 2015. The subset of patients who converted to TKA within 2 years after knee arthroscopy was identified and matched by age and sex to a control population that did not convert to TKA. Rates of conversion to TKA were calculated. Prearthroscopic digital radiographs were reviewed and Kellgren-Lawrence (KL) grades were compared among case and control populations. Univariable analyses and multivariable regression analysis were performed. Eight hundred seven of 16,061 (5.02%) patients aged 50 or older were converted to TKA within 2 years following ipsilateral knee arthroscopy. In univariable analysis, the rate of conversion to TKA in patients aged between 50 and 54 was 2.94%, compared with 4.44% in patients aged between 55 and 64, and 8.32% in patients 65 or older (p < 0.0001). Female sex was associated with a higher rate of conversion to TKA in univariable analysis (5.93 vs. 4.02% in males, p < 0.0001). KL grades were higher among patients who converted to TKA compared with those who did not (p < 0.0001). In a multivariable regression model controlling for age, sex, and KL grade, only increased KL grade was associated with increased odds of conversion to TKA. In the appropriately selected older patient, the risk of conversion to TKA within 2 years of knee arthroscopy is low (∼5%). Patients with KL grade 2 or higher at the time of arthroscopy should be counseled on the increased odds of early conversion to TKA.

Promoting Bone Formation and Healing in Segmental Defects Through Ectopic Induced Membrane.

We aimed to determine whether addition of an in vivo ectopic induced membrane (EM) to the Masquelet Technique enhanced angiogenesis and bone formation in a segmental defect. After generating and stabilizing a diaphyseal femur defect, 10 rats received a polymethylmethacrylate (PMMA) spacer within the defect (control); 10 received another PMMA spacer implanted subcutaneously (EM). We removed the spacers and added autograft; the excised EM was added to their autograft (EM group). Post-mortem x-rays assessed bone formation and bridging. Osteogenesis in the proximal defect was significantly more uniform (p < 0.01), and there was greater amount of bone remodeling distally in the EM group (p < 0.05). There was no difference in bone formation (p = 0.19) but greater degrees of bridging in the EM group (2.20 vs. 1.20, p = 0.09). The EM resulted in more homogeneous proximal osteogenesis and increased bone remodeling distally. These findings could lead to more consistent and predictable bone healing. (Journal of Surgical Orthopaedic Advances 31(3):161-165, 2022).

Virtual Reality and Augmented Reality-Translating Surgical Training into Surgical Technique.

PURPOSE OF REVIEW: As immersive learning outside of the operating room is increasingly recognized as a valuable method of surgical training, virtual reality (VR) and augmented reality (AR) are increasingly utilized in orthopedic surgical training. This article reviews the evolving nature of these training tools and provides examples of their use and efficacy. The practical and ethical implications of incorporating this technology and its impact on both orthopedic surgeons and their patients are also discussed. RECENT FINDINGS: Head-mounted displays (HMDs) represent a possible adjunct to surgical accuracy and education. While the hardware is advanced, there is still much work to be done in developing software that allows for seamless, reliable, useful integration into clinical practice and training. Surgical training is changing: AR and VR will become mainstays of future training efforts. More evidence is needed to determine which training technology translates to improved clinical performance. Volatility within the HMD industry will likely delay advances in surgical training.

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

OBJECTIVES: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. DESIGN: Consecutive retrospective cohort review. SETTING: Eighteen academic orthopedic trauma centers. PATIENTS/PARTICIPANTS: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. INTERVENTION: Humeral shaft nonunion repair and assessment of postoperative radial nerve function. MAIN OUTCOME: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. RESULTS: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. CONCLUSION: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Achieving Stability in Revision Total Hip Arthroplasty.

Instability remains one of the leading causes of revision total hip arthroplasty. It is important to understand the etiology of recurrent instability prior to surgical intervention to solve instability. Understanding the patient factors and surgical factors that lead to instability is critical. Once the decision to have surgery has been made, it is critical to correct the problem that lead to instability. Today, several options exist to help reduce the risk of instability, but correction of component malposition is the most critical. This chapter reviews current options in the treatment of recurrent instability.

Teaching Cortical-Screw Tightening: A Simple, Affordable, Torque-Directed Training Protocol Improves Resident Performance.

BACKGROUND: Cortical-screw insertion is a fundamental skill in orthopaedic surgery, yet, to our knowledge, no standardized method of teaching this skill exists. The purpose of this study was to evaluate a training protocol that was designed to teach residents how to tighten a cortical screw without causing any stripping. METHODS: Twenty-five residents and 8 attending surgeons from an orthopaedic residency program tightened cortical screws in a synthetic bone model with a digital torque screwdriver using 3 different techniques: percutaneous; open, dominant hand; and open, nondominant hand. The residents then participated in a training protocol during which each tightened additional screws while receiving real-time torque feedback. During training, the residents targeted 50% to 70% of the stripping torque for each screw. They were assessed at baseline, immediately after training, and at 12 to 15 weeks after training. During each assessment, the percentage of screws that were tightened in the target range and the percentage of stripped screws were recorded. The costs of the training protocol were assessed. RESULTS: After training, all of the residents tightened screws with lower insertional torque compared with their baseline, but only the senior residents tightened more screws in the target range and stripped fewer screws. The attending surgeons, when compared with the residents at baseline, tightened more screws in the target range and tended to strip fewer screws, but these differences were absent at final testing. Costs included $1,927 for durable equipment and an estimated $74 per resident per training session for consumable goods. CONCLUSIONS: The senior residents inserted more screws in the target range and stripped fewer screws after participating in this training protocol, but the junior residents did not show significant improvement. Implementation of this training protocol for all residents may improve clinical performance but, because our sample size was limited, additional study is required to assess skill transfer to clinical practice. CLINICAL RELEVANCE: Cortical-screw tightening is a fundamental skill in orthopaedics, and completion of this torque-directed training protocol may accelerate residents' skill acquisition.

The Incidence of Durotomy and its Clinical and Economic Impact in Primary, Short-segment Lumbar Fusion: An Analysis of 17,232 Cases.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To determine the incidence of durotomy in primary short-segment lumbar fusion and assess its clinical and economic impacts. SUMMARY OF BACKGROUND DATA: The incidence of durotomy during primary lumbar fusion and its economic impact are not well described. METHODS: The Nationwide Inpatient Sample was queried for all primary 1- or 2-level lumbar fusions performed in adults for lumbar spinal stenosis between 2009 and 2011; only elective cases without concurrent diagnoses of vertebral infection, fracture, or tumor were included. χ and t-tests were used as appropriate to compare categorical and continuous variables, respectively. Multivariate regression analysis was performed to identify factors independently associated with incidental durotomy, as well as total hospital charges, costs, and length of stay. RESULTS: Among 17,232 cases, 802 incidental durotomies were identified (rate 4.65%). The multivariate odds of durotomy in the oldest patients (age ≥ 73) were 2.4 times greater than the odds of durotomy in the youngest patients (age ≤ 56; P < 0.0001). Durotomy was associated with increased neurological complications and longer hospital stay. Length of stay was a significant driver of cost. The multivariate odds of dural tears in teaching hospitals was significantly higher compared with nonteaching hospitals (odds ratio 1.27; 95% confidence interval, 1.06-1.52; P < 0.005). Durotomy was associated with a $10,885 increase in total hospital charges, and a $3,873 increase in estimated total costs (compared with no durotomy group with P < 0.0001). CONCLUSION: Increasing age is a risk factor for durotomy in primary lumbar fusion. Durotomy is associated with neurological complications, increased length of stay, greater healthcare costs, and is more common in teaching hospitals. Length of stay is an independent driver of cost and complications. LEVEL OF EVIDENCE: 3.

Distinct effects of losartan and atenolol on vascular stiffness in Marfan syndrome.

We conducted a randomized, double-blind trial of losartan (100 mg QD) versus atenolol (50 mg QD) for 6 months in adults with Marfan syndrome. Carotid-femoral pulse wave velocity (PWV), central augmentation index (AIx), aortic diameter and left ventricular (LV) function were assessed with arterial tonometry and echocardiography. Thirty-four subjects (18 female; median age 35 years, IQR 27, 45) were randomized. Central systolic and diastolic blood pressure decreased comparably with atenolol and losartan (p = 0.64 and 0.31, respectively); heart rate decreased with atenolol (p = 0.02), but not with losartan. PWV decreased in patients treated with atenolol (-1.15 ± 1.68 m/s; p = 0.01), but not in those treated with losartan (-0.22 ± 0.59 m/s; p = 0.15; between-group difference p = 0.04). In contrast, AIx decreased in the losartan group (-9.6 ± 8.6%; p < 0.001) but not in the atenolol group (0.9 ± 6.2%, p = 0.57; between-group difference p < 0.001). There was no significant change in aortic diameters or LV ejection fraction in either treatment group. In adults with Marfan syndrome, 6 months of treatment with atenolol improves PWV, whereas losartan reduces the AIx. By improving vascular stiffness via distinct mechanisms of action, there is physiologic value to considering the use of both medications in individuals with Marfan syndrome.

The effect of salsalate therapy on endothelial function in a broad range of subjects.

BACKGROUND: Inflammation is fundamental to the development of atherosclerosis. We examined the effect of anti-inflammatory doses of salicylate on endothelium-dependent vasodilation, a biomarker of cardiovascular risk, in a broad range of subjects. METHODS AND RESULTS: We performed a randomized, double-blind, placebo-controlled crossover trial evaluating the effects of 4 weeks of high-dose salsalate (disalicylate) therapy on endothelium-dependent flow-mediated and endothelium-independent vasodilation. Fifty-eight subjects, including 17 with metabolic syndrome, 13 with atherosclerosis, and 28 healthy controls, were studied. Among all subjects, endothelium-dependent flow-mediated vasodilation decreased after salsalate compared with placebo therapy (P=0.01), whereas nitroglycerin-mediated, endothelium-independent vasodilation was unchanged (P=0.97). Endothelium-dependent flow-mediated vasodilation after salsalate therapy was impaired compared with placebo therapy in subjects with therapeutic salicylate levels (n=31, P<0.02) but not in subjects with subtherapeutic levels (P>0.2). CONCLUSIONS: Salsalate therapy, particularly when therapeutic salicylate levels are achieved, impairs endothelium-dependent vasodilation in a broad range of subjects. These data raise concern about the possible deleterious effects of anti-inflammatory doses of salsalate on cardiovascular risk. CLINICAL TRIAL REGISTRATION URL: www.clinicaltrials.gov. Unique Identifiers: NCT00760019 and NCT00762827.

Targeting inflammation using salsalate in patients with type 2 diabetes: effects on flow-mediated dilation (TINSAL-FMD).

OBJECTIVE: To test whether inhibiting inflammation with salsalate improves endothelial function in patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: We conducted an ancillary study to the National Institutes of Health-sponsored, multicenter, randomized, double-masked, placebo-controlled trial evaluating the safety and efficacy of salsalate in targeting inflammation to improve glycemia in patients with T2D. Flow-mediated, endothelium-dependent dilation (FMD) and endothelium-independent, nitroglycerin-mediated dilation (NMD) of the brachial artery were assessed at baseline and 3 and 6 months following randomization to either salsalate 3.5 g/day or placebo. The primary end point was change in FMD at 6 months. RESULTS: A total of 88 participants were enrolled in the study, and data after randomization were available for 75. Patients in the treatment and control groups had similar ages (56 years), BMI (33 kg/m(2)), sex (64% male), ethnicity, current treatment, and baseline HbA1c (7.7% [61 mmol/mol]). In patients treated with salsalate versus placebo, HbA1c was reduced by 0.46% (5.0 mmol/mol; P < 0.001), fasting glucose by 16.1 mg/dL (P < 0.001), and white blood cell count by 430 cells/µL (P < 0.02). There was no difference in the mean change in either FMD (0.70% [95% CI -0.86 to 2.25%]; P = 0.38) or NMD (-0.59% [95% CI -2.70 to 1.51%]; P = 0.57) between the groups treated with salsalate and placebo at 6 months. Total and LDL cholesterol were 11 and 16 mg/dL higher, respectively, and urinary albumin was 2.0 µg/mg creatinine higher in the patients treated with salsalate compared with those treated with placebo (all P < 0.009). CONCLUSIONS: Salsalate does not change FMD in peripheral conduit arteries in patients with T2D despite lowering HbA1c. This finding suggests that salsalate does not have an effect on vascular inflammation, inflammation does not cause endothelial dysfunction in T2D, or confounding effects of salsalate mitigate favorable effects on endothelial function.