Improving alignment in total knee arthroplasty: a cadaveric assessment of a surgical navigation tool with computed tomography imaging.

PURPOSE: To investigate the accuracy of an imageless, optical surgical navigation tool to assist with femoral and tibial bone cuts performed during TKA. PATIENTS AND METHODS: Six board-certified orthopedic surgeons participated in a laboratory cadaver investigation, performing femoral and tibial bone cuts with the assistance of a computer navigation tool. Femoral and tibial varus/valgus, tibial slope, femoral flexion, and both femoral and tibial rotation measurements from the device were compared with angular measurements calculated from computed tomography (CT) images of the knees. RESULTS: Measurements with the navigation tool were highly correlated with those obtained from CT scans in all three axes. For the distal femoral cut, the absolute mean difference in varus/valgus was 0.83° (SD 0.46°, r = 0.76), femoral flexion was 1.91° (SD 1.16°, r = 0.85), and femoral rotation was 1.29° (SD 1.01°, r = 0.88) relative to Whiteside's line and 0.97° (SD 0.56°, r = 0.81) relative to the posterior condylar axis. For the tibia, the absolute mean difference in varus/valgus was 1.08° (SD 0.64°, r = 0.85), posterior slope was 2.78° (SD 1.40°, r = 0.60), and rotation relative to the anteroposterior axis (posterior cruciate ligament to the medial third of the tibial tuberosity) was 2.98° (SD 2.54°, r = 0.79). CONCLUSION: Utilization of an imageless navigation tool may aid surgeons in accurately performing and monitoring femoral and tibial bone cuts, and implant rotation in TKA and thus, more accurately align TKA components.

Mepivacaine Versus Bupivacaine Spinal Anesthesia for Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Mepivacaine is an intermediate acting amide local anesthetic that can be used for neuraxial anesthesia in total joint arthroplasty (TJA) with a shorter duration of action (1.5-2 hours) compared to the more commonly used local anesthetic bupivacaine. The purpose of this study was to perform a systematic review and meta-analysis comparing bupivacaine and mepivacaine spinal anesthesia during elective TJA and the surgical outcomes of the time to full neurologic motor return, pain, mobility, length of stay (LOS), and complications including transient neurologic symptoms and urinary function. METHODS: PubMed, Ovid MEDLINE, and Ovid Embase were screened for "arthroplasty, spinal anesthesia, bupivacaine, and mepivacaine," in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 159 studies were screened and 5 studies were evaluated. Data were compared regarding motor function return, mobility (distance ambulated), pain (visual analog scale [VAS]), LOS, and postoperative complications. RESULTS: Full-text screening yielded 5 studies (3 randomized controlled trials and 2 retrospective cohort studies), with a total of 1,550 patients. Mepivacaine spinals had an earlier return to motor function (154 minutes vs 170 minutes, 95% CI: [-31.6, -0.9], P = .04), shorter LOS (25.95 hours vs 29.96 hours, 95% CI: [-6.8, -1.2], P = .01), and decreased urinary retention (7.15% vs 10.58%, 95% CI: [-6.3%, -0.6%], P = .02) with no differences in pain (VAS 3.57 vs 3.68, 95% CI: [-2.1, 1.9], P = .90) or distance ambulated (94.2 ft vs 89.1 ft, 95% CI: [-15, 25.2], P = .60) compared to bupivacaine spinal anesthesia. CONCLUSIONS: The method of anesthesia administration has been an increasing area of focus for quicker and safer recovery to allow for early ambulation and facility discharge. The rapid recovery facilitated by mepivacaine may further enable outpatient TJA and enhance patient recovery. LEVEL OF EVIDENCE: III.

Virtual Physical Education During COVID-19: Exploring Future Directions for Equitable Online Learning Tools.

Introduction: School closures prompted by the COVID-19 pandemic reduced opportunities for US youth to be physically active and disproportionately impacted health disparities in this population. Physical education provides the largest intervention to support the physical activity of school-aged youth, but teachers' opinions about how to maintain quality programming during virtual learning periods remain unexplored. Applying a diversity, equity and inclusion framework, this study explored physical education teachers' perceived significance of different design features for an online teaching tool to promote physical activity equity during school closures. Methods: Previous literature and focus groups informed the development of a survey administered in summer/fall 2020. Survey participants (n = 60) were physical education teachers from 400 randomly selected US preschool-12th grade schools drawing from a national database. Participants rated the significance of four design features in relation to five key attributes of an online supplement to in-person physical education programs. One-way ANOVAs were used to assess differences in teachers' ratings by demographic characteristics. Results: Between-group differences were found in teacher ratings of design features related to the usability, accessibility, equitability, and formal assessment capabilities of an online physical education tool. Differences were based on teacher gender, school level, and geographic location. Conclusions: Future research to promote physical activity equity among preschool-12th grade youth should examine tailored virtual physical education learning tools that address what teachers perceive to be the most significant design features to support equitable physical education among diverse student groups.

COVID-19 Impact on Young Arthroplasty Surgeons.

BACKGROUND: The current coronavirus crisis, COVID-19, has affected all orthopedic surgeons. Surgeons at early stages of their career are at risk of being affected differently than their more established counterparts. METHODS: We conducted an online survey for members of the Young Arthroplasty Group to determine what effects this had on their current practice. RESULTS: Nearly 40% of our surveyed group responded ranging from residents, fellows, and early career surgeons. All groups had been affected by the crisis, with different impacts on each subgroup. CONCLUSION: COVID-19 had significant impact on young surgeons affecting their compensation, redeployment, and career advancement. Available resources should be offered to this group, where available, to mitigate the impact of the crisis.

Evaluation of the Painful Total Knee Arthroplasty.

Total knee arthroplasty (TKA) has been associated with notable improvements in health-related quality of life of patients with end-stage knee arthritis. Although most patients experience substantial symptomatic relief after TKA, up to 19% of patients are unsatisfied with their outcome. With the dramatic, projected increase in the number of TKAs performed annually, it is crucial to appreciate the various modes of failure associated with this procedure. A comprehensive understanding of the symptomatology and thorough clinical examination aid in identifying the etiology of ongoing knee pain. Ancillary testing including conventional laboratory analyses, imaging studies, and diagnostic injections supplement a thorough history and physical examination. In addition, novel laboratory markers, RNA/DNA-based tests, and novel imaging modalities are emerging as beneficial tools in evaluating patients with a painful TKA. A well-structured, algorithmic approach in the management of these patients is essential in correctly diagnosing the patient and optimizing clinical outcomes.

High Failure Rates of Concomitant Periprosthetic Joint Infection and Extensor Mechanism Disruption.

BACKGROUND: Patients presenting with both chronic periprosthetic joint infection (PJI) and extensor mechanism disruption (EMD) pose a significant challenge. As there is little in the literature regarding outcomes of patients with concomitant PJI and EMD, we performed a multicenter study to evaluate the outcomes. METHODS: Sixty patients with concomitant diagnoses of PJI and EMD were evaluated from 5 institutions. Patient demographics, presentation type, surgical management, and outcomes including recurrent infections, final surgery, and ambulatory status were documented. RESULTS: Fifty-three of 60 patients had an attempted extensor mechanism reconstruction/repair (EMR) of which 12 (23%) were successful, averaging 3.5 (range, 2-7) intervening surgeries. Forty-one patients (77%) were considered failures with recurrence of infection as most common failure (80%); 26 ended in fusion, 10 in above knee amputation, 3 with chronic resection arthroplasty, and 2 with chronic spacers/EMD. Seven patients had no attempt at EMR but proceeded directly to fusion (n = 6) or amputation (n = 1). There was no statistical difference between groups that had success or failure of EMR in age, American Society of Anesthesiologists Physical Status Classification System, or body mass index. CONCLUSION: Our study demonstrates that concomitant EMD and PJI is a dreaded combination with poor outcomes regardless of treatment. Eradication of infection and reconstruction of the extensor mechanism often require numerous surgeries and despite great effort often end in failure. Consideration of early fusion or amputation may be preferable in some patients to avoid the morbidity and mortality of repeated surgeries.

Rotating Hinge Implants for Complex Primary and Revision Total Knee Arthroplasty.

BACKGROUND: Contemporary rotating hinge knee (RHK) prosthesis has shown improved survival rates over earlier generations. However, reports of high complication and mechanical failure rates highlight the need for more clinical outcome data in the complex primary and revision setting. The purpose of this study is to report our results of using a contemporary rotating hinge for complex primary and revision total knee arthroplasty. METHODS: Using a prospectively maintained surgical database, 79 knees in 76 patients who underwent an RHK of a single design for either a complex primary (14 knees) or revision total knee arthroplasty (65 knees) were identified. This included 19% undergoing an RHK for periprosthetic joint infection and 32.9% who had concomitant extensor mechanism repair. The cohort consisted of 60 women and 16 men with a mean age of 66.7 years (range 39-89) at the time of surgery. Patient outcomes were assessed using Knee Society Scores and radiographs were reviewed for signs of wear and loosening. Failure rates were estimated using Kaplan-Meier survival curves. RESULTS: At a minimum of 2 years, 13 patients had died and 4 were lost to follow-up, leaving 62 knees in 59 patients who were followed for a mean of 55.2 months (range 24-146). The mean Knee Society Scores improved from 35.7 to 66.2 points (P < .01). The incidence of complications was 38.7%. The most common complications were periprosthetic fracture, extensor mechanism rupture, and periprosthetic infection. Estimated survival was 70.7% at 5 years. CONCLUSION: Despite improvements in design and biomaterials, there remains a relatively high complication rate associated with the use of a modern RHK implant. While aseptic loosening was rare, periprosthetic fracture, infection, and extensor mechanism failure were substantial emphasizing the complex nature of these cases.

Poor Outcomes of Irrigation and Debridement in Acute Periprosthetic Joint Infection With Antibiotic-Impregnated Calcium Sulfate Beads.

BACKGROUND: One proposed strategy to increase the success of irrigation and debridement with implant retention for the treatment of acute periprosthetic joint infection (PJI) is the use of dissolvable antibiotic-impregnated calcium sulfate beads to provide a local depot of antibiotics. The purpose of this study was to evaluate the outcome of such an approach. METHODS: Thirty-two patients with acute hematogenous (18 patients; 1 bilateral) or acute postoperative (14 patients) PJIs who underwent irrigation and debridement with implant retention and addition of antibiotic-impregnated calcium sulfate beads were retrospectively reviewed. PJI followed 27 total knee arthroplasties and 6 total hip arthroplasties. The most common infecting organisms were methicillin-sensitive Staphylococcus aureus (13 of 33) and Streptococcus (9 of 33). The primary outcome parameter was recurrence of infection according to the Musculoskeletal Infection Society criteria. Patients were followed up for a minimum of 3 months or until failure. RESULTS: At a mean of 12.7 months (range, 3-30 months), 16 of the 33 patients failed (48%). Acute hematogenous and acute postoperative PJI had similar failure rates at 47% and 50%, respectively (P = .88). Seven failures required a 2-stage exchange, while 8 patients were treated with chronic antibiotic suppression, being unwilling or unable to undergo further surgical intervention. CONCLUSION: The addition of antibiotic-impregnated calcium sulfate beads does not appear to improve outcomes of irrigation and debridement with implant retention in the setting of acute hematogenous or acute postoperative PJI. Given the short follow-up in this report, this represents a best-case scenario and the overall failure rate may be higher with further follow-up.

One-Year Outcomes of Total Meniscus Reconstruction Using a Novel Fiber-Reinforced Scaffold in an Ovine Model.

BACKGROUND: Meniscus injuries and resulting meniscectomies lead to joint deterioration, causing pain, discomfort, and instability. Tissue-engineered devices to replace the meniscus have not shown consistent success with regard to function, mechanical integrity, or protection of cartilage. PURPOSE: To evaluate a novel resorbable polymer fiber-reinforced meniscus reconstruction scaffold in an ovine model for 52 weeks and assess its integrity, tensile and compressive mechanics, cell phenotypes, matrix organization and content, and protection of the articular cartilage surfaces. STUDY DESIGN: Controlled laboratory study. METHODS: Eight skeletally mature ewes were implanted with the fiber-reinforced scaffold after total meniscectomy, and 2 additional animals had untreated total meniscectomies. Animals were sacrificed at 52 weeks, and the explants and articular surfaces were analyzed macroscopically. Explants were characterized by ultimate tensile testing, confined compression creep testing, and biochemical, histological, and immunohistochemical analyses. Cartilage damage was characterized using the Mankin score on histologic slides from both the femur and tibia. RESULTS: One sheep was removed from the study because of a torn extensor tendon; the remaining 7 explants remained fully intact and incorporated into the bone tunnels. All explants exhibited functional tensile loads, tensile stiffnesses, and compressive moduli. Fibrocartilagenous repair with both types 1 and 2 collagen were observed, with areas of matrix organization and biochemical content similar to native tissue. Narrowing in the body region was observed in 5 of 7 explants. Mankin scores showed less cartilage damage in the explant group (femoral condyle: 3.43 ± 0.79, tibial plateau: 3.50 ± 1.63) than in the meniscectomy group (femoral condyle: 8.50 ± 3.54, tibial plateau: 6.75 ± 2.47) and were comparable with Mankin scores at the previously reported 16- and 32-week time points. CONCLUSION: A resorbable fiber-reinforced meniscus scaffold supports formation of functional neomeniscus tissue, with the potential to prevent joint degeneration that typically occurs after total meniscectomy. Further studies with improvements to the initial mechanics of the scaffold and testing for longer time periods are warranted. CLINICAL RELEVANCE: Meniscectomy is an extremely common orthopaedic procedure, and few options currently exist for the treatment of significant loss of meniscus tissue. Successful development of a tissue-engineered meniscus scaffold could substantially reduce the incidence of postmeniscectomy joint degeneration and the subsequent procedures used for its treatment.

Can Both Cruciate Ligaments Be Preserved in Knee Arthroplasty? Eight- to Nine-Year Follow-Up of a Bicompartmental Knee Replacement.

Preservation of native knee anatomy may confer improved patient satisfaction, as suggested by patient satisfaction scores in unicondylar versus total knee replacement. Bicompartmental knee replacement (BKR) implants similarly promote native tissue preservation. We retrospectively reviewed 42 consecutive patients who underwent BKR from 2006 to 2007. Outcome measures were evaluated. At an average follow-up of 103 months (range 87-110), 34/42 (81%) of implants survived. Among the retained implants, the Knee Society Score (KSS) grade was excellent in 26/34 (76.5%), good in 5/34 (14.7%), fair in 3/34 (8.8%), and poor in 0/34 (0%) of cases. Midterm results of BKR demonstrated 81% survival and 76% with excellent KSS grading. Despite a 20% revision rate at the short-term follow-up, the retained implants functioned well at the midterm follow-up.

Acute multiple flexor tendon injury and carpal tunnel syndrome after open distal radius fracture.

Although the rupture of extensor tendons after distal radius fractures is well described, acute flexor tendon ruptures are much less common. We report a case of acute rupture of the flexor pollicis longus and flexor carpi radialis tendons with acute carpal tunnel syndrome after a Gustilo-Anderson type II open distal radius fracture. We reviewed the literature to identify risk factors for tendon rupture and the development of carpal tunnel syndrome.

Experiential Learning in Kinesiology: A Student Perspective.

OVERVIEW: Service learning is a form of experiential learning that pairs academic educational experiences and community organizations to promote training, civic engagement, and meaningful service by students to their community. Kinesiology programs have moved toward increasing experiential and service learning options in health promotion for their students, but few have evaluated the student perceptions of these programs. PURPOSE: The purpose of the current study was to conduct a qualitative evaluation of a service learning course for Kinesiology majors located in a low-income urban area. METHODS: Ten recent graduates of a department of Kinesiology were enrolled in focus groups, stratified by gender, facilitated by a graduate research assistant not affiliated with their school. Focus group discussions were audiotaped, transcribed and analyzed for themes. RESULTS: Nine themes were identified including: (1) Personal and professional experience, (2) decision to participate, (3) location decision, (4) self-efficacy, (5) perceptions of program members, (6) social interaction, (7) personal and program communication, (8) physical facilities and (9) program outcomes. Students positively evaluated the learning experience as valuable to their personal and professional development; noted changes in their perceptions of low-income communities and increases to self-efficacy and skill acquisition from the beginning to the end of the course; and observed significant needs and improvements in physical, emotional and social outcomes of community members. CONCLUSIONS: This study demonstrated multiple and varied benefits of a service learning program for Kinesiology students. On-going evaluation of service learning programs in health promotion is needed to enhance student and community outcomes.

Successful Total Meniscus Reconstruction Using a Novel Fiber-Reinforced Scaffold: A 16- and 32-Week Study in an Ovine Model.

BACKGROUND: Meniscus injuries in the United States result in an estimated 850,000 surgical procedures each year. Although meniscectomies are the most commonly performed orthopaedic surgery, little advancement has been made in meniscus replacement and regeneration, and there is currently no total meniscus replacement device approved by the Food and Drug Administration. HYPOTHESIS: A novel fiber-reinforced meniscus scaffold can be used as a functional total meniscus replacement. STUDY DESIGN: Controlled laboratory study. METHODS: A tyrosine-derived, polymer fiber-reinforced collagen sponge meniscus scaffold was evaluated mechanically (tensile and compressive testing) and histologically after 16 and 32 weeks of implantation in an ovine total meniscectomy model (N = 20; 16 implants plus 4 meniscectomies, divided equally over the 2 time periods). The extent of cartilage damage was also measured on tibial plateaus by use of toluidine blue surface staining and on femoral condyles by use of Mankin scores on histological slides. RESULTS: Scaffolds induced formation of neomeniscus tissue that remained intact and functional, with breaking loads approximating 250 N at both 16 and 32 weeks compared with 552 N for native menisci. Tensile stiffness values (99 and 74 N/mm at 16 and 32 weeks, respectively) were also comparable with those of the native meniscus (147 N/mm). The compressive modulus of the neomeniscus tissue (0.33 MPa at both 16 and 32 weeks) was significantly increased compared with unimplanted (time 0) scaffolds (0.15 MPa). There was histological evidence of extensive tissue ingrowth and extracellular matrix deposition, with immunohistochemical evidence of types I and II collagen. Based on significantly decreased surface damage scores as well as Mankin scores, the scaffold implants provided greater protection of articular cartilage compared with the untreated total meniscectomy. CONCLUSION: This novel fiber-reinforced meniscus scaffold can act as a functional meniscus replacement, with mechanical properties similar to those of the native meniscus, while protecting the articular cartilage of the knee from the extensive damage after a total meniscectomy. CLINICAL RELEVANCE: This meniscus replacement scaffold has the potential to improve surgical treatment and provide better long-term outcomes for those suffering from severe meniscus damage.

Radioprotection provides functional mechanics but delays healing of irradiated tendon allografts after ACL reconstruction in sheep.

Successful protection of tissue properties against ionizing radiation effects could allow its use for terminal sterilization of musculoskeletal allografts. In this study we functionally evaluate Achilles tendon allografts processed with a previously developed radioprotective treatment based on (1-ethyl-3-(3-dimethylaminopropyl)carbodiimide) crosslinking and free radical scavenging using ascorbate and riboflavin, for ovine anterior cruciate ligament reconstruction. Arthroscopic anterior cruciate ligament (ACL) reconstruction was performed using double looped allografts, while comparing radioprotected irradiated and fresh frozen allografts after 12 and 24 weeks post-implantation, and to control irradiated grafts after 12 weeks. Radioprotection was successful at preserving early subfailure mechanical properties comparable to fresh frozen allografts. Twelve week graft stiffness and anterior-tibial (A-T) translation for radioprotected and fresh frozen allografts were comparable at 30 % of native stiffness, and 4.6 and 5 times native A-T translation, respectively. Fresh frozen allograft possessed the greatest 24 week peak load at 840 N and stiffness at 177 N/mm. Histological evidence suggested a delay in tendon to bone healing for radioprotected allografts, which was reflected in mechanical properties. There was no evidence that radioprotective treatment inhibited intra-articular graft healing. This specific radioprotective method cannot be recommended for ACL reconstruction allografts, and data suggest that future efforts to improve allograft sterilization procedures should focus on modifying or eliminating the pre-crosslinking procedure.

Promoting successful aging through competitive sports participation: insights from older adults.

In this study we explored the experience of competing in the Senior Games and the resultant contributions to the successful aging of older adults. We used in-depth interviews with older adults who participated in the National Senior Games. Analysis of the data produced five central themes: (a) perseverance, (b) career development and significant effort, (c) personal and social benefits, (d) unique ethos, and (e) identification as a senior athlete. We found that participating in the Senior Games as a form of serious leisure enhanced the well-being of older adults and could be utilized as a means by which to maintain a healthy lifestyle.

E2f1-3 switch from activators in progenitor cells to repressors in differentiating cells.

In the established model of mammalian cell cycle control, the retinoblastoma protein (Rb) functions to restrict cells from entering S phase by binding and sequestering E2f activators (E2f1, E2f2 and E2f3), which are invariably portrayed as the ultimate effectors of a transcriptional program that commit cells to enter and progress through S phase. Using a panel of tissue-specific cre-transgenic mice and conditional E2f alleles we examined the effects of E2f1, E2f2 and E2f3 triple deficiency in murine embryonic stem cells, embryos and small intestines. We show that in normal dividing progenitor cells E2f1-3 function as transcriptional activators, but contrary to the current view, are dispensable for cell division and instead are necessary for cell survival. In differentiating cells E2f1-3 function in a complex with Rb as repressors to silence E2f targets and facilitate exit from the cell cycle. The inactivation of Rb in differentiating cells resulted in a switch of E2f1-3 from repressors to activators, leading to the superactivation of E2f responsive targets and ectopic cell divisions. Loss of E2f1-3 completely suppressed these phenotypes caused by Rb deficiency. This work contextualizes the activator versus repressor functions of E2f1-3 in vivo, revealing distinct roles in dividing versus differentiating cells and in normal versus cancer-like cell cycles.