Minimally Invasive Lateral Corpectomy of the Thoracolumbar Spine: A Case Series of 20 Patients.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To report our experience with corpectomy of the thoracolumbar (TL) spine through a minimally invasive lateral retropleural or retroperitoneal approach. METHODS: This is a retrospective case series of 20 consecutive patients who underwent minimally invasive TL corpectomy and spinal reconstruction. Electronic medical records were reviewed for demographic, operative, and clinical outcome data. RESULTS: Between 2015 and 2019, 20 consecutive cases of minimally invasive TL corpectomy were performed, comprising 12 men (60%) and 8 women (40%) with a mean age of 54.3 years. Indications for surgery were infection (n = 6, 30%), metastatic disease (n = 2, 10%), fracture (n = 6, 30%), and calcified disc herniation (n = 6, 30%). Partial and complete corpectomy was performed in 5 patients (25%) and 15 patients (75%), respectively. Mean operative time and estimated blood loss was 276.2 minutes and 558.4 mL, respectively. Mean length of stay from admission and surgery were 14.6 and 11.4 days, respectively. Mean length of stay from surgery for elective cases was 4.2 days. Mean follow-up time was 330.4 days. Visual analogue scale score improved from 7.7 to 4.5 (P < .01). There were a total of 3 postoperative complications in 2 patients, including 1 mortality for urosepsis. One patient had revision spinal surgery for adjacent segment disease. CONCLUSIONS: Corpectomy and reconstruction of the TL spine is feasible and safe using a minimally invasive lateral retropleural or retroperitoneal approach. Since this is a relatively new technique, more studies are needed to compare the short- and long-term radiographic and clinical outcomes between minimally invasive versus open corpectomy of the TL spine.

Gluteus Medius Insertion Damage: A Comparison of Reconstruction and Hip Fracture Nails.

This study assessed damage to the gluteus medius tendon insertion when performing trochanteric nailing with either a reconstruction nail or a cephalomedullary nail. Ten cadavers were randomized to receive proximal reaming for either a reconstruction nail or cephalomedullary nail; the contralateral hip served as an internal control. One specimen was found to have a displaced femoral neck fracture and was excluded from data analysis. Reconstruction nailing led to tendon damage in 4 of 9 hips, compared to 8 of 9 with hip fracture nailing (p = 0.29). In the reconstruction nail group, the average amount of tendon damaged was 3% (range 0-10%), while in the hip fracture nail group, the average was 15% (range 0-20.3%) (p = 0.0003). Open reaming for placement of a reconstruction nail caused less gluteus medius tendon damage when compared to open reaming for placement of a hip fracture nail. (Journal of Surgical Orthopaedic Advances 29(2):77-80, 2020).

Outcomes of Early Surgical Intervention in Geriatric Proximal Femur Fractures Among Patients Receiving Direct Oral Anticoagulation.

OBJECTIVE: To evaluate the prehospital use of direct oral anticoagulant (DOAC) agents on the outcomes of early surgical fixation of a geriatric hip fracture. DESIGN: Case control study. SETTING: Two academic Level 1 trauma centers. INTERVENTION: Early (<48 h) surgical fixation of a geriatric proximal femur fracture. PATIENTS: Nineteen patients receiving Pradaxa (dabigatran), Eliquis (apixaban), or Xarelto (rivaroxaban) who underwent surgery between 2010 and 2015 and 74 control patients. MAIN OUTCOME MEASUREMENTS: Time to surgery, transfusion rates, changes in hemoglobin levels, postoperative complications, readmission rates, and survival out to 1 year. RESULTS: There were no differences in transfusions, changes in hemoglobin levels, wound complications, or survival at any time point. Patients on DOAC had a longer delay to reach the operating room (28.9 h v 21.4 h P = 0.03) and were more likely to undergo readmission within 30 days (21% vs. 5.3% P = 0.05). No readmissions occurred for a complication of the surgical site, bleeding, or a venous thromboembolic event. CONCLUSIONS: Geriatric patients with hip fractures receiving DOAC before admission did not demonstrate worse outcomes with early surgical intervention. The increased readmission rate in this population seems attributable to the underlying cardiac conditions for which the patients were receiving anticoagulation. These results suggest that the delay recommended for patients using a DOAC before elective procedures may be unwarranted in the surgically urgent setting of a hip fracture. Additional studies will be necessary for appropriate meta-analysis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing Lumbar Disc Space Preparation With Fluoroscopy Versus Cone Beam-Computed Tomography and Navigation: A Cadaveric Study.

STUDY DESIGN: Cadaveric study. OBJECTIVE: This cadaveric study sought to evaluate the efficacy of disc space preparation with cone beam-computed tomography with navigation (CBCT+N) for instrument placement compared with instrument placement with conventional fluoroscopy. SUMMARY OF BACKGROUND DATA: Disc space preparation from a transforaminal lumbar approach is challenging with respect to visualization, and surgeons currently rely on tactile feel and two-dimensional imaging in the operating room to assess instrument positioning. METHODS: Two orthopedic spine surgeons performed 40 disc space preparations after eight cadavers were randomly assigned to fluoroscopy versus CBCT+N. Digital images of each vertebral endplate were captured and the percent disc removed by area for the total disc and by quadrants was determined using digital imaging software. RESULTS: There were 20 lumbar disc levels prepared in the fluoroscopy group. There were 3 thoracolumbar, and 17 lumbar disc levels prepared in the experimental group. Percent disc removed relative to the total area of the disc, as determined by the digital imaging software, was higher in the CBCT+N group (P ≤ 0.0001). More disc was removed in both the anterior contralateral and posterior contralateral quadrants in the CBCT+N group (P = 0.0006 and P ≤ 0.0001 respectively). The intraclass correlation coefficient among blinded reviewers for percent disc removed was 0.759 (95% confidence interval, 0.587-0.866)]. There was no difference in time to complete disc space preparation, number of instrument passes, or number of endplate violations between the two groups (P = 0.28, P = 0.92, and P = 0.34 respectively). CONCLUSION: The results of this cadaveric investigation reveal that CBCT+N guidance may be used to assess instrument placement for interbody disc space preparation in a similar length of time, with no difference in instrument passes or endplate violations, in comparison with fluoroscopy. LEVEL OF EVIDENCE: 5.

Use of ankle magnetic resonance imaging in the active duty military population: the results of a process improvement project.

BACKGROUND: Preventing overuse of magnetic resonance imaging (MRI) for diagnosing ankle pathology was the goal of a process improvement project at a military treatment facility. METHODS: Ordering patterns for MRI of nonorthopaedic providers and orthopaedic surgeons were evaluated over 2 separate periods. An educational initiative on appropriate use of MRI in evaluating ankle complaints was conducted between the 2 periods. RESULTS: Between October 2009 and March 2010, 230 ankle MRIs were performed at our institution, compared to 347 ankle MRIs performed between December 2012 and August 2013. A lower number of patients underwent operative procedures after the education process than before (17% versus 25%). Fellowship-trained foot and ankle surgeons produced the highest number of operative patients with their MRI ordering practices (P=.003 and P=.0001 for Phases 1 and 2 respectively). There was no change in the number of ankle MRI studies ordered each month following the educational initiative (38.3 and 38.5 for Phases 1 and 2 respectively). CONCLUSIONS: The majority of patients undergoing ankle MRI did not undergo operative intervention. Foot and ankle surgeons produce the highest number of operative patients with their MRI ordering practices. Education alone was ineffective in altering ankle MRI ordering patterns.

Increased Anterior Column Exposure Using the Anterior Intrapelvic Approach Combined With an Anterior Superior Iliac Spine Osteotomy: A Cadaveric Study.

OBJECTIVE: To determine whether the addition of an anterior superior iliac spine (ASIS) osteotomy to the lateral window, when combined with the anterior intrapelvic (AIP) surgical approach, would improve visualization of the iliopectineal eminence and allow for predictable and safe clamp application. METHODS: Ten lateral window approaches to the iliac fossa were developed in conjunction with the AIP approach on 10 fresh-frozen cadaveric pelvi. A calibrated digital image was taken from the surgeon's optimal viewing angle to capture the visualized osseous surface of the false pelvis with emphasis on the iliopectineal eminence. An ASIS osteotomy was then performed and an additional calibrated image was obtained to identify any increased visualization of the iliopectineal eminence. Using ImageJ software (NIH, Bethesda, MD), the additional surface area afforded to the surgeon was calculated. An AIP approach was then performed to confirm complete exposure of the anterior column and whether a Weber clamp could safely be placed across the iliopectineal eminence. RESULTS: The lateral window, osteotomy, and AIP approach were successfully accomplished in all 10 specimens. Before performing an ASIS osteotomy, a mean of 20.3 cm (range: 14.5-25.6 cm) of the false pelvis adjacent to the pelvic brim was visualized. After completion of the osteotomy, the mean visualized surface area increased significantly to 28.4 cm (range: 14.6-45.6 cm) (P < 0.0168). Clamp placement through the lateral window was unsuccessful in all 10 specimens. After completion of the AIP approach, complete visualization of the iliopectineal eminence was confirmed and safe clamp application through the lateral window possible in all 10 specimens. CONCLUSION: ASIS osteotomy through the lateral window significantly improved visualization and access to the iliopectineal eminence in this cadaveric model, which suggests that it may be a suitable alternative to the traditional ilioinguinal approach for select fracture patterns when combined with an AIP approach.

Risk of Obtaining Routine Cultures During Presumed Aseptic Orthopaedic Procedures.

Treating patients with antibiotics that are selected based on routine cultures obtained from presumed aseptic orthopaedic procedures may lead to an increased risk of antibiotic-related complications without reducing the rate of late deep infection. Routine cultures obtained from 60 of 169 procedures resulted in 23 (38.3%) positive and 37 (61.7%) negative results. Twenty-two patients (13.5%) developed late infections. Seven of 14 patients with positive cultures, who were treated with antibiotics, developed a late infection, while two of nine patients with routine cultures, who received no antibiotic treatment, developed a late infection. Six of 37 patients with negative cultures and seven of 109 patients with no cultures developed a late infection. In patients who developed late deep infection, the microorganism isolated on routine culture only corresponded to the microorganism causing late infection 55.5% of the time. Of all patients treated with antibiotics, seven (29%) experienced an antibiotic-related complication (p = .01). (Journal of Surgical Orthopaedic Advances 26(4):239-245, 2017).

Resuscitation and Treatment of Shock.

Hemorrhage continues to be the most common cause of death among service members wounded in combat. Injuries that were previously nonsurvivable in previous wars are now routinely seen by combat surgeons in forward surgical units, the result of improvements in body armor, the universal use of field tourniquets to control extremity hemorrhage at the point of injury, and rapid air evacuation strategies. Combat orthopaedic surgeons remain a vital aspect of the forward surgical unit, tasked with assisting general surgical colleagues in the resuscitation of patients in hemorrhagic shock while also addressing traumatic amputations, open and closed long bone fractures, and mechanically unstable pelvic trauma. Future military and civilian trauma research endeavors will seek to identify how the advances made in the past 15 years will translate toward the emerging battlefield of the future, one where forward surgical units must be lighter, smaller, and more mobile to address the changing scope of military combat operations.

Postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following arthroscopic anterior cruciate ligament reconstruction in an adolescent: A case report and review of the literature.

We present a case of postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following an arthroscopic anterior cruciate ligament reconstruction in an adolescent male with no pertinent medical history. The patient presented to the emergency department nine days after the operation with fever, an elevated white blood cell count, knee pain, and effusion. Arthrocentesis of the knee yielded purulent fluid that tested positive for S. mitis. Repeat intraoperative cultures revealed E. corrodens. In addition to antibiotics, the patient's treatment course included arthroscopic irrigation and debridement in the operating room as well as removal of graft material and fixation devices. To our knowledge, this is the first case of a polymicrobial infection of E. corrodens and S. mitis causing septic arthritis in a teenager following arthroscopic anterior cruciate ligament reconstruction.

Identifying obstacles to return to duty in severely injured combat-related servicemembers with amputation.

The capacity of servicemembers with amputation to return to duty after combat-related amputation and the associated disabilities remains largely unknown. The purpose of this study was to examine the disabling conditions and return to duty rates of servicemembers with amputation across all service branches following major limb amputations from September 2001 through July 2011. Pertinent medical information, military occupation status, return to duty designation, disabling conditions, and disability ratings for each servicemember were obtained from the Physical Evaluation Board Liaison Office (PEBLO). Across all service branches, 16 (2%) servicemembers were found fit for duty (Fit) and allowed to continue with their preinjury occupation. Another 103 (11%) were allowed to continue on Active Duty (COAD) in a less physically demanding role. More than half (554, 56%) were determined fully disabled (PEBLO rating > 75); the average disability rating was 73. COAD and Fit Army servicemembers had lower Injury Severity Scores than other servicemembers (17.4, p = 0.009 and 11.2, p < 0.001, respectively). Despite improvements in their care and rehabilitation, only 13% of all servicemembers with amputation are able to return to Active Duty and many have multiple disabling conditions that contribute to a very high level of disability.