Virtual Orthopaedic Examination of the Lower Extremity: The Know-How of an Emerging Skill.

¼: Telemedicine has become an emerging necessity in the practice of orthopaedic surgery following the paradigm shift that was brought on by the COVID-19 pandemic. ¼: Physical examination is an integral component of orthopaedic care and plays a crucial role in diagnosis. ¼: Based on our experience and expert opinion in the literature, we recommend the following infrastructure for a virtual orthopaedic physical examination: a computing device with a functioning camera and high-definition input/output audio, a 720p (high-definition) display, a processing speed of 3.4 GHz, an internet connection speed range from 1 to 25 Mbps, adequate lighting, a steady camera that is positioned 3 to 6 ft (0.9 to 1.8 m) from the patient, a quiet environment for the examination, and clothing that exposes the area to be examined. ¼: When performing a virtual examination of the lower extremity, inspection, range of motion, and gait analysis can be easily translated by verbally instructing the patient to position his or her body or perform the relevant motion. Self-palpation accompanied by visual observation can be used to assess points of tenderness. Strength testing can be performed against gravity or by using household objects with known weights. Many special tests (e.g., the Thessaly test with knee flexion at 20° for meniscal tears) can also be translated to a virtual setting by verbally guiding patients through relevant positioning and motions. ¼: Postoperative wound assessment can be performed in the virtual setting by instructing the patient to place a ruler next to the wound for measuring the dimensions and using white gauze for color control. The wound can be visually assessed when the patient's camera or smartphone is positioned 6 to 18 in (15 to 46 cm) away and is held at a 45° angle to the incision.

The Effects of Space Microgravity on Hip and Knee Cartilage: A New Frontier in Orthopaedics.

INTRODUCTION: Given the expansion of commercial and recreational space exploration, orthopaedic surgeons will need to understand the implications of microgravity on cartilaginous damage and to anticipate the resulting pathology from accelerated chondrolysis. The purpose of this systematic review is to evaluate the effects of space and microgravity on hip and knee articular cartilage, including its impact on joint mobility and functional status. MATERIALS AND METHODS: A review of the current literature was performed utilizing the terms "joints," "joint mobility," "articular cartilage," "knee," "hip," "space," "microgravity," and "osteoarthritis" in PubMed and Google Scholar from 1990 to 2018, yielding a total of 1,400 citations following the removal of 500 duplicates. Following screening by eligibility criteria, five reports were included. RESULTS: Dysregulation of osteogenesis and weakened structural integrity of hip and knee cartilage were demonstrated secondary to microgravity. Adequate cartilage repair requires Earth-like conditions as signified by a statistically significant increase in serum cartilage oligomeric matrix protein concentrations in astronauts. Reduced loading led to the degradation of knee ligaments and menisci which may pose a risk for subluxation or dislocation. Murine studies demonstrated decreased articular cartilage thickness in the medial femoral condyle and patella as assessed by ultrasound. Additionally, glycosaminoglycan levels in unloaded rats were lower than weight-bearing rats, with a concomitant increase in matrix metalloproteinase-13 protein, degrading collagen. Return to weight-bearing demonstrated partial recovery of cartilaginous degeneration. CONCLUSIONS: Space and associated microgravity conditions adversely impact articular cartilage as demonstrated in murine and human studies. The pathogenetic process occurs due to the mechanically responsive nature of cartilage, with an increase in cartilage metabolism in microgravity. There remains a marked paucity of literature regarding the gravitational force necessary for adequate cartilage survival and the impact of space-related radiation on cartilage repair. Additionally, further studies should assess pharmacologic interventions, such as recombinant human fibroblast growth factor to stimulate cartilaginous growth.

A Multicenter Study of the Epidemiology of Deep Surgical Site Infections in Children With Nonidiopathic Early-Onset Scoliosis Including Associated Pathogens.

STUDY DESIGN: Retrospective descriptive. OBJECTIVES: Identify incidence and risk of deep surgical site infections (SSIs), associated pathogens, and antibiotic susceptibility in patients with nonidiopathic early-onset scoliosis (EOS) undergoing growth-friendly (GF) spine surgery. BACKGROUND: SSIs following GF procedures for EOS are well described, but epidemiologic trends in associated pathogens have not been well characterized. METHODS: The Children's Spine Study Group database was queried for children ≤18 years of age undergoing GF procedures for nonidiopathic EOS at 11 institutions from September 2001 to January 2016. Deep SSIs reported within 90 days of procedures were reviewed for associated pathogens and their susceptibility profiles. Data were analyzed to calculate incidence and risk. RESULTS: 593 patients (median age 5.7 years, IQR 3.3-8.0 years) with scoliosis due to congenital (45%), neuromuscular (39%), and syndromic (16%) disorders underwent 5,072 procedures. The incidence of deep SSIs per patient was 12.6%; 75 patients had one or more deep SSIs. The risk of deep SSIs per procedure was 1.95% as 99 SSIs occurred after the 5072 procedures. Overall, 48% of deep SSIs followed expansion procedures. Pathogen(s) were cultured from 92% of SSIs including gram-positive cocci (GPC, 90.1%) and/or gram-negative rods (GNR, 17.6%). Methicillin-susceptible Staphylococcus aureus (48.4% of SSIs), methicillin-resistant S. aureus (23.1%), and coagulase negative staphylococci (CoNS, 8.8%) were the most common GPCs. Escherichia coli (5.5% of SSIs), Enterobacter cloacae (4.4%), and Pseudomonas aeruginosa (4.4%) were the most common among GNRs. GNR susceptibility to cefazolin was 41% during the study period, whereas GPC susceptibility to cefazolin was 59%. CONCLUSION: The risk of SSIs can potentially be reduced for this vulnerable population by routinely reviewing the local epidemiology of SSIs, including the associated pathogens and their susceptibility patterns. As GNR susceptibility to cefazolin was only 41%, expanding prophylaxis to include aminoglycosides for GNR is prudent. LEVEL OF EVIDENCE: Level IV.

Biomarkers for Femoroacetabular Impingement and Hip Osteoarthritis: A Systematic Review and Meta-analysis.

BACKGROUND: The early recognition and management of patients with hip lesions, such as femoroacetabular impingement (FAI) and early hip osteoarthritis (OA), may preempt significant hip morbidity. The identification of reliable biomarkers may help guide decision making in an efficient and cost-effective manner. PURPOSE: To determine the biomarkers that have been associated with FAI as well as identify serum, synovial, and urinary analytes that have shown clinical utility in the prediction or identification of hip OA. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The terms "hip arthroscopy," "femoroacetabular impingement," "labral tear," "osteoarthritis," and "biomarker" were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, yielding 276 articles. After screening, 7 articles were included. Pooled estimates were calculated utilizing a fixed-effects inverse-variance model weighted for individual study size. RESULTS: A total of 1747 patients with a mean age of 37.5 ± 4.5 years (76.4% female) were identified. Forty-three unique biomarkers were assessed. Although general proinflammatory cytokines IL-1 and TNF-α exhibited inconsistent trends in arthritic hips, IL-6 demonstrated a consistent increase (+84.8% [95% CI, 81.9%-87.6%]; P < .05). A significant difference was found in levels of the fibronectin-aggrecan complex (FAC) in patients with OA compared with controls (0.08 ± 0.40 vs 1.15 ± 0.35 µg/mL, respectively; P < .001). It was the only specific analyte to show a significant difference between those with and without OA. In the setting of FAI, cartilage oligomeric matrix protein (COMP) was significantly increased in athletes after adjusting for concurrent knee and hip OA. A statistically significant difference was present in FAI-positive hips (9.0 ± 0.1 [95% CI, 8.8-9.3]) compared with controls (8.4 ± 0.1 [95% CI, 8.2-8.4]) (P < .05). Other biomarkers, such as CXCL3, which exhibited statistically significant differences compared with controls, did not control for underlying factors such as age and concomitant lesions. CONCLUSION: COMP and FAC are specific biomarkers with potential utility in the diagnosis and management of FAI and hip OA, given their ability to differentiate between controls and patients with hip lesions. Further research is necessary to identify their ability in determining disease severity, predicting the response to treatment, and establishing an association with the risk of long-term OA.

Predictors of Extended Length of Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Segmental Instrumented Fusion: An Analysis of 407 Surgeries Performed at a Large Academic Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). SUMMARY OF BACKGROUND DATA: Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. METHODS: A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. RESULTS: Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ±â€Š2 vs. 7 ±â€Š2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ±â€Š548 vs. 488 ±â€Š341 cm, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ±â€Š2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS. CONCLUSION: Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay. LEVEL OF EVIDENCE: 3.

Systematic Review and Meta-analysis of Outcomes After Hip Arthroscopy in Femoroacetabular Impingement.

BACKGROUND: Femoroacetabular impingement (FAI) has become a more commonly recognized cause of limited hip range of motion and hip pain among young adults and athletes. Hip arthroscopy is recommended for the surgical treatment of this disorder, unless specific contraindications exist. Despite the increasing rate of published studies in this area, there remains no aggregate data for outcomes after this approach. PURPOSE: To evaluate risk factors and outcomes after arthroscopic management of FAI, including return to play, revision rate, surgical and nonsurgical complications, change in α-angle, intraoperative bone resection, and patient-reported outcomes. STUDY DESIGN: Meta-analysis and systematic review. METHODS: A review of the current literature was performed with the terms "femoroacetabular impingement," "hip arthroscopy," and numerous variations thereof in PubMed, EMBASE, BioMed Central, Cochrane, Science Direct, and Scopus, yielding 1723 abstracts. After screening by eligibility criteria, 31 articles were included. The incidence of bilateral FAI was determined by enrollment data, and pooled estimates were calculated for postoperative patient-reported outcome measures, α-angles, return to sport, postoperative complications, and reoperation risk. RESULTS: A total of 1981 hips among 1911 patients were identified, with a mean ± SD age of 29.9 ± 1.9 years and 29.5 ± 14.0 months of follow-up. The incidence of bilateral FAI in these studies that required operative intervention was 3.6%. The pooled risk of reoperation after hip arthroscopy, including revision surgery or subsequent total hip arthroplasty, was 5.5% (95% CI, 3.6%-7.5%). The risk of clinical complications was 1.7% (95% CI, 0.9%-2.5%). In total, 87.7% of patients demonstrated return to sport after surgery (95% CI, 82.4%-92.9%, P < .001), and all patient-reported outcomes improved postoperatively, with the highest increase observed in the Hip Outcome Score sports scale (41.7 points; 95% CI, 34.1-49.4; P < .001). The α-angle decreased by an average of 23.6° (95% CI, 18.2°-29.0°; P < .001). We identified 11 factors associated with the success of hip arthroscopy in FAI and 16 factors associated with failure or negative outcomes. CONCLUSION: A high percentage of patients return to sport activities after hip arthroscopy for FAI, with a low rate of complications and reoperation. All patient-reported outcome measures, except for mental health, significantly improved after surgery.

Outcomes of Joint Preservation Procedures for Cartilage Injuries in the Hip: A Systematic Review and Meta-analysis.

BACKGROUND: The detection and management of chondral injuries of the hip, especially in a younger patient population, may preempt joint degeneration. Although the outcomes of preservation techniques have been well described for other weightbearing joints, such as the knee, evidence for hip joint preservation after procedures such as microfracture and autologous chondrocyte implantation remains in its infancy. PURPOSE: To evaluate outcomes of joint preservation procedures in the hip, including the success rate and patient-reported outcomes (PROs). STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This review was performed using the terms "hip arthroscopy," "microfracture," "autologous chondrocyte implantation," "fibrin glue," "osteochondral transfer," and variations thereof in 5 electronic databases, yielding 325 abstracts. After the application of eligibility criteria, 19 articles were included. Weighted means were calculated for PROs, and pooled estimates were calculated for age, follow-up, chondral lesion size, and success of hip preservation procedures with a random-effects proportion meta-analysis. RESULTS: A total of 1484 patients (1502 hips) were identified across 19 studies (mean age, 38.0 ± 1.3 years; mean follow-up, 31.8 ± 9.6 months). Hip joint preservation techniques demonstrated a high success rate, ranging from 85.6% to 99.7%. The mean pooled chondral lesion size was 2.5 ± 0.3 cm2 (95% CI, 1.9-3.0 cm2). Microfracture was the most frequent technique, utilized by 11 studies, and demonstrated an 89.6% success rate (95% CI, 82.4%-96.7%). The highest pooled success rate was exhibited by autologous membrane-induced chondrogenesis in 3 studies (99.7% [95% CI, 99.0%-100.0%]). All PROs demonstrated a statistically significant increase postoperatively, including the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Activities of Daily Living and Hip Outcome Score-Sports-Specific Subscale (all P < .05). The visual analog scale for pain also demonstrated a statistically significant decrease of 37.2% (P < .05). CONCLUSION: Hip preservation procedures demonstrate a high success rate, with microfracture representing the most frequently utilized cartilage preservation technique in the peer-reviewed literature. PROs significantly improved after surgery. Further investigation of hip preservation modalities with long-term follow-up is required to create evidence-based clinical recommendations and treatment algorithms.

Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections.

OBJECTIVE: To compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion. STUDY DESIGN: Retrospective cohort study. SUMMARY OF BACKGROUND DATA: Although PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population. METHODS: Patients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used. RESULTS: 115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC. CONCLUSION: Utilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis. LEVEL OF EVIDENCE: Level II.

Return to Play After Hip Arthroscopy: A Systematic Review and Meta-analysis.

BACKGROUND: The use of arthroscopic treatment for intra-articular hip pathology has demonstrated improved patient-reported outcomes (PROs) with a lower rate of complications, reoperation, and patient morbidity as compared with traditional methods. Although the use of this minimally invasive approach has increased in prevalence, no evidence-based return-to-play (RTP) criteria have been developed to ensure an athlete's preparedness for sporting activities. PURPOSE: To determine if there exists sufficient evidence in the literature to support an RTP protocol and functional assessment after hip arthroscopy, as well as to assess the mean rate and duration of RTP. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The search terms "hip arthroscopy," "return to play," and 10 related terms were searched in PubMed, Cochrane Library, Scopus, and Web of Science, yielding 263 articles. After screening, 22 articles were included. RTP timeline, rehabilitation protocols, and conditional criteria measures were assessed with previously established criteria. Pooled estimates were calculated for RTP rate and duration, and weighted mean scores were determined for PROs. RESULTS: A total of 1296 patients with 1442 total hips were identified. Although 54.5% (12 of 22) of studies did not provide a guideline for RTP duration after hip arthroscopy, 36.4% (8 of 22) recommended a duration of 4 months, while 9.1% (2 of 22) recommended 3 months. The most frequently described postoperative rehabilitation protocols were weightbearing guidelines (15 studies) and passive motion exercises (9 studies). Only 2 studies satisfied the criteria for a sufficient RTP protocol, and 3 provided a specific replicable test for RTP. The mean RTP duration was 7.4 months (95% CI, 6.1-8.8 months), and the return rate was 84.6% (95% CI, 80.4%-88.8%; P = .008) at a mean ± SD follow-up of 25.8 ± 2.4 months. Mean modified Harris Hip Score (mHHS) improved from 63.1 to 84.1 postoperatively (+33.3%), while Non-arthritic Hip Score improved from 61.7 to 86.8 (+40.7%). A lower preoperative mHHS was significantly associated with a higher postoperative improvement ( r = -0.95, P = .0003). CONCLUSION: Significant variability exists in RTP protocols among institutions owing to a lack of standardization. Despite a high overall rate of RTP and improvement in PROs after hip arthroscopy, the majority of rehabilitation protocols are not evidence based and rely on expert opinion. No validated functional test currently exists to assess RTP.

Acute Kidney Injury Secondary to Cell Saver in Posterior Spinal Fusion.

BACKGROUND: Autologous blood transfusion, commonly referred to as cell saver, is frequently used in spinal fusion to salvage red blood cells because of the risk of significant intraoperative blood loss. This case report describes a case of acute kidney injury (AKI) secondary to cell saver use. Our objective is to increase the knowledge about the process of red blood cell salvage and this exceedingly rare complication. METHODS: Chart and renal biopsy results for a single case were reviewed and reported in this retrospective study. RESULTS: A healthy 18-year-old male patient underwent posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis with utilization of intraoperative autologous blood transfusion. The patient subsequently developed hematuria and AKI with a peak creatinine of 13.9 mg/dL. An extensive clinical workup, including autoimmune serology, excluded any identifying causes. A renal biopsy showed pigment-induced acute tubular necrosis. CONCLUSIONS: This case, to our knowledge, is the first and only case report of AKI secondary to cell saver demonstrated by renal biopsy. The literature has shown both the benefit of cell saver by decreasing the need for allogeneic transfusion and the risk of transient hematuria. However, this case demonstrates the importance of monitoring patients for potential complications.

Temporary occipital fixation in young children with severe cervical-thoracic spinal deformity.

OBJECTIVE The long-term effects of instrumentation and fusion of the occipital-cervical-thoracic spine on spinal growth in young children are poorly understood. To mitigate the effects of this surgery on the growing pediatric spine, the authors report a novel technique used in 4 children with severe cervical-thoracic instability. These patients underwent instrumentation from the occiput to the upper thoracic region for stabilization, but without bone graft at the craniovertebral junction (CVJ). Subsequent surgery was then performed to remove the occipital instrumentation, thereby allowing further growth and increased motion across the CVJ. METHODS Three very young children (15, 30, and 30 months old) underwent occipital to thoracic posterior segmental instrumentation due to cervical or upper thoracic dislocation, progressive kyphosis, and myelopathy. The fourth child (10 years old) underwent similar instrumentation for progressive cervical-thoracic scoliosis. Bone graft was placed at and distal to C-2 only. After follow-up CT scans demonstrated posterior arthrodesis without unintended fusion from the occiput to C-2, 3 patients underwent removal of the occipital instrumentation. RESULTS Follow-up cervical spine flexion/extension radiographs demonstrated partial restoration of motion at the CVJ. One patient has not had the occipital instrumentation removed yet, because only 4 months have elapsed since her operation. CONCLUSIONS Temporary fixation to the occiput provides increased biomechanical stability for spinal stabilization in young children, without permanently eliminating motion and growth at the CVJ. This technique can be considered in children who require longer instrumentation constructs for temporary stabilization, but who only need fusion in more limited areas where spinal instability exists.