Spinal Fusion in Patients With Classic Amyoplasia and General Arthrogryposis.

BACKGROUND: Arthrogryposis multiplex congenita is a group of conditions characterized by joint contractures affecting 2 or more joints. This study describes results of spinal fusion in patients with classic amyoplasia and general arthrogryposis. METHODS: IRB approved retrospective review of patients with a diagnosis of classic amyoplasia and general arthrogryposis who had a primary definitive posterior spinal fusion between 1990 and 2017 at a single pediatric institution. Patients with distal and syndromic arthrogryposis were excluded as well as patients treated with growth-sparing spinal instrumentation. The Modified Clavien-Dindo-sink (MCDS) classification system was used to describe postoperative complications. RESULTS: Over the 28-year period, 342 patients were diagnosed with amyoplasia and general arthrogryposis. Among the 342 patients, 60 (18%) had scoliosis, and 22 (6% of the cohort and 37% of those with scoliosis) were treated surgically. Six patients had growth-sparing techniques, initial fusion elsewhere, or ˂1 year of follow-up, leaving 15 patients. Of the 15, 9 (60%) had a posterior spinal fusion (PSF) and 6 (40%) had a combined anterior spinal fusion (ASF)/PSF. The ASF/PSF group was significantly younger at surgery, had a greater American Society of Anesthesiologists status, longer surgery duration, and lower implant density. The average preoperative major coronal deformity in ASF/PSF patients (108 degrees) was greater than patients treated with PSF alone (88 deg). There were 11 complications in 7 patients, with the most common being deep infection requiring reoperation (5/11, 45%). There was 1 instance (1/11, 9%) of each: prolonged intensive care unit admission (>72 h), superficial wound dehiscence, symptomatic implants requiring removal/revision, coronal plane progression requiring extension of fusion, recurrent pneumothorax requiring return to OR, and pseudoarthrosis leading to implant failure (without revision). Complications occurred in 1/9 (11%) PSF-only patients and 6/6 (100%) ASF/PSF patients with all 6 ASF/PSF patients requiring at least 1 reoperation. The average coronal correction was 48% in the PSF-only group and 28% in the ASF/PSF group. CONCLUSION: Complication rates after spinal fusion for scoliosis in arthrogryposis multiplex congenita patients are high, especially in patients undergoing ASF/PSF, deep infection is common, and major coronal plane curve correction is modest. LEVEL OF EVIDENCE: II Retrospective Study.

Complications of primary total hip arthroplasty in human immunodeficiency virus-positive patients with femoral head osteonecrosis.

BACKGROUND: Femoral head osteonecrosis (FHON) is a well-recognised complication in patients with human immunodeficiency virus (HIV) infection. Total hip arthroplasty (THA) is a reliable solution to FHON and has provided functional improvement and pain relief in these patients. Higher complication rates, in particular infections, have been reported in the series of THAs done in the HIV-positive patients. The purpose of this study was to evaluate the complication rate of THA for FHON in HIV-positive patients managed with the highly active antiretroviral therapy (HAART) protocols. METHODS: A retrospective review was performed of HIV-positive patients with FHON who underwent THAs over a 10-year period at a single institution. RESULTS: A total of 56 THAs (44 patients) met the inclusion criteria. The mean age at the time of THAs was 47 (range 34-60) years. Of the 44 patients, 39 (88.6%) were males. The mean follow-up was 6.6 (range 2.0-11.3) years. The overall complication rate was 12.5%, with 2 (3.6%) cases of deep periprosthetic infections. CONCLUSIONS: HIV-positive patients with FHON undergoing THAs do have a considerable complication rate (12.5%). The deep periprosthetic infection rate (3.6%) in these patients, however, has decreased with contemporary disease modification protocols.

Differences Between Total Ankle Replacement and Ankle Arthrodesis in Post-operative Complications and Reoperations at 30 Days and One Year.

Purpose Total ankle replacement (TAR) and ankle arthrodesis (AA) are two commonly performed procedures for end-stage arthritis of the ankle joint. The aim of this study was to analyze the differences in the rates of complications and reoperations at both 30 days and one year within a matched sample of TAR and AA patients from a large database population. Methods A commercially available patient database record, known as the PearlDiver database (www.pearldiverinc.com, Colorado Springs, CO, USA), was used for this study. Patients undergoing TAR and AA were identified using Current Procedural Terminology (CPT) codes. After matching both TAR and AA groups for confounding variables, such as diabetes, smoking, obesity, and comorbidities scores, the differences in the rates of complications at 30 days and one year and the rate of reoperation at one year were evaluated in both groups. Results After matching for confounding variables, there were 1287 patients in each group. There was no significant difference in the male/female ratio. Within each group, 430 patients were diabetic, 102 patients smoked, and 543 patients were obese. The rate of surgical site infection (SSI) and wound dehiscence were higher at 30 days in the AA group. About 63.45% of complications happened after 30 days. The AA group showed a higher rate of SSI, wound dehiscence, mechanical complications, and pneumonia at one year. The rate of reoperation was also higher in the AA group at one year. Conclusion Ankle arthrodesis is associated with a higher rate of local and systemic complications at 30 days and one year, along with a higher reoperation rate at one year, when compared to total ankle replacement. Most complications happened after 30 days, suggesting that studies reporting complications within 30 days following AA and TAR may underestimate the true rates of complications.

Demographic Factors Associated With an Increased Incidence of Intra-articular Injuries After Delayed Anterior Cruciate Ligament Reconstruction.

Background: Delays from the time of an anterior cruciate ligament (ACL) tear to surgical reconstruction are associated with an increased incidence of meniscal and chondral injuries. Purpose: To evaluate the association between delays in ACL reconstruction (ACLR) and risk factors for intra-articular injuries across 8 patient demographic subsets. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We performed a retrospective chart review of all patients who underwent ACLR from January 2009 to May 2015 at a single institution. Variables collected were age, sex, body mass index, time from injury to surgery, and presence of meniscal tears and chondral injuries. Demographic subsets were created according to sex, age (<27 vs ≥27 years), body mass index (<25 vs ≥25 kg/m2), and injury setting (sports vs non-sports related). Subsets were divided by time from injury to ACLR: 0 to <6 months (control group), 6 to <12 months, and ≥12 months. Multivariate logistic regression-generated odds ratios (ORs) were calculated. Results: Overall, 410 patients were included. ORs were significant for an increased incidence of medial meniscal tears (MMTs) (OR, 1.12-3.72; P = .02), medial femoral condyle (MFC) injuries (OR, 1.18-4.81; P = .02), and medial tibial plateau (MTP) injuries (OR, 1.33-31.07; P = .02) with surgical delays of 6 to <12 months. With ≥12-month delays, significance was found for MMTs (OR, 2.92-8.64; P < .001), MFC injuries (OR, 1.86-5.88; P < .001), MTP injuries (OR, 1.37-21.22; P = .02), lateral femoral condyle injuries (OR, 2.41-14.94; P < .001), and lateral tibial plateau injuries (OR, 1.15-5.27; P = .02). In the subset analysis, differences in the timing, location, rate, and pattern of chondral and meniscal injuries became evident. Female patients and patients with non-sports-related ACL tears had less risk of associated injuries with delayed surgery, while other demographic groups showed an increased injury risk. Conclusion: When analyzing patients who were symptomatic enough to eventually require surgery, an increased incidence of MMTs and medial chondral injuries was associated with ≥6-month delays in ACLR, and an increased incidence of lateral chondral injuries was associated with ≥12-month delays. Female patients and patients with non-sports-related ACL tears had less risk of injuries with delayed ACLR.

Standardized total knee arthroplasty pathway improves outcomes in minority patients.

OBJECTIVES: Inferior total knee arthroplasty (TKA) outcomes are reported in minority populations. Standardized TKA pathways improve outcomes but have not been studied extensively in minority populations. This study evaluated the impact of TKA pathway standardization at an urban teaching hospital that predominantly treats minority patients. STUDY DESIGN: Retrospective cohort study. METHODS: This study compared primary TKA outcomes before and after implementation of a standardized multidisciplinary pathway that emphasized preoperative education and discharge planning, preemptive multimodal pain control, and early rehabilitation. Patients were grouped as "nonpathway" (n = 144) or "pathway" (n = 182) based on whether they underwent TKA before or after pathway implementation. Outcomes included length of stay (LOS), patient-controlled analgesia (PCA) use, blood transfusion, postoperative hemoglobin, complications, and discharge disposition. Analysis involved negative binomial and multiple logistic regression models, t tests, and Fisher's exact tests. RESULTS: Mean (SD) age was 61.6 (8.7) years, and 36.5% were men. Ethnicity of the patients included Hispanic (44.5%), African American (27.9%), Asian (14.1%), and White (12.9%). Pathway and nonpathway patients were similar demographically and racially. Pathway patients had shorter LOS (P = .04), less PCA use (P < .001), more frequent discharge home (P = .03), fewer transfusions (P = .002), and higher postoperative hemoglobin (P < .001). Overall incidence of complications was similar (P = .61). Nonpathway patients developed more cardiopulmonary complications (P = .02), whereas pathway patients had more wound dehiscence (P = .01). CONCLUSIONS: Compared with nonpathway patients, standardized TKA pathway patients had shorter LOS, decreased PCA use, increased discharge to home, fewer blood transfusions, and higher postoperative hemoglobin, with no difference in total incidence of complication.

Anterior Cruciate Ligament Tears: The Impact of Increased Time From Injury to Surgery on Intra-articular Lesions.

BACKGROUND: Previous research has shown that meniscal and articular cartilage lesions increase with time in the anterior cruciate ligament (ACL)-deficient knee. PURPOSE: To analyze the association between increased time from ACL injury to reconstruction and the presence of intra-articular lesions. DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective chart review was performed for patients who sustained an ACL injury and underwent reconstruction from January 1, 2009, to May 14, 2015. Factors analyzed included age, sex, and body mass index, as well as time from injury to surgery, the presence of meniscal tears, and the presence of cartilage lesions. The data were evaluated to quantify the association between time from ACL injury to reconstruction and presence of intra-articular lesions. RESULTS: Overall, 405 patients were included in this study. Regarding time from injury, 27.3% patients were treated at <3 months, 23.6% at 3 to <6 months, 18% at 6 to <12 months, 13.6% at 12 to <24 months, 10.6% at 24 to <60 months, and 6.9% at ≥60 months. When compared with the group treated <3 months from injury, a significant increase in the rate of medial meniscal tears was seen in the groups treated at 6 to <12 months (odds ratio [OR], 2.2), 12 to <24 months (OR, 3.5), 24 to <60 months (OR, 7.0), and ≥60 months (OR, 6.3). A similar trend was seen with medial femoral condyle lesions in the groups treated at 6 to <12 months (OR, 2.5), 12 to <24 months (OR, 2.6), 24 to <60 months (OR, 2.6), and ≥60 months (OR, 6.9). The prevalence of lateral tibial plateau and lateral femoral condyle lesions also significantly increased with increased time between ACL injury and reconstruction, but this association was not seen until 24 to <60 months (ORs, 5.1 and 11.5, respectively). CONCLUSION: For patients undergoing ACL reconstruction, an interval >6 months between injury and surgery was associated with an increased prevalence of medial meniscal tears and medial compartment chondral lesions at the time of surgery. An interval >24 months between injury and surgery was associated with an increased prevalence of lateral compartment chondral lesions at the time of surgery.