Introduction
Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative ...outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications.
Methods
We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis;
P
< 0.05 was the significant threshold.
Results
There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (
P
< 0.001 in univariate,
P
< 0.001 in multivariate), but not in fixation type (
P
< 0.001 in univariate, but
P
= 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard’s nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (
P
= 0.13 vs.
P
< 0.001, respectively).
Conclusion
We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.
Background:
Elbow ulnar collateral ligament (UCL) repair with suture brace augmentation shows good time-zero biomechanical strength and a more rapid return to play compared with UCL reconstruction. ...However, there are concerns about overconstraint or stress shielding with nonabsorbable suture tape. Recently, a collagen-based bioinductive absorbable structural scaffold has been approved by the Food and Drug Administration for augmentation of soft tissue repair.
Purpose/Hypothesis:
This study aimed to assess the initial biomechanical performance of UCL repair augmented with this scaffold. We hypothesized that adding the bioinductive absorbable structural scaffold to primary UCL repair would impart additional time-zero restraint to the valgus opening.
Study Design:
Controlled laboratory study.
Methods:
Eight cadaveric elbow specimens—from midforearm to midhumerus—were utilized. In the native state, elbows underwent valgus stress testing at 30o, 60o, and 90o of flexion, with a cyclical valgus rotational torque. Changes in valgus rotation from 2- to 5-N·m torque were recorded as valgus gapping. Testing was then performed in 4 states: (1) native intact UCL—with dissection through skin, fascia, and muscle down to an intact UCL complex; (2) UCL-transected—distal transection of the ligament off the sublime tubercle; (3) augmented repair with bioinductive absorbable scaffold; and (4) repair alone without scaffold. The order of testing of repair states was alternated to account for possible plastic deformation during testing.
Results:
The UCL-transected state showed the greatest increase in valgus gapping of all states at all flexion angles. Repair alone showed similar valgus gapping to that of the UCL-transected state at 30° (P = .62) and 60° of flexion (P = .11). Bioinductive absorbable scaffold–augmented repair showed less valgus gapping compared with repair alone at all flexion angles (P = .021, P = .024, and P = .024 at 30°, 60°, and 90°, respectively). Scaffold-augmented repair showed greater gapping compared with the native state at 30° (P = .021) and 90° (P = .039) but not at 60° of flexion (P = .059). There was no difference when testing augmented repair or repair alone first.
Conclusion:
UCL repair augmented with a bioinductive, biocomposite absorbable structural scaffold imparts additional biomechanical strength to UCL repair alone, without overconstraint beyond the native state. Further comparative studies are warranted.
Clinical Relevance:
As augmented primary UCL repair becomes more commonly performed, use of an absorbable bioinductive scaffold may allow for improved time-zero mechanical strength, and thus more rapid rehabilitation, while avoiding long-term overconstraint or stress shielding.
Background
Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2–23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the ...Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN.
Patients and methods
A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip–apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life.
Results
The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a
p
-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (
p
= 0.027 and
p
= 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (
p
= 0.027 and
p
< 0.05, respectively).
Conclusions
According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures.
Level of evidence
Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.
Purpose
This study was designed to (1) evaluate the clinical outcomes after arthroscopic subspinal decompression in patients with hip impingement symptoms and low AIIS, and to (2) assess the presence ...of low anterior inferior iliac spine on the pre-operative radiographs of patients with established subspinal impingement diagnosed intra-operatively.
Methods
Retrospective analysis of patients who underwent arthroscopic subspinal decompression has been performed. The indications for surgery were femoroacetabular impingement (FAI), or subspinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine.
Results
Thirty-four patients underwent arthroscopic subspinal decompression between 2012 and 2015. The patients were followed for a median of 25 months (13–37 months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients and grade 3 anterior inferior iliac spine was found in 7 patients. MHHS, HOS, and HOSS scores increased from median (range) pre-operative scores of 55 (11–90), 48 (20–91) and 20 (0–80) to 95 (27–100), 94 (30–100) and 91 (5–100), respectively (
p
< 0.0001,
p
= 0.001,
p
< 0.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6/34 patients via AP radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21/34 (61.8%) patients.
Conclusions
Arthroscopic subspinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13 months follow-up. Low AIIS is often under-diagnosed on AP pelvis and lateral frog radiographs and if left untreated, may result in unresolved symptoms and failed procedure.
Level of evidence
IV.
Objectives:
Matrix-induced autologous chondrocyte implantation (MACI) is a well-established method for knee cartilage restoration that uses autologous chondrocytes seeded onto a porcine membrane.
...Preserving chondrocyte viability while ensuring the correct size and contour of the MACI membrane is critical to the outcome. Traditional manual preparation has been performed using scissors (Sc). More recently, custom cutters (CC) have made preparation easier and more efficient. However, the effect of the MACI preparation method on cell viability is currently unknown. The purpose of this study was to determine the difference in chondrocyte viability between MACI membranes prepared with either the Sc or CC technique. Our hypothesis was that there would be no difference in overall cell viability between groups.
Methods:
The study was approved by the Institutional Review Board (IRB), and all the patients were consented prior to surgery. The remnant MACI membrane following surgical implantation (N=5 patients) was utilized for study purposes. A board-certified and fellowship-trained surgeon prepared each membrane on the back table using sterile technique. Preparation included an untouched region (control), a hand-cut 15 mm circular region (Sc), and a custom-cut 15mm circular region (CC). The samples were carefully transported in media to the laboratory setting. In the laboratory, The Sc and the CC regions were further divided into three distinct zones depending on their proximity to the cutting area (i.e., impact, adjacent, and central zones), and tested using confocal laser scanning microscopy with 3D Spot Segmentation to quantify the percentage of Live/Dead cells within the various zones (percentage of live cells and cell density were presented in x105/cm2). The Impact Zone, which was the closest to the cutting edge, was defined by the boundary of high cell density. This was followed by the Adjacent Zone between the Impact Zone and the most inner Central Zone. The size of the Impact Zone was calculated relative to the size of the entire sample. The increase of dead cells in the affected zones were calculated relative to the total cell count and represented as a percentage. Results were analyzed statistically.
Results:
The cell viability was lower in the Impact Zone of both the Sc (40.94% ± 2.85, p < 0.005) and CC (36.42% ± 3.85, p < 0.005) groups when compared to the Adjacent Zone (74.17% ± 2.8 and 77.69% ± 2.97, respectively). The cell viability remained high in the Central Zone in all samples, with no significant differences between the Sc and CC groups. (77.18% ± 1.38 to 79.95% ± 1.99, p>.05). The average cell density in both Impact and Adjacent Zones was 5.84 ± 0.26 to 6.49 ± 0.34 x 105/cm2 (p>.05) respectively. The total size of the Impact Zone in both Sc and CC groups was 9.22% ± 0.79 for the CC group and 10.17% ± 1.59 for the Sc group, p>.05. Similarly, the percentage of non-viable cells resulting from the cutting preparation was 3.75% ± 0.38 and 3.97% ± 0.22 for the custom cut and hand-cut groups, respectively, without significant differences between the groups.
Conclusions:
MACI membrane prepared with either the Sc or CC technique demonstrated a significant reduction in cell viability in the Impact Zone (i.e. periphery) as compared to the Central Zone of the MACI transplant. The Impact Zone was estimated to be approximately 10% of the overall membrane with roughly 4% increased cell death attributed to membrane cutting in each group. There was no difference in the overall chondrocyte viability or size of the Impact Zone when comparing Sc to CC groups. Based on these study results, surgeons may consider using either technique when performing the MACI procedure.
Background:
With a greater understanding of the importance of the acetabular labrum in the function of the hip, labral repair is preferred over debridement. However, in some scenarios, preservation ...or repair of the labrum is not possible, and labral reconstruction procedures have been growing in popularity as an alternative to labral resection.
Purpose:
To provide an up-to-date analysis of the literature to determine the overall efficacy of labral reconstruction when compared with labral repair or resection.
Study Design:
Systematic review; Level of evidence, 3.
Methods:
PubMed, Embase, and MEDLINE databases were searched for literature regarding labral reconstruction in the hip before July 21, 2020. The results were screened and evaluated by 2 reviewers, and a third reviewer resolved any discrepancies. The final studies were evaluated using the MINORS (Methodological Index for Non-randomized Studies) score.
Results:
There were 7 comparative studies that fit the inclusion criteria, with 228 hips from 197 patients. The mean follow-up was 34.6 months, and the mean age of all patients was 38.34 years. There were slightly more female patients than male patients (105 vs 92). Arthroscopic reconstruction was performed in 86% of studies (6/7); open surgical techniques, in 14% (1/7). A variety of grafts was used in the reconstructions. The indications for labral reconstruction and outcome measures varied in these publications. Nine patients were lost follow-up, and 6 patients converted to total hip replacement postlabral reconstruction. The assessment of these comparative studies illustrated statistically equivalent results between labral reconstruction and labral repair. Comparisons of labral reconstruction with labral resection also showed statistically equivalent postoperative patient-reported outcome scores; however, the rates of conversion to total hip arthroplasty were significantly higher in the population undergoing resection.
Conclusion:
The review of current available comparative literature, which consists entirely of level 3 studies, suggests that labral reconstruction does improve postoperative outcomes but does not demonstrate superiority over repair. There may, however, be benefit to performing labral reconstruction over resection owing to the higher rate of conversion to total hip arthroplasty in the labral resection group.
Background: Tibial tubercle osteotomy (TTO) can realign the patellofemoral joint and reduce patellofemoral contact stress. Anteriorization can reduce compressive patellofemoral loads and ...medialization shifts the pulling direction on the patella, thereby lowering the load on the lateral compartments. Indications: Patellofemoral instability, patellofemoral malalignment, and distal and lateral chondral defects. Technique Description: The Multi-Directional Tibial Tubercle Transfer System (MD3T) uses a generic 3-dimensional cutting template to create 2 compound wedges that are individually transposed and adjusted to achieve multiplanar correction. For isolated tibial tubercle anteriorization, the primary wedge is solely used and the proximal bone defect is filled with autograft taken from the distal part of the wedge and synthetic bone graft substitution. For tibial tubercle medialization, the primary and secondary wedges are transposed, filling each other's respective spaces. Through the transposition of the primary and secondary wedges, partial filling of the defect with the patient's own bone is achieved, reducing the bone defect. For combined anteromedialization, both of these techniques are merged. Results: During walking fatigue test and chair rising test in a cadaveric simulated 42-day healing period, no loosening or cracking occurred. Clinical study results on this technique are pending. Conclusion: The MD3T system achieves with its wedge technique a precise and reproducible multiplanar correction in TTO. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
A proper reduction and internal fixation of posterior malleolar fractures can be challenging, as intraoperative fluoroscopy often underestimates the extent of the fracture. Our aim was to assess the ...value of a modified classification system for posterior malleolar fractures, which is based on computed tomography (CT) images, optimizing screw trajectory during fluoroscopic-guided surgery, and to compare it to the Lauge-Hansen classification system to the CT-based classification.
A retrospective review of all ankle fracture operations from January 2014 to December 2016 was performed. Fractures were included if a CT scan was performed within 1 week of the surgery, and the posterior malleolar fragment occupied one third or more of the antero-posterior talar surface or jeopardize the ankle stability. Eighty-five adult ankle fractures with posterior malleolar fragments were included in this study. Fractures were categorized into one of three types, namely "postero-lateral," "postero-medial," or "postero-central," according to the location of the fracture fragment on axial CT image. An optimal trajectory angle for a single-lag screw fixation was measured on the CT cut between a central antero-posterior line and the line intersecting the posterior fragment perpendicular to the major fracture line. Mean trajectory angles were calculated for each fracture type. Fractures were also categorized according to the Lauge-Hansen system.
The mean trajectory angle was 21° lateral for "postero-lateral" fragments, 7° lateral for "postero-central" fragments, and 28° medial for "postero-medial" fragments (p < 0.01 for comparisons among the groups). The range of trajectory angles within each group was about 10°, as compared to about 20° within each Lauge-Hansen type. There were no differences in trajectory angle among the Lauge-Hansen groups (p > 0.05 for all comparisons).
There are 3 distinct anatomic subgroups of posterior malleolar fragments, each with an ideal screw trajectory that needs to be used in order to achieve an optimal reduction and fixation.
Platelet-Rich Plasma (PRP) injection has become a desirable alternative to Partial Plantar Fasciotomy (PPF) surgery and steroid injection for patients with chronic plantar fasciitis (CPF) due to its ...potential for shorter recovery times, reduced complications, and similar activity scores. As such, we compared PRP treatment to PPF surgery in patients with CPF. Between January 2015 and January 2017, patients were randomly divided into two groups, a PRP treatment group, and a PPF group. All procedures were performed by a single foot and ankle fellowship-trained specialist surgeon. Visual Analog Score (VAS) and Roles-Maudsley Scale (RM) were collected during the preoperative visit and 3, 6, and 12 months postoperatively. The patients were also closely followed by a physiotherapist. There were 16 patients in each group after four patients refused to participate. Patients in the PPF had low Roles-Maudsley Scale (RM) scores compared to the PRP group one-year after treatment (3.77 vs. 2.72,
< 0.0001). Both procedures showed a reduction in RM scores during the follow-up year (9 to 1.62 for PPF and 8.7 to 2.4 for PRP). There was no significant change in VAS pain between the two groups (
= 0.366). Patients treated with PRP injection reported a significant increase in their activity scores, shorter recovery time, and lower complication rates compared to PPF treatment. Moreover, with respect to existing literature, PRP may be as efficient as steroid injection with lower complication rates, including response to physical therapy. Therefore, PRP treatment may be a viable option before surgery as an earlier line treatment for CPF. Level of Clinical Evidence: II.
: Anticoagulation use in the elderly is common for patients undergoing femoral neck hip surgery. However, its use presents a challenge to balance it with associated comorbidities and benefits for the ...patients. As such, we attempted to compare the risk factors, perioperative outcomes, and postoperative outcomes of patients who used warfarin preoperatively and patients who used therapeutic enoxaparin.
: From 2003 through 2014, we queried our database to determine the cohorts of patients who used warfarin preoperatively and the patients who used therapeutic enoxaparin. Risk factors included age, gender, Body Mass Index (BMI) > 30, Atrial Fibrillation (AF), Chronic Heart Failure (CHF), and Chronic Renal Failure (CRF). Postoperative outcomes were also collected at each of the patients' follow-up visits, including number of hospitalization days, delays to theatre, and mortality rate.
: The minimum follow-up was 24 months and the average follow-up was 39 months (range: 24-60 months). In the warfarin cohort, there were 140 patients and 2055 patients in the therapeutic enoxaparin cohort. Number of hospitalization days (8.7 vs. 9.8,
= 0.02), mortality rate (58.7% vs. 71.4%,
= 0.003), and delays to theatre (1.70 vs. 2.86,
< 0.0001) were significantly longer for the anticoagulant cohort than the therapeutic enoxaparin cohort. Warfarin use best predicted number of hospitalization days (
= 0.00) and delays to theatre (
= 0.01), while CHF was the best predictor of mortality rate (
= 0.00). Postoperative complications, such as Pulmonary Embolism (PE) (
= 0.90), Deep Vein Thrombosis (DVT) (
= 0.31), and Cerebrovascular Accidents (CVA) (
= 0.72), pain levels (
= 0.95), full weight-bearing status (
= 0.08), and rehabilitation use (
= 0.34) were similar between the cohorts.
Warfarin use is associated with increased number of hospitalization days and delays to theatre, but does not affect the postoperative outcome, including DVT, CVA, and pain levels compared to therapeutic enoxaparin use. Warfarin use proved to be the best predictor of hospitalization days and delays to theatre while CHF predicted mortality rate.
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