Search

Without intervention, 80% of hips with osteonecrosis (ON) will progress. Core decompression (CD) has shown favorable results (60–80% survivorship) in early stage ON, and recently, bone marrow aspirate concentration (BMAC) injection into the decompressed femoral head has been proposed to stimulate healing of the necrotic lesion and improve outcomes and survivorship. We reviewed the clinical and radiographic outcomes of 51 Steinberg stage 2 hips in 31 patients who underwent CD + BMAC for ON with a minimum of 1 year follow-up. We evaluated preoperative visual analog pain scores (VAS), Steinberg stage based on radiographs, and Kerboul angle as measured on magnetic resonance imaging. Clinical outcomes were reported as a change in VAS at final follow-up, hip and disability osteoarthritis score for joint replacements (HOOS, JR) score at final follow-up, advancement in Steinberg stage based on radiographs, or decision to proceed with total hip arthroplasty (THA). At an average of 27 months, VAS scores improved from 7 to 2.3 (p

Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections.We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups.We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion30 minutes preoperatively (group A), and 49.6% began infusion30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012).Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.

Purpose To examine finger, thumb, hand, wrist, and forearm fractures in the National Hockey League (NHL) and determine: (1) basic demographic data, (2) return to sport (RTS) rates, (3) performance after RTS, and (4) the difference in RTS between players treated operatively versus conservatively. Methods NHL players with finger, thumb, hand, wrist, and forearm fractures between the 1995-1996 and 2014-2015 seasons were identified through team injury reports and archives on public record. Player demographics, RTS rate, games played per season, and performance score for each player were recorded and compared between the preinjury season and one season following injury. Results A total of 247 total NHL players with hand, wrist, and forearm fractures were identified, consisting of 30.8% finger, 38.5% hand, 13.8% thumb, 14.6% wrist, and 2.4% forearm fractures. Defenseman comprised the majority of players (40.1%). The overall RTS rate was 98.0%, with no significant difference between players with surgery or between injury location groups. In total, 52 players (21.1%) underwent surgery with no significant correlation of surgery rates based on fracture location. The mean number of missed games was 13.8 ± 9.9, with players sustaining wrist and forearm fractures missing the largest number of games (21.6 ± 17.7and 22.8 ± 7.5 games missed, respectively). There was no significant change in games played or performance scores 1 year after injury for players with any of the fracture types compared with baseline preoperative games played and performance. Conclusions NHL players have a high RTS rate following hand, wrist, and forearm fractures. Players were able to return to preinjury performance within 1 year, regardless of treatment or type of fracture. Level of Evidence Level IV, case series.

Background There is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. Methods A retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. Results The Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. Conclusion The benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

Background Medicare’s Bundled Payments for Care Initiative (BPCI) is a risk-sharing alternative payment model. There is a concern that BPCI providers may avoid operating on obese patients and active smokers to reduce costs. We sought to understand if increased focus on these patient factors has led to a change in patient demographics in Medicare-insured patients undergoing total knee arthroplasty (TKA). Methods We retrospectively reviewed all patients who underwent TKA at an academic orthopedic specialty hospital between 1/1/13 and 8/31/19. Surgical date, insurance provider, BMI, and smoking status were collected. Patients were categorized as a current, former, or never smoker. Patients were categorized as obese if their BMI was >30 kg/m2, morbidly obese if their BMI was >40 kg/m2, and super obese if their BMI was >50 kg/m2. Results In total, 10,979 patients with complete insurance information were analyzed. There was no statistically significant change in the proportion of Medicare patients who were active smokers (4.34% in 2013, 4.85% in 2019, Pearson correlation coefficient = 0.6092, P = .146). The proportion of Medicare patients with BMI >30 kg/m2 increased over the study period (35.84% in 2013, 55.77% in 2019, Pearson correlation coefficient = 0.8505, P = .015). When looking at patients with BMI >40 kg/m2 and >50 kg/m2, there was no significant change. Conclusions Despite concern that reimbursement payments could alter access to care for patients with certain risk factors, this study did not find a noticeable difference in the representation of patients with obesity and smoking status undergoing TKA following the installation of BPCI. Level of Evidence III, retrospective observational analysis.

Background The second and third metacarpals are firmly attached, immobile structures which for the stable pillar of the hand. The trapezoid has been described as the keystone of the wrist, allowing a wide range of functional motion as well as inherent anatomic and biomechanical stability to the carpus. Case Description We describe a novel boxing injury with a 180-degree in situ dislocation of the right trapezoid with concomitant second and third carpometacarpal (CMC) joint dislocations. Open anatomic reduction of the trapezoid was obtained, and subsequent percutaneous pinning of the metacarpals allowed for a full functional recovery and return to sports at 6 months. Literature Review Combined trapezoid and CMC dislocations are extremely rare and have only been previously described in high-energy mechanism injuries, involving a direct dorsal force such as from the steering wheel in a motor vehicle collision. There are no previous reports of this injury occurring in the setting of direct axial load along the metacarpals in a clenched fist such as in a punch or fighting injury. Clinical Relevance The rare nature of this combined injury, its novel mechanism, and the difficulty in interpreting acute injury and postreduction radiographs require that the treating physician have a high degree of clinical suspicion for associated injuries when CMC dislocations are identified. Treatment strategies incorporating intraoperative fluoroscopy, open anatomic reduction of the trapezoid under direct visualization along with closed reduction, and pinning of the metacarpals reestablish carpal stability and provide excellent long-term results.

Background There are no studies to date analyzing the effect of spinal malalignment on outcomes of total knee arthroplasty (TKA). Knee flexion is a well-described lower extremity compensatory mechanism for maintaining sagittal balance with increasing spinal deformity. The purpose of this study was to determine whether a subset of patients with poor range of motion (ROM) after TKA have unrecognized spinal deformity, predisposing them to knee flexion contractures and stiffness. Methods We retrospectively evaluated a consecutive series of patients who underwent manipulation under anesthesia (MUA) for poor ROM after TKA. Using standing full-length biplanar images, knee alignment and spinopelvic parameters were measured. Patients were stratified by pelvic incidence minus lumbar lordosis as a measure of spinal sagittal alignment with a mismatch of ≥10° defined as abnormal, and we calculated the incidence of sagittal spinal deformity. Results Average ROM before MUA was extension 3° and flexion 83°. About 62% of patients had a pelvic incidence minus lumbar lordosis mismatch of ≥10°. In the spinal deformity group, post-MUA ROM was improved for flexion only, whereas both flexion and extension were improved in the nondeformity group. Conclusion Compensatory knee flexion because of sagittal spinal deformity may predispose to poor ROM after TKA. Patients with clinical suspicion should be worked up preoperatively and counseled accordingly.

Introduction: Isolated tibial tubercle fractures or patellar tendon ruptures are common injuries in adolescents. However, combined tubercle fractures with patellar tendon ruptures are rare, and hence, there are no definitive methods of surgical fixation or post-operative protocols. Case Report: A 13-year-old healthy girl sustained an extensor mechanism injury after the left knee hyperflexion during a fall from skateboarding. On examination, the extensor mechanism was not functional against gravity. Radiographic imaging revealed a displaced tibial tubercle fracture with patella alta, and magnetic resonance imaging revealed a concomitant patellar tendon avulsion from the tubercle. From a supine position on a radiolucent table, under general anesthesia and a femoral nerve block, the tibial tubercle fracture was fixed using two fully-threaded cortical screws. The patellar tendon was repaired with Fiber Wire through the Krakow method and secured through a tibial transosseous tunnel. A supplemental Fiber Wire was passed through a patellar tunnel and into a tibial tunnel to mitigate tension on the tendon repair. Post-operative knee motion was limited for 1 week to 60° of passive flexion, and full weight-bearing was permitted in a knee immobilizer. Conclusion: Given the rarity of this combined extensor mechanism injury in adolescents and despite several different fixation methods reported in the literature, there is no clearly superior surgical technique. This case demonstrates a technique allowing for stability of the tubercle fracture and robust repair of the patellar tendon that permits early range of motion and weight-bearing.

BACKGROUND: Greater trochanteric apophyseodesis and isolated trochanteric descent seek to prevent abductor weakness in patients with a hip deformity because of Legg-Calvé-Perthes disease; however, no studies have evaluated radiographic findings or abductor strength in children treated with these procedures. QUESTIONS/PURPOSES: (1) Do children with Waldenström Stage III Legg-Calvé-Perthes disease treated with either isolated greater trochanteric descent or isolated greater trochanteric apophyseodesis achieve improved radiographic findings (Stulberg classification or neck-shaft angle) compared with those who underwent no surgical treatment? (2) Do children treated with one of those procedures achieve greater abductor strength than those who did not have surgery? METHODS: Between 2006 and 2010, we treated 89 children with Waldenström Type III Legg-Calvé-Perthes disease (reossification). Of these, 27.9% (12 patients) underwent greater trochanteric descent, 25.6% (11 patients) underwent greater trochanteric apophyseodesis, and 46.5% (20 patients) did not have surgery. During that time, the decision to perform either apophyseodesis or trochanteric descent was made by the surgeon based on the subjective appearance of remaining growth from the greater trochanter. Nonsurgical management was chosen by the parents of the patients after the risks and benefits of surgery were discussed. During greater trochanteric descent, the greater trochanter was osteotomized and fixed distally with two 7.0-mm screws. During greater trochanteric apophyseodesis, the physis was identified fluoroscopically, and the lateral half of the growth plate was drilled. Nonoperative treatment involved serial clinical and radiographic evaluations every 3 to 6 months. All children in all groups were available for follow-up at a minimum of 6 years. The median follow-up durations for children undergoing greater trochanteric descent, greater trochanteric apophyseodesis, and control cohorts were 6.6 years (range 6.0-8.2 years), 6.5 years (range 6.1-9.2 years), and 7.4 years (range 6.0-9.1 years), respectively. On presentation, each patient’s affected hip was classified according to the Stulberg classification by the operating surgeon and an orthopaedic surgeon not involved in the child’s care. The neck-shaft angle was measured for each patient before surgery and at the final follow-up examination. Abductor strength was assessed by a pediatric orthopaedic fellow and a physical therapist with the patient in the lateral decubitus position. Each patient was given a muscle strength score on a scale of 0 to 10 points, per a modification of the Medical Research Council scale to allow for a narrower range. We had 80% power to detect an 8° difference in the neck-shaft angle between the greater trochanteric apophyseodesis and nonoperative management cohorts. A sample size of 6.8 patients per cohort would be necessary to detect the above endpoint. RESULTS: With the numbers available, we found no differences among the groups in the proportion of patients with Stulberg Class 2 femoral heads (two of 12 patients in the isolated trochanteric descent group, three of 11 in the isolated trochanteric apophyseodesis group, and two of 20 who did not undergo surgery; p = 0.46). Likewise, there were no differences among the three groups in terms of the neck-shaft angle at a minimum of 6 years of follow-up (122° ± 6°, 119° ± 7°, and 126° ± 8° in the isolated trochanteric descent, isolated trochanteric apophyseodesis, and nonoperative groups, respectively). There were no differences among the groups in term of the median abductor strength test result: seven of 10 (range 6-8), six of 10 (range 6-8), and six of 10 (range 6-10; p = 0.34). CONCLUSION: Because neither isolated greater trochanteric descent nor greater trochanteric apophyseodesis alone had an effect on hip morphology or abductor strength in children with sequellae of Legg-Calvé-Perthes disease, we conclude these types of extraarticular surgery are ineffective. Therefore, we no longer perform isolated trochanteric descent or apophyseodesis. LEVEL OF EVIDENCE: Level III, therapeutic study.

INTRODUCTION Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain. The diagnostic utility of these radiographs is debatable. METHODS Patients presenting for the first time to a shoulder clinic with atraumatic shoulder pain received a plain radiographic series. After considering their medical history and physical examination, we made a preliminary diagnosis and formulated a tentative treatment plan. We then reviewed the radiographs and determined whether the addition of these radiographs altered the diagnosis and/or treatment. RESULTS A total of 343 patients met the inclusion criteria. Age >50 years (odds ratio, 3.3; 95% confidence interval, 1.9 to 5.8; P < 0.00001) and weakness in forward elevation (odds ratio, 2.9; 95% confidence interval, 1.6 to 5.4; P = 0.0003) were associated with the presence of radiographic findings. Plain radiographs altered the proposed diagnosis in only 14.9% (51/343) of cases. However, clinical management was changed in only 1.7% of cases. Plain radiographs had no effect on clinical management in 97.4% of patients younger than 50 years. DISCUSSION Plain radiographs rarely alter the diagnosis or affect management in the setting of atraumatic shoulder pain, particularly in patients younger than 50 years. Patients may be exposed to unnecessary radiation, and the healthcare system as a whole may be burdened with the increased cost of this imaging modality. LEVEL OF EVIDENCE Level II (diagnostic).

Introduction: Treatment options for carbapenem-resistant Enterobacteriaceae (CRE) infections are limited and CRE infections remain associated with high clinical failure and mortality rates, particularly in vulnerable patient populations. A Phase 3, multinational, open-label, randomized controlled trial (TANGO II) was conducted from 2014 to 2017 to evaluate the efficacy/safety of meropenem–vaborbactam monotherapy versus best available therapy (BAT) for CRE. Methods: A total of 77 patients with confirmed/suspected CRE infection (bacteremia, hospital-acquired/ventilator-associated bacterial pneumonia, complicated intra-abdominal infection, complicated urinary tract infection/acute pyelonephritis) were randomized, and 47 with confirmed CRE infection formed the primary analysis population (microbiologic-CRE-modified intent-to-treat, mCRE-MITT). Eligible patients were randomized 2:1 to meropenem–vaborbactam (2 g/2 g over 3 h, q8h for 7–14 days) or BAT (mono/combination therapy with polymyxins, carbapenems, aminoglycosides, tigecycline; or ceftazidime-avibactam alone). Efficacy endpoints included clinical cure, Day-28 all-cause mortality, microbiologic cure, and overall success (clinical cure + microbiologic eradication). Safety endpoints included adverse events (AEs) and laboratory findings. Results: Within the mCRE-MITT population, cure rates were 65.6% (21/32) and 33.3% (5/15) [95% confidence interval (CI) of difference, 3.3% to 61.3%; P = 0.03)] at End of Treatment and 59.4% (19/32) and 26.7% (4/15) (95% CI of difference, 4.6% to 60.8%; P = 0.02) at Test of Cure;.Day-28 all-cause mortality was 15.6% (5/32) and 33.3% (5/15) (95% CI of difference, − 44.7% to 9.3%) for meropenem–vaborbactam versus BAT, respectively. Treatment-related AEs and renal-related AEs were 24.0% (12/50) and 4.0% (2/50) for meropenem–vaborbactam versus 44.0% (11/25) and 24.0% (6/25) for BAT. Exploratory risk–benefit analyses of composite clinical failure or nephrotoxicity favored meropenem–vaborbactam versus BAT (31.3% [10/32] versus 80.0% [12/15]; 95% CI of difference, − 74.6% to − 22.9%; P < 0.001). Conclusions: Monotherapy with meropenem–vaborbactam for CRE infection was associated with increased clinical cure, decreased mortality, and reduced nephrotoxicity compared with BAT. Clinical Trials Registration: NCT02168946. Funding: The Medicines Company. © 2018, The Author(s).

BACKGROUND: Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients. Recurrences are common after antibiotic therapy. Actoxumab and bezlotoxumab are human monoclonal antibodies against C. difficile toxins A and B, respectively.METHODS: We conducted two double-blind, randomized, placebo-controlled, phase 3 trials, MODIFY I and MODIFY II, involving 2655 adults receiving oral standard-of-care antibiotics for primary or recurrent C. difficile infection. Participants received an infusion of bezlotoxumab (10 mg per kilogram of body weight), actoxumab plus bezlotoxumab (10 mg per kilogram each), or placebo; actoxumab alone (10 mg per kilogram) was given in MODIFY I but discontinued after a planned interim analysis. The primary end point was recurrent infection (new episode after initial clinical cure) within 12 weeks after infusion in the modified intention-to-treat population.RESULTS: In both trials, the rate of recurrent C. difficile infection was significantly lower with bezlotoxumab alone than with placebo (MODIFY I: 17% [67 of 386] vs. 28% [109 of 395]; adjusted difference, -10.1 percentage points; 95% confidence interval [CI], -15.9 to -4.3; PCONCLUSIONS: Among participants receiving antibiotic treatment for primary or recurrent C. difficile infection, bezlotoxumab was associated with a substantially lower rate of recurrent infection than placebo and had a safety profile similar to that of placebo. The addition of actoxumab did not improve efficacy. (Funded by Merck; MODIFY I and MODIFY II ClinicalTrials.gov numbers, NCT01241552 and NCT01513239 .).