Orthopedics

Dutcher, L., Lo, E.Y., Mascarenhas, L., Majekodunmi, T. and Krishnan, S.G. (2021). “Custom Prosthetic Reconstruction for Severe Proximal Humeral Bone Loss Status Post Infected Arthroplasty: A Case Report.” JBJS Case Connect 11(1).

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CASE: A 68-year-old male, status post revision right reverse total shoulder arthroplasty (RTSA) for periprosthetic fracture, suffered a periprosthetic joint infection necessitating 2-stage revision. Imaging revealed 8.6 cm of ipsilateral proximal humeral bone loss (PHBL) including loss of the greater and lesser tuberosities. A 2-stage revision was performed using an antibiotic spacer, followed by a custom long-stem RTSA for definitive reconstruction. Two years postoperatively, the patient had significantly improved pain and functional range of motion. CONCLUSION: Custom long-stem RTSA could serve as a potentially viable reconstructive option in patients with severe PHBL.

Brodsky, J.W., Jaffe, D., Pao, A., Vier, D., Taniguchi, A., Daoud, Y., Coleman, S. and Scott, D.J. (2021). “Long-term Functional Results of Total Ankle Arthroplasty in Stiff Ankles.” Foot Ankle Int Feb 8;1071100720977847. [Epub ahead of print].

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BACKGROUND: Total ankle arthroplasty (TAA) is advocated over ankle arthrodesis to preserve ankle motion (ROM). Clinical and gait analysis studies have shown significant improvement after TAA. The role and outcomes of TAA in stiff ankles, which have little motion to be preserved, has been the subject of limited investigation. This investigation evaluated the mid- to long-term functional outcomes of TAA in stiff ankles. METHODS: A retrospective study of prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 (5-13) years postoperatively used 1-way analysis of variance and multivariate regression analysis to compare among preoperative and postoperative demographic data (age, gender, body mass index, years postsurgery, and diagnosis) and gait parameters according to quartiles of preoperative sagittal ROM. RESULTS: The stiffest ankles had a mean ROM of 7.8 degrees, compared to 14.3 degrees for the middle 2 quartiles, and 21.0 degrees for the most flexible ankles. Patients in the lowest quartile (Q1) also had statistically significantly lower step length, speed, max plantarflexion, and power preoperatively. Postoperatively, they increased step length, speed, max plantarflexion, and ankle power to levels comparable to patients with more flexible ankles preoperatively (Q2, Q3, and Q4). They had the greatest absolute and relative increases in these parameters of any group, but the final total ROM was still statistically significantly the lowest. CONCLUSION: Preoperative ROM was predictive of overall postoperative gait function at an average of 7.6 (range 5-13) years. Although greater preoperative sagittal ROM predicted greater postoperative ROM, the stiffest ankles showed the greatest percentage increase in ROM. Patients with the stiffest ankles had the greatest absolute and relative improvements in objective function after TAA, as measured by multiple gait parameters. At intermediate- to long-term follow-up, patients with stiff ankles maintained significant functional improvements after TAA. LEVEL OF EVIDENCE: Level III, comparative study.

Oguayo, C.C., Chu, J. and Jones, A.L. (2021). “A Community Orthopaedic Residency Approach to Education and Training During the COVID-19 Pandemic.” J Am Acad Orthop Surg Glob Res Rev 5(1).

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BACKGROUND: The COVID-19 pandemic has rapidly affected all facets of everyday life including the practice of medicine. Hospital systems and medical practices have evolved to protect patients, physicians, and staff and conserve personal protective equipment and resources. Orthopaedic practices have been specifically affected by social distancing and stay at home guidelines, limiting in-office practice and elective surgery restrictions. This, in turn, has had an effect on resident education. Previous literature has been published regarding how academic programs have adjusted to these changes. However, the effects on smaller orthopaedic residencies with nonacademic faculty has not been discussed. The orthopaedic residency at Baylor University Medical Center of Dallas is a fifteen-resident program with a combination of hospital employed and private practice faculty. We adjusted our resident education in mid-March 2020 to keep residents safe while trying to maximize surgical and clinical education and outside research. GOALS: Our goals were to come up with a plan allowed for continuing high-level patient care and resident education while protecting residents and limiting burnout. MODEL: We devised a four-team system with five-day call periods. Interactions between teams were strictly minimized. We also moved to a web-based academic curriculum and devised a system for safe resident participation in surgical cases. The model has been adjusted based on attending and resident feedback. CONCLUSION: Until we develop effective treatments or vaccination for COVID-19, there is a possibility that it will be an ongoing threat. Resident education must also adapt to the changing environment while continuing to provide residents safe opportunities for patient care, didactic education, and research. We believe we have come up with a sustainable, adaptable model for resident education during this challenging time.

Hatem, M. and Martin, H.D. (2021). “Low Back Pain Improves After Surgery for Lesser Trochanteric-Ischial Impingement.” Arthroscopy Jan 15;S0749-8063(21)00017-7. [Epub ahead of print].

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PURPOSE: To assess the effects of surgery for lesser trochanteric-ischial impingement (LTI) on low back pain. METHODS: The records of patients with LTI who underwent endoscopic partial resection of the lesser trochanter (LT) between May of 2017 and February of 2019 were reviewed. Inclusion criteria were the presence of low back pain in association with hip pain, diagnosis of LTI, and partial resection of the LT to treat LTI. Exclusion criteria were less than 12 months of postoperative follow-up and hip or spine surgery after the LTI surgery. Patients were assessed before surgery and at the most recent follow-up with the modified Harris Hip Score and Oswestry Disability Index for lumbar spine. RESULTS: Thirty patients (31 hips) met the inclusion criteria. Four patients were lost to follow-up. Two patients with borderline dysplasia and grade 1 and 2 osteoarthritis underwent total hip arthroplasty after the partial resection of the LT. The results are presented considering the remaining 24 patients (25 hips). The average age at surgery was 51 years (range 32-65 years). The mean follow-up after the surgery for LTI was 19 months (range 12-35 months). The mean ± SD ODI improved from 48% ± 15 before the LTI surgery to 21% ± 22 (P < .001) at the most recent follow-up. Improvement in the Oswestry Disability Index above the minimal clinical important difference was observed in 16 patients (67%) following the LTI surgery. The mean ± SD modified Harris Hip Score improved from 55.8 ± 14 before LTI surgery to 81.3 ± 14.3 (P < .001). CONCLUSIONS: Decrease in low back pain above the minimal clinically important difference is observed in 2 of 3 patients after partial resection of the LT. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Brodsky, J.W., Scott, D.J., Ford, S., Coleman, S. and Daoud, Y. (2021). “Functional Outcomes of Total Ankle Arthroplasty at a Mean Follow-up of 7.6 Years: A Prospective, 3-Dimensional Gait Analysis.” J Bone Joint Surg Am Jan 15. [Epub ahead of print].

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BACKGROUND: In vivo gait analysis provides objective measurement of patient function and can quantify that function before and after ankle reconstruction. Previous gait studies have shown functional improvement for up to 4 years following total ankle arthroplasty (TAA), but to date, there are no published studies assessing function at ≥5 years following TAA. We hypothesized that patients who underwent TAA would show significant improvements in walking function at a minimum follow-up of 5 years, compared with their preoperative function, as measured by changes in temporospatial, kinematic, and kinetic gait parameters. METHODS: Three-dimensional gait analysis with a 12-camera digital motion-capture system and double force plates was utilized to record temporospatial, kinematic, and kinetic measures in 33 patients who underwent TAA with either the Scandinavian Total Ankle Replacement (Stryker; n = 28) or Salto Talaris Ankle (Integra LifeSciences; n = 5). Gait analysis was performed preoperatively and at a minimum follow-up of 5 years (mean, 7.6 years; range, 5 to 13 years). RESULTS: Significant improvements were observed in multiple gait parameters, with temporospatial increases in cadence (+9.5 steps/min; p < 0.0001), step length (+4.4 cm; p = 0.0013), and walking speed (+0.2 m/s; p < 0.0001), and kinematic increases in total sagittal range of motion (+2.0°; p = 0.0263), plantar flexion at initial contact (+2.7°; p = 0.0044), and maximum plantar flexion (+2.0°; p = 0.0488). Kinetic analysis revealed no loss of peak ankle power, despite patients aging. CONCLUSIONS: To our knowledge, this is the first study to report 7-year functional outcomes of TAA, quantified by objective, in vivo measurements of patient gait. Patients were shown to have sustained improvement in multiple objective parameters of gait compared with preoperative function. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.