Orthopedics

Hatem, M., Khoury, A.N., Richard, E.L., Jones, A.L. and Martin, H.D. (2020). “Femoral derotation osteotomy improves hip and spine function in patients with increased or decreased femoral torsion.” Arthroscopy Aug 20;S0749-8063(20)30686-1. [Epub ahead of print.].

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To evaluate the outcomes of proximal femoral derotation osteotomy (PFDO) on the hip and spine function of patients with abnormal femoral torsion METHODS: This retrospective study included patients who underwent PFDO to treat increased or decreased femoral torsion between July of 2014 and February of 2019. The exclusion criteria were: previous fracture, fixation of slipped capital femoral epiphysis or osteotomy in the ipsilateral femur; PFDO associated to varus or valgus osteotomy; Tönnis grade 2 or 3 osteoarthritis; and PFDO performed to treat knee abnormalities. Hip function was assessed through the modified Harris Hip Score (mHHS). A subgroup of consecutive patients with low back pain before the PFDO and operated after 2017 had the spine function assessed through the Oswestry disability index (ODI) RESULTS: A total of 37 hips (34 patients) were studied: 15 hips with increased femoral torsion and 22 with decreased femoral torsion. Eight patients were male and 26 female. The average age at PFDO was 33 years (range, 15 to 54 years). At a mean follow-up of 24 months (range, 12 to 65 months), the mean mHHS improved from 58.1 ± 14.3 before PFDO to 82 ± 15.6 at the most recent follow-up (p<0.001). Improvement in the mHHS above the minimum clinically important difference (MCID) was observed in 33 hips (89%). In the subgroup of 14 consecutive patients with ODI available, the ODI improved from a mean of 45% ± 16% before the PFDO to 22% ± 17% at the most recent follow-up (p=0.001). Nine (64.3%) of the 14 patients presented improvement in the ODI above the MCID. Revision procedure with a larger intramedullary nail was necessary in two hips to treat nonunion CONCLUSION: Proximal femoral derotation osteotomy improves the hip and spine function in patients with increased or decreased femoral torsion and non-arthritic hips.

Karakkattil, P. S., E. Trudelle-Jackson, A. Medley and C. Swank (2020). “Effects of two different types of ankle-foot orthoses on gait outcomes in patients with subacute stroke: a randomized crossover trial.” Clin Rehabil 34(8): 1094-1102.

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OBJECTIVE: To identify whether patients in the subacute stage of stroke, with foot drop, would have better gait outcomes when using a double-adjustable AFO (DA AFO) or a posterior leaf spring AFO (PLS AFO) at baseline without practice and to determine whether one week of practice would significantly change gait outcomes with either of the AFOs. DESIGN: Within-subject 2 × 2 repeated measures design. SETTING: Postacute and outpatient rehabilitation center. PARTICIPANTS: Twenty individuals with mean age of 57 years (SD: 12.0 years) with subacute stroke. INTERVENTIONS: Participants were measured using DA AFO and PLS AFO at baseline. Follow-up measurements were taken after one week of practice with each type of AFO in randomly assigned order. OUTCOME MEASURES: Gait endurance (6-Minute Walk Test (6MWT)), gait symmetry, and gait velocity at self-selected and fast-paced velocity measured using GAITRite gait analysis system and patient report of AFO preference. RESULTS: At baseline, no significant differences were found between the 2 AFOs (P > 0.05). There was no significant interaction (P > 0.05) of AFO and practice for gait endurance, symmetry, and velocity. Main effect of practice was significant for gait endurance (P < 0.001), self-selected velocity (P = 0.001), and fast-paced velocity (P < 0.001). In all, 16 participants preferred using DA AFO for walking. CONCLUSIONS: No difference between DA AFO and PLS AFO was found on measures of gait endurance, symmetry, and velocity at baseline or after practice. With practice over time, participants improved in gait endurance and velocity regardless of AFO type.

Jain, A., S. Yeramaneni, K. M. Kebaish, M. Raad, J. L. Gum, E. O. Klineberg, H. Hassanzadeh, M. P. Kelly, P. G. Passias, C. P. Ames, J. S. Smith, C. I. Shaffrey, S. Bess, V. Lafage, S. Glassman, L. Y. Carreon and R. A. Hostin (2020). “Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery.” Spine (Phila Pa 1976) 45(14): 1009-1015.

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STUDY DESIGN: Economic modeling of data from a multicenter, prospective registry. OBJECTIVE: The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis. METHODS: Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05). RESULTS: BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P < 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in >52% of patients. CONCLUSION: BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research. LEVEL OF EVIDENCE: 2.

Rizkalla, J. M., T. Lines, Y. Daoud and J. Zide (2020). “Instagram and Pilon Fractures: An Analysis of Social Media and Its Relationship to Patient Injury Perception.” Foot Ankle Spec Jul 20;1938640020940837. [Epub ahead of print.].

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Background: The purpose of this study was to investigate social media posts regarding pilon fractures and its relationship to patient injury perception. We evaluated Instagram media posts in patients who have suffered pilon fractures for the following variables: gender, tone, discussion of rehabilitation, activities of daily living (ADL) reference, incision/scar reference, pain, post of radiograph/imaging, external fixation reference, discussion of bracing/splinting, pre- or postoperative swelling, and need for reoperation. Results were determined by comparing each variable to gender and tone of the post to study patient injury perception. Methods: Public Instagram posts from within a 1-year time period were isolated and evaluated using the hashtag “#pilonfracture.” Individual posts were analyzed by authors. In total, 241 patient posts were included for investigation and analysis of patient injury perception via social media. Results: Of all included posts, 88% of posts had a positive tone. A majority of the posts (66.8%) mentioned rehabilitation and postoperative progress. There were significant associations between positive tone and rehabilitation (P = .0001), as well as positive tone and ADLs (P = .0361). Conclusion: Reported outcomes after surgical management of pilon fractures are generally poor. Nonetheless, this analysis of patients sharing their experience on social media after open reduction internal fixation of pilon fractures demonstrates a mostly positive attitude toward the injury and recovery. A positive tone of the post was significantly associated with mentions of rehabilitation and ADLs.Levels of Evidence: Level III: Retrospective comparative study.

Rizkalla, J. M., B. P. Gladnick, A. A. Bhimani, D. S. Wood, K. J. Kitziger and P. C. Peters, Jr. (2020). “Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.” Curr Rev Musculoskelet Med 13(4): 416-424.

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PURPOSE OF REVIEW: The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic. RECENT FINDINGS: SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting “elective” surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely “elective” procedure, versus an “urgent” procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into “elective” versus “urgent” categories. In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one’s peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.