Orthopedics

Pfeffer, G. B., T. Gonzalez, J. Brodsky, J. Campbell, C. Coetzee, S. Conti, G. Guyton, D. N. Herrmann, K. Hunt, J. Johnson, W. McGarvey, M. Pinzur, S. Raikin, B. Sangeorzan, A. Younger, M. Michalski, T. An and N. Noori (2020). “A Consensus Statement on the Surgical Treatment of Charcot-Marie-Tooth Disease.” Foot Ankle Int Jun 1;1071100720922220. [Epub ahead of print]. 1071100720922220.

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BACKGROUND: Charcot-Marie-Tooth (CMT) disease is a hereditary motor-sensory neuropathy that is often associated with a cavovarus foot deformity. Limited evidence exists for the orthopedic management of these patients. Our goal was to develop consensus guidelines based upon the clinical experiences and practices of an expert group of foot and ankle surgeons. METHODS: Thirteen experienced, board-certified orthopedic foot and ankle surgeons and a neurologist specializing in CMT disease convened at a 1-day meeting. The group discussed clinical and surgical considerations based upon existing literature and individual experience. After extensive debate, conclusion statements were deemed “consensus” if 85% of the group were in agreement and “unanimous” if 100% were in support. CONCLUSIONS: The group defined consensus terminology, agreed upon standardized templates for history and physical examination, and recommended a comprehensive approach to surgery. Early in the course of the disease, an orthopedic foot and ankle surgeon should be part of the care team. This consensus statement by a team of experienced orthopedic foot and ankle surgeons provides a comprehensive approach to the management of CMT cavovarus deformity. LEVEL OF EVIDENCE: Level V, expert opinion.

Malik, F., R. T. Zreik, D. J. Hedges, J. Nakitandwe, S. Lee, R. A. Ward, M. B. McCarville, A. Pappo and A. Bahrami (2020). “Primary bone sarcoma with BCOR internal tandem duplication.” Virchows Arch 476(6): 915-920.

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BCOR internal tandem duplications (ITDs) and rearrangements are implicated in the oncogenesis of a subset of undifferentiated sarcomas. To date, BCOR ITD sarcomas have been exclusively found in non-appendicular infantile soft tissues, whereas BCOR-rearranged sarcomas occur in both bones and soft tissues affecting a wider patient age range. Little is known about patient outcome in BCOR ITD sarcomas. We present a BCOR-expressing, primary bone, undifferentiated sarcoma case involving an adolescent male’s left tibia that, unexpectedly, harbored a BCOR ITD instead of a BCOR rearrangement. Furthermore, the patient achieved a partial histologic response after receiving a Ewing sarcoma chemotherapy regimen. Our case expands the clinical spectrum of BCOR ITD sarcomas and suggests that childhood and adult BCOR-expressing sarcomas with an undifferentiated histology should be considered for both BCOR rearrangement and ITD screening. Accurate BCOR mutation identification in undifferentiated sarcomas is essential to define their clinical spectrum and to develop effective management strategies.

Kizaki, K., S. Uchida, A. Shanmugaraj, C. C. Aquino, A. Duong, N. Simunovic, H. D. Martin and O. R. Ayeni (2020). “Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review.” Knee Surg Sports Traumatol Arthrosc Apr 3. [Epub ahead of print].

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URPOSE: Clinicians are not confident in diagnosing deep gluteal syndrome (DGS) because of the ambiguity of the DGS disease definition and DGS diagnostic pathway. The purpose of this systematic review was to identify the DGS disease definition, and also to define a general DGS diagnostic pathway. METHODS: A systematic search was performed using four electronic databases: PubMed, MEDLINE, EMBASE, and Google Scholar. In eligibility criteria, studies in which cases were explicitly diagnosed with DGS were included, whereas review articles and commentary papers were excluded. Data are presented descriptively. RESULTS: The initial literature search yielded 359 articles, of which 14 studies met the eligibility criteria, pooling 853 patients with clinically diagnosed with DGS. In this review, it was discovered that the DGS disease definition was composed of three parts: (1) non-discogenic, (2) sciatic nerve disorder, and (3) nerve entrapment in the deep gluteal space. In the diagnosis of DGS, we found five diagnostic procedures: (1) history taking, (2) physical examination, (3) imaging tests, (4) response-to-injection, and (5) nerve-specific tests (electromyography). History taking (e.g. posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (e.g. tenderness in deep gluteal space, pertinent positive results with seated piriformis test, and positive Pace sign), and imaging tests (e.g. pelvic radiographs, spine and pelvic magnetic resonance imaging (MRI)) were generally performed in cases clinically diagnosed with DGS. CONCLUSION: Existing literature suggests the DGS disease definition as being a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space. Also, the general diagnostic pathway for DGS was composed of history taking (posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (tenderness in deep gluteal space, positive seated piriformis test, and positive Pace sign), and imaging tests (pelvic radiographs, pelvic MRI, and spine MRI). This review helps clinicians diagnose DGS with more confidence. LEVEL OF EVIDENCE: IV.

Bhimani, A. A., J. M. Rizkalla, K. J. Kitziger, P. C. Peters, Jr., R. D. Schubert and B. P. Gladnick (2020). “Surgical automation reduces operating time while maintaining accuracy for direct anterior total hip arthroplasty.” J Orthop 22: 68-72.

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Objective: Investigate the efficiency/accuracy of surgical automation versus manual component implantation in DA THA. Methods: Retrospective review of 111 hips: 51 hips via automation and 60 hips via manual technique for DA THA. Results: OR time averaged 8 min faster in the Automated group, compared to Manual group (p = 0.0009). Average femoral size was one size larger in the Automated group compared to Manual group (p = 0.007). No clinically significant differences were found between Manual and Automated groups for cup position or limb-length discrepancy. One calcar fracture occurred in the Automated group. Conclusion: Surgical automation is efficient and accurate for DA THA.

Rizkalla, J. M., T. Lines and S. Nimmons (2019). “Classifications in Brief: The Denis Classification of Sacral Fractures.” Clin Orthop Relat Res 477(9): 2178-2181.

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In their original description, Denis et al. described three zones of injury: Zone I: injuries located lateral to the neuroforamina; Zone II: injuries that involve the neuroforamina, but not the spinal canal; and Zone III: injuries that extend into the spinal canal, with primary or associated fracture lines. The study found that neurologic injuries occurred in 5.9% of fractures lateral to the sacral foramina (Zone 1). In transforaminal fractures (Zone 2), 28.4% of patients had a neurologic deficit. Meanwhile, central fractures (Zone 3) had the highest likelihood of neurologic injury (56.7%) [6] (Fig. 1). Furthermore, Zone III fractures are often divided into four different types, including: (1) flexion fracture with anterior angulation, (2) flexion fracture with anterior angulation and posterior displacement, (3) extension fractures with anterior displacement, and (4) comminuted fracture of the upper segment of the sacrum without displaced alignment of sacrum. (Excerpt from text, p. 2179; no abstract available.)