Acetabular "Fleck" Sign: Outcomes of Surgical Repair.

BACKGROUND: Traumatic, posterior hip dislocations in the pediatric population are typically managed by closed reduction to achieve a concentric hip joint. The presence of an acetabular "fleck" sign, despite concentric reduction, has been shown to signify significant hip pathology. The purpose of this study was to evaluate the outcomes of open labral repair through a surgical hip dislocation (SHD) in a consecutive series of patients with an acetabular "fleck" sign associated with a traumatic hip dislocation/subluxation. METHODS: A retrospective review of patients between 2008 and 2022 who presented to a single, level 1 pediatric trauma center with a traumatic posterior hip dislocation/subluxation was performed. Patients were included if they had an acetabular "fleck" sign on advanced imaging and underwent open labral repair through SHD. Medical records were reviewed for sex, age, laterality, mechanism of injury (MOI), and associated orthopaedic injuries. The modified Harris hip score (mHHS) was utilized as the primary clinical outcomes measure. Patients were assessed for the presence of heterotopic ossification (HO) and complications, including implant issues, infection, avascular necrosis (AVN), and post-traumatic dysplasia. RESULTS: Twenty-nine patients (23 male, average age: 13.0±2.7 y; range: 5.2 to 17.3) were identified. Eighteen injuries were sports related, 9 caused by motor vehicle accidents, and 1 pedestrian struck. All patients were found to have an acetabular "fleck" sign on CT (26 patients) or MRI (5 patients). Associated injuries included: femoral head fracture (n=6), pelvic ring injury (n=3), ipsilateral femur fracture (n=2), and ipsilateral PCL avulsion (n=1). At the latest follow-up (2.2±1.4 y), all patients had returned to preinjury activity/sport. Three patients developed asymptomatic, grade 1 HO in the greater trochanter region. There was no incidence of AVN. One patient developed post-traumatic acetabular dysplasia due to early triradiate closure. mHHS scores showed excellent outcomes (n=21, 94.9±7.4, range: 81 to 100.1). CONCLUSIONS: The acetabular "fleck" sign indicates a consistent pattern of osteochondral avulsion of the posterior/superior labrum. Restoring native hip anatomy and stability is likely to improve outcomes. SHD with open labral repair in these patients produces excellent clinical outcomes, with no reported cases of AVN. LEVEL OF EVIDENCE: Level IV-therapeutic.

Use of a Novel Buffered Hypertonic Saline Solution for Fluid Replacement and Resuscitation During Spinal Surgery in Adolescents.

Background: During major orthopedic procedures, such as posterior spinal fusion (PSF), isotonic fluids, colloids, starches, or gelatins are commonly used to replace the preoperative fluid deficit and provide ongoing fluid resuscitation. Given recent concerns regarding the potential adverse physiologic effects of albumin solutions, we have modified our intraoperative practice to include the use of a novel 2% buffered hypertonic saline solution during major orthopedic procedures. We present our preliminary clinical experience with this novel fluid for intraoperative resuscitation and its impact on limiting the use of 5% albumin. Methods: A retrospective review was performed to identify patients who received 2% buffered hypertonic saline during PSF. The intraoperative course of these patients was compared to case-matched control patients who received standard care with isotonic fluids plus 5% albumin as an adjunct for intravascular resuscitation. Results: The study cohort included 23 patients who received 2% buffered hypertonic saline and 25 in the case-matched control group. There was no difference in the volume of intraoperative isotonic crystalloid fluids, estimated blood loss, and urine output between the two groups. In the control cohort, 19 of 25 patients (76%) received 5% albumin compared to only six of 23 patients (26%, P = 0.0005) in the 2% buffered hypertonic saline group. The final pH was higher in the patients that received 2% buffered hypertonic saline than in the control group (7.40 ± 0.03 versus 7.36 ± 0.06, P = 0.0131). Additionally, the starting and final serum sodium values were higher in the patients that received 2% buffered hypertonic saline, although no difference was noted in the mean change from the starting value (average increase of 2 mEq/L in both groups). Conclusion: Use of a novel 2% buffered hypertonic saline solution for intraoperative resuscitation during major orthopedic procedures decreases the need for 5% albumin while avoiding the development of hyperchloremic metabolic acidosis which may occur with standard sodium chloride solutions.

Radiographic and clinical outcomes after definitive spine fusion for skeletally immature patients with idiopathic scoliosis.

PURPOSE: To assess the intermediate-term radiographic and clinical outcomes of skeletally immature idiopathic scoliosis (IS) patients that underwent definitive fusion (DF). METHODS: A retrospective review of patients with IS who were Risser 0 with open tri-radiate cartilages at the time of DF with minimum 5-year follow-up. Outcomes included Scoliosis Research Society (SRS)-30 scores, major Cobb angle, pulmonary function tests (PFTs), and unplanned returns to the operating room (UPROR). Adding-on was defined as progression of the major Cobb angle > 5° or tilt of the lowest instrumented vertebra > 5°. RESULTS: Thirty-two patients (78% female, mean age 12.2 ± 1.3 years old, mean preoperative major Cobb 64.8° ± 15.9) were included. Of these patients, 20 (62.5%) experienced adding-on and 6 (18.8%) required a revision surgery to correct their progressive spinal deformity. Adding-on was associated with lower 5-year postoperative SRS scores for appearance (3.7 ± 0.7 vs 4.4 ± 0.3, p = 0.0126), mental health (4.2 ± 0.6 vs 4.6 ± 0.3, p = 0.0464), satisfaction with treatment (4.0 ± 0.8 vs 4.7 ± 0.4, p = 0.0140), and total score (4.0 ± 0.4 vs 4.4 ± 0.2, p = 0.0035). The results of the PFTs did not differ between groups. Patients experienced an average of 0.53 UPROR/patient. CONCLUSION: DF in skeletally immature patients results in a high rate of adding-on, which adversely affects Health-Related Quality of Life. However, reoperation rates, both planned and unplanned, remain lower when compared to patients undergoing growth-friendly treatment.

Orthopaedic Manifestations of Thanatophoric Dwarfism: A Case Report.

CASE: We report the rare case of a 3-year-old male patient with thanatophoric dwarfism, a fatal skeletal dysplasia that arises from an autosomal dominant mutation in the fibroblast growth factor receptor 3 gene. The role of the orthopaedic surgeon in the in the management of this disease is discussed. CONCLUSION: We advocate for the close monitoring of disease progression by the orthopaedic surgery team and offer a potential surgical intervention that may help prevent cardiorespiratory demise.

Return to the Operating Room for Unplanned Pin Removal After Percutaneous Pinning of Supracondylar Humerus Fractures: A Retrospective Review.

BACKGROUND: Pin migration is a common complication associated with closed reduced and percutaneous pinning (CRPP) of supracondylar humerus fractures (SCHF) in children. Though this complication occurs frequently, little work has been done to elicit circumstances surrounding this complication. The purpose of this study was to evaluate patients with SCHF treated with percutaneous pins who needed to return to the operating room for pin removal. METHODS: This was a multicenter study involving children treated at 6 pediatric tertiary care centers between 2010 and 2020. Retrospective chart review was performed to identify children aged 3 to 10 years of age with a diagnosis of a SCHF. Current Procedural Terminology (CPT) codes were used to identify patients who underwent CRPP of their injuries. CPT codes for deep hardware removal requiring procedural sedation or anesthesia were used to identify patients who needed to return to the operating room for hardware removal. RESULTS: Between 2010 and 2020, 15 out of 7862 patients who were treated for SCHF at our 6 participating study centers experienced pin migration requiring a return to the operating room for pin removal, yielding a complication rate of 0.19%. Twelve (80%) of these injuries were Wilkins modification of the Gartland classification Type III, while the remaining injuries were Type II. 2-pin fixation constructs were used in nine (60%) children; 3-pin fixation constructs were used in 6 (40%) children. Pin migration was noted 23.2±7.0 days postoperatively at clinic follow-up. Four patients were noted to have multiple pins buried at follow-up. Four patients required 1-centimeter incisions for exposure of the buried pins, while surgeons were able to remove the buried pin with just a needle driver and blunt dissection in the remainder of patients. CONCLUSIONS: Pin migration is a common complication of closed reduction and percutaneous pinning of SCHF. There is variation in pin site management to prevent migration in the absence of underlying risk factors. LEVEL OF EVIDENCE: Level III.

Staged Correction of Severe Recurrent Clubfoot Deformity With Dislocation of the Chopart Joint Using a Hexapod External Fixator and Unconventional Arthrodesis.

Despite success of the Ponseti method, a subset of patients with clubfeet experience residual deformity. Surgical release after unsuccessful serial casting can lead to residual clubfoot deformities, including a flat-top talus. We present a case of a 17-year-old boy with a dysmorphic ankle and a complete dorsal dislocation of the Chopart joint. Because of pain with activities and functional limitations, the patient underwent a staged correction of the dislocation. The deformity was corrected through a staged approach using a Taylor Spatial Frame, navicular excision, talocuneiform arthrodesis, and calcaneocuboid arthrodesis. One year postoperatively, the patient is pain free with notable functional gains.

Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty. METHODS: We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake. RESULTS: Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements. CONCLUSION: This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively. CLINICAL TRIALS REGISTRY: NCT03380754.

Total Knee Arthroplasty: Opioid-Free Analgesia in a Patient with Opioid-Induced Hyperalgesia: A Case Report.

CASE: Pain control after total knee arthroplasty (TKA) remains a significant challenge, especially in the context of certain patient-specific factors. We present a case of a 59-year-old woman with opioid-induced hyperalgesia who was referred for left knee pain and end-stage tricompartmental degenerative joint disease after failure of conservative management. We outline an approach to control postoperative pain in patients undergoing TKA who have severe opioid contraindications. CONCLUSIONS: TKA and rehabilitation with a 6-year follow-up period was accomplished using a multimodal nonopioid approach, consisting of a combination of gabapentin, acetaminophen, ketorolac, meloxicam, methocarbamol, a tunneled femoral nerve catheter, and periarticular injection.

Pain Control After Total Hip Arthroplasty: A Randomized Controlled Trial Determining Efficacy of Fascia Iliaca Compartment Blocks in the Immediate Postoperative Period.

BACKGROUND: The purpose of this randomized controlled trial is to identify if a fascia iliaca block reduces postoperative pain and narcotic consumption and improves early functional outcomes in primary total hip arthroplasty (THA) performed through the mini-posterior approach. METHODS: Patients were recruited from September 2017 to September 2019. Eligible patients received a primary THA using a mini-posterior approach with epidural anesthesia. Postoperatively, patients were randomized to receive a fascia iliaca compartment block or a placebo block. Numeric Rating Scale pain scores, narcotic consumption, and functional outcomes were recorded at regular intervals postoperatively. RESULTS: Upon study completion, 122 patients were available for final analysis. There was no difference in the average pain scores at any time interval between the placebo and block groups during the first 24 hours (P = .21-.99). There was no difference in the morphine equivalents consumed between the groups during any time interval postoperatively (P = .06-.95). Functional testing showed no difference in regards to distance walked during the first therapy session (67.1 vs 68.3 ft., P = .92) and timed-up-and-go testing (63.7 vs 66.3 seconds, P = .86). There was an increased incidence of quadriceps weakness in the block group (22% vs 0%, P = .004) requiring alterations in therapy protocols. CONCLUSION: This randomized trial shows that a fascia iliaca compartment block does not improve functional performance and does not decrease pain levels or narcotic usage after mini-posterior THA, but does increase the risk of quadriceps weakness postoperatively. Based on these results we do not recommend routine fascia iliaca compartment blocks after THA performed with the mini-posterior approach.

Intravenous and Oral Tranexamic Acid Are Equivalent at Reducing Blood Loss in Thoracolumbar Spinal Fusion: A Prospective Randomized Trial.

STUDY DESIGN: A prospective randomized trial of patients enrolled at a university affiliated tertiary medical center between February and December 2017. OBJECTIVE: To compare perioperative blood loss in patients undergoing elective posterior thoracolumbar fusion who were treated with intravenous (IV) versus oral (PO) tranexamic acid (TXA). SUMMARY OF BACKGROUND DATA: The use of antifibrinolytic agents such as TXA to decrease operative blood loss and allogenic blood transfusions is well documented in the literature. While evidence supports the use of IV and topical formulations of TXA in spine surgery, the use of PO TXA has not been studied. METHODS: Eighty-three patients undergoing thoracolumbar fusion were randomized to receive 1.95 g of PO TXA 2 hours preoperatively or 2 g IV TXA (1 g before incision and 1 g before wound closure) intraoperatively. The sample was further stratified into three categories based on number of levels fused (1-2 level fusions, 3-5, and >5). The primary outcome was the reduction of hemoglobin. Secondary outcomes included calculated blood loss, drain output, postoperative transfusion, complications, and length of hospital stay. Equivalence analysis was performed with a two one-sided test (TOST). A P-value of <0.05 suggested equivalence between treatments. RESULTS: Fourty three patients received IV TXA and 40 patients received PO TXA. Patient demographic factors were similar between groups except for body mass index (BMI). The mean reduction of hemoglobin was similar between IV and PO groups (3.36 g/dL vs. 3.43 g/dL, respectively; P = 0.01, equivalence). Similarly, the calculated blood loss was equivalent (1235 mL vs. 1312 mL, respectively; P = 0.02, equivalence). Eight patients (19%) in IV TXA group received a transfusion compared with five patients in PO TXA group (13%) (P = 0.44). One patient (2% and 3% in IV and PO, respectively) in each group experienced a deep venous thrombosis/pulmonary embolism (P = 0.96). CONCLUSION: Patients treated with IV and PO TXA experienced the same perioperative blood loss after spinal fusions. Given its lower cost, PO TXA represents an excellent alternative to IV TXA in patients undergoing elective posterior thoracolumbar fusion and may improve healthcare cost-efficiency in the studied population. LEVEL OF EVIDENCE: 1.

Bone marrow stromal cells from aged male rats have delayed mineralization and reduced response to mechanical stimulation through nitric oxide and ERK1/2 signaling during osteogenic differentiation.

Bone marrow stromal cells (MSCs) are a source of osteoblast precursors that can be recruited during bone remodeling or injury, both important processes in aging populations. With advancing age, alterations in bone structure and mineralization are often associated with an increase in osteoporosis and fracture risk. Changes in the number of osteoprogenitor cells and their osteogenic potential may occur with advancing age; however few studies have considered the influence of mechanical conditions. Here, we investigated the ability of bone MSCs from mature and aged rats to differentiate into osteoblasts and to respond to short and long periods of mechanical stimulation through signaling by ERK1/2, nitric oxide (NO), and prostaglandin E(2) (PGE(2)) during differentiation. Mineralization was delayed and reduced, but extracellular matrix production appeared less affected by increased age. Differentiating MSCs from aged animals had a decreased response to short and long periods of mechanical stimulation through ERK1/2 signaling, and to long periods of mechanical loading through NO signaling early and late during differentiation. Increases in relative PGE(2) signaling were higher in MSCs from aged animals, which could compensate for reduced ERK1/2 and NO signaling. The decreased mineralization may decrease the ability of cells from aged animals to respond to mechanical stimulation through ERK1/2 and NO signaling, with increased impairment over differentiation time. Decreasing the delay in mineralization of MSCs from aging animals might improve their ability to respond to mechanical stimulation during bone remodeling and injury, suggesting therapies for bone fragility diseases and tissue engineering treatments in elderly populations.