Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study.

BACKGROUND: Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty. This study aimed to evaluate the effects of 2 intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following total joint arthroplasty in diabetic patients. METHODS: A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective total knee arthroplasty (TKA) between May 6, 2020, and December 17, 2021 was conducted. Patients who received 1 dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received 2 doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences, postoperative pain as Verbal Rating Scale pain scores, and postoperative complications. RESULTS: The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. Verbal Rating Scale pain scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION: Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.

The Effect of Working Time and Application Technique on Cement Penetration into a Tibial Model.

Background: Aseptic loosening of the cemented tibial component is a source of failure in total knee arthroplasty. This study examined common techniques for cement application by quantifying depth and volume of penetration into tibia models. Material and methods: Thirty-six composite tibia models were cemented with a tibial component using 3 application techniques (gun, osteotome, and layered) with either early or late cement working time. Computed tomography and 3D-modeling were used to quantify volume and depth of penetration. Statistical analysis was conducted with analysis of variance with Bonferroni correction and Student's t-test. Results: No difference was found in overall volume of penetration between early and late cement application (P = .16). Beneath the baseplate, the layered technique had significantly less penetration and averaged less than 3 mm with early and late cement. The gun technique had the greatest depth of penetration with early cement and averaged greater than 3 mm in all zones regardless of cement working time. The osteotome technique achieved significantly greater depth of penetration around the keel with early and late cement, P < .01. Conclusions: Using a cement gun ensures adequate penetration beneath the baseplate regardless of cement working time while the osteotome technique is effective to increase penetration around the implant keel. According to our study, applying cement early in its working time may not increase volume of penetration. This study raises concern regarding adequate cement penetration using the layered technique for cementing the tibial component in total knee arthroplasty, and future research is warranted.

Targeting the Gut Microbiome for Inflammation and Pain Management in Orthopedic Conditions.

The human gut microbiome can be altered with probiotics, prebiotics, synbiotics, and anti-inflammatory foods and spices as part of an evidence-based strategy that targets inflammation and pain in common orthopedic conditions. Implementing these strategies avoids adverse effects associated with nonsteroidal anti-inflammatory drugs and minimizes the potential for opioid use. This review focuses exclusively on human trials studying the effects of gut microbiome alterations to address pain and inflammatory markers in common orthopedic conditions: osteoarthritis, rheumatoid arthritis, fractures/osteoporosis, and bone pain associated with chemotherapy. Individualized supplementation strategies can be further explored with the information in this review. [Orthopedics. 2022;45(5):e226-e234.].

Preoperative supine traction radiographs often result in higher Lenke classifications than supine bending radiographs in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective chart and radiographic review. OBJECTIVE: The purpose of this study is to determine if both traction and side-bending radiographs yield the same Lenke classification. Supine side-bending radiographs are used to evaluate curve flexibility and assign Lenke classification in Adolescent Idiopathic Scoliosis (AIS). Supine traction radiographs are another tool used by treating surgeons to gauge flexibility and appropriate levels for spinal fusion in AIS. METHODS: Retrospective chart and radiographic review were performed on AIS patients that underwent a posterior spinal fusion from 2008 to 2017. Cobb angles and Lenke classifications were determined on all upright posterioanterior (PA) spine radiographs, supine traction radiographs, and four supine bending radiographs. Statistical analysis using independent t tests and chi-square tests as appropriate were compared between patients with or without discordant Lenke classifications with p value set at < 0.05 for statistical significance. RESULTS: 184 patients met inclusion criteria, 36 males and 148 females. The average Cobb angle for the proximal thoracic (PT) curve was 27.2°, main thoracic (MT) curve was 60.5°, and thoracolumbar/lumbar (TL/L) curve was 48.0°. Significantly less curve correction was found with supine traction radiographs compared with bending radiographs: PT (23.1° vs 18.9°, p < 0.001), MT (38.9° vs 37.9°, p = 0.015), and TL/L (25.9° vs. 18.0°, p < 0.001). Lenke Classification was found concordant in 151/184 (82.1%). Traction views in the discordant Lenke classification group demonstrated less curve correction than those in the concordant group: PT (27.4° vs. 22.1°, p = 0.011), MT (45.3° vs. 37.5°, p < 0.001), and TL/L (29.3° vs 25.1°, p = 0.019). CONCLUSION: Supine traction and supine bending radiographs provided a concordant Lenke classification 82.1% of the time. However, supine traction radiographs demonstrate less curve correction, a higher Lenke classification, and underestimated the TL/L curve correction to a greater degree. A single supine traction film is not an adequate substitute to side-bending radiographs when determining Lenke classification in patients with Adolescent Idiopathic Scoliosis. LEVEL OF EVIDENCE: III.

Incisionless Partial Medial Meniscectomy.

Knee arthroscopy has evolved greatly from its inception in the twentieth century. Of the many arthroscopic knee surgeries, meniscectomy is the most commonly performed. Arthroscopic meniscectomy is the most common orthopaedic surgical procedure performed in the United States. We continue to develop more minimally invasive procedures, and the NanoScope has provided a new generation of possibilities. The system does not require the use of a standard incision or portal, and with the use of nanoinstruments, we can perform treatments as well as diagnostic arthroscopy without incisions. This technique provides an updated incisionless option to perform a partial medial meniscectomy.

Closed Reduction of an Irreducible Knee Dislocation: A Case Report.

ADDITION TO ORTHOPEDIC LITERATURE: Posterolateral knee dislocations are extremely rare and generally require open reduction; however, we were able to provide closed reduction by reproducing mechanism of injury with a technique described in the literature. This is the second reported case of such accomplishment. INTRODUCTION: Posterolateral knee dislocation is the most common form of "irreducible" knee dislocations. Buttonholing of the medial femoral condyle through medial soft tissues of the knee results in entrapment. We report the second known case of successful closed reduction. CASE PRESENTATION: A 51-year-old female with morbid obesity sustained a right posterolateral knee dislocation shown on plain radiograph. This was accompanied by lateral patella dislocation and a dimple sign at the medial joint line after a fall from standing height produced a rotational mechanism. CONCLUSION: This is the second reported case of successful closed reduction to an injury that has been generally established to be "irreducible." The technique used closely matches that described in the only other reported case and involves reproduction of the mechanism of injury. This establishes additional evidence to a previously isolated report of successful acute treatment that counters the current narrative.

The use of a tablet computer to complete the DASH questionnaire.

PURPOSE: To determine whether electronic self-administration of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire using a tablet computer increased completion rate compared with paper self-administration. METHODS: We gave the DASH in self-administered paper form to 222 new patients in a single hand surgeon's practice. After a washout period of 5 weeks, we gave the DASH in self-administered tablet computer form to 264 new patients. A maximum of 3 questions could be omitted before the questionnaire was considered unscorable. We reviewed the submitted surveys to determine the number of scorable questionnaires and the number of omitted questions in each survey. We completed univariate analysis and regression modeling to determine the influence of survey administration type on respondent error while controlling for patient age and sex. RESULTS: Of the 486 total surveys, 60 (12%) were not scorable. A significantly higher proportion of the paper surveys (24%) were unscorable compared with electronic surveys (2%), with significantly more questions omitted in each paper survey (2.6 ± 4.4 questions) than in each electronic survey (0.1 ± 0.8 questions). Logistic regression analysis revealed survey administration mode to be significantly associated with DASH scorability while controlling for age and sex, with electronic survey administration being 14 times more likely than paper administration to yield a scorable DASH. CONCLUSIONS: In our retrospective series, electronic self-administration of the DASH decreased the number of omitted questions and yielded a higher number of scorable questionnaires. Prospective, randomized evaluation is needed to better delineate the effect of survey administration on respondent error. CLINICAL RELEVANCE: Administration of the DASH with a tablet computer may be beneficial for both clinical and research endeavors to increase completion rate and to gain other benefits from electronic data capture.

Tibial compression is anabolic in the adult mouse skeleton despite reduced responsiveness with aging.

The ability of the skeleton to adapt to mechanical stimuli diminishes with age in diaphyseal cortical bone, making bone formation difficult for adults. However, the effect of aging on adaptation in cancellous bone, tissue which is preferentially lost with age, is not well characterized. To develop a model for early post-menopausal women and determine the effect of aging on cancellous bone adaptation in the adult mouse skeleton, in vivo tibial compression was applied to adult (26 week old) osteopenic female mice using loading parameters, peak applied load and peak diaphyseal strain magnitude, that were previously found to be osteogenic in young, growing (10 week old) mice. A Load-Matched group received the same peak applied loads (corresponding to +2100 µÎµ at the medial diaphysis of the tibia) and a Strain-Matched group received the same peak diaphyseal strains (+1200 µÎµ, requiring half the load) as the young mice. The effects of mechanical loading on bone mass and architecture in adult mice were assessed using micro-computed tomography and in vivo structural stiffness measures. Adaptation occurred only in the Load-Matched group in both the metaphyseal and diaphyseal compartments. Cancellous bone mass increased 54% through trabecular thickening, and cortical area increased 41% through medullary contraction and periosteal expansion. Adult mice were able to respond to an anabolic stimulus and recover bone mass to levels seen in growing mice; however, the adaptive response was reduced relative to that in 10 week old female mice for the same applied load. Using this osteogenic loading protocol, other factors affecting pathological bone loss can be addressed using an adult osteopenic mouse model.