Acetabular Fracture Outcomes and Complications: An International Comparison.

Introduction: Despite the groundbreaking research by Judet and Letournel in the 1960s, the specific equipment, surgical approach, fixation strategy, and post-operative course for treating acetabular fractures have not been standardized. Therefore, this study aimed to compare technological resources, operative procedures, and post-operative complications between patients treated for acetabular fractures in Romania and the United States (U.S.). Methods: Between February 2011 and August 2018, a total of 116 Romanian patients and 373 U.S. patients underwent open reduction and internal fixation for acetabular fractures. Data were collected prospectively for Romania and retrospectively for the U.S. The authors used T-tests, Fisher's exact tests, and odds ratios to analyze categorical data while ordinal date were assessed using logistic regression. Results: U.S. patients had higher comorbidity rates for diabetes, obesity, and hypertension. However, the initial quality of reduction, graded with Matta's criteria, was similar between American and Romanian patients. Post-operatively, U.S. patients had significantly higher Brooker criteria scores for heterotopic ossification. Rates of deep vein thrombosis, infections, sciatic nerve lesions, and loss of reduction between the two countries were not significantly different. Conclusions: Given the similar initial reduction quality despite technological differences, the authors suggest that fundamental factors, such as surgeon training and experience, may have a greater impact than the availability of technologically advanced operative resources. Future research focusing on the efficacy of these advanced resources for acetabular fracture fixation could help determine their true impact on patient outcomes and improve the cost-effectiveness of this surgery.

Managing Post-Operative Pain in Orthopedic Patients: An International Comparison.

Introduction: Opioids play a crucial role in post-operative pain management in America, but not in some other countries. We sought to determine if a discrepancy in opioid use between the United States (U.S.) and Romania, a country that administers opioids in a conservative fashion, would show in subjective pain control differences. Methods: Between May 23, 2019, and November 23, 2019, 244 Romanian patients and 184 American patients underwent total hip arthroplasty or the surgical treatment of the following fractures: bimalleolar ankle, distal radius, femoral neck, intertrochanteric, and tibial-fibular. Opioid and non-opioid analgesic medication use and subjective pain scores during the first and second 24 hours after surgery were analyzed. Results: Subjective pain scores for the first 24 hours were higher among patients in Romania compared to the U.S. (p < 0.0001), but Romanians reported lower pain scores than U.S. patients in the second 24-hours (p < 0.0001). The quantity of opioids given to U.S. patients did not differ significantly based on sex (p = 0.4258) or age (p = 0.0975). However, females reported higher pain scores than male patients following the studied procedures (p = 0.0181). No sex-based differences in pain scores were noted among Romanian patients. Conclusions: Higher pain scores in American females, despite equivalent amounts of narcotics to their male counterparts, and the absence of a difference in Romanians suggested that the current American post-operative pain regimen may be tailored to the needs of male patients. In addition, it pointed to the impacts of gender, compared to sex, in pain experiences. Future research should look for the safest, most efficacious pain regimen suitable for all patients.

Variation in tibial tuberosity lateralization and distance from the tibiofemoral joint line: An anatomic study.

BACKGROUND: To describe variation in tibial tuberosity position in a normal adult population and inter-rater reliability of measurements of tibial tuberosity position. METHODS: Surface models of 161 proximal tibia specimens (83 female, 78 male; 80 black, 81 white; age 28.7years, SD 7.5) were created with a three-dimensional laser scanner. Percent lateralization, tuberosity-eminence angle, and distance from joint surface were measured for each specimen. Variation in tuberosity position by sex, race, age, height, and BMI was calculated. Multivariate regression was used to assess for demographic factors independently associated with tuberosity positioning. RESULTS: Mean percent lateralization was 57.9% (SD 2.4, range 52.4-64.9%). Tuberosity-eminence angle mean was 11.03° (SD 2.8, range 0-18.7°). Percent lateralization and tuberosity-eminence angle were not influenced by sex, race, age, height or, BMI (p>0.05). Mean tuberosity distance from joint surface was 29.2mm (SD 3.5, range 16.6-38.6mm) and larger in males than females (30.7mm (SD 2.9), 27.6mm (SD 3.3); p<0.001). Tuberosity distance from joint surface increased 0.18mm on average per 1.0cm increase in height (p<0.001). Inter-rater reliability was high for distance from joint surface (Cronbach alpha=0.99) and percent lateralization. CONCLUSIONS: Tibial tuberosity percent lateralization falls in a narrow range for individuals, whereas tuberosity-eminence angle and distance from joint line are more variable. Inter-rater reliability is high for percent lateralization and distance for the joint surface. Distance of tibial tuberosity from joint surface is associated with sex and height.

Perioperative Allogeneic Red Blood-Cell Transfusion Associated with Surgical Site Infection After Total Hip and Knee Arthroplasty.

BACKGROUND: Perioperative allogeneic red blood-cell transfusion is a suspected risk factor for surgical site infection (SSI) after total joint arthroplasty (TJA), but the interrelationships among SSI risk, transfusion dose, preoperative anemia, and the presence of coagulopathies have not been well described. METHODS: Data on SSI within 1 year after surgery as well as on transfusion with blood products within 30 days after surgery were obtained for 6,788 patients who had undergone primary or revision total hip or knee arthroplasty from 2000 to 2011 in a single hospital system. Multivariate logistic regression modeling was used to determine the independent association between allogeneic red blood-cell transfusion and SSI. RESULTS: There was a dose-dependent association between allogeneic red blood-cell transfusion and SSI, with the infection rate increasing as the transfusion dose increased from 1 unit (odds ratio [OR] = 1.97; 95% confidence interval [CI] = 1.38, 2.79; p < 0.001), to 2 units (OR = 2.20; CI = 1.37, 3.44; p = 0.002), to 3 units (OR = 3.66; CI = 1.72, 7.16; p = 0.001), and to >3 units (OR = 7.40; CI = 4.91, 11.03; p < 0.001) after controlling for medical comorbidities, planned procedure, preoperative anemia, and preexisting coagulopathies. A preexisting bleeding disorder (OR = 2.09; CI = 1.57, 2.80; p < 0.001) and clotting disorder (OR = 1.37; CI = 1.14, 1.64; p = 0.001) and preoperative anemia (OR = 3.90; CI = 3.31, 4.61; p < 0.001) were all independent risk factors for transfusion after adjusting for the planned procedure. CONCLUSIONS: We found a dose-dependent relationship between allogeneic red blood-cell transfusion and SSI risk after total hip or knee arthroplasty. Additionally, preoperative anemia or a known bleeding or clotting disorder were risk factors for the need for allogeneic red blood-cell transfusion. Our findings underscore the need for preoperative risk assessment, methods to limit surgical tissue injury, and optimized blood conservation strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The ACL injury response: A collagen-based analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injuries do not effectively heal. Tendon graft tissue after reconstruction shows rapid tissue turnover and 'ligamentization.' It is unknown whether native torn ACL tissue undergoes significant collagen turnover after injury or is arrested by the intraarticular environment. It is also unknown whether injury mechanism or chronicity affect torn ligament tissue turnover. METHODS: Thirty-three mid-substance ACL biopsies were obtained during primary arthroscopic ACL reconstruction (n=31; nine contact injuries, 22 non-contact injuries, 22 males, 11 females; mean age 28.5 years; median injury to surgery time 12 weeks), or from cadavers as uninjured ACL (n=2). As a marker for collagen turnover, immature collagen cross-link content was determined by ninhydrin reagent assays. The immature cross-link content was assessed against injury mechanism, patient age, and injury to surgery time. Histochemical analysis was conducted on two uninjured ACL cadaveric controls, a four-week-old ACL tear, and a four-year-old ACL tear. RESULTS: Contact and non-contact groups were not demographically different with respect to sex, patient age, injury to surgery time, and activity involvement prior to injury, which ranged from basketball to logging. Collagen crosslink content was very low across all samples, suggesting high tissue turnover between injury and surgery regardless of injury mechanism (non-contact: 1.68ng/mol, CI 0.48-2.89; contact: 1.50ng/mol, CI 0.14-2.86; p=0.842). CONCLUSION: Collagen turnover occurs rapidly after ACL injury regardless of contact or non-contact mechanism. Robust tissue turnover starts within the first several weeks after injury and persists to some extent throughout the life of the torn ACL.

Treatment Options for Patellar Tendinopathy: A Systematic Review.

PURPOSE: To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies. METHODS: A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively. RESULTS: A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P = .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI -20% to 60%). CONCLUSIONS: Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6 months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Utilizing reamer irrigator aspirator (RIA) autograft for opening wedge high tibial osteotomy: A new surgical technique and report of three cases.

INTRODUCTION: The lateral closing wedge high tibial osteotomy (HTO) was popularized by Coventry in the 1960s. In the 1990s the medial opening wedge osteotomy gained popularity because it could achieve greater valgus correction and it did not require dissociation of the fibula from the tibia, an important consideration when treating varus knees with lateral and posterolateral ligament deficiencies (Noyes' double-varus and triple-varus knees). However, it has the disadvantage of requiring bone graft to fill bony defects. Recently, the reamer-irrigator-aspirator (RIA; Synthes, Paoli, PA) system was developed, and as a result of this procedure, a large amount of usable autogenous bone graft can be collected safely for use. To our knowledge, there is no published series combining opening wedge HTO with the use of RIA obtained autogenous bone graft. PRESENTATION OF CASE: We present a novel technique in which a series of three patients underwent opening wedge HTO using ipsilateral, retrograde femur RIA graft to fill the bone defect. All patients had satisfactory clinical and radiologic outcomes following the new technique at latest follow up. DISCUSSION: Opening wedge high tibial osteotomy is a well-documented and accepted orthopedic procedure, however, has the disadvantage of requiring varying amounts of bone graft. Traditionally, iliac crest or tricortical allograft have been the grafting modalities of choice, however both have inherent drawbacks to their use. In our series, the use of RIA autograft is a safe and reliable harvest technique for high tibial osteotomy, providing abundant and quality autogenous bone graft. CONCLUSION: All three of our patients achieved radiographic union with high clinical patient satisfaction without any major complications. We feel this novel technique is a safe and acceptable operative solution grafting opening wedge osteotomies about the knee.

Evaluation of popliteal artery injury risk with locked lateral plating of the tibial plateau.

OBJECTIVES: This study was undertaken to determine if there is increased likelihood of popliteal artery injury as one places a fixed-angle lateral proximal tibia locking plate with posterior plate lift off and or anterior plate translation from the ideal position. METHODS: A Synthes (Synthes USA, West Chester, PA) 3.5-mm and 4.5-mm lateral proximal tibia locking plate was placed consecutively on each of six specimens in the straight lateral (SL) position. Screw position with respect to the medial cortex was recorded as well as the distance of the posterior most screw tip to the popliteal artery. Next a 3-mm shim was placed under the posterior edge of the same plate to mimic posterior plate lift off (LO) followed by placement of a 6-mm shim. The same experiment was repeated with the plate translated 5 mm anteriorly (AT). RESULTS: The popliteal artery was injured in zero of six specimens using the 3.5-mm plate. The popliteal artery was injured in six of six specimens using the 4.5-mm plate in the 5-mm AT 6-mm LO position, five of six with 5-mm AT and 3-mm LO, two of six with only 5-mm AT, four of six with SL and 6-mm LO, two of six with SL and 3-mm LO, and zero of six with SL. CONCLUSION: The Synthes 4.5-mm plate can put the popliteal artery at risk with as little as 3-mm posterior liftoff in the intended straight lateral position or with 5-mm anterior plate translation with no posterior liftoff. Therefore, placement of the 4.5-mm plate in the proper position and confirmation of its position with a true lateral radiograph is paramount to avoid injury to the popliteal artery.