Osteoporosis Treatment and Outcomes in Patients Undergoing Adult Spinal Deformity Surgery.

BACKGROUND: This study aims to evaluate the prevalence and treatment of osteoporosis in patients undergoing long spinal fusion for adult spinal deformity (ASD) and compare the impact of osteoporosis treatment on surgical and radiographic outcomes. METHODS: We conducted a retrospective study of adult patients aged ≥40 years who underwent thoracolumbar ASD surgery at a single academic center between 2015 and 2021. We recorded demographic information, procedural details, and pharmacologic treatments. Primary outcomes included preoperative and postoperative sagittal vertical axis, pelvic incidence-lumbar lordosis mismatch, and postoperative complications such as surgical site infection, pseudarthrosis, proximal junctional kyphosis (PJK), and proximal junctional failure. Patients with osteoporosis were compared to those without. RESULTS: Among 168 patients, the prevalence of osteoporosis was 28.6%. Osteoporotic patients were older and predominantly female. At the time of surgery, 70.8% of osteoporotic patients were receiving pharmacologic treatment. Preoperative pelvic incidence-lumbar lordosis mismatch and sagittal vertical axis did not differ significantly between osteoporotic and nonosteoporotic cohorts. Both cohorts showed similar postoperative improvements. The osteoporotic cohort had a higher rate of PJK (35.4% vs. 17.5%, p=0.01), but no significant difference in proximal junctional failure rates. No significant differences were found between monotherapy and combination therapy outcomes for osteoporotic patients. CONCLUSIONS: Osteoporotic patients undergoing ASD surgery exhibited similar surgical outcomes and alignment improvements compared to nonosteoporotic patients, despite a higher rate of PJK. Pharmacological treatment appears beneficial in managing osteoporosis-related surgical risks. These findings highlight the importance of identifying and treating osteoporosis in ASD patients to minimize complications.

The effect of shoulder prosthesis stem length on failure due to torsional loading. A biomechanical study in composite humeri.

Background: Shoulder arthroplasty is becoming increasingly common. With evolving implant designs, multiple humeral stem options exist for the surgeon to choose from. New stemless and short-stem systems are modular, remove less native bone stock, and better adapt to patient anatomy. It has been suggested that shorter stem implants may be protective against periprosthetic fracture; however, this has not been mechanistically evaluated. Therefore, this study aimed to biomechanically test synthetic humeri with long-stem, short-stem, and stemless arthroplasty components in a torsional manner to evaluate their response to loading and characterize failure. Methods: Twenty-four synthetic humeri were implanted with long stem, short stem, or stemless uncemented prosthesis, 8 in each group. Humeri were mounted in a custom testing jig with a morse taper interfacing with a mechanical testing system. After a 20N axial force, specimens were torsionally loaded to failure at 15 degrees/sec, with 50 Hz collection. Torque vs. rotation curves were generated for each specimen, and stiffness, yield, ultimate strength, and failure load were measured. ANOVA and post hoc pairwise comparisons were used to assess effect of stem type on mechanical test variable. The association of the stem type with fracture type was analyzed by a Fisher's Exact test. Statistical significance was set at P < .05. Results: During torsional loading, long-stem implants were significantly stiffer than short or stemless implants. The angle of implant yielding was similar across stem designs; however, stemless implants had a lower yield torque. This correlated with a decreased yield energy in stemless compared to short stems as well. Maximum torque and failure torque was also significantly higher in short-stem and long-stem implants compared to stemless. Discussion: Periprosthetic fractures in shoulder arthroplasty are a concern in low-energy trauma, and stem design likely plays a significant role in early implant-bone failure. Our results suggest stemless implants under torsional load fail at lower stress and are less stiff than stemmed implants. The failure mechanism of stemless implants through metaphyseal cancellous bone emphasizes the effect bone quality has on implant fixation. There is likely a balance of torsional stability to survive physiologic loads while minimizing diaphyseal stress and risk of diaphyseal periprosthetic fracture. This combined with revision and fixation options represent decisions the surgeon is faced with when performing shoulder arthroplasty.

Small-Bore Needle Arthroscopic Extensor Carpi Radialis Brevis Release Results in Improved Outcomes at One Year Postoperatively.

Purpose: To evaluate outcomes of patients who underwent small-bore needle arthroscopic extensor carpi radialis brevis (ECRB) release for the management of recalcitrant lateral epicondylitis. Methods: Patients who underwent elbow evaluation and ECRB release using a small-bore needle arthroscopy system were included in this study Thirteen patients were included. Quick Disabilities of the Arm Shoulder and Hand and Single Assessment Numerical Evaluation scores, as well as overall satisfaction scores, were collected. A 2-tailed paired t-test was conducted to assess the statistical significance of the differences observed between preoperative and 1-year postoperative scores with significance set at P < .05. Results: There was a statistically significant improvement in both outcome measures (P < .001) and a 92.3% satisfaction rate with no significant complications at a minimum 1-year follow-up. Conclusions: Patients with recalcitrant lateral epicondylitis treated with ECRB release using needle arthroscopy demonstrated significantly improved Quick Disabilities of the Arm Shoulder and Hand and Single Assessment Numerical Evaluation scores postoperatively, without complications. Level of Evidence: IV, retrospective case series.

A Comparison of Prognostic Models to Facilitate Surgical Decision-Making for Patients With Spinal Metastatic Disease.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Compare the performance of and provide cutoff values for commonly used prognostic models for spinal metastases, including Revised Tokuhashi, Tomita, Modified Bauer, New England Spinal Metastases Score (NESMS), and Skeletal Oncology Research Group model, at three- and six-month postoperative time points. SUMMARY OF BACKGROUND DATA: Surgery may be recommended for patients with spinal metastases causing fracture, instability, pain, and/or neurological compromise. However, patients with less than three to six months of projected survival are less likely to benefit from surgery. Prognostic models have been developed to help determine prognosis and surgical candidacy. Yet, there is a lack of data directly comparing the performance of these models at clinically relevant time points or providing clinically applicable cutoff values for the models. MATERIALS AND METHODS: Sixty-four patients undergoing surgery from 2015 to 2022 for spinal metastatic disease were identified. Revised Tokuhashi, Tomita, Modified Bauer, NESMS, and Skeletal Oncology Research Group were calculated for each patient. Model calibration and discrimination for predicting survival at three months, six months, and final follow-up were evaluated using the Brier score and Uno's C, respectively. Hazard ratios for survival were calculated for the models. The Contral and O'Quigley method was utilized to identify cutoff values for the models discriminating between survival and nonsurvival at three months, six months, and final follow-up. RESULTS: Each of the models demonstrated similar performance in predicting survival at three months, six months, and final follow-up. Cutoff scores that best differentiated patients likely to survive beyond three months included the Revised Tokuhashi score=10, Tomita score=four, Modified Bauer score=three, and NESMS=one. CONCLUSION: We found comparable efficacy among the models in predicting survival at clinically relevant time points. Cutoff values provided herein may assist surgeons and patients when deciding whether to pursue surgery for spinal metastatic disease. LEVEL OF EVIDENCE: 4.

Loose Body Versus Trochlear Biopsy Matrix-Induced Autologous Chondrocyte Implantation (MACI) MOCART Scores and IKDC Reported Outcomes in Pediatric Patients.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) has shown promising results in the treatment of osteochondral lesions of the knee. A recent study showed similar viability comparing chondrocytes harvested from the intercondylar notch compared to those harvested from osteochondral loose bodies. However, there is limited evidence assessing how these different biopsies perform clinically. The goal of this study was to compare both radiographic and patient-reported outcomes in patients with patellar and femoral osteochondral lesions treated with MACI using either a standard intercondylar notch biopsy or an osteochondral loose body biopsy. METHODS: A retrospective study was performed on all pediatric autologous chondrocyte implantation procedures performed from 2014 to 2017 at a single institution. Patients were divided into 2 groups: one group had cartilage derived from a standard intercondylar notch biopsy (n=9) and the other group had cartilage derived from an osteochondral loose body found within the ipsilateral knee (n=10). At a minimum of 1-year postimplantation, magnetic resonance imagings of the operative knee were performed and the Magnetic Resonance Observation of Cartilage Repair Tissue Knee Score (MOCART 2.0) knee score was used to assess the integrity and quality of the cartilage repair tissue. Interclass correlation coefficients were calculated between the 2 groups. International Knee Documentation Committee (IKDC) outcome scores were determined at a minimum 2 years post-implantation. RESULTS: The interclass correlation coefficient between three independent examiners for the MOCART scoring was excellent at 0.94. With regards to the MOCART score, the loose body group had an insignificant 17-point lower median score at 63 [interquartile range (IQR): 58 to 89] compared to the intercondylar group at 80 (IQR: 65 to 90) ( P =0.15). There was no difference in IKDC scores with the loose body group having a median score of 82 (IQR: 65 to 95) and the intercondylar group having a median score of 84 (IQR: 53 to 99) ( P =0.90). CONCLUSION: These results demonstrate that osteochondral loose bodies can be used as viable harvest site in MACI procedures with no difference in functional and radiographic outcomes at 2 years postimplantation. This may limit both short and long-term donor site morbidity. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The Operative Treatment of Scapula Fractures: An Analysis of 10,097 Patients.

Background: The indications for operative treatment of scapula fractures have been debated over the past decade. Our purpose was to determine 1) the incidence and trends in the operative treatment of scapula fractures, 2) the incidence of conversion from operative fixation to total or hemi-shoulder arthroplasty (THSA) and 3) rates of associated injuries in scapula fractures. We hypothesized that the operative treatment of scapula fractures is increasing over time and that scapula fractures treated with open reduction and internal fixation (ORIF) would have increased risk for conversion to THSA. Methods: The Humana Inc. administrative claims database was queried from 2008 to 2015. Patients with any scapular fracture, ORIF of scapula fracture, total or hemi-shoulder arthroplasty, and associated injuries were identified by ICD-9 and CPT codes. Analysis was performed for 1) all patients with a scapula fracture undergoing operative fixation (i.e. ORIF and THSA), 2) all scapular fractures treated with ORIF with subsequent conversion to ipsilateral THSA, and 3) all associated injuries. Results: There were 10,097 scapula fractures (28.4% glenoid, 48% female). 60% occurred in patients 65 years and older. There were 198 (1.96%) fractures (70% glenoid) treated with ORIF. There were 287 (2.84%) fractures (45% glenoid) treated with THSA (76% total shoulder). The rate of ORIF of scapular fractures did not significantly increase (RR=0.87, p=0.58). There was a significant increase in THSA as primary treatment of scapula fractures in 2015 compared to 2007 (RR=0.43, p=0.0016). Conversion from ORIF to THSA was 12.6% (25/198). Scapula fractures treated with ORIF were at significant risk for conversion to THSA (RR=4.77, p<0.0001). Associated injuries occurred in nearly 50% of scapula fractures-other fractures, lung contusion and pneumothorax/hemothorax ranking the highest, accounting for 37%, 14.5% and 8.3% of all associated injuries, respectively. Conclusion: The incidence of operative treatment of scapula fractures was 1.96% and 2.84% for ORIF and THSA, respectively. Scapular fractures previously treated with ORIF were at significant risk for conversion to THSA. Although ORIF in scapular fractures did not significantly increase over time, both THSA and overall (ORIF+THSA) operative treatment of scapula fractures increased significantly. Level of Evidence: IV.

COVID-19 and Youth Sports: What Are the Risks of Getting Back on the Field Too Quickly?

The widespread shutdown in response to the coronavirus disease 2019 (COVID-19) pandemic, although varied across state and county levels, has undoubtedly impacted everyone to some degree. Within the pediatric population, the closure of schools and organized youth athletic programs has resulted in a unique situation that has made athletes physically deconditioned and at risk for injury. As sports and competition gradually restart, there are considerable risks to the skeletally immature athlete. The anatomic and physiologic changes that occur to bone and cartilage during growth make the young athlete particularly susceptible to both acute and overuse injuries. In the context of the pandemic, deconditioning, obesity, lack of variety, and the resultant mental health burden pose unique challenges in ensuring that young athletes safely return to the field. This review aims to identify risk factors for sport-related injuries and to outline strategies for minimizing these injuries as pediatric patients return-to-play after COVID-19. [Pediatr Ann. 2021;50(11):e465-e469.].

Sarcopenia is Associated with Nonunion of Open Tibia and Ankle Fractures.

Background: Sarcopenia is a clinical syndrome of diminished muscle mass and function associated with disability, poor surgical outcomes, and mortality. Open fractures of the tibia and ankle have a high risk for complications including nonunion and surgical site infection (SSI). The purpose of this study is to determine if sarcopenia is associated with SSI and nonunion in individuals that sustain open fractures of the tibia and ankle. Methods: 111 consecutive adults who underwent operative fixation of open fractures of the tibia or ankle from 2006-2017 with preoperative CT of the abdomen and pelvis were retrospectively identified at a single institution. Eleven patients were lost to follow-up. The psoas index (PI = (RPA+LPA)/ height2 (cm2/m2)) was calculated from bilateral psoas cross sectional areas measured on axial CT scans at the L3 pedicle. Patients were stratified by the presence of sarcopenia as defined by established gender specific PI cut-offs of <3.85 cm2/m2 (women) and <5.45 cm2/m2 (men). Records were also abstracted for comorbidities to determine a Charlson Comorbidity Index (CCI) score and postoperative complications including fracture nonunion and SSI. Logistic regression was used to model the relationships between complications, sarcopenia and other factors. Results: 16/100 (16%) patients met gender specific criteria for the diagnosis of sarcopenia by PI. There was no difference in gender, age, or burden of medical comorbidity according to CCI between the sarcopenic and non-sarcopenic groups (all p>0.05). Nonunion occurred in 6 patients with sarcopenia (38%) and 12 without sarcopenia (18%) (Relative risk=2.42, 95%C!=1.08-5.43, p=0.0314). No association was found between sarcopenia and SSI, BMI, smoking status, ISS, and Gustilo and Anderson (GA) classification of open fracture (all p>0.2). GA classification was strongly associated with infection, with each successive classification having a nearly 3-fold increase in risk (p=0.0217). Conclusion: Sarcopenia is an independent risk factor for fracture nonunion following operative fixation of open tibia or ankle fracture, but is not predictive of surgical site infection. Gustilo Anderson classification is strongly associated with SSI risk. Psoas index is a straightforward and objective method of identifying sarcopenia in patients with open fractures. Diagnosing sarcopenia in these individuals can inform medical decision making and patient counseling regarding risk for nonunion. Further work is needed to identify effective interventions to improve outcomes in these patients.Level of Evidence: III.

A case of Histoplasma capsulatum variety capsulatum septic arthritis successfully treated with surgery, systemic antifungals, and local amphotericin cement beads.

Histoplasma capsulatum variety capsulatum (H. capsulatum) is a thermally dimorphic fungus that is endemic to the Mississippi River and Ohio River valley regions. Of the hundreds of thousands of patients exposed to this fungus, less than 1% develop a severe illness most commonly manifesting as pulmonary disease. Septic arthritis from hematogenous seeding with H. capsulatum or from direct inoculation has been reported only rarely in the literature. The first case of septic arthritis of the shoulder due to H. capsulatum occurring in an immunocompromised patient, treated successfully with irrigation and debridement, systemic antifungals, and local delivery of amphotericin B with cement beads, is reported here. Importantly, the addition of local amphotericin B delivery by cement beads to conventional treatment likely led to clinical cure in this patient.