Phenytoin is associated with increased risk of osteoporosis and fragility fractures in adult epileptic patients.

INTRODUCTION: Osteoporotic fractures lead to significant decreases in the quality of life with increases in morbidity, mortality, and disability. Treatment with a variety of anti-epileptic drugs, such as phenytoin, has been understood to cause a decrease in bone mineral density. MATERIALS AND METHODS: Cohort A was identified as patients that were 18-55 years old that had epilepsy and recurrent seizures that were also prescribed phenytoin. Cohort B was identified as patients that were 18-55 years old that had epilepsy and recurrent seizures but were not prescribed phenytoin or other anti-epileptic medications. Cohorts were matched for relevant confounding pathologies and demographic factors. Outcomes were evaluated from 1 day to 5 years after the indexed event. RESULTS: A total of 35,936 patients with epilepsy that were prescribed phenytoin were matched with 109,335 patients with epilepsy that were not prescribed phenytoin. Patients on phenytoin therapy were at significantly higher risk for osteoporosis without pathological fracture, fracture of metatarsal bone, fracture of shoulder and upper arm, fracture of distal radius, fracture of thoracic vertebra, fracture of cervical vertebra, fracture of lumbar vertebra, fracture of femoral head or neck, pertrochanteric fracture, femoral shaft fracture, and distal tibia fracture (all outcomes p < 0.001). CONCLUSION: Epileptic patients on phenytoin therapy that were 18-55 years old exhibited higher associated risk of osteoporosis and osteoporotic-fragility fractures of various regions. Patients that undergo phenytoin therapy for epilepsy treatment should be educated on the increased risk of bone fractures and have appropriate lifestyle and diet modifications.

Risk Factors Associated With Postoperative Cardiac Events Following Total Hip and Knee Arthroplasty.

BACKGROUND: This study investigated the prevalence of adverse cardiac events following a total joint arthroplasty and subsequently analyzed risk factors that may increase the likelihood of these events. METHODS: Data for this study were extracted from a large national database. Chi-squared analyses and multivariate modelings were performed to determine the risk factors associated with 30-day perioperative troponin elevation, myocardial infarction (MI), and heart failure. We identified 80,544 total hip arthroplasty (THA) patients and 112,531 total knee arthroplasty (TKA) patients and analyzed the following cardiac risk factors: diabetes, renal insufficiency, prior MI, hypertension, and cerebrovascular disease. RESULTS: There were 34% of THA patients and 52% of TKA patients who had at least one of the studied risk factors. At-risk THA patients had 2.2, 5.9, and 5.3 times the odds of troponin elevation, MI, and postoperative heart failure, respectively, within 1 month compared to the control group (P < .0001). The TKA group had 2.9, 5.3, and 5.9 times the odds of troponin elevation, MI, and postoperative heart failure within 1 month compared to the control group (P < .0001). For both procedures, prior MI had the highest odds of resulting in perioperative troponin elevation and MI. Renal insufficiency had the highest odds of resulting in perioperative heart failure. CONCLUSIONS: Risk stratification for postoperative complications in orthopedic surgery is important to minimize adverse outcomes. This study highlights the need for consideration of risk factors prior to joint arthroplasty surgery. LEVEL OF EVIDENCE: Level III, Prognostic.

Return to Play Rates Following Operative Ankle Fractures Differ Between High- and Low-Performing National Football League Athletes.

This study investigated predictive factors for return to play among National Football League athletes after operative treatment of ankle fractures and the impacts of these injuries on career longevity and player performance. Athletes who underwent surgery to repair ankle fractures from the 2013 to 2017 seasons were identified from injury reserve lists and press releases. Demographics and season metrics were collected before and after the injury. Statistical analysis assessed for differences in recorded variables between injured and uninjured players. Thirty-one players met study inclusion criteria. Twenty-two (71%) athletes successfully returned to play. Players who did not return showed no significant differences (P>.05) in position, age, body mass index, number of games or seasons played preinjury, or snaps per game the season prior to injury and had a significantly lower (42.6%, P=.013) preinjury season approximate value (SAV) compared with returning players. Returning athletes showed no significant differences (P>.05) in SAV or snaps per game compared with their preinjury season or with uninjured controls. A high preinjury SAV is associated with successful return to play. No difference in game time or performance metrics was detectable between returning players and uninjured controls, or between preinjury and postinjury seasons. [Orthopedics. 2024;47(1):22-27.].

Isolated medial patellofemoral reconstruction outcomes: A systematic review and meta-analysis.

BACKGROUND: Treatment of patellar instability remains up for debate, and a combination of tibial tubercle osteotomy and medial patellofemoral ligament reconstruction (MPFLr) of the medial patellofemoral ligament (MPFL) has become the mainstay treatment for recurrent lateral patellar dislocation. Due to limited small studies, there remains a variety of surgical techniques still being practiced. The use of MPFL reconstruction, in isolation, has demonstrated promise. PURPOSE: The purpose of this systematic review and meta-analysis is to investigate if isolated medial patellofemoral ligament reconstruction (iMPFLr) can safely and efficaciously restore knee stability and to present the patient demographics, surgical techniques, graft choices, clinical outcomes, and complications after iMPFLr for recurrent patellar dislocation (RPD). METHODS: A review of the current literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, yielded 299 abstracts. Twenty-seven articles met the inclusion/exclusion criteria accounting for 1200 patients. Data was pooled and analyzed focusing on patient demographics, graft type used, Kujala, International Knee Documentation Committee (IKDC), Lysholm, Tegner, and complications. RESULTS: Across all studies the weighted mean age was found to be an average of 24.5 years, BMI was 24.9 kg/m2, follow-up was 47.3 months, as 67% were female, TT-TG distance was 15.3 mm, and Caton Deschamps index 1.11. The pooled effect size difference of pre versus post assessment of Kujala was -2.8, IKDC was -4.5, Lysholm was -6.4, and Tegner was -0.74. The pooled complication rate was found to be 8% across all included studies. A subgroup analysis was also performed, specifically looking at how single bundle, double bundle, gracilis, semitendinosus and knee angle during fixation effect outcome data. CONCLUSION: This systematic review and meta-analysis demonstrates that isolated MPFL reconstruction is a safe and effective treatment for recurrent patellar dislocations. Given the efficacy of isolated MPFL reconstruction, future investigations should aim to uncover the exact TT-TG distance, trochlear dysplasia, and patella alta grade for selecting patients to undergo this procedure. Furthermore, more primary research needs to be conducted on this topic due to the overall lack of published data from randomized controlled studies and no broad standardization of outcome measurements. LEVEL OF EVIDENCE: (4) Systematic Review and Meta-Analysis.

Publication Trends of Residents Accepted for Shoulder and Elbow Fellowships.

This study aims to evaluate the research productivity trends in orthopaedic residents who were selected for shoulder and elbow fellowships from 2010 to 2019. We hypothesize that residents matching into orthopaedic shoulder and elbow fellowships are increasing both their publication number and publication quality from 2010 to 2019. Fellows of orthopaedic shoulder and elbow programs from 2010 to 2019 were identified through publicly accessible information on fellowship programs. Each fellow's publication data during their residency was collected via publicly available search engines, and analyzed to include: fellowship year, residency years, fellowship program and location, total publications, number of publications in high-impact general orthopaedic and shoulder and elbow journals, and authorship position. A total of 176 orthopaedic shoulder and elbow fellows from 17 different programs were identified and included in the study. The fellows produced a total of 668 publications, published 172 articles in high impact journals, and had first authorship on 49% of the studies. On average, there were 3.8 publications per fellow per year from 2010 to 2019. There were 5.7 publications produced per fellow in 2018-2019, compared to just 2.92 publications per fellow in 2010-2011. Overall, there was an increasing trend in publications, publications in high impact journals, and first authorship publications per applicant matching into shoulder and elbow fellowship from 2010 to 2019. (Journal of Surgical Orthopaedic Advances 31(4):205-208, 2022).

Bone tissue engineering techniques, advances and scaffolds for treatment of bone defects.

Bone tissue engineering (BTE) aims to develop strategies to regenerate damaged or diseased bone using a combination of cells, growth factors, and biomaterials. This article highlights recent advances in BTE, with particular emphasis on the role of the biomaterials as scaffolding material to heal bone defects. Studies encompass the utilization of bioceramics, composites, and myriad hydrogels that have been fashioned by injection molding, electrospinning, and 3D bioprinting over recent years, with the aim to provide an insight into the progress of BTE along with a commentary on their scope and possibilities to aid future research. The biocompatibility and structural efficacy of some of these biomaterials are also discussed.

Interviewing in the Wake of COVID-19: How Orthopaedic Residencies, Fellowships, and Applicants Should Prepare for Virtual Interviews.

On May 7, 2020, the Coalition for Physician Accountability's released "Medical Students in the Class of 2021: Moving Across Institutions for Post Graduate Training," which comprises official recommendations on keeping programs and medical students safe during the upcoming match cycle with the challenges posed by COVID-19. In these recommendations, away rotations are discouraged, and all programs are compelled to commit to virtual interviews. Unlike employers and applicants in other industries, orthopaedic residency/fellowship programs and candidates seeking those positions have not routinely conducted virtual interviews. Without in-person interviews, applicants may perceive a limited ability to demonstrate their qualifications, judge program culture, and gauge ultimate program compatibility. Likewise, programs may perceive the inability to evaluate a candidate in real time, physically show program strengths, and ultimately judge applicant compatibility. Careful preparation and execution of a virtual interview can overcome these perceived limitations, whereas benefits, such as decreased cost for both programs and applicants, can make virtual interviews appealing. The purpose of this review was to help define a virtual interview, illustrate the benefits, and offer tips to both programs and applicants on how to prepare and perform optimally on an interview day.

Editorial Commentary: Mesenchymal Stem Cells in the Shoulder Subacromial Bursa: Do Cells Understand Statistical Significance?

Local, arthroscopic harvest of mesenchymal stem cells is of interest due to their potential to augment healing. The high rates of retear after rotator cuff repair are a significant concern, and solutions, such as augmentation with mesenchymal stem cells, are being sought. The subacromial bursa of the shoulder is a potential source of cells to augment healing.

Outcomes of Lisfranc Injuries Treated with Joint-Preserving Fixation.

BACKGROUND: Open reduction and internal fixation (ORIF) with transarticular screws to stabilize Lisfranc injuries may increase the risk of arthritis or affect outcomes. Joint-preserving fixation using staples, bridge plating, or Lisfranc screws avoids iatrogenic articular damage. This study analyzes functional outcomes and complications in Lisfranc-injury patients who underwent joint-preserving fixation. MATERIALS AND METHODS: We conducted a retrospective review of patients treated for Lisfranc injury at a Level 1 trauma center from July 2008 to October 2015. Patients over 18 years of age, with no concomitant procedures in the lower extremities, were included. Functional outcomes were evaluated through American Orthopaedic Foot and Ankle Society (AOFAS) scores. RESULTS: Fourteen patients met the inclusion criteria. The average followup time was 57 months (range 22-102 months). AOFAS scores averaged 80.4 (standard deviation [SD] 16) at the time of the latest followup, with time to return to regular activities averaging 34 weeks (SD 25 weeks). Five patients had their hardware removed, and two required subsequent fusion during the followup period. The single complication involved a screw backing out, with subsequent removal. CONCLUSIONS: In this case series, joint-preserving fixation for Lisfranc injuries offered similar AOFAS scores as those reported for ORIF with transarticular screws but with a decreased rate of hardware removal and need for midfoot fusion.

Editorial Commentary: Neuropathy After Fascia Iliaca Blocks for Hip Arthroscopy: Should We Just Blame Anesthesia?

Hip arthroscopy has been the subject of recent controversy in the literature with regard to outcomes and complications. The current investigation demonstrates a significant increase in the risk of postoperative medial thigh neuropathy with fascia iliaca block. Although the association between lateral thigh and groin numbness with traction and anterior portal instrumentation cannot be ruled out, this investigation begs the question: Should we just blame anesthesia? Probably not, as regional blocks, portal placement, and traction are all likely to play some role.

Editorial Commentary: Posterior Cruciate Ligament Femoral Techniques: The "Critical Corner" Is Just Not as Exciting as the "Killer Turn".

The "killer turn" between the graft and tibial tunnel in posterior cruciate ligament reconstruction has always been of technical and clinical importance. The "critical corner" of the graft and femoral tunnel has garnered less interest. Technical advances in arthroscopic instrumentation have allowed a move from inside-out to outside-in techniques, which can assist with tunnel placement and drilling. While these techniques do not impact the "killer turn," they have been demonstrated to decrease the acuity of the "critical corner," but there remains no evidence of impact on graft rupture or clinical outcomes.

Evaluation of the Area of the Lisfranc Ligament Damaged by Screw Fixation.

BACKGROUND: A cannulated screw is currently the standard fixation method to reduce and stabilize diastasis at the lisfranc joint following injury. Currently, there is no literature examining the area of the lisfranc ligament damaged by screw placement. The objective of this investigation is to define the area of the ligament damaged by fixation with a 3.5-mm cannulated screw. MATERIALS AND METHODS: Twelve cadaveric feet were dissected to identify the Lisfranc ligament metatarsal insertion site and origin on the medial cuneiform. A 3.5-mm cannulated screw was then passed over the course of the ligament and removed. The Lisfranc joint was then dissected to measure the dimensions of the ligament and damage from screw passage at the origin and insertion using imaging software. RESULTS: Mean injury area on the metatarsal was 3.49 mm2 and the area of injury for the cuneiform was 3.33 mm2. The mean percent of the area damaged was calculated to be 1.75% and 2.43% at the cuneiform and metatarsal, respectively. CONCLUSION: A proportionally small area of the Lisfranc ligament is disrupted following screw fixation, but the implications of this on ligament healing and outcomes remain to be elucidated. LEVELS OF EVIDENCE: Level V: Cadaveric study.

Dual Purpose Use of Flexor Hallucis Longus Tendon for Management of Chronic Achilles Tendon Ruptures.

Background: Chronic Achilles tendon ruptures are uncommon and increase long-term morbidity when untreated. There is no standard treatment for this condition. Methods: Chronic Achilles tendon rupture was repaired in 10 patients by harvesting the flexor hallucis longus tendon (FHL) using a minimally invasive technique. It was then transferred to the calcaneus and the remnant used to bridge the gap for reconstructing the Achilles tendon itself. The patients were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot Scale. Results: Patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. Average follow-up time was 30.9 months (range = 17-43 months). The average postoperative AOFAS score was 78.5 (range = 54-94). The average postoperative score for pain was 33.5 out of 40; for function, 38.7 out of 50; and for alignment, 6.3 out of 10. A single surgical site infection requiring Incision and Drainage (I&D) was the only operative complication noted. No patient developed a significant deformity of the hallux after transfer. Conclusions: FHL transfer using a minimally invasive harvest for the treatment of chronic Achilles tendon ruptures produces good to excellent outcome measures as judged by an AOFAS score of 75 or greater while minimizing risk to the medial neurovascular bundle. Levels of Evidence: Case series, Level IV: Retrospective.

Editorial Commentary: Technical Advances in Fixation for Arthroscopic Anterior Cruciate Ligament Reconstruction Won't Take the Place of Good Technique Or a Strong Arm!

Advances in fixation technology have improved the time-zero stability of grafts used for anterior cruciate ligament reconstruction, but the clinical impact of this is unclear. Adjustable-loop-length devices are the latest iteration of cortical fixation and offer retensioning of the graft after tibial fixation. This capability is absent in traditional closed-looped devices and interference screws, but there are concerns with the adjustable mechanism maintaining tension with cyclic loading. Although this advance may represent an additional tool for fine-tuning graft tension, it does not replace good technique in the use of anterior cruciate ligament fixation devices.

Coculture of meniscus cells and mesenchymal stem cells in simulated microgravity.

Simulated microgravity has been shown to enhance cartilaginous matrix formation by chondrocytes and chondrogenesis of mesenchymal stem cells (MSCs). Similarly, coculture of primary chondrocytes with MSCs has been shown as a strategy to simultaneously retain the differentiated phenotype of chondrocytes and enhance cartilaginous matrix formation. In this study, we investigated the effect of simulated microgravity on cocultures of primary human meniscus cells and adipose-derived MSCs. We used biochemical, qPCR, and immunofluorescence assays to conduct our investigation. Simulated microgravity significantly enhanced cartilaginous matrix formation in cocultures of primary meniscus cells and adipose-derived MSCs. The enhancement was accompanied by increased hypertrophic differentiation markers, COL10A1 and MMP-13, and suppression of hypertrophic differentiation inhibitor, gremlin 1 (GREM1).

The Effect of Suture Anchor Insertion Angle on Calcaneus Pullout Strength: Challenging the Deadman's Angle.

BACKGROUND: Refractory cases of Achilles tendinopathy amenable to surgery may include reattachment of the tendon using suture anchors. However, there is paucity of information describing the optimal insertion angle to maximize the tendon footprint and anchor stability in the calcaneus. The purpose of this investigation is to compare the fixation strength of suture anchors inserted at 90° and 45° (the Deadman's angle) relative to the primary compressive trabeculae of the calcaneus. METHODS: A total of 12 matched pairs of adult cadaveric calcanei were excised and potted to approximate their alignment in vivo. Each pair was implanted with 5.5-mm bioabsorbable suture anchors placed either perpendicular (90°) or oblique (45°) to the primary compressive trabeculae. A tensile load was applied until failure of anchor fixation. Differences in failure load and stiffness between anchor fixation angles were determined by paired t-tests. RESULTS: No significant differences were detected between perpendicular and oblique suture anchor insertion relative to primary compressive trabeculae in terms of load to failure or stiffness. CONCLUSION: This investigation suggests that the fixation strength of suture anchors inserted perpendicular to the primary compression trabeculae and at the Deadman's angle are possibly comparable. LEVELS OF EVIDENCE: Biomechanical comparison study.

Mental health interventions and priorities for research for adult survivors of torture and systematic violence: a review of the literature.

This research describes the development and findings of a literature review and analysis meant to inform the international torture and trauma treatment community. The review focuses on interventions that have been used among populations affected by torture, based on a review of journals indexed in commonly used search engines. Work on the review began in September 2008 and continued to be updated until March 2014. In total, 88 studies of interventions for torture victims were identified. Studies ranged from randomized controlled trials utilizing evidence-based treatments to case studies employing non-structured, supportive therapies. Based on the results of the analysis, we have included recommendations for interventions that demonstrate effectiveness in treating survivors of torture and other systematic violence who suffer from PTSD, depression and anxiety. Priorities for mental health research for survivors of torture and other systematic violence are also recommended.

The use of a lot quality assurance sampling methodology to assess and manage primary health interventions in conflict-affected West Darfur, Sudan.

BACKGROUND: Organizations working in conflict-affected areas have a need to monitor and evaluate their programs, however this is often difficult due to the logistical challenges of conflict areas. Lot quality assurance sampling may be a suitable method of assessing programs in these situations. METHODS: We conducted a secondary data analysis of information collected during Medair's routine program management functions. Medair's service area in West Darfur, Sudan was divided into seven supervisory areas. Using the available population information, a sampling frame was developed and interviews were conducted from randomly selected caretakers of children in each supervisory area every six months over 19 months. A survey instrument with questions related to key indicators for immunizations and maternal, newborn, and child health was used for the interviews. Based on Medair's goals for each indicator, decision rules were calculated for the indicators; these decision rules determined which supervisory areas and indicators performed adequately in each assessment period. Pearson's chi-squared tests, adjusted for the survey design using STATA "svy: tab" commands, were used to detect overall differences in coverage in this analysis. RESULTS: The coverage of tetanus toxoid vaccination among pregnant women increased from 47.2 to 69.7 % (p value = 0.046), and births attended by a skilled health professional increased from 35.7 to 52.7 % (p value = 0.025) from the first to last assessment periods. Measles vaccinations declined from 72.0 to 54.1 % (p value = 0.046). The estimated coverage for the proportion of women receiving a postpartum dose of vitamin A (54.7 to 61.3 %, p value = 0.44); pregnant women receiving a clean delivery kit (54.6 to 47.1 %, p value = 0.49); and pentavalent vaccinations (49.7 to 42.1 %, p value = 0.28) did not significantly change. CONCLUSIONS: Lot quality assurance sampling was a feasible method for Medair staff to evaluate and optimize primary health programs in a conflict-affected area. Medair managers were able to collect, analyze, and disseminate data to staff alongside the routine work of the organization. These results suggest LQAS may be used in other complex humanitarian emergencies in which there are logistical challenges and limited resources.

Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial.

BACKGROUND: Systematic violence is a long-standing problem in Iraq. Research indicates that survivors often experience multiple mental health problems, and that there is a need for more rigorous research that targets symptoms beyond post-traumatic stress (PTS). Our objective was to test the effectiveness of two counseling therapies in Southern Iraq in addressing multiple mental health problems among survivors of systematic violence: (1) a transdiagnostic intervention (Common Elements Treatment Approach or CETA); and (2) cognitive processing therapy (CPT). The therapies were provided by non-specialized health workers since few MH professionals are available to provide therapy in Iraq. METHODS: This was a randomized, parallel, two site, two-arm (1:1 allocation), single-blinded, wait-list controlled (WLC) trial of CETA in one site (99 CETA, 50 WLC), and CPT in a second site (129 CPT, 64 WLC). Eligibility criteria were elevated trauma symptoms and experience of systematic violence. The primary and secondary outcomes were trauma symptoms and dysfunction, respectively, with additional assessment of depression and anxiety symptoms. Non-specialized health workers (community mental health worker, CMHW) provided the interventions in government-run primary health centers. Treatment effects were determined using longitudinal, multilevel models with CMHW and client as random effects, and a time by group interaction with robust variance estimation, to test for the net difference in mean score for each outcome between the baseline and follow up interview. Multiple imputation techniques were used to account for missingness at the item level and the participant level. All analyses were conducted using Stata 12. RESULTS: The CETA intervention showed large effect sizes for all outcomes. The CPT intervention showed moderate effects sizes for trauma and depression, with small to no effect for anxiety or dysfunction, respectively. CONCLUSIONS: Both CETA and CPT appear to benefit survivors of systematic violence in Southern Iraq by reducing multiple mental health symptoms, with CETA providing a very large benefit across a range of symptoms. Non-specialized health workers were able to treat comorbid symptoms of trauma, depression and anxiety, and dysfunction among survivors of systematic violence who have limited access to mental health professionals. The trial further supports the use of evidence-based therapies in lower-resource settings. TRIAL REGISTRATION AND PROTOCOL: This trial was registered at ClinicalTrials.gov on 16 July 2010 with an identifier of NCT01177072 as the Study of Effectiveness of Mental Health Interventions among Torture Survivors in Southern Iraq. The study protocol can be downloaded from the following website: http://tinyurl.com/CETA-Iraq-Protocol . In the protocol, the CETA intervention is given a different name: components-based intervention or CBI.

Arthroscopic Excision of a Symptomatic Os Trigonum.

PURPOSE: To report the clinical outcomes of arthroscopic excision for a symptomatic os trigonum initially viewing through the posteromedial ankle portal with the motorized instrument in the posterolateral portal. METHODS: A retrospective review of a consecutive series of patients with symptomatic os trigonum failing nonoperative management and treated with arthroscopic excision was performed. Demographic data, clinical data, American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores, and Single Assessment Numeric Evaluation scores were obtained. Any complications and the time required to return to sports or full activities were recorded. RESULTS: Twenty-four patients with an arthroscopic excision of a symptomatic os trigonum were included. There were 13 male and 11 female patients. The average age was 36.7 ± 17 years. Twenty-one isolated os trigonum excisions and 3 excisions combined with other procedures were studied. At a mean follow-up of 26 months (range, 24 to 31 months), average preoperative AOFAS scores significantly improved from 55.3 to 92.3 postoperatively (P < .0001). The preoperative AOFAS function component improved from 17.1 to 33.8 (P < .0001). The mean postoperative Single Assessment Numeric Evaluation score was 90. Patients reported full activity at an average of 1.5 months with no limitations at an average of 7.8 months after surgery. The only complication was a posterior tibial nerve calcaneal branch neurapraxia. CONCLUSIONS: Arthroscopic excision in the prone position without traction of a symptomatic os trigonum viewing initially through the posteromedial portal with a high-speed burr in the posterolateral portal resulted in significantly improved AOFAS scores with a single transient neurapraxia in 24 patients. Patients returned to their normal daily activities without limitations at an average of 1.5 months. LEVEL OF EVIDENCE: Level IV, therapeutic case series.