Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients.

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization. Methods: A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. Results: We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05). Conclusion: Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time. Level of Evidence: Level III, retrospective cohort study.

Asymptomatic Intraosseous Meningioma of the Humerus: A Case Report and Review of the Literature.

Meningiomas are the most common central nervous system tumor. They are typically benign neoplasms but may produce neurological symptoms due to mass effect. Meningiomas may also extend to extradural locations; however, these account for only a small percentage of all meningiomas. Most extradural meningiomas arise in intraosseous locations, usually within the cranial bones or vertebrae. However, this is a rare case of extradural extension of an asymptomatic intracranial meningioma to the proximal humerus in the absence of any musculoskeletal symptoms. To the best of our knowledge, this presentation of an extradural intraosseous meningioma has not previously been reported in the literature. We present a case of an incidental intraosseous meningioma in a 66-year-old man. This patient was initially being screened for metastasis of stage IA1 adenocarcinoma of the lung, and a positron emission tomography (PET) scan revealed a focus of activity in the proximal diaphysis of the right humerus suspicious for malignancy. The upper extremity magnetic resonance imaging (MRI) demonstrated an indeterminate lesion. Curettage of the humeral lesion revealed an intraosseous psammomatous meningioma without evidence of metastatic lung carcinoma. Our case report aims to illustrate the importance of considering alternative metastatic sources, such as intracranial meningioma, during the investigation of an indeterminate bony lesion. This is the first case to illustrate asymptomatic intraosseous meningioma in an appendicular skeletal location, highlighting the need for thorough source investigation.

Management Options for Extensor Mechanism Discontinuity in Patients With Total Knee Arthroplasty.

Extensor mechanism disruption is one of the most dreaded complications of total knee arthroplasty. At times, the disruption is associated with infection, the paucity of soft tissue, and loosening of implants. Treatment decisions made by surgeons are guided by their experience and expertise. The purpose of this article is to provide the readers with an evidence-based comprehensive review which, in turn, should help them in diagnosis and selecting the best treatment strategy for individual patients. In the following article, we have discussed extensor mechanism disruptions of varying severity at various anatomical levels. We also covered both operative and non-operative measures in different clinical situations. The analysis of various articles published in the literature would also help orthopedic surgeons to understand the probable outcomes of the particular treatment option chosen and to counsel their patients accordingly.

Aneurysmal Bone Cyst of the Distal Femoral Metaphysis in a Four-year-old Female Patient Presenting with a Pathologic Fracture: A Case Report.

Aneurysmal bone cysts (ABCs) are benign osteolytic vascular lesions that are capable of aggressive local expansion and bone destruction. These tumors are most common in adolescent patients and constitute approximately 9% of benign tumors. ABCs can present a diagnostic challenge, as they share several histological and radiographic characteristics with more aggressive lesions, including giant cell tumors and malignant telangiectatic osteosarcomas. The management of ABCs is diverse, but the most common approach includes lesion curettage with bone grafting. Here, we present the case of a large, central ABC of the distal femur in a young, previously healthy female who presented to the emergency room with a pathologic fracture.

The role of recombinant PTH in human fracture healing: a systematic review.

OBJECTIVES: Human parathyroid hormone (PTH) is known to be efficacious in the treatment of osteoporosis and reduction of risk of vertebral and nonvertebral fractures; however, its role in the enhancement of human fracture healing is controversial. Our objective is to conduct a systematic literature review on the use of recombinant PTH in human fracture healing to (1) evaluate the evidence for recombinant PTH in human fracture healing and (2) assess whether there are notable differences between previous case reports and prospective trials. DATA SOURCES: We performed a literature search in PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews for "teriparatide," "PTH (1-84)," "fracture," and "healing." STUDY SELECTION: References of retrieved articles were screened for additional studies, and exclusion criteria were applied. DATA EXTRACTION: Due to the limited publications on the subject, case reports and case series were included in our data analysis. DATA SYNTHESIS: Due to the limited publications on the subject, our data are presented in simple tabular format. CONCLUSIONS: Our literature review yielded 16 publications on the use of recombinant PTH in human fracture healing and 2 randomized controlled trial with 1 retrospective subgroup analysis. There continues to be anecdotal evidence for the use of recombinant PTH to enhance fracture healing. There are discrepancies in study design in the randomized controlled trials and the majority of case reports and, additional prospective studies are warranted.

Atypical femoral fractures: a review of the literature.

Bisphosphonates are the most commonly used drugs worldwide for treating osteoporosis. Atypical femoral fractures most commonly are associated with prolonged bisphosphonate use. They also may occur with denosumab use or in patients without a history of using these drugs. In this article, we provide a comprehensive review of the mechanism of action of bisphosphonate and the definition, incidence, epidemiology, pathogenesis, diagnosis, management, and prevention of atypical femoral fractures.

Heat and radiofrequency plasma glow discharge pretreatment of a titanium alloy promote bone formation and osseointegration.

Orthopedic and dental implants manifest increased failure rates when inserted into low density bone. We determined whether chemical pretreatments of a titanium alloy implant material stimulated new bone formation to increase osseointegration in vivo in trabecular bone using a rat model. Titanium alloy rods were untreated or pretreated with heat (600°C) or radiofrequency plasma glow discharge (RFGD). The rods were then coated with the extracellular matrix protein fibronectin (1 nM) or left uncoated and surgically implanted into the rat femoral medullary cavity. Animals were euthanized 3 or 6 weeks later, and femurs were removed for analysis. The number of trabeculae in contact with the implant surface, surface contact between trabeculae and the implant, and the length and area of bone attached to the implant were measured by histomorphometry. Implant shear strength was measured by a pull-out test. Both pretreatments and fibronectin enhanced the number of trabeculae bonding with the implant and trabeculae-to-implant surface contact, with greater effects of fibronectin observed with pretreated compared to untreated implants. RFGD pretreatment modestly increased implant shear strength, which was highly correlated (r(2) = 0.87-0.99) with measures of trabecular bonding for untreated and RFGD-pretreated implants. In contrast, heat pretreatment increased shear strength 3-5-fold for both uncoated and fibronectin-coated implants at 3 and 6 weeks, suggesting a more rapid increase in implant-femur bonding compared to the other groups. In summary, our findings suggest that the heat and RFGD pretreatments can promote the osseointegration of a titanium alloy implant material.