International Journal of Orthopedics
|Journal Papers (12)||Details||Call for Paper||Manuscript submission||Publication Ethics||Contact||Authors' Guide Line|
Intrauterine Random Premature Physeal Arrest: Case Report and Literature Review
William J Shaughnessy and Hamlet A Peterson
Fetal intrauterine premature random partial or complete physeal arrest is a rare, previously unreported congenital deformity. This paper presents a neonate with a fetal intrauterine vascular insufficiency of one upper extremity present at birth, which subsequently developed multiple random premature physeal arrests, all distal to the site of the vascular insufficiency. Some of the physeal arrests were complete, some partial, and some physes remain normal. The distal humerus, proximal and distal radius and ulna, and two metacarpals all have premature physeal arrests. The first metacarpal physeal bar and second metacarpal physeal bar equivalent were excised at age 7 years I month. The result of the surgery and the ultimate limb deformity may not be known for several years. Although neither the exact dates, nor the age of the fetus at the time of the intrauterine injuries are known, the radiologic identification of metaphysealphyseal abnormalities at multiple sites at age 32 days of life, represents the youngest recorded patient to have comparison x-rays which document multiple random ischemic physeal arrests. This is also the first recorded patient with intrauterine vascular deficiency to have surgical excision of either a physeal bar or a physeal bar equivalent. The purpose of this article is to encourage orthopedic surgeons to be involved in the initial and extended care of patients with neonatal limb vascular deficiency with one of the goals being early identification of bone growth abnormality
Angle Measurement on Plain X-ray and CT Scans as a Guideline for Treatment Decision on Patients with Hip Dysplasia – An Intra-and interrater Reliability Study on 50 Adults with Suspected Hip Dysplasia
Signe Elbrønd , Trine Torfing , Søren Overgaard and Uffe Jørgensen
Background and purpose: Using CT scans is thought to improve the angle measuring when treatment decisions making for developmental dysplasia of the hip (DDH) is sought for.The precision in these angles is however uncertain. We sought to 1) determine the reliability and validity ofthe lateral center-edge angle of Wiberg (CE’AP), the acetabular angle of Tönnis (AA), the alpha angle and the acetabular version on CT and 2) compare it with the reliability and validity for CE’AP and AA on X-ray. We compared trained and untrained observers. Methods:Intrarater/interrater reliability study based on 50 patients with suspected hip dysplasia. Intrarater reliability on X-ray is determined for CE’AP, AA and the anterior-posterior alpha angle. Intrarater/interrater reliability on CT is determined for CE’AP, AA, acetabular angle and the alpha angle. The reliability is evaluated with χ2 test, Bland-Altman plots and the inter correlation coefficient (ICC). Results: The interrater ICC is almost perfect for CEAP, AA and acetabular version (0.952, 0.895, 0.899), but the alpha angle shows moderate, verging on substantial, agreement (0.608). The intrarater ICC on X-ray for CE’AP and AA are 0.838 (CI 0.767-0.888) and 0.767 (CI 0.671-0.838) climbing to 0.948 (CI0.924-0.965) and 0.9713 (CI 0.958-0.981) on CT. Interpretation: When the same handbook is followed, the CE’AP, AA and acetabular version is highly reproducible for all observers on CT scans. The precision for angle measuring increases with the use of CT. A better approach for measuring CAM deformity, than the alpha angle, should be sought for.
Osteosarcoma Metastasis: An Unmet Clinical Need and Unique Drug Development Opportunity
Samuel Stewart , Dalit Barkan , David Warshawsky and Chand Khanna
The great majority of cancer deaths result from drug-resistant recurrence that has spread from the initial tumor. Consistent with this, osteosarcoma patients will often develop metastatic disease following primary tumor resection and adjuvant chemotherapy. This latency can be explained by the presence of undetected, non-dividing disseminated tumor cells (“DTCs”) that have developed mechanisms of longterm stress adaptation and dormancy to enable their survival until re-awakened to form overt metastasis. Importantly, these mechanisms are unique and specific to the biology and the circumstances of these DTCs, namely, the conditions of the microenvironment at the secondary sites. We suggest the term “metastatic endurance” to encompass a combination of the following features of DTCs at secondary sites: stress adaptation, survival, and dormancy. To date, little progress has been made in the area of DTCs-directed therapies. Our unique perspective on metastasis biology (i.e., metastatic endurance) both arises from, and delivers, in vitro and ex vivo assays that enable efficient drug discovery and preclinical efforts that target DTCs. Pet dogs and humans share the biology of osteosarcoma metastasis and late recurrence following stress adaptation and dormancy of DTCs. Pet canine osteosarcoma drug clinical trials therefore inform human osteosarcoma trials, enabling novel potential therapies to advance with the support of a community receptive to metastasis-prevention clinical trials. In addition to the extreme importance of finding better drugs for osteosarcoma patients, this disease serves as an outstanding “model” for recurrence in other cancers and provides a unique opportunity to develop drugs that target metastatic-progression for various cancers.
ACL Reconstruction and Biomechanics
Iñaki Mediavilla and Mikel Aramberri
The goal of ACL reconstruction is to restore the normal knee anatomy and biomechanics. However, not all ACL reconstructions protect the knee joint from developing osteoarthritis. It’s difficult to replicate both the original anatomy and original biomechanics. All knee structures interact geometrically and mechanically with each other. The overall strength behavior of the ACL is the result of the sum of the individual strength behavior of each of its fibers. And each of its fibers length changes according to the knee movement. Typically, single-bundle (SB) transtibial ACL reconstructions have been performed taking into account “isometric” criterion. In this respect, replicating the anteromedial (AM) fibers of original ACL. But it has been suggested that transtibial SB reconstructions can lead to some degree of rotational instability when the knee is close to extension. Recently, in order to have greater rotational stabilizing different surgical options have been proposed. One of those is “anatomic” SB ACL reconstruction selecting the femoral footprint center. But “anatomic” ACL reconstructions cause greater changes in length during the range of movement of the knee than the transtibial ACL reconstructions. Another one of them is the double bundle (DB) ACL reconstruction which involves reconstructing each of these original AM and posterolateral (PL) bundles separately. It achieves better anteroposterior and rotational knee stability “in vitro” but is more technically demanding. Lateral extra-articular procedures in combination with ACL reconstruction has been proposed as a way of potentially improving rotational stability and clinical outcomes.
Spinal Alignment, Balance and Harmony through the Ages
Most of the studies about the alignment of the body and subsequently the spine are based on static considerations reported through clinical and mostly radiological views Frontal and Lateral in standing position. From the last 25 years the measurements were done almost exclusively with angles exploring of course the frontal plane with the Cobb angle and mainly the sagittal plane projection of the various segments of the spine including pelvis, with also the Cobb angle principles. This drive to angular formulas comparing patients without deformities considered as normal and those with deformities. The consequences of this almost univocal approach were that the planning of the surgical corrections was done on a purely angular goal. This results in a subsequent extension of the fusion/ instrumentation areas and too frequent failures either with the severe flattening of the back or with so called Proximal junctional kyphosis resulting in immediate or late deterioration of the balance and functional results of the patient.
Extreme-Lateral Lumbar Interbody Fusion (XLIF) with Intraoperative Neurophysiological Monitoring - A Safe and Minimally Invasive Surgical Approach to the Anterior Lumbar Spine
Nikolai G. Rainov, Dimitar Haritonov and Volkmar Heidecke
Aims: Minimally invasive surgical approaches to the spine continue to evolve. We describe here the technique and the results of a recently developed minimally invasive surgical approach to the lumbar spine, the extreme-lateral lumbar interbody fusion (XLIF) approach. Methods: The XLIF approach to the anterior lumbar disc space allows for complete discectomy, vertebral body distraction, large graft placement, and disc height restoration. It achieves these goals with minimal trauma to the surrounding tissues. The psoas muscle is traversed with a minimum of trauma, and the lumbosacral plexus is protected by the use of intraoperative real-time electromyography (EMG) neuromonitoring. Results: A group of 31 patients with degenerative lumbar disease, metastatic tumors to the spine, or with spondylodiscitis have undergone XLIF in combination with percutaneous transpedicular screw fixation. All patients have experienced improvement of low back pain and most have improved neurologically. No procedure-related severe side effects or complications have been encountered. There was no permanent nerve damage to the lumbosacral plexus. Conclusions: This study demonstrates that the XLIF approach for anterior lumbar fusion is a safe and minimally invasive surgical technique, which avoids significant intraoperative blood loss and has no major intraoperative or postoperative complications and side effects. The XLIF approach allows for a wide and very convenient surgical access to the anterior lumbar disc space without the potential complications of a trans-abdominal procedure.
Thoracolumbar Burst Fracture in Patients with Neurological Deficit: An Evidence-Based Systematic Review Comparing Anterior Versus Posterior Surgical Approach for Spinal Decompression and Fixation
Nicandro Figueiredo, Nikola Vagic, Rajamagesh Duraisamy, Wesley Arruda, Krzysztof Wasilewski, Hafez Ahmed and Zbigniew Brodzinski
Design: Systematic review Objective: To identify prospective comparative clinical studies of thoracolumbar (TL) burst fractures associated with neurological deficit, to find out which surgical approach is the most appropriate: anterior approach (AA) or posterior approach (PA) for decompression and fixation of unstable TL fractures. Methods: Evidence-based systematic review of the literature in PubMed and Cochrane Data Base was conducted, comparing AA versus PA for the surgical treatment of TL fractures with neurological deficit. The search was restricted to articles written in English, published in the last 20 years (1998-2018). Results: Three clinical studies comparing AA with PA for the surgical treatment of TL fractures in patients with neurological deficit were included (Level of Evidence I-III). One article was a randomized controlled trial (RCT), Evidence Level I; 1 a prospective, comparative study (Level II); and 1 a retrospective, comparative study (Level III). The RCT demonstrated that AA group had better neurological improvement and vertebral height restoration than the PA. The other 2 studies, reported similar neurological improvement. Nonetheless, PA group had shorter operation time and is associated with less blood loss than AA. Conclusions: Level I of Medical Evidence, Recommendation Grade B,was provided with this systematic review which indicates that for decompression and fixation of the thoracolumbar fractures in patients with neurological deficit: 1) anterior approach (AA) was superior to posterior approach (PA) for neurological recovery; 2) AA was superior to PA for vertebral height restoration; 3) PA had shorter operation time and less intraoperative blood loss than AA.
Pre-operative Weight Loss – Plan for Stepwise Incorporation of Registered Dietitian Nutritionists into an Orthopaedic Practice
Derek F Amanatullah, Levonti Ohanisian , David Ivanov , Marsha Schofield and Lucille Beseler
Approximately 40% of US adults have a body mass index that is considered obese. Joint replacements in patients with obesity come with an increased relative risk of infection, mechanical failure, and revision surgery. Therefore, preoperative weight loss is recommended for select patients in an attempt to improve postoperative outcomes. The incorporation of registered dietitian nutritionists has demonstrated significant improvement in patient weight loss when integrated into a clinical practice, however, this integration is often not utilized in orthopaedic clinics. The purpose of this review is to provide a stepwise plan to incorporate a registered dietitian nutritionist into an orthopaedic practice�.
Coagulase Negative Staphylococcal Isolates from Prosthetic Knee Infections Show Diverse Speciation and a High Rate of Antibiotic Resistance
Arthur R. Bartolozzi, Niaz Banaei, Indre Budvytiene, Robert Manasherob, Stuart B. Goodman, James I. Huddleston, William J. Maloney and Derek F. Amanatullah
The incidence of infection associated with primary total knee arthroplasty (TKA) is up to 2.5% with $1.62 billion estimated in system costs. Adverse outcomes depend on bacterial species with methicillin resistant strains carrying the highest burden. Prior research has focused on Staphylococcus aureus. Our study identifies the species and resistance patterns of coagulase negative Staphylococcus species that infect knee prostheses. TKA infections positive for coagulase negative Staphylococcal species subsequently treated by four joint surgeons from 2015-2019 were included. Matrix-assisted laser desorption ionization (MALDI) time of flight mass spectrometry was used and scores greater than 2.00 were considered to identify unique species. There were 68 TKA infections treated during the study period and 29 (42%) cultured a coagulase negative Staphylococcal species. Of these, 16 (55%) were S. epidermidis, 6 (21%) were S. lugdunensis, 5 (17%) were S. capitus, 1(3%) was S. warneri and 1 (3%) was S. haemolyticus. Further, 14 (48%) were positive for the mecA gene conferring resistance to methicillin. All species were identified by MALDI with an average score of 2.12 ± 0.13. Coagulase negative Staphylococcal species from TKA infections showed a range of species which could suggest multiple etiologies for sustaining an infection . While the mecA gene was present more commonly than reported averages, it was present in strains with resistance to many antibiotics not just beta lactams.
Ilizarov Distraction Osteogenesis for Reconstruction of Long Bone Defects Following Primary Malignant Bone Tumour Resection
Neal Jacobs, David Stubbs and Martin McNally
Aims: Primary malignant tumours of long bones (PMTLB) are rare and pose considerable reconstructive challenges. Distraction osteogenesis is one of the reconstruction options available. We present a systematic review of bone transport reconstruction following resection of PMTLB. We also present the results of our own retrospective case series. The review aims to identify the magnitude of global experience using distraction osteogenesis for reconstruction of bone defects resulting from PMTLB along with associated outcomes. Specific questions asked include: What is the number of cases reported? What is the tumour recurrence rate? Are high grade tumours or chemotherapy a contraindication? Methods: A systematic review of PubMed, Ovid Medline and Embase databases was performed in accordance with PRISMA guidelines. A retrospective review of our institution’s experience was also undertaken. Results: We identified 67 clearly documented cases among 21 papers in the literature of distraction osteogenesis being used primarily in the reconstruction of bone defects from PMLTB. There was a large proportion of high grade tumours with 64% requiring chemotherapy, and the reported local recurrence rate was 1.5%. Our own case series of 8 patients resulted in successful limb salvage in 7 cases, with excellent outcomes, and one case of local recurrence following initial misdiagnosis. Conclusions: Distraction osteogenesis offers an effective but rarely used biological reconstruction option for bone defects in the management of PMTLB. In selected cases, excellent long term functional outcomes can be achieved, and chemotherapy for high grade tumours need not be a contraindication.
Evaluation of Pulmonary Metastases Resection in Patients with Osteosarcoma
Alcânia Walburga de Souza Pereira dos Reis, Carla Donato Macedo, Vivian Tostes, Renato de Oliveira, Anderson de Oliveira, Maria Teresa de Seixas Alves, Bruna Fernanda Silva Cardoso, Henrique Manoel Lederman and Antônio Sergio Petrilli
Introduction: Osteosarcoma (OS) is the tumor malignant primary bone more common in childhood and in adolescence. The worst prognostic factor associated with the disease is the presence of metastasis at diagnosis. Among patients with metastatic disease, there is a tendency for a better response to treatment with cure through complete resection when there are only pulmonary and monumental lesions present. Objectives: To evaluate the impact of pulmonary nodule resection in patients with suspected OS metastasis. Methods: Bank review of 36 patient data with OS metastatic diagnosed in the period 2005-2015 in hospital on pediatric oncology in São Paulo, Brazil. Results: Among the 36 patients included in the study, 19.4% were considered inoperable at diagnosis. Of the 29 patients operated, 9 (30%) patients had lesions false- positive. In the surgical procedure were resected 266 nodes, with only 43.6% were diagnosed in the chest tomography showing that surgical resection was 3.4 times higher in the identification of nodes in relation to the examination of image. Of the 29 operated patients, 14 patients had a single nodule (including nodes smaller than 0.5 cm or larger than 1 cm) diagnosed with OS metastasis in 70% of them after the procedure. The survival rate overall in our population was of 52.3 months and, when excluded from the false positive, the average estimate of survival was 41 months. When we analyzed relapsed patients, almost 50% of those who could be approached three or more times had a higher overall survival rate than the group who could not be surgically approached.
Clinical Outcomes and Shoulder Kinematics for the “Gray Zone” Extra-articular Scapula Fracture in 5 Patients
Jyoti Sharma, Candice Maenza , Andrea Myers , Erik B. Lehman , Andrew R Karduna , Robert L Sainburg and April D Armstrong
Aims: There is a subset of scapula fractures, which can be considered in the “gray zone,” where treatment guidelines are not clear-cut, based on published literature. Our paper presents the outcomes of five such scapula fractures treated non-operatively. Methods: Adult patients who had been treated non-operatively at our institution for an isolated scapula fracture from 2003-2012 were found using Current Procedural Terminology (CPT) codes. Based on injury imaging, these five patients had scapula fractures in the “gray zone.” Subjects completed questionnaires [Simple Shoulder Test (SST), PROMIS Global Health Scale vs 1.1, PROMIS SF vs 1.0 Physical Function 12a, and the American Shoulder and Elbow Surgeons Score (ASES)] and physical exams were performed to assess range of motion and strength. Glenohumeral kinematics were obtained via motion analysis using the Trackstar 6 Degree of Freedom (DOF) motion tracking system by Northern Digital Incorporated. Results: All subjects were right hand dominant. 3/5 fractures involved left, non-dominant, scapulae. Motion analysis demonstrated similar recruitment of the scapula during the glenohumeral rhythm for the fractured shoulders compared with the same arm of age matched control subjects. No significant differences occurred in either range of motion (ROM) or scapula-humeral coordination when comparing uninjured scapulae to the same arm of age matched control subjects. Conclusions: All subjects’ demonstrated acceptable clinical outcomes when treated non-operatively. Minor differences were seen in subjective surveys. However, the kinematic analysis showed no differences in measured scapula-humeral rhythm or range of motion. It is proposed that immediate controlled range of motion and rehabilitation be considered in these patients and could be the focus of a larger prospective study. Level of Evidence: Level IV (Case Series).