Penetrating Blast Injury to the Knee of a United States Soldier Treated with Allograft Mosaicplasty

Objective: This is the first report of successful allograft mosaicplasty treatment of a large osteochondral lesion of the knee caused by a blast fragment sustained during combat operations. The patient was able to return to active duty following rehabilitation. Methods: An active-duty infantryman sustained an osteochondral lesion of the medial femoral condyle caused by a metallic fragment of an explosively formed projectile. Initial treatment consisted of removal of the foreign body and primary closure. The patient continued to experience pain, mechanical symptoms, and repeated effusions after initial nonoperative treatment. Allograft mosaicplasty of the lesion utilizing two 18-mm-diameter fresh allograft osteochondral plugs was performed at 6 months post-injury. Results: At 2-year follow-up, the patient remains on active duty with marked improvement in symptoms. Two years postoperatively, his outcome scores are 72 of 100 on the Western Ontario and McMaster University osteoarthritis scoring index (WOMAC) and 60 of 100 on the Knee Injury and Osteoarthritis Outcome Score (KOOS). His follow-up x-rays and MRI demonstrate intact articular cartilage and subchondral bone incorporation. Conclusion: Penetrating injuries to joints are commonplace in the battlefield environment. Combat injuries to the knee are frequently associated with articular cartilage injury. While numerous cartilage restoration techniques have been used with success for the treatment of osteochondral injuries to the femoral condyles, no published reports describe the use of allograft mosaicplasty in this location for open, penetrating injuries with focal cartilage loss. This is the first documented use of allograft mosaicplasty for a traumatic osteochondral defect of the medial femoral condyle caused by a metallic projectile. The patient was able to return to active duty following rehabilitation. We demonstrate a high level of functioning is possible following allograft mosaicplasty of a large osteochondral lesion caused by penetrating ballistic trauma

Short-term effects of teriparatide versus placebo on bone biomarkers, structure, and fracture healing in women with lower-extremity stress fractures: A pilot study

Aims In this pilot, placebo-controlled study, we evaluated whether brief administration of teriparatide (TPTD) in premenopausal women with lower-extremity stress fractures would increase markers of bone formation in advance of bone resorption, improve bone structure, and hasten fracture healing according to magnetic resonance imaging (MRI). Methods: Premenopausal women with acute lower-extremity stress fractures were randomized to injection of TPTD 20-µg subcutaneous (s.c.) (n = 6) or placebo s.c. (n = 7) for 8 weeks. Biomarkers for bone formation N-terminal propeptide of type I procollagen (P1NP) and osteocalcin (OC) and resorption collagen type-1 cross-linked C-telopeptide (CTX) and collagen type 1 cross-linked N-telopeptide (NTX) were measured at baseline, 4 and 8 weeks. The area between the percent change of P1NP and CTX over study duration is defined as the anabolic window. To assess structural changes, peripheral quantitative computed topography (pQCT) was measured at baseline, 8 and 12 weeks at the unaffected tibia and distal radius. The MRI of the affected bone assessed stress fracture healing at baseline and 8 weeks. Results: After 8 weeks of treatment, bone biomarkers P1NP and OC increased more in the TPTD- versus placebo-treated group (both p ≤ 0.01), resulting in a marked anabolic window (p ≤ 0.05). Results from pQCT demonstrated that TPTD-treated women showed a larger cortical area and thickness compared to placebo at the weight bearing tibial site, while placebo-treated women had a greater total tibia and cortical density. No changes at the radial sites were observed between groups. According to MRI, 83.3% of the TPTD- and 57.1% of the placebo-treated group had improved or healed stress fractures (p = 0.18). Conclusions: In this randomized, pilot study, brief administration of TPTD showed anabolic effects that TPTD may help hasten fracture healing in premenopausal women with lower-extremity stress fractures. Larger prospective studies are warranted to determine the effects of TPTD treatment on stress fracture healing in premenopausal women

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

Background: To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.Materials and methods: A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.Prospero: CRD42020178171.Results: The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.Conclusions: MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures

FAI761036-ICMJE – Supplemental material for Tibiotalocalcaneal Arthrodesis With Bulk Talar Allograft for Treatment of Talar Osteonecrosis

<p>Supplemental material, FAI761036-ICMJE for Tibiotalocalcaneal Arthrodesis With Bulk Talar Allograft for Treatment of Talar Osteonecrosis by Kenneth W. DeFontes III, Joshua Vaughn, Jeremy Smith, and Eric M. Bluman in Foot & Ankle International</p

Associated Joint Pain with Controlled Ankle Movement (CAM) Walker Boot Wear

Category: Ankle Introduction/Purpose: A controlled ankle movement (CAM) walker boot is often prescribed for patients with a lower extremity injury or disorder. CAM boot wear, however, may cause gait alterations and leg-length discrepancy, which are commonly associated with joint pain. This study evaluates the location, frequency and duration of secondary site pain relating to immobilization in a CAM walker boot. Methods: Patients wearing a CAM walker boot for treatment of a foot or ankle injury were prospectively enrolled and evaluated for new or worsened secondary site pain. Surveys at four time points were completed to evaluate the presence of secondary site pain, its severity, and its impact on overall function. Results: The final study population included 46 patients (mean age 49 years). At transition out of the boot (mean, 4.2 weeks), 31 patients (67%) reported secondary site pain either new or worse than baseline with an average of 1.6 secondary pain sites. The secondary sites most susceptible to pain were the lower back, contralateral hip, and ipsilateral knee. A majority (84%) of these pains began within the first two weeks of boot wear. Secondary site pain was less common after transition out of the boot: 18 patients (39%) at 1 month, 15 patients (33%) at 3 months. The mean VAS for secondary site pains at transition out of boot was 51.2. Statistical significance was found correlating secondary site pain and a history of chronic pain (P=.04). Conclusion: Secondary site pain after CAM walker boot wear was common. The frequency and severity of pain lessened with time after transition out of the boot. Yet, one-third of patients still had new or worsened secondary site pain three months after cessation of boot wear

Primary Care Physicians’ Preferences Regarding Communication from Orthopaedic Providers

Category: Other Introduction/Purpose: Musculoskeletal consultations constitute a growing portion of primary care physician (PCP) referrals. Optimization of communication between PCPs and orthopaedists can potentially reduce the time PCPs spend in the electronic medical record (EMR). This, in turn, may help reduce burnout. However, little is known about the preferences of PCPs regarding communication from orthopaedic specialists. The current study therefore investigated the preferences of PCPs across a large health network regarding communication from orthopaedists. Methods: One hundred and seventy-five PCPs across 15 practices within our health network were surveyed. These providers universally used the Epic Systems EMR. PCPs were asked to report their years in practice, panel size, typical number of electronic clinical messages received each day, time spent in the EMR after normal clinical hours, and burnout level. Likert scales and top-box scores were used to assess the PCPs’ perceived importance of communication from orthopedists in specific clinical scenarios. PCPs were further asked to report their preferred method of communication in each scenario and overall interest in communication from orthopaedists. Regression analyses were performed to determine if any PCP characteristics are associated with communication preferences and overall PCP interest in communication from orthopaedists. Results: A total of 107 (61%) PCPs completed the survey. PCPs most commonly rated communication from orthopaedists as highly important when the orthopaedist needed information from the PCP. In this scenario, PCPs preferred to receive an Epic Staff Message. Other scenarios rated as important included: the decision for surgery, hospitalization, and a major clinical change. In these scenarios, a CC’d Chart rather than Staff Message was preferred. Increased EMR use after-hours was associated with diminished odds of having high interest in communication from orthopaedists (odds ratio=0.65, 95% confidence interval: 0.48-0.88, P=0.005). Ninety-three PCPs (86.9%) reported spending at least 1 hour a day in Epic after normal clinical hours. Twenty-seven (25.2%) spent more than 3 hours. Forty-six PCPs (42.9%) reported experiencing at least one symptom of burnout. Conclusion: In the current study, there were distinct preferences among PCPs regarding clinical communication from orthopaedic surgeons. In addition, there was evidence of substantial burnout and after-hours work effort by PCPs. Our results may be helpful in optimizing communication between PCPs and orthopaedists, while also reducing time spent in the EMR by PCPs