The role of postoperative radiation and coordination of care in patients with metastatic bone disease of the appendicular skeleton

Metastatic bone disease affects approximately 300,000 people in the United States, and the burden is rising. These patients experience significant morbidity and decreased survival. The management of these patients requires coordinated care among a multidisciplinary team of physicians, including orthopaedic surgeons. This article reviews the role of radiation therapy after orthopaedic stabilization of impending or realized pathologic extremity fractures. Orthopaedic surgeons have an opportunity to benefit patients with metastatic bone disease by referring them for consideration of post-operative radiation therapy. Further research into rates of referral and the effect on clinical outcomes in this population is needed

Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation

Currently, open reduction–internal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduce donor-site morbidity and improve functional and objective outcomes after open reduction–internal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation

Arthroscopic Posteromedial Capsular Release

Post-traumatic or postsurgical flexion contractures of the knee can significantly limit function and lead to gait abnormalities. In this setting, interventions to regain full extension may include bracing, physical therapy, and open or arthroscopic surgery. Open surgical approaches to restore full motion often demand extensive recovery and promote further adhesions and loss of motion, which has led to the advent of arthroscopic techniques to address these pathologies. We present a safe, effective, and reproducible arthroscopic technique for posteromedial capsular release to address knee flexion contractures

Intraarticular arthrofibrosis of the knee alters patellofemoral contact biomechanics

Abstract Background Arthrofibrosis in the suprapatellar pouch and anterior interval can develop after knee injury or surgery, resulting in anterior knee pain. These adhesions have not been biomechanically characterized. Methods The biomechanical effects of adhesions in the suprapatellar pouch and anterior interval during simulated quadriceps muscle contraction from 0 to 90° of knee flexion were assessed. Adhesions of the suprapatellar pouch and anterior interval were hypothesized to alter the patellofemoral contact biomechanics and increase the patellofemoral contact force compared to no adhesions. Results Across all flexion angles, suprapatellar adhesions increased the patellofemoral contact force compared to no adhesions by a mean of 80 N. Similarly, anterior interval adhesions increased the contact force by a mean of 36 N. Combined suprapatellar and anterior interval adhesions increased the mean patellofemoral contact force by 120 N. Suprapatellar adhesions resulted in a proximally translated patella from 0 to 60°, and anterior interval adhesions resulted in a distally translated patella at all flexion angles other than 15° (p < 0.05). Conclusions The most important finding in this study was that patellofemoral contact forces were significantly increased by simulated adhesions in the suprapatellar pouch and anterior interval. Anterior knee pain and osteoarthritis may result from an increase in patellofemoral contact force due to patellar and quadriceps tendon adhesions. For these patients, arthroscopic lysis of adhesions may be beneficial

Trends in Utilization and Patient Demographics for Shoulder Instability Procedures from 2010 to 2019

INTRODUCTION: Improved technique and increased surgeon experience has optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there is limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographics (age and gender) from 2010-2019 for four shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR). METHODS: We identified over 87,00 patients using an all-payer claims database. The utilization rate was defined as the number of cases for a procedure divided by the total number surgical cases for shoulder instability for any given year. Age was divided into three groups: \u3c25, 25-35, \u3e35-years-old. Trends were reported in terms of compounded annual growth rates (CAGR). RESULTS: While ABR was the most common shoulder instability procedure overall (91% utilization rate), LP had the greatest increase in utilization from 2010-2019 (2.0% to 4.5%; CAGR: +9.8%). In comparison, the utilization for ABB increased +4.3% annually while OBR declined -6.9% annually. The utilization of ABR showed minimal change. Notably, LP was performed more frequently on younger patients over time. The percentage of patients \u3c25-years-old who underwent LP increased from 30% to 41% from 2010-2019 (+3.4%). There was a trend toward performing more LP on men versus women (+1.2% vs. -3.5%, P \u3c 0.05), although most cases (68%) were still performed on men. CONCLUSION: ABR continues to account for most shoulder instability procedures. LP had the greatest increase in utilization rate from 2010-2019 and has now surpassed OBR in utilization rate. ABB is also being more frequently performed but only represents a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedure were male and \u3c25-years-old

Lateral meniscus posterior root and meniscofemoral ligaments as stabilizing structures in the ACL-deficient knee: a biomechanical study

Background: The biomechanical effects of lateral meniscal posterior root tears with and without meniscofemoral ligament (MFL) tears in anterior cruciate ligament (ACL)–deficient knees have not been studied in detail. Purpose: To determine the biomechanical effects of the lateral meniscus (LM) posterior root tear in ACL-intact and ACL-deficient knees. In addition, the biomechanical effects of disrupting the MFLs in ACL-deficient knees with meniscal root tears were evaluated. Study Design: Controlled laboratory study. Methods: Ten paired cadaveric knees were mounted in a 6-degrees-of-freedom robot for testing and divided into 2 groups. The sectioning order for group 1 was (1) ACL, (2) LM posterior root, and (3) MFLs, and the order for group 2 was (1) LM posterior root, (2) ACL, and (3) MFLs. For each cutting state, displacements and rotations of the tibia were measured and compared with the intact state after a simulated pivot-shift test (5-Nm internal rotation torque combined with a 10-Nm valgus torque) at 0, 20, 30, 60, and 90 of knee flexion; an anterior translation load (88 N) at 0, 30, 60, and 90 of knee flexion; and internal rotation (5 Nm) at 0, 30, 60, 75, and 90. Results: Cutting the LM root and MFLs significantly increased anterior tibial translation (ATT) during a pivot-shift test at 20 and 30 when compared with the ACL-cut state (both Ps < .05). During a 5-Nm internal rotation torque, cutting the LM root in ACL-intact knees significantly increased internal rotation by between 0.7 ± 0.3 and 1.3 ± 0.9 (all Ps .2). For an anterior translation load, cutting the LM root in ACL-deficient knees significantly increased ATT only at 30 (P ¼ .007). Conclusion: The LM posterior root was a significant stabilizer of the knee for ATT during a pivot-shift test at lower flexion angles and internal rotation at higher flexion angles. Clinical Relevance: Increased knee anterior translation and rotatory instability due to posterior lateral meniscal root disruption may contribute to increased loads on an ACL reconstruction graft. It is recommended that lateral meniscal root tears be repaired at the same time as an ACL reconstruction to prevent possible ACL graft overload

Lateral meniscus posterior root and meniscofemoral ligaments as stabilizing structures in the ACL-deficient knee: a biomechanical study

Background: The biomechanical effects of lateral meniscal posterior root tears with and without meniscofemoral ligament (MFL) tears in anterior cruciate ligament (ACL)–deficient knees have not been studied in detail. Purpose: To determine the biomechanical effects of the lateral meniscus (LM) posterior root tear in ACL-intact and ACL-deficient knees. In addition, the biomechanical effects of disrupting the MFLs in ACL-deficient knees with meniscal root tears were evaluated. Study Design: Controlled laboratory study. Methods: Ten paired cadaveric knees were mounted in a 6-degrees-of-freedom robot for testing and divided into 2 groups. The sectioning order for group 1 was (1) ACL, (2) LM posterior root, and (3) MFLs, and the order for group 2 was (1) LM posterior root, (2) ACL, and (3) MFLs. For each cutting state, displacements and rotations of the tibia were measured and compared with the intact state after a simulated pivot-shift test (5-N·m internal rotation torque combined with a 10-N·m valgus torque) at 0°, 20°, 30°, 60°, and 90° of knee flexion; an anterior translation load (88 N) at 0°, 30°, 60°, and 90° of knee flexion; and internal rotation (5 N·m) at 0°, 30°, 60°, 75°, and 90°. Results: Cutting the LM root and MFLs significantly increased anterior tibial translation (ATT) during a pivot-shift test at 20° and 30° when compared with the ACL-cut state (both Ps .2). For an anterior translation load, cutting the LM root in ACL-deficient knees significantly increased ATT only at 30° (P = .007). Conclusion: The LM posterior root was a significant stabilizer of the knee for ATT during a pivot-shift test at lower flexion angles and internal rotation at higher flexion angles. Clinical Relevance: Increased knee anterior translation and rotatory instability due to posterior lateral meniscal root disruption may contribute to increased loads on an ACL reconstruction graft. It is recommended that lateral meniscal root tears be repaired at the same time as an ACL reconstruction to prevent possible ACL graft overload

Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors

OBJECTIVE: There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS: Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS: Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p \u3c 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence-lumbar lordosis mismatch \u3e 10°, higher postoperative T1PA; p \u3c 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p \u3c 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p \u3c 0.05). Anterior column support with an L5-S1 interbody fusion was protective against failure (p \u3c 0.05). CONCLUSIONS: Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful