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Journal Cover JBJS Open Access
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  This is an Open Access Journal Open Access journal
   ISSN (Online) 2472-7245
   Published by LWW Wolters Kluwer Homepage  [290 journals]
  • The Utility of False-Profile Radiographs for the Detection of
           Osteoarthritis Progression in Acetabular Dysplasia

    • Authors: Akiho; Shunsuke; Yamamoto, Takuaki; Kinoshita, Koichi; Matsunaga, Ayumi; Ishii, Satohiro; Ishimatsu, Tetsuro
      Abstract: imageBackground: Both the lateral center-edge angle and acetabular roof obliquity on anteroposterior radiographs are well-known prognostic predictors of osteoarthritis progression in patients with acetabular dysplasia. However, few studies have evaluated osteoarthritis progression on false-profile radiographs. In the present study, osteoarthritis progression was evaluated on anteroposterior and false-profile radiographs.Methods: We retrospectively evaluated 76 patients with acetabular dysplasia with Tönnis grade-0 or 1 osteoarthritis, from a group of 179 patients (209 hips), who had undergone unilateral periacetabular osteotomy from 1995 to 2005. We evaluated the hip joint of the contralateral, untreated side. All patients were followed for ≥10 years. Of the 76 patients, 52 patients with Tönnis grade-0 or 1 osteoarthritis at the latest follow-up were categorized into the non-progression group and the remaining 24 patients with Tönnis grade-2 or 3 osteoarthritis were categorized into the progression group. We evaluated patient characteristics as well as radiographic parameters, including the preoperative lateral center-edge angle, acetabular roof obliquity, and anterior center-edge angle.Results: The mean duration of follow-up was 12.6 years (range, 10 to 19 years). On univariate analysis, body weight, body mass index, and all radiographic parameters indicating the severity of acetabular dysplasia significantly differed between the 2 groups. On multivariate analysis, both the anterior center-edge angle and acetabular roof obliquity were considered to be significant predictive factors for osteoarthritis progression. On receiver operating characteristic curve analysis, the cutoff values for the lateral center-edge angle, acetabular roof obliquity, and anterior center-edge angle were 15.5°, 15.5°, and 12.5°, respectively.Conclusions: In addition to the lateral center-edge angle and acetabular roof obliquity, we showed that the anterior center-edge angle is a possible prognostic predictor of osteoarthritis progression. These findings indicate that radiographic parameters based on the false-profile view are relevant. Additionally, patients with an anterior center-edge angle of ≤12.5° and a lateral center-edge angle of ≤15.5° seem to be at higher risk of osteoarthritis progression over a 10-year period.Level of Evidence: Prognostic Level IV. See Instructions for
      Authors for a complete description of levels of evidence.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
  • Standardized Note Templates Improve Electronic Medical Record
           Documentation of Neurovascular Examinations for Pediatric Supracondylar
           Humeral Fractures

    • Authors: Cao; Jue; Farmer, Ryan; Carry, Patrick M.; Goodfellow, Maria; Gerhardt, David C.; Scott, Frank; Heare, Travis; Miller, Nancy H.
      Abstract: imageBackground: Optimization of the electronic medical record (EMR) is essential to support the clinician and to improve the quality and efficiency of patient care. The present report describes the development and implementation of a standardized template that is embedded in the EMR and is focused on a comprehensive physical examination during the evaluation of pediatric supracondylar humeral fractures. We compared the completeness of physical examinations as well as the timing of detection and documentation of neurovascular injuries before and after implementation of the template. We hypothesized that the use of a template would increase the completeness of examinations and would lead to earlier documentation of neurovascular injuries.Methods: A multidisciplinary quality-improvement task force was created to address neurovascular documentation practices for patients who underwent operative treatment of supracondylar humeral fractures. Following a series of formative and process evaluations, a standardized EMR template was implemented. Neurovascular examination documentation practices that were in use before (pre-template group, n = 224) and after (template group, n = 300) the implementation of the template were compared. Logistic regression analyses of the 2 groups were used to compare the likelihood of a complete neurovascular examination and the timing of neurovascular injury identification.Results: There was significant improvement in the documentation of the vascular (odds ratio [OR], 70.7; 95% confidence interval [CI], 39.5 to 126.6; p < 0.0001), motor (OR, 17.6; 95% CI, 9.5 to 32.7; p < 0.0001), and sensory (OR, 23.9; 95% CI, 12.9 to 44.4; p < 0.0001) examinations in the template group. Neurological injuries were more likely to be identified preoperatively in the template group compared with the pre-template group (OR, 6.8; 95% CI, 1.7 to 27.1; p = 0.0067).Conclusions: The incorporation of a standardized template in the EMR improved the completeness and timing of documentation of neurological injury. Standardized EMR templates developed by a clinically driven multidisciplinary task force have the potential to improve the quality of clinical documentation and to ease communication among providers.Level of Evidence: Level III. See Instructions for
      Authors for a complete description of levels of evidence.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
  • Tip-Apex Distance Is Most Important of Six Predictors of Screw Cutout
           After Internal Fixation of Intertrochanteric Fractures in Women

    • Authors: Fujii; Tatsuya; Nakayama, Shun; Hara, Masahiko; Koizumi, Wataru; Itabashi, Takashi; Saito, Masahito
      Abstract: imageBackground: Six risk factors for screw cutout after internal fixation of intertrochanteric fractures have been reported. The purpose of the present study was to evaluate and compare the impact of the 6 risk factors of screw cutout to clarify the most important one.Methods: We enrolled 8 consecutive patients who had screw cutout and 48 random control subjects after internal fixation of intertrochanteric fractures treated with proximal femoral nail antirotation systems at our institution. All of the patients were female. The group that had screw cutout and the control group were retrospectively evaluated and compared with respect to the OTA/AO classification, presence of a posterolateral fragment, types of reduction pattern on anteroposterior and lateral radiographic images, position of the screw, and the presence of a tip-apex distance (TAD) of ≥20 mm. The impact of each factor on screw cutout was assessed using backward stepwise multivariable logistic regression analysis with the Akaike information criterion. Risk stratification was assessed using classification and regression tree (CART) analysis.Results: Among 6 risk factors, only a TAD of ≥20 mm had a significant impact on screw cutout, with an adjusted odds ratio of 12.4 (95% confidence interval, 1.6 to 129.0; p = 0.019). CART analysis also demonstrated that a TAD of ≥20 mm was the most important risk stratification factor (p < 0.001).Conclusions: Among the 6 previously reported screw cutout-related factors, only a TAD of ≥20 mm was associated with screw cutout after internal fixation of intertrochanteric fractures with proximal femoral nail antirotation systems.Level of Evidence: Therapeutic Level III. See Instructions for
      Authors for a complete description of levels of evidence.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
  • The Anatomy of the Articularis Genus Muscle and Its Relation to the
           Extensor Apparatus of the Knee

    • Authors: Grob; Karl; Gilbey, Helen; Manestar, Mirjana; Ackland, Timothy; Kuster, Markus S.
      Abstract: imageBackground: The anatomy of the articularis genus muscle has prompted speculation that it elevates the suprapatellar bursa during extension of the knee joint. However, its architectural parameters indicate that this muscle is not capable of generating enough force to fulfill this function. The purpose of the present study was to investigate the anatomy of the articularis genus, with special emphasis on its relationship with the adjacent vastus intermedius and vastus medialis muscles.Methods: The articularis genus muscle was investigated in 18 human cadaveric lower limbs with use of macrodissection techniques. All components of the quadriceps muscle group were traced from origin to insertion, and their affiliations were determined. Six limbs were cut transversely in the middle third of the thigh. The modes of origin and insertion of the articularis genus, its nerve supply, and its connections with the vastus intermedius and vastus medialis were studied.Results: The muscle bundles of the articularis genus were organized into 3 main layers: superficial, intermediate, and deep. The bundles of the superficial layer and, in 60% of the specimens, the bundles of the intermediate layer originated from both the vastus intermedius and the anterior and anterolateral surfaces of the femur. The bundles of the deep layer and, in 40% of the specimens, the bundles of the intermediate layer arose solely from the anterior surface of the femur. The distal insertion sites included different levels of the suprapatellar bursa and the joint capsule. A number of connections between the articularis genus and the vastus intermedius were found. While the vastus medialis inserted into the whole length of the vastus intermedius aponeurosis, it included muscle fibers of the articularis genus, building an intricate muscle system supplied by nerve branches of the same medial deep division of the femoral nerve.Conclusions: The articularis genus, vastus medialis, and vastus intermedius have a complex, interacting architecture, suggesting that the articularis genus most likely does not act as an independent muscle. With support of the vastus intermedius and vastus medialis, the articularis genus might be able to function as a retractor of the suprapatellar bursa. The finding of likely interplay between the articularis genus, vastus intermedius, and vastus medialis is supported by their concurrent innervation.Clinical Relevance: The association between the articularis genus, vastus medialis, and vastus intermedius may be more complex than previously believed, and this close anatomical connection could have functional implications for knee surgery. Dysfunction, scarring, or postoperative arthrofibrosis of the sophisticated interactive mechanism needs further investigation.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
  • Magnetically Controlled Devices Parallel to the Spine in Children with
           Spinal Muscular Atrophy

    • Authors: Lorenz; Heiko M.; Badwan, Batoul; Hecker, Marina M.; Tsaknakis, Konstantinos; Groenefeld, Katharina; Braunschweig, Lena; Hell, Anna K.
      Abstract: imageBackground: Children with severe spinal deformity frequently are managed with growth-friendly implants. After initial surgery, externally controlled magnetic rods allow spinal deformity correction during growth without further surgical intervention. The ability to lengthen the spine without additional surgical procedures is especially beneficial in high-risk children, such as those with spinal muscular atrophy (SMA). The purpose of the present study was to assess the level of control of spinal deformity in a homogeneous group of patients with SMA who were managed with magnetically controlled implants for 2 years.Methods: This prospective, nonrandomized study included 21 non-ambulatory children with type-II SMA and progressive scoliosis who were managed bilaterally with a magnetically controlled implant that was inserted parallel to the spine with use of rib-to-pelvis hook fixation. Radiographic measurements of scoliotic curves, kyphosis, lordosis, pelvic obliquity, and spinal length were performed before and after implantation of the magnetically controlled device and during external lengthening. The mean duration of follow-up was 2 years.Results: The mean main curve of patients without prior vertical expandable prosthetic titanium rib (VEPTR) treatment decreased from 70° before implantation of the magnetically controlled device to 30° after implantation of the device. Correction was maintained during the follow-up period, with a mean curve of 31° at the time of the latest follow-up at 2.2 years. Pelvic obliquity was surgically corrected by 76% (from 17° to 4°) and remained stable during follow-up. Thoracic kyphosis could not be corrected within the follow-up period. Spinal length of children without prior spinal surgery increased by>50 mm immediately after device implantation and steadily increased at a rate of 13.5 mm/yr over the course of treatment. During treatment, 4 general complications occurred and 6 lengthening procedures failed, with 3 patients requiring surgical revision.Conclusions: Bilateral implantation of an externally controlled magnetic rod with rib-to-pelvis fixation represents a safe and efficient method to control spinal deformity in children with SMA, achieving sufficient and stable curve correction as well as increased spinal length. The complication rate was lower than those that have been described for VEPTR and other growing rod instrumentation strategies.Level of Evidence: Therapeutic Level IV. See Instructions for
      Authors for a complete description of levels of evidence.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
  • Total Ankle Arthroplasty for Rheumatoid Arthritis in Japanese Patients: A
           Retrospective Study of Intermediate to Long-Term Follow-up

    • Authors: Hirao; Makoto; Hashimoto, Jun; Tsuboi, Hideki; Ebina, Kosuke; Nampei, Akihide; Noguchi, Takaaki; Tsuji, Shigeyoshi; Nishimoto, Norihiro; Yoshikawa, Hideki
      Abstract: imageBackground: Outcomes after total ankle arthroplasty (TAA) combined with additive techniques (augmentation of bone strength, control of soft-tissue balance, adjustment of the loading axis) for the treatment of rheumatoid arthritis were evaluated after intermediate to long-term follow-up. The influences of biologic treatment on the outcomes after TAA were also evaluated.Methods: We performed a retrospective observational study involving 50 ankles (44 patients) that underwent TAA for the treatment of rheumatoid arthritis. The mean duration of follow-up was 7.1 years. Clinical outcomes were evaluated with use of the Japanese Society for Surgery of the Foot (JSSF) scale score and a postoperative self-administered foot-evaluation questionnaire (SAFE-Q). Radiographic findings were evaluated as well. These parameters also were compared between patients managed with and without biologic treatment.Results: This procedure significantly improved the clinical scores of the JSSF rheumatoid arthritis foot and ankle scale (p < 0.0001). Forty-eight of the 50 ankles had no revision TAA surgery. Subsidence of the talar component was seen in 8 ankles (6 in the biologic treatment group and 2 in the non-biologic treatment group); 2 of these ankles (both in the biologic treatment group) underwent revision TAA. The social functioning score of the SAFE-Q scale at the time of the latest follow-up was significantly higher in the biologic treatment group (p = 0.0079). The dosage of prednisolone (p = 0.0003), rate of usage of prednisolone (p = 0.0001), and disease-activity score (p < 0.01) at the time of the latest follow-up were all significantly lower in the biologic treatment group.Conclusions: TAA is recommended for the treatment of rheumatoid arthritis if disease control, augmentation of bone strength, control of soft-tissue balance, and adjustment of the loading axis are taken into account. The prevention of talar component subsidence remains a challenge in patients with the combination of subtalar fusion, rheumatoid arthritis, and higher social activity levels.Level of Evidence: Therapeutic Level III. See Instructions for
      Authors for a complete description of levels of evidence.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
  • Pulsation and Collimation During Fluoroscopy to Decrease Radiation: A
           Cadaver Study

    • Authors: Yamashita; Kazuta; Higashino, Kosaku; Hayashi, Hiroaki; Hayashi, Fumio; Fukui, Yoshihiro; Sairyo, Koichi
      Abstract: imageBackground: Awareness of the harmful effects of long-term low-dose radiation is rising. Many studies have assessed both patient and physician exposure to radiation in association with the use of fluoroscopy in the operating room. However, to our knowledge, previous studies have not assessed, in a detailed fashion, the reduction in radiation exposure that pulsation and collimation provide.Methods: Seven fresh cadavers were irradiated for 5 minutes with C-arm fluoroscopy with use of standard x-ray and pulsed and collimated x-ray beams. The x-ray sources were placed under the table, over the table, and lateral to the table. Radiation exposure doses were measured at different points, such as the center of the radiation field on the cadaver as well as at the locations of the surgeon’s hand and thyroid gland. In addition, Monte Carlo simulation (a physics equation to predict exposure) was performed to estimate the dose reduction and to confirm the experimental results.Results: The radiation exposure doses associated with the use of pulsed fluoroscopy (8 times per second) were reduced by approximately 30% for the patient and by approximately 70% for the surgeon’s hand and thyroid gland as compared with those associated with the use of continuous fluoroscopy. The radiation exposure doses associated with the use of collimated beams were reduced to approximately 65% for the surgeon’s hand and thyroid gland as compared with those associated with the use of non-collimated fluoroscopy. These results were consistent with the simulation, and the phenomena could be appropriately explained by physics.Conclusions: The present study revealed the effectiveness of pulsed and collimated x-ray beams in reducing radiation exposure doses resulting from C-arm fluoroscopy. Surgeons should consider using the techniques of pulsed fluoroscopy and collimation to protect patients and themselves from radiation.Clinical Relevance: This study presents data regarding the reduction of radiation exposure provided by pulsed fluoroscopy and collimation.
      PubDate: Thu, 28 Dec 2017 00:00:00 GMT-
       
 
 
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