Hospital For Special Surgery Research Articles

Efficacy of perioperative cryotherapy combined with intra-articular injection of tranexamic acid in total knee arthroplasty.

To evaluate the efficacy and safety of perioperative cryotherapy combined with intra-articular injection of tranexamic acid (TXA) in total knee arthroplasty (TKA) and explore a new strategy of enhanced recovery after TKA. We randomly divided 200 patients into 4 groups: normal saline (10 mL) by drainage (Group A, placebo); intra-articular injection of TXA (1 g, 10 mL, Group B); normal saline (10 mL) and continuous cryotherapy postoperatively (Group C) and intra-articular injection of TXA (1 g, 10 mL) and continuous cryotherapy postoperatively (Group D). Primary outcomes were blood loss volume, postoperative pain and circumference variation. We also recorded consumption of analgesics, postoperative length of stay (p-LOS), range of motion (ROM), function score (Hospital for Special Surgery) and severe complications. There were statistically significant differences in postoperative drainage volume, total blood loss, hidden blood loss, and visual analogue scale at rest and walking on postoperative day 1 (POD1), POD2, POD3, ROM (POD3, 7, discharge, postoperative month), circumference variation (POD3, 7), p-LOS, Hospital for Special Surgery score (discharge) and drop of hemoglobin on POD3 (P < .05) among 4 groups, but there were no significant differences in intraoperative blood loss, postoperative prothrombin, activated partial thromboplastin time, overall number of patients or total consumption of oxycodone and perioperative complications (e.g., incidence of surgical site infection, deep venous thrombosis, and cold injury) among them (P > .05). Continuous cryotherapy combined with intra-articular injection of TXA provides short-term advantages in reducing blood loss, pain, postoperative swelling, p-LOS and increasing ROM and joint function in the early postoperative period after TKA without increasing any severe complications.

Golfing after Orthopaedic Surgery: A longitudinal follow-up (GOLF) study protocol.

The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undertaken of arthroplasty patients at both sites. The results of this prospective study will provide clinicians with accurate data to deliver to patients with regard to the likelihood of return to golf and timing of when they can expect to return to golf following their hip, knee, ankle, or shoulder arthroplasty, as well as their joint-specific functional outcomes. This will help patients to manage their postoperative expectations and plan their postoperative recovery pathway.

A prospective study to analyze the functional outcome of the femoral neck system in femoral neck fractures

Abstract Background: In 2017, a new fixation device called the femoral neck system (FNS), manufactured by DePuy Synthes orthopedics company of Johnson &amp; Johnson, was introduced to manage femoral neck fractures. The primary objective of this study was to present our firsthand experience with this device in treating femoral neck fractures and to evaluate its clinical outcomes. Materials and Methods: With ethical committee approval, we conducted a prospective study involving patients aged 18 years or older but no more than 60 years. The study included a final sample size of 30 participants, selected based on specific inclusion and exclusion criteria. Patient records were reviewed to collect data on blood loss, fracture type, internal fixation methods, and the duration of clinical follow-up. Continuous variables were analyzed, and their mean values, standard deviations, and ranges were reported. The clinical assessment of patients was carried out using the Harris hip score and postoperative X-rays at regular intervals. Results: In our study, the gender distribution among the patients showed that 60% were females and 40% were males. The patient’s average age was 44.12 years, with a standard deviation of 2 years. The functional outcomes of patients treated with FNS using the hospital for special surgery (HSS) method were compared at different postoperative time points: 6 weeks, 3 months, and 12 months. The statistical analysis revealed significant differences in functional outcomes at these time intervals. During the study, two cases of postoperative complications were observed among the patients. These complications were addressed through specific interventions, namely bipolar hemiarthroplasty and shoe raise to correct limb shortening. Conclusion: Our study demonstrated that FNS yielded positive outcomes, significantly improving the HSS scores. Additionally, we observed that FNS was associated with minimal intraoperative blood loss in the cases we examined.

Comparative Analysis of Posterior Approach Versus Anterior Approach for Posterior Tibial Plateau Fractures: A Systematic Review and Meta-analysis.

Posterior tibial plateau fractures can lead to significant posttraumatic instability if not treated properly. It remains unclear which surgical approach achieves better patient outcomes. The objective of this systematic review and meta-analysis was to assess postoperative outcomes in patients undergoing anterior, posterior, or combined approach for posterior tibial plateau fractures. The PubMed, Embase, Web of Science, The Cochrane Library, and Scopus were searched for studies published before October 26, 2022, comparing anterior, posterior, or combined approaches for posterior tibial plateau fractures. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Outcomes included complications, infections, range of motion (ROM), operation time, union rates, and functional scores. Significance was set at p < 0.05. Meta-analysis was conducted with STATA software. In total, 29 studies with a total of 747 patients were included for quantitative and qualitative analysis. Compared with other approaches, the posterior approach for posterior tibial plateau fractures was associated with a better ROM and shorter operative time. The complication rates, infection rates, union time, and hospital for special surgery (HSS) scores were not significantly different between surgical approaches. The posterior approach for posterior tibial plateau fractures offers advantages such as improved ROM and shorter operative time. However, there are concerns regarding prone positioning in patients with medical or pulmonary comorbidities and indications in polytrauma cases. Further prospective studies are needed to determine the optimal approach for these fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Poster 154: Top Orthopaedic Sports Medicine Fellowship Programs as Perceived by Applicants

Objectives: Despite the high volume of orthopaedic sports medicine fellowship applicants and growing interest in the field, fellowship applicants’ attitudes and preferences towards programs are not well known. The objectives of this study were to determine the top orthopaedic surgery sports medicine fellowship programs in the United States and the most important aspects of fellowship programs as perceived by applicants. Methods: An anonymous survey was distributed via email and text message to all individuals who applied to one particular orthopaedic sports medicine fellowship program during the 2017-18 through 2021-22 application cycles. The survey asked applicants to rank what they considered to be the top-10 orthopaedic sports medicine fellowship programs in the United States prior to and after completion of their application cycle, based on operative and nonoperative experience, faculty, game coverage, research, and work/life balance. Final rank was calculated by awarding 10 points for a 1st place vote, 9 points for a 2nd place vote, etc., with total number of points used to determine final ranking for each program. Secondary outcomes included application patterns, relative importance of different fellowship program aspects, and preferred type of practice. Results: Ninety-three surveys were completed overall. Based on total numbers of points, applicants voted the top orthopaedic sports medicine fellowships programs to be: 1) the Steadman Philippon Research Institute, 2) Rush University, and 3) Hospital for Special Surgery, both prior to and following the application cycle (Table 1). Forty-two percent of applicants applied to all of their perceived top-10 programs with 66% of respondents applying to at least 8 of their top-10 programs. Interestingly, 10% of applicants applied to 4 or fewer of their top-10 programs. Of those who did not apply to all programs in their top-10, 92% thought the program did not fit their preferences and 47% thought they were not competitive for those programs. When asked to rank programs upon completion of the application cycle, each of the top-10 programs prior to the application cycle remained in the top-10 (Table 1). Nearly all of the applicants agreed/strongly agreed (99%) that the personalities of the attendings they met on their interviews influenced their rank list decision upon completion of the application cycle. When ranking fellowship program aspects, fellowship reputation and faculty members were most likely to be ranked highest in importance. Factors such as research opportunities, private practice versus academic setting, and number of fellows were all more likely to be ranked last in importance (Table 2). Most applicants (83%) applied to both academic and private practice programs. Conclusions: This study demonstrates that most orthopaedic sports medicine fellowship applicants highly valued program reputation and faculty member personalities in choosing a fellowship program and that the application/interview process did not have a significant effect on how individuals perceive the top programs. The findings of this study may have significant implications on future application cycles and the programs to which potential applicants may apply. [Table: see text][Table: see text]

Preoperative simulated surgery on 3D model assists osteotomy feasibility verification and surgical guidance for patients with cubitus valgus/varus deformity: a retrospective observational study

BackgroundAs the common delayed complication of supracondylar fractures in children, cubitus valgus/varus deformity might lead to pain and loss of motion of the elbow. The current corrective treatment might not be accurate enough and even contribute to postoperative deformity. This study retrospectively analyzed the clinical value of preoperative simulated surgery on 3D model-assisted osteotomy feasibility verification and surgical guidance for cubitus valgus/varus deformity.MethodsSeventeen patients were selected from January 2017 and November 2019. Deformities were analyzed from imaging data and 3D models and corrected after the simulated operations. The radiographic evaluation comprised osseous union, carrying angle, and anteversion angle of the distal humerus. The clinical evaluation was performed according to the Hospital for Special Surgery (HSS) scoring system.ResultsAll patients underwent the operation successfully and had no postoperative deformity. The carrying angle was significantly improved postoperatively (P < 0.001). The anteversion angle of the distal humerus did not change significantly (P > 0.05). The HSS score rose after surgery (P < 0.001). The function of the elbow joint was excellent in seven cases and good in ten cases.ConclusionSimulated surgery on 3D model plays an important role in osteotomy plan and surgical guidance, contributing to good surgical efficacy.

CUSTOMER SATISFACTION INDEX (CSI) PASIEN ASING TERHADAP PENYAJIAN MAKANAN DI RUMAH SAKIT KHUSUS BEDAH BIMC KUTA KABUPATEN BADUNG

The Customer Satisfaction Index (CSI) is an index to determine the level of overall customer satisfaction with an approach that considers the importance of the product or service attributes being measured. One of the factors that determine customer satisfaction is the consumers perception of service quality which focuses on five service dimensions, are Responsiveness, Reliability, Empathy, Tangible and Assurance. The type of research that will be carried out is an observational research type with a cross sectional research design and descriptive analysis. The population of this study were all foreign patients who were hospitalized at the BIMC Kuta Special Surgery Hospital, Badung Regency, and the sample from this study was part of the population who had the following criteria, patients who were treated for at least 1 day and received regular food, man and women over the age of 18 years, are willing to be research subjects by filling out the informed consent and the patient is conscious and able to communicate. Based on the 26 samples studied, overall the patients stated that they were good with the presentation of food provided by the hospital, namely with an index of 3,412 where if this value was percentage it was already above the standard hospital satisfaction value of 85%. This is in accordance with the results of the feed back form given from the hospital to patients where in May 2021 it showed a good satisfaction value with food presentation, which was 85%. Keywords : Customer Satisfaction Index, food presentation

Highly Active Middle School Athletes Demonstrate Poor Motor Skill Proficiency.

Fundamental movement skills (FMS) are critical components to lifelong participation in sports and physical activity. With the rise in early sports specialization, mastery of motor skills may be limited in youth athletes. The purpose of this study was to assess FMS proficiency in highly active middle school athletes and determine whether proficiency differed between specialization levels and sex. (1) Most athletes would fail to achieve proficiency in all domains of the Test of Gross Motor Development (TGMD-2), (2) highly specialized athletes would demonstrate lower proficiency in all domains of the TGMD-2, and (3) male athletes would demonstrate higher proficiency than female athletes. Cross-sectional. Level 4. A total of 91 athletes were recruited (44 male, 12.6 ± 0.9 years). Activity level was quantified using the Hospital for Special Surgery (HSS) Pediatric Functional Activity Brief Scale (Pedi-FABS), specialization level was determined using the Jayanthi Specialization Scale, and the TGMD-2 was used to assess FMS proficiency. Descriptive statistics were used to describe gross motor, locomotor, and object control percentile rank. A 1-way analysis of variance (ANOVA) was used to assess differences in percentile rank between low, moderate, and high specialization groups and independent samples t tests were used to compare sexes (α < 0.05). Mean Pedi-FABS score was 23.6 ± 4.9. In total, 24.2%, 38.5%, and 37.4% of athletes classified as low, moderate, and highly specialized, respectively. Mean percentile ranks were 56.2%, 64.7%, and 62.6% for locomotor, object control, and gross motor domains, respectively. No athlete achieved a percentile rank >99% in any domain of the TGMD-2, and there was no significant difference between specialization groups or sex. Despite high activity levels, no athlete demonstrated proficiency in any domain of the TGMD-2, and there was no difference in proficiency between specialization levels or by sex. Sport participation, regardless of level, does not ensure adequate mastery of FMS.

Short- and mid-term effectiveness of unicompartmental knee arthroplasty for post-traumatic arthritis of knee

To investigate the short- and mid-term effectiveness of unicompartmental knee arthroplasty (UKA) for post-traumatic arthritis (PTA) of knee. The clinical data of 30 patients with PTA of unilateral knee between March 2014 and September 2021 was retrospectively analyzed. There were 14 males and 16 females with an average of 64.5 years (range, 33-81 years). The average body mass index was 26.7 kg/m 2 (range, 19.8-35.6 kg/m 2). The types of injuries that caused PTA included intra-articular fracture in 16 cases, extra-articular fracture in 8 cases, and soft tissue injury in 6 cases. The initial injuries were treated by conservative therapy in 12 cases and by surgical therapy in 18 cases. Ten cases were medial compartment osteoarthritis and 20 cases were lateral compartment osteoarthritis. According to Kellgren-Lawrence staging, there were 19 cases of grade Ⅲ and 11 cases of grade Ⅳ. The operative time, the length of hospital stay, complications, and subjective satisfaction were recorded. The Oxford Knee Function Score (OKS), Hospital for Special Surgery (HSS) score, and knee range of motion (ROM) were used to evaluate knee function. Weight-bearing X-ray films were taken to measure the femoro-tibial angle (FTA) and to assess alignment correction of the lower limb. The operative time ranged from 50 to 95 minutes (mean, 63.7 minutes), the length of hospital stay ranged from 3 to 8 days (mean, 6.9 days). Superficial infection occurred in 2 patients, while the remaining incisions healed by first intention. There was no deep vein thrombosis or neurovascular injury. All patients were followed up 17-109 months (median, 70 months). At last follow-up, OKS score, HSS score, and ROM in 30 cases significantly improved when compared with those before operation (P<0.05). Lower limb alignment was significantly corrected and there was significant difference in FTA of the varus and valgus knees between pre- and post-operation ( P<0.05). The patient satisfaction rate was 86.7% (26/30). Two cases developed contralateral osteoarthritis progression during follow-up. No bearing dislocation, prosthesis loosening or sinking occurred and none required further revision. For patients with PTA of knee, UKA can obtain definite short- and mid-term effectiveness with high patient satisfaction.

Effect of body mass index on short-term effectiveness of high tibial osteotomy in treatment of varus knee arthritis

To investigate the effect of body mass index (BMI) on the short-term effectiveness of high tibial osteotomy (HTO) in the treatment of varus knee arthritis. The clinical data of 84 patients (84 knees) with varus knee arthritis treated with HTO between May 2016 and August 2020 were retrospectively analyzed. According to BMI, the patients were divided into normal group (32 patients in group A, BMI<25 kg/m 2), overweight group (27 patients in group B, BMI>30 kg/m 2), and obese group (25 patients in group C, BMI>30 kg/m 2). The BMI of groups A, B, and C were (23.35±0.89), (26.65±1.03), and (32.05±1.47) kg/m 2, respectively. There was no significant difference ( P>0.05) in gender, age, surgical side, disease duration, and preoperative Hospital for Special Surgery (HSS) score, visual analogue scale (VAS) score, knee range of motion, and hip-knee-ankle angle (HKA) between groups. The operation time, intraoperative dominant blood loss, and the decrease of hemoglobin on the 3rd day after operation were recorded and compared between groups. The improvement of knee joint function and pain status were evaluated by knee joint HSS score, knee range of motion, and VAS score before and after operation, and measuring the HKA of patients on X-ray film. During the follow-up, the X-ray films of the knee joint were reexamined to observe the position of the internal fixator and the healing of osteotomy. All patients completed the operation successfully and were followed up 8-40 months (mean, 19.3 months). There was no significant difference in follow-up time, operation time, intraoperative dominant blood loss, and the decrease of hemoglobin on the 3rd day after operation between groups ( P>0.05). No operative complications such as severe vascular or nerve injury occurred. After operation, deep venous thrombosis of lower extremities occurred in 1 case in groups A and B respectively, and fat liquefaction of surgical incision occurred in 2 cases in group C. There was no significant difference in the incidence of perioperative complications between groups (3.1% vs. 3.7% vs. 8.0%) ( P=0.689). During the follow-up, there was no bone nonunion, plate fracture or loosening. At last follow-up, HSS score, VAS score, knee range of motion, and HKA significantly improved in the 3 groups when compared with those before operation ( P<0.05), but there was no significant difference in the differences of the above indexes between groups before and after operation ( P>0.05). BMI does not affect the short-term effectiveness of HTO in the treatment of varus knee arthritis. HTO can be selected for overweight and obese patients after standard medical treatment is ineffective.

Artificial intelligence-based detection of posterior tibial slope on X-ray images of unicompartmental knee arthroplasty patients

ObjectiveThis paper aims to improve the assessment of the outcomes of unicompartmental knee arthroplasty (UKA) from the angle of posterior tibial slope (PTS) on X-Ray images, using the artificial intelligence (AI) tool of RetinaNet. MethodsFirstly, RetinaNet was trained and tested on patients who underwent unilateral knee replacement surgery in our hospital due to osteoarthritis in the medial compartment of either their left or right knee between July 2018 and July 2022. The trained network was applied to detect the region of interest (ROI) on the pre- and postoperative X-ray images of each subject. Next, the subjects were divided into three groups according to the PTS changes measured by the trained RetinaNet. Furthermore, the surgical effect of UKA was evaluated from multiple angles, including pre- and postoperative PTSs, knee joint mobility (KJM) values, the Hospital for Special Surgery (HSS) scores, as well as the Joint Replacement Forgetting Index (JRFI). ResultsAfter training, the RetinaNet achieved an astounding accuracy level, with the Cronbach's alpha value 0.864 (95%CI 0.762–0.915). There significant differences were found between Group II and Group I (P = 0.017) and Group III and Group I (P = 0.032); in terms of JRFI, Group II had a significantly better than Group I (P = 0.011) and Group III (P = 0.037). ConclusionsThe trained RetinaNet is suitable for assisting with PTS measurements in X-ray images; the PTS variation through UKA should be controlled within 2° to ensure the best possible surgical effect.

High tibial osteotomy for acute correction and subsequent gradual tensioning of the posterolateral knee ligament complex in treating genu varum combined with a lateral thrust using the Ilizarov technique in adults: surgical technique and early results

ObjectiveTo report the early results of using the Ilizarov technique in performing medial wedge opening high tibial osteotomy (MWOHTO) combined with gradual tensioning of the posterolateral corner in adult patients presenting with genu varum (GV) and lateral thrust.MethodsA prospective case series study included 12 adult patients with a mean age of 25.2 ± 8.1 years who presented with GV deformity associated with lateral thrust. They were evaluated clinically using the “hospital for special surgery” (HSS) knee scoring system. Radiological evaluation was performed using long film from hip to knee to ankle (HKA) radiographs; the overall mechanical alignment was measured as the HKA angle, the upper tibial deformity was measured as the medial proximal tibial angle (MPTA), and the joint line convergence angle (JLCA) was measured. Surgical technique included using Ilizarov for MWOHTO below the level of the tibial tubercle, acute correction of the GV deformity, fibular osteotomy, and gradual distalization of the proximal fibula.ResultsAfter a mean follow-up of 26.3 ± 6.4 months, all osteotomies were united. All patients achieved fibular osteotomy site bony union except two with a fibrous union. The HSS score showed improvement from a mean preoperative score of 88.7 ± 7.6 to a postoperative 97.3 ± 3.9 (P < 0.05). The overall mechanical lower limb alignment improved significantly from a mean preoperative HKA of 164.5 ± 3.2 to a postoperative 178.9 ± 1.6 (P < 0.05). The MPTA improved significantly from 74.6 ± 4.1 to 88.9 ± 2.3, as well as the JLCA from 12.17 ± 1.9 to 2.3 ± 1.7 (P < 0.05). Grade 1 pin tract infection was developed in four patients and was treated conservatively. In two patients, mild pain over the fibular osteotomy site was relieved over time. The lateral thrust reoccurred at the last follow-up evaluation in the two poliomyelitis patients.ConclusionMWOHTO, concomitant with tensioning the knee lateral soft tissue structure at the same setting through applying an Ilizarov apparatus, showed promising functional and radiological outcomes.

Effect of Schatzker type VI tibial plateau fractures combined with a proximal fibular and/or posterolateral joint facet fracture on early postoperative functional recovery

PurposeThe objective of this study was to investigate the effect of proximal fibular and/or posterolateral joint facet (PJF) fractures on early functional recovery after Schatzker type VI tibial plateau fractures (TPFs).MethodsSeventy-nine patients with Schatzker type VI TPFs sustained from November 2016 to February 2021 were divided into three groups according to the integrity of the proximal fibula and PJF (groups A, B, and C). Details including demographics, duration of surgery, and complications were recorded. The Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) score, Hospital for Special Surgery (HSS) score, lateral knee pain and lateral hamstring tightness were ascertained at the final follow-up. The HSS and WOMAC scores have high reliability in evaluating knee function and osteoarthritis.ResultsThere was a significant difference in the HSS score between groups A and C (P < 0.001) and between groups B and C (P = 0.036). The hospital stay was significantly different between groups A and C (P = 0.038) and between groups B and C (P = 0.013). There was a significant difference in lateral knee pain and lateral hamstring tightness between groups A and C (P < 0.001) and between groups B and C (P < 0.001).ConclusionOur study demonstrates that proximal fibular and PJF fractures do not increase the time from injury to surgery, the incidence of complications, or the duration of surgery for Schatzker type VI TPFs. However, fractures of the proximal fibula significantly increase the hospital stay, reduce knee function, and cause lateral knee pain and lateral hamstring tightness. Combined proximal fibular fracture is more decisive than PJF involvement for prognosis.

DNA Variation in Spinal Pathologies: Genetics Running Down the Spine

Commentary Nearly 400 types of skeletal malformations, including those that involve the spine, have been characterized by molecular and cellular analyses1. Identification of genetic components that control the integrity of intervertebral discs—and that predispose to spinal degeneration in aging patients when mutated—represents a challenging goal. Spinal conditions that occur later in life may emerge from faulty musculoskeletal tissue repair after accidental injury and the influences of comorbidities. The collective stochastic and often undocumented events in the life of a patient can easily complicate attempts at defining genetic predispositions. To manage the statistical noise that comes from random mutations within the human population (“nature”) and the randomness of life’s events (“nurture”), it is necessary to examine massive genetic data sets with many thousands of patients. Technological advances that allow cost-effective DNA sequencing have made it feasible to compare large patient populations matched on the basis of specific codes for medical conditions. Consequently, several studies have made impressive attempts at defining genetic variations linked to a range of surgically relevant musculoskeletal complications, including degenerative rotator cuff disease2, arthroplasty3, adhesive capsulitis of the shoulder4, and end-stage knee osteoarthritis5. The current paper by Bovonratwet et al. at the Hospital for Special Surgery in New York provides the latest installment in a growing set of orthopaedic studies in this journal that investigate the relationship between genetic variations and the risk of surgery for spinal conditions. Similar to prior published efforts by Yanik et al.2, Brüggemann et al.3, and Kulm et al.4,5, the study by Bovonratwet et al. leverages the power of the UK Biobank, which has genetic data for about 400,000 patients, of whom a total of about 20,000 (∼5%) had 1 of 4 spinal conditions (i.e., lumbar spondylolisthesis, spinal stenosis, degenerative disc disease, and pseudarthrosis after spinal fusion). Results from this large data set (“training population”) were then tested using the FinnGen database (“test population”) for validation. The analysis yielded multiple different genetic variants across 7 chromosomes. On average, the authors discovered 2 distinct loci per spinal condition. These findings are consistent with the genetic complexities of spinal conditions and suggest that the diseases are polygenic, as expected. Several nucleotide variants associated with 4 common spinal conditions were located in loci encoding anonymous genes that have not been experimentally explored. Degenerative disc disease was associated with a locus containing 2 genes that affect chondrogenesis: CHST3 (for carbohydrate sulfotransferase 3) promotes sulfation of chondroitin, and SMAD3 is the inducible target of chondrogenic transforming growth factor (TGF)-β signaling. Remarkably, 1 chromosomal region significantly associated with both lumbar spondylolisthesis and spinal stenosis contained overlapping sets of genes (i.e., GFPT1 and NFU1) that encode proteins involved in cell metabolism. These genes represent attractive targets for studies on genetic causality for these 2 spinal conditions. While it is tempting to speculate about potential mechanistic implications, the genetic biomarkers for spinal conditions mapped to large regions containing several genes. Whether these genes are even expressed in cell types and tissues relevant to homeostasis and repair of spinal tissues remains to be determined. Lack of similarity among studies indicates that endogenous tissue-specific repair processes may be predominant in the genetic landscape. One major strength of this study is the control for demographics and comorbidities. Yet, even with access to nearly 400,000 people who form a fairly homogeneous study cohort (i.e., White elderly people in Britain), this population size is not nearly large enough to identify the many genes that undoubtedly contribute to spinal conditions. The observation that only a few genetic variants were replicated in the Finnish cohort may further reflect the polygenicity of disease factors and genetic differences of Finnish patients. In closing, just as our emotions can run up or down our spine depending on whether we are in a positive or negative mood, genetic variation appears to affect spinal diseases. Some DNA mutations may literally be running down our spine, by destroying either disc integrity or our capacity for repair after injury. The positive news is that recognition of genetic predispositions may enhance consideration of behavioral modifications or guide surgical decisions. The paper by Bovonratwet et al. will inspire future studies, while bringing us 1 step closer to that goal.

Comparison of Arthroscopic-Assisted Percutaneous Internal Fixation With a Modified Reducer Versus Open Reduction and Internal Fixation for Schatzker Type II and III Tibial Plateau Fractures.

Tibial plateau fractures require anatomical reduction and stable fixation to achieve satisfactory results. In addition, addressing any related injuries is of paramount importance. Arthroscopic reduction and internal fixation (ARIF) has been promoted as a possible technique to treat tibial plateau fractures. To compare the effectiveness of ARIF with this modified reducer and open reduction and internal fixation (ORIF) for Schatzker types II and III tibial plateau fractures. Cohort study; Level of evidence, 3. We retrospectively reviewed 68 patients who were treated for Schatzker type II or III tibial plateau fractures between August 1, 2014, and October 31, 2018. Patients were categorized into the ARIF (n = 33) and ORIF groups (n = 35). The groups were compared regarding intra-articular injuries, duration of hospital stay, complications, and clinical outcomes-including the International Knee Documentation Committee (IKDC) score, the Hospital for Special Surgery (HSS) score, and range of motion (ROM). The paired t test was used to compare preoperative and postoperative data, and the chi-square test was used to compare the IKDC and HSS scores. The median follow-up period was 36 months (26-40 months). Additional intra-articular lesions were found in 29 patients-21 in the ARIF group and 8 in the ORIF group (P = .02). A significant difference was observed in the duration of hospital stay-3.58 ± 1.46 days for the ARIF group and 4.57 ± 1.12 days for the ORIF group (t = -3.169; P = .002). All fractures healed within 3 months after surgery. The complication rate for all patients was 11%, with no significant difference between the ARIF and ORIF groups (t = 1.244; P = .265). At the final follow-up, there were no significant differences between the 2 groups in the IKDC score, HSS score, and ROM (P > .05 for all). ARIF with a modified reducer was found to be an effective, reliable, and safe procedure for the treatment of Schatzker types II and III tibial plateau fractures. Both ARIF and ORIF provided equally good results, while ARIF offered a more precise evaluation and reduced the duration of hospital stay.

CORR Insights®: What is the Role of Stem Size and Offset in the Risk of Nonseptic Revision of the Exeter® 150-mm Stem? A Study From the Swedish Arthroplasty Register.

1Professor of Clinical Orthopedic Surgery, The Hospital for Special Surgery, New York, NY, USA C. N. Cornell, The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA, Email: [email protected] This CORR Insights® is a commentary on the article “What is the Role of Stem Size and Offset in the Risk of Nonseptic Revision of the Exeter® 150-mm Stem? A Study From the Swedish Arthroplasty Register” by Itayem and colleagues available at: DOI: 10.1097/CORR.0000000000002670. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

The use of a walking aid before surgery is not related to worse short-term outcomes after simultaneous bilateral total knee arthroplasty

Introduction: No study has been performed to compare patients’ pre- and post-operative knee disability, functional status, and length of hospital stay after surgery between patients with and without using a walking aid. Methods: One-hundred forty-five patients were enrolled and divided into four groups based on whether they used any walking aids before surgery: no walking aid, one cane, one elbow crutch, and two elbow crutches. The groups were compared for knee disability (Hospital for Special Surgery (HSS) knee score), functional status (Iowa Level of Assistance Scale (ILAS)), and length of hospital stay. Results: For the pre-operative HSS knee scores, no statistically significant differences were found between the groups ( p &gt; 0.05). For the pre-operative ILAS scores, the patients without using walking aids had better functional status than those using any walking aids ( p &lt; 0.05). For the post-operative outcomes, no statistically significant differences were found between the groups in the HSS knee and the ILAS scores and length of hospital stay after surgery. Conclusion: In this population, using any walking aids before surgery is related to worse pre-operative functional status but not to the pre-operative knee disability. Furthermore, it is not related to the short-term outcomes after surgery.

Four Decades of Foot and Ankle Research Activity: A Scientometric study of Subspecialty Foot and Ankle Journals.

To evaluate foot and ankle documents using scientometric methods and provide insight into global research activities. This scientometric study was conducted at the Department of Spine Surgery, Ganzhou People's Hospital, China. Documents on foot and ankle from 1980 to 2019 were retrieved from the Scopus database. The number of documents, year of publication, journal, country, institution, author, h-index, and top-cited documents were analyzed. In total, 11313 documents were retrieved. The annual research output on foot and ankle showed a dramatic increase over the past four decades, especially in the past decade (p = 0.000). Foot & Ankle International published the biggest number of documents (44.48%). The United States contributed more than half (52.17%) of the global production, followed by the United Kingdom (11.39%), and Germany (3.62%). The United States had the highest h-index (109). The Hospital for Special Surgery (1.87%) ranked first in terms of productivity, followed by Union Memorial Hospital (1.37%), and Duke University Medical Center (1.24%). The most productive author was Myerson MS (1.25%), followed by Schon LC (0.77%), and Hyer CF (0.74%). Research on foot and ankle has thrived rapidly over the past four decades, particularly in the last decade. The United States contributes the most to the quantity and quality of foot and ankle documents.

In closed wedge distal femur osteotomies for correction of valgus malalignment overcorrection of mLDFA should be avoided.

The purpose of the study was to investigate the influence of the mLDFA (mechanical lateral distal femur angle) as a parameter in varus realignment osteotomies for valgus deformities of the knee. We hypothesized that joint line obliquity with mLDFA > 90° after distal femur osteotomy (DFO) is associated with inferior clinical outcome. In a retrospective study, a total of 52 patients with isolated femoral valgus deformities were included in the study. The mean postoperative follow-up was 70.5 (SD 33.3) months (standard deviation SD±33.3). In all patients, a distal femur osteotomy was performed. A clinical examination and survey of questionnaires was conducted with the HSS (Hospital for Special Surgery), LG (Lysholm-Gilquist), and KOOS (Knee Injury and Osteoarthritis Outcome Score) scores. Several radiological parameters were assessed on long-standing x-rays: mechanical tibio-femoral angle (mTFA), mLDFA, mechanical medial proximal tibia angle (mMPTA), joint-line convergence angle (JLCA). The ttest was used for normally distributed data. The Mann-Whitney U test was performed in non-normally distributed data. The mLDFA was 84.9° (SD±2.3) preop and changed to 91.9° (SD±3, 22.9) postop. The mTFA (mechanical tibio-femoral angle) was 5.2° (SD±2.9°) preop and -1.8° (SD±2.9) postop demonstrating a difference of 6.7°. For analysis, the data was divided into two groups based on postop mLDFA. Group 1: mLDFA ≤ 90°; Group 2: > 90°. Postoperatively, a mean mLDFA of 88.6° (SD±1.4°) was measured in group 1 and 93.9° (SD±2.1) in group 2. The change in mLDFA was 4.7° (SD±1.6) in group 1 and 8.4° (SD±2.8) in group 2. Preoperatively, the mTFA was 4.8° (SD±1.9) in group 1 and 5.5° (SD±3.3) in group 2. Postoperatively, the mTFA decreased in group 1 by 4.8° (SD±2.3) to -0.1° (SD±2.1). In group 2, the mTFA decreased by 8.2° (SD±3.8) to -2.8° (SD±2.9). Regarding the HSS, group 1 showed a 10.4 points better score than group 2 (p<0.01). Also, regarding the Lysholm, a significant difference of 16.9 points was found (p<0.01). Correction of valgus knees using closed wedge DFO leads to good clinical results. A postoperative mLDFA of 85-90° results in superior clinical outcome compared to mLDFA > 90°. Joint-line obliquity should be avoided using double level osteotomy, if needed. III.

CORR Insights®: How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study.

1Resident Physician, Hospital for Special Surgery, New York, NY, USA C. J. DeFrancesco, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA, Email: [email protected] This CORR Insights® is a commentary on the article “How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study” by Miettinen and colleagues available at: DOI: 10.1097/CORR.0000000000002638. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.