Radiographic Outcome Measures Research Articles

371 Pre-Clinical Models of Penetrating Brain Injury: Study Protocol for a Systematic Review

OBJECTIVES/GOALS: Penetrating brain injury (PBI) differs both physiologically and in clinical outcomes when compared to blunt-force traumatic brain injury (TBI). Despite this, there are few pre-clinical models of PBI described in the literature. To address this gap, we will develop a study protocol for a systematic review. METHODS/STUDY POPULATION: Three electronic databases (PubMed, Embase, Web of Science) will be searched using keywords and controlled vocabulary related to animal models, computational models, simulations, and disease key words including traumatic brain injury and penetrating brain injury. The primary outcome will be the method of PBI modeling. Secondary outcomes will be related to bibliographic information, computational analysis, and histochemical, radiographic, behavioral, and human clinical biomarkers and outcome measures used in PBI models. A panel of independent investigators will review publications resulting from this search strategy to identify relevant studies. The protocol will adhere to PRISMA-P guidelines. RESULTS/ANTICIPATED RESULTS: Eligible studies will include both exploratory and descriptive research, and both quantitative and qualitative data. A summary of selected studies will be presented, and the synthesis will follow a narrative framework. DISCUSSION/SIGNIFICANCE: This protocol provides a framework for comprehensively evaluating pre-clinical PBI models with focus on methodology. PBI is a phenotypically unique disease and is under studied. This protocol will be of great benefit to clinicians and scientists in this emerging field and can help monitor future progress in translational research.

Limited evidence in support of bone marrow aspirate concentrate as an additive to the bone marrow stimulation for osteochondral lesions of the talus: a systematic review and meta‐analysis

AbstractPurposeBone marrow aspirate concentrate can be used as an additive to surgical treatment of osteochondral lesions of the talus. This systematic literature review aims to study the effect of the additional use of bone marrow aspirate concentrate on top of a surgical treatment for osteochondral lesions of the talus on clinical outcomes compared to surgical treatment alone.MethodsAn online literature search was conducted using PubMed (Medline), Embase (Ovid), and the Cochrane library for all studies comparing a surgical intervention with bone marrow aspirate concentrate, with a surgical intervention without bone marrow aspirate concentrate. The methodological quality was rated according to the methodological index for non‐randomised studies checklist. The primary outcome measure were clinical outcomes. Secondary outcome measures consisted of revision rate, complication rate, radiographic outcome measures and histological analyses. Subgroups were created based on type of surgical intervention used in the studies. If multiple articles were included in a subgroup, a linear random‐effects model was used to compare the bone marrow aspirate concentrate‐augmented group with the control group.ResultsOut of 1006 studies found, eight studies with a total of 718 patients were included. The methodological quality, assessed according to the methodological index for non‐randomised studies checklist, was weak. A significantly better functional outcome measures (p < 0.05) was found in the subgroup treated with bone marrow stimulation + bone marrow aspirate concentrate compared to the group treated with bone marrow stimulation alone, based on three non‐blinded studies. No significant differences regarding clinical outcomes were found in the subgroups comparing matrix‐induced autologous chondrocyte implantation with matrix‐induced bone marrow aspirate concentrate, osteochondral autologous transplantation alone with osteochondral autologous transplantation + bone marrow aspirate concentrate and autologous matrix‐induced chondrogenesis plus peripheral blood concentrate vs. matrix‐associated stem cell transplantation bone marrow aspirate concentrate.ConclusionThere is insufficient evidence to support a positive effect on clinical outcomes of bone marrow aspirate concentrate as an additive to surgical treatment of osteochondral lesions of the talus. However, based on the safety reports and initial results, sufficiently powered, patient‐ and researcher‐blinded, prospective randomised controlled trials are justified and recommended. Until then, we advise not to implement a therapy (addition of bone marrow aspirate concentrate) without clinical evidence that justifies the additional costs involved.Level of evidenceLevel III.

Restoration of Hip Geometry after Femoral Neck Fracture: A Comparison of the Femoral Neck System (FNS) and the Dynamic Hip Screw (DHS).

The femoral neck system (FNS) was introduced as a minimally invasive fixation device for managing femoral neck fractures. To compare radiographic, clinical, and patient-reported outcome measures (PROMs) of femoral neck fracture patients following FNS compared to dynamic hip screw (DHS) implantation combined with an anti-rotational screw. Patients who underwent closed reduction and internal fixation of a femoral neck fracture between 2020 and 2022 were retrospectively included. We measured leg length, femoral offset, and centrum-collum-diaphyseal (CCD) angle in plain radiographs. Scar length, Harris Hip Score, short-form health survey 36-item score (SF-36), and Numeric Rating Scale (NRS) were assessed during follow-up visits. We included 43 patients (22 females) with a median age of 66 (IQR 57, 75). In both groups, leg length differences between the injured and the contralateral side increased, and femoral offset and CCD angle differences were maintained over time. FNS patients had shorter scars and reported fewer emotional problems and more energy. There were no differences between groups regarding the remaining SF-36 sub-scores, Harris Hip Score, and NRS. The FNS allows for a comparable leg length, femoral offset, and CCD angle reconstruction while achieving similarly high functional and global health scores to the DHS.

5 year follow up of a hydroxyapatite coated short stem femoral component for hip arthroplasty: a prospective multicentre study

Short stem, uncemented femoral implants for hip arthroplasty are bone conserving achieving stability through initial metaphyseal press-fit and biological fixation. This study aimed to evaluate the survivorship, mid-term function and health related quality of life outcomes in patients who have undergone total hip arthroplasty (THA) with a fully hydroxyapatite coated straight short stem femoral component with up to 5 years follow-up. 668 patients were recruited to a multicentre study investigating the performance of the cementless Furlong Evolution® stem for THA. 137 patients withdrew at various time points. The mean follow-up was 49 months. Clinical (Harris Hip Score (HHS), radiographic and patient-reported outcome measures—Oxford Hip Score (OHS) and EuroQol 5D (EQ-5D), were recorded pre-operatively and at 6 weeks, 6 months, 1 year, 3 year and 5 year follow ups. At 5-year follow-up, 12 patients underwent revision surgery, representing a cumulative revision rate of 1.8%. Median OHS, HHS and EQ5D scores improved significantly: OHS improved from a pre-operative median of 21 (IQR 14–26) to 47 (IQR 44–48) (p < 0.001). HHS improved from 52 (IQR 40–63) to 98 (IQR 92–100) (p < 0.001) and EQ5D improved from 70 (IQR 50–80) to 85 (IQR 75–95) (p < 0.001). This fully HA-coated straight short femoral stem implant demonstrated acceptable mid-term survivorship and delivered substantial improvements in function and quality of life after THA.

Radiographic parameters of pelvic and proximal femoral morphology do not predict outcomes for direct anterior total hip arthroplasty

BackgroundRadiographic predictors of outcomes associated with direct anterior approach (DAA) total hip arthroplasty (THA) are largely unknown. Anecdotally, some surgeons limit surgery to patients with low body mass index (BMI) or “favorable” bony morphology. Objective data on the impact of these factors is limited. We sought to determine radiographic and demographic predictors of outcomes after DAA arthroplasty. MethodsA consecutive series of patients undergoing unilateral, elective DAA THA, who had linked pre- and post-operative patient reported outcome scores, from January 1, 2017 to March 30, 2019 were included. Radiographic measurements, including proxies for pelvic overhang, femoral canal access, acetabular morphologic changes, and markers of disease severity, were performed on calibrated radiographs. Intra-observer consistency was also evaluated. Outcome measures included disease specific and general health patient-reported outcomes scores, while surgical difficulty was approximated by estimated blood loss and surgical time. Multivariate analyses were performed to determine statistically significant correlations. Results168 patients were included. Overall, patients experienced significant improvement in outcome scores (mean ∆ HOOS-JR 39.4, PROMIS-physical 12.3). There were two reoperations (1.2%), for recurrent dislocation. Female sex (p = 0.015) and increasing age (p == 0.019) were associated with shorter surgical times. No statistically significant correlations were found between the radiographic parameters and outcome measures. Intraclass correlation coefficients of the radiographic measurements were overall strong (0.73–1.0). ConclusionWe demonstrated consistent results in this series of patients despite variation in bony morphology. Our findings suggest that DAA THA can be safely performed on a broader patient population.

Midterm outcomes of autologous bridging of rotator cuff tears with an autologous tendon patch (TEAR patch)

Large and massive rotator cuff tears and tears after failed surgical repair are a challenging clinical problem with different treatment options. The purpose of the study was to evaluate the mid-term outcomes following rotator cuff repair (RCR) with autologous hamstring tendon graft bridging (TEAR patch) with the hypothesis, that outcomes would be reasonable and complication rates low. This is a retrospective case series study of patients who underwent open RCR using a TEAR patch from June, 2015 to March, 2019. evidence of cuff tear arthropathy, advanced fatty infiltration, moderate to severe arthropathy and workers compensation board or litigation involved. Clinical outcome measures: Constant score (CS), Disabilities of Arm, Shoulder and Hand score (DASH), Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), range of motion (ROM) and manual muscle test (MMT) for forward elevation, abduction, external and internal rotation, patient satisfaction, willingness to do the operation again. Radiographic outcome measures: MRI, ultrasound and radiographs: Graft integrity and acromiohumeral distance (AHD). 44 patients were followed (89%) for ≥ 2 years (45 shoulders, mean age 60.3 years (48-76), mean follow-up 4.3 years (2-6)). All clinical outcome measures (CS, DASH, SST, SSV, ROM, and MMT) demonstrated significant improvement except active external and internal rotation. At 2 years follow-up, the mean patient satisfaction was high (12.2 out of 15 points) and 33 of 38 patients (73.3%) would do the operation again. A perfect graft integration was observed in n=30 (66.7%) a small gap in n=7 (15.6%), a retear in n=3 (7%) and a complete failure of the tendon patch in n=5 (11%) patients. Graft integrity was strongly correlated with the postoperative AHD (r=0.599 , p=0.001 ) and the gain in AHD (r=0.599 , p=0.001) but not with ROM or PROM's or patient satisfaction. Four patients required revision surgeries (three due to deep infection and one for poor function and pain). Mid-term clinical and radiographic outcomes following RCR with graft bridging using a TEAR patch were reasonable. The procedure resulted in improved shoulder function and a high level of patient satisfaction. The revision rate is acceptable in view of the specific patient group and treatment alternatives. The described technique of the TEAR patch can be a valuable alternative to existing methods and a novel autograft source for rotator cuff surgeries that need bridging of a tendon defect.

Diffusion Basis Spectrum Imaging Identifies Clinically Relevant Disease Phenotypes of Cervical Spondylotic Myelopathy.

Prospective cohort study. Apply a machine learning clustering algorithm to baseline imaging data to identify clinically relevant cervical spondylotic myelopathy (CSM) patient phenotypes. A major shortcoming in improving care for CSM patients is the lack of robust quantitative imaging tools to guide surgical decision-making. Advanced diffusion-weighted magnetic resonance imaging (MRI) techniques, such as diffusion basis spectrum imaging (DBSI), may help address this limitation by providing detailed evaluations of white matter injury in CSM. Fifty CSM patients underwent comprehensive clinical assessments and diffusion-weighted MRI, followed by DBSI modeling. DBSI metrics included fractional anisotropy, axial and radial diffusivity, fiber fraction, extra-axonal fraction, restricted fraction, and nonrestricted fraction. Neurofunctional status was assessed by the modified Japanese Orthopedic Association, myelopathic disability index, and disabilities of the arm, shoulder, and hand. Quality-of-life was measured by the 36-Item Short Form Survey physical component summary and mental component summary. The neck disability index was used to measure self-reported neck pain. K-means clustering was applied to baseline DBSI measures to identify 3 clinically relevant CSM disease phenotypes. Baseline demographic, clinical, radiographic, and patient-reported outcome measures were compared among clusters using one-way analysis of variance (ANOVA). Twenty-three (55%) mild, 9 (21%) moderate, and 10 (24%) severe myelopathy patients were enrolled. Eight patients were excluded due to MRI data of insufficient quality. Of the remaining 42 patients, 3 groups were generated by k-means clustering. When compared with clusters 1 and 2, cluster 3 performed significantly worse on the modified Japanese Orthopedic Association and all patient-reported outcome measures (P<0.001), except the 36-Item Short Form Survey mental component summary (P>0.05). Cluster 3 also possessed the highest proportion of non-Caucasian patients (43%, P=0.04), the worst hand dynamometer measurements (P<0.05), and significantly higher intra-axonal axial diffusivity and extra-axonal fraction values (P<0.001). Using baseline imaging data, we delineated a clinically meaningful CSM disease phenotype, characterized by worse neurofunctional status, quality-of-life, and pain, and more severe imaging markers of vasogenic edema. II.

Defining "successful" treatment outcomes in adolescent idiopathic scoliosis: a scoping review.

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis that affects children aged 10-18years old, manifesting in a three-dimensional spinal deformity. This study aimed to explore outcome measures used in defining AIS treatment success. Particularly, analyzing the extent of qualitative and quantitative (radiographic and quality of life domains) measures to evaluate AIS and whether AIS treatment approaches (surgical, bracing and physiotherapy) influences outcomes used as proxies of treatment success. EMBASE and MEDLINE databases were used to conduct a systematic scoping review with 654 search queries. 158 papers met the inclusion criteria and were screened for data extraction. Extractable variables included: study characteristics, study participant characteristics, type of study, type of intervention approach and outcome measures. All 158 studies measured quantitative outcomes. 61.38% of papers used radiographic outcomes whilst 38.62% of papers used quantitative quality of life outcomes to evaluate treatment success. Irrespective of treatment intervention utilized, the type of quantitative outcome measure recorded were similar in proportion. Moreover, of the radiographic outcome measures, the subcategory Cobb angle was predominantly used across all intervention approaches. For quantitative quality of life measures, questionnaires investigating multiple domains such as SRS were primarily used as proxies of AIS treatment success across all intervention approaches. This study identified that no articles employed qualitative measures of describing the psychosocial implications of AIS in defining treatment success. Although quantitative measures have merit in clinical diagnoses and management, there is increasing value in using qualitative methods such as thematic analysis in guiding clinicians to develop a biopsychosocial approach for patient care.

Long-term adjacent segment degeneration at average 21-year follow-up of posterior instrumented fusion for adolescent idiopathic scoliosis.

Posterior instrumented fusion for progressive adolescent idiopathic scoliosis (AIS) is generally considered to have good outcomes, but very long-term reviews are rare. Data on adjacent segment degeneration (ASD) following posterior instrumented thoracic fusion for AIS are lacking. The primary aim was to assess the incidence of ASD and to correlate this with radiographic measures and patient-reported outcome measures (PROMs). The secondary aim was to assess maintenance of curve correction at very long-term follow-up. This single-surgeon consecutive case series of 47 AIS patients was identified from a prospectively collated dataset. As the primary outcome, ASD was assessed radiographically using the Mimura grading system. Pulmonary function tests and PROMs were assessed along with secondary radiographic outcome measures. Radiographic follow-up was achieved in 77% (36/47) of patients at an average of 21years (range, 16.5-26.5years) after surgery. Radiographic evidence of ASD was seen in 64%. PROMs showed a mean Oswestry disability index of 12.1% with an overall Scoliosis Research Society 22 score averaging at 3.7 out of 5. The Coronal Cobb Angle was corrected from an average of 57° preoperatively to 19° immediately postoperatively, deteriorating to 22° at final review, maintaining a 61% curve correction. Radiographic evidence of ASD was found in 64% of the cohort. The patient-reported outcome measures were good, with few limitations to activities.

Comparison of Outcomes of Scapholunate Ligament Reconstruction Techniques.

Introduction Injury to the scapholunate interosseous ligament (SLIL) is a common cause of carpal instability, yet surgical management of chronic SLIL disruption remains challenging with no optimal technique identified. Purpose The purpose of this meta-analysis was to comparatively review the available evidence of clinical, radiographic, and patient-reported outcome measures among popular techniques of SLIL reconstruction (capsulodesis, tenodesis, and bone-tissue-bone graft) to better guide management of SLIL injuries. Methods A total of 1,172 patients from 42 included studies were assessed. Standardized data extraction and analysis were performed. The mean of postoperative outcome assessments with standard deviation was used to calculate pooled standardized mean difference with 95% confidence interval. Results Visual Analog Scale (VAS) score for postoperative pain was lowest in bone-tissue-bone patients at 0.9 ( p = 0.0360). Bone-tissue-bone patients had the highest percentage of "excellent" functional outcomes at 64.5% ( p < 0.0001). Disabilities of the Arm, Shoulder, and Hand (DASH)/QuickDASH score was best in bone-tissue-bone patients at 9.7 ( p < 0.0001). Patient-Rated Wrist Evaluation (PRWE) score was best in tenodesis patients at 37.8 ( p = 0.0255). There were no statistically significant differences in grip strength, range of motion, or radiographic outcomes among the techniques. Conclusion Existing data demonstrate some benefit of bone-tissue-bone reconstruction over capsulodesis and tenodesis in pain reduction and functional improvement of the injured wrist. No statistically significant differences among radiographic outcomes could be ascertained, possibly attributable to the heterogeneity of procedures. This review provides an updated reference and highlights the need for multicenter trials with longer term follow-up and more standardized outcome measures.

Comparative study between medial displacement calcaneal osteotomy using modified step plate and arthroereisis for management of planovalgus feet

Background: Flexible flatfoot is a common condition that is characterized by hindfoot valgus with longitudinal medial-arch collapse. Many strategies for treatment have been reported but according to the current literature, controversy remains. Objectives: To compare the clinical and radiological outcomes of medializing calcaneal osteotomy utilizing modified step plate and subtalar arthroereisis utilizing conical subtalar implant for patients with symptomatic flexible pes planus. Methods: A prospective, randomized, double center study was conducted between May 2017 and May 2019 at the Foot and Ankle Department of Cairo University Hospital and El Sahel Teaching Hospital on 26 patients (37 feet) with flexible flat feet to compare between medial displacement calcaneal osteotomy using modified locked step plate (group A) compromising 17 feet and arthroereisis using subtalar implant (group B) compromising 20 feet. Results: By the end period of the study, 25 males and 12 females were available for our analysis of results with a mean follow-up period of 10.14 months (range 7–14 months), clinical scoring (American Orthopaedic Foot and Ankle Society score, Foot Functional Index) with radiological analysis revealed a non-significant difference between both groups, the overall complication rate was 16.2%. Conclusion: Both medial displacement calcaneal osteotomy and subtalar arthroereisis significantly improved radiographic and subjective clinical outcome measures in the surgical treatment of painful flexible planovalgus feet. The less-invasive nature and lower potential morbidity suggest that judicious use of arthroereisis implants is an appropriate alternative.

Functional and Radiologic Outcomes Following Fifth Metatarsal Fracture Non-Operative Treatment: A Retrospective Chart Review with Application of the RUST Score From 2019-2021

Category: Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: Fifth metatarsal fractures are a common injury of the foot, however, there remains a lack of consensus regarding the management of Zone I and II fifth metatarsal fractures. The evidence shows varied outcomes between operative management and non-operative interventions. Additionally, there is limited discussion on radiographic outcomes following these fractures, with no established scoring system to assess radiographic healing. The radiographic union scale in tibial (RUST) fractures is an assessment tool designed to standardize radiographic assessment and outcome measures based on cortical bridging. The aim of this study is to assess the functional and radiologic outcomes for patients with base of fifth metatarsal fractures (Zone I-III) utilizing the RUST score as a method for standardized assessment of radiographic healing. Methods: We performed a secondary retrospective chart review of patients with base of fifth metatarsal fractures treated by six orthopedic surgeons at University of Colorado Orthopaedics from 2018-2021. We collected information on treatment modality and the functional, radiographic, and patient reported outcomes. Patients were included who attended minimum two visits and had x-ray available. The x-rays were read by a fellowship trained foot and ankle surgeon, and were assessed based on presence of displacement, resorption, and overall healing. The RUST scoring system was applied when fracture appeared healed and assessed on the four cortices (anterior, posterior, medial, and lateral) of the 5th metatarsal bone by assigning a score from 1 to 3 based on appearance. The scores were combined for a minimum of 4 (not healed) and a maximum of 12 (completely healed). Differences between outcomes were evaluated using an unpaired t-test and figures are reported with standard error. Results: Out of 196 total patients, 109 were excluded due to shaft fracture or insufficient follow-up, leaving 87 non-operative patients with base of fifth metatarsal fractures available for analysis. Radiographically, the average time to resorption was 37 days and average time to healing was 98 days, which was significantly longer than when patients began weight bearing at 44 days (p&lt;0.001), but not significantly different than return to normal shoe wearing at 75 days (p=0.077). While 96% of patients at visit 4 were weight bearing and wearing normal shoes, only 73% had radiographic healing. The average RUST score at visit 2 was 10.14 (n=21) improving to 10.5 (n=12) by visit 4. To note, only 30% of patients presented for all four visits and the average final follow- up was 106 days after injury. Conclusion: Patients treated non-operatively for base of fifth metatarsal fractures have significantly shorter timelines for functional healing compared to evidence of radiographic healing. Overall RUST score at visit 4 supports those patients did not reach full cortical healing as the average score was 10.5 out of 12 possible points. Most patients have signs of resorption on x-ray by their second visit, but many do not continue follow up for complete evidence of healing. This highlights the importance of functional healing in treatment decisions for Zone I and II fractures and overall good prognosis regardless of complete healing radiographically.

Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: Case Series With an Operative Video Using Fluoroscopy-Based Instrument Tracking Guidance.

Lateral lumbar interbody fusion has inherent limitations, such as the necessity to reposition the patient. To overcome this limitation, the prone transpsoas (PTP) approach for lateral lumbar interbody fusion has been developed. To report clinical and radiographic outcome measures of a series of patients who underwent PTP at our hospital. A retrospective chart review was conducted to identify patients who underwent PTP for degenerative lumbar spine disease between September 2019 and August 2021. A thorough analysis of clinical and radiographic outcome measures for these patients was conducted. Our search resulted in the identification of 15 consecutive patients. Four patients were operated using the assistance of fluoroscopy-based instrument tracking. Overall, the mean follow-up duration was 11.9 ± 7.9 months. Radiographically, the PTP approach resulted in significant postoperative improvement of lumbar lordosis ( P = .03) and pelvic incidence minus lumbar lordosis ( P &lt; .005). No significant difference was found postoperatively in other regional sagittal alignment parameters, including pelvic tilt, sacral slope, or pelvic incidence. Clinically, the patients' Oswestry Disability Indices ( P = .002) and Short Form Survey-12 Physical Scores improved significantly ( P = .01). The estimated mean blood loss for patients who underwent the PTP procedure was 137.7 ± 96.4 mL, the mean operative time was 212.5 ± 77.1 minutes, and the mean hospital stay was 2.7 ± 1.4 days. One patient each had superficial wound infection, transient paralytic ileus, transient pulmonary embolism, transient urinary retention, or required revision lumbar surgery. This study demonstrates that the PTP approach is associated with significant improvement in radiographic and clinical outcomes.

Reliability of acetabular index measurement in developmental dysplasia of the hip screening by orthopaedic trainees: a comparative study

Background: Radiographic measurements are used for screening of developmental dysplasia of the hip (DDH) in children. The ability to detect acetabular dysplasia requires validated radiographic outcome measures. The acetabular index (AI) measurement has been shown to be a reliable measure worldwide. This study aims to test the reliability of the AI measurement in a DDH screening population by orthopaedic junior and senior residents. Methods: The review examined 470 radiographs taken during 4 yr (2016-2019) in a university hospital. AI measurement was performed by two surgeons, four senior residents, and four junior residents at three different times. The intraobserver and interobserver reliability for each group was assessed. Results: The intraobserver reliability intraclass correlation coefficient (ICC) for the AI measurement performed by seniors was excellent at 0.98 (confidence interval [CI] 0.98 to 0.99) for the right side and 0.99 (CI 0.98 to 0.99) for left side. Indistinguishably, the ICC for AI measurement performed by orthopaedic juniors for right and left side was excellent at 0.96 (CI 0.95 to 0.97) and 0.95 (CI 0.95 to 0.96), respectively. The overall ICCs for interobserver reliability for the AI measurement between professors, seniors, and juniors for right and left side was between good and excellent at 0.89 (CI 0.87 to 0.90) and 0.89 (CI 0.87 to 0.91), respectively. Conclusions: Orthopaedic juniors are less reliable in terms of intraobserver and interobserver variability in detecting DDH in screening program in comparison with seniors using AI measurement in a pediatric orthopaedic clinic. Level of Evidence: Level III.

Intra-articular Calcaneal Fracture Treatment With Staged Medial External Fixation.

To compare the clinical and radiographic outcomes between the conventional delayed and staged approaches for intra-articular calcaneus fractures in which early definite fixation could not be performed because of severe soft tissue injury. From January 2015 to May 2019, a total of 32 cases with acute intra-articular calcaneal fractures met criteria and were enrolled in the study. We compared the outcomes of intra-articular calcaneal fractures that underwent delayed internal fixation between groups treated with a conventional delayed approach (non-EF group) vs a temporary medial external fixation (EF group). Clinical outcome measures included a 10-point visual analog scale score, the AOFAS score, and the Foot Function Index. Radiographic outcome measures included Böhler angle, talar declination angle, and calcaneal width. Reduction of the posterior facet was assessed on CT scans. The first 15 (46.9%) were treated with a conventional delayed approach, and the latter 17 (53.1%) were treated with a staged approach with temporary medial external fixation. Clinical outcomes were not different between the groups at the last follow-up. The time from injury to definite internal fixation was shorter by an average of 3.8 days in the EF group (P = .001). The Böhler angle, talar declination angle, and calcaneal width were not different between the groups before surgery and at the last follow-up. Reduction of the posterior facet on CT scans was significantly better in the EF group than in the non-EF group (good/excellent = 94% vs 60%, respectively, P = .033). The staged approach using medial external fixation for displaced intra-articular calcaneus fractures could be an effective method to decrease the time to definitive internal fixation and obtain optimal reduction of the posterior facet. Level III, retrospective case-control study.

Radiographic and clinical outcomes of minimally invasive surgery versus open osteotomies for the correction of hallux valgus.

Hallux valgus is a common disease which causes pain and dysfunction of the foot. Although numerous methods of procedures have been introduced, a single procedure cannot correct all deformities of hallux valgus. The study aims to evaluate the radiographic and clinical effectiveness of a new minimally invasive surgery (MIS) versus open Chevron-Akin procedures. This was a retrospective comparative study. Data were collected from May 2018 to January 2020. A total of 27 patients (31 feet) undergoing MIS for hallux valgus were included in this study. The average age of patients underwent MIS was 59.9years. The mean follow-up was 25.1months. Open osteotomies were performed in 30 patients (31 feet) during the same period. The mean age of these patients at the time of surgery was 59.1years. The mean follow-up was 26.1months. Pre-operative and post-operative radiographic outcome measures included HVA, IMA, DMAA, the Sgarlato's angle and the length of the first metatarsal, and distance between the dorsal cortex of first and second metatarsal necks. The AOFAS and VAS were used to assess foot function. The preoperative HVA in MIS group and open group were 34.8° and 33.1° respectively. The post-operative HVA were 20.4° and 13.7°. The pre-operative IMA in MIS group and open group were 13.0° and 12.1°. The post-operative IMA were 11.4° and 5.5° respectively. The pre-operative DMAA were 14.8° and 15.1° respectively. The post-operative DMAA were 6.3° and 8.7°. The AOFAS increased from 44.0 to 90.2 in MIS group and from 47.6 to 89.5 in open group. The VAS decreased from 7.3 to 1.3 in MIS group and from 7.1 to 1.2 in open group. Although open osteotomies were superior than MIS in HVA and IMA, MIS showed advantages in correcting DMAA. MIS provided equivalent functional outcomes compared to open surgery.

Distalization of the Tibial Tubercle for Patellar Stabilization Combined With Medial Patellofemoral Ligament Reconstruction: Length of Distalization or Residual Patella Alta and its Affect on Outcome

Background: Previous research supports that distal translation of the tibial tubercle osteotomy (dTTO) for patients with recurrent lateral patellar dislocation (R-LPD) and patella alta is effective for surgical patellar stabilization. Hypothesis/Purpose: The main purpose of this article is to evaluate (1) the results of modifying the surgical threshold and postoperative goal of patellar height measurements for surgical stabilization originated in the “menu à la carte” approach to patellar surgical stabilization and (2) the relationship between the distance distalized in millimeters and postoperative complications. Our hypothesis was that dTTO with medial patellofemoral ligament reconstruction (MPFL-R) will successfully stabilize the patella with improvement in outcome scores and few complications, using a modification of the original menu à la carte as our surgical algorithm. Study Design: Case series; Level of evidence, 4. Methods: A total of 68 consecutive patients with R-LPD underwent dTTO and MPFL-R for surgical patellar stabilization by a single surgeon between May 2009 and September 2015. Surgical indications were R-LPD combined with patella alta. The surgical threshold for dTTO was Caton-Deschamps index (CDI) or Insall-Salvati ratio ≥1.4 and/or a patellar trochlear index <0.15. The postoperative surgical goal for patellar height was a CDI of 1.1 to 1.2. Length of the distalization was computed by using the CDI measurement as the primary intraoperative guide and measured intraoperatively with a ruler. Clinical, radiographic, and patient outcome measures were reviewed. Results: The mean CDI preoperatively was 1.40 and postoperatively it was 1.09. The mean distalization was 9.9 mm (range, 4-15 mm). Three patients (4.4%) had frank R-LPD postoperatively. Ten patients had residual patella alta (CDI >1.2), with 1 redislocation. Mean postoperative CDI in the recurrent dislocation group was 1.13 (range, 1.06-1.25) as compared with 1.09 (range, 0.92-1.35) in the nonrecurrent group (P = 0.65). Complications included 3 tibial fractures (4.4%) and postoperative knee arthrofibrosis in 6 patients (8.8%), with mean distalization greater in the arthrofibrosis group (P = .04). Knee injury and Osteoarthritis Outcome Score (KOOS) values improved in all domains, including a 31–point increase in Quality of Life. Conclusion: dTTO with MPFL-R for patients with patella alta leads to a high rate of normalization of patellar height measurements (87%) and patellar stabilization (95.6%). Residual patella alta is not associated with an increased risk of recurrence. The length of dTTO up to 15 mm is not associated with an increase in postoperative complications, except for an increased prevalence of arthrofibrosis (8.8%).

Endodontic pulp revitalization in traumatized necrotic immature permanent incisors: Early failures and long-term outcomes-A longitudinal cohort study.

AimThis prospective cohort study evaluates clinical and radiographical outcomes of endodontic pulp revitalization (PR) of traumatized necrotic incisors.MethodologyPulp revitalization was performed in 75 traumatized necrotic immature incisors from 71 patients. The radiographic outcome measures were continued root formation (width and length), root resorption, apex closure, periapical index, and root development stage. The clinical outcome measures were percussion pain, palpation pain, pathological tooth mobility, swelling, sinus tract, ankylosis, crown discolouration, response to pulp sensitivity test, and subjective pain. Treatment outcomes were categorized as a success based on the absence of clinical symptoms and when radiographic evidence was present for apical healing and continued root development. The performed statistical tests were repeated measures anova, pairwise comparisons of interactions (t‐test), McNemar's test, and linear regression model.ResultsIn 45 of 75 teeth (60%), PR was successful with the resolution of clinical and radiographic signs and continued root development. PR failed due to the absence of bleeding (n = 19) and persistent infection (n = 11). PR showed statistically significant increases in root length (11%), and dentinal wall thickness (30%), root maturation (pre‐operative 3.38 [CI 1.88; 4.88]; post‐operative 4.04, [CI 2.56; 5.52]) apical closure (71.4%), healing of pre‐operative apical periodontitis (100%), and healing of pre‐operative inflammatory root resorptions (100%). Three predictive variables for continued root maturation were identified – root development stage at entry (p = .0001, β 0.649), [CI 0.431; 0.867], trauma to the soft tissues (p = .026, β −0.012), [CI −0.0225; −0.015], and pre‐operative dentinal wall thickness (p = .009, β −0.001); [CI −0.001; 0.0001].ConclusionsOur findings indicate that PR provides satisfactory clinical and radiographical outcomes in traumatized necrotic incisors. The failed cases were related to lack of bleeding and persistent infections, indicating that new techniques are needed to improve the predictability of PR.

Adult Isthmic Spondylolisthesis: A Radiographic and Outcomes Analysis Comparing Circumferential Fusions Versus TLIF Procedures.

This was a retrospective cohort study. The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS). Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique. Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set at P -value &lt;0.05. A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) ( P =0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99, P &lt;0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm, P &lt;0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm, P &lt;0.001). Both groups significantly improved in all PROMs ( P &lt;0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%, P =0.049), there was no difference in the rate of 30-day readmissions ( P =0.520) or revision surgeries between techniques ( P =0.057). Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions.

111 Comparison of Hounsfield Units Versus T-Score in Predicting Postoperative Proximal Junctional Kyphosis

INTRODUCTION: Vertebral body (VB) bone quality is generally estimated indirectly via femoral neck dual-energy x-ray absorptiometry (DEXA) to counsel patients on their risk for development of proximal junctional kyphosis (PJK) after thoraco-lumbar fusion for adult spinal deformity. It is currently unknown whether direct measurement of VB bone quality through Hounsfield unit analysis (HUs) can successfully stratify patients on their risk of delayed complications. METHODS: 108 patients who underwent surgery for ASD were enrolled. Demographic characteristics, radiologic measurements, complication profile, and clinical outcomes were recorded both pre- and post-operatively. A Youden J-statistic was calculated based on an ROC analysis of the UIV Hounsfield unit data to give a single HU threshold to segregate patients into either a high or low HU group. Patient groups were then compared with respect to the mentioned clinical and radiographic outcome measures. RESULTS: Youden statistic revealed a HU threshold value of 126.8 for maximal group stratification. Significant change in proximal junctional cobb angle (PJCA) was observed between the low and high HU groups at one and two years (p &lt; 0.0001 and p = 0.0001 respectively). This was not similarly seen in hip or spine DEXA analysis (p &gt; 0.05). CONCLUSION: Assessment of bone quality via pre-operative measurement of the UIV VB HU can predict post-operative changes in PJCA. UIV HUs &lt; 126.8 are associated with 2.8x elevated risk of developing post-operative PJK. Current standard of care measurement of bone quality via femoral neck DEXA is of more limited utility compared to HU analysis.