Showing papers in "Journal of Bone and Joint Surgery, American Volume in 2013"

Periprosthetic Joint Infection Increases the Risk of One-Year Mortality

Abstract: Background: Periprosthetic joint infection continues to potentially complicate an otherwise successful joint replacement. The treatment of this infection often requires multiple surgical procedures associated with increased complications and morbidity. This study examined the relationship between periprosthetic joint infection and mortality and aimed to determine the effect of periprosthetic joint infection on mortality and any predictors of mortality in patients with periprosthetic joint infection. Methods: Four hundred and thirty-six patients with at least one surgical intervention secondary to confirmed periprosthetic joint infection were compared with 2342 patients undergoing revision arthroplasty for aseptic failure. The incidence of mortality at thirty days, ninety days, one year, two years, and five years after surgery was assessed. Multivariate analysis was used to assess periprosthetic joint infection as an independent predictor of mortality. In the periprosthetic joint infection population, variables investigated as potential risk factors for mortality were evaluated. Results: Mortality was significantly greater (p < 0.001) in patients with periprosthetic joint infection compared with those undergoing aseptic revision arthroplasty at ninety days (3.7% versus 0.8%), one year (10.6% versus 2.0%), two years (13.6% versus 3.9%), and five years (25.9% versus 12.9%). After controlling for age, sex, ethnicity, number of procedures, involvedjoint,bodymassindex,andCharlsonComorbidityIndex,revisionarthroplastyforperiprostheticjointinfectionwas associated with a fivefold increase in mortality compared with revision arthroplasty for aseptic failures. In the periprosthetic joint infection population, independent predictors of mortality included increasing age, higher Charlson Comorbidity Index, history of stroke, polymicrobial infections, and cardiac disease. Conclusions: Although it is well known that periprosthetic joint infection is a devastating complication that severely limits joint function and is consistently difficult to eradicate, surgeons must also be cognizant of the systemic impact of periprosthetic joint infection and its major influence on fatal outcome in patients. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees.

Abstract: Background: Deep surgical site infection following total knee arthroplasty is a devastating complication. Patient and surgical risk factors for this complication have not been thoroughly examined. The purpose of this study was to evaluate risk factors associated with deep surgical site infection following total knee arthroplasty in a large U.S. integrated health-care system. Methods: A retrospective review of a prospectively followed cohort of primary total knee arthroplasties recorded in a total joint replacement registry from 2001 to 2009 was conducted. Records were screened for deep surgical site infection with use of a validated algorithm, and the results were adjudicated by chart review. Patient factors, surgical factors, and surgeon and hospital characteristics were identified with use of the total joint replacement registry. Cox regression models were used to assess risk factors associated with deep surgical site infection. Results: A total of 56,216 total knee arthroplasties were identified; 63.0% were done in women, the average age of the patients was 67.4 years (standard deviation [SD] = 9.6), and the average body mass index (BMI) was 32 kg/m2 (SD = 6). The incidence of deep surgical site infection was 0.72% (404/56,216). In a fully adjusted model, patient factors associated with deep surgical site infection included a BMI of ≥35 (hazard ratio [HR] = 1.47), diabetes mellitus (HR = 1.28), male sex (HR = 1.89), an American Society of Anesthesiologists (ASA) score of ≥3 (HR = 1.65), a diagnosis of osteonecrosis (HR = 3.65), and a diagnosis of posttraumatic arthritis (HR = 3.23). Hispanic race was protective (HR = 0.69). Protective surgical factors included use of antibiotic irrigation (HR = 0.67), a bilateral procedure (HR = 0.51), and a lower annual hospital volume (HR = 0.33). Surgical risk factors included quadriceps-release exposure (HR = 4.76) and the use of antibiotic-laden cement (HR = 1.53). In a subanalysis, operative time was a risk factor, with a 9% increased risk per fifteen-minute increment. Conclusions: Use of a comprehensive infection surveillance system, combined with a total joint replacement registry, identified patient and surgical factors associated with infection following total knee arthroplasty in a large sample. High-risk patients should be counseled, and modifiable clinical conditions should be optimized. Use of antibiotic irrigation should be encouraged, but antibiotic-laden cement may not be useful. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Estimating the Burden of Total Knee Replacement in the United States

Abstract: Background: In the last decade, the number of total knee replacements performed annually in the United States has doubled, with disproportionate increases among younger adults. While total knee replacement is a highly effective treatment for end-stage knee osteoarthritis, total knee replacement recipients can experience persistent pain and severe complications. We are aware of no current estimates of the prevalence of total knee replacement among adults in the U.S. Methods: We used the Osteoarthritis Policy Model, a validated computer simulation model of knee osteoarthritis, and data on annual total knee replacement utilization to estimate the prevalence of primary and revision total knee replacement among adults fifty years of age or older in the U.S. We combined these prevalence estimates with U.S. Census data to estimate the number of adults in the U.S. currently living with total knee replacement. The annual incidence of total knee replacement was derived from two longitudinal knee osteoarthritis cohorts and ranged from 1.6% to 11.9% in males and from 2.0% to 10.9% in females. Results: We estimated that 4.0 million (95% confidence interval [CI]: 3.6 million to 4.4 million) adults in the U.S. currently live with a total knee replacement, representing 4.2% (95% CI: 3.7% to 4.6%) of the population fifty years of age or older. The prevalence was higher among females (4.8%) than among males (3.4%) and increased with age. The lifetime risk of primary total knee replacement from the age of twenty-five years was 7.0% (95% CI: 6.1% to 7.8%) for males and 9.5% (95% CI: 8.5% to 10.5%) for females. Over half of adults in the U.S. diagnosed with knee osteoarthritis will undergo a total knee replacement. Conclusions: Among older adults in the U.S., total knee replacement is considerably more prevalent than rheumatoid arthritis and nearly as prevalent as congestive heart failure. Nearly 1.5 million of those with a primary total knee replacement are fifty to sixty-nine years old, indicating that a large population is at risk for costly revision surgery as well as possible long-term complications of total knee replacement. Clinical Relevance: These prevalence estimates will be useful in planning health services specific to the population living with total knee replacement.

Societal and Economic Impact of Anterior Cruciate Ligament Tears

Abstract: Background: An anterior cruciate ligament (ACL) tear is a common knee injury, particularly among young and active individuals. Little is known, however, about the societal impacts of ACL tears, which could be large given the typical patient age and increased lifetime risk of knee osteoarthritis. This study evaluates the cost-effectiveness of ACL reconstruction compared with structured rehabilitation only. Methods: A cost-utility analysis of ACL reconstruction compared with structured rehabilitation only was conducted with use of a Markov decision model over two time horizons: the short to intermediate term (six years), on the basis of Level-I evidence derived from the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database; and the lifetime, on the basis of a comprehensive literature review. Utilities were assessed with use of the SF-6D. Costs (in 2012 U.S. dollars) were estimated from the societal perspective and included the effects of the ACL tear on work status, earnings, and disability. Effectiveness was expressed as quality-adjusted life years (QALYs) gained. Results: In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a QALY gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation. Conclusions: ACL reconstruction is the preferred cost-effective treatment strategy for ACL tears and yields reduced societal costs relative to rehabilitation once indirect cost factors, such as work status and earnings, are considered. The cost of an ACL tear over the lifetime of a patient is substantial, and resources should be directed to developing innovations for injury prevention and for altering the natural history of an ACL injury.

Efficacy and Safety of Surgical Decompression in Patients with Cervical Spondylotic Myelopathy: Results of the AOSpine North America Prospective Multi-Center Study

Abstract: Background: Cervical spondylotic myelopathy is the leading cause of spinal cord dysfunction worldwide. The objective of this study was to evaluate the impact of surgical decompression on functional, quality-of-life, and disability outcomes at one year after surgery in a large cohort of patients with this condition. Methods: Adultpatientswithsymptomaticcervicalspondyloticmyelopathyandmagneticresonanceimagingevidenceof spinal cord compression were enrolled at twelve North American centers from 2005 to 2007. At enrollment, the myelopathy was categorized as mild (modified Japanese Orthopaedic Association [mJOA] score ‡ 15), moderate (mJOA = 12 to 14), or severe (mJOA < 12). Patients were followed prospectively for one year, at which point the outcomes of interest included the mJOA score, Nurick grade, Neck Disability Index (NDI), and Short Form-36 version 2 (SF-36v2). All outcomes at one year were compared with the preoperative values with use of univariate paired statistics. Outcomes were also compared among the severity classes with use of one-way analysis of variance. Finally, a multivariate analysis that adjusted for baseline differences among the severity groups was performed. Treatment-related complication data were collected and the overall complication rate was calculated. Results: Eighty-five (30.6%) of the 278 enrolled patients had mild cervical spondylotic myelopathy, 110 (39.6%) had moderate disease, and 83 (29.9%) had severe disease preoperatively. One-year follow-up data were available for 222 (85.4%) of 260 patients. There was a significant improvement from baseline to one year postoperatively (p < 0.05) in the mJOA score, Nurick grade, NDI score, and all SF-36v2 health dimensions (including the mental and physical health composite scores) except general health. With the exception of the change in the mJOA, the degree of improvement did not depend on the severity of the preoperative symptoms. These results remained unchanged after adjusting for relevant confounders in the multivariate analysis. Fifty-two patients experienced complications (prevalence, 18.7%), with no significant differences among the severity groups. Conclusions: Surgical decompression for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality-of-life outcomes at one year of follow-up for all disease severity categories. Furthermore, complication rates observed in the study were commensurate with those in previously reported cervical spondylotic myelopathy series. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial.

Abstract: Background: There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment. Methods: In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed. Results: The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001). Conclusions: Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Adverse Local Tissue Reaction Arising from Corrosion at the Femoral Neck-Body Junction in a Dual-Taper Stem with a Cobalt-Chromium Modular Neck

Abstract: Background: Femoral stems with dual-taper modularity were introduced to allow additional options for hip-center restoration independent of femoral fixation in total hip arthroplasty. Despite the increasing availability and use of these femoral stems, concerns exist about potential complications arising from the modular neck-body junction. Methods: This was a multicenter retrospective case series of twelve hips (eleven patients) with adverse local tissue reactions secondary to corrosion at the modular neck-body junction. The cohort included eight women and three men who together had an average age of 60.1 years (range, forty-three to seventy-seven years); all hips were implanted with a titanium-alloy stem and cobalt-chromium-alloy neck. Patients presented with new-onset and increasing pain at a mean of 7.9 months (range, five to thirteen months) following total hip arthroplasty. After serum metal-ion studies and metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) revealed abnormal results, the patients underwent hip revision at a mean of 15.2 months (range, ten to twenty-three months). Tissue specimens were examined by a single histopathologist, and the retrieved implants were studied with use of light and scanning electron microscopy. Results: Serum metal levels demonstrated greater elevation of cobalt (mean, 6.0 ng/mL) than chromium (mean, 0.6 ng/mL) or titanium (mean, 3.4 ng/mL). MRI with use of MARS demonstrated adverse tissue reactions in eight of nine patients in which it was performed. All hips showed large soft-tissue masses and surrounding tissue damage with visible corrosion at the modular femoral neck-body junction. Available histology demonstrated large areas of tissue necrosis in seven of ten cases, while remaining viable capsular tissue showed a dense lymphocytic infiltrate. Microscopic analysis was consistent with fretting and crevice corrosion at the modular neck-body interface. Conclusions: Corrosion at the modular neck-body junction in dual-tapered stems with a modular cobalt-chromium-alloy femoral neck can lead to release of metal ions and debris resulting in local soft-tissue destruction. Adverse local tissue reaction should be considered as a potential cause for new-onset pain in patients with these components, and early revision should be considered given the potentially destructive nature of these reactions. A workup including serologic studies (erythrocyte sedimentation rate and C-reactive protein), serum metal levels, and MARS MRI can be helpful in establishing this diagnosis. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.

Abstract: Background: Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias. Results: The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty. Conclusions: Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reverse Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis in Patients with a Biconcave Glenoid

Abstract: Background: The biconcave glenoid in patients with primary glenohumeral osteoarthritis represents a surgical challenge because of the associated static posterior instability of the humeral head and secondary posterior glenoid erosion. The purpose of the present study was to evaluate the clinical and radiographic results of reverse total shoulder arthroplasty for the treatment of primary osteoarthritis in patients with a biconcave glenoid without rotator cuff insufficiency. Methods: We performed a retrospective review of twenty-seven reverse shoulder arthroplasties that were performed from 1998 to 2009 for the treatment of primary glenohumeral osteoarthritis and biconcave glenoid. Eighty-one percent of the patients were female, and the mean age of the patients at the time of surgery was 74.1 years (range, sixty-six to eighty-two years). All patients had a preoperative computed tomography arthrogram to allow for the measurement of glenoid retroversion and humeral head subluxation. The mean preoperative retroversion was 32°, and the mean subluxation of the humeral head with respect to the scapular axis was 87%. Seventeen patients had a reverse shoulder arthroplasty without bone graft, whereas ten had an associated bone graft to compensate for posterior glenoid erosion. Clinical outcomes were evaluated with the Constant score and shoulder range of motion. Results: The mean duration of follow-up was fifty-four months (range, twenty-four to 139 months). The mean Constant score increased from 31 points preoperatively to 76 points at the time of the latest follow-up (p < 0.0001). Active forward flexion, external rotation, and internal rotation also significantly increased (p < 0.0001). Complications occurred in four patients (15%) and included early loosening of the glenoid component (one patient) and neurologic complications (three patients). No radiolucent lines were observed around the central peg or screws of the glenoid component. Grade-1 or 2 scapular notching was present in ten shoulders (37%). No recurrence of posterior instability was observed. Conclusions: Reverse shoulder arthroplasty for the treatment of primary glenohumeral osteoarthritis in patients with a biconcave glenoid without rotator cuff insufficiency can result in excellent clinical outcomes. Reverse shoulder arthroplasty is a viable surgical option to solve both the problem of severe static posterior glenohumeral instability and severe glenoid erosion. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Societal and Economic Value of Rotator Cuff Repair

Abstract: Approximately 4.5 million patient visits related to shoulder pain occur each year in the United States1. Disorders of the rotator cuff range from painful rotator cuff syndromes to full-thickness tears of varying sizes and functional limitations2. Outcomes for rotator cuff tears improve with both surgical and nonsurgical treatment3. With the aging of the U.S. population and increased labor force participation of the elderly, the burden of rotator cuff tears in the U.S. is an important issue. Using outpatient data from Colorado, Florida, Maryland, New Jersey, New York, and Wisconsin in the State Ambulatory Surgery Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we find that more than two-thirds of patients treated with rotator cuff repair are of working age4. In addition, the prevalence of rotator cuff tears increases with age5. Despite these factors, few studies have examined the burden of rotator cuff tears and the economic impact of treatment is largely unknown. Societal costs of a medical condition include direct and indirect costs. Direct costs are those associated with diagnosis and treatment, while indirect costs include lost income due to inability to work or lower wages, missed workdays, and disability payments. The purpose of this study was to determine the value of operative treatment for rotator cuff tears, with value determined by reductions in costs to society from rotator cuff repair compared with nonoperative treatment. Markov models are commonly used in cost-effectiveness analysis. In assessing the value of rotator cuff repair, these models are useful because long-term clinical studies do not exist and the risk of an outcome is continuous over time. By taking a societal perspective, we estimated the costs and benefits of rotator cuff repair to patients, employers, and payers.

Comparison of Hemiarthroplasty and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures in Elderly Patients

Abstract: Background: Treatment of complex three and four-part proximal humeral fractures with hemiarthroplasty in elderly patients has yielded mixed clinical results Reverse shoulder arthroplasty has emerged as a treatment option for comminuted proximal humeral fractures for these patients The purpose of the study was to perform a prospective evaluation of patient outcomes comparing hemiarthroplasty and reverse shoulder arthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients Methods: Fifty-three consecutive elderly patients (average age, 744 years) underwent an arthroplasty for a complex proximal humeral fracture Indications for arthroplasty were four-part fractures, three-part fractures with severe comminution of the greater tuberosity, and fractures that involved an articular split of the humeral head Twenty-six patients underwent hemiarthroplasty (the HA group), followed by twenty-seven patients who underwent reverse shoulder arthroplasty (the RSA group) A total of forty-seven patients (twenty-three in the HA group and twenty-four in the RSA group) were available for follow-up at a minimum of two years Results: Final average outcome scores were lower in the HA group than in the RSA group (American Shoulder and Elbow Surgeons [ASES] score of 62 versus 77 [p = 00001] and Simple Shoulder Test [SST] of 58 versus 74 [p = 00062]), and patient-reported satisfaction was lower in the HA group than in the RSA group (61% versus 91%; p = 0038) Radiographic healing of the tuberosities occurred in 61% of the patients in the HA group compared with 83% of the patients in the RSA group (p = 017) Forward elevation of the arm was higher in the RSA group (139°) than in the HA group (100°) (p = 00002), but no significant differences were observed for shoulder external rotation or internal rotation Complication rates in both groups were similar Three patients (13%) in the HA group elected revision to reverse shoulder arthroplasty because of failed tuberosity healing and resultant shoulder pseudoparesis Conclusions: In this series, reverse shoulder arthroplasty resulted in better clinical outcomes and a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the elderly Level of Evidence: Therapeutic Level II See Instructions for Authors for a complete description of levels of evidence

The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma.

Abstract: Background: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. Methods: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. Results: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. Conclusions: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition.

Abstract: The AAOS Evidence-Based Guideline on Treatment of Osteoarthritis of the Knee, 2nd Edition, includes only less-invasive alternatives to knee replacement. This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines. ### Conservative Treatments: Recommendations 1-6 #### RECOMMENDATION 1 We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. Strength of Recommendation: Strong #### RECOMMENDATION 2 We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥25. Strength of Recommendation: Moderate #### RECOMMENDATION 3A We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of …

Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: long-term results at a minimum follow-up of ten years.

Abstract: Background: Transfer of the latissimus dorsi tendon to the greater tuberosity of the humerus for treatment of an irreparable rotator cuff tear has been reported to yield good-to-excellent short to intermediate-term results in well-selected patients. The purpose of this study was to evaluate the long-term outcome of such transfers for irreparable posterosuperior rotator cuff tears to determine the durability of the results and to identify risk factors for an unfavorable outcome. Methods: Fifty-seven shoulders in fifty-five patients (seventeen women and thirty-eight men with a mean age of fifty-six years) were managed with latissimus dorsi tendon transfer. Final follow-up was performed at a mean of 147 months. Outcome measures included the Constant score and the Subjective Shoulder Value (SSV). Osteoarthritis, the acromiohumeral distance, and the so-called critical shoulder angle were assessed on standardized radiographs. Results: Forty-six shoulders in forty-four patients were available at the time of final follow-up. The mean SSV increased from 29% preoperatively to 70% at the time of final follow-up, the relative Constant score improved from 56% to 80%, and the pain score improved from 7 to 13 points (p < 0.0001 for all). Mean flexion increased from 118° to 132°, abduction increased from 112° to 123°, and external rotation increased from 18° to 33°. Mean abduction strength increased from 1.2 to 2.0 kg (p = 0.001). There was a slight but significant increase in osteoarthritic changes. Inferior results occurred in shoulders with insufficiency of the subscapularis muscle and fatty infiltration of the teres minor muscle. Superior functional results were observed in shoulders with a small postoperative critical shoulder angle. Conclusions: Latissimus dorsi tendon transfer offered an effective treatment for irreparable posterosuperior rotator cuff tears, with substantial and durable improvements in shoulder function and pain relief. Shoulders with fatty infiltration of the teres minor muscle and insufficiency of the subscapularis muscle tended to have inferior results, as did those with a large critical shoulder angle. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the Spine Patient Outcomes Research Trial (SPORT).

Abstract: Background: Questions remain as to the effect that obesity has on patients managed for symptomatic lumbar disc herniation The purpose of this study was to determine if obesity affects outcomes following the treatment of symptomatic lumbar disc herniation Methods: An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial for the treatment of lumbar disc herniation A comparison was made between patients with a body mass index of <30 kg/m2 (nonobese) (n = 854) and those with a body mass index of ≥30 kg/m2 (obese) (n = 336) Baseline patient demographic and clinical characteristics were documented Primary and secondary outcomes were measured at baseline and at regular follow-up time intervals up to four years The difference in improvement from baseline between operative and nonoperative treatment was determined at each follow-up period for both groups Results: At the time of the four-year follow-up evaluation, improvements over baseline in primary outcome measures were significantly less for obese patients as compared with nonobese patients in both the operative treatment group (Short Form-36 physical function, 373 compared with 477 points [p < 0001], Short Form-36 bodily pain, 442 compared with 500 points [p = 0005], and Oswestry Disability Index, −337 compared with −401 points [p < 0001]) and the nonoperative treatment group (Short Form-36 physical function, 231 compared with 320 points [p < 0001] and Oswestry Disability Index, −214 compared with −261 points [p < 0001]) The one exception was that the change from baseline in terms of the Short Form-36 bodily pain score was statistically similar for obese and nonobese patients in the nonoperative treatment group (309 compared with 334 points [p = 039]) At the time of the four-year follow-up evaluation, when compared with nonobese patients who had been managed operatively, obese patients who had been managed operatively had significantly less improvement in the Sciatica Bothersomeness Index and the Low Back Pain Bothersomeness Index, but had no significant difference in patient satisfaction or self-rated improvement In the present study, 775% of obese patients and 869% of nonobese patients who had been managed operatively were working a full or part-time job No significant differences were observed in the secondary outcome measures between obese and nonobese patients who had been managed nonoperatively The benefit of surgery over nonoperative treatment was not affected by body mass index Conclusions: Obese patients realized less clinical benefit from both operative and nonoperative treatment of lumbar disc herniation Surgery provided similar benefit over nonoperative treatment in obese and nonobese patients Level of Evidence: Prognostic Level II See Instructions for Authors for a complete description of levels of evidence

The stabilizing mechanism of the Latarjet procedure: a cadaveric study.

Abstract: Background: The Latarjet procedure has been used commonly for extra-articular treatment of anterior glenohumeral joint instability. Recently, the technique also has been used as a bone-grafting procedure to repair large glenoid defects. The “sling effect” and the “bone-block effect” have been proposed as the stabilizing mechanisms of this procedure. The aim of this study was to determine the stabilizing mechanisms of this procedure. Methods: Eight fresh-frozen shoulders were prepared and tested with use of a custom testing machine instrumented with a load cell. With a 50-N axial force applied to the humerus, the humeral head was translated anteriorly. Translational force was measured at both the end-range and the mid-range arm positions, with the capsule intact, after creation of a Bankart lesion, after creation of a large glenoid defect, and after the Latarjet procedure with no load and then three different sets of loads applied to the subscapularis and conjoint tendons. Then, these two tendons were removed to observe the contribution of the sling effect to the stability. Finally, the sutures attaching the coracoacromial ligament to the capsular flap were removed in order to observe the effect of that attachment. Results: The translational force, which decreased significantly after creation of a Bankart lesion or a large glenoid defect, returned to the intact-condition level after the Latarjet procedure was performed. At the end-range arm position, the contribution of the sling effect by the subscapularis and conjoint tendons was 76% to 77% as the load changed, and the remaining 23% to 24% was contributed by the suturing of the capsular flap. At the mid-range position, the contribution of the sling effect was 51% to 62%, and the remaining 38% to 49% was contributed by the reconstruction of the glenoid. Conclusions: The main stabilizing mechanism of the Latarjet procedure was the sling effect at both the end-range and the mid-range arm positions. Clinical Relevance: The Latarjet procedure remains an effective procedure for restoring stability to an unstable glenohumeral joint, particularly when there is glenoid bone deficiency.

Time to failure after rotator cuff repair: a prospective imaging study.

Abstract: Background: Failure of tendon healing after a rotator cuff repair is demonstrated by magnetic resonance imaging (MRI) as a fluid-filled defect within the tendon. The frequency of, and factors associated with, failure of the tendon repair to heal have been the focus of many clinical studies. The timing of when these defects occur has not been previously studied in a large prospectively defined patient population, to our knowledge. It was our hypothesis that the majority of failures occur within twelve weeks after surgery. Methods: One hundred and thirteen patients were enrolled in a multi-institutional prospective study. All patients had a standardized arthroscopic repair of a full-thickness tear of 1 to 4 cm as well as sequential MRI studies at six intervals from two weeks to fifty-two weeks. MRIs were reviewed at the time of imaging by the treating surgeon. Standardized patient-oriented clinical data were collected, physical examination was performed, and strength measurements were made preoperatively and postoperatively. Results: The treating surgeons diagnosed a recurrent tear with MRI in nineteen (17%) of the 113 patients within one year after surgery. The mean time to the retear was 19.2 weeks. There was a linear increase in retears over the first twenty-six weeks after surgery, and one additional tear was diagnosed between twenty-six and fifty-two weeks after repair. Conclusions: Retears primarily occur between six and twenty-six weeks after arthroscopic rotator cuff repair, and few additional tears occur thereafter. A substantial number of retears occur between twelve and twenty-six weeks after repair. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.

Abstract: Background: There has been a major and alarming increase in readmission rates following total joint arthroplasty. With proposed changes in reimbursement policy, increased rates of unplanned readmission following arthroplasty will penalize providers. In particular, it has been proposed that specific complications—so-called “zero-tolerance” complications—are unacceptable and that their treatment will not qualify for reimbursement. The purpose of this study was to identify the incidence, causes, and risk factors for readmission following total joint arthroplasty. Methods: An institutional arthroplasty database was utilized to identify those patients undergoing total knee or hip arthroplasty from January 2004 through December 2008. A total of 10,633 admissions for primary arthroplasty (5207 knees and 5426 hips) were identified. The same database was used to identify patients requiring an unplanned readmission within ninety days of discharge. Multivariate logistic regression was utilized to determine the independent predictors of readmission within ninety days. Results: There were 591 unplanned readmissions within ninety days of discharge following 564 (5.3%) of the 10,633 admissions for total joint arthroplasty. The most common cause of readmission was joint-related infection, followed by stiffness. Black race, male sex, discharge to inpatient rehabilitation, increased duration of hospital stay, unilateral replacement, decreased age, decreased distance between home and the hospital, and total knee replacement were independent predictors of readmission within ninety days. Conclusions: The high incidence of readmissions secondary to potential “zero-tolerance” events suggests that these are not easily preventable complications. In addition, longer hospitalization and discharge to an inpatient continued-care facility increased the risk of readmission. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operative treatment of osteochondral lesions of the talus.

Abstract: ➤ Osteochondral lesions of the talus are common injuries in recreational and professional athletes, with up to 50% of acute ankle sprains and fractures developing some form of chondral injury. Surgical treatment paradigms aim to restore the articular surface with a repair tissue similar to native cartilage and to provide long-term symptomatic relief. ➤ Arthroscopic bone-marrow stimulation techniques, such as microfracture and drilling, perforate the subchondral plate with multiple openings to recruit mesenchymal stem cells from the underlying bone marrow to stimulate the differentiation of fibrocartilaginous repair tissue in the defect site. The ability of fibrocartilage to withstand mechanical loading and protect the subchondral bone over time is a concern. ➤ Autologous osteochondral transplantation techniques replace the defect with a tubular unit of viable hyaline cartilage and bone from a donor site in the ipsilateral knee. In rare cases, a graft can also be harvested from the ipsilateral talus or contralateral knee. The limitations of donor site morbidity and the potential need for an osteotomy about the ankle should be considered. Some anterior or far posterior talar lesions can be accessed without arthrotomy or with a plafondplasty. ➤ Osteochondral allograft transplantation allows an osteochondral lesion with a large surface area to be replaced with a single unit of viable articular cartilage and subchondral bone from a donor that is matched to size, shape, and surface curvature. The best available evidence suggests that this procedure should be limited to large-volume cystic lesions or salvage procedures. ➤ Autologous chondrocyte implantation techniques require a two-stage procedure, the first for chondrocyte harvest and the second for implantation in a periosteum-covered or matrix-induced form after in vivo culture expansion. Theoretically, the transplantation of chondrocyte-like cells into the defect will result in hyaline-like repair tissue.

Cancer Risk After Use of Recombinant Bone Morphogenetic Protein-2 for Spinal Arthrodesis

Abstract: Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a growth factor known to have in vitro effects on the growth and invasiveness of cancer. It has been approved by the U.S. Food and Drug Administration in limited doses for single-level anterior spinal arthrodesis, but it is commonly used off-label and at high doses. The effect of rhBMP-2 on the risk of cancer has been a concern. We sought to evaluate the risk of new cancers in patients receiving high-dose rhBMP-2. Methods: We used publicly available data from a pivotal, multicenter, randomized controlled trial of patients with degenerative lumbar spine conditions who underwent a single-level instrumented posterolateral arthrodesis with either high-dose rhBMP-2 in a compression-resistant matrix (CRM) (rhBMP-2/CRM; n = 239) or autogenous bone graft (control group; n = 224). We compared the risks of new cancers in the rhBMP-2/CRM and control groups at two and five years after surgery. Results: At two years, with 86% follow-up, there were fifteen new cancer events in eleven patients in the rhBMP-2/CRM group compared with two new cancer events in two patients in the control group treated with autogenous bone graft. The incidence rate of new cancer events per 100 person-years was 3.37 (95% confidence interval [CI], 1.89 to 5.56) in the rhBMP-2/CRM group at two years compared with 0.50 (95% CI, 0.06 to 1.80) in the control group. The incidence rate ratio was 6.75 (95% CI, 1.57 to 60.83; p = 0.0026) at two years. Calculated in terms of the number of patients with one or more cancer events two years after the surgery, the incidence rate per 100 person-years was 2.54 (95% CI, 1.27 to 4.54) in the rhBMP-2/CRM group compared with 0.50 (95% CI, 0.06 to 1.82) in the control group at two years; the incidence rate ratio was 5.04 (95% CI, 1.10 to 46.82; p = 0.0194). At five years, there was a 37% loss of follow-up, but a significantly greater incidence of cancer events was still observed in the rhBMP-2/CRM group. Conclusions: A high dose of 40 mg of rhBMP-2/CRM in lumbar spinal arthrodesis was associated with an increased risk of new cancer. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement: a randomized controlled trial (TRANX-H).

Abstract: Background: Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. Methods: A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications. Results: Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p < 0.0001), the length of stay by 1.0 days (95% CI, −0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months. Conclusions: Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Glenoid Component Retroversion Is Associated with Osteolysis

Abstract: Background: It has been suggested that glenoid component retroversion and eccentric loading are an important mechanism leading to glenoid component loosening, but little clinical data have been published to support this concept. Methods: Sixty-six shoulders underwent total shoulder replacement with an all-polyethylene press-fit pegged glenoid component designed for osseous ingrowth for treatment of osteoarthritis. These shoulders were followed clinically and with radiographs for an average (and standard deviation) of 3.8 ± 1.8 years (range, two to seven years). Preclinical radiographic loosening was defined as osteolysis around the central peg of the glenoid component. Results: Of the sixty-six shoulders, twenty (30%) had osteolysis around the center peg. The length of time after replacement (p = 0.0006), preoperative glenoid retroversion (p = 0.036), and postoperative glenoid component retroversion (p = 0.041) were correlated with osteolysis around the glenoid center peg and an increase in the Lazarus component loosening grade. Postoperative retroversion correlated with preoperative retroversion (Pearson correlation coefficient = 0.44, 95% confidence interval [CI] = 0.19 to 0.64, p = 0.0011). The presence of osteolysis around the center peg was not correlated with a worse clinical outcome defined by shoulder scores or a reoperation due to glenoid loosening. After adjustment for follow-up time, excessive postoperative glenoid retroversion (≥15°) was associated with an increased odds of osteolysis (odds ratio = 5.23, 95% CI = 1.31 to 20.9]), whereas preoperative glenoid retroversion was associated with no change in the odds of osteolysis. Conclusions: Osteolysis around the center peg of a glenoid component is correlated with component retroversion of ≥15°. This finding suggests that there should be additional investigation into the effects of correcting preoperative glenoid retroversion to prevent osteolysis around the center peg. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Peripheral nerve repair and reconstruction.

Abstract: When possible, direct repair remains the current standard of care for the repair of peripheral nerve lacerations. In large nerve gaps, in which direct repair is not possible, grafting remains the most viable option. Nerve scaffolds include autologous conduits, artificial nonbioabsorbable conduits, and bioabsorbable conduits and are options for repair of digital nerve gaps that are <3 cm in length. Experimental studies suggest that the use of allografts may be an option for repairing larger sensory nerve gaps without associated donor-site morbidity.

Use of patient-reported outcome measures in foot and ankle research.

Abstract: Background In the orthopaedic literature, there is a wide range of clinical outcome measurement tools that have been used in evaluating foot and ankle procedures, disorders, and outcomes, with no broadly accepted consensus as to which tools are preferred. The purpose of this study was to determine the frequency and distribution of the various outcome instruments used in the foot and ankle literature, and to identify trends for use of these instruments over time. Methods We conducted a systematic review of all original clinical articles reporting on foot and/or ankle topics in six orthopaedic journals over a ten-year period (2002 to 2011). All clinical patient-reported outcome rating instruments used in these articles were recorded, as were study date, study design, clinical topic, and level of evidence. Results A total of 878 clinical foot and ankle articles that used at least one patient-reported outcome measure were identified among 16,513 total articles published during the ten-year period. There were 139 unique clinical outcome scales used, and the five most popular scales (as a percentage of foot/ankle outcome articles) were the American Orthopaedic Foot & Ankle Society (AOFAS) scales (55.9%), visual analog scale (VAS) for pain (22.9%), Short Form-36 (SF-36) Health Survey (13.7%), Foot Function Index (FFI) (5.5%), and American Academy of Orthopaedic Surgeons (AAOS) outcomes instruments (3.3%). The majority of articles described Level-IV studies (70.1%); only 9.4% reported Level-I studies. Conclusions A considerable variety of outcome measurement tools are used in the foot and ankle clinical literature, with a small proportion used consistently. The AOFAS scales continue to be used at a high rate relative to other scales that have been validated. Data from the present study underscore the need for a paradigm shift toward the use of consistent, valid, and reliable outcome measures for studies of foot and ankle procedures and disorders. It is not clear which existing validated outcome instruments will emerge as widely used and clinically meaningful. Clinical relevance These data support the need for a paradigm shift toward the consistent use of valid and reliable outcome measures for foot and ankle clinical research.

Patient satisfaction: Implications and predictors of success.

Abstract: Patient satisfaction is an individual's cognitive evaluation of, and emotional reaction to, his or her health-care experience. This concept is increasing in importance as survey data are being used by health-care facilities for self-assessment, accreditation requirements, and compensation formulas. High patient satisfaction is associated with increased market share, financial gains, decreased malpractice claims, and improved reimbursement rates. Modifiable factors that contribute to satisfaction include physician-patient communication, the setting of appropriate expectations, minimization of waiting times, and provision of continuity of care. There are also factors that are less amenable to change, including chronic illness, opioid dependence, and sociodemographic status. Satisfaction with a surgical outcome differs from satisfaction with an office visit. Accurate expectations and patient-reported outcome measures are important determinants of satisfaction after a surgical procedure. Physicians can improve patient satisfaction in their practice by understanding the implications of satisfaction and the predictors of success.

The role of mechanical loading in tendon development, maintenance, injury, and repair.

Abstract: ➤ Tendon injuries often result from excessive or insufficient mechanical loading, impairing the ability of the local tendon cell population to maintain normal tendon function. ➤ The resident cell population composing tendon tissue is mechanosensitive, given that the cells are able to alter the extracellular matrix in response to modifications of the local loading environment. ➤ Natural tendon healing is insufficient, characterized by improper collagen fibril diameter formation, collagen fibril distribution, and overall fibril misalignment. ➤ Current tendon repair rehabilitation protocols focus on implementing early, well-controlled eccentric loading exercises to improve repair outcome. ➤ Tissue engineers look toward incorporating mechanical loading regimens to precondition cell populations for the creation of improved biological augmentations for tendon repair.

Novel scaffold-based BST-CarGel treatment results in superior cartilage repair compared with microfracture in a randomized controlled trial.

Abstract: Background: Microfracture, the standard of care, is recognized to be an incomplete solution for cartilage damage. BST-CarGel, a chitosan-based medical device, is mixed with autologous whole blood and is applied to a microfractured cartilage lesion in which it physically stabilizes the clot and guides and enhances marrow-derived repair. An international, multicenter, randomized controlled trial was conducted to evaluate BST-CarGel treatment compared with microfracture alone in the repair of cartilage lesions in the knee. Methods: Eighty patients between the ages of eighteen and fifty-five years with a single, symptomatic focal lesion on the femoral condyles were randomized to BST-CarGel and microfracture treatment (n = 41) or microfracture treatment alone (n = 39). The primary end points of repair tissue quantity and quality at twelve months were assessed by quantitative three-dimensional magnetic resonance imaging measuring the degree of lesion filling and T2 relaxation time with use of standardized one and twelve-month posttreatment scans. The secondary end point at twelve months was clinical benefit determined with the Western Ontario and McMaster Universities Osteoarthritis Index. The tertiary end point was quality of life determined by the Short Form-36. Safety was assessed through the recording of adverse events. Results: Patient baseline characteristics were similar in the two groups, although baseline lesion areas were slightly larger on quantitative magnetic resonance imaging for the BST-CarGel group compared with the microfracture group. Blinded quantitative magnetic resonance imaging analysis demonstrated that, at twelve months, when compared with microfracture treatment alone, BST-CarGel treatment met both primary end points by achieving statistical superiority for greater lesion filling (p = 0.011) and more hyaline cartilage-like T2 values (p = 0.033). The lesion filling values were 92.8% ± 2.0% for the BST-CarGel treatment group and 85.2% ± 2.1% for the microfracture treatment group, and the mean T2 values were 70.5 ± 4.5 ms for the BST-CarGel treatment group and 85.0 ± 4.9 ms for the microfracture treatment group. Western Ontario and McMaster Universities Osteoarthritis Index subscales for pain, stiffness, and function yielded equivalent improvement for both groups at twelve months, which were significant (p < 0.0001) from baseline. Treatment safety profiles were considered comparable. Conclusions: At twelve months, BST-CarGel treatment resulted in greater lesion filling and superior repair tissue quality compared with microfracture treatment alone. Clinical benefit was equivalent between groups at twelve months, and safety was similar. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial.

Abstract: Background: We conducted a prospective, randomized, controlled multicenter trial to compare operative with nonoperative treatment of displaced intra-articular calcaneal fractures. Methods: Eighty-two patients who presented to five trauma centers from 1994 to 1998 with an intra-articular calcaneal fracture with ≥2 mm of displacement (as verified by computed tomography) were randomized to operative or nonoperative treatment. Independent observers followed the two groups radiographically and clinically at one year and eight to twelve years. The primary outcome measures were a visual analog scale (VAS) for pain and function and the self-administrated Short Form (SF)-36 general health outcome questionnaire. The secondary outcome measures were residual pain evaluated with a VAS, the American Orthopaedic Foot & Ankle Society (AOFAS) scale, and the Olerud-Molander (OM) scale. Results: Forty-two patients in the operative treatment group and forty in the nonoperative group were included. The two groups were comparable with respect to age, sex, and fracture types. Seventy-six patients were available for follow-up at one year and fifty-eight at eight to twelve years. The primary and secondary outcome measures did not differ significantly between the two treatment groups at one year of follow-up. At eight to twelve years of follow-up, there was a trend toward better scores on the patient-reported primary VAS score for pain and function (p = 0.07) and the physical component of the SF-36 (p = 0.06) in the operative group. The prevalence of radiographically evident posttraumatic subtalar arthritis was lower in the operative group (risk reduction, 41%). Conclusions: Operative treatment was not superior in managing displaced intra-articular calcaneal fractures at one year of follow-up but appeared to have some benefits at eight to twelve years. Operative treatment was associated with a higher risk of complications but a reduced prevalence of posttraumatic arthritis evident on follow-up radiographs. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Contribution of Kinesophobia and Catastrophic Thinking to Upper-Extremity-Specific Disability

Abstract: Background: Upper-extremity-specific disability correlates with mood and coping strategies. The aim of this study was to determine if two psychological factors, kinesiophobia (fear of movement) and perceived partner support, contribute significantly to variation in upper-extremity-specific disability in a model that included factors known to contribute to variation such as depression, pain anxiety, and catastrophic thinking. Methods: We performed an observational cross-sectional study of 319 patients who each had one of the following conditions: trigger finger (n = 94), carpal tunnel syndrome (n = 29), trapeziometacarpal arthrosis (n = 33), Dupuytren contracture (n = 31), de Quervain syndrome (n = 28), wrist ganglion cyst (n = 32), lateral epicondylosis (n = 41), and a fracture of the distal part of the radius treated nonoperatively six weeks previously (n = 31). Each patient completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and questionnaires measuring symptoms of depression, pain anxiety, catastrophic thinking, kinesiophobia, and perceived level of support from a partner or significant other. Stepwise multiple linear regression was used to determine significant independent predictors of the DASH score. Results: Men had significantly lower (better) DASH scores than women (21 versus 31; p < 0.01). DASH scores also differed significantly by diagnosis (p < 0.01), marital status (p = 0.047), and employment status (p < 0.01). The DASH score correlated significantly with depressive symptoms (p < 0.01), catastrophic thinking (p < 0.01), kinesiophobia (p < 0.01), and pain anxiety (p < 0.01) but not with perceived partner support. The best multivariable model of factors associated with greater arm-specific disability (according to the DASH score) included sex, diagnosis, employment status, catastrophic thinking, and kinesiophobia and accounted for 55% of the variation. Conclusions: In this sample, kinesiophobia and catastrophic thinking were the most important predictors of upper-extremity-specific disability in a model that accounted for symptoms of depression, anxiety, and pathophysiology (diagnosis) and explained more than half of the variation in disability. Perceived partner support was not a significant factor. The consistent and predominant role of several modifiable psychological factors in disability suggests that patients may benefit from a multidisciplinary approach that optimizes mindset and coping strategies.

The mechanism of action of induced membranes in bone repair.

Abstract: Background: Inducement of foreign-body granulation tissue is a relatively novel therapeutic modality in bone repair. A two-stage bone reconstruction method, known as the Masquelet technique, combines inducement of a granulation tissue membrane and subsequent bone autografting as a biphasic technique allowing reconstruction of large bone defects. In light of their already well-characterized osteogenesis-improving capabilities in animals, we performed this translational study to investigate these membranes in patients. Methods: Fourteen patients with complicated fractures and bone defects were randomly selected for this study. Biopsy samples of foreign-body-induced membranes were collected at different time points during scheduled surgical procedures. The membranes were co-cultured with mesenchymal stromal cells, and differentiation into the osteoblastic lineage was assessed by measuring alkaline phosphatase activity, aminoterminal propeptide of type-I procollagen (PINP) production, and Ca2+ concentration. Histological characteristics were evaluated with image analysis. Quantitative reverse transcription polymerase chain reaction was used to measure vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), and type-I collagen (Col-1) expression. Results: The induced membranes were characterized histologically by maturating vascularized fibrous tissue. The vascularization was greatest in one-month-old samples and decreased to <60% in three-month-old samples. One-month-old membrane samples had the highest expression of VEGF, IL-6, and Col-1, whereas two-month-old membranes expressed <40% of the levels of the one-month-old membranes. Specific alkaline phosphatase activity, PINP production, and Ca2+ concentration were increased in co-cultures when a membrane sample was present. In cultures of one-month-old membranes, PINP production was more than two times and Ca2+ deposition was four times higher than that in cultures of two-month-old membranes. Conclusions: The induced membranes have osteogenesis-improving capabilities. These capabilities, however, appear to decrease over time. We speculate that the optimal time for performing second-stage surgery may be within a month after implantation of foreign material. Clinical Relevance: The two-stage bone reconstruction method is an easily adaptable technique for repair of large bone defects. Further understanding of membrane biology and maturation in humans can help to optimize current procedures and improve their overall success rate.