Citations

Background: The purpose of the present study was to identify trends in management and to compare the outcomes and complications following nonoperative and operative management (including external fixation, closed reduction and percutaneous pinning, and open reduction and internal fixation) for distal radial fractures in patients ≥65 years of age. Methods: We performed a retrospective analysis, with use of the OptumLabs Data Warehouse database, of patients ≥65 years of age who had been managed for a distal radial fracture between 2009 and 2014 (as indicated by diagnosis codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification). Ninety-day and 1-year complication rates per 1,000 fractures were analyzed overall and by treatment modality. Results: Thirteen thousand, seven hundred and thirteen distal radial fractures were analyzed. The overall 90-day complication rate was 36.5 per 1,000 fractures, and the 1-year upper-extremity-specific complication rate was 236.2 and 307.5 per 1,000 fractures for nonoperative and operative management, respectively. Overall, post-injury stiffness was the most common 1-year upper-extremity-specific complication (incidence, 11.5%). There was no significant difference between operative and nonoperative management in terms of 90-day complication rates. However, operative management had a higher 1-year complication rate than nonoperative management (307.5 versus 236.2 per 1,000 fractures). Overall, the 5 most common upper-extremity-specific complications following operative treatment of distal radial fracture were stiffness (16.0%), chronic regional pain syndrome (9.9%), median neuropathy (8.0%), implant-related complications (3.8%), and tendon-related complications (2.8%). Stiffness was significantly more frequent following operative management (16.0% versus 9.8%; p < 0.01). Conclusions: Operative management of a distal radial fracture should be carefully considered when discussing treatment options with patients ≥65 years of age. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVEThe authors sought to assess whether Hounsfield units (HU) increase following teriparatide treatment and to compare HU increases with changes in bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DEXA).METHODSA retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. The authors identified patients who had been treated with at least 6 months of teriparatide and compared HU and BMD as measured on DEXA scans before and after treatment.RESULTSFifty-two patients were identified for analysis (46 women and 6 men, average age 67 years) who underwent an average of 20.9 ± 6.5 months of teriparatide therapy. The mean ± standard deviation HU increase throughout the lumbar spine (L1–4) was from 109.8 ± 53 to 133.9 ± 61 HU (+22%, 95% CI 1.2–46, p value = 0.039). Based on DEXA results, lumbar spine BMD increased from 0.85 to 0.93 g/cm2 (+9%, p value = 0.044). Lumbar spine T-scores improved from −2.4 ± 1.5 to −1.7 ± 1.5 (p value = 0.03). Average femoral neck T-scores improved from −2.5 ± 1.1 to −2.3 ± 1.0 (p value = 0.31).CONCLUSIONSTeriparatide treatment increased both HU and BMD on DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the 9% improvement determined with DEXA. These results support some surgeons’ subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. To the authors’ knowledge, this is the first study demonstrating an increase in HU with teriparatide treatment.

Objective This study aims to (1) determine and validate living cartilage allograft transplantation as a novel source for viable osteochondral allograft (OCA) tissues and (2) perform histologic and viability comparisons of living donor cartilage tissues to currently available clinical-grade standard processed grafts. Design Using healthy cartilage from well-preserved contralateral compartments in 27 patients undergoing total knee arthroplasty (TKA) and 10 clinical-grade OCA specimens obtained immediately following operative implantation, standard and living donor OCA quality was evaluated at the time of harvest and following up to 3 weeks of storage on the basis of macroscopic International Cartilage Repair Society grade, histology, and viability. Results Osteochondral samples demonstrated a consistent decrease in viability and histologic quality over the first 3 weeks of storage at 37°C, supporting the utility of an OCA paradigm shift toward early implantation, as was the clinical standard up until recent adoption of transplantation at 14 to 35 days following donor procurement. Samples from the 10 clinical-grade OCAs, implanted at an average of 23 days following graft harvest demonstrated a mean viable cell density of 45.6% at implantation, significantly lower ( P < 0.01) than the 93.6% viability observed in living donor allograft tissues. Conclusions Osteochondral tissue viability and histologic quality progressively decreases with ex vivo storage, even when kept at physiologic temperatures. Currently available clinical OCAs are stored for 2 to 5 weeks prior to implantation and demonstrate inferior viability to that of fresh osteochondral tissues that can be made available through the use of a living donor cartilage program.

Background: Treatment outcomes and risk factors for neurological deficits in pediatric patients with an os odontoideum are unclear. Methods: We reviewed the data for 102 children with os odontoideum who were managed at 11 centers between 2000 and 2016 and had a minimum duration of follow-up of 2 years. Thirty-one children had nonoperative treatment, and 71 underwent instrumented posterior cervical spinal arthrodesis for the treatment of C1-C2 instability. Nonoperative treatment consisted of observation (n = 29) or immobilization with a cervical collar (n = 1) or halo body jacket (n = 1). Surgical treatment consisted of atlantoaxial (n = 50) or occipitocervical (n = 21) arthrodesis. One patient also underwent transoral odontoidectomy. Results: Thirty children (29%) presented with neurological deficits, 28 of whom had radiographic atlantoaxial instability (atlantoaxial distance >5 mm) or limited space (≤13 mm) available for the spinal cord (risk ratio, 7.8 [95% confidence interval, 2.0 to 31] compared with children with no radiographic risk factors). The 27 children without neurological deficits or atlantoaxial instability at presentation underwent nonoperative treatment and remained asymptomatic. Of the initial nonoperative cohort, one child developed atlantoaxial instability, and another had a persistent neurological deficit; both children underwent spinal arthrodesis during the study period. One child with cervical instability declined surgery and remained asymptomatic. Spinal fusion occurred in 68 patients in the surgical group by the end of the study period (mean, 3.7 years; range, 2.0 to 11.8 years). Surgical complications occurred in 21 children, including nonunion in 12, new neurological deficits in 4, cerebrospinal fluid leak in 2, symptomatic instrumentation requiring removal 2, and vertebral artery injury in 1. Nine children underwent revision surgery. In the surgical group, Japanese Orthopaedic Association neurological function scores improved significantly from preoperatively to the latest follow-up for the upper extremities (p = 0.026) and lower extremities (p = 0.007). Conclusions: The risk of developing a neurological deficit was strongly associated with atlantoaxial instability and limited space available for the spinal cord in children with os odontoideum. Nonoperative treatment was safe for asymptomatic patients without atlantoaxial instability. Spinal arthrodesis resolved the neurological deficits of children with symptomatic os odontoideum. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Purpose The aim of this study is to review the management of all paediatric humerus diaphyseal fractures treated at a single institution over a 20-year period. Methods Retrospective review from between 1996 and 2016 identified 96 humerus shaft fractures in paediatric patients (0 to 17 years). After excluding those deceased from inciting trauma, pathological and perinatal fractures, 80 patients remained for analysis. Data collected included age, fracture type, displacement, nerve palsy, treatment, complications and time to union. Radiographs were reviewed at the time of injury and at latest follow-up. Results Of 80 paediatric humeral diaphyseal fractures, 65 (81%) were treated with immobilization. In all, 15 (19%) fractures were treated with surgical stabilization. Most common indications were fracture displacement, open fractures and to improve mobilization in patients with multiple injuries. Fractures were stabilized with a plate (eight), flexible nails (five), external fixation (one) and percutaneous pinning (one). The operative group, compared with the nonoperative group, was older, had more high-energy mechanisms, more open fractures and increased fracture displacement. All patients in the nonoperative and operative groups went on to union with minimal complications. A nerve palsy was present in five patients (6%)with three of the five involving the radial nerve (4%). All nerve palsies were observed and had full neurological recovery. Conclusion Over a 20-year period nonoperative management of paediatric humerus shaft fractures was successful in the majority of patients. Operative stabilization, when rarely indicated, had a low complication rate and improved radiographic alignment. All nerve injuries fully recovered without surgical intervention. Level of evidence IV

Vibrational characteristics of the bone are directly dependent on bone’s physical properties. In this paper, a vibrational method for bone evaluation is introduced. We propose a new type of quantitative vibro-acoustic method based on acoustic radiation force of ultrasound for bone characterization in patients with fracture. In this method, we excite the clavicle and ulna by an ultrasound radiation force (URF) pulse. The URF pulse induces vibrations in the bone, resulting in an acoustic wave that is measured by a hydrophone placed on the skin. The resulting acoustic signals were used for wave velocity estimation based on cross-correlation technique. To further separate different vibration characteristics, we adopt a variational mode decomposition (VMD) technique to decompose the received signal into an ensemble of band-limited intrinsic mode functions, which allows analyzing the acoustic signals in terms of their constitutive components. We conducted a prospective study that included a total of 15 patients, 12 with clavicle fractures and 3 with ulna fractures. The contralateral intact bones were used as control. Statistical analysis demonstrated that fracture bones can be differentiated from intact bone with a detection probability of 80%. Also, we introduce a “healing factor” that quantifies the progress of healing in clavicle bones. Statistical analysis showed that healing factor can track the progress of healing in clavicle in 80% of fractures.

Purpose: The goal of this study was to evaluate patient and surgical factors predictive of excellent functional and isokinetic test results 6-months following anterior cruciate ligament (ACL) reconstruction in a group of pediatric patients with open physes. Methods: We retrospectively reviewed the records of all patients 14 years of age or younger that underwent ACL reconstruction from 2000 to 2015. An excellent 6-month outcome was defined as greater than 85% in isokinetic strength and greater than 90% in functional tests when compared to the non-operative extremity. We then utilized univariate and multivariate statistical models to identify patient and/or surgical factors associated with excellent 6-month outcomes. Results: Eighty-six patients (46 male, 42 female) with open physes on preoperative radiographs were included in the study, with a mean age of 13.6 (range, 8.4-14.9), body mass index (BMI) of 22.1 (range, 15.6-36.0), Tegner activity score of 8.8 (6.0-9.0). Thirty-four patients (40%) met the criteria for the excellent 6-month group, which left 52 (60%) in the delayed 6-month group. In univariate analysis, no single preoperative factor correlated with excellent 6-month outcome. The two groups were statistically similar in terms of age, BMI, time to surgery, preoperative arc of motion, presence of concomitant meniscal tear, cartilage damage, graft size, use of a nerve block or tourniquet, operative time, and tourniquet time. Use of a nerve block trended towards delayed outcomes (p = 0.051). Conclusion: Children undergoing ACL reconstruction only have a 40% chance of achieving an excellent rehabilitation result at 6 months. We found no statistically significant patient or surgical characteristics that could predict this outcome. Utilizing a nerve block is a factor which will need to be further evaluated. Significance: Studies in the adult population have identified preoperative patient and surgical factors associated with excellent 6-month isokinetic and functional test results. This pediatric cohort did not find similar results as many of these children were young, healthy and fit. However, the variability of the outcome casts doubts on applying adult rehabilitation protocols to children.

Introduction: It is unknown whether functional and isokinetic testing at 6 months following ACL reconstruction in patients with open-physes correlates with longer term outcomes. The purpose of this study was to compare subsequent ACL rupture risk, knee function, and activity level in patients with open-physes who had excellent 6-month testing to those who did not. Methods: Between the years of 2000 and 2015, 86 patients with open-physes underwent ACL reconstruction and had functional and isokinetic testing performed at 6-months post-operatively. Thirty-four (40%) tested in the excellent range in all categories of both functional and isokinetic testing and were labeled the excellent group. The remaining 52 (60%) patients were labeled the delayed testing group. Data regarding patient, injury, and surgical characteristics were retrospectively collected. The rate of second ACL injury as well as clinical outcome scores were collected postoperatively. Results: Graft rupture rate was 23.4% (n = 8) in the excellent group and 15.4% (n = 8) in the delayed group (p = 0.51). In the excellent group, 20.5% (n = 7) had a contralateral ACL tear versus 11.5% (n = 6) in the delayed group (p = 0.40). Five patients in the excellent group and 4 patients in the delayed group sustained both graft failure and contralateral ACL tear. The overall prevalence of second ACL injury was 29% in the excellent group and 23% in the delayed group. The delayed group returned to sport at an average of 8.8 months whereas the excellent group returned at an average of 6.6 months (p < 0.01). At mean follow up of 3.59 years, the excellent group had a higher Tegner activity level (8.9 versus 8.3) than the delayed group (p < 0.02). Conclusion: Pediatric patients with open-physes who had excellent isokinetic strength and functional testing 6-months postoperatively returned to sport sooner than those who did not. There was no statistical difference in either graft failure or contralateral ACL disruption between these groups. However, both groups had unacceptably high rates of second ACL injury (29% for the excellent group and 23% for the delayed group). Significance: Excellent 6 month return of strength and function was not protective of subsequent ACL disruption, the rate of which remains dismal within this pediatric population. Development of more sensitive functional measures for children could help to change these poor outcomes and guide clinicians when to allow return to sport.

Vibrational characteristics of bone are directly dependent on its physical properties. In this study, a vibrational method for bone evaluation is introduced. We propose a new type of quantitative vibro-acoustic method based on the acoustic radiation force of ultrasound for bone characterization in persons with fracture. Using this method, we excited the clavicle or ulna by an ultrasound radiation force pulse which induces vibrations in the bone, resulting in an acoustic wave that is measured by a hydrophone placed on the skin. The acoustic signals were used for wave velocity estimation based on a cross-correlation technique. To further separate different vibration characteristics, we adopted a variational mode decomposition technique to decompose the received signal into an ensemble of band-limited intrinsic mode functions, allowing analysis of the acoustic signals by their constitutive components. This prospective study included 15 patients: 12 with clavicle fractures and three with ulna fractures. Contralateral intact bones were used as controls. Statistical analysis demonstrated that fractured bones can be differentiated from intact ones with a detection probability of 80%. Additionally, we introduce a “healing factor” to quantify the bone healing progress which successfully tracked the progress of healing in 80% of the clavicle fractures in the study.

Abstract Background The use of mesenchymal stem cells (MSCs) in clinical applications for the treatment of musculoskeletal disease is steadily increasing in office-based practice. The so-called “first generation” of MSCs is defined as autologous stem cells that have undergone minimal manipulation and are used for a homologous purpose. Systematic reviews of the clinical trials completed to date of such MSCs enable practitioners to better understand what is currently known about the outcomes and side effects of such treatments. Study Design A systematic review of human clinical studies of office-based MSC therapy for the treatment of painful degenerative musculoskeletal conditions. Methods A search of the Ovid MEDLINE, EMBASE, and Scopus databases was conducted from 2006 through September 2016. Seven hundred sixty-one records were identified from database searching, and two records from reference review of included papers. Studies with human subjects that evaluated treatment of musculoskeletal disease with minimally manipulated MSCs were included. Results Eight studies were included in this review based on selection criteria. A total of 941 patients were included, 841 of whom received cellular products, and no significant adverse events were reported. Symptomatology generally improved, though no differences were seen over controls where present. Conclusion Support in the literature is strongest for the use of bone marrow aspirate concentrate (BMAC) injections for the treatment of knee pain, but applications of the use of BMAC and peripheral blood–derived MSCs for the treatment of hip pain, tendon pain, and disc pain have all been reported. Further research is required, with large randomized controlled trials.