Alejandro Marquez-Lara

Nonsteroidal Anti-Inflammatory Drugs and Bone-Healing: A Systematic Review of Research Quality.

Background: Nonsteroidal anti‐inflammatory drugs (NSAIDs) are often avoided by orthopaedic surgeons because of their possible influence on bone‐healing. This belief stems from multiple studies, in particular animal studies, that show delayed bone‐healing or nonunions associated with NSAID exposure. The purpose of this review was to critically analyze the quality of published literature that evaluates the impact of NSAIDs on clinical bone‐healing. Methods: A MEDLINE and Embase search was conducted to identify all articles relating to bone and fracture‐healing and the utilization of NSAIDs. All human studies, including review articles, were identified for further analysis. Non‐English‐language manuscripts and in vitro and animal studies were excluded. A total of twelve clinical articles and twenty‐four literature reviews were selected for analysis. The quality of the clinical studies was assessed with a modified Coleman Methodology Score with emphasis on the NSAID utilization. Review articles were analyzed with regard to variability in the cited literature and final conclusions. Results: The mean modified Coleman Methodology Score (and standard deviation) was significantly lower (p = 0.032) in clinical studies that demonstrated a negative effect of NSAIDs on bone‐healing (40.0 ± 14.3 points) compared with those that concluded that NSAIDs were safe (58.8 ± 10.3 points). Review articles also demonstrated substantial variability in the number of cited clinical studies and overall conclusions. There were only two meta‐analyses and twenty‐two narrative reviews. The mean number (and standard deviation) of clinical studies cited was significantly greater (p = 0.008) for reviews that concluded that NSAIDs were safe (8.0 ± 4.8) compared with those that recommended avoiding them (2.1 ± 2.1). Unanimously, all reviews admitted to the need for prospective randomized controlled trials to help clarify the effects of NSAIDs on bone‐healing. Conclusions: This systematic literature review highlights the great variability in the interpretation of the literature addressing the impact of NSAIDs on bone‐healing. Unfortunately, there is no consensus regarding the safety of NSAIDs following orthopaedic procedures, and future studies should aim for appropriate methodological designs to help to clarify existing discrepancies to improve the quality of care for orthopaedic patients. Clinical Relevance: This systematic review highlights the limitations in the current understanding of the effects of NSAIDs on bone healing. Thus, withholding these medications does not have any proven scientific benefit to patients and may even cause harm by increasing narcotic requirements in cases in which they could be beneficial for pain management. This review should encourage further basic‐science and clinical studies to clarify the risks and benefits of anti‐inflammatory medications in the postoperative period, with the aim of improving patient outcomes.

Defining the long-toss: A professional baseball epidemiological study

Background: Despite widespread use of long-toss throwing in baseball as a component of arm conditioning, interval throwing programs, and rehabilitation, long-toss distance and throwing mechanics remain controversial. Purpose: To ascertain the perceived definition of long-toss throwing through a survey of professional pitchers, pitching coaches (PCs), and certified athletic trainers (ATCs) associated with Major League Baseball. Study Design: Descriptive epidemiology study. Methods: Pitchers, PCs, and ATCs associated with 5 Major League Baseball organizations completed an anonymous survey that collected demographic data, personal use of long-toss throwing, and their perception of the distance and throwing mechanics that comprised long-toss. Results: A total of 321 surveys were completed by 271 pitchers, 19 PCs, and 31 ATCs. For all respondents, the mean distance considered as long-toss was 175 ft (95% CI, 170-181 ft). Respondents categorized the throwing mechanics of long-toss, with 36% reporting throwing “on a line” and 70% reporting long-toss as “not on a line.” Of those throwing “on a line,” 28% reported using crow-hop footwork while 60% used crow-hop footwork when throwing “not on a line.” Interpretation of long-toss distance significantly varied by position: pitchers, 177 ft (95% CI, 171-183 ft); PCs, 177 ft (95% CI, 155-200 ft); and ATCs, 157 ft (95% CI, 144-169 ft) (P = .048). When asked when long-toss throwing is used, pitchers reported using it more frequently in preseason (P = .007), during the season (P = .015), and in the off-season (P = .002) compared with that by ATCs. Functional goals for long-toss throwing demonstrated that pitchers and PCs use long-toss for shoulder stretching more frequently than ATCs (P < .001 and P = .026, respectively). ATCs used long-toss more than pitchers for interval throwing programs (P < .001). Conclusion: The definition varies for long-toss throwing distance and throwing mechanics. Pitchers and PCs believe that long-toss comprised longer distances than ATCs and employed long-toss differently for strength conditioning, training, stretching, and rehabilitation. This discrepancy highlights a potential lost opportunity for protecting the shoulder. While long-toss is an important tool, a more scientific definition is warranted to better elucidate its role in enhancing throwing performance and rehabilitation.

Relationship of Sacral Fractures to Nerve Injury: Is the Denis Classification Still Accurate?

Objective: Use modern computed tomographic imaging to reassess neurological injury risks associated with zone I–III sacral fractures as originally described by Denis et al. Design: Retrospective case–control study. Setting: University Level I Trauma Center. Patients/Participants: One thousand five hundred seven consecutive patients who presented with sacral fractures between January 2000 and August 2012. Main Outcome Measurements: Patients were stratified based on the diagnosis of acute neurological injury. The risk of severe and complex sacral fractures based on the presence of nerve injury was assessed. Results: The rate of nerve injury was significantly lower compared with historic data (3.5% vs. 21.6%, P < 0.001). Acute nerve injury was a significant risk factor for displaced (odds ratio [OR]: 8.4, 95% confidence interval [CI], 1.4–51.9) and comminuted (OR: 5.2, 95% CI, 1.7–16.3) sacral fractures as well as zone II (OR: 3.4, 95% CI, 1.1–10.1) and III (OR: 3.9, 95% CI, 1.0–16.4) fractures. Conclusions: The incidence of nerve injuries associated with sacral fractures is significantly lower than originally published by Denis et al. Patients with a nerve injury were highly correlated with having a displaced, comminuted, or zone III fracture, or spinopelvic dissociation; the authors recommend a fine cut computerized tomography for further investigation if these findings are not apparent on initial radiographic imaging. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A percutaneous, minimally invasive annulus fibrosus needle puncture model of intervertebral disc degeneration in rabbits:

Purpose: Various animal models have been proposed to mimic the pathophysiologic process of intervertebral disc degeneration, a leading cause of back pain. The purpose of this study is to describe a minimally invasive technique via percutaneous needle puncture of the annulus fibrosus in New Zealand white rabbits. Methods: Under fluoroscopic guidance, an 18-gauge spinal needle was inserted 2 cm lateral to the midline spinous process. The needle was slowly advanced at approximately 45° angle until it was adjacent to the L5/L6 disc space. Lateral and anteroposterior views were used to verify correct needle position before advancing into the nucleus pulposus. The rabbits underwent weekly X-rays for 4 weeks to assess disc height index. MRI T2 relaxation was evaluated at week four to assess morphological changes. Discs were histologically graded on a 12-point scale to assess degeneration and compared to discs obtained from uninjured rabbits. Results: There were no complications associated with the percutaneous needle puncture procedure. All animals survived the duration of the experiment. Four weeks after injury, the disc height had progressively narrowed to approximately 50% of baseline. MRI assessment at the 4-week time point demonstrated a mean T2 relaxation time at the L5/L6 level that was 20.9% of the T2 relaxation time at the uninjured L4/L5 disc level (p < 0.001). Histological analysis demonstrated lamellar disorganization of the annulus and decreased cellularity and proteoglycan content within the injured nucleus compared to uninjured control discs. Conclusion: The present study demonstrated a reliable technique of inducing an annular tear via a percutaneous needle puncture. Compared to open surgical approaches, the percutaneous model produces similar progressive disc degeneration while minimizing harm to the animal subjects. Clinical Relevance: The present study establishes a technique for the introduction of novel therapeutic agents to treat disc degeneration that may translate to future clinical trials.

Previous History of Breast Cancer Increases Rates of Pulmonary Embolism and Costs after Total Knee Arthroplasty: An Evaluation of 185,114 Matched Patients

&NA; Risk factors for adverse events after total knee arthroplasty (TKA) relating to malignancy have not been well studied. Thus, the purpose of this study was to conduct a retrospective case‐control outcome and cost analysis after TKA in this population. Patients with a history of breast cancer (BrCa) were identified based on the International Classification of Disease 9th revision codes. An age‐ and sex‐matched cohort was also identified of patients without a history of BrCa. Complications, length of stay, comorbidity burden, and reimbursements were tracked at 90 days. Each cohort comprised 92,557 patients. Length of stay was similar between cohorts (p = 0.627). Comorbidity status and incidence of pulmonary embolism (PE), lower extremity ultrasound, and chest computed tomography (CT) use were higher in patients with a history of BrCa (p < 0.05 for all). Control patients had a lower incidence of acute myocardial infarction (0.14 vs. 0.21%; p < 0.001). Surgical complications were similar. The 90‐day reimbursements were greater in patients with a history of BrCa (US

Arthroscopic Treatment of Hip Chondral Defect With Microfracture and Platelet-Rich Plasma–Infused Micronized Cartilage Allograft Augmentation

13,990 vs. US

Return-to-Play and Performance Outcomes of Professional Athletes in North America After Hip Arthroscopy From 1999 to 2016:

13,033 for controls; p = 0.021). Surgeons should be aware of the increased risk of PE after TKA in patients with a history of BrCa as well as increased 90‐day costs, which warrant great attention.

Arthroscopic Management of Hip Chondral Defects: A Systematic Review of the Literature

Over the past decade, arthroscopic microfracture has become increasingly popular to treat full-thickness (Outerbridge grade IV) chondral defects of the hip. This procedure borrows marrow stimulation treatment principles and techniques from knee arthroscopy, with similar mixed clinical outcomes that may be more favorable in the short term (<2 years) and poorer in the long term. Despite these varied outcomes, microfracture remains the most frequently used technique to treat small focal chondral defects because of the relative ease and cost-effectiveness of the procedure. Consequently, recent efforts have been aimed at improving or augmenting traditional microfracture to achieve more consistent success. BioCartilage (Arthrex, Naples, FL) is a biologically active scaffold containing allograft cartilage that, when combined with autologous conditioned platelet-rich plasma and placed in a defect in which microfracture was performed, may provide a superior repair that mimics native hyaline cartilage rather than the less-durable fibrocartilage that is formed with microfracture alone. This Technical Note and accompanying video review the pertinent techniques, pearls, and potential pitfalls of the microfracture procedure augmented with BioCartilage in the treatment of symptomatic full-thickness chondral defects of the hip.

Intraoperative CT and Surgical Navigation for Iliosacral Screws: Technique for Patients With Sacral Dysmorphism

Background: The effect of hip arthroscopy on athletic performance compared with preinjury levels for professional athletes in different sports remains unknown. In addition, while return rates have been reported for professional baseball, football, and hockey players, return rates have not been reported for professional basketball players. Hypothesis: Professional athletes in 4 major North American sports would be able to return to their sport and preoperative level of performance at a high rate after arthroscopic hip surgery. Study Design: Descriptive epidemiology study. Methods: Major League Baseball (MLB), National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL) athletes who underwent hip arthroscopy were identified through a previously reported protocol based on public sources. Successful return to play (RTP) was defined as returning for at least 1 professional regular season game after surgery. Performance scores were calculated by use of previously established scoring systems. Each player served as his own control, with the season prior to surgery defined as baseline. To make comparisons across sports, the authors adjusted for expected season and career length differences between sports and calculated percentage changes in performance. Results: The authors identified 227 procedures performed on 180 professional athletes between 1999 and 2016. Successful RTP was achieved in 84.6% (192/227) of the procedures. Compared with all other athletes, NBA athletes returned at a similar rate (85.7%, P ≥ .999). NFL offensive linemen returned at a significantly lower rate than all other athletes (61.1%, P = .010). NHL athletes returned at a significantly higher rate than all other athletes (91.8%, P = .048) and demonstrated significantly decreased performance during postoperative season 1 compared with baseline (–35.1%, P = .002). Lead leg surgery for MLB athletes (batting stance for hitters, pitching stance for pitchers) resulted in a 12.7% reduction in hitter performance score (P = .041), a 1.3% reduction in pitcher fastball velocity (P = .004), and a 60.7% reduction in pitch count (P = .007) one season after surgery compared with baseline. Players in nearly every sport demonstrated significant reductions in game participation after surgery. Conclusion: This study supports the hypothesis that hip arthroscopy in professional athletes is associated with excellent rates of return at the professional level. However, postoperative performance outcomes varied based on sport and position.