Lindsay T. Kleeman

C5 palsy after cervical laminectomy and fusion: does width of laminectomy matter?

BACKGROUND CONTEXT A common complication of cervical laminectomy and fusion with instrumentation (CLFI) is development of postoperative C5 nerve palsy. A proposed etiology is excess nerve tension from posterior drift of the spinal cord after decompression. We hypothesize that laminectomy width will be significantly increased in patients with C5 palsy and will correlate with palsy severity. PURPOSE The purposes of this study were to evaluate laminectomy width as a risk factor for C5 palsy and to assess correlation with palsy severity. STUDY DESIGN/SETTING This is a retrospective, single-institution clinical study. PATIENT SAMPLE Patient population included all patients with cervical spondylotic myelopathy who underwent CLFI between 2007 and 2014 by a single surgeon. Patients who underwent CLFI for trauma, infection, or tumor or had previous or circumferential cervical surgery were excluded. All patients with a new C5 palsy received a postoperative magnetic resonance imaging. An additional computed tomography (CT) scan was ordered to assess hardware. All control patients received a CT scan at 6 months postoperatively to evaluate fusion. OUTCOME MEASURES The association between width of laminectomy and development of postopeative C5 palsy was measured. METHODS Patient comorbidities including obesity, smoking history, and diabetes were recorded in addition to preopertaive and postoperative deltoid and biceps motor strength. Sagittal alignment was measured with C2-C7 Cobb angle preopertaive and postoperative radiographs. The width of laminectomy was measured in a blinded fashion on the postoperative CT scan by two observers. RESULTS Seventeen patients with C5 nerve palsy and 12 controls were identified. There were no baseline differences in age, sex, diabetes, smoking history, number of surgical levels, or sagittal alignment. Body mass index was significantly higher in the control cohort. There was no significant increase in the C3-C7 laminectomy width in patients with postoperative C5 palsy. The width of laminectomy measurments were highly similar between the two observers. There was no correlation between laminectomy width and palsy severity. CONCLUSIONS This is the largest series of C5 palsies after laminectomy documented with CT imaging. Laminectomy width was not associated with an increased risk of postoperative C5 palsy at any level. Reduction in laminectomy width may not reduce rate of postoperative nerve palsy.

Bearing Surfaces for Total Hip Arthroplasty

Metal-on-highly cross-linked polyethylene is considered the preferred bearing surface for conventional total hip arthroplasty because of its safety profile and excellent results in the first 10 to 15 years of use. However, with younger patient age, activity expectations increase, and the life expectancy of patients with total hip arthroplasty also has increased, so interest remains in other bearing couples. These other options include the use of various ceramic composites for the femoral head on highly cross-linked polyethylene, the so-called second-generation antioxidant polyethylenes, and ceramic acetabular liners. Several of these bearing couples have shown excellent wear rates in vitro, and short-term clinical studies have demonstrated favorable wear and safety results. It is uncertain whether any of these bearing couples should be adopted at present. Understanding the unique properties and possible complications of these bearing couples is critical for appropriate implant selection.

Risks and Benefits of the Different Types of Gloves used in the Perioperative Setting

The role of powder gloves in allergic reactions, infections, wound healing and granuloma formation has been known for many years. Despite a gradual shift away from powder gloves over the last several decades, many healthcare professionals and facilities continue to use powder gloves as the FDA has continued to refrain from issuing a comprehensive formal ban. However, recent advancements in glove technology and position statements by professional societies have continued the push for removal of powder gloves from all clinical and surgical settings and will hopefully entirely eradicate usage in the coming years.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy: Is there a Difference in Perioperative Complications compared with Periacetabular Osteotomy Alone?

Purpose: To evaluate the safety of hip arthroscopy combined with a periacetabular osteotomy (PAO) compared with PAO alone in treating concomitant intra-articular pathology in hip dysplasia. Materials and methods: Forty-one patients (46 hips) with symptomatic hip dysplasia were retrospectively reviewed. Preand postoperative radiographic data and intraoperative data consisting of estimated blood loss, intraoperative and postoperative blood transfusions, operative time, and length of hospital stay were recorded. The complications occurring within the first 3 months after surgery including lateral femoral cutaneous and pudendal nerve neuropraxia, wound complications, and reoperations were recorded. Additionally, rates of deep venous thrombosis and other major adverse outcomes (myocardial infarction, pulmonary embolism, stroke, death) were examined. Results: Twenty-one patients (24 hips) underwent PAO alone. Twenty patients (22 hips) underwent hip arthroscopy followed immediately by PAO. There were no significant differences in the 90-day complication rates between the two groups, comparing the rate of neuropraxia (p = 0.155) and wound complications (p = 0.6). Operative time for PAO alone was 179 minutes (standard deviation [SD] ± 37) compared with 251 minutes (SD ± 52) for combined hip arthroscopy and PAO (p < 0.001). No incidence of deep vein thrombosis or major adverse events was noted in either group. Preoperative lateral center edge angle (LCEA) and acetabular index (AI) were 14° and 20° respectively, in the PAO-alone group and 19° and 16° respectively, in the combined group. Postoperatively, LCEA was 29° in the PAOalone group and 30° in the combined group. Postoperative AI was 11° in the PAO-alone group and 5° in the combined group. Conclusion: This study demonstrates that hip arthroscopy in combination with PAO to treat intra-articular pathology shows no difference in 90-day complication rates when compared with PAO alone. RETROSPECTIVE COMPARATIVE STUDY 1,2Fellow, 3Resident, 4,5Surgeon, 6Professor 1Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, USA 2Department of Orthopaedic Surgery, Rady Children’s Hospital San Diego, California, USA 3,4,6Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA 5Mount Kisco Medical Group, Fishkill, New York, USA Corresponding Author: Julie A Neumann, Fellow, KerlanJobe Orthopaedic Clinic, Los Angeles, California, USA, Phone: +2253175800, e-mail: Julie.Neumann.MD@gmail.com 10.5005/jp-journ ls-10017-1083 Level of evidence: Level III, retrospective comparative study

Novel Use of a Trabecular Metal Augment in a Severe Acetabular Defect

Many total hip arthroplasties are complicated by severe acetabular bone loss, limiting reconstruction options. This case report details the use of a 54-mm trabecular metal straight buttress and press-fit jumbo cup to reconstruct an especially large superior and medial defect (Paprosky type IIIB). Specifically, the large defect was reconstructed by placing the augment superior-medially in the acetabular defect instead of simply superiorly and attached to the iliac wing as it is more commonly employed. To our knowledge, there has been no reported use of a similar augment to fill such a defect in this way. This technique represents a promising potential option for reconstruction of especially large superior and medial acetabular defects

Stability of Ankle Fracture–dislocations following Successful Closed Reduction

Introduction: Following successful closed reduction, the ideal timing of operative fixation for ankle fracture–dislocations is not well understood. We sought to describe the rate at which initial reduction is lost between the Emergency Department (ED) and clinic visits, and to identify factors associated with loss of reduction. Materials and methods: We identified 30 patients with isolated, closed ankle fracture–dislocations that were successfully reduced and splinted in the ED prior to operative intervention. The maintenance of reduction at follow-up clinic visit was defined as a success, and loss of reduction was defined as a failure. Results: There were 17 (57%) successes and 13 (43%) failures. When the ratio of posterior malleolus (PM) fracture fragment size to complete articular surface was >0.1, rate of failure was 65% compared with 18% when the ratio was ≤0.1 (p = 0.016). Conclusion: Ankle fracture–dislocations with a larger PM fracture fragment size may warrant consideration of earlier operative intervention. Level of evidence: IV, Case Series.

Assessment Measures for Evaluation of Outcomes in Transtibial Amputees resulting from Trauma: A Systematic Review

Introduction: Amputations secondary to high-energy open fractures and blast, ballistic, and crush injuries to the lower extremity are common challenges faced by military and civilian orthopaedic surgeons. A lack of consensus on domains to be measured and quality of prosthetic rendering pose methodological challenges to researchers and clinicians alike. We conducted a systematic review of the literature to summarize which domains of health, prosthetic fit, and prosthetic alignment are used to describe outcomes for lower extremity amputees secondary to trauma. Materials and methods: A search of PubMed, Cochrane, and Embase was conducted including the keywords: Amputation, traumatic, transtibial, survey, and metric. Articles were selected based on whether the study assessed clinical outcomes following transtibial amputation following trauma. Experimental and observational comparative studies and case series were included. Study characteristics and results were extracted using standardized data forms. The number of unique measures recorded, the frequency of measure use, and the number outcome measures were validated and were compiled. Results: Literature search ultimately resulted in 273 articles being included. A conceptual model was constructed to capture and organize the causal and temporal relationships between fit, alignment, and outcome. Of the 68 articles that used questionnaires to assess prosthetic fit, 37 used a questionnaire designed specifically for the study as opposed to a published or validated tool. Four validated tools were commonly used to capture patient satisfaction with a prosthesis: The OPUS, PEQ, TAPES, and the Socket Comfort Fit Score. Prosthetic alignment was assessed in 19 of 273 articles. One article validated the use of an alignment jig for quantification and prescription of prostheses. Totally, 8 of 19 articles assessing alignment used gait analysis and ground reaction forces to capture differences due to alterations in alignment. Discussion: Choice of an appropriate outcome measure is critical in generating evidence to support treatment decisions for patients undergoing transtibial amputation after trauma. We found a large number of different tools being used across studies, making results difficult to compare. Prosthetic fit and comfort of the residual limb in the socket and the alignment of REVIEW ARTICLE 1Resident, 2Associate Professor 1Department of Orthopaedic Surgery, Duke University, Durham North Carolina, USA 2Department of Orthopaedic Surgery, In-Residence–USCF, San Francisco, California, USA Corresponding Author: Rita Baumgartner, Resident, Department of Orthopaedic Surgery, Duke University, Durham, North Carolina USA, e-mail: rita.baumgartner@duke.edu 10.5005/jp-journals-10017-1077 the socket and the shank of the prosthesis make up the foundation for the proposed conceptual model. In order to distinguish effects attributable to an intervention of interest vs the impact of the quality of the socket fitting, validation of a clinically objective scoring system to assess socket fit is necessary. Conclusion: A large number of different tools are currently being used across studies to assess outcomes for transtibial amputees resulting from trauma, and there is a need for development and validation of a clinically objective scoring system to assess socket fit.

Role of the Clinical Research Coordinator in Orthopaedic Research: Making Research Less Onerous

Conducting clinical research can be challenging. The challenges are derived from not only the logistical difficulties of proper scientific conduct but also the many regulatory bodies that are in place to safeguard against harm in subjects involved in clinical research. With the advent of the role of the Clinical Research Coordinator (CRC) these challenges have improved. However, many don’t understand the exact role of the CRC.