Matthew E. Deren

Stress Fractures of the Pelvis and Legs in Athletes: A Review

Context: Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time. Evidence Acquisition: PubMed articles published from 1974 to January 2012. Results: Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. Conclusions: These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.

Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature

BACKGROUND While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior. METHODS A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material. RESULTS This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables. CONCLUSION Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft. LEVEL OF EVIDENCE Level IV.

Prewarming Operating Rooms for Prevention of Intraoperative Hypothermia During Total Knee and Hip Arthroplasties

Prewarming operating rooms has been shown to limit hypothermia in pediatric surgical patients but may be associated with extreme discomfort for surgeons. We examined the effect of prewarming operating rooms on core temperatures during knee and hip arthroplasties. Sixty-six patients were randomized to the prewarmed group at 24 °C or control group at 17 °C. The prewarmed group core temperature (mean, 36.14 °C) before active warming was significantly higher (P = .018) than that of the control group (mean, 35.83 °C). By the start of surgery, the difference was 36.01 °C prewarmed vs 35.83 °C control, P = .038. There was no significant difference in the last recorded mean temperatures between groups: 36.35°C (prewarmed) vs 36.16 °C (control). A prewarmed operating room for adults undergoing knee or hip arthroplasty had minimal effect on preventing intraoperative hypothermia.

A review of bone growth stimulation for fracture treatment

Delay or failure of fracture healing is a common, significant clinical problem confronting orthopaedic surgeons. Treatment options consist of invasive surgical techniques, such as internal and external fixation, bone grafting, and more radically, amputation. Noninvasive options include bone growth stimulation. A PubMed search was performed for basic science and clinical articles regarding bone growth stimulation in the English language. Articles were assessed for study design, size, validity (with previously published literature), technology utilized, and method of treatment. The search identified articles from 1957 to present. These articles were reviewed, and ten additional references (i.e. book chapters) were analyzed as well. Meta-analysis of the data on bone growth stimulators for delayed and nonunion of fractures is difficult because of the heterogeneity of various trials and device specifications. Large, randomized, placebo-controlled trials are lacking, and much of the data reflect larger case series and comparative studies. Nevertheless, basic science and clinical evidence support the efficacy of bone growth stimulation as a fracture healing modality in the appropriate clinical situation.

A Review of Modern Management of Lateral Epicondylitis

Abstract Lateral epicondylitis, or tennis elbow, is the most common cause of elbow pain. This degenerative condition can manifest as an acute process lasting < 3 months or a chronic process often refractory to treatment. Symptom resolution occurs in 70% to 80% of patients within the first year. A “watch-and-wait” approach can be an appropriate treatment option, although physical therapy has been shown to be an effective first-line therapy. Corticosteroids, while providing relief of pain in the acute setting, may be detrimental to recovery in the long term. Platelet-rich plasma injections, although recently well publicized, have not been proven by well-controlled clinical trials to be effective therapy. For patients with symptoms refractory to conservative management, surgical intervention has shown to be a successful treatment modality.

Assessment and Treatment of Malnutrition in Orthopaedic Surgery

Malnutrition in orthopaedic patients, a condition that is overlooked and understudied, has substantial effects on outcomes1-6. Underweight and malnourished elderly patients are at risk of experiencing reduced well-being and autonomy as well as increased mortality as compared with their counterparts of normal weight7. Malnutrition may be simply defined as an imbalance of energy, protein, and nutrients leading to functional and compositional adverse effects on the body8,9. By this definition, as much as 15% of ambulatory and 65% of hospitalized patients are malnourished10. Without adequate nutrition, orthopaedic patients are more susceptible to infections, slower healing rates, and sarcopenia (reduced lean body mass and muscle function)8. Stratifying malnutrition on the basis of etiology (e.g., “starvation-related,” “chronic disease-related,” and “acute injury or illness-related”) facilitates the formation of a more clinically relevant definition11. In starvation, the primary problem is reduced intake, possibly due to socioeconomic factors or secondary to anorexia6. With chronic disease and acute injury, increases in resting energy expenditure and protein requirements due to the inflammatory response contribute to malnourishment7. The new etiology-based approach to the diagnosis of malnutrition …

Biological and Chemical Removal of Primary Cilia Affects Mechanical Activation of Chondrogenesis Markers in Chondroprogenitors and Hypertrophic Chondrocytes

Chondroprogenitors and hypertrophic chondrocytes, which are the first and last stages of the chondrocyte differentiation process, respectively, are sensitive to mechanical signals. We hypothesize that the mechanical sensitivity of these cells depends on the cell surface primary cilia. To test this hypothesis, we removed the primary cilia by biological means with transfection with intraflagellar transport protein 88 (IFT88) siRNA or by chemical means with chloral hydrate treatment. Transfection of IFT88 siRNA significantly reduced the percentage of ciliated cells in both chondroprogenitor ATDC5 cells as well as primary hypertrophic chondrocytes. Cyclic loading (1 Hz, 10% matrix deformation) of ATDC5 cells in three-dimensional (3D) culture stimulates the mRNA levels of chondrogenesis marker Type II collagen (Col II), hypertrophic chondrocyte marker Type X collagen (Col X), and a molecular regulator of chondrogenesis and chondrocyte hypertrophy bone morphogenetic protein 2 (BMP-2). The reduction of ciliated chondroprogenitors abolishes mechanical stimulation of Col II, Col X, and BMP-2. In contrast, cyclic loading stimulates Col X mRNA levels in hypertrophic chondrocytes, but not those of Col II and BMP-2. Both biological and chemical reduction of ciliated hypertrophic chondrocytes reduced but failed to abolish mechanical stimulation of Col X mRNA levels. Thus, primary cilia play a major role in mechanical stimulation of chondrogenesis and chondrocyte hypertrophy in chondroprogenitor cells and at least a partial role in hypertrophic chondrocytes.

Increased Mortality in Elderly Patients with Sarcopenia and Acetabular Fractures

Background: Sarcopenia is a condition of clinically relevant loss of muscle mass and function. Acetabular fractures in elderly patients are common and difficult to treat. This study aimed to determine if sarcopenia is common in elderly patients with acetabular fractures and correlates with lower-energy mechanisms of injury, higher rates of complications, and higher mortality than patients with normal muscle mass. Methods: The Rhode Island Hospital Trauma Database was queried for patients who were ≥60 years of age from 2005 to 2014 using the International Classification of Diseases, Ninth Revision, code for closed acetabular fracture, 808.0. Charts were retrospectively reviewed for demographic data, operative intervention, mechanism of injury, mortality, comorbidities, and other factors. Computed tomography (CT) was used to determine the muscle cross-sectional area and to calculate the skeletal muscle index. Results: The database revealed 192 patients coded for acetabular fracture; of these, 181 were correctly diagnosed. Ninety-nine patients had recorded body mass index (BMI) and adequate CT scans to measure the skeletal muscle index. Forty-two patients (42.4%) had sarcopenia, and 57 patients (57.6%) did not have sarcopenia. There were no significant differences in demographic characteristics between the groups with the exception of BMI and sex. BMI was higher in patients who did not have sarcopenia (31.7 kg/m2) than it was in patients with sarcopenia (23.6 kg/m2) (p < 0.001). Male sex was significantly greater (p = 0.0104) in patients with sarcopenia at 76.2% (32 of 42 patients) than in patients without sarcopenia at 50.9% (29 of 57 patients). Fractures in patients without sarcopenia were associated with a higher-energy mechanism of injury in 78.9% of cases compared with 52.4% of cases of patients with sarcopenia (p = 0.005). Sarcopenia was significantly associated (p = 0.0419) with increased 1-year mortality (28.6%) compared with the absence of sarcopenia (12.3%). This association was even stronger if in-hospital mortality was excluded (p = 0.00074). Finally, anterior column fractures were more likely (p = 0.017) to be sustained by patients with sarcopenia at 47.6% (20 patients) than by patients who did not have sarcopenia at 24.6% (14 patients). Conclusions: Sarcopenia is common in elderly patients with acetabular fractures and is associated with lower-energy mechanisms, anterior column fractures, and higher risk of 1-year mortality. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Posterior Sternoclavicular Dislocations: A Brief Review and Technique for Closed Management of a Rare But Serious Injury

Posterior sternoclavicular dislocations are rare but serious injuries. The proximity of the medial clavicle to the vital structures of the mediastinum warrants caution with management of the injury. Radiographs are the initial imaging test, though computed tomography and magnetic resonance imaging are essential for diagnosis and preoperative planning. This paper presents an efficient diagnostic approach and effective technique of closed reduction of posterior sternoclavicular dislocations with a brief review of open and closed reduction procedures.

Internal impingement: a review on a common cause of shoulder pain in throwers.

Abstract Internal impingement is a term used to describe the pathologic contact of the undersurface of the rotator cuff with the glenoid. It typically occurs in overhead athletes, particularly throwers. In these athletes, the bones and soft tissues adapt to allow these athletes to have a supraphysiologic range of motion. In many athletes, these changes may lead to symptoms of internal impingement. This article discusses the background, biomechanics, pathophysiology, clinical and radiographic assessment, treatments, and outcomes of this disorder.