Scott M. Eskildsen

Use of an IL1-receptor antagonist to prevent the progression of tendinopathy in a rat model.

This study evaluated if inhibiting IL1‐β activity with an IL1‐receptor antagonist (IL1‐RA) will prevent pathologic changes commonly seen in tendinopathy. Thirty‐six Sprague–Dawley retired‐breeder rats were divided into three groups having weekly bilateral patellar tendon injections: CON (0.1 ml Saline), CAR (0.1 ml 2% carrageenan), IL1‐RA (0.1 ml 2% CAR plus 0.94 mg of the IL1‐RA, 2.5 mg/kg). Carrageenan was used to establish tendinopathy in two groups due to its ability to develop tendinopathy in prior studies. Animals were euthanized 3 weeks after initial injection. The CAR group demonstrated significantly (p < 0.05) shorter tendon lengths (8.61 ± 0.38 mm) relative to CON (8.94 ± 0.38 mm) that was prevented in the IL1‐RA (9.02 ± 0.30 mm) as well as significantly increased collagenase activity in the CAR (0.061 ± 0.043) compared to CON (0.027 ± 0.015) (p<  0.05). By histological evaluation, the CAR group demonstrated significantly greater inflammation than IL1‐RA, and CON (p < 0.05). CAR showed a trend for increased cross‐sectional area relative to CON that was absent in the IL1‐RA. IL1‐RA can effectively inhibit the development of mechanical, chemical, and histologic changes seen with carrageenan‐induced tendonitis.

Patient Satisfaction Is Associated With Time With Provider But Not Clinic Wait Time Among Orthopedic Patients

Clinic wait time is considered an important predictor of patient satisfaction. The goal of this study was to determine whether patient satisfaction among orthopedic patients is associated with clinic wait time and time with the provider. The authors prospectively enrolled 182 patients at their outpatient orthopedic clinic. Clinic wait time was defined as the time between patient check-in and being seen by the surgeon. Time spent with the provider was defined as the total time the patient spent in the examination room with the surgeon. The Consumer Assessment of Healthcare Providers and Systems survey was used to measure patient satisfaction. Factors associated with increased patient satisfaction included patient age and increased time with the surgeon (P=.024 and P=.037, respectively), but not clinic wait time (P=.625). Perceived wait time was subject to a high level of error, and most patients did not accurately report whether they had been waiting longer than 15 minutes to see a provider until they had waited at least 60 minutes (P=.007). If the results of the current study are generalizable, time with the surgeon is associated with patient satisfaction in orthopedic clinics, but wait time is not. Further, the study findings showed that patients in this setting did not have an accurate perception of actual wait time, with many patients underestimating the time they waited to see a provider. Thus, a potential strategy for improving patient satisfaction is to spend more time with each patient, even at the expense of increased wait time. [Orthopedics. 2017; 40(1):43-48.].

Technical Tip and Cost Analysis for Lesser Toe Plantar Plate Repair With a Curved Suture Needle

The plantar plate is a thick ligamentous connection between the distal plantar metatarsal metaphyseal flare and the plantar base of the proximal phalanx. It has been recognized as the primary stabilizer of the metatarsophalangeal joint (MTP), and attenuation can lead to pain, instability, subluxation, and frank dislocation, including the eponymous “cross over toe” deformity. Insufficiency can result from acute traumatic tears but more commonly is the result of gradual degeneration, frequently associated with concomitant structural forefoot pathology including hammer or claw toe deformity or adjacent hallux valgus or rigidus. Tears tend to occur distally, and the second digit is most commonly affected. While most authors recommend conservative treatment before progressing to operative intervention, several operative techniques have been developed for recalcitrant cases. Initially, these involved tendon transfers and soft tissue releases, often used in conjunction. Synovectomy and osseous decompression were also described. Recurrence and continued pain were the most common complications seen after indirect repair techniques, and a cadaveric study suggested direct repair as a biomechanically viable alternative. These observations initially led to a technique utilizing a plantar approach for direct plantar plate repair or, in cases of more extensive damage, plantar plate transection with advancement and anchoring into the base of the proximal phalanx. Plantar repairs initially demonstrated good results when used in conjunction with tendon transfers and interphalangeal fusion. A dorsal approach for direct plantar plate repair subsequently gained attention as it has the potential to avoid painful plantar scars and allow access to adjacent MTPs through a single incision. Following a cadaveric study demonstrating its feasibility, multiple dorsal approach techniques were developed utilizing a metatarsal shortening osteotomy. At least 3 of these involve proprietary instruments to facilitate suture passage through the substance of the distal plantar plate. These facilitate efficient procedures and early data suggest good results, but the financial cost is substantial. The purpose of this article is to describe a technical modification to the dorsal approach to facilitate plantar plate repair without the relatively expensive proprietary instruments used for suture passage through the distal aspect of the plate and to analyze and discuss the potential associated cost reductions.

An Algorithmic Approach to Venous Thromboembolism Prophylaxis in Spine Surgery.

Venous thromboembolic embolism (VTE) is a potentially serious and life-threatening complication in spine surgery. However, VTE incidence and prophylaxis in spine surgery remains controversial. Current recommendations for VTE prophylaxis address “spine surgery” as a single broad category and mainly consider patient factors when determining risk. We performed a literature review to determine the varying VTE and bleeding risks within spine surgery to develop an individualized prophylactic algorithm. Our review suggests that the current guidelines on VTE prophylaxis for spine surgery from NASS and ACCP are suboptimal. Consideration of (1) patient-related VTE risks, (2) procedure-related VTE risks, and (3) the risk of neurological compromise from bleeding complications will more appropriately balance safety and effectiveness when choosing a VTE prophylaxis method. To better individualize VTE prophylaxis, we have developed the VTE Prophylaxis Risk/Benefit Score that considers this currently available best evidence to arrive at a recommendation for the most appropriate form of VTE prophylaxis. This algorithm informs the surgeon to help make a more nuanced and individualized determination of prophylaxis.

The use of an IL1-receptor antagonist to reverse the changes associated with established tendinopathy in a rat model: XXXX

Interleukin‐1 (IL1) is a cytokine that plays a role in inflammation and is a potential contributor to the inflammation present in tendinopathy. Its inhibition may be of use in the treatment of tendinopathy and has been a target for treatment. To evaluate how an IL1‐receptor antagonist (IL1‐RA) reverses pathologic changes associated with established patellar tendinopathy, we randomized 48 Sprague‐Dawley retired breeder rats into three groups having weekly bilateral patellar tendon injections for 6 weeks. The control group received 0.1 mL saline for 6 weeks. The intervention groups were treated with 0.1 mL 2% carrageenan for 4 weeks. Beginning at week three, the IL1‐RA group received 0.94 mg of the IL1‐RA (2.5 mg/kg) added to the 0.1 mL 2% carrageenan and 0.94 mg of the IL1‐RA alone for the final 2 weeks, while the CAR received 0.1 mL saline for the final 2 weeks. Animals were euthanized 6 weeks after initial injection. The CAR group demonstrated significantly (P < 0.05) shorter tendon lengths (7.81 ± 0.44 mm) than the control (8.25 ± 0.58 mm) and IL1‐RA (8.34 ± 0.52 mm) group (P < 0.05). Macroscopically, plaque‐like formations were reduced and margins of the tendon were more evident in the IL1‐RA group compared to the CAR group. CAR group demonstrated significantly greater histopathologic changes (inflammatory cell density, disorganization of collagen, nuclear rounding, and angiogenesis) than the control and IL1‐RA group. No significant difference in mechanical properties of the tendon was noted. These findings demonstrate IL1‐RA can reduce pathologic changes in the patellar tendon in an established tendonitis model although did not demonstrate a difference in mechanical properties.

Systemic cobaltism manifesting as oral mucosal discoloration and metallic gustation after metal-on-metal hip resurfacing

Systemic cobaltism is a debilitating complication of metal-on-metal (MoM) arthroplasty. In this report, we review a case of a 54-year-old female with metallosis from a MoM hip resurfacing and varying degrees of black discoloration of her tongue and metallic gustation as a result of systemic cobaltism. After explanting the metal components, thorough debridement, and conversion to ceramic-on-polyethylene arthroplasty, the patient’s oral mucosal discoloration and metallic gustation resolved. This represents the first documentation of systemic cobaltism from MoM hip resurfacing manifesting as oral mucosal discoloration and metallic gustation with resolution after explant, debridement, and conversion to ceramic-on-polyethylene total hip arthroplasty.

Timed Up and Go test is predictive of Patient-Reported Outcomes Measurement Information System physical function in patients awaiting total knee arthroplasty

Background The Patient Reported Outcomes Measurement Information System (PROMIS) Computerized Adaptive Test (CAT) physical function rapidly assesses self-reported function capability. The Timed Up and Go (TUG) test is often used in clinical practice, but administration may be impeded by space and patient limitations. PROMIS CAT can potentially address these limitations, but we lack evidence if TUG and health indicators are predictors of PROMIS CAT. This study assessed whether TUG, body mass index (BMI), numeric pain rating scale (NPRS), and smoking status were predictors of PROMIS CAT in total knee arthroplasty (TKA) candidates. Methods Sixty-five TKA candidates completed the PROMIS CAT physical function test using an iPad application. TUG, NPRS, BMI, and smoking status were obtained at the clinic visit or from medical records. Univariate and multiple regression analyses identified the strongest predictors of PROMIS CAT. Results TUG was the best predictor of PROMIS CAT physical function based on simple regression (r = −0.43, 95% CI = −0.62 to −0.20) or multiple regression (βˆ = −0.45, 95% CI = −0.73 to −0.17) analyses. BMI and NPRS did not incrementally help predict the PROMIS score beyond TUG. Smoking status did not contribute to the prediction of the PROMIS CAT score. Conclusions The findings suggest that the PROMIS CAT physical function is not a surrogate for the TUG performance-based measure in candidates for TKA. However, TUG was the best predictor of PROMIS physical function compared with BMI, NPRS, and smoking status. Clinicians should consider both patient-reported and performance-based measures when evaluating function for TKA outcomes.

The Effect of a Door Alarm on Operating Room Traffic During Total Joint Arthroplasty

Operating room traffic has been implicated in several studies to contribute to the risk of surgical site infections and periprosthetic joint infections. The purpose of this study was to evaluate the effect of a door alarm on operating room traffic during total joint arthroplasty. This prospective cohort study evaluated 100 consecutive primary total hip and knee arthroplasty surgeries performed by a single surgeon. An inconspicuous electronic door counter was placed on the substerile operating room door. Door openings and time left ajar were recorded. After 50 cases, an audible alarm was placed on the substerile operating room door that sounded continuously when the door was ajar. Door-opening data were then recorded for an additional 50 cases. There was a significant difference in the overall mean door openings per minute (P<.001) between the period with no alarm (0.53±0.1) and with an alarm (0.42±0.1). This effect slowly decreased over the time of the intervention, with door openings per minute increasing by a factor of 1.01. The percentage of time the door was left ajar per case also decreased significantly (P<.001) with the alarm (6.63%±1.6%) compared with no alarm (8.65%±1.5%). This study indicates that the use of a door alarm can decrease door openings and potentially the risk for surgical site infection. However, the effect is subject to tolerance and may not result in the elimination of unnecessary operating room traffic long term. [Orthopedics. 2017; 40(6):e1081-e1085.].

Canted seating of the Stryker Modular Dual Mobility liner within a Trident hemispherical acetabular shell

A 75-year-old woman who suffered a left femoral neck fracture underwent a left total hip arthroplasty using a Stryker Trident (Kalamazoo, MI) hemispherical acetabular shell and Modular Dual Mobility (MDM) metal liner. Post-operative radiographs demonstrated canted seating of the liner. The patient was taken immediately back to the operating room where the acetabular liner appeared well seated superiorly but was in a canted position inferiorly. Removal and replacement was performed and post-operative radiographs demonstrated complete seating. Subsequent follow up at 6 months demonstrated good clinical function with no adverse radiographic findings. Canted seating is a potential complication of the MDM metal liner. Providers should be aware of potential incomplete seating inferiorly despite the superior portion of the liner being well seated.