Timothy T. Roberts

Bone grafts, bone substitutes and orthobiologics: The bridge between basic science and clinical advancements in fracture healing

The biology of fracture healing is better understood than ever before, with advancements such as the locking screw leading to more predictable and less eventful osseous healing. However, at times one’s intrinsic biological response, and even concurrent surgical stabilization, is inadequate. In hopes of facilitating osseous union, bone grafts, bone substitutes and orthobiologics are being relied on more than ever before. The osteoinductive, osteoconductive and osteogenic properties of these substrates have been elucidated in the basic science literature and validated in clinical orthopaedic practice. Furthermore, an industry built around these items is more successful and in demand than ever before. This review provides a comprehensive overview of the basic science, clinical utility and economics of bone grafts, bone substitutes and orthobiologics.

Management of chronic musculoskeletal pain.

&NA; Chronic musculoskeletal pain results from a complex interplay of mechanical, biochemical, psychological, and social factors. Effective management is markedly different from that of acute musculoskeletal pain. Understanding the physiology of pain transmission, modulation, and perception is crucial for effective management. Pharmacologic and nonpharmacologic therapies such as psychotherapy and biofeedback exercises can be used to manage chronic pain. Evidence‐based treatment recommendations have been made for chronic pain conditions frequently encountered by orthopaedic surgeons, including low back, osteoarthritic, posttraumatic, and neuropathic pain. Extended‐release tramadol; select tricyclic antidepressants, serotonin reuptake inhibitors, and anticonvulsants; and topical medications such as lidocaine, diclofenac, and capsaicin are among the most effective treatments. However, drug efficacy varies significantly by indication. Orthopaedic surgeons should be familiar with the widely available safe and effective nonnarcotic options for chronic musculoskeletal pain.

ISSLS Prize Winner: Dynamic Loading-Induced Convective Transport Enhances Intervertebral Disc Nutrition

Study Design. Experimental animal study of convective transport in the intervertebral disc. Objective. To quantify the effects of mechanical loading rate on net transport into the healthy and degenerative intervertebral disc in vivo. Summary of Background Data. Intervertebral disc degeneration is linked with a reduction in transport to the avascular disc. Enhancing disc nutrition is, therefore, a potential strategy to slow or reverse the degenerative cascade. Convection induced by mechanical loading is a potential mechanism to augment diffusion of small molecules into the disc. Methods. Skeletally mature New Zealand white rabbits with healthy discs and discs degenerated via needle puncture were subjected to low rate axial compression and distraction loading for 2.5, 5, 10, 15, or 20 minutes after a bolus administration of gadodiamide. Additional animals with healthy discs were subjected to high-rate loading for 10 minutes or no loading for 10 minutes. Transport into the disc for each loading regimen was quantified using post–contrast-enhanced magnetic resonance imaging. Results. Low-rate loading resulted in the rapid uptake and clearance of gadodiamide in the disc. Low-rate loading increased net transport into the nucleus by a mean 16.8% and 12.6% in healthy and degenerative discs, respectively. The kinetics of small molecule uptake and clearance were accelerated in both healthy and degenerative discs with low-rate loading. In contrast, high-rate loading reduced transport into nucleus by a mean 16.8%. Conclusion. These results illustrate that trans-endplate diffusion can be enhanced by forced convection in both healthy and degenerative discs in vivo. Mechanical loading–induced convection could offer therapeutic benefit for degenerated discs by enhancing uptake of nutrients and clearance of by-products. Level of Evidence: 4

Diagnosis and Management of Langerhans Cell Histiocytosis

Langerhans cell histiocytosis is a rare group of disorders without a well-understood etiology. Known formerly as histiocytosis X, the disease has a wide spectrum of clinical presentations, including eosinophilic granuloma (solitary bone lesion), diabetes insipidus, and exophthalmos. It is also known by several eponyms, including Hand-Schüller-Christian disease when it manifests as a triad of cranial bone lesions and Letterer-Siwe disease when it is found in infantile patients with severely disseminated disease. Children aged 5 to 15 years are most commonly affected. Many of these patients initially present to orthopaedic surgeons, and misdiagnosis is frequent. To accurately diagnosis and treat these patients, the orthopaedic surgeon must be familiar with the clinical manifestations and pathophysiology of the disease as well as the treatment guidelines and outcomes for Langerhans cell histiocytosis.

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike.

Objective: Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. Design: Retrospective case–control study. Setting: Level 1 academic trauma center. Patients: A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. Intervention: Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). Main Outcome Measures: Surgical timing, intervention type, perioperative complications, and postoperative length of stay. Results: Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM–7:30 AM) for all femoral neck fractures (66.7%–19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). Conclusions: In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

BACKGROUND Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers. METHODS We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845). RESULTS MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048). CONCLUSIONS MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.

Orthopaedic Considerations for the Adult With Osteogenesis Imperfecta

Osteogenesis imperfecta is a heritable group of collagen-related disorders that affects up to 50,000 people in the United States. Although the disease is most symptomatic in childhood, adults with osteogenesis imperfecta also are affected by the sequelae of the disease. Orthopaedic manifestations include posttraumatic and accelerated degenerative joint disease, kyphoscoliosis, and spondylolisthesis. Other manifestations of abnormal collagen include brittle dentition, hearing loss, cardiac valve abnormalities, and basilar invagination. In general, nonsurgical treatment is preferred for management of acute fractures. High rates of malunion, nonunion, and subsequent deformity have been reported with both closed and open treatment. When surgery is necessary, surgeons should opt for load-sharing intramedullary devices that span the entire length of the bone; locking plates and excessively rigid fixation generally should be avoided. Arthroplasty may be considered for active patients, but the procedure frequently is associated with complications in this patient population. Underlying deformities, such as malunion, bowing, rotational malalignment, coxa vara, and acetabular protrusio, pose specific surgical challenges and underscore the importance of preoperative planning.

Preliminary trauma radiographs misrepresent pubic diastasis injuries.

The goal of this study was to evaluate the role of portable primary trauma survey radiographs in the evaluation and management of anteroposterior (AP) compression pelvic injuries. A retrospective analysis was conducted at a level I academic trauma center. Twenty-seven adults with AP compressive class pelvic ring injuries who received both portable pelvic radiographs and pelvic computed tomography (CT) imaging in an unbound pelvic state were included. Three orthopedic surgeons performed independent measurements of diastasis on portable pelvic radiographs and coronal pelvic CT reconstructions. Measurement techniques were standardized among observers and were repeated after 8 weeks to assess intraobserver reliability. Nonoperative vs operative treatments were correlated with the initial magnitude of pelvic injury on CT and portable radiographic images. Independent measurements of diastasis on both radiographs and CT scans showed excellent intraobserver reliability (average correlation coefficient, 0.986) and interobserver reliability (average correlation coefficient, 0.979). Compared with diastasis measurements on CT scans, portable pelvic radiographs overestimated diastasis by an average of 49%, or 12.6 mm (P<.0001; 95% confidence interval, 9.6-15.6). Portable pelvic films were less precise than standard pelvic radiographs in measuring the size of femoral head controls (R(2)=0.919 vs 0.759; P=.004). In 12 of the 27 patients evaluated, radiographic indications for operative pelvic fixation were met by portable radiographs but not CT scans, and 11 of these patients ultimately underwent operative fixation. Portable AP pelvic radiographs may distort and exaggerate pelvic bony injuries, especially those involving anterior pelvic structures. Surgeons should use caution when making management decisions based on preliminary portable pelvic radiographs.

The Evaluation and Treatment of Polyostotic Lesions

The approach to skeletal lesions has been well described1-3. Nevertheless, these lesions remain intimidating to both clinicians and patients. This is particularly true in the setting of polyostotic lesions, which can represent a metastatic process. Although it is imperative to consider this diagnosis, especially in adults, multicentric skeletal lesions can be the manifestation of a plethora of processes, ranging from non-neoplastic and benign conditions to more devastating malignant lesions and metastatic disease (Table I). In order to ensure accurate diagnosis and treatment, orthopaedic surgeons must be familiar with these conditions and the necessary workup. This article presents the approach to polyostotic disease while also reviewing some of the more common conditions presenting as multicentric skeletal lesions. View this table: TABLE I Non-Neoplastic, Benign, and Malignant Conditions That Can Present As Polyostotic Disease* There are many ways in which patients with polyostotic lesions present to orthopaedic surgeons. Some patients already will have had imaging studies performed, whereas others are being seen for the first time. Regardless, a thorough history and physical examination must be performed as it is only with the combination of a history, physical examination, and imaging that a differential diagnosis can be appropriately formulated. Once a lesion is identified, a bone scan is useful for …

Orthopaedic Case of the Month: A 62-year-old Woman With Neck Pain and Neurologic Findings

A 62-year-old woman presented with 3 months of intractable neck pain with recent onset of upper extremity weakness and paresthesias. She reported no fever, weight loss, fatigue, or generalized malaise. She had subtle complaints of hand dexterity loss but said she had no problems with balance, and no bladder or bowel complaints. Analgesics and antispasmodic medications did not relieve her pain. Her medical history was significant for hypertension, hyperlipidemia, diabetes mellitus Type II, multiple sclerosis, depression, anxiety, obesity, and hypothyroidism. There was no history of antecedent trauma, previous rheumatologic phenomena, recurrent infections, or bleeding dyscrasia. There was no family history of cancer or congenital skeletal abnormalities. Review of systems was otherwise negative. On physical examination, the patient was afebrile with normal vital signs. She was oriented to person, time, and environment. The head was normocephalic and sclerae were anicteric. ROM of the neck was normal, and she had no pain with movement of her neck. She had no palpable lymphadenopathy. There was no tenderness to palpation of the posterior shoulder musculature. Cranial nerves II through XII were grossly intact; signs of hypocalcemia including Chvostek’s sign and Trousseau’s signs were not elicited. Abdominal examination was benign without hepatomegaly or splenomegaly. Neurologically, the patient had some mild weakness with wrist extension and finger extension on the left (C 4/5) but an otherwise normal examination with intact sensation and motor function in her lower extremities. Reflexes were brisk and symmetric. Hoffmann’s sign was positive but symmetric suggesting an upper motor neuron lesion, but there was no elicitable clonus. Babinski response was plantar indicating a normal neurologic response in the lower extremities. Laboratory examination showed a white blood cell count of 7.8, hematocrit of 37.3, mean corpuscular volume (MCV) of 84, with a normal differential (54% segmented neutrophils, 9% band neutrophils, 33% lymphocytes), normal chemistries including a serum calcium of 8.9 mg/dL, and an erythrocyte sedimentation rate of 100 mm/hour. We obtained CT scans of the cervical spine (Fig. 1), head, and chest, abdomen, and pelvis, MR images of the spine (Fig. 2), and a whole-body bone scan.