Clinical Orthopaedics and Related Research

Clinical Orthopaedics and Related Research

Editorial: Beware of Studies Claiming that Social Factors are “Independently Associated” with Biological Complications of Surgery

01-09-2019 – Leopold, Seth S.

Journal Article

No abstract available

Editor’s Spotlight/Take 5: Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study

01-09-2019 – Leopold, Seth S.

Journal Article

No abstract available

Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study

01-09-2019 – Bunzli, Samantha; O’Brien BHealthSci, Penny; Ayton, Darshini; Dowsey, Michelle; Gunn, Jane; Choong, Peter; Manski-Nankervis, Jo-Anne

Journal Article

Background In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and TKA is overused. Empirical evidence and qualitative observations suggest that patients’ willingness to accept nonsurgical interventions for knee OA is low. A qualitative investigation of why patients may feel that such interventions are of little value may be an important step toward increasing their use in the treatment of knee OAQuestions/purposes This qualitative study was embedded in a larger study investigating patient-related factors (beliefs/attitudes toward knee OA and its treatment) and health-system related factors (access, referral pathways) known to influence patients’ decisions to seek medical care. In this paper we focus on the patient-related factors with the aim of exploring why patients may feel that nonsurgical interventions are of little value in the treatment of knee OA.
Methods A cross-sectional qualitative study was conducted in a single tertiary hospital in Australia. Patients with endstage knee OA on the waiting list for TKA were approached during their preadmission appointment and invited to participate in one-to-one interviews. As prescribed by the qualitative approach, data collection and data analysis were performed in parallel and recruitment continued until the authors agreed that the themes identified would not change through interviews with subsequent participants, at which point, recruitment stopped. Thirty-seven patients were approached and 27 participated. Participants were 48% female; mean age was 67 years. Participants’ beliefs about knee OA and its treatment were identified in the interview transcripts. Beliefs were grouped into five belief dimensions: identity beliefs (what knee OA is), causal beliefs (what causes knee OA), consequence beliefs (what the consequences of knee OA are), timeline beliefs (how long knee OA lasts) and treatment beliefs (how knee OA can be controlled).
Results All participants believed that their knee OA was “bone on bone” (identity beliefs) and most (> 14 participants) believed it was caused by “wear and tear” (causal beliefs). Most (> 14 participants) believed that loading the knee could further damage their “vulnerable” joint (consequence beliefs) and all believed that their pain would deteriorate over time (timeline beliefs). Many (>20 participants) believed that physiotherapy and exercise interventions would increase pain and could not replace lost knee cartilage. They preferred experimental and surgical treatments which they believed would replace lost cartilage and cure their knee pain (treatment beliefs).
Conclusions Common misconceptions about knee OA appear to influence patients’ acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. Once the participants in this study had been “diagnosed” with “bone-on-bone” changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage. Future research involving larger, more representative samples are needed to understand how widespread these beliefs are and if/how they influence treatment decisions. In the meantime, clinicians seeking to encourage acceptance of nonsurgical interventions may consider exploring and targeting misconceptions that patients hold about the identity, causes, consequences, timeline, and treatment of knee OA.
Level of Evidence Level II, prognostic study.

Cochrane in CORR®: Conservative Management Following Closed Reduction of Traumatic Anterior Dislocation of the Shoulder

01-09-2019 – Prada, Carlos; Bhandari, Mohit

Journal Article

No abstract available

Virtue Ethics in a Value-driven World: Medical Training and Moral Distress

01-09-2019 – Humbyrd, Casey Jo

Journal Article

No abstract available

Your Best Life: When Mindfulness is Not the Answer—Alternative Approaches to Managing Anger and Conflict

01-09-2019 – Kelly, John D. IV

Journal Article

No abstract available

Residency Diary: Intern Year Part 2 (March-May)—Teams in Residency

01-09-2019 – LeBrun, Drake G.

Journal Article

No abstract available

Pearls: How to Perform a Controlled Adjustable Loop Suspensory Button Flip Under Direct Visualization During ACL Reconstruction

01-09-2019 – Fabricant, Peter D.

Journal Article

No abstract available

ArtiFacts: Gottfried “Götz” von Berlichingen—The “Iron Hand” of the Renaissance

01-09-2019 – Ashmore, Kevin; Cialdella, Sergio; Giuffrida, Alberto; Kon, Elizaveta; Marcacci, Maurillo; Di Matteo, Berardo

Journal Article

No abstract available

Editorial Comment: Selected Proceedings From the 2017-18 European Knee Society Meetings

01-09-2019 – Thienpont, Emmanuel

No abstract available

Are Serum Metal Ion Levels a Concern at Mid-term Followup of Revision Knee Arthroplasty With a Metal-on-metal Hinge Design?

01-09-2019 – Klasan, Antonio; Meine, Esko; Fuchs-Winkelmann, Susanne; Efe, Turgay; Boettner, Friedrich; Heyse, Thomas Jan

Journal Article

Background Elevated serum levels of chromium and cobalt ions in metal-on-metal (Mo
M) bearing surfaces is a well-known phenomenon in THA. However, few studies have addressed this issue in complex primary and revision knee arthroplasty using a Mo
M hinged mechanism, and no study, to our knowledge, has investigated knees with Mo
M hinges in patients without megaprostheses (tumor prostheses).
Questions/purposes We analyzed a series of patients who received Mo
M hinged revision knee prostheses and asked: (1) What are the serum metal ion levels at short-term followup? (2) Is there any correlation between metal ion levels and the Knee Society Score (KSS) at this followup?Methods Between 2013 and 2017, we performed 198 revision knee arthroplasties, of which 32 (17.7%) were performed with a latest-generation Mo
M hinge knee design. In addition, three complex primary TKAs utilizing the same design were included in this study. The device features a metal-on-polyethylene bearing with a Mo
M hinge. During that period, our general indications for using a hinge were single-stage and two-stage revision surgeries, revisions with large bone defects, and primary TKA with > 20° mechanical malalignment or collateral ligament insufficiency. Of the 35 patients who received this device, 23 patients (65% of the overall group who received this implant; 11 males, 12 females) were available for followup at a median of 28 months (range, 13-61 months), and the remaining 12 (35%) patients were lost to followup. Our rationale for reporting before the more typical 2-year minimum was the finding of elevated serum ion levels with unclear clinical significance. Median age at the time of surgery was 68 years (range, 52-84 years). None of the patients included in the study had other implants with Mo
M bearings. Serum ion levels of chromium (III) and cobalt were assessed using mass spectrometry. Ion levels > 5 ppb were considered elevated. Clinical outcome was assessed using the original KSS.
Results Median chromium serum level was 6.3 ppb (range, 0.6–31.9 ppb) and median cobalt serum level was 10.5 (range, 1.0–47.5 ppb). Of the 23 patients, 16 had elevated serum ion levels. There was a moderate correlation between KSS and both chromium (p = 0.029, r = 0.445) and cobalt (p = 0.012, r = 0.502) levels.
Conclusions Elevated metal ion levels and radiolucent lines are common after surgery with this Mo
M hinge design at short-term followup, and we believe this finding is of great concern. Although no patient has yet been revised, these patients will be closely monitored. We recommend that serum ion analysis become a routine part of followup after any hinge TKA in an attempt to better understand the potential consequences of this phenomenon.
Level of Evidence Level IV, therapeutic study.

CORR Insights®: Are Serum Metal Ion Levels a Concern at Mid-term Followup of Revision Knee Arthroplasty With a Metal-on-metal Hinge Design?

01-09-2019 – Eskelinen, Antti

Journal Article

No abstract available

Does Accelerometer-based Navigation Have Any Clinical Benefit Compared with Conventional TKA? A Systematic Review

01-09-2019 – Budhiparama, Nicolaas C.; Lumban-Gaol, Imelda; Ifran, Nadia N.; Parratte, Sebastien; Nelissen, Rob

Journal Article

Background Accelerometer-based navigation is a handheld navigation tool that was introduced to offer a simpler technique compared with more-cumbersome computer-assisted surgery (CAS). Considering the increasing number of adopters, it seems important to evaluate the potential clinical benefits of this technology compared with conventional TKA.
Questions/purposes In this systematic review, we asked: (1) Is accelerometer-based navigation more accurate than conventional TKA? (2) Does accelerometer-based navigation provide better functional outcome than conventional TKA? (3) Does accelerometer-based navigation increase surgical time or decrease the risk of complications or reoperations compared with conventional TKA?Methods This systematic review included all comparative prospective and retrospective studies published in the MEDLINE/PubMed and Cochrane libraries over the last 10 years. Inclusion criteria were all studies in English that compared accelerometer-based navigation with conventional TKA. Eleven studies met these criteria with 621 knees in accelerometer-based navigation group and 677 knees in conventional TKA group. Results related to alignment, objective and subjective functional scores, duration of surgery, complications and reoperations were extracted and compared between accelerometer-based-navigation and conventional TKA. Methodological quality was assessed using Methodological Index for Non-Randomized Studies (MINORS) tool (for nonrandomized control trials) and Cochrane Risk of Bias (for randomized control trials (RCTs). All studies with fair or better quality were included. Four RCTs and six nonrandomized studies comparing accelerometer-based navigation to conventional TKA were found.
Results Inconsistent evidence on mechanical axis alignment was found, with five of nine studies slightly favoring the accelerometer-based navigation group, and the other four showing no differences between the groups. Only two of eight studies favored accelerometer-based navigation in terms of tibial component alignment in the coronal plane; the other six found no between-group differences. Similarly, mixed results were found regarding other metrics related to component alignment; a minority of studies favored accelerometer-based navigation by a small margin, and most studies found no between-group differences. Only three studies evaluated functional outcome and none of them showed a difference in range of motion or patient-reported outcomes. Most studies, six of seven, found no between-group differences concerning surgical time; one study demonstrated a slight increase in time with accelerometer-based navigation. There were no between-group differences in terms of the risk of complications, which generally were uncommon in both groups, and no reoperations or revisions were reported in either group.
Conclusions We found conflicting evidence about whether accelerometer-based navigation reduces the number of coronal-plane outliers or improves alignment to a clinically important degree, and we found no evidence that it improves patient-reported outcomes or reduces the risk of complications or reoperations. Accelerometer-based navigation may increase surgical time. The overall quality of the evidence was low, which suggested that any observed benefits were overestimated. Given the absence of higher-quality evidence demonstrating compelling benefits of this accelerometer-based navigation technology, it should not be widely adopted.
Level of Evidence Level III, therapeutic study.

CORR Insights®: Does Accelerometer-based Navigation Have Any Clinical Benefit Compared with Conventional TKA? A Systematic Review

01-09-2019 – Argenson, Jean-Noel A.

Journal Article

No abstract available

Tissue Adhesive for Wound Closure Reduces Immediate Postoperative Wound Dressing Changes After Primary TKA: A Randomized Controlled Study in Simultaneous Bilateral TKA

01-09-2019 – Gromov, Kirill; Troelsen, Anders; Raaschou, Sofie; Sandhold, Håkon; Nielsen, Christian Skovgaard; Kehlet, Henrik; Husted, Henrik

Journal Article

Background Prolonged wound drainage after TKA is associated with increased risk of infection. To decrease wound drainage, tissue adhesive has been suggested as an adjunct to wound closure after TKA; however, no studies of which we are aware have investigated the effect of tissue adhesive in a modern fast-track TKA setting.
Questions/purposes The purpose of this study was to evaluate the effect of wound closure using a high-viscosity tissue adhesive in simultaneous bilateral TKA with respect to (1) postoperative wound drainage, measured as number of dressing changes in the first 72 hours postoperatively; and (2) wound healing assessed using the ASEPSIS score.
Methods Thirty patients undergoing simultaneous bilateral TKA were included in the study. The left knee was randomized to receive either standard three-layer closure with staples or the same closure supplemented with tissue adhesive with the opposite treatment used on the contralateral knee. One patient underwent a constrained TKA and underwent revision 2 days after the index procedure and was therefore excluded leaving 29 patients (58 knees) for analysis. Sixty-two percent (n = 18) were female. Mean age was 64 years (range, 42-78 years). Mean body mass index was 28 kg/m2 (range, 21–38 kg/m2). Postoperative wound drainage was evaluated as drainage resulting in a dressing change. The wound dressing was changed if it was soaked to the borders of the absorbable dressing at any point. The nurses changing the dressing were blinded to treatment allocation up to the first dressing change. The number of dressing changes during the first 72 hours postoperatively was recorded. The secondary study endpoint was the ASEPSIS score, which is a clinical score assessing wound healing. ASEPSIS score, measured by a nurse not involved in the treatment, was compared between the groups at 3 weeks followup.
Results Knees with tissue adhesive underwent fewer dressing changes (median, 0; interquartile range IQR, 0-1) compared with the contralateral knee (IQR, 1-2; difference of medians, one dressing change; p = 0.001). A total of 59% of knees in the intervention group did not undergo any dressing changes before discharge, whereas 24% of knees in the control group did not undergo any dressing changes before discharge (p = 0.02). The knees in the intervention group and the control group did not differ with respect to ASEPSIS score at 3 weeks.
Conclusions Tissue adhesive as an adjunct to standard wound closure after primary TKA reduced the number of dressing changes after surgery, but did not change the appearance or healing of the wound at 3 weeks based on the ASEPSIS scores. Whether the small differences observed here in terms of the number of dressing changes performed will justify the additional costs associated with using this product or whether there are other differences associated with the use of tissue adhesive that may prove important such as patient preferences or longer term differences in wound healing or infection should be studied in the future.
Level of Evidence Level I, therapeutic study.

CORR Insights®: Tissue Adhesive for Wound Closure Reduces Immediate Postoperative Wound Dressing Changes After Primary TKA: A Randomized Controlled Study in Simultaneous Bilateral TKA

01-09-2019 – Mont, Michael A.

Journal Article

No abstract available

Does Medial Patellofemoral Osteoarthritis Influence Outcome Scores and Risk of Revision After Fixed-bearing Unicompartmental Knee Arthroplasty?

01-09-2019 – Berger, Y.; Ftaita, S.; Thienpont, E.

Journal Article

Background Patellofemoral osteoarthritis (OA) and anterior knee pain sometimes are considered contraindications for unicompartmental knee arthroplasty (UKA). However, several studies have demonstrated excellent patient-reported outcome scores in patients with patellofemoral OA treated with medial mobile-bearing UKA. Because these studies assessed the outcome of mobile-bearing UKA only, we were interested to see whether that finding also applies to fixed-bearing medial UKA.
Questions/purposes (1) Does patellofemoral OA influence patient-reported outcome scores after medial fixed-bearing UKA? (2) Does untreated medial patellofemoral OA increase the revision rate after medial fixed-bearing UKA?Methods Between 2008 and 2015, one surgeon performed 308 medial fixed-bearing UKAs of a single design. Of those, 80 (26%) had patellofemoral OA of at least moderate severity (ICRS III or IV), and 228 (74%) did not. During that period, the surgeon did not use patellofemoral OA as a contraindication to UKA. In all, 13 patients (10%) in the patellofemoral OA group were lost before 2-year minimum followup, and 20 (11%) in the control group (without patellofemoral OA) were lost; all other patients were available, seen in the last 5 years, and included in this retrospective study. Mean (± SD) followup in the patellofemoral OA group was 39 ± 25 months, and it was 41 ± 23 in the control group. There were 100 women and 120 men. Patients had a mean age ± SD of 65 ± 10 years and mean ± SD BMI of 29 ± 4.5 kg/m2.
The intraoperative status of the patellofemoral joint was assessed using the International Cartilage Repair Society (ICRS) classification. The primary study endpoint was the Forgotten Joint Score (FJS-12); we also compared scores on the Lonner Patello
Femoral Score (LPFS), Oxford Knee Score (OKS) and Short-Form 12 (SF-12). With the numbers available, we had 80% power to detect a difference of 12.3 points on the Forgotten Joint Score. A secondary endpoint was femoral or tibial component revision for any reason verified over the phone for each included patient.
Results With the numbers available, there was no difference in FJS-12 score between the UKA with patellofemoral OA group and the group without patellofemoral OA 71 ± 29 versus 77 ± 26, mean difference – 6; 95% CI, -16 to 4.5; p = 0.270). Likewise, with the numbers available, we saw no differences in LPFS, OKS and SF-12. There was no difference in survivorship from all-cause revision at 4 years between the patellofemoral OA group and the group without patellofemoral OA (98%; 95% CI, 85.8–99.7 versus 99.5%; 95% CI, 96.0–99.2%; p = 0.352).
Conclusions Patients with medial osteoarthritis in this single-center study generally benefitted from medial fixed-bearing UKA with good-to-excellent outcomes scores at short term, whether or not medial patellofemoral wear is present.
Level of Evidence Level III, therapeutic study.

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting

01-09-2019 – Jennings, John D.; Pinninti, Angelica; Kakalecik, Jaquelyn; Ramsey, Frederick V.; Haydel, Christopher

Journal Article

Background Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions.
Questions/purposes (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints?Methods Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient’s willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire.
Results Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference MD, 0.1 ± 0.6; 95% CI, 0.0–0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0–0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon’s perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0–0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0–0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1–0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8–1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1–0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7–1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5–0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA.
Conclusions Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician’s attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care.
Level of Evidence Level II, therapeutic study.

CORR Insights®: Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting

01-09-2019 – Mistovich, R. Justin

Journal Article

No abstract available

Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

01-09-2019 – Shapiro, Lauren M.; Harris, Alex H.S.; Eppler, Sara L.; Kamal, Robin N.

Journal Article

Background Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated.
Questions/purposes (1) Will Quick
DASH scores change after patients complete the tasks on the questionnaire compared with baseline Quick
DASH scores? (2) Will the change in Quick
DASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their Quick
DASH scores by greater than a minimally clinically important difference (MCID) of 14 points?Methods During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men 45%, 72 women 55%; 112 in the intervention group 85% and 20 in the control group 15%). First, all patients who completed the Quick
DASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the Quick
DASH and completed a followup Quick
DASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the Quick
DASH at baseline and a followup Quick
DASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) Quick
DASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in Quick
DASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the Quick
DASH. Fisher’s exact test was used to evaluate the difference between groups in those reaching an MCID of 14.
Results In the intervention group, the Quick
DASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points 95% CI, 12 to 16; p < 0.001). The change in Quick
DASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 95% CI, -17 to -7; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in Quick
DASH scores greater than the 14-point MCID (43 of 112 38% versus two of 20 10%; odds ratio, 5.4 95% CI, 1 to 24%; p = 0.019).
Conclusions Reported disability can be reduced, thereby improving PROMs, if patients complete Quick
DASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models.
Level of Evidence Level II, therapeutic study.

CORR Insights®: Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

01-09-2019 – Crijns, Tom J.

Journal Article

No abstract available

What Are the Uses and Limitations of Time-driven Activity-based Costing in Total Joint Replacement?

01-09-2019 – Pathak, Shravani; Snyder, Daniel; Kroshus, Thomas; Keswani, Aakash; Jayakumar, Prakash; Esposito, Kelly; Koenig, Karl; Jevsevar, David; Bozic, Kevin; Moucha, Calin

Journal Article

Background With increasing emphasis on value-based payment models for primary total joint arthroplasty (TJA), there is greater need for orthopaedic surgeons and hospitals to better understand the actual costs and resource use of TJA. Time-driven activity-based costing (TDABC) is a methodology for accurate cost estimation, but its application in the TJA care pathway across institutions/regions has not yet been analyzed.
Questions/purposes In this systematic review of studies applying TDABC to primary TJA, we investigated the following: (1) Is there variation in TDABC methodology and cost estimates across institutions? (2) Is a standard set of direct and indirect costs included across studies? (3) Is there a difference in cost estimates derived from TDABC and traditional hospital cost-accounting approaches? and (4) How are institutions using TDABC (process and outputs) with respect to the TJA care pathway?Methods A comprehensive search strategy was developed that included the keywords “TDABC,” “time-driven activity-based cost,” “THA,” “TKA,” “THR,” “TKR,” and “TJR” in the PubMed/MEDLINE, EMBASE, Web of Science, Ovid SP, Scopus, and Science
Direct databases for articles published between 2004 and 2018 as well as extensive hand searching and citation mining. Relevant studies (n = 15) were screened to include THA or TKA as the focus of the TDABC model, full-text articles, TDABC-based cost estimates for TJA, and studies written in English (n = 8). Due to the heterogeneity of outcomes/methodology in TDABC studies involving TJA, quality assessment was based on each study’s adherence to the seven steps delineated by Kaplan et al. in their original publication introducing TDABC in health care.
Results There was substantial variation in TDABC methodology (especially in scope), adherence to the seven steps of TDABC, and data collection. Only five of eight studies incorporated indirect costs into their TDABC calculation, with notable differences in which direct and indirect expenses were included. TDABC-based cost estimates for TJA ranged from USD 7081 to USD 29,557, with variation driven by the TJA timeframe and whether implant costs were included in the costing calculation. TDABC was most frequently used to compare against traditional hospital accounting methods (n = 4), to increase operational efficiency (n = 4), to reduce wasted resources (n = 3), and to mitigate risk (n = 3).
Conclusions TDABC-based cost estimates are more granular and useful in practice than those calculated via traditional hospital accounting; however, there is a lack of standardized principles to guide TDABC implementation (especially for indirect costs) due to institutional and regional differences in TDABC application. Although TDABC methodology will likely continue to vary somewhat between studies, standardized principles are needed to guide the definition, estimation, and reporting of costs to enable detailed examination of study methodology and inputs by readers.
Level of Evidence Level III, economic and decision analysis.

CORR Insights®: What Are the Uses and Limitations of Time-driven Activity-based Costing in Total Joint Replacement?

01-09-2019 – Srikumaran, Uma

Journal Article

No abstract available

What is the Diagnostic Accuracy of MRI for Component Loosening in THA?

01-09-2019 – Burge, Alissa J.; Konin, Gabrielle P.; Berkowitz, Jennifer L.; Lin, Bin; Koff, Matthew F.; Potter, Hollis G.

Journal Article

Background Implant loosening is a common cause of reoperation after THA. Plain radiographs have been the default modality to evaluate loosening, although radiographs provide a relatively insensitive assessment of integration; cross-sectional modalities may provide a more detailed evaluation but traditionally have suffered from metal-related artifacts. We sought to determine whether MRI is capable of reliably detecting operatively confirmed component loosening in patients after hip arthroplasty.
Questions/purposes (1) Is assessing implant integration using MRI (with multiacquisition variable resonance image combination, MAVRIC) repeatable between readers? (2) What is the sensitivity and specificity of MRI with MAVRIC to evaluate component loosening, using intraoperative assessment as a gold standard? (3) How does the sensitivity and specificity of MRI with MAVRIC for surgically confirmed component loosening compare with those of radiographs?Methods Between 2012 and 2017, 2582 THAs underwent revision at one institution. Of those, 219 had a preoperative MRI with MAVRIC. During that period, the most common indication for obtaining an MRI was evaluation of potential adverse local tissue reaction. The surgeons’ decision to proceed with revision was based on their overall assessment of clinical, imaging, and laboratory findings, with MRI findings cited as contributing to the decision to revise commonly occurring in the setting of recalled implants. Of the THAs that underwent MRI, 212 were included in this study, while seven were excluded due to equivocal operative notes (5) and excessively poor quality MRI (2). MRI was performed at 1.5T using a standardized arthroplasty imaging protocol, including MARS (metal artifact reduction sequencing) and MAVRIC techniques. Two independent musculoskeletal fellowship-trained readers (one with 26 and one with 5 years of experience) blinded to operative findings scored a subset of 57 hips for implant integration based on Gruen zone and component loosening (defined as complete circumferential loss of integration around a component) to evaluate interobserver reliability. A third investigator blinded to imaging findings reviewed operative notes for details on the surgeon’s assessment of intraoperative loosening.
Results Gwet’s agreement coefficients (AC) were used to describe interobserver agreement; these are similar to Cohen’s kappa but are more resistant to certain paradoxes, such as unexpectedly low values in the setting of very high or low trait prevalence, or good agreement between readers on marginal counts. Almost perfect interobserver agreement (AC2 = 0.81–1.0) was demonstrated for all acetabular zones and all femoral Gruen zones on MRI, while perfect (AC1 = 1.0) agreement was demonstrated for the overall assessment of acetabular component loosening and near perfect agreement was shown for the assessment of femoral component loosening (AC1 = 0.98). MRI demonstrated a sensitivity and specificity of 83% (95% CI, 65–96) and 98% (95% CI, 97–100), respectively, for acetabular component loosening and 75% (95% CI, 55–94) and 100% (95% CI, 100–100), respectively, for femoral component loosening. Radiographs demonstrated a sensitivity and specificity of 26% (95% CI, 12–47) and 100% (95% CI, 96–100), respectively, for acetabular component loosening and 20% (95% CI, 9–47) and 100% (95% CI, 100–100), respectively, for femoral component loosening.
Conclusion MRI may provide a repeatable assessment of implant integration and demonstrated greater sensitivity than radiographs for surgically confirmed implant loosening in patients undergoing revision THA at a single institution. Additional multi-institutional studies may provide more insight into the generalizability of these findings.
Level of Evidence Level III, diagnostic study.

CORR Insights®: What is the Diagnostic Accuracy of MRI for Component Loosening in THA?

01-09-2019 – Cooper, H. John

Journal Article

No abstract available

Primary Monoblock Inset Reverse Shoulder Arthroplasty Resulted in Decreased Pain and Improved Function

01-09-2019 – Levy, Jonathan C.; Berglund, Derek; Vakharia, Rushabh; DeVito, Paul; Tahal, Dimitri S.; Mijc, Dragomir; Ameri, Bijan

Journal Article

Background The first-generation, lateral-center-of-rotation reverse shoulder arthroplasty (RSA) modular design has demonstrated durable early-, mid-, and long-term outcomes. The second-generation monoblock implant shares a similar design but eliminates the modular junction and facilitates inset placement within the metaphysis to avoid humeral-sided junctional failures and facilitate metaphyseal press-fit. However, no paper has specifically examined the radiographic findings and improvements in pain and function after the use of this next generation design.
Questions/purposes (1) After second-generation, lateral-center-of-rotation monoblock RSA, what are the improvements in shoulder scores, general health scores, and ROM at a minimum of 2 years of followup? (2) Are the differences in shoulder scores, health scores, and ROM associated with fixation (cemented versus cementless components)? (3) How frequently do complications occur (defined as humeral loosening, dislocation, baseplate failure, scapular notching, acromial fractures, and revision surgery) after inset monoblock RSA?Methods We retrospectively studied patients undergoing primary RSA between 2010 and 2015 with preoperative data and a minimum of 2 years of clinical followup. Of the 329 primary RSA performed during this period, 125 were excluded based on the use of a different generation humeral stem of the same design, three based on need for a nickel-free implant, and 39 due to a lack of preoperative shoulder scores. Of the remaining 162 patients, 137 patients (85%) met the inclusion criteria with a mean age of 74 years (range, 46–90 years). The predominant indications were osteoarthritis with a massive rotator cuff tear (74%) and fracture sequelae (16%). During the study, humeral implants were typically inserted using an uncemented press-fit technique (85%), with only 21 patients requiring a cemented humeral stem. The mean clinical and radiographic followup period was 37 months (range, 24–82 months). Patient-reported outcome measures (PROMs) including the Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, VAS for pain, SF-12, Single Assessment Numeric Evaluation, and measured active motion (forward elevation and external and internal rotation) were recorded at pre- and postoperative intervals. Postoperative radiographs were evaluated for baseplate failure, glenoid and humeral loosening, scapular notching, and acromion fractures. Complications were recorded in the longitudinally maintained institutional repository.
Results At the most recent followup examination, there were improvements in measured motion, general health outcomes, and all PROMs. There were no differences between the cemented and press-fit techniques. Complications observed included 17 of 137 patients (12%) with scapular notching, six postoperative acromion fractures (4%), and two revision procedures (1%). No patients experienced gross humeral loosening or baseplate failure.
Conclusions Primary RSA using a second-generation monoblock inset humeral component resulted in improvements in pain and functional outcomes as well as low rates of acromion fractures, humeral radiolucency, and complications. Future studies are needed to provide a more definitive analysis on the use of an uncemented technique for humeral stem fixation and the effect of an inset stem on postoperative acromion fractures.
Level of Evidence Level IV, therapeutic study.

CORR Insights®: Primary Monoblock Inset Reverse Shoulder Arthroplasty Resulted in Decreased Pain and Improved Function

01-09-2019 – Ricchetti, Eric T.

Journal Article

No abstract available

CORR Insights®: What Are the Complications, Survival, and Outcomes After Revision to Reverse Shoulder Arthroplasty in Patients Older Than 80 Years?

01-09-2019 – Chamberlain, Aaron M.

No abstract available

Clinical and Molecular Analysis of Pathologic Fracture-associated Osteosarcoma: MicroRNA profile Is Different and Correlates with Prognosis

01-09-2019 – Lozano Calderón, Santiago A.; Garbutt, Cassandra; Kim, Jason; Lietz, Christopher E.; Chen, Yen-Lin; Bernstein, Karen; Chebib, Ivan; Nielsen, G. Petur; Deshpande, Vikram; Rubio, Renee; Wang, Yaoyu E.; Quackenbush, John; Delaney, Thomas; Raskin, Kevin; Schwab, Joseph; Cote, Gregory; Spentzos, Dimitrios

Journal Article

Background Micro
RNAs are small, noncoding RNAs that regulate the expression of posttranslational genes. The presence of some specific micro
RNAs has been associated with increased risk of both local recurrence and metastasis and worse survival in patients with osteosarcoma. Pathologic fractures in osteosarcoma are considered to be more the manifestation of a neoplasm with a more aggressive biological behavior than the cause itself of worse prognosis. However, this has not been proved at the biological or molecular level. Currently, there has not been a micro
RNA profiling study of patients who have osteosarcoma with and without pathologic fractures that has described differences in terms of micro
RNA profiling between these two groups and their correlation with biologic behavior.
Questions/purposes (1) In patients with osteosarcoma of the extremities, how do the micro
RNA profiles of those with and without pathologic fractures compare? (2) What relationship do micro
RNAs have with local recurrence, risk of metastasis, disease-specific survival, and overall survival in osteosarcoma patients with pathologic fractures?Methods Between 1994 and 2013, 217 patients were diagnosed and treated at our institution for osteosarcoma of the extremities. Patients were excluded if (1) they underwent oncologic resection of the osteosarcoma at an outside institution (two patients) or (2) they were diagnosed with an extraskeletal osteosarcoma (29 patients) or (3) they had less than 1 year of clinical follow-up and no oncologic outcome (local recurrence, metastasis, or death) (four patients). A total of 182 patients were eligible. Of those, 143 were high-grade osteosarcomas. After evaluation of tumor samples before chemotherapy treatment, a total of 80 consecutive samples were selected for sequencing. Demographic and clinical comparison between the sequenced and non-sequenced patients did not demonstrate any differences, confirming that both groups were comparable. Diagnostic samples from the extremities of 80 patients with high-grade extremity osteosarcomas who had not yet received chemotherapy underwent micro
RNA sequencing for an ongoing large-scale osteosarcoma genome profiling project at our institution. Six samples were removed after a second look by a musculoskeletal pathologist who verified cellularity and quality of samples to be sequenced, leaving a total of 74 patients. Of these, two samples were removed as they were confirmed to be pelvic tumors in a second check after sequencing. The final study sample was 72 patients (11 patients with pathologic fractures and 61 without). Sequencing data were correlated with fractures and local recurrence, risk of metastasis, disease-specific survival, and overall survival through Kaplan-Meier analyses.
Results Several micro
RNAs were expressed differently between the two groups. Among the markers with the highest differential expression (edge
R and DESeq algorithms), Hsa-m
IR 656-3p, hsa-mi
R 493-5p, and hsa-mi
R 381-3p were upregulated in patients with pathologic fractures, whereas hsa-mi
R 363, hsa-mi
R 885-5p, and has-mi
R 20b-5p were downregulated. The highest differential expression fracture and nonfracture-associated micro
RNA markers also distinguished groups of patients with different metastasis risk, a well as different disease-specific and overall survival. Furthermore, the profile of pathologic fractures demonstrated a higher differential expression for micro
RNA markers that were previously associated with a higher risk of metastasis and lower survival rates in patients with osteosarcoma.
Conclusions In patients who have osteosarcoma, the micro
RNA profiles of those with pathologic fractures are different than of patients without pathologic fractures. The highest differential expression mircro
RNA molecules in patients with pathologic fractures predict also higher risk of metastatic disease as well as worse disease-specific survival and overall survival. Furthermore, we found higher differential expression of micro
RNAs in the pathologic fracture group previously associated with poor prognosis. The higher risk of metastasis and poorer overall survival in patients with pathologic fractures is inherent to tumor aggressive biologic behavior. It is plausible that the fracture itself is not the direct cause of worse prognosis but another manifestation of tumor biologic aggressiveness. Identification of these molecules through liquid biopsies may help to determine which patients may benefit from surgery before fractures occur. The same technology can be applied to identify patterns of response to conventional chemotherapy, assisting in more specific and accurate systemic therapy.
Level of Evidence Level III, prognostic study.

The Pediatric Toronto Extremity Salvage Score (pTESS): Validation of a Self-reported Functional Outcomes Tool for Children with Extremity Tumors

01-09-2019 – Piscione, Janine; Barden, Wendy; Barry, Janie; Malkin, Alexandra; Roy, Trisha; Sueyoshi, Tyki; Mazil, Karen; Salomon, Steven; Dandachli, Firas; Griffin, Anthony; Saint-Yves, Hugo; Giuliano, Pina; Gupta, Abha; Ferguson, Peter; Scheinemann, Katrin; Ghert, Michelle; Turcotte, Robert E.; Lafay-Cousin, Lucie; Werier, Joel; Strahlendorf, Caron; Isler, Marc; Mottard, Sophie; Afzal, Samina; Anderson, Megan E.; Hopyan, Sevan

Journal Article

Background The physical function of children with sarcoma after surgery has not been studied explicitly. This paucity of research is partly because of the lack of a sufficiently sensitive pediatric functional measure. The goal of this study was to establish and validate a standardized measure of physical function in pediatric patients with extremity tumors.
Questions/purposes (1) What is the best format and content for new upper- and lower-extremity measures of physical function in the pediatric population? (2) Do the new measures exhibit floor and/or ceiling effects, internal consistency, and test-retest reliability? (3) Are the new measures valid?Methods In Phase 1, interviews with 17 consecutive children and adolescents with bone tumors were conducted to modify the format and content of draft versions of the pediatric Toronto Extremity Salvage Score (p
TESS). In Phase 2, the p
TESS was formally translated into French. In Phase 3, 122 participants between 7 and 17.9 years old with malignant or benign-aggressive bone tumors completed the limb-specific measure on two occasions. Older adolescents also completed the adult TESS. Floor and ceiling effects, internal consistency, test-retest reliability, and validity were evaluated.
Results Feedback from interviews resulted in the removal, addition, and modification of draft items, and the p
TESS-Leg and p
TESS-Arm questionnaires were finalized. Both versions exhibited no floor or ceiling effects and high internal consistency (α > 0.92). The test-retest reliability was excellent for the p
TESS-Leg (intraclass correlation coefficient ICC = 0.94; 95% CI, 0.90-0.97) and good for the p
TESS-Arm (ICC = 0.86; 95% CI, 0.61-0.96). Known-group validity (ability to discriminate between groups) was demonstrated by lower mean p
TESS-Leg scores for participants using gait aids or braces (mean = 68; SD = 21) than for those who did not (mean = 87; SD = 11; p < 0.001). There was no significant difference between p
TESS arm scores among respondents using a brace (n = 5; mean = 73; SD = 11) and those without (n = 22; mean = 83; SD = 19; p = 0.13). To evaluate construct validity, we tested a priori hypotheses. The duration since chemotherapy correlated moderately with higher p
TESS-Leg scores (r = 0.4; p < 0.001) but not with p
TESS-Arm scores (r = 0.1; p = 0.80), and the duration since tumor resection correlated moderately with higher p
TESS-Leg scores (r = 0.4; p < 0.001) but not p
TESS-Arm scores (r = 0.2; p = 0.4). Higher VAS scores (that is, it was harder to do things) antecorrelated with both p
TESS versions (p
TESS-Leg: r = -0.7; p < 0.001; p
TESS-Arm: r = -0.8; p < 0.001). To assess criterion validity, we compared the p
TESS with the current “gold standard” (adult TESS). Among adolescents, strong correlations were observed between the TESS and p
TESS-Leg (r = 0.97, p < 0.001) and p
TESS-Arm (r = 0.9, p = 0.007).
Conclusions: Both p
TESS versions exhibited no floor or ceiling effects and had high internal consistency. The p
TESS-Leg demonstrated excellent reliability and validity, and the p
TESS-Arm demonstrated good reliability and reasonable validity. The p
TESS is recommended for cross-sectional evaluation of self-reported physical function in pediatric patients with bone tumors.
Level of Evidence Level II, outcome measurement development.

CORR Insights®: The Pediatric Toronto Extremity Salvage Score (pTESS): Validation of a Self-reported Functional Outcomes Tool for Children with Extremity Tumors

01-09-2019 – Davidson, Darin

Journal Article

No abstract available

When Should We Wean Bracing for Adolescent Idiopathic Scoliosis?

01-09-2019 – Cheung, Jason Pui Yin; Cheung, Prudence Wing Hang; Luk, Keith Dip-Kei

Journal Article

Background Current brace weaning criteria for adolescents with idiopathic scoliosis (AIS) are not well defined. Risser Stage 4, ≥ 2 years since the onset of menarche, and no further increase in body height over 6 months are considered justifications for stopping bracing. However, despite adherence to such standards, curve progression still occurs in some patients, and so better criteria for brace discontinuation are needed.
Questions/purposes (1) Is no change in height measurements over 6 months and Risser Stage 4 sufficient for initiating brace weaning? (2) What is the association between larger curves (45°) at brace weaning and the progression risk? (3) Are a more advanced Risser stage, Sanders stage, or distal radius and ulna classification associated with a decreased risk of curve progression? (4) When should we wean patients with AIS off bracing to reduce the time for brace wear while limiting the risk of postweaning curve progression?Methods All AIS patients who were weaned off their braces from June 2014 to March 2016 were prospectively recruited and followed up for at least 2 years after weaning. A total of 144 patients were recruited with mean followup of 36 ± 21 months. No patients were lost to followup. Patients were referred for brace weaning based on the following criteria: they were Risser Stage 4, did not grow in height in the past 6 months of followup, and were at least 2 years postmenarche. Skeletal maturity was assessed with Risser staging, Sanders staging, and the distal radius and ulna classification. Curve progression was determined as any > 5° increase in the Cobb angle between two measurements from any subsequent six monthly followup visits. All radiographic measurements were performed by spine surgeons independently as part of their routine consultations and without knowledge of this study. Statistical analyses included an intergroup comparison of patients with and without curve progression, binomial stepwise logistic regression analysis, odds ratios (ORs) with their 95% confidence intervals (CIs), and a risk-ratio calculation. A reasonable protective maturity stage would generate an OR < 1.
Results Among patients braced until they had no change in height for 6 months, were 2 years postmenarche for girls, and Risser Stage 4, 29% experienced curve progression after brace weaning. Large curves (≥ 45°) were associated with greater curve progression (OR, 5.0; 95% CI, 1.7–14.8; p = 0.002) as an independent risk factor. Patients weaned at Sanders Stage 7 (OR, 4.7; 95% CI, 2.1–10.7; p < 0.001), radius Grade 9 (OR, 3.9; 95% CI, 1.75–8.51; p = 0.001), and ulna Grade 7 (OR, 3.1; 95% CI, 1.27–7.38; p = 0.013) were more likely to experience curve progression. The earliest maturity indices with a reasonable protective association were Sanders Stage 8 (OR, 0.21; 95% CI, 0.09–0.48; p < 0.001), and radius Grade 10 (OR, 0.42; 95% CI, 0.19–0.97; p = 0.042) with ulna Grade 9 (no patients with curve progression).
Conclusion Brace weaning indications using Risser staging are inadequate. Curve progression is expected in patients with large curves, irrespective of maturity status. Bone age measurement by either Sanders staging or the distal radius and ulna classification provides clearer guidelines for brace weaning, resulting in the least postweaning curve progression. Weaning in patients with Sanders Stage 8 and radius Grade 10/ulna Grade 9 provides the earliest and most protective timepoints for initiating brace weaning.
Level of Evidence Level II, prognostic study.

CORR Insights®: When Should We Wean Bracing for Adolescent Idiopathic Scoliosis?

01-09-2019 – Hosalkar, Harish

Journal Article

No abstract available

Biomechanical Function and Size of the Anteromedial and Posterolateral Bundles of the ACL Change Differently with Skeletal Growth in the Pig Model

01-09-2019 – Cone, Stephanie G.; Lambeth, Emily P.; Ru, Hongyu; Fordham, Lynn A.; Piedrahita, Jorge A.; Spang, Jeffrey T.; Fisher, Matthew B.

Journal Article

Background ACL injuries are becoming increasingly common in children and adolescents, but little is known regarding age-specific ACL function in these patients. To improve our understanding of changes in musculoskeletal tissues during growth and given the limited availability of pediatric human cadaveric specimens, tissue structure and function can be assessed in large animal models, such as the pig.
Questions/purposes Using cadaveric porcine specimens ranging throughout skeletal growth, we aimed to assess age-dependent changes in (1) joint kinematics under applied AP loads and varus-valgus moments, (2) biomechanical function of the ACL under the same loads, (3) the relative biomechanical function of the anteromedial and posterolateral bundles of the ACL; and (4) size and orientation of the anteromedial and posterolateral bundles.
Methods Stifle joints (analogous to the human knee) were collected from female Yorkshire crossbreed pigs at five ages ranging from early youth to late adolescence (1.5, 3, 4.5, 6, and 18 months; n = 6 pigs per age group, 30 total), and MRIs were performed. A robotic testing system was used to determine joint kinematics (AP tibial translation and varus-valgus rotation) and in situ forces in the ACL and its bundles in response to applied anterior tibial loads and varus-valgus moments. To see if morphological changes to the ACL compared with biomechanical changes, ACL and bundle cross-sectional area, length, and orientation were calculated from MR images.
Results Joint kinematics decreased with increasing age. Normalized AP tibial translation decreased by 44% from 1.5 months (0.34 ± 0.08) to 18 months (0.19 ± 0.02) at 60° of flexion (p < 0.001) and varus-valgus rotation decreased from 25° ± 2° at 1.5 months to 6° ± 2° at 18 months (p < 0.001). The ACL provided the majority of the resistance to anterior tibial loading at all age groups (75% to 111% of the applied anterior force; p = 0.630 between ages). Anteromedial and posterolateral bundle function in response to anterior loading and varus torque were similar in pigs of young ages. During adolescence (4.5 to 18 months), the in situ force carried by the anteromedial bundle increased relative to that carried by the posterolateral bundle, shifting from 59% ± 22% at 4.5 months to 92% ± 12% at 18 months (data for 60° of flexion, p < 0.001 between 4.5 and 18 months). The cross-sectional area of the anteromedial bundle increased by 30 mm2 throughout growth from 1.5 months (5 ± 2 mm2) through 18 months (35 ± 8 mm2; p < 0.001 between 1.5 and 18 months), while the cross-sectional area of the posterolateral bundle increased by 12 mm2 from 1.5 months (7 ± 2 mm2) to 4.5 months (19 ± 5 mm2; p = 0.004 between 1.5 and 4.5 months), with no further growth (17 ± 7 mm2 at 18 months; p = 0.999 between 4.5 and 18 months). However, changes in length and orientation were similar between the bundles.
Conclusion We showed that the stifle joint (knee equivalent) in the pig has greater translational and rotational laxity in early youth (1.5 to 3 months) compared with adolescence (4.5 to 18 months), that the ACL functions as a primary stabilizer throughout growth, and that the relative biomechanical function and size of the anteromedial and posterolateral bundles change differently with growth.
Clinical Relevance Given the large effects observed here, the age- and bundle-specific function, size, and orientation of the ACL may need to be considered regarding surgical timing, graft selection, and graft placement. In addition, the findings of this study will be used to motivate pre-clinical studies on the impact of partial and complete ACL injuries during skeletal growth.

CORR Insights®: Biomechanical Function and Size of the Anteromedial and Posterolateral Bundles of the ACL Change Differently with Skeletal Growth in the Pig Model

01-09-2019 – Wilson, Nicole A.

Journal Article

No abstract available

Classifications in Brief: The Denis Classification of Sacral Fractures

01-09-2019 – Rizkalla, James M.; Lines, Tanner; Nimmons, Scott

Journal Article

No abstract available