Outcomes of Medicare Outpatient Total Knee Arthroplasty at an Ambulatory Surgery Center

Background: Total knee arthroplasty (TKA) was removed from the “inpatient only” list for Medicare Beneficiaries in 2018. As a result, outpatient TKA’s have been performed at ambulatory surgery centers (ASC) more frequently. This study aims to evaluate outcomes of medicare patients who underwent outpatient TKA at an ASC. Methods: We conducted a retrospective cohort review of medicare patients who underwent TKA at an ASC between January 1st, 2020 and June 30th, 2020 performed by six orthopedic surgeons. Results: Thirty-six patients were identified who underwent primary TKA. There was a mean age of 72.4 and body mass index of 30.9. The mean preoperative range of motion was -6.7 degrees of extension and 114.8 degrees of flexion, two and six week post operative extension of -3.8 degrees and flexion of 104 degrees and -2.7 degrees and 114.6 degrees respectively. Preoperative physical and mental patient reported outcomes measurement and information system scores were 43.2 and 53.4 respectively and 49.4 and 53.1 post operatively. Preoperative patient reported outcomes measure with the knee injury and osteoarthritis outcome score was 48.4 and 72.8 post operatively. There were two patients (5.5%) with complications of arthrofibrosis that required manipulation under anesthesia. Total recovery time and time within the ASC were on average 200 minutes and 398.6 minutes respectively. Conclusion: Without adverse events within the first six months, this study suggests that outpatient TKA can be safely performed in medicare patients at an ASC.

Limited Effect of Generalized Systematic Lockdown on Urgent Orthopedic and Limb Trauma Surgery in a Geographical Area Mildly Affected by the First of SARS-CoV-2 Pandemic: A Multicentric Study (Limited Effect of Lockdown in an Area Mildly affected by the Pandemic)

Purpose: The SARS-CoV-2 pandemic led to a systematic lockdown of populations in many countries along with the reorganization of care systems to respond to this unprecedented health crisis. This study determined (i) the number of urgent surgical operations carried out during the lockdown in a region of France mildly affected by the SARS-CoV-2 pandemic, and (ii) the types of surgery concerned (main characteristics). Methods: A retrospective, comparative, observational, multicentric study of urgent orthopedic and limb trauma surgery during lockdown was conducted. It included three reference care centers of which two were teaching hospitals. A comparison was made with data for the same period in 2019. For each patient, the following data were collected: date of surgery, age, sex, place of residence, and standardized descriptors used to classify the injury anatomically, context in which the injury occurred, and SARS-CoV-2 PCR status. Results: 1098 patients underwent surgery against 1266 over the same period in 2019, a non-significant difference of −13.3% (p = 0.11) [−39.2% in Week 13 (p = 0.02), +7.6% in Week 19 (p = 0.16)]. Except for bone injuries of the hand and wrist (+13.4%, p = 0.07), a decrease in activity was observed for all anatomic locations, and especially for the distal radius (−55.8%, p = 0.001), ankle (−40.5%, p = 0,01). The context in which the injury occurred changed, with in particular a significant decrease in the number of sport accidents (−80.0%, p < 0.001) and road traffic accidents (−41.8%, p = 0.04), and an increase in DIY and gardening accidents (+62.7%, p < 0.001). Conclusion: The decrease in emergency surgery was much less marked in this geographical area mildly affected by the pandemic. Health policy that sets ways to ensure continuity in the care needed by the population must be adapted locally when a global health crisis strikes. Level of proof: 4 – Descriptive epidemiological study.

Anatomic Study of Exposed Posterior Malleolus Using the Posterolateral Ankle Approach

We compared the effect of the posterolateral ankle approach on the exposed posterior malleolus and vascular nerves in order to reduce the probability of vascular nerve injury during surgical exposure. Five corpses were randomly allocated to incision A and B groups. The tip of the lateral malleolus was used as a starting point, while the lateral line of the Achilles tendon was used as the endpoint to its trisection. Using the two points near the side of the Achilles tendon, we drew two vertical horizontal lines to represent incisions A and B, then measured the horizontal distances between the tip of the lateral malleolus and incision A (a), the tip of the lateral malleolus and incision B (b), and the tip of the lateral malleolus and the midpoint of the sural nerve and small saphenous vein (c). We then exposed the fibula from the posterior portion of the peroneus brevis muscles, dissected the flexor pollicis longus from the posterior edge of the fibula, and used Vernier calipers to measure the maximum length and width of the exposed bone block. There was no statistically significant difference between distances (a) and (c), but there was a significant difference between distances (b) and (c). The length of the exposed posterior malleolus did not differ significantly between incisions A and B, but the width differed significantly. Exposing the posterior malleolus using an approach closer to the lateral Achilles tendon is less likely to injure the sural nerve and small saphenous vein and results in a larger exposed area and easier manipulation. Thus, this could be a better surgical treatment for ankle fractures.

Functional Outcome of Distraction Osteogenesis Using Linear Rail System (LRS) in Adults with Isolated Femoral Bone Gap

Background: The management of bone gap in the femoral shaft has remained difficult and challenging to the orthopaedic and trauma Surgeons. Distraction osteogenesis using the linear rail system (LRS) may be a useful tool in bridging such defects in our environment. Objective: To study the radiologic bone union, functional outcome and complications of distraction osteogenesis in the management of femoral bone gap using linear rail system (LRS). Methodology: A hospital based prospective interventional study conducted at National Orthopaedic Hospital, Dala and Albarka clinic, Dandishe, Kano, between March 2013 and March 2018. Sixty-eight cases were recruited. Every patient had LRS applied after adequate debridement when needed. Primary or interval corticotomy was done depending on the extent of soft tissue dissection in relation to the corticotomy site. Follow up was done until the regenerate had corticalized and LRS removed. Complications were noted and recorded. Radiologic union and functional outcome were assessed using the RUST and ASAMI outcome scores respectively. Data was analyzed using SPSS version 20. Results: Sixty-eight cases were recruited with M: F ratio of 16: 1. The mean age was 36.7 +/- 10.5years. The age range between 36-45years was more commonly treated representing 34(50.0%). Primary corticotomy was done in 52 (76.5%) while interval corticotomy was done in 16 (23.5%). The mean regenerate length achieved was 9.6 +/- 2.7cm. The mean duration of treatment was 20.3 +/- 6 months. Radiologic union was achieved in 66 (97.1%) patients. Sixty-four (94.1%) had excellent or good ASAMI functional outcome scores. Sixty-six (97.1%) were either very satisfied or satisfied with their treatment while 2 (2.9%) were indifferent. The common complications were intermittent pin tract infections recorded in 28 (41.2%), knee stiffness in 18 (26.5), proximal or distal varus deformity in 10 (14.7%) and non-union in 2 (2.9%) of cases. Conclusion: Distraction osteogenesis using LRS can achieve bone union and excellent outcome in the management of bone gap in the femur. However, intermittent pin tract infection, knee stiffness and varus deformities post significant challenges.

Shoulder Function Following Latarjet Procedure for Recurrent Anterior Shoulder Instability

Introduction: Anterior shoulder dislocation and recurrent glenohumeral instability is very common in the young active population. It is usually caused by trauma, and often compounded by associated bony Bankart and Hill-Sachs lesions, which distort the anatomy. This causes instability and dysfunction of the joint and these can be addressed by, amongst others, a Latarjet surgical procedure. Hypothesis: We hypothesize that since the Latarjet procedure results in stability and good functional outcome, our results are expected to compare favourably to the rest of the published literature. Methods: A retrospective study of 31 patients treated with the Latarjet procedure at Helen Joseph hospital, Johannesburg South Africa was undertaken during the period of January 2005 to December 2013. The minimum follow up was 6 months. Stability was assessed looking at re-dislocation rate and the clinical functional outcome was measured using the Constant Score. Results: There were no shoulder re-dislocations and the mean Constant score was 85.35. 74% had a Constant Score above 80. 68% were pain free and 61% had normal activities of daily living while 68% had a full range of motion and 68% had full power. Conclusion: The Latarjet results in stability and good functional outcome. In our patient cohort, the Latarjet procedure provided reliable stability to the shoulder joint. Pain was alleviated, shoulder muscle power was preserved, range of shoulder motion was restored and patients did return to pre injury activities of daily living.

A Rare Case of a Transphyseal Distal Humerus Fracture in a Pediatric Patient

Birth injuries are uncommon and occur in less than 1% of the population. Transphyseal fractures of the distal humerus typically occur in children younger than three years old and may result from birth trauma in cases where excessive traction or obstetrical maneuvers are required. Early and accurate diagnosis is necessary for successful management. Differential diagnosis includes non-accidental trauma, brachial plexus injury, elbow dislocation, septic arthritis and osteomyelitis. This case report describes a rare case of a transphyseal distal humerus fracture in a pediatric patient.

Relation between vitamin D deficiency and osteoarthritis

Purpose of the Work: The main objective of our work is to determine the relationship between osteoarthritis and deficiency of vitamin D in our region in central Europe and to make a database for further researches, to be effective in investigating, controlling, and preventing OA and vitamin D deficiency in our population. Methodology: We perform a retrospective study in adult patients≥25years with osteoarthritis big joints from their health records, which were seen at the osteology clinic of University Hospital Louise Pasteur during the year 2018. The authors analyse the blood tests of Vitamin D level, calcium level, phosphorus level, B ALP, glomerular filtration rate (GFR) levels in the serum of these patients. Results: There were 47 patients with osteoarthritis. All of these patients had Vitamin D deficiency. The mean age of our group is 71 years. 12.8% (7) are male and 87.2% (41)are female. The mean of vitamin D is 24mmol/l (normal range 75-200 nmol/l), Calcium level with in normal range, Phosphorus level mean was within normal range and B ALP level within normal. Conclusion: Osteoarthritis increased by deficiency of vitamin D level in blood serum and increasing with age. Vitamin D is a fat-soluble vitamin that regulates calcium and phosphorus metabolism, maintenance of the normal skeletal and muscular systems. Most of the patients show OA in hip and knee and in advanced age 71 years. Vitamin D supplementation may be a safe method to treat and prevent OA.

Management of Cauda Equina Syndrome: NHS Staff Perceptions in a DGH

Objective: Cauda Equina Syndrome (CES) is a challenging condition to diagnose due to such variability in clinical features and poor correlation with MRI findings. It requires surgery within hours to avoid damage to the bowel, bladder, sexual organs and lower limbs. There are empirical studies exploring patients’ perspectives of having CES, however, there is no literature to review NHS staff perceptions of managing this neurosurgical emergency. The aim is to explore perceptions of senior clinical staff who commonly manage patients with suspected CES in secondary care within the Emergency Department (ED) and Trauma and Orthopaedics (T&O) to improve the management of CES. The main objective is to identify barriers to successful management and possible solutions to improve care. Methods: A self-administered non-validated questionnaire was designed to identify barriers experienced and potential solutions. In addition, a Nominal Group Technique (NGT) was used to gain a greater insight. The qualitative data obtained was analysed by thematic analysis. Results: The questionnaire generated a 73% response rate. Six senior clinicians attended the NGT with representation from the three clinical specialities; ED, T&O and Advanced Physiotherapy Practitioner (APP). The challenges and potential solutions were categorised into themes and subthemes. The barriers highlighted included; staff confidence in clinical diagnosis; fear of litigation and inter-professional relations; patient psychosocial factors, expectations and comorbidities; lack of agreed local pathway. The solutions raised include; staff training; standardising local/national pathway; access to daily Magnetic Resonance Imaging (MRI) slots. Conclusion: Patient safety and accurate diagnosis of CES is at the forefront of decision-making despite organisation barriers and limitations of existing pathways. A shift away from admission to expedite an urgent MRI requires a change to traditional clinical practice and expectations. In times of rising pressures and financial constraints, collaborative working is essential to implement and sustain the required changes highlighted in this study.

Increasing posterior condyle cut for high-flex knee prosthesis may injure popliteus tendon origin: a cadaveric study

Background: High-flex total knee prosthesis designs were proposed to improve flexion in total knee replacement (TKA). One of high-flex features is increasing posterior condyle cut which put popliteal tendon in higher risk of injury and may result in gap changes. Methods: Thirty-six popliteal origin sites from eighteen fresh cadavers were measured distances between the posterior rim of popliteal tendon origin and posterior border of the lateral femoral condyle (distance A) using digital “Vernier caliper”. The mean distances were compared to posterior condyle thickness of different prosthesis designs. Results: The mean of distance A on the right knee was 9.59 ±1.66 mm (6.03-12.70) while the mean of distance A on the left knee was 9.13 ± 1.78 mm (5.80-11.07). Posterior condyle thickness of the femoral prostheses varies upon their design and size from 7.4 to 10 mm for standard model and from 8.2 to 12.5 mm for high-flex design. Possibilities of popliteal tendon injury during posterior condyle bone cut were 16.7% to 66.7% for standard model and 27.8% to 97.2% for the high-flex design. Conclusion: High-flex TKA prosthesis with thicker posterior condyle relates to higher possibility of popliteal tendon origin injury compared to standard one.

Impact of COVID-19 on Pediatric and Adult Orthopaedics

Background: Social practices, hospital guidelines, and government regulations in response to COVID-19 have influenced orthopaedic practice volumes. The widespread cessation of non-essential surgeries has greatly decreased elective practices, but the extent to which trauma volumes diminish remains unknown. Access to common sites of orthopaedic injury was limited during this period, including organized sports, playgrounds, and travel. Methods: To examine the effect of COVID-19 in pediatric and adult practices, considering local responses to the pandemic, weather effects, and school activity. We retrospectively examined orthopaedic clinic changes for the first five months of the year in 2019 and 2020. An administrative database was used to obtain volume data for OR cases, OP visits, and OP clinic procedures. Temperature and precipitation records were collected for the same period. Results: All aspects of the adult practice greatly decreased in March, April, and May compared to the previous year. The largest decreases in OR cases occurred in April for adults, with a slight increase in May, but volumes remained decreased compared to the previous year. Pediatric and adult OP visits and OR cases dropped similarly in March and April. This trend continued into May for OP visits, but only pediatric OR visits increased in May. Conclusion: Practice trends from 2019 to 2020 established in January and February abruptly altered in the following months. Institutional cessation of elective procedures and government issued statewide stay-at-home orders greatly impacted orthopaedic volumes during this period. Decreased opportunity for social activity contributed to drops in pediatric and adult trauma. Proactive responses by local schools aided in a more rapid decline of pediatric trauma compared to adults in the month of March.