Publications by Year: 2025

STUDY DESIGN: Retrospective Cohort Study.

OBJECTIVE: Restoration of lordosis in lumbar fusion reduces low back pain, decreases adjacent segment degeneration, and improves postoperative outcomes. However, the potential effects of changes in segmental lordosis on adjacent-level and global lordosis remain less understood. This study aims to examine the relationships between segmental (SL), adjacent-level, and global lumbar lordosis following L5-S1 Anterior Lumbar Interbody Fusion (ALIF).

METHODS: 80 consecutive patients who underwent single-level L5-S1 ALIF were divided into 3 groups based on the degree of change (∆) in index-level segmental lordosis: <5° (n = 23), 5°-10° (n = 29), >10° (n = 28). Radiographic parameters measured included global lumbar, segmental, and adjacent level lordosis, sacral slope, pelvic tilt, pelvic incidence, and PI-LL mismatch.

RESULTS: Patients with ∆SL 5°-10° or ∆SL >10° both showed significant increases in global lumbar lordosis from preoperative to final follow-up. However, patients with ∆SL >10° showed statistically significant losses in adjacent level lordosis at both immediate postoperative and final follow-up compared to preoperative. When comparing patients with ∆SL >10° to those with ∆SL 5-10°, there were no significant differences in global lumbar lordosis at final follow-up, due to significantly greater losses of adjacent level lordosis in these patients.

CONCLUSION: The degree of compensatory loss of lordosis at the adjacent level L4-L5 correlated with the extent of segmental lordosis creation at the index L5-S1 level. This may suggest that the L4 to S1 segment acts as a "harmonious unit," able to accommodate only a certain amount of lordosis and further increases in segmental lordosis may be mitigated by loss of adjacent-level lordosis.

BACKGROUND: Forearm stiffness can be caused by distal radioulnar joint (DRUJ) capsular contractures, which can occur after trauma such as a distal radius fracture. In this setting, a DRUJ capsular release may help improve forearm rotation, but the long-term functional outcomes remain unknown. The purpose of this case series is to investigate the short-term improvement in total pronosupination arc range of motion and long-term patient-reported outcomes (PROs) after DRUJ capsular release.

METHODS: We performed a retrospective review of consecutive patients who underwent DRUJ capsular release. Range of motion prior to surgery and at final short-term follow-up was collected and analyzed with a Wilcoxon signed-rank test. Patient-reported outcomes including QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores were obtained as medians with interquartile range (IQR), while patient satisfaction was measured on a 4-point Likert scale.

RESULTS: Five patients met the inclusion criteria with a median short-term follow-up of 5.5 (IQR: 4.3-10.3) months. The median preoperative supination was 25° (IQR: 0°-35°), and the median postoperative supination was 50° (IQR: 40°-60°; P = .03). The median preoperative pronation was 45° (IQR: 10°-60°), and the median postoperative pronation was 70° (IQR: 60°-80°; P = .04). After the long-term median follow-up of 10.9 (IQR 9.7-11.2) years, all the patients were satisfied or very satisfied with the results of the surgery. The median QuickDASH score was 13.6 (IQR: 9.1-20.5), and the median PROMIS UE score was 46.5 (IQR: 43.8-47.7).

CONCLUSIONS: Distal radioulnar joint capsular release can improve pronation and supination in patients with posttraumatic forearm stiffness and is associated with high long-term patient satisfaction.

OBJECTIVE: To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative cardiopulmonary resuscitation (CPR) in surgical patients with frailty.

BACKGROUND: The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of CPR in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown.

METHODS: We performed qualitative thematic analysis of transcripts from semistructured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at 2 academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients.

RESULTS: We identified 5 themes: (1) perceptions of perioperative CPR in patients with frailty vary by provider specialty, (2) judgments regarding the appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology, (3) resuscitation in patients with frailty is sometimes associated with moral distress, (4) biases, such as ableism and ageism, may skew clinicians' perceptions of the appropriateness of perioperative CPR in patients with frailty, and (5) evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate.

CONCLUSIONS: Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases, such as ageism and ableism.

BACKGROUND:  Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount.

METHODS:  Herein we aim to understand efforts supporting the nascent field of preventive surgery, including (1) enhanced risk stratification, (2) medical optimization and prehabilitation, (3) surgical mitigation techniques, and (4) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized.

RESULTS:  Although multiple risk mitigation methods have demonstrated clear benefits, including prophylactic surgical procedures and earlier involvement of plastic surgery, their use is widely variable across institutions. Many current risk assessment tools are suboptimal for supporting more algorithmic approaches to reduce surgical risk.

CONCLUSION:  Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.

PURPOSE: To evaluate the safety and efficacy of ultrasound-guided percutaneous thrombin injection for the treatment of upper extremity pseudoaneurysms.

METHODS: An institutional database containing 8,316,467 radiology reports was searched for suitable cases over a 241-month period. Fourteen female and 10 male patients, average age of 69.7 years (range 29-93) underwent a total of 26 procedures for the management of upper extremity pseudoaneurysms, involving the radial (n = 9), brachial (n = 9) or other upper extremity arteries (n = 6). Baseline demographic and pseudoaneurysm characteristics were documented, together with primary and secondary success, failures, and complications. All procedures were performed with real-time ultrasound guidance.

RESULTS: The mean pseudoaneurysm volume was 9.93 cm3 (range 0.06-111.62 cm3). Twelve cases were related to central line placement or arterial access. Primary success was obtained in 50% (n = 12) after a single ultrasound-guided thrombin injection, and secondary success was achieved in an additional six (for a total success of 75%). Success was highest for the treatment of brachial artery pseudoaneurysms (87.5%), and in those who were diagnosed within 7 days of the inciting event, findings that were statistically significant (p-value 0.046 and 0.002, respectively).

CONCLUSIONS: Ultrasound-guided percutaneous thrombin injection is safe and effective for managing upper extremity pseudoaneurysms.

Treatment of symptomatic thumb carpometacarpal (CMC) joint synovitis can be challenging. Surgical options in these patients are often limited due to the patient's youth and lack of arthrosis. One of the most commonly used techniques involves the use of the flexor carpi radialis to reconstruct the ligamentous complex of the thumb CMC joint. This technique is technically challenging and involves a wide exposure to the CMC joint. Furthermore, outcomes data on this technique are relatively lacking. We propose a novel minimally invasive technique to confer stability to the thumb CMC joint in the setting of persistent subluxation/synovitis using the Arthrex MiniTightrope system. Our clinical results are encouraging at mean 24 months postoperative with nearly all patients experiencing both statistically and clinically meaningful improvements in QuickDASH and Visual Analog Scale pain scores.

PURPOSE: The popularity of minimally invasive (MIS) foot surgery continues to grow. However, it comes with certain limitations that present notable challenges. One significant hurdle is the absence of direct visualization of neurovascular structures and tendons. The objective of this study is to present fluoroscopic heatmaps that illustrate the trajectories of major structures encountered during MIS midfoot procedures.

METHODS: Sequential dissection was performed on nine below-knee cadaveric specimens and critical structures were identified and marked, including anterior tibialis tendon (ATT), extensor hallucis longus tendon (EHL), extensor digitorum longus tendon (EDL), superficial peroneal nerve (SPN) and dorsal neurovascular bundle (DNVB) were dissected. Subsequently, flexible wires were positioned and securely placed adjacent to the medial and/or lateral borders of these structures to visualize their trajectories on X-ray imaging. Anteroposterior (AP) and oblique fluoroscopic images of the foot, featuring a calibration marker, were obtained alongside standard photographs. All fluoroscopy images were adjusted to a uniform scale and standardized to a single foot fluoroscopy. The coordinates of the structures were marked on these standardized foot AP and oblique fluoroscopic views. These coordinates were then utilized to generate heatmaps.

RESULTS: Successfully generated heatmaps encompassed the DNVB, ATT, EDL, EHL, and SPN, on AP and oblique fluoroscopic images of the foot. The color gradient used visually represents varying magnitudes, with red indicating the most frequent locations of the structures and blue signifying lower occurrences. These heatmaps also illustrate the highest-risk areas for iatrogenic injury to the structures during MIS procedures.

CONCLUSION: This study can empower surgical navigation and improve safety in MIS midfoot procedures by providing surgeons with a fluoroscopic heatmap detailing the trajectories of major anatomical structures. The findings from this study present a valuable opportunity to improve surgical accuracy and safety.

BACKGROUND: Proximal humerus fractures are common in adults aged 65 and older and provide challenges for osteoporotic patients due to the risk of suboptimal fixation and complications. Locking plates are often utilized to treat two-part fractures; however, ongoing concerns about their stability exist. This pilot study investigates the biomechanical impact of subchondral locking screws compared to unicortical screws in osteoporotic two-part cadaveric proximal humerus fractures.

METHODS: Using dual-energy X-ray absorptiometry (DXA), cadaveric shoulder specimens from eight female Caucasian donors with comparable bone mineral densities were used for the study. Either unicortical or bicortical locking screws (the latter representing subchondral screws in real surgeries) were utilized to fix locking plates. Axial load to failure and cyclic physiologic abduction moments were applied in biomechanical testing.

FINDINGS: The study found no statistically significant difference in interfragmentary displacement between the unicortical and bicortical groups (p = 0.78). The mechanical properties of both groups were found to be comparable in terms of yield (p = 0.59), ultimate (p = 0.86), and fracture strengths (p = 0.70). Furthermore, rigidity analysis did not identify any significant difference between the two groups (p = 0.22).

INTERPRETATION: Our findings indicate that there is little to no difference in the stability of the construct for osteoporotic two-part proximal humerus fractures, in contrast to general recommendations against unicortical screws. This pilot study suggests that the choice between unicortical and subchondral locking screws may not significantly affect biomechanical characteristics in osteoporotic two-part proximal humerus fractures, despite the study's limitations.

BACKGROUND: In Ethiopia, orthopaedic services are limited, and many injured children undergo traditional bonesetting (TBS) despite its association with limb- and life-threatening complications. We sought to identify the risk factors for amputation and a prolonged hospitalization of >7 days in children who presented to hospitals after undergoing TBS.

METHODS: Over a 15-month period, we prospectively enrolled children who presented to 8 Ethiopian hospitals after undergoing TBS. Separately for each outcome (amputation and prolonged hospitalization), we used multivariable logistic regression to evaluate associations between the outcome and 16 covariates, including demographic and injury characteristics, parent or guardian preference for TBS, and TBS topical treatments and immobilization methods.

RESULTS: We enrolled 460 children (mean age, 9.0 ± 4.0 years; 75% male) representing 8 Ethiopian regions and diverse demographic and socioeconomic backgrounds. Elbow injuries (194 patients; 42.2%) and closed fractures and/or dislocations (364 patients; 79.1%) were most common. TBS treatments included topical inorganic (190 patients; 41.3%) or organic (82 patients; 17.8%) material application and rigid (166 patients; 36.1%) or soft (182 patients; 39.6%) immobilization. Twenty-six children (5.7%) underwent an amputation, and 102 (22.2%) had a prolonged hospitalization. The odds of amputation were higher for children from rural communities (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 2.01 to 22.41) and for children with only non-osseous injuries (AOR, 5.76; 95% CI, 1.56 to 21.28). The odds of prolonged hospitalization were higher for children who were 11 to 17 years old (AOR, 2.77; 95% CI, 1.18 to 6.50) and for children with open fractures with a grade of ≥2 (AOR, 4.52; 95% CI, 1.33 to 15.28) but were lower for children from households with secondary education or higher (AOR, 0.40; 95% CI, 0.21 to 0.79). TBS with rigid immobilization increased the odds of amputation (AOR, 5.84; 95% CI, 1.74 to 19.60) and prolonged hospitalization (AOR, 2.20; 95% CI, 1.02 to 4.73). TBS organic topical treatment (with mud, leaves, or butter) increased the odds of amputation (AOR, 3.88; 95% CI, 1.40 to 10.73).

CONCLUSIONS: For children who underwent TBS prior to hospital presentation, rigid splinting by bonesetters increased the odds of amputation and prolonged hospitalization. TBS organic topical treatments also increased the odds of amputation. Training bonesetters to avoid these dangerous practices may prevent devastating complications for children in Ethiopia.

LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

AIMS: The Birmingham Orthopaedic Oncology Meeting (BOOM), held in January 2024, convened 309 delegates from 53 countries to discuss and refine 21 consensus statements on the optimal management of chondrosarcoma.

METHODS: With representation from Europe (43%; n = 133), North America (17%; n = 53), South America (16%; n = 49), Asia (13%; n = 40), Australasia (5%; n = 16), the Middle East (4%; n = 12), and Africa (2%; n = 6), the combined experience of treating bone sarcomas among attendees totalled approximately 30,000 cases annually, equivalent to 66 years of experience in the UK alone. The meeting's process began with the formation of a local organizing committee, regional leads, and a scientific committee comprising representatives from 150 specialist units across 47 countries. Supported by major orthopaedic oncology organizations, the meeting used a modified Delphi process to develop consensus statements through online questionnaires, thematic groupings, narrative reviews, and anonymous pre-meeting polling.

RESULTS: Strong (> 80%) consensus was achieved on 19 out of 21 statements, reflecting agreement among delegates. Key areas of consensus included the role of radiology in diagnosis and surveillance, the management of locally recurrent disease, and the treatment of dedifferentiated chondrosarcoma. Notably, there was agreement that routine chemotherapy has no role in chondrosarcoma treatment, and radiological surveillance is safe for intraosseous chondrosarcomas. Despite the overall consensus, areas of controversy remain, particularly regarding the treatment of atypical cartilage tumours and surgical margins. These unresolved issues underscore the need for further research and collaboration within the orthopaedic oncology community.

CONCLUSION: BOOM represents the largest global consensus meeting in orthopaedic oncology, providing valuable guidance for clinicians managing chondrosarcoma worldwide. The consensus statements offer a reference for clinical practice, highlight key research priorities, and aim to improve patient outcomes on a global scale.