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Cook JL, Rucinski K, Wissman R, Crecelius C, DeFroda S, Crist BD. Outcomes following open acetabular labrum reconstruction: Comparing fresh-frozen tendon with fresh meniscus allograft transplantation. J Orthop 2024; 53:13-19. [PMID: 38450061 PMCID: PMC10912234 DOI: 10.1016/j.jor.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024] Open
Abstract
Background Symptomatic acetabular labral insufficiency in young, active patients is often treated with labral repair or reconstruction using fresh-frozen allografts. However, fresh-frozen tendon allografts do not have tissue or material properties that closely mimic acetabular labral fibrocartilage. Recent studies suggest meniscal allografts may be a better biomechanical, geometric, and material alternative for acetabular labrum reconstruction (ALR). Hypothesis Patients undergoing open ALR using fresh meniscus allograft transplants (MAT) will have better outcomes than those using fresh-frozen tendon allografts transplants (TAT) when comparing initial treatment success, diagnostic imaging assessments, and patient-reported pain and function scores. Study design Cohort Study. Methods With IRB approval, patients undergoing ALR with either TAT or MAT were included when initial (>1-year) outcomes data related to treatment success, pain, and function were available. In addition, a subcohort of patients underwent magnetic resonance imaging at least 6-months after surgery to evaluate allograft healing. Results Initial success rate, defined as no need for ALR revision or conversion to total hip arthroplasty (THA), was 88.9% for the entire group (n = 27, TAT = 5, MAT = 22) with 1 (20%) patient in the TAT cohort and 2 patients (9.9%) in the MAT cohort undergoing THA. In the MAT cohort, significant improvements were documented for physical function and pain scores at 1 year and final follow-up (FFU)(mean 26.8 months). Improvements in pain and function were noted at 1-year, but not at FFU (mean 59.6 months) in the TAT group. MRIs completed at least 6 months after labrum reconstruction showed improved allograft integrity and integration in the MAT cohort over the TAT cohort. Conclusion For acetabular labrum reconstructions, MAT was associated with a higher initial success rate, superior patient reported outcomes, and subjectively better MRI findings when compared to TAT.
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Affiliation(s)
- James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - Kylee Rucinski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - Robert Wissman
- Department of Radiology, University of Missouri, Columbia, MO, USA
| | - Cory Crecelius
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Steven DeFroda
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - Brett D. Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
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Rucinski K, Cook JL, Schweser KM, Crist BD. Short-Term Outcomes After Bipolar Osteochondral Allograft Transplantation (OCAT) in the Ankle. J Foot Ankle Surg 2024; 63:207-213. [PMID: 37972816 DOI: 10.1053/j.jfas.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
Treatment options for symptomatic cartilage loss in the ankle are not consistently effective. This study documents initial outcomes for patients undergoing bipolar OCAT in the ankle after advances in tissue preservation, transplantation techniques, and patient management strategies were implemented. Patients were prospectively enrolled into a registry designed to follow outcomes after OCAT in the ankle. Fourteen patients were included for analyses (12 primary OCAT, 2 revision OCAT). Four patients underwent Bipolar OCAT (tibia, talus) and 10 Bipolar+ OCAT (tibia, talus, fibula). Short-term (median follow-up 43, range 13-73 months) success was documented for 13 patients. Radiographic assessments indicated OCA integration and maintenance of joint space in 12 patients. Statistically significant (p < .030) and clinically meaningful improvements in AAOS and VAS pain scores were noted at 3 months, 6 months, 1 year, and 2 years following OCA transplantation when compared to preoperative measures. For patients that were nonadherent to postoperative restriction and rehabilitation protocols, all 1-year postoperative PROs were significantly lower (p < .050) than for patients who were adherent. The successful outcomes documented in 13 of 14 patients in conjunction with significant and clinically meaningful improvements in patient-reported measures of pain and function support OCA transplantation as an appropriate treatment option in indicated patients. These improvements in outcomes were associated with advances in OCA preservation, preimplantation treatment, transplantation techniques, and patient management strategies, suggesting this shift in practice be considered for OCA transplantation in the ankle.
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Affiliation(s)
- Kylee Rucinski
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO; Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO
| | - James L Cook
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO; Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO
| | - Kyle M Schweser
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO
| | - Brett D Crist
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO; Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO.
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Wolfe PN, Stoker AM, Crist BD, Leary E, Bozynski CC, Cook JL. Evaluation of mechanistic serum and urine biomarkers for secondary osteoarthritis associated with developmental dysplasia of the hip. J Orthop 2023; 42:24-29. [PMID: 37601815 PMCID: PMC10435905 DOI: 10.1016/j.jor.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/09/2023] [Accepted: 05/24/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Determine measurable differences for mechanistic urine and serum biomarkers in patients with developmental dysplasia of the hip (DDH) prior to, and following, secondary hip osteoarthritis (OA) when compared to controls. Design Urine and serum were collected from individuals with developmental dysplasia of the hip (n = 39), prior to (Pre-OA DDH, n = 32) and following diagnosis of secondary hip OA (Post-OA DDH, n = 7), age-matched Pre-OA controls (n = 35), and age-matched Post-OA controls (n = 12). Samples were analyzed for protein biomarkers with potential for differentiation of hip status through a Mann-Whitney U test with a Benjamini-Hochberg correction. Results Several interleukin and degradation related proteins were found to be differentially expressed when comparing DDH-related hip status prior to and following diagnosis of hip OA. In addition, MCP-1 and TIMP-1 were significantly different between younger and older patients in the control cohorts. Conclusion These results provide initial evidence for serum and urine protein biomarkers that define clinically relevant stages of symptomatic DDH and its progression to secondary hip osteoarthritis categorized by known mechanisms of disease. Level of evidence III.
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Affiliation(s)
- Preston N. Wolfe
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, United States
- Arthrex, Inc, Naples, FL, United States
| | - Aaron M. Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, United States
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, United States
| | - Brett D. Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, United States
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, United States
| | - Emily Leary
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, United States
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, United States
| | - Chantelle C. Bozynski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, United States
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, United States
| | - James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, United States
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, United States
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Nauth A, Crist BD, Morshed S, Watson JT, Pape HC. Management of aseptic nonunions and severe bone defects: let us get this thing healed! OTA Int 2023; 6:e258. [PMID: 37533443 PMCID: PMC10392436 DOI: 10.1097/oi9.0000000000000258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/29/2022] [Indexed: 08/04/2023]
Abstract
Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided.
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Affiliation(s)
- Aaron Nauth
- Department of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Brett D. Crist
- Department of Orthopaedic Surgery, One Hospital, Columbia, MO
| | - Saam Morshed
- UCSF/SFGH Orthopaedic Trauma Institute, San Francisco, CA
| | - J. Tracy Watson
- Department of Orthopaedic Surgery, St. Louis University Health Science Center, Saint Louis, MO; and
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Wolfe PN, Stoker AM, Leary E, Crist BD, Bozynski CC, Cook JL. Evaluation of Serum and Urine Biomarker Panels for Developmental Dysplasia of the Hip Prior to Onset of Secondary Osteoarthritis. Cartilage 2023:19476035231163032. [PMID: 37051936 DOI: 10.1177/19476035231163032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE Evaluate serum and urine biomarker panels for their capabilities in discriminating between individuals (13- to 34-years-olds) with healthy hips versus those with developmental dysplasia of the hip (DDH) prior to diagnosis of secondary hip osteoarthritis (OA). DESIGN Urine and serum were collected from individuals (15-33 years old) with DDH, prior to and following diagnosis of hip OA, and from age-matched healthy-hip controls. Samples were analyzed for panels of protein biomarkers with potential for differentiation of hip status using receiver operator characteristic curve (area under curve [AUC]) assessments. RESULTS Multiple urine and serum biomarker panels effectively differentiated individuals with DDH from healthy-hip controls in a population at risk for developing secondary hip OA with the best performing panel demonstrating an AUC of 0.959. The panel comprised of two serum and two urinary biomarkers provided the highest combined values for sensitivity, 0.85, and specificity, 1.00, while a panel of four serum biomarkers provided the highest sensitivity, 0.93, while maintaining adequate specificity, 0.71. CONCLUSION Results of this study indicate that panels of protein biomarkers measured in urine and serum may be able to differentiate young adults with DDH from young adults with healthy hips. These data suggest the potential for clinical application of a routine diagnostic method for cost-effective and timely screening for DDH in at-risk populations. Further development and validation of these biomarker panels may result in highly sensitive and specific tools for early diagnosis, staging, and prognostication of DDH, as well as treatment decision making and monitoring capabilities. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Preston N Wolfe
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - Aaron M Stoker
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - Emily Leary
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Chantelle C Bozynski
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
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Cherian N, Oladeji L, Ohnoutka C, Touhey D, Sauer M, Schweser KA, Kfuri M, Cook JL, Della Rocca GJ, Crist BD. Erratum to 'Risk of shortening in operatively treated proximal femur fractures with cephalomedullary nails with dynamically versus statistically locked helical blades' [Injury volume 54 issue 2 (2023) Pages 669-676]. Injury 2023; 54:1230. [PMID: 36849303 DOI: 10.1016/j.injury.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Nathan Cherian
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Lasun Oladeji
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Cole Ohnoutka
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Dan Touhey
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Madeline Sauer
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Kyle A Schweser
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - James L Cook
- Missouri Orthopaedic Institute, University of Missouri, Columbia, MO, United States
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States
| | - Brett D Crist
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO, 65212, United States.
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Rucinski K, Leary E, Crist BD, Cook JL. Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population. Injury 2023; 54:880-886. [PMID: 36725488 DOI: 10.1016/j.injury.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population. METHODS This retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury. RESULTS Data were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 "no-show" appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single. CONCLUSIONS In the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.
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Affiliation(s)
- Kylee Rucinski
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA.
| | - Emily Leary
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA
| | - James L Cook
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA
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Cherian N, Oladeji L, Ohnoutka C, Touhey D, Sauer M, Schweser KA, Kfuri M, Cook JL, Rocca GJD, Crist BD. Risk of shortening in operatively treated proximal femur fractures with cephalomedullary nails with dynamically versus statistically locked helical blades. Injury 2023; 54:669-676. [PMID: 36539309 DOI: 10.1016/j.injury.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/28/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cephalomedullary nails (CMN) have proven to be effective for the fixation of unstable pertrochanteric hip fractures, but limited data exists regarding the degree of shortening that occurs with nailing systems that offer "dynamically" versus "statistically" locked helical blades. This study aimed to determine the incidence, timing, and amount of postoperative fracture shortening in patients with pertrochanteric hip fractures treated with "dynamically" versus "statistically" locked helical blades. METHODS A retrospective review was performed on patients requiring operative fixation of pertrochanteric fractures. Inclusion criteria were patients aged 55 or older, low energy mechanism of injury, primary surgical open reduction and internal fixation of the injury, surgery performed by a fellowship-trained orthopaedic traumatologist, and radiographic follow up until healing or failure (minimum of 3 months). Quantification of fracture shortening was determined using the lateral screw protuberance method. Fracture shortening measurements were calculated from immediate post-operative films and subsequent radiographs at each follow-up visit. RESULTS 222 patients met inclusion criteria (123 using Depuy Synthes Trochanteric Fixation Nail proximal femoral nailing system (TFN) with static locking; 65 TFN with dynamic locking; 23 using Depuy Synthes Trochanteric Fixation Nail-Advanced proximal nailing system (TFNA) with static locking; and 11 TFNA with dynamic locking). When comparing the final screw protuberance, the TFN dynamic (10.31 mm), TFNA static (9.52 mm), and TFNA dynamic (7.02 mm) groups were found to be significantly less compared to the TFN static cohort (11.67 mm; p < 0.001). The distribution of fracture shortening was found to be significant (p < 0.01). Interval measurements of fracture shortening by repeated measures of ANOVA within groups showed statistically significant increases in screw protuberance for the TFN static (p < 0.001), TFN dynamic (p < 0.001), and TFNA static (p < 0.01) cohorts within the first 60 days postoperatively. The TFNA with dynamic locking group was found to have statistically significant increases until the first 100 days post-operatively (p < 0.02). DISCUSSION The incidence of fracture shortening remains high even with the use of cephalomedullary nails, regardless of dynamization status. Current pertrochanteric fixation constructs continue to favor fracture healing at the direct expense of fracture shortening.
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Affiliation(s)
- Nathan Cherian
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Lasun Oladeji
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Cole Ohnoutka
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Dan Touhey
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Madeline Sauer
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Kyle A Schweser
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - James L Cook
- Missouri Orthopaedic Institute, University of Missouri, Columbia, MO, United States
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States
| | - Brett D Crist
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1 Hospital Drive, Columbia, MO 65212, United States.
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Voss EE, Goode RD, Cook JL, Crist BD. Survey of Orthopaedic Trauma Providers: Is MRI Superior to CT Scan for Evaluating and Preoperative Planning for Tibial Plateau Fractures? Mo Med 2022; 119:261-265. [PMID: 36035573 PMCID: PMC9324694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A computerized tomography (CT) scan is the current advanced imaging standard of care for evaluation and preoperative planning for tibial plateau fractures, but magnetic resonance imaging (MRI) is emerging as a better method to identify soft tissue injuries. This study compares MRI and CT for fracture classification, associated soft tissue injuries, and preoperative planning for tibial plateau fractures. MRI offers lack of radiation and enhanced soft tissue evaluation, and as a result improved preoperative planning. MRI was favored among survey respondents for preoperative planning, Schatzker classification, and surgical approach planning.
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Affiliation(s)
- Elliott E Voss
- Medical student at the University of Missouri School of Medicine, Columbia, Missouri
| | | | - James L Cook
- Department of Orthopeadic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Brett D Crist
- Department of Orthopeadic Surgery, University of Missouri School of Medicine, Columbia, Missouri
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Zitsch BP, James CR, Crist BD, Stoker AM, Della Rocca GJ, Cook JL. A prospective randomized double-blind clinical trial to assess the effects of leukocyte-reduced platelet-rich plasma on pro-inflammatory, degradative, and anabolic biomarkers after closed pilon fractures. J Orthop Res 2022; 40:925-932. [PMID: 34185333 DOI: 10.1002/jor.25123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/19/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
Posttraumatic osteoarthritis (PTOA) significantly affects patients with pilon fractures even after adequate anatomical reduction, and treatment strategies targeting the biologic mediators of PTOA are needed. This study was designed to determine the effects of intra-articular injection of platelet-rich plasma (PRP) on synovial fluid (SF) biomarkers for patients undergoing open reduction and internal fixation (ORIF) of pilon fractures. Patients undergoing staged management of pilon fractures were enrolled in a prospective, double-blinded, randomized, and placebo-controlled clinical trial to determine the effects of a single intra-articular injection of leukocyte-reduced PRP on SF biomarkers. Arthrocentesis of the injured and uninjured ankles was performed at the time of external skeletal fixation (ESF) and ORIF. Patients were randomized to receive either autogenous leukocyte-reduced PRP or saline (control) via intra-articular injection into the injured ankle at the time of ESF. SF biomarker concentrations were compared-uninjured, injured pretreatment, and saline-injected or PRP-injected. Eleven patients (PRP, n = 5; saline, n = 6) completed the study. Twenty-one uninjured, and 11 injured pretreatment, five PRP-treated, and six saline-treated SF samples were analyzed. PRP-treated SF contained significantly higher levels of PDGF-AA (p = 0.046) and significantly lower levels of MMP-3 (p = 0.042), MMP-9 (p = 0.009), IL-1β (p = 0.049), IL-6 (p < 0.01), IL-8 (p = 0.048), and PGE2 (p < 0.04). This study provided mechanistic data to suggest that a single intraarticular injection of leukocyte-reduced PRP is associated with anti-inflammatory, anti-degradative, and anabolic responses compared with saline control. These findings provide the impetus for investigating long-term clinical outcomes after PRP injection as an orthobiologic adjunct to ORIF for mitigating the incidence and severity of PTOA after pilon fractures.
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Affiliation(s)
| | - Christopher R James
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | | | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
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Singh K, Weitlich JD, Zitsch BP, Schweser KM, Cook JL, Crist BD. Which surgical approach provides maximum visualization and access for open reduction and internal fixation (ORIF) of femoral neck fractures? Injury 2022; 53:1131-1136. [PMID: 34809924 DOI: 10.1016/j.injury.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Appropriate visualization of the femoral neck is critical when performing open reduction and internal fixation (ORIF) of a femoral neck fracture. The purpose of this study was to objectively identify which surgical approach provided the most extensive visualization of the femoral neck during ORIF. Our hypothesis was that the Smith-Petersen approach with rectus release would provide the most extensive visualization. METHODS Ten cadaveric hips were utilized to compare 4 different surgical approaches to the femoral neck: Smith-Petersen (SP), Smith-Petersen with rectus release (SPwR), Watson-Jones (WJ), and Hueter approach. After surgical exposure, calibrated digital images were captured and analyzed using a computer software program to determine the percent-area visualized. Three trained investigators separately assessed each specimen to determine clinical visualization and ability of the surgeon to manually outline anatomic locations of the femoral neck: subcapital, trans-cervical, and basicervical. Data were analyzed for significant (p < 0.05) differences using ANOVA and Fisher Exact tests. RESULTS For calculated percent-visualization, SP and SPwR allowed for significantly more (p = 0.003) visualization than the Hueter and WJ approaches. For surgeon visualization, SP and SPwR were significantly higher (p < 0.029) when compared to WJ. The ability for the individual surgeon to outline the femoral neck's anatomical landmarks was significantly higher (p < 0.049) with SP and Hueter approaches compared with SPwR. CONCLUSION The SP and SPwR provided superior visualization of femoral neck anatomy compared to Hueter and WJ approaches. Similarly, the SP approach allowed for optimal surgeon visualization of and access to clinically relevant femoral neck anatomic landmarks compared to other approaches assessed.
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Affiliation(s)
- Keerat Singh
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - John D Weitlich
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Bradford P Zitsch
- Thompson Laboratory for Regenerative Orthopaedics, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Kyle M Schweser
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - James L Cook
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA; University of Missouri School of Medicine, One Hospital Drive, Columbia, MO 65212, USA
| | - Brett D Crist
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA.
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Kfuri M, Crist BD, Stannard JP. Preoperative Planning and Preservation of the Knee with Complex Osteotomies. Mo Med 2022; 119:144-151. [PMID: 36036038 PMCID: PMC9339400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The knee is a complex structure composed of bone, cartilage, menisci, ligaments and muscles, which all work synergistically to optimize congruence, stability, and function. Osteotomies are procedures addressing an abnormal joint alignment, shifting the mechanical load from a diseased joint compartment to a healthier one. Preoperative planning is an important art of identifying the source of abnormal load distribution to the joint, enabling the surgeon to simulate a deformity correction ahead of the surgical procedure.
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Affiliation(s)
- Mauricio Kfuri
- James P. Stannard and Carolyn A. Stannard Distinguished Professor in Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
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13
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Cook JL, Stannard JP, Stoker AM, Rucinski K, Crist BD, Cook CR, Crecelius C, Smith MJ, Stucky R. Biologic Joint Restoration: A Translational Research Success Story. Mo Med 2022; 119:115-121. [PMID: 36036037 PMCID: PMC9339389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Treatment options that result in consistently successful outcomes for young and active patients with joint disorders are needed. This article summarizes two decades of rigorous research using a bedside-to-bench- to-bedside translational approach based on the One Health - One Medicine concept that culminated in successful clinical use of biologic joint restoration options for treatment of knee, hip, ankle, and shoulder problems in this growing patient population.
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Affiliation(s)
- James L Cook
- William and Kathryn Allen Distinguished Chair in Orthopaedic Surgery; Director, Thompson Laboratory for Regenerative Orthopaedics (TLRO) and Mizzou BioJoint® Center; and Vice Chair, Orthopaedic Research Division, University of Missouri - Columbia, Columbia, Missouri
| | - James P Stannard
- TLRO and Department of Orthopaedic Surgery (DOS), University of Missouri - Columbia, Columbia, Missouri
| | - Aaron M Stoker
- TLRO, University of Missouri - Columbia, Columbia, Missouri
| | - Kylee Rucinski
- TLRO, University of Missouri - Columbia, Columbia, Missouri
| | - Brett D Crist
- TLRO and DOS, University of Missouri - Columbia, Columbia, Missouri
| | - Cristi R Cook
- TLRO, University of Missouri - Columbia, Columbia, Missouri
| | - Cory Crecelius
- TLRO, University of Missouri - Columbia, Columbia, Missouri
| | | | - Renee Stucky
- TLRO, University of Missouri - Columbia, Columbia, Missouri
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14
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Crist BD. Consider Emergency Department Stress Examinations on Lateral Compression Type-1 Pelvic Ring Injuries with Complete Sacral Fractures: Commentary on an article by Graham J. DeKeyser, MD, et al.: "Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable". J Bone Joint Surg Am 2022; 104:e13. [PMID: 35171132 DOI: 10.2106/jbjs.21.01367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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15
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Crist BD. CORR Insights®: What Is Important to Patients Who Are Recovering From an Open Tibial Fracture? A Qualitative Study. Clin Orthop Relat Res 2022; 480:273-275. [PMID: 34860181 PMCID: PMC8747484 DOI: 10.1097/corr.0000000000002080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Brett D Crist
- Professor, Department of Orthopaedic Surgery, University of Missouri-Columbia, University Hospital, Columbia, MO, USA
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16
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Obremskey WT, Rickert MM, Miller AN, Schemitsch GW, Nauth A, Crist BD, Gardner MJ, Watson JT, Schemitsch EH. Augmentation of Fracture Repair: Is Anything Ready for Prime Time? Instr Course Lect 2022; 71:329-344. [PMID: 35254792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
There continues to be a significant burden of disease associated with the delayed healing of common fractures. Despite a number of trials focused on the augmentation of fracture repair, management remains controversial and evidence regarding cost-effectiveness is lacking. The recent evidence that has challenged traditional thinking regarding management of fracture healing problems will be evaluated.
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17
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Gulbrandsen TR, Wynn M, Garrone AJ, Hulick RM, Spitler CA, Crist BD. Does Anterior Impaction Affect Radiographic Outcomes of Pilon Fractures? Iowa Orthop J 2022; 42:30-35. [PMID: 36601235 PMCID: PMC9769345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background The outcomes of pilon fractures are multifactorial. Anterior articular impaction requires sagittal plane correction (anterior distal tibia angle (ADTA)) with articular reduction. However, there is a risk of avascular necrosis of the articular fragments and postoperative tibiotalar arthritis. The purpose of this study was to determine if the presence of anterior impaction affects radiographic alignment after definitive fixation. Methods Retrospective cohort study of patients who underwent operative management for pilon fractures at two academic, level 1 trauma centers between September 2005-September 2016. Fractures were categorized as having anterior impaction or no anterior impaction after review of preoperative radiographic and computer tomography imaging. Patient demographics and postoperative time to union was recorded. Quality of reduction was measured using (ADTA) (degrees), lateral distal tibia angle (LDTA) (degrees), and lateral talar station (LTS) (millimeters) from postoperative radiographs. Statistical analysis compared fracture patterns with anterior impaction to those without. Results 208 patients met inclusion criteria. 132 fractures (63.4%) were determined to have anterior impaction. Cohorts were similar in demographics and medical comorbidities (p>0.05). Mean ADTA, LTDA, and LTS for the anterior impaction group 83.5°, 89.7°, and 2.4mm versus 84.6°, 89.9°, and 2.0mm in the group without anterior impaction. Cohorts significantly differed in ADTA(p=0.01), but not LDTA(p=0.12) or LTS(p=0.44). No significant differences were found between cohorts with infection (>0.05), nonunion(p=0.76), unplanned reoperation(p=0.56), or amputation(p=0.34). Conclusion This study demonstrated no significant differences in the coronal or sagittal plane alignment when comparing definitively fixed pilon fractures with and without anterior impaction. Additional studies are needed to evaluate the longterm clinical impact of failing to restore ADTA. Level of Evidence: III.
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Affiliation(s)
- Trevor R Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malynda Wynn
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Robert M Hulick
- University of Mississippi Medical Center Department of Orthopedics, Jackson, Mississippi, USA
| | - Clay A Spitler
- University of Alabama at Birmingham Department of Orthopedics, Birmingham, Alabama, USA
| | - Brett D Crist
- University of Missouri-Columbia Department of Orthopaedic Surgery, Columbia, Missouri, USA
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18
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Woods JC, Cook JL, Bozynski CC, Tegethoff JD, Kuroki K, Crist BD. Does Irrigating While Drilling Decrease Bone Damage? Iowa Orthop J 2022; 42:22-29. [PMID: 36601237 PMCID: PMC9769353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Heat generated during bone drilling may be associated with thermal necrosis and direct damage, leading to complications after surgery. This preclinical study evaluates the in vivo effects of saline irrigation, drilling device type, and device sharpness on heat generation and bone damage in viable cortical bone. Methods Bicortical drilling of each tibial diaphysis from anesthetized research dogs was performed to evaluate temperature and bone damage using five different devices with or without saline irrigation. Results Saline irrigation and sharp drill bits were associated with smaller temperature increases and less acute osteonecrosis. Conventional trocar tip Kirschner wires were associated with the largest temperature increase and the most acute osteonecrosis changes. Conclusion The use of saline irrigation during bone drilling reduces temperature change and osteonecrosis. Furthermore, we recommend that the use of dull drill bits or standard tip Kirschner wires be avoided. Lastly, drill bit design can directly contribute to bone damage during drilling. Clinical Relevance This study provides in vivo data from a preclinical model to validate the benefits of saline irrigation and sharp drill bits during bone drilling to regulate increases in temperature and decrease associated osteonecrosis. Risk for early implant loosening and poor surgical outcome is influenced by thermal osteonecrosis of bone such that consistent use of saline irrigation, sharp drill bits, and optimized designs may have important clinical advantages. Level of Evidence: II.
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Affiliation(s)
- Justin C Woods
- University of Missouri Department of Orthopaedic Surgery, Columbia, Missouri, USA
| | - James L Cook
- University of Missouri Department of Orthopaedic Surgery, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, Columbia, Missouri, USA
| | - Chantelle C Bozynski
- University of Missouri Department of Orthopaedic Surgery, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, Columbia, Missouri, USA
| | | | - Keiichi Kuroki
- Veterinary Medical Diagnostic Laboratory, University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - Brett D Crist
- University of Missouri Department of Orthopaedic Surgery, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, Columbia, Missouri, USA
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19
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Wolfe PN, Campfield BD, Crist BD, Keeney JA, Smith MJ, Cook JL, Stoker AM. Bacterial DNA screening to characterize surgical site infection risk in orthopaedic patients. J Orthop 2021; 27:56-62. [PMID: 34483551 DOI: 10.1016/j.jor.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022] Open
Abstract
Purpose To provide an initial characterization of relevant bacterial DNA profiles for patients undergoing closed-fracture fixation or total joint arthroplasties. Patients and methods Swabs were collected and analyzed using Polymerase Chain Reaction from adult patients undergoing closed-fracture fixation or total shoulder, knee, or hip arthroplasties. Results Bacterial DNA profiles varied across the different orthopaedic patient populations, and produced uncharacteristic profile shifts with direct relevance to each clinical infection. Conclusion Findings provide a foundational dataset regarding bacterial colonization of relevant anatomic sites that can act as sources of surgical site infections for patients.
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Affiliation(s)
- Preston N Wolfe
- University of Missouri, Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA.,University of Missouri, Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA
| | - Brian D Campfield
- Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA, USA
| | - Brett D Crist
- University of Missouri, Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA.,University of Missouri, Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA
| | - James A Keeney
- University of Missouri, Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA.,University of Missouri, Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA
| | - Matthew J Smith
- University of Missouri, Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA.,University of Missouri, Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA
| | - James L Cook
- University of Missouri, Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA.,University of Missouri, Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA
| | - Aaron M Stoker
- University of Missouri, Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA.,University of Missouri, Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO, 65212, USA
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20
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Abstract
Antibiotic-coated intramedullary nails have been popularized in recent decades for treating long-bone infections. They are especially useful in treating diaphyseal infections requiring stability, such as those involving fractures and nonunions. The nails are made by injecting antibiotic-impregnated polymethylmethacrylate or "cement" around a metal core using a silicone tube as a mold. There are a variety of techniques that can be used to customize the nail to the affected site. Antibiotic cement has long been demonstrated as an effective local antibiotic delivery system. It is able to elute high concentrations of antibiotics while having little systemic toxicity. Several case series have reported good outcomes using this technique, defined by bone union and infection control. Further research is needed to determine the amount of weight that can safely be transferred through the nail and to optimize antibiotic elution.
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Affiliation(s)
- Jane Z Liu
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
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21
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Abstract
Fracture healing is a complex cascade of cellular and molecular processes. These processes require the appropriate cellular and molecular environment to ensure the restoration of skeletal stability and resolution of inflammation. In order for fracture healing to occur, the necessary building blocks for bone metabolism and synthesis must be supplied through proper nutrition. Pharmacologic therapies aimed at modulating the inflammatory response to fractures have the potential to interfere with the synthesis of molecules needed for the production of bone. Infection can interfere with, and even prevent normal fracture healing from occurring. Cellular and genetic treatment strategies are actively being developed to target deficiencies, and bridge gaps that can influence how fractures heal. Evolving technologies, including nutritional supplementation, pharmacotherapies, antibiotics, surgical techniques, as well as genetic and cellular therapies, have the potential to enhance, optimize, and even revolutionize the process of fracture healing.
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Affiliation(s)
- Brian H Mullis
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew S Gudeman
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Joseph Borrelli
- Department of Orthopaedic Surgery and Sports Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
| | - Mark A Lee
- Department of Orthopaedic Surgery, University of California - Davis, CA
| | - Andrew R Evans
- Department of Orthopedics, The Warren Alpert School of Medicine, Brown University/Rhode Island Hospital, Providence, RI
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Abstract
OBJECTIVE To identify how diabetes impacts the risk of complications requiring further surgery (deep surgical site infection, nonunion, amputation, and arthrodesis) after pilon fracture fixation. DESIGN Retrospective cohort study. SETTING Level 1 academic trauma center. PATIENTS Two hundred seventy-nine pilon fractures (276 patients) were identified. A retrospective review was performed to find patients who presented for open reduction and internal fixation of a tibial pilon fracture (OTA/AO 43). Patient demographics, medical comorbidities, OTA/AO fracture type, and surgical outcomes were reviewed. INTERVENTION Patients were stratified into cohorts based on the presence or absence of diabetes at the time of surgery. MAIN OUTCOME MEASUREMENTS The complications of interest that proved significant during univariate analyses were then entered into a multivariable logistic regression model using a stepwise method to identify the independent predictors for complications. RESULTS There were 43 fractures (15.4%) in patients with diabetes mellitus; 17 (39.5%) of whom were insulin-dependent diabetics. Diabetic patients were significantly more likely to have a higher body mass index (34.81 vs. 29.57, P = 0.002) and be older (55.30 ± 16.3 years vs. 41.70 ± 14.05, P < 0.001) at the time of injury. Patients without diabetes were more likely to sustain an OTA/AO 43-C3 fracture (36.0% vs. 11.6%, P = 0.001). Diabetic patients were 5.5 times more likely to require an arthrodesis [95% confidence interval (CI) = 1.894-16.214; P = 0.001] and 2.7 times more likely to develop a deep infection (95% CI = 1.261-5.630; P = 0.008). CONCLUSIONS Overall, diabetic patients in this study were 3.64 times more likely (95% CI = 1.854-7.159; P < 0.001) to experience any complication, despite having less complex fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lasun O Oladeji
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO; and
- Missouri Orthopaedic Institute, Columbia, MO
| | - Brooks Platt
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO; and
- Missouri Orthopaedic Institute, Columbia, MO
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO; and
- Missouri Orthopaedic Institute, Columbia, MO
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Arnone JC, Crist BD, Ward CV, El-Gizawy AS, Pashuck T, Della Rocca GJ. Variability of human femoral geometry and its implications on nail design. Injury 2021; 52:109-116. [PMID: 32958339 DOI: 10.1016/j.injury.2020.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The objectives of this study are to present a new method of quantifying variability in human femoral geometry and to use this data to optimize intramedullary nail geometry for a better fit within the femoral canal. METHODS Computed tomography (CT) scans of forty intact adult human femora were divided according to race, sex, and age, and were reconstructed digitally into three-dimensional solid models. Geometric features were then measured and compared among groups using ANOVA. An average geometric model was generated, from which an optimal intramedullary (IM) nail curvature function was derived. Insertion of the derived optimal nail and of two currently-available commercial nails into the femur having the highest degree of curvature was then simulated via finite element methods. RESULTS Substantial variability in femoral curvature was observed among the population sample. Sex was found to correlate most strongly with femoral size; males tend to have larger femora than females. Although the average femoral radius of curvature for African Americans was slightly higher than for Caucasians, the difference was not statistically significant. Curvature did not vary across the sample by age, sex or race. Finite element analysis results simulating IM nail insertion using the geometrically-optimized nail showed a substantial decrease in von Mises stress when compared to tested commercially-available IM nails. Fracture was predicted within the posterior canal wall for commercially available nails, as the generated stresses exceeded the allowable stress of cortical bone, but not for the geometrically-optimized nail. CONCLUSIONS Considering variation in femoral geometry among patients when designing implantable fixation devices may be important. Femoral size differs between adults by sex, with males being larger than females. Pattern of curvature, however, did not differ, although there may be slight differences between European and African Americans. As such, the proposed average femoral curvature function calculated here may be sufficient for the entire population. According to finite element analysis, insertion-induced stresses in the femur were within the allowable range for the geometrically-optimized nail and appear more desirable than in other common nail designs.
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Affiliation(s)
- Joshua C Arnone
- Department of Mechanical and Aerospace Engineering, University of Missouri, Columbia, MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Carol V Ward
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, MO, USA
| | - A Sherif El-Gizawy
- Department of Mechanical and Aerospace Engineering, University of Missouri, Columbia, MO, USA
| | - Troy Pashuck
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
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Abstract
Many of the metals used in orthopaedic surgical implants are immunologically active and can cause hypersensitivity reactions. Most of these metal hypersensitivity (MHS) reactions are type IV/delayed-type hypersensitivity reactions. The most common form of all metal hypersensitivity reactions is allergic contact dermatitis (ACD) caused by nickel. The purpose of this review is to examine the evidence regarding hypersensitivity to orthopaedic implants and provide current recommendations for evaluating these patients. We report on four case examples of patients where it was determined that metal allergy led to complications related to surgery. The most common symptoms for patients with MHS-associated failures are localized soft tissue reaction including delayed wound healing and/or recurrent wound issues. The best way to avoid postoperative issues is to routinely ask patients prior to surgery if they have any known MHS including problems with cosmetic jewelry. If this is known before surgery, titanium or carbon fiber implants should be used for fracture fixation and arthroplasty implantation choice should be modified based on the specific arthroplasty performed. MHS-associated failures are a diagnosis of exclusion and must be contemplated after judicious workup of localized soft tissue reaction including delayed wound healing and/or recurrent wound issues.
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Affiliation(s)
| | - Brett D. Crist
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, USA,Corresponding author. University of Missouri Department of Orthopaedic Surgery, One Hospital Drive, N119, Columbia, MO, 65212, USA.
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25
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Abstract
Tibial plateau fractures account for approximately 8% of fractures in the elderly population. Treatment strategies in the elderly are similar to those for younger patients; however, practitioners must account for the elevated comorbidity burden in this population. To date, few studies have analyzed age-based outcomes in patients with tibial plateau fractures. Therefore, the purpose of this study was to determine age-related variances in demographics, fracture characteristics, mechanism of injury, and complications. A 10-year retrospective review was conducted to identify patients who received treatment for a tibial plateau fracture. There were 351 patients (360 tibial plateau fractures) who were identified and subsequently stratified according to their age at the time of injury. Patients were classified as elderly if they were 65 years of age or older at the time of injury; all other patients were included in the control cohort. These two cohorts were analyzed using bivariate analysis to isolate for age-related variations with respect to risk factors, mechanism of injury, and complications. There were 351 patients (360 tibial plateau fractures) with a median follow-up of 1.84 ± 2.44 years who met inclusion criteria. There were a greater proportion of women in the elderly cohort as compared with the younger cohort (60.0 vs. 43.4%, p = 0.06). Elderly patients were significantly more likely to present with diabetes (33.3 vs. 16.1%, p = 0.01) or osteoporosis (14.3 vs. 1.6%, p = 0.001). Younger patients were significantly more likely to require further surgery to address ligament (12.6 vs. 0%, p = 0.008), meniscus (20.9 vs. 7.1%, p = 0.036), or cartilage pathology (13.6 vs. 0%, p = 0.005). There was no difference in the arthroplasty conversion rate (4.8% elderly vs. 7.9% control, p = 0.755). While elderly patients presented with a greater comorbidity burden, they had equivalent or better short-term outcomes when compared with their younger peers when treated with open reduction and internal fixation (ORIF). Despite the recent interest in primary total knee arthroplasty for elderly patients with tibial plateau fractures, the results of this study suggest that elderly patients may respond well when treated with ORIF following a tibial plateau fracture.
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Affiliation(s)
- Lasun O Oladeji
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - John R Worley
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
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26
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Capo J, Liporace F, Yingling JM, Glait S, Pfeiffer F, Crawford AC, Volgas D, Crist BD, Dailey T, Della Rocca GJ. Pressure reducing skin pie-crusting in extremity trauma: An in-vitro biomechanical study and human case series. Injury 2020; 51:1266-1270. [PMID: 32199627 DOI: 10.1016/j.injury.2020.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results. MATERIALS AND METHODS This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up. RESULTS The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months). CONCLUSION Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity.
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Affiliation(s)
- John Capo
- Department of Orthopaedic Surgery, RWJ Barnabas Health - Jersey City Medical Center, 355 Grand Street, Jersey City 07302, NJ, USA
| | - Frank Liporace
- Department of Orthopaedic Surgery, RWJ Barnabas Health - Jersey City Medical Center, 355 Grand Street, Jersey City 07302, NJ, USA
| | - John Michael Yingling
- Department of Orthopaedic Surgery, RWJ Barnabas Health - Jersey City Medical Center, 355 Grand Street, Jersey City 07302, NJ, USA.
| | | | - Ferris Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.
| | - Adam C Crawford
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - David Volgas
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.
| | - Tyler Dailey
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
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27
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Gulbrandsen TR, Hulick RM, Polk AJ, Weldy JM, Howell KL, Spitler CA, Crist BD. Does surgical approach affect sagittal plane alignment and pilon fracture outcomes? Injury 2020; 51:750-758. [PMID: 32008815 DOI: 10.1016/j.injury.2020.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/07/2020] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Sagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement. PATIENTS AND METHODS A retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs. RESULTS 580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02). CONCLUSIONS The sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.
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Affiliation(s)
- Trevor R Gulbrandsen
- University of Iowa Hospitals and Clinics, Department of Orthopedic Surgery, Iowa City, IA, United States
| | - Robert M Hulick
- University of Mississippi Medical Center, Department of Orthopaedic Surgery, Jackson, MS, United States
| | - Andrew J Polk
- University of Missouri School of Medicine, Columbia, MO, United States
| | - John M Weldy
- University of Mississippi Medical Center, Department of Orthopaedic Surgery, Jackson, MS, United States
| | - Kathryn L Howell
- Tulane University, Department of Orthopaedic Surgery, New Orleans, LA, United States
| | - Clay A Spitler
- University of Mississippi Medical Center, Department of Internal Medicine, Jackson, MS, United States; University of Alabama-Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States
| | - Brett D Crist
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, United States.
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Kim PJ, Attinger CE, Constantine T, Crist BD, Faust E, Hirche CR, Lavery LA, Messina VJ, Ohura N, Punch LJ, Wirth GA, Younis I, Téot L. Negative pressure wound therapy with instillation: International consensus guidelines update. Int Wound J 2019; 17:174-186. [PMID: 31667978 PMCID: PMC7003930 DOI: 10.1111/iwj.13254] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/30/2019] [Accepted: 10/04/2019] [Indexed: 11/29/2022] Open
Abstract
The use of negative pressure wound therapy with instillation and dwell time (NPWTi‐d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi‐d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi‐d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi‐d. Principal aims of the meeting were to update recommendations based on panel members' experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi‐d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi‐d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation.
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Affiliation(s)
- Paul J Kim
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Thomas Constantine
- Department of Surgery, Toronto Cosmetic Surgery Institute, Toronto, Canada
| | - Brett D Crist
- Department of Orthopedic Surgery, University of Missouri Health Care, Columbia, Missouri
| | - Elizabeth Faust
- Wound, Ostomy, Continence Specialist, Tower Health System, West Reading, Pennsylvania
| | - Christoph R Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Klinik für Plastische und Handchirurgie, Universität Heidelberg, Ludwigshafen, Germany
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Valerie J Messina
- Wound Healing Center, MemorialCare Long Beach Medical Center, Long Beach, California
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Laurie J Punch
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Garrett A Wirth
- Wound Healing Center, MemorialCare Long Beach Medical Center, Long Beach, California
| | - Ibby Younis
- Department of Plastic Surgery, Royal Free Hospital University College Hospital, London, UK
| | - Luc Téot
- Department of Plastic Surgery, Montpellier University Hospital, Montpellier, France
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Oladeji LO, Dreger TK, Pratte EL, Baumann CA, Stannard JP, Volgas DA, Della Rocca GJ, Crist BD. Erratum to: Total Knee Arthroplasty versus Osteochondral Allograft: Prevalence and Risk Factors following Tibial Plateau Fractures. J Knee Surg 2019; 32:e1. [PMID: 29797303 DOI: 10.1055/s-0038-1654705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Lasun O Oladeji
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Tina K Dreger
- Department of Orthopaedic Surgery, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Eli L Pratte
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Charles A Baumann
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - David A Volgas
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | | | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Oladeji LO, Dreger TK, Pratte EL, Baumann CA, Stannard JP, Volgas DA, Rocca GJD, Crist BD. Total Knee Arthroplasty versus Osteochondral Allograft: Prevalence and Risk Factors following Tibial Plateau Fractures. J Knee Surg 2019; 32:380-386. [PMID: 29669383 DOI: 10.1055/s-0038-1641593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Orthopaedic surgeons commonly have the misconception that patients with tibial plateau fractures will likely go on to posttraumatic knee arthritis requiring total knee arthroplasty (TKA). In younger patients, osteochondral allograft (OCA) transplantation is an alternative method to address posttraumatic knee arthritis. The purpose of this study was (1) to identify our institutional failure rate following tibial plateau open reduction and internal fixation (ORIF) (failure was defined as conversion to TKA or OCA); (2) to determine if there are patient- or injury-related risk factors predictive of failure; and (3) to characterize differences between patients treated with TKA versus those treated with OCA transplantation. A 10-year retrospective review was conducted to identify patients treated at our institution with a tibial plateau fracture. Patients included in the final analysis were at least 18 years of age with an articular fracture (AO/OTA 41 B/C). The primary outcome was subsequent ipsilateral OCA or TKA. There were 350 patients (359 tibial plateau fractures) with a mean follow-up of 22.3 months (range, 6-133 months) who met inclusion criteria. Twenty-seven fractures (7.5%) were subsequently converted to a TKA or OCA at an average of 3.75 ± 3.1 years following their initial surgery. Patients who consumed tobacco were 2.3 times more likely to require a joint replacement (confidence interval [CI], 1.0-5.2; p = 0.04). Those patients who received an OCAs were significantly younger as compared with their TKA peers, both at time of initial injury (37 vs. 51 years, p = 0.02) and at time of surgery (41 vs. 55 years, p = 0.009). The joint replacement rate in this study is similar to those studies in the published literature that focused solely on the prevalence of conventional TKA. Tobacco is a risk factor for failure following tibial plateau ORIF. Patients who were treated with an OCA were younger at time of injury and failure.
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Affiliation(s)
- Lasun O Oladeji
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Tina K Dreger
- Department of Orthopaedic Surgery, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Eli L Pratte
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Charles A Baumann
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - David A Volgas
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | | | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Crist BD, Pfeiffer FM, Khazzam MS, Kueny RA, Della Rocca GJ, Carson WL. Biomechanical evaluation of location and mode of failure in three screw fixations for a comminuted transforaminal sacral fracture model. J Orthop Translat 2018; 16:102-111. [PMID: 30723687 PMCID: PMC6350021 DOI: 10.1016/j.jot.2018.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 12/04/2022] Open
Abstract
Background Pelvic ring–comminuted transforaminal sacral fracture injuries are rotationally and vertically unstable and have a high rate of failure. Objective Our study purpose was to use three-dimensional (3D) optical tracking to detect onset location of bone–implant interface failure and measure the distances and angles between screws and line of applied force for correlation to strength of pelvic fracture fixation techniques. Methods 3D relative motion across sacral–rami fractures and screws relative to bone was measured with an optical tracking system. Synthetic pelves were used. Comminuted transforaminal sacral–rami fractures were modelled. Each pelvis was stabilised by either (1) two iliosacral screws in S1, (2) one transsacral screw in S1 and one iliosacral screw in S1 and (3) one trans-alar screw in S1 and one iliosacral screw in S1; groups 4–6 consisted of fixation groups with addition of anterior inferior iliac pelvic external fixator. Eighteen-instrumented pelvic models with right ilium fixed simulate single-leg stance. Load was applied to centre of S1 superior endplate. Five cycles of torque was initially applied, sequentially increased until permanent deformation occurred. Five cycles of axial load compression was next applied, sequentially increased until permanent deformation occurred, followed by axial loading to catastrophic failure. A Student t test was used to determine significance (p < 0.05). Results The model, protocol and 3D optical system have the ability to locate how sub-catastrophic failures initiate. Our results indicate failure of all screw-based constructs is due to localised bone failure (screw pull-in push-out at the ipsilateral ilium–screw interface, not in sacrum); thus, no difference was observed when not supplemented with external fixation. Conclusion Inclusion of external fixation improved resistance only to torsional loading. Translational Potential of this Article Patients with comminuted transforaminal sacral–ipsilateral rami fractures benefit from this fixation.
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Affiliation(s)
- Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Michael S Khazzam
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, 1801 Inwood Road, Dallas, TX 75390, USA
| | - Rebecca A Kueny
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestraße 15, 21073, Hamburg, Germany
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - William L Carson
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
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Crist BD, Oladeji LO, Della Rocca GJ, Volgas DA, Stannard JP, Greenberg DD. Evaluating the Duration of Prophylactic Post-Operative Antibiotic Agents after Open Reduction Internal Fixation for Closed Fractures. Surg Infect (Larchmt) 2018; 19:535-540. [DOI: 10.1089/sur.2018.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Brett D. Crist
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Gregory J. Della Rocca
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - David A. Volgas
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - James P. Stannard
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - David D. Greenberg
- Department of Orthopaedic Surgery, St. Louis University Hospital, St. Louis, Missouri
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Wessel AR, Crist BD, Stannard JP, Della Rocca GJ, Stoker AM, Bozynski CC, Cook CR, Kuroki K, Ahner CE, Cook JL. Assessment of Reamer Irrigator Aspirator System (RIA) filtrate for its osteoinductive potential in a validated animal model. Injury 2018; 49:1046-1051. [PMID: 29685704 DOI: 10.1016/j.injury.2018.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/04/2018] [Accepted: 04/14/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Previous studies indicate that Reamer Irrigator Aspirator (RIA) filtrate contains proteins that have the potential to stimulate bone healing. This study aimed to determine the osteoinductive capabilities of RIA filtrate in a validated in vivo model. METHODS With Institutional Review Board approval, RIA filtrates from 9 patients were collected. The filtrate was processed to remove cells and inorganic particles. A portion of each sample was set aside for protein analysis while the remainder was lyophilized and prepared for implantation. With Animal Care and Use Committee approval, athymic mice (n = 16; 32 hind limbs) were randomly assigned to 1 of 4 groups (n = 8 limbs per group) for percutaneous gastrocnemius muscle injection of demineralized bone matrix (DBM) (10 mg), lyophilized RIA powder (10 mg), RIA liquid (10 mg of lyophilized RIA powder in 100ul phosphate buffered saline (PBS)), or DBM (10 mg) + RIA liquid (10 mg in 100ul PBS). Radiographs were obtained 2, 4, and 8 weeks after injection. At 8 weeks, mice were sacrificed and the entire gastrocnemius muscle from each hind limb was collected and processed for histologic examination. Histological sections and radiographs were assessed for ossification/calcification. Data were compared for statistically significant (p < 0.05) differences among groups and strong (R > 0.7) correlations between outcome measures. RESULTS The protein composition of RIA filtrates was consistent among patients and matched previous data. For all groups, radiographic scores were significantly (p < 0.014) higher (more calcification/ossification) at 8 weeks compared to 2 weeks. Radiographic scores for the DBM and DBM + RIA liquid groups were significantly higher than RIA liquid and RIA powder at 4 weeks and 8 weeks (p < 0.019 and p < 0.049, respectively). Histologic scores were significantly (p = 0.004) higher in the DBM + RIA liquid group compared to the RIA liquid group at 8 weeks. Histologic scores showed strong correlations (r > 0.77) to radiographic scores for all groups. CONCLUSION RIA filtrate liquid and powder were osteoinductive in vivo with new bone formation being most abundant using a combination of DBM and RIA filtrate in this validated animal model. RIA filtrate has potential for clinical use in augmenting bone healing treatments.
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Affiliation(s)
- Alex R Wessel
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA
| | | | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA
| | - Chantelle C Bozynski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA
| | - Keiichi Kuroki
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA
| | - Carin E Ahner
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA; Division of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, PA, USA
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, USA.
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Affiliation(s)
- David R Mehr
- Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia
| | - Paul E Tatum
- Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia
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Crijns TJ, Janssen SJ, Davis JT, Ring D, Sanchez HB, Amini MH, Appleton P, Babis GC, Babst RH, Ballas EG, Barquet A, Begue T, Bishop J, Borris LC, Buckley R, Chesser T, Choudhari P, Cornell C, Crist BD, DeCoster TA, Elias N, Frihagen F, Garnavos C, Giordano V, Haverlag R, Havlicek T, Hurwit S, Ibrahim EF, Iyer VM, Jenkinson R, Jeray K, Kabir K, Kanakaris NK, Klostermann C, Kreder HJ, Kreis B, Kristan A, Lygdas P, McGraw I, Mica L, Mirck B, Moreta-Suarez J, Morgan SJ, Nikolaou VS, Omara T, Pesantez R, Pirpiris M, Poelhekke L, Pountos I, Prayson M, Quell M, Rodríguez-Roiz JM, Satora W, Schandelmaier P, Schepers T, Short NL, Smith RM, Spoor A, Stojkovska Pemovska E, Swiontkowski M, Taitsman L, Tosounidis T, Tyllianakis M, Van bergen C, Van de Sande M, Van Helden S, Verbeek DO, Wascher DC, Weil Y. Reliability of the classification of proximal femur fractures: Does clinical experience matter? Injury 2018; 49:819-823. [PMID: 29549969 DOI: 10.1016/j.injury.2018.02.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 02/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master. QUESTIONS/PURPOSES We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup. METHODS This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss' kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons. RESULTS There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001). CONCLUSIONS This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.
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Affiliation(s)
- Tom J Crijns
- Department of Surgery and Perioperative Care, Dell Medical School, Health Discovery Building 6.706, 1701 Trinity St., Austin, TX 78723, USA.
| | - Stein J Janssen
- Department of General Surgery, OLVG, Oosterpark 9, 1091 AC Amsterdam, The Netherlands.
| | - Jacob T Davis
- Department of Orthopaedic Surgery, JPS Health Network, 1500 S. Main St, Fort Worth, TX 76104, USA.
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, Health Discovery Building 6.706, 1701 Trinity St., Austin, TX 78723, USA.
| | - Hugo B Sanchez
- Department of Orthopaedic Surgery, Acclaim Physician Group, Ben Hogan Center, 800 5th Ave, Suite 400, Fort Worth, TX 76104, USA.
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Patel D, Worley JR, Volgas DA, Crist BD. The Effectiveness of Osteoporosis Screening and Treatment in the Midwest. Geriatr Orthop Surg Rehabil 2018; 9:2151459318765844. [PMID: 29623238 PMCID: PMC5882069 DOI: 10.1177/2151459318765844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/12/2018] [Accepted: 02/15/2018] [Indexed: 01/22/2023] Open
Abstract
Introduction: With osteoporosis on the rise across the United States, the goal of this prospective study is to determine the effectiveness of our Midwest level-1 trauma center in diagnosing, treating, and educating osteoporosis patients after fracture with the use of questionnaires. Secondarily, we aimed to identify barriers that prevent our patients from complying with bone health recommendations. Methods: One hundred participants (≥55 years) were given 2 questionnaires (Fracture Risk Assessment Tool and a study-specific questionnaire) that were administered during the patient’s visit to the orthopedic trauma clinic. A group of patients diagnosed with osteoporosis was compared to a group of patients not diagnosed with osteoporosis. Statistical analyses were performed using SPSS 24 (IBM Corp, Chicago, Illinois). Results: Patients who had been diagnosed with osteoporosis were significantly older (72.7 vs 66.5, P = .009) and more were women (86.2% vs 66.2%, P = .043). Significantly, fewer patients without the diagnosis of osteoporosis had a history of fragility fracture (56.3%) compared to 92.9% of those diagnosed with osteoporosis (P < .001). Of those with dual-energy X-ray absorptiometry (DXA) recommended by a healthcare provider, 20 (55.6%) of those without the diagnosis of osteoporosis and 13 (52%) of those with the diagnosis of osteoporosis had DXA screening before their fragility fracture (P = .499). More patients diagnosed with osteoporosis (93.1%) were taking calcium and vitamin D supplementation compared to 66.2% of those without the diagnosis of osteoporosis (P = .005). Only 37.9% of patients with the diagnosis of osteoporosis were receiving US Food and Drug Administration–approved medications for the management of their disease. Discussion: In patients without previous osteoporosis diagnosis, 59 (83.1%) of the 71 claimed that they did not receive any preventative education about osteoporosis, while 21 (72.4%) of the 29 patients with the diagnosis of osteoporosis claimed that they did not receive a preventative education (P = .165). Both groups lacked optimum diagnosis, treatment, and education of osteoporosis. Conclusion: Our study highlights the need for a deliberate effort of a multidisciplinary team to focus efforts in all stages of osteoporosis management.
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Affiliation(s)
- Dharmik Patel
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - John R Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - David A Volgas
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
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Crist BD, Eastman J, Lee MA, Ferguson TA, Finkemeier CG. Femoral Neck Fractures in Young Patients. Instr Course Lect 2018; 67:37-49. [PMID: 31411399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Femoral neck fractures in patients 55 years or younger, although relatively uncommon, may cause considerable surgeon stress because they may be thought to be surgical emergencies and are difficult to manage, resulting in serious complications. Orthopaedic surgeons should understand the optimal timing for, the reduction options and techniques for, the fixation options for, and the results of surgical management of femoral neck fractures in patients 55 years or younger. The optimal timing of the surgical management of femoral neck fractures in these patients is a subject of debate. Anatomic reduction, which correlates with patient outcomes, is the goal in the management of femoral neck fractures whether it is attained via open or closed means. Multiple surgical approaches, including the Watson-Jones, Smith-Petersen, and Hueter approaches, may be used for the open reduction of femoral neck fractures. Multiple options are available for fixation, with cannulated screws and the compression hip screw most used in the literature. These implants should provide torsional stability, minimal bone loss, and a length-stable construct. Currently, no ideal implant exists. The outcomes of young patients with a femoral neck fracture who undergo surgical treatment depend more on fracture type, fracture reduction, and stable fixation than early surgical management; however, surgical management should not be excessively delayed.
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Affiliation(s)
- Brett D Crist
- Associate Professor, Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Goode SC, Beshears JL, Goode RD, Wright TF, King A, Crist BD. Putting the Brakes on Breaks: Osteoporosis Screening and Fracture Prevention. Geriatr Orthop Surg Rehabil 2017; 8:238-243. [PMID: 29318086 PMCID: PMC5755845 DOI: 10.1177/2151458517743153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/22/2017] [Accepted: 09/28/2017] [Indexed: 01/21/2023] Open
Abstract
Introduction This prospective study sought to implement a screening tool to identify and risk stratify at-risk patients for osteoporosis and evaluate patient knowledge of osteoporosis and fragility fractures in an orthopedic trauma clinic affiliated with a level 1 trauma academic center. Methods Of 297 eligible patients, 291 were screened and risk stratified. Patients completed an osteoporosis screening questionnaire and were risk stratified. Lifestyle advice was given to patients at low fracture risk. A dual-energy X-ray absorptiometry scan was ordered for patients at intermediate fracture risk. A referral was initiated for treatment to a bone health specialist in high fracture risk patients. Twenty patients completed a knowledge-based pretest/posttest. Results A total of 291 patients were screened, which represented 97.7% of patients over the age of 50. Of those patients, 165 (56.7%) patients met criteria for further osteoporosis evaluation as they were considered either intermediate or high risk for future fractures. One hundred thirty-six (82.4%) patients were referred for bone mineral density evaluation. For the knowledge-based evaluation portion, patients had a 33% gain in knowledge (P = .0004). The largest knowledge deficit identified pertained to osteoporosis risk factors and lifestyle management. Discussion The use of an osteoporosis screening questionnaire in the orthopedic trauma clinic produced clinically significant improvement in identification of at-risk patients. A lack of knowledge regarding osteoporosis and fragility fractures was found to exist among these patients. Conclusion The implementation of an osteoporosis screening tool to identify, risk stratify, and treat patients with osteoporosis and related fragility fractures can be successfully integrated into a busy clinical practice.
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Affiliation(s)
- Sarah C Goode
- College of Nursing, University of South Alabama, Mobile, AL, USA
| | | | | | - Theresa F Wright
- College of Nursing, University of South Alabama, Mobile, AL, USA
| | - Anita King
- College of Nursing, University of South Alabama, Mobile, AL, USA
| | - Brett D Crist
- Boone Hospital Center, University of Missouri, Columbia, MO, USA
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Harvin WH, Oladeji LO, Della Rocca GJ, Murtha YM, Volgas DA, Stannard JP, Crist BD. Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures. Injury 2017; 48:2597-2601. [PMID: 28889934 DOI: 10.1016/j.injury.2017.08.064] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/17/2017] [Accepted: 08/29/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. METHODS A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. RESULTS Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p=0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. CONCLUSIONS Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.
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Affiliation(s)
- William H Harvin
- University of Texas Health Sciences Center at Houston, Department of Orthopaedic Surgery, 6431 Fannin Street, Houston, TX 77030, USA
| | - Lasun O Oladeji
- University of Missouri School of Medicine, Department of Orthopaedic Surgery, One Hospital Drive, N119, Columbia, MO 65212, USA
| | - Gregory J Della Rocca
- Duke University Department of Orthopaedic Surgery, 40 Duke Medicine Circle, Duke Clinic 1H, Durham, NC 27710, USA
| | - Yvonne M Murtha
- University of Missouri School of Medicine, Department of Orthopaedic Surgery, One Hospital Drive, N119, Columbia, MO 65212, USA
| | - David A Volgas
- University of Missouri School of Medicine, Department of Orthopaedic Surgery, One Hospital Drive, N119, Columbia, MO 65212, USA
| | - James P Stannard
- University of Missouri School of Medicine, Department of Orthopaedic Surgery, One Hospital Drive, N119, Columbia, MO 65212, USA
| | - Brett D Crist
- University of Missouri School of Medicine, Department of Orthopaedic Surgery, One Hospital Drive, N119, Columbia, MO 65212, USA.
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Oladeji LO, Stannard JP, Cook CR, Kfuri M, Crist BD, Smith MJ, Cook JL. Effects of Autogenous Bone Marrow Aspirate Concentrate on Radiographic Integration of Femoral Condylar Osteochondral Allografts. Am J Sports Med 2017; 45:2797-2803. [PMID: 28737949 DOI: 10.1177/0363546517715725] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transplantation of fresh osteochondral allografts (OCAs) is an attractive treatment option for symptomatic articular cartilage lesions in young, healthy patients. Because the lack of OCA bone integration can be a cause of treatment failure, methods for speeding and enhancing OCA bone integration to mitigate this potential complication are highly desirable. PURPOSE To determine if autogenous bone marrow aspirate concentrate (BMC) treatment of large femoral condylar OCAs would be associated with superior radiographic OCA bone integration compared with nontreated allografts during the critical first 6 months after surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A review of patients enrolled in a prospective registry who were treated with transplantation of large OCAs to one or both femoral condyles at our institution from March 12, 2013 to March 14, 2016 was performed. Patients were stratified into 2 groups based on BMC treatment versus no BMC treatment; the treatment was nonrandomized and was rooted in a shift in practice and a continuing effort to optimize OCA transplantation at our institution. Patients were excluded if they did not have orthogonal view radiographs performed at 6 weeks, 3 months, and 6 months postoperatively. Each condyle undergoing OCA transplantation was assessed individually by an independent musculoskeletal radiologist, who was blinded to the treatment group and time point. OCAs were assessed with respect to graft integration (0%-100%; 0 = no integration, 100 = complete integration) and degree of sclerosis (0-3; 0 = normal, 1 = mild sclerosis, 2 = moderate sclerosis, and 3 = severe sclerosis) of the graft at each time point. RESULTS This study identified 17 condyles in 15 patients who underwent OCA transplantation without BMC and 29 condyles in 22 patients who underwent OCA transplantation with BMC. The BMC group had significantly ( P = .033) higher graft integration scores at 6 weeks, 3 months, and 6 months after surgery. Graft sclerosis was significantly ( P = .017) less in the BMC group at 6 weeks and 3 months, with no significant difference at 6 months after surgery. When combining the groups to examine the influence of smoking on graft integration, nonsmokers had significantly ( P = .007) higher graft integration scores at 6 months. CONCLUSION Large femoral condylar OCAs treated with autogenous BMC before implantation showed superior radiographic integration to bone and less sclerosis during the initial 6-month postoperative period. BMC treatment of OCAs may mitigate the failure of OCA bone healing.
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Affiliation(s)
- Lasun O Oladeji
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Matthew J Smith
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
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Schweser KM, Crist BD, Nguyen VH. Combined orthogeriatric and fracture liaison service for improved postfracture patient care. Osteoporos Sarcopenia 2017; 3:159. [PMID: 30775522 PMCID: PMC6372833 DOI: 10.1016/j.afos.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/26/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kyle M Schweser
- Department of Orthopaedic Surgery, School of Medicine, University of Missouri, Columbia, MO, USA
- Public Health Program, Department of Health Sciences, School of Health Professions, University of Missouri, Columbia, MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, School of Medicine, University of Missouri, Columbia, MO, USA
- Public Health Program, Department of Health Sciences, School of Health Professions, University of Missouri, Columbia, MO, USA
| | - Vu H Nguyen
- Public Health Program, Department of Health Sciences, School of Health Professions, University of Missouri, Columbia, MO, USA
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Wasterlain AS, Melamed E, Bello R, Karia R, Capo JT, Vochteloo A, Powell AJ, Marcus A, Andreas P, Miller AN, Berner AA, Altintas B, Sears BW, Calfee RP, Ekholm C, Fernandes C, Porcellini G, Jones C, Moreno-Serrano CL, Manke C, Crist BD, Haverkamp D, Hanel D, Merchant M, Rikli DA, Shafi M, Patiño JM, Duncan SF, Ballas EG, Harvey E, Walbeehm E, Schumer ED, Evans PJ, Suarez F, Lopez-Gonzalez F, Seibert FJ, DeSilva G, Bayne GJ, Guitton T, Nancollas M, Lane LB, Westly SK, Villamizar HA, Pountos I, Hofmeister E, Biert J, Goslings JC, Bishop J, Gillespie JA, Grandi Ribeiro Filho JE, Huang JI, Nappi JF, Rubio J, Scolaro JA, Yao J, Chivers K, Jeray K, Lee K, Rumball KM, Mica L, Adolfsson LE, Borris LC, Benson L, Austin LS, Richard MJ, Kastelec M, Costanzo RM, Kessler MW, Palmer MJ, Pirpiris M, Grafe MW, Akabudike NM, Shortt NL, Kanakaris NK, Wilson N, Levy O, Althausen P, Lygdas P, Sancheti P, Parnes N, Krause P, Jebson P, Guenter L, Peters R, Ramli RM, Shatford R, Rowinski S, Gilbert RS, Kamal RN, Zura RD, Rodner C, Pesantez R, Ruch D, Kennedy SA, Hurwit S, Kaplan S, Kronlage S, Meylaerts S, Omara T, Swiontkowski M, DeCoster T. The Effect of Price on Surgeons' Choice of Implants: A Randomized Controlled Survey. J Hand Surg Am 2017; 42:593-601.e6. [PMID: 28606437 DOI: 10.1016/j.jhsa.2017.05.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 05/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection. METHODS We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naïve" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed. RESULTS For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naïve surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naïve surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%). CONCLUSIONS Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analyses I.
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Affiliation(s)
- Amy S Wasterlain
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY.
| | - Eitan Melamed
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Ricardo Bello
- Universidad Central de Venezuela, Ciudad Universitaria de Caracas, Caracas, Venezuela
| | - Raj Karia
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - John T Capo
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
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Abstract
PURPOSE OF THE REVIEW The purposes of this study are to examine the literature within the past 5 years regarding osteoporosis and offer a discussion on new topics and controversies. RECENT FINDINGS Patient compliance with therapy remains an issue. The effectiveness of Vitamin D and calcium are being called into question Atypical femur fractures have been associated with bisphosphonate and denosumab use. Treatment is both surgical and pharmaceutical. A multidisciplinary approach to osteoporotic fractures is important and having some form of fracture liaison service (FLS) improves the efficacy of osteoporotic care and decreases secondary fractures. Screening for osteoporosis remains low. Ultrasound may be cost-effective for diagnosis. Understanding of osteoporosis has come a long way in the medical community, but the translation to the lay community has lagged behind. Patients often take a laissez-faire attitude toward osteoporosis that can affect compliance. Information read by patients often focuses on complications, such as atypical femur fractures and myocardial infarctions. It is essential for providers to be able to discuss these issues with patients. Newer medications and more cost-effective diagnostic tests exist, but availability may be limited. FLS are effective, but the most cost-effective model for therapy still eludes us. Areas for further investigation include FLS models, the effectiveness of vitamin supplementation, and more ubiquitous and cost-effective diagnostic tools.
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Affiliation(s)
- Kyle M Schweser
- Department of Orthopaedic Surgery, University of Missouri, N116, One Hospital Dr, Columbia, MO, 65212, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, N116, One Hospital Dr, Columbia, MO, 65212, USA.
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Smith MJ, Reiter MJ, Crist BD, Schultz LG, Choma TJ. Improving Patient Satisfaction Through Computer-Based Questionnaires. Orthopedics 2016; 39:e31-5. [PMID: 26709557 DOI: 10.3928/01477447-20151218-07] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/20/2015] [Indexed: 02/03/2023]
Abstract
Patient-reported outcome measures are helping clinicians to use evidence-based medicine in decision making. The use of computer-based questionnaires to gather such data may offer advantages over traditional paper-based methods. These advantages include consistent presentation, prompts for missed questions, reliable scoring, and simple and accurate transfer of information into databases without manual data entry. The authors enrolled 308 patients over a 16-month period from 3 orthopedic clinics: spine, upper extremity, and trauma. Patients were randomized to complete either electronic or paper validated outcome forms during their first visit, and they completed the opposite modality at their second visit, which was approximately 7 weeks later. For patients with upper-extremity injuries, the Penn Shoulder Score (PSS) was used. For patients with lower-extremity injuries, the Foot Function Index (FFI) was used. For patients with lumbar spine symptoms, the Oswestry Disability Index (ODI) was used. All patients also were asked to complete the 36-Item Short Form Health Survey (SF-36) Health Status Survey, version 1. The authors assessed patient satisfaction with each survey modality and determined potential advantages and disadvantages for each. No statistically significant differences were found between the paper and electronic versions for patient-reported outcome data. However, patients strongly preferred the electronic surveys. Additionally, the paper forms had significantly more missed questions for the FFI (P<.0001), ODI (P<.0001), and PSS (P=.008), and patents were significantly less likely to complete these forms (P<.0001). Future research should focus on limiting the burden on responders, individualizing forms and questions as much as possible, and offering alternative environments for completion (home or mobile platforms).
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Peterson BE, Bal S, Aggarwal A, Crist BD. Novel Technique: Knee Arthrodesis Using Trabecular Metal Cones with Intramedullary Nailing and Intramedullary Autograft. J Knee Surg 2016; 29:510-5. [PMID: 26551067 DOI: 10.1055/s-0035-1566738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The failed total knee arthroplasty is a challenge to the surgeon and the patient. Infection, bone loss, and instability lead to a chronically painful and dysfunctional limb. Two-stage revision arthroplasty has been successful in clearing a majority of periprosthetic joint infections. However, there are many cases when the multiply revised and infected total knee arthroplasty cannot be salvaged. We report, a review of knee arthrodesis and a novel technique to manage significant bone loss. The use of trabecular metal cones and a long intramedullary nail can be used in concert with an autologous intramedullary bone graft to provide a stable, length restoring construct with sufficient biology to heal very large bone voids. With this technique we have successfully restored function and stability in the failed knee arthroplasty.
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Affiliation(s)
- Blake E Peterson
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Sonny Bal
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Ajay Aggarwal
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Brett D Crist
- Department of Orthopaedic Trauma, University of Missouri, Columbia, Missouri
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Crist BD, Stoker AM, Stannard JP, Cook JL. Analysis of relevant proteins from bone graft harvested using the reamer irrigator and aspirator system (RIA) versus iliac crest (IC) bone graft and RIA waste water. Injury 2016; 47:1661-8. [PMID: 27269417 DOI: 10.1016/j.injury.2016.05.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 05/16/2016] [Accepted: 05/19/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Femoral reaming using a Reamer Irrigator Aspirator (RIA) can produce greater than three liters of waste water per procedure, which contains cells and proteins that could promote bone healing. This purpose of this study was to determine the protein profile of RIA waste water and compare protein synthesis by cells harvested via RIA versus iliac crest (IC) bone graft. METHOD Bone graft was collected from 30 patients-15 using RIA from the femur and 15 harvested from the iliac crest. Waste water collected during the RIA procedure was analyzed in 12 patients. Cells from each graft were cultured in monolayer using growth media for 14days and inductive media for the next 14days. Media samples were collected on days 14, 21, and 28. Proteins for analysis were chosen based on their potential in bone healing, pro-inflammatory, and anti-inflammatory processes. RESULTS Proteins present in RIA waste water indicate the potential for clinical use of this filtrate as an adjunct for enhancing bone production, healing, and remodeling. Similarly, cells cultured from RIA bone graft harvests compared favorably to those from iliac crest bone grafts with respect to their potential to aid in bone healing. CONCLUSION RIA waste water has potential to serve as an autogenic and allogenic enhancer for bone healing. Continued development of processing protocols for viable commercial use of the waste water and pre-clinical studies designed to evaluate RIA waste water products for bone healing are ongoing.
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Affiliation(s)
- Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA.
| | - Aaron M Stoker
- Comparative Orthopaedic Laboratory, University of Missouri, Columbia, USA
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, USA; Comparative Orthopaedic Laboratory, University of Missouri, Columbia, USA
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Robertson MW, Galloway SJ, Crist BD, Gray AD. Not as Straight(forward) as an Arrow: Ultrasound Use to Detect a Carbon-Fiber Foreign Body: A Case Report. JBJS Case Connect 2016; 6:e29. [PMID: 29252663 DOI: 10.2106/jbjs.cc.o.00159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE A fifteen-year-old boy sustained an archery injury when a carbon-fiber arrow shaft embedded in the volar aspect of his left forearm. The shaft was removed, but at a follow-up visit he still felt the sensation of a retained foreign body in the tissue. Although radiographs were negative, ultrasound examination found three foreign bodies of various lengths still located in the soft tissue. Further surgery removed the objects without difficulty. CONCLUSION Ultrasound examination can be a valuable diagnostic tool when radiographs yield inconclusive results after penetrating wounds due to radiolucent foreign bodies.
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Affiliation(s)
- Michael W Robertson
- Departments of Orthopaedic Surgery (M.W.R., B.D.C., and A.D.G.) and Family & Community Medicine (A.D.G.), University of Missouri, Columbia, Missouri
- Orthopaedic Trauma Division, CoxHealth, Springfield, Missouri
| | | | - Brett D Crist
- Departments of Orthopaedic Surgery (M.W.R., B.D.C., and A.D.G.) and Family & Community Medicine (A.D.G.), University of Missouri, Columbia, Missouri
| | - Aaron D Gray
- Departments of Orthopaedic Surgery (M.W.R., B.D.C., and A.D.G.) and Family & Community Medicine (A.D.G.), University of Missouri, Columbia, Missouri
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Crist BD, Anderson LK, Murtha YM, Della Rocca GJ. Negative pressure wound therapy in orthopaedic patients and the financial impact of delay in discharge for unfunded and Medicaid patients. Current Orthopaedic Practice 2016. [DOI: 10.1097/bco.0000000000000349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hood MA, Murtha YM, Della Rocca GJ, Stannard JP, Volgas DA, Crist BD. Prevalence of Low Vitamin D Levels in Patients With Orthopedic Trauma. Am J Orthop (Belle Mead NJ) 2016; 45:E522-E526. [PMID: 28005107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Low levels of serum vitamin D have been linked to numerous musculoskeletal and nonmusculoskeletal conditions. Vitamin D deficiency appears relatively high among various patient subpopulations, including patients with fracture nonunion. We conducted a retrospective study to determine the prevalence of vitamin D deficiency and insufficiency in a large population of patients with orthopedic trauma. The study included all patients who were over age 18 years, had no risk factors for vitamin D deficiency, and were treated for an acute fracture at a Level 1 trauma center. Between January 2009 and September 2010, 889 trauma patients had recorded serum 25-hydroxyvitamin D levels. Overall prevalence of combined vitamin D deficiency/insufficiency was 77%; prevalence of vitamin D deficiency alone was 39%. There were no statistically significant (P < .05) age or sex differences among the population. There did not appear to be a seasonal difference. Vitamin D deficiency and insufficiency in acute orthopedic trauma patients appear very common. Further investigation is needed to fully understand the clinical significance.
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Affiliation(s)
| | | | | | | | | | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO.
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Kim PJ, Attinger CE, Crist BD, Gabriel A, Galiano RD, Gupta S, Lantis Ii JC, Lavery L, Lipsky BA, Teot L. Negative Pressure Wound Therapy With Instillation: Review of Evidence and Recommendations. Wounds 2015; 27:S2-S19. [PMID: 26966814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Negative pressure wound therapy with instillation (NPWTi) and dwell time is an adjunctive treatment modality for selected complex wounds. Because of the greater amount of research now available, a multidisciplinary expert panel comprising the fields of podiatry, plastic and general surgery, burn treatment, infectious diseases, and orthopedics was convened on July 11, 2015, to produce a summary of the data and recommendations on the use of NPWTi. The panel members each reviewed available published literature on NPWTi in the PubMed, Cochrane, and Google Scholar databases from 1 January 2012 up until 20 July 2015 using the string search term negative pressure wound therapy instillation provided by the panel moderator; there were no restrictions on the language or type of publication. Panel members discussed their experiences and worked to reach consensus on several predefined topics. NPWTi was found to be most appropriate for properly selected complex hosts or wounds such as patients with multiple comorbidities, patients with an American Society of Anesthesiology Classification ≥ 2, severe traumatic wounds, diabetic foot infections, and wounds complicated by invasive infection or extensive biofilm. NPWTi should not be used routinely to treat simple wounds or hosts without comorbidities.There is evidence that when NPWTi is added to standard of care in properly selected cases it provides better overall clinical outcomes than standard of care alone, even when including NPWT. Based on published evidence and panel member experience, the Panel recommends a dwell time - fluid briefly instilled into the wound and allowed to diffuse for a user-specified time - of 10-20 minutes followed by 2-4 hours of negative pressure at -125 mmHg, although larger wounds may need times of up to 6 hours. Normal saline (0.9%) is the preferred solution for NPWTi, except in special situations. NPWTi with dwell time is an adjunct to other standard principles of appropriate wound assessment and treatment (e.g., debridement, pressure offloading, systemic antibiotic therapy, vascular assessment and revascularization when needed, or glycemic control).
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Affiliation(s)
- Paul J Kim
- Department of Plastic Surgery and Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | | | - Brett D Crist
- Department of Orthopedic Surgery, University of Missouri, Columbia, MO
| | - Allen Gabriel
- PeaceHealth Medical Group Plastic Surgery, Vancouver, WA
| | - Robert D Galiano
- Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Subhas Gupta
- Loma Linda University Medical Center, Department of Plastic Surgery, Loma Linda, CA
| | | | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Luc Teot
- Wound Healing Unit and Burns Surgery, Montpellier University Hospital, Montpellier, France
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