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Tigchelaar SS, Wang AR, Vaca SD, Li Y, Steinberg GK. Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease. Stroke 2024; 55:1254-1260. [PMID: 38567531 DOI: 10.1161/strokeaha.123.044693] [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] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network that is rupture-prone. Steno-occlusive changes in the posterior cerebral arteries (PCAs) may contribute to worsened outcomes in patients with MMD; however, there is little information on the incidence and natural history of posterior circulation MMD (PCMMD). We describe clinical PCMMD characteristics in a large cohort of patients with MMD. METHODS We retrospectively reviewed patients with MMD treated between 1991 and 2019 at a large academic medical center. Demographics, perioperative outcomes, and radiological phenotypes were recorded for 770 patients. PCA disease was graded as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe or occluded) based on cerebral angiography. Patients with angiographically confirmed MMD diagnosis with at least 6 months follow-up and completion of revascularization surgery were included; patients with intracranial atherosclerosis, intracranial dissection, vasculitis, and undefined inflammatory processes were excluded. The presence of stenosis/occlusion was graded radiographically to assess for disease progression and the prevalence of risk factors related to reduced progression-free survival. RESULTS In all, 686 patients met the inclusion criteria, with PCA disease identified in 282 (41.1%) patients. Of those 282 patients with PCMMD, disease severity ranged from 99 (35.1%) with mild, 72 (25.5%) with moderate, and 111 (39.4%) with severe. The total number of postoperative complications was significantly associated with PCMMD severity (P=0.0067). Additionally, PCMMD severity correlated with worse postoperative modified Rankin Scale scores (P<0.0001). At a mean follow-up of 6.0±3.9 (range, 0.1-25.0) years, a total of 60 (12.6%) patients showed new/worsening PCMMD. The overall postoperative, progression-free survival in patients with PCMMD was 95.4% at 1 year, 82.4% at 3 years, 68.8% at 5 years, and 28.3% at 10 years, with prognostic factors for progression including preoperative PCMMD status, history of tobacco use, and hypertension (P<0.0001, P<0.001, and P<0.0001, respectively). CONCLUSIONS PCA disease involvement in MMD is associated with higher rates of ischemic perioperative complications and worsened functional outcomes, likely due to reduced collateral flow. Ten-year progression of PCA disease is highly likely and should be monitored throughout follow-up; future studies will assess the impact of PCA disease progression on long-term outcomes.
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Affiliation(s)
- Seth S Tigchelaar
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Allan R Wang
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Silvia D Vaca
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Yiping Li
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
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Wadhwa H, Rohde M, Oquendo Y, Chen MJ, Tigchelaar SS, Bellino M, Bishop J, Gardner MJ. Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery. Eur J Orthop Surg Traumatol 2024; 34:1025-1029. [PMID: 37865628 DOI: 10.1007/s00590-023-03763-z] [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] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery. METHODS We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression. RESULTS Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p = 0.463; 15.4% vs. 28%, p = 0.181). Median units transfused did not differ between groups (2 ± 1 vs. 2 ± 1, p = 0.515; 2 ± 1 vs. 2 ± 0, p = 0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions. CONCLUSION Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.
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Affiliation(s)
- Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Matthew Rohde
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA.
| | - Yousi Oquendo
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael Bellino
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Julius Bishop
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
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Padmanabhan J, Chen K, Sivaraj D, Henn D, Kuehlmann BA, Kussie HC, Zhao ET, Kahn A, Bonham CA, Dohi T, Beck TC, Trotsyuk AA, Stern-Buchbinder ZA, Than PA, Hosseini HS, Barrera JA, Magbual NJ, Leeolou MC, Fischer KS, Tigchelaar SS, Lin JQ, Perrault DP, Borrelli MR, Kwon SH, Maan ZN, Dunn JCY, Nazerali R, Januszyk M, Prantl L, Gurtner GC. Allometrically scaling tissue forces drive pathological foreign-body responses to implants via Rac2-activated myeloid cells. Nat Biomed Eng 2023; 7:1419-1436. [PMID: 37749310 PMCID: PMC10651488 DOI: 10.1038/s41551-023-01091-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/02/2023] [Indexed: 09/27/2023]
Abstract
Small animals do not replicate the severity of the human foreign-body response (FBR) to implants. Here we show that the FBR can be driven by forces generated at the implant surface that, owing to allometric scaling, increase exponentially with body size. We found that the human FBR is mediated by immune-cell-specific RAC2 mechanotransduction signalling, independently of the chemistry and mechanical properties of the implant, and that a pathological FBR that is human-like at the molecular, cellular and tissue levels can be induced in mice via the application of human-tissue-scale forces through a vibrating silicone implant. FBRs to such elevated extrinsic forces in the mice were also mediated by the activation of Rac2 signalling in a subpopulation of mechanoresponsive myeloid cells, which could be substantially reduced via the pharmacological or genetic inhibition of Rac2. Our findings provide an explanation for the stark differences in FBRs observed in small animals and humans, and have implications for the design and safety of implantable devices.
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Affiliation(s)
- Jagannath Padmanabhan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kellen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Dharshan Sivaraj
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Dominic Henn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Britta A Kuehlmann
- Department of Plastic and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Hudson C Kussie
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Eric T Zhao
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Anum Kahn
- Cell Sciences Imaging Facility (CSIF), Beckman Center, Stanford University, Stanford, CA, USA
| | - Clark A Bonham
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Teruyuki Dohi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas C Beck
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Artem A Trotsyuk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Zachary A Stern-Buchbinder
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter A Than
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Hadi S Hosseini
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Janos A Barrera
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Noah J Magbual
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Melissa C Leeolou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Katharina S Fischer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Seth S Tigchelaar
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - John Q Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David P Perrault
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Sun Hyung Kwon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Zeshaan N Maan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Januszyk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Lukas Prantl
- Department of Plastic and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Geoffrey C Gurtner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
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Medress ZA, Bobrow A, Tigchelaar SS, Henderson T, Parker JJ, Desai A. Augmented Reality-Assisted Resection of a Large Presacral Ganglioneuroma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e284-e285. [PMID: 36701554 DOI: 10.1227/ons.0000000000000542] [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] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/22/2022] [Indexed: 01/27/2023] Open
Affiliation(s)
- Zachary A Medress
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | | | - Seth S Tigchelaar
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | | | - Jonathon J Parker
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Atman Desai
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
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Sivaraj D, Fischer KS, Kim TS, Chen K, Tigchelaar SS, Trotsyuk AA, Gurtner GC, Lee GK, Henn D, Nazerali RS. Outcomes of Biosynthetic and Synthetic Mesh in Ventral Hernia Repair. Plast Reconstr Surg Glob Open 2022; 10:e4707. [PMID: 36530858 PMCID: PMC9746774 DOI: 10.1097/gox.0000000000004707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 06/17/2023]
Abstract
The introduction of mesh for reinforcement of ventral hernia repair (VHR) led to a significant reduction in hernia recurrence rates. However, it remains controversial whether synthetic or biologic mesh leads to superior outcomes. Recently, hybrid mesh consisting of reinforced biosynthetic ovine rumen (RBOR) has been developed and aims to combine the advantages of biologic and synthetic mesh; however, outcomes after VHR with RBOR have not yet been compared with the standard of care. Methods We performed a retrospective analysis on 109 patients, who underwent VHR with RBOR (n = 50) or synthetic polypropylene mesh (n = 59). Demographic characteristics, comorbidities, postoperative complications, and recurrence rates were analyzed and compared between the groups. Multivariate logistic regression models were fit to assess associations of mesh type with overall complications and surgical site occurrence (SSO). Results Patients who underwent VHR with RBOR were older (mean age 63.7 versus 58.8 years, P = 0.02) and had a higher rate of renal disease (28.0 versus 10.2%, P = 0.01) compared with patients with synthetic mesh. Despite an unfavorable risk profile, patients with RBOR had lower rates of SSO (16.0 versus 30.5%, P = 0.12) and similar hernia recurrence rates (4.0 versus 6.78%, P = 0.68) compared with patients with synthetic mesh. The use of synthetic mesh was significantly associated with higher odds for overall complications (3.78, P < 0.05) and SSO (3.87, P < 0.05). Conclusion Compared with synthetic polypropylene mesh, the use of RBOR for VHR mitigates SSO while maintaining low hernia recurrence rates at 30-month follow-up.
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Affiliation(s)
- Dharshan Sivaraj
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Katharina S. Fischer
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Trudy S. Kim
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Kellen Chen
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Seth S. Tigchelaar
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Artem A. Trotsyuk
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Geoffrey C. Gurtner
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Gordon K. Lee
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Dominic Henn
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
| | - Rahim S. Nazerali
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif
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Goodnough LH, Wadhwa H, Tigchelaar SS, DeBaun MR, Chen MJ, Graves ML, Gardner MJ. Indications for cement augmentation in fixation of geriatric intertrochanteric femur fractures: a systematic review of evidence. Arch Orthop Trauma Surg 2022; 142:2533-2544. [PMID: 33829301 DOI: 10.1007/s00402-021-03872-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 12/06/2020] [Accepted: 03/23/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation. METHODS The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size < 5, nontraumatic or periprosthetic fractures, and nonunion or revision surgery were excluded. Study selection adhered to PRISMA criteria. RESULTS 801 studies were identified, of which 40 met study criteria. 9 studies assessed effect of cement augmentation on fracture displacement. All but one found that cement decreased fracture displacement. 10 studies assessed effect of cement augmentation on total load or cycles to failure. All but one demonstrated that augmented implants increased this variable. Complication rates of cement augmentation during ORIF of intertrochanteric fractures ranged from 0 to 47%, while non-augmented implants ranged from 0 to 51%. Reoperation rates ranged from 0 to 11% in the cement-augmented group and 0 to 11% in the non-augmented group. Fixation failure ranged from 0 to 11% in the cement-augmented group and 0 to 20% in the non-augmented group. Nonunion ranged from 0 to 3.6% in the cement-augmented group and 0 to 34% in the non-augmented group. CONCLUSIONS Calcium phosphate or PMMA-augmented CMN fixation of IT fractures increased construct stability and improved outcomes in biomechanical and early clinical studies. The findings of these studies suggest an important role for cement augmentation in patient populations at high risk of mechanical failure.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway St., Pavilion C, 4th Floor, Redwood, CA, 94063, USA.
| | - Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway St., Pavilion C, 4th Floor, Redwood, CA, 94063, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway St., Pavilion C, 4th Floor, Redwood, CA, 94063, USA
| | - Malcolm R DeBaun
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway St., Pavilion C, 4th Floor, Redwood, CA, 94063, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway St., Pavilion C, 4th Floor, Redwood, CA, 94063, USA
| | - Matt L Graves
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway St., Pavilion C, 4th Floor, Redwood, CA, 94063, USA
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Wadhwa H, Oquendo YA, Tigchelaar SS, Warren SI, Koltsov JCB, Desai A, Veeravagu A, Alamin TF, Ratliff JK, Hu SS, Cheng I. Advanced Age Does Not Impact Outcomes After 1-level or 2-level Lateral Lumbar Interbody Fusion. Clin Spine Surg 2022; 35:E368-E373. [PMID: 34724454 DOI: 10.1097/bsd.0000000000001270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/30/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective comparative study. OBJECTIVE The objective of this study was to assess the effect of increased age on perioperative and postoperative complication rates, reoperation rates, and patient-reported pain and disability scores after lateral lumbar interbody fusion (LLIF). SUMMARY OF BACKGROUND DATA LLIF was developed to minimize soft tissue trauma and reduce the risk of vascular injury; however, there is little evidence regarding the effect of advanced age on outcomes of LLIF. METHODS Patients who underwent LLIF from 2009 to 2019 at one institution with a minimum 6-month follow-up were retrospectively reviewed. Patients less than 18 years old with musculoskeletal tumor or trauma were excluded. The primary outcome was the preoperative to postoperative change in the Numeric Pain Rating Scale (NPRS) for back pain. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and change in Oswestry Disability Index were also evaluated. Relationships with age were assessed both with age as a continuous variable and segmenting by age below 70 versus 70+. RESULTS In total, 279 patients were included. The median age was 65±13 years and 159 (57%) were female. Age was not related to improvements in back NPRS and Oswestry Disability Index. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and radiographic fusion rate also were not related to age. After multivariable risk adjustment, increasing age was associated with greater improvements in back NPRS. The decrease in back NPRS was 0.68 (95% confidence interval: 0.14, 1.22; P=0.014) points greater for every 10-year increase in age. Age was not associated with rates of complication, readmission, or reoperation. CONCLUSIONS LLIF is a safe and effective procedure in the elderly population. Advanced age is associated with larger improvements in preoperative back pain. Surgeons should consider the benefits of LLIF and other minimally invasive techniques when evaluating elderly candidates for lumbar fusion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | - Atman Desai
- Neurosurgery, Stanford University Medical Center, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery, Stanford University Medical Center, Stanford, CA
| | | | - John K Ratliff
- Neurosurgery, Stanford University Medical Center, Stanford, CA
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Wadhwa H, Chen MJ, Tigchelaar SS, Bellino MJ, Bishop JA, Gardner MJ. Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery. Injury 2021; 52:1783-1787. [PMID: 33832703 DOI: 10.1016/j.injury.2021.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/15/2020] [Revised: 03/01/2021] [Accepted: 03/27/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion. METHODS Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared. RESULTS Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion. CONCLUSION Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Michael J Bellino
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA.
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Wadhwa H, Tigchelaar SS, Chen MJ, Koltsov JCB, Bellino MJ, Bishop JA, Gardner MJ. Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery. Eur J Orthop Surg Traumatol 2021; 32:363-369. [PMID: 33891154 DOI: 10.1007/s00590-021-02985-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration. METHODS We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion. RESULTS Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p < 0.01) and intraoperative IV fluids (p < 0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70 years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion. CONCLUSION In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.
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Affiliation(s)
- Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jayme C B Koltsov
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael J Bellino
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Tigchelaar SS, Azevedo-Pereira RL, Dong C, liang X, Bliss T, Steinberg G. Abstract P815: Decoding the Cross-Talk Between Grafted Neural Stem Cells and Host Brain to Predict the Molecular Mechanisms of Stem Cell-Induced Functional Recovery After Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is a leading cause of long-term disability and death in the united states. The development of new therapies for stroke are sorely needed. There is great hope that stem cell therapy will create a paradigm shift in the treatment of stroke patients. A barrier to ensuring clinical success of stem cell therapy is the paucity of understanding of the mechanisms by which stem cells exert their beneficial effects. Using a novel mRNA purification method, we identified 50 genes encoding extracellular space proteins, expressed by human neural stem cells (hNSCs) whose expression positively correlated with functional recovery. In this study, we focus on one of the paracrine factors from grafted hNSCs that correlated best with functional recovery, to investigate its therapeutic potential in promoting recovery after stroke.
Male nude rats underwent stroke using the distal middle cerebral artery occlusion (dMCAo) model. One week following stroke, osmotic pumps were prepared and loaded with recombinant MTN-2. The osmotic pumps were inserted into the peri-infarct area and infused recombinant MTN-2 for 5 days. Post-stroke, animals were assessed for functional recovery for 5 weeks using both the Montoya staircase test and the whisker-paw reflex test to assess for forelimb function, dexterity, side bias, and placing deficits.
After 5 weeks, brain tissue was isolated to assess glial cell morphology. Brain sections were stained with GFAP and IBA1 to visualize astrocytes and microglia, respectively. Confocal images were processed and analyzed using the Bitplane Imaris image analysis software. Output measurements of number of cells/mm2, cell volume, cell branching, and process length and thickness were obtained to characterize the changes in astrocytic and microglial response to injury and paracrine factor treatment.
By identifying paracrine factors that are responsible for the regeneration of brain tissue following implantation of hNSCs in stroke brain, this work will increase the likelihood of successful clinical translation of stem cell therapy for stroke. Moreover, elucidating these molecular pathways important for brain recovery may ultimately identify novel therapeutic targets and offer hope to millions of Americans who live with the devastating effects of stroke.
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Affiliation(s)
| | | | - Chen Dong
- Neurosurgery, Stanford, Stanford, CA
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Tigchelaar SS, Wang A, Li Y, Steinberg G. Abstract MP9: Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.mp9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network of small, weak blood vessels that are prone to rupture. Steno-occlusive changes in the posterior cerebral arteries (PCA) may contribute to worse outcomes in MMD patients, however, there is a paucity of information on the incidence and natural history of MMD patients with PCA disease.
We retrospectively reviewed the charts of patients with MMD treated between 1987 and 2019. Demographics, peri-operative outcomes, and radiological phenotypes were recorded for 450 patients. PCA disease was scored as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe, or occluded).
Out of 450 patients, 164 (34.4%) had concurrent PCA disease. In patients with PCA disease, the extent of occlussion was mild in 56 (34%), moderate in 41 (25%), and severe in 67 (40.9%) patients. In total, there were 319 females (70.9%), with a higher proportion of female MMD patients having severe or moderate PCA disease (p=0.038). Patients with severe and moderate PCA disease had higher Suzuki grades (p<0.0001), more extensive collateral angiopathy (p<0.0001), more frequent cerebrovascular accidents on presentation (p=0.012), higher hemodynamic scores (p=0.022), and a greater frequency of post-operative ischemic complications (p=0.019). Peak modified Rankin Scale (mRS) scores were higher in patients with any severity of PCA disease (p=0.0006).
Over a mean follow-up of 6.94±4.16 years, 28 patients (8.86%) developed new or progressive PCA disease. Bilateral disease was present in 66 patients (14.7%) and was associated with higher Suzuki grades (p<0.0001), more extensive collateral angiopathy (p<0.0001), and greater post-operative ischemic complications (p=0.011). Peak mRS scores were higher in patients with bilateral disease compared to patients with no PCA disease (p<0.0001).
PCA disease involvement is associated with higher rates of ischemic peri-operative complications and poor functional outcomes likely due to reduced collateral flow. Progression of PCA disease is not uncommon. Future studies are needed to assess the impact of PCA disease progression on long-term outcomes.
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Goodnough LH, Wadhwa H, Tigchelaar SS, Pfaff K, Heffner M, Van Rysselberghe N, DeBaun MR, Bishop JA, Gardner MJ. Cephalomedullary helical blade is independently associated with less collapse in intertrochanteric femur fractures than lag screws. Eur J Orthop Surg Traumatol 2021; 31:1421-1425. [PMID: 33587180 DOI: 10.1007/s00590-021-02875-8] [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] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws. DESIGN Retrospective cohort study. SETTING Single U.S. Level I Trauma Center. PATIENTS 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up. INTERVENTION Lag screw or helical blade in a cephalomedullary nail. OUTCOME MEASURES The primary outcome was fracture site collapse at 3 months. RESULTS There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7 mm, inter-quartile range 2.5-7.8 mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7-11.2 mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5 mm less collapse (95%CI - 4.2, - 0.72 mm, p 0.006) and lower likelihood of excessive collapse (> 10 mm at 3 months, OR 0.3, 95% CI 0.13-0.74, p 0.007), regardless of fracture pattern. CONCLUSIONS Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA.
| | - Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
| | - Kayla Pfaff
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
| | - Michael Heffner
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
| | | | - Malcolm R DeBaun
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
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Chen MJ, Hollyer I, Wadhwa H, Tigchelaar SS, Van Rysselberghe NL, Bishop JA, Bellino MJ, Gardner MJ. Management of the posterior wall fracture in associated both column fractures of the acetabulum. Eur J Orthop Surg Traumatol 2021; 31:1047-1054. [PMID: 33386470 DOI: 10.1007/s00590-020-02850-9] [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] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The primary aim of this study was to compare clinical outcomes in patients with associated both column (ABC) acetabular fractures with fracture of the posterior wall (PW), in which the PW underwent reduction and fragment-specific fixation versus those that were treated with column fixation alone. Secondary aims were to assess PW fracture incidence and morphology, as well as to compare radiographic outcomes including fracture healing and interval displacement of the PW in those that did and did not undergo fragment-specific fixation of the PW. METHODS This was a retrospective series of ABC acetabular fractures treated at a single Level I trauma center. Separate fractures of the PW were identified, and associated features were assessed. Associated both column fractures that underwent reduction and fragment-specific fixation of the PW where then compared to ABC fractures with PW involvement that underwent column reconstruction alone. Radiographic and clinical outcomes were compared. RESULTS Fractures of the PW occurred in 55.7% of ABC fractures and were associated with central displacement of the femoral head. The majority of PW fractures were large and involved the acetabular roof. All PW fractures healed without displacement by 3 months, regardless of whether or not reduction and stabilization was performed. Mid-term outcomes at 1-year were similar regardless of whether or not the PW was reduced and stabilized, with regards to Tönnis grade, Merle d'Aubigné-Postel score, and conversion to total hip arthroplasty. CONCLUSION Reduction and fragment-specific fixation of the PW component of ABC acetabular fractures did not improve outcomes in this small comparative study. Posterior wall fractures associated with ABC patterns are frequently large-sized fragments that involve the acetabular roof and are rendered stable after reconstruction of the columns.
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Affiliation(s)
- Michael J Chen
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.
| | - Ian Hollyer
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Noelle L Van Rysselberghe
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Michael J Bellino
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
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Goodnough LH, Wadhwa H, Tigchelaar SS, DeBaun MR, Chen MJ, Bishop JA, Gardner MJ. Trochanteric fixation nail advanced with helical blade and cement augmentation: early experience with a retrospective cohort. Eur J Orthop Surg Traumatol 2020; 31:259-264. [PMID: 32804288 DOI: 10.1007/s00590-020-02762-8] [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] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
Intra-articular screw cut-out is a potential complication of intertrochanteric femur fracture fixation with a cephalomedullary nail. Cement augmentation of fixation in the proximal segment offers the prospect of increased stability and fewer complications, but clinical experience with non-resorbable cement is limited. To determine the handling properties and efficacy of this new technique, we performed a retrospective propensity-matched cohort of forty-four geriatric intertrochanteric femur fractures treated with a cephalomedullary nail with (n = 11) or without (n = 33) augmentation with non-resorbable cement injected into the proximal segment. In the patients treated with cement augmentation, at minimum 3-month follow-up, there were no instances of intra-articular cut-out, and no increase in re-operation compared to conventional fixation. Cement augmentation appears to be safe and effective in geriatric intertrochanteric femur fractures to mitigate risk of cut-out.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA.
| | - Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Malcolm R DeBaun
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
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Chen MJ, Wadhwa H, Tigchelaar SS, Frey CS, Gardner MJ, Bellino MJ. Trochanteric osteotomy for acetabular fracture fixation: a case series and literature review. Eur J Orthop Surg Traumatol 2020; 31:161-165. [PMID: 32743685 DOI: 10.1007/s00590-020-02753-9] [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] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/25/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE This study examined osteotomy union and heterotopic ossification (HO) after performing digastric trochanteric osteotomies during open reduction and internal fixation (ORIF) of acetabular and combined femoral head fractures. Femoral head osteonecrosis and trochanteric screw removal were secondarily assessed. METHODS Twenty-six patients treated at a Level I trauma center, from years 2003 to 2019, who received a digastric trochanteric osteotomy during acetabular and combined femoral head fracture ORIF through a posterior surgical approach were retrospectively identified. Osteotomies were fixed with two 3.5 mm cortical lag screws. Rates of osteotomy union, HO, femoral head osteonecrosis, and trochanteric screw removal were determined. RESULTS All osteotomies went onto union without displacement or failure of fixation. Only three (12%) patients developed severe HO (modified-Brooker class III-IV). There were no instances of femoral head osteonecrosis and only one (7%) patient required trochanteric screw removal. CONCLUSIONS The digastric trochanteric osteotomy heals reliably with low rates of severe HO, femoral head osteonecrosis, and screw removal for soft-tissue irritation. A review of the literature is presented and found comparable findings.
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Affiliation(s)
- Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.
| | - Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Christopher S Frey
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Michael J Bellino
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
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