Publications by authors named "Austin Fragomen"

97 Publications

Core psychosocial issues for children and adolescents in the context of limb lengthening and reconstruction surgery treatment.

J Child Orthop 2021 Apr;15(2):122-129

Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, USA.

Purpose: Addressing the psychosocial needs of adolescents can improve surgical outcomes. The aim of this retrospective comparative study was to understand the core psychosocial factors that shaped the experiences of adolescents who underwent multiple limb lengthening/reconstruction surgeries (LLRS).

Methods: A novel 62-question survey was developed and administered to 31 patients from the study institution. Data was obtained using a self-report inventory assessing medical care, communication/connection to doctor, peer relations, physical space, self-esteem, counselling/clergy, physical/emotional support, school issues and concerns about future. This survey and demographic questions were administered to young adults (now aged 18 to 30 years) who underwent LLRS treatment between the ages of 11 to 20 years.

Results: Psychosocial needs were determined to be within the categories of body image/self-esteem, subjective perception of treatment, patient-physician relationship, role of parents, peer interactions, academic performance and hospital experience. Patients valued parental involvement while also wanting their surgeon to speak directly to them. They preferred to be in private rooms on the paediatric floor and to not socialize while in the hospital. They were indifferent to keeping up with friends, speaking to a counsellor and having their surgeon inquire about their emotions. They expressed concern about pain, carrying out activities and the financial impact of surgery.

Conclusions: Adolescent LLRS patients value focused psychosocial support from their surgeon and caregivers. This perceived level of support influences their ability to cope with their condition. These findings helped us understand the psychological issues and preferences of adolescents who underwent LLRS and can assist orthopaedic surgeons in providing holistic care.

Level Of Evidence: IV.
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http://dx.doi.org/10.1302/1863-2548.15.200207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138787PMC
April 2021

Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty.

Strategies Trauma Limb Reconstr 2020 Sep-Dec;15(3):157-162

Limb Lengthening and Complex Reconstruction Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, United States.

Background: Ankle distraction arthroplasty has emerged as an alternative treatment for ankle arthritis. There are few reports on the magnetic resonance imaging (MRI) findings after distraction arthroplasty. This study sought to determine whether there are positive changes on MRI after ankle distraction and improvements on X-ray. Additionally, patient-reported outcomes and joint range of motion (ROM) after ankle distraction are described.

Materials And Methods: Thirty-two patients (mean age 49 years) who underwent ankle distraction had pre-operative and one-year postoperative MRIs, which were graded using a modified whole-organ magnetic resonance imaging score (WORMS). Ankle joint space and ROM were measured. A non-validated three-item questionnaire was administered to assess functional outcomes.

Results: Although the anterior quadrant of the ankle showed a trend to improvement in cartilage morphology on the postoperative MRI, the WORMS did not demonstrate a significant difference in any of its subcategories. While reduction in joint osteophytes was observed and maintained short term, this was mainly due to resection intraoperatively. X-rays revealed a significant increase in joint space, and there was a significant increase in ankle dorsiflexion. Eight-seven percent of the patients were satisfied with their functional outcome.

Conclusion: At short-term follow-up, MRI scores after ankle distraction arthroplasty did not demonstrate significant improvement despite positive changes on X-ray and improved clinical outcomes and ankle ROM. Further study on larger patient numbers with longer follow-up is required.

Level Of Evidence: IV, Case Series.

How To Cite This Article: Haleem AM, Galal S, Nwawka OK, . Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty. Strategies Trauma Limb Reconstr 2020;15(3):157-162.
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http://dx.doi.org/10.5005/jp-journals-10080-1512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121115PMC
May 2021

Intentional Temporary Limb Deformation for Closure of Soft-Tissue Defects in Open Tibial Fractures.

J Orthop Trauma 2021 06;35(6):e189-e194

Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY.

Objectives: (1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction.

Design: Multicenter retrospective cohort.

Setting: Level I trauma center.

Patients/participants: Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo-Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure.

Intervention: Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator.

Outcome Measurements: Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score.

Results: The average age was 45.3 (20-70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients.

Conclusion: Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115737PMC
June 2021

Limb Lengthening in Russell-Silver Syndrome: An Update Confirming Safe and Speedy Healing.

J Pediatr Orthop 2021 May 13. Epub 2021 May 13.

Hospital for Special Surgery The Mount Sinai Hospital, New York, NY.

Introduction: Russell-Silver syndrome (RSS) is a unique cause of syndromic, and often severe, limb length discrepancy (LLD). RSS causes growth retardation both in utero and postnatally, with asymmetry in limb length more noticeable as growth progresses throughout childhood and adolescent. We aim to present the largest cohort in the literature on limb lengthening in patients with RSS and to validate previous literature supporting faster bony consolidation in these patients with more robust data. We further aim to establish differences in healing within this cohort based on age, sex, segment lengthened, or type of lengthening procedure performed, to help refine patient expectations and guide practitioners in treating this population.

Methods: This was a retrospective study of patients with a diagnosis of RSS who underwent a limb lengthening procedure for the purpose of limb equalization. They were compared with a historic control group of patients who underwent limb lengthening for LLD of a non-RSS etiology. The primary outcome measure was bone healing index (BHI).

Results: The RSS group consisted of 24 patients with 29 segments lengthened, and was compared with a historic control group consisting of 20 patients with 22 segments lengthened (Goldman). Patients with RSS had a significantly lower BHI, and therefore faster healing of their lengthening site, than their non-RSS peers (P=0.02). Within the RSS cohort, we did not detect a difference in BHI based on intervention type or sex, but we did find a trend toward faster healing in femurs over tibiae (P=0.08), and established that younger patients tended toward lower BHIs (P<0.01).

Conclusions: Our results confirmed with more robust data the prior finding that patients with RSS may undergo limb lengthening procedures at least as safely as their non-RSS counterparts, and with even faster bony consolidation, especially in younger patients. We hypothesize that concurrent treatment with growth hormone supplementation may contribute to this finding, although further study is necessary. This is the largest cohort of RSS patients treated with limb lengthening for LLD reported in the literature, and these findings will help to guide surgeon decision-making when treating this unique population.

Level Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001855DOI Listing
May 2021

STRYDE versus PRECICE magnetic internal lengthening nail for femur lengthening.

Arch Orthop Trauma Surg 2021 May 13. Epub 2021 May 13.

Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College Cornell University, New York, NY, USA.

Introduction: Magnetic internal lengthening nails (MILNs) have been used for femoral lengthening to avoid complications associated with external fixation. The titanium version of the MILN (PRECICE) has been in use since 2011 but had limitations (50-75 lb) in post-operative weight bearing. A new stainless-steel version of the MILN (STRYDE) allows 150-250 lb of post-operative weight bearing. The aim is to compare the outcomes of using these two different MILNs for both unilateral and bilateral femoral lengthening.

Methods: A single-center, retrospective cohort study was conducted in which patients' records were reviewed from the period from January 2017 to March 2020. A total of 66 femoral lengthening procedures were included in the study and were divided into two groups: STRYDE group (30 femora) and PRECICE group (36 femora). Outcomes assessed were the 6-months post-operative Limb Deformity-Scoliosis Research Society (LD-SRS) Score, adjacent joint range of motion (ROM), average distraction rate, bone healing index (BHI), and complications.

Results: No statistically significant difference was found between the two groups in regard to the (LD-SRS) score, hip ROM, or knee ROM. Statistically significant differences were found between the two groups in regard to BHI (average of 0.84 months/cm and 0.67 months/cm for STRYDE and PRECICE, respectively) and distraction rate (average of 0.6 mm/day and 0.9 mm/day for STRYDE and PRECICE, respectively). No mechanical nail complications were reported in the STRYDE group compared to three events of nail failure in the PRECICE group. One femur in the PRECICE group needed BMAC injection for delayed healing compared to four femurs in the STRYDE group.

Conclusion: The STRYDE MILN yields comparable functional results to those of PRECICE MILN and shows fewer mechanical nail complications. However, STRYDE MILN requires a slower distraction rate and yields slower healing (larger BHI).

Level Of Evidence: Level III, Therapeutic study.
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http://dx.doi.org/10.1007/s00402-021-03943-8DOI Listing
May 2021

Proximal tibial osteotomy for genu varum: Radiological evaluation of deformity correction with a plate external fixator.

World J Orthop 2021 Mar 18;12(3):140-151. Epub 2021 Mar 18.

Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY 10021, United States.

Background: High tibial osteotomy (HTO) is a well-known procedure for the correction of knee varus. The purpose of this study was to compare the radiological results and accuracy of deformity correction performed using two different techniques: acute opening wedge correction using a plate and gradual correction with a monolateral external fixator.

Aim: To compare of the radiological results of two different techniques: acute opening wedge correction (a plate and screw) and gradual correction (external fixator).

Methods: A total of 43 patients with plates and 36 patients with external fixators were included. All patients had moderate uniplanar varus deformities. We measured radiographic parameters, including the mechanical axis deviation (MAD), medial proximal tibial angle (MPTA), Caton-Deschamps Index (CDI), posterior proximal tibial angle, and joint line obliquity angle (JLOA). The accuracy of MAD correction was calculated based on a correction goal of neutral or overcorrection for medial compartment arthritis.

Results: Demographics including age, body mass index, sex, and preoperative deformities were similar between the groups. The MAD significantly improved from 23.6 mm medial to the midline (SD = 8.2 mm) to 6.9 mm lateral to the midline (SD = 5.4 mm) ( < 0.001). The accuracy of MAD correction did not differ between the groups and was 96.1% (SD = 8.1%) in the plate group and 98.2% (SD = 5.2%) in the external fixator group ( = 0.18). The MPTA significantly improved from 83.9° (SD = 2.9°) to 90.9° (SD = 3.3°) ( < 0.001), and the change was similar between the groups. Differences were noted in patella height, with a CDI change of -19.2% (SD = 13.7%) and 3.1% (SD = 8.0%) for the plate and external fixator groups, respectively ( < 0.001). The change in JLOA was 1.6 degrees (SD = 1.1 degrees) and 0.9 degrees (SD = 0.9 degrees) for the plate and external fixator groups, respectively ( = 0.04).

Conclusion: Reliable correction of moderate varus alignment was achieved with both the acute opening wedge technique with a plate and the gradual monolateral external fixator technique. The patellar height decreased with the open wedge plate technique. Joint line obliquity decreased to a greater degree with the open wedge plate technique, perhaps as a result of medial collateral ligament release. The appropriate technique should be selected based on surgeon and patient preferences; however, external fixation may be a better choice when the preservation of patellar height is deemed important.
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http://dx.doi.org/10.5312/wjo.v12.i3.140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995338PMC
March 2021

Limb Length Discrepancy and Angular Deformity due to Benign Bone Tumors and Tumor-like Lesions.

J Am Acad Orthop Surg Glob Res Rev 2021 Mar 10;5(3). Epub 2021 Mar 10.

From the Hospital for Special Surgery, New York, NY (Dr. Reif, Dr. Fragomen, and Dr. Rozbruch), and the Charité-Universitätsmedizin Berlin, Berlin, Germany (Ms. Matthias).

Benign bone tumors and tumor-like lesions are frequently diagnosed in children and adolescents. The immature skeleton is at risk for growth disturbances and deformity because of the effects of the lesions on normal bone architecture and the physis. The development, manifestation, and severity of the limb length inequality and deformity differs between the various bone pathologies. Distraction osteogenesis, osteotomy, and guided growth are key tools in the treatment of limb inequality and deformity using a combination of external and internal fixation devices.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954373PMC
March 2021

Intramedullary Antibiotic Depot does not Preclude Successful Intramedullary Lengthening or Compression.

J Orthop Trauma 2020 Dec 28;Publish Ahead of Print. Epub 2020 Dec 28.

Louisiana State University Health Science Center, New Orleans, LA, and Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD Hospital for Special Surgery, New York, NY Penn Medicine, Philadelphia, PA Hospital for Special Surgery, New York, NY Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD.

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http://dx.doi.org/10.1097/BOT.0000000000002054DOI Listing
December 2020

Hip-Sparing Equalization Procedures for Leg-Length Discrepancy After Total Hip Arthroplasty: A Retrospective Case Series.

HSS J 2020 Dec 24;16(Suppl 2):400-407. Epub 2020 Jul 24.

Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Leg-length discrepancy (LLD) after primary THA is not uncommon. Little is known, however, about the role of hip-sparing procedures for equalization of LLD after THA.

Questions/purposes: The aim of this study is to report our experiences with these techniques in patients presenting at one institution over a 10-year period.

Methods: We retrospectively reviewed records at one institution to find patients who had sought surgical treatment for LLD after THA between January 2007 and August 2017. Patients who had LLD related to conditions other than the THA, such as bone loss or traumatic defects, were excluded. We recorded the time after THA, laterality, and LLD. Assessment of LLD was performed using clinical and radiographic examinations. Patient demographics and true LLD were recorded, as were prior conservative treatment, equalization procedure performed, final leg length after equalization surgery, time to healing, and complications.

Results: After exclusion of patients with LLD related to other causes, eight patients in whom conservative treatment had failed and who had undergone hip-sparing leg-length equalization surgery were included in the study. The average age was 44.6 years (range, 18 to 66 years). Seven of the patients were female. The pre-operative mean LLD was 3.1 cm (range 1.5 to 7 cm). In those who were long after THA, ipsilateral (THA-side) shortening of femur with a retrograde intramedullary nail (IMN;  = 1) or with a plate ( = 1) was performed. In those who were short after THA, ipsilateral femur lengthening with retrograde Precice nails ( = 2), ipsilateral tibial lengthening with Precice nails ( = 2), or contralateral femur shortening with a retrograde IMN ( = 2) was performed. The average time to full consolidation or union was 6.6 months (range, 2 to 19 months). Two patients had delayed union. All patients but one were satisfied with final results.

Conclusion: We believe that hip-sparing equalization procedures can be part of the treatment algorithm of LLD after THA. These advancements in the field are promising and might expand the indications of lengthening and equalization procedures to include LLD after THA.
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http://dx.doi.org/10.1007/s11420-020-09770-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749886PMC
December 2020

A novel translation system for circular external fixation to correct translational bony deformities.

Injury 2021 Apr 21;52(4):1079-1082. Epub 2020 Nov 21.

Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, USA. Electronic address:

Translational deformities are common complications of conservatively managed bone fractures and some surgically managed fractures with unstable patterns. Realigning the bones can be difficult when soft tissue, scars and calluses form. These deformities can be easily corrected with hexapodalic-based external fixators, but these fixators are not widely available in developing countries. We describe a stable and reliable Ilizarov frame that can be used to treat these deformities and show results of clinical cases.
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http://dx.doi.org/10.1016/j.injury.2020.11.058DOI Listing
April 2021

A Staged Approach to Combined Extra-articular Limb Deformity Correction and Total Ankle Arthroplasty for End-Stage Ankle Arthritis.

Foot Ankle Int 2021 Mar 13;42(3):257-267. Epub 2020 Nov 13.

Hospital for Special Surgery, New York, NY, USA.

Background: Patients presenting with end-stage ankle osteoarthritis (OA) in the setting of a concomitant extra-articular limb deformity pose a challenging problem that has not yet been described in the literature. We describe a case series of patients treated with external and internal fixation techniques followed by total ankle arthroplasty (TAA) in a staged approach to treat this complex presentation.

Methods: Eight patients with limb deformity and end-stage ankle OA who underwent staged deformity correction and TAA from 2016 to 2019 at our institution were retrospectively identified. Average age was 58.5 (range, 49-68) years, with an average follow-up of 2.6 (range, 0.8-4.2) years. All patients underwent limb reconstruction with either tibial osteotomy with a circular frame (n=6) or intramedullary nail (n=2). Limb deformities consisted of the following: posttraumatic tibial malunion (2), limb length discrepancy (1), acquired tibial deformity (1), genu varum (2), or genu valgum (2). Radiographic parameters were assessed pre- and postoperatively on 51-inch standing and ankle radiographs: limb length discrepancy (LLD), genu varum/valgum deformity, recurvatum deformity, mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, anterior distal tibial angle, and tibiotalar alignment. Pre- and postoperative patient-reported outcomes were assessed using 2 metrics, the Limb Deformity-Scoliosis Research Society (LD-SRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Intensity, Pain Interference, Global Physical Function, and Global Mental Function).

Results: Following staged limb deformity correction and TAA, all patients achieved correction of LLD and angular deformities of the lower limb, along with restoration of normal alignment of the ankle joint. There was significant mean improvement in all patient-reported LD-SRS and PROMIS domains, except for LD-SRS mental health. LD-SRS function improved from 2.6 (±0.7) to 4.6 (±0.2), = .008; pain improved from 2.9 (±0.9) to 4.8 (±0.2), = .012; self-image improved from 2.9 (±0.4) to 4.7 (±0.3), < .001; and total LD-SRS improved from 3.3 (±0.4) to 4.8 (±0.2), = .002. Average satisfaction was 4.9 (±0.3). PROMIS physical function improved from 32.3 (±6.8) to 51.3 (±5.3), = .008; pain interference improved from 66.0 (±9.1) to 41.3 (±6.2), = .004; pain intensity improved from 60.0 (±13.3) to 33.1 (±5.3), = .007; global physical health improved from 39.3 (±6.8) to 60.7 (±5.1), = .002; global mental health improved from 54.8 (±5.9) to 65.6 (±2.8), = .007. There was one incidence of pin site infection and one reoperation.

Conclusion: Deformity correction with either external frame or intramedullary nail fixation followed by TAA in a staged approach was a viable surgical option in the treatment of end-stage ankle OA with concurrent extra-articular limb deformity. This unique approach was capable of achieving deformity correction with improved patient-reported outcomes, minimal complications, and good patient satisfaction.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1177/1071100720965120DOI Listing
March 2021

Antibiotic Cement-Coated interlocking Intramedullary Nails in the Treatment of Septic Complex Lower Extremity Reconstruction; A Retrospective Analysis with Two year Minimum Follow up.

J Bone Jt Infect 2020 29;5(4):176-183. Epub 2020 May 29.

Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA.

To report on our experience with antibiotic cement coated interlocking intramedullary nails (ACC-IMNs) for limb salvage in septic complex lower extremity reconstruction with a minimum of 2-year follow up. We retrospectively reviewed the records of all consecutive patients who underwent a limb salvage procedure with ACC-IMNs. We reviewed patients' demographics, the preoperative infecting organism, and host type, time to bone union, complications, limb salvage rates, and infection control rates. There were 28 patients with a mean age of 62 years (range 22-88). The mean follow up period was 40 months (range 28-84). The ACC-IMNs were used in 14 patients (50 %) to achieve knee fusion after failed revisions of infected total knee arthroplasty, in 8 patients (28%) for septic tibial nonunion, and in 6 patients (21%) with ankle fusion nonunions. Bony union/fusion was achieved in 87 % (21/24) of patients. The infection was controlled in 80% (21/26) of patients. Four out the five patients who had recurrent infection were type B hosts (p=0.63). The limb salvage rate was 89% (25/28). The overall complication rate was 32%. The use of ACC-IMNs was an effective treatment strategy and associated with high limb salvage and bone union rates. Furthermore, the infection recurrence rate was low. Knee fusion patients after failed TKA should be counseled preoperatively for a potential high complication rate.
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http://dx.doi.org/10.7150/jbji.46570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358971PMC
May 2020

Integrated Limb Lengthening Is Superior to Classical Limb Lengthening: A Systematic Review and Meta-analysis of the Literature.

J Am Acad Orthop Surg Glob Res Rev 2020 06 12;4(6). Epub 2020 Jun 12.

Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY.

Integrated limb lengthening combines both internal and external fixation methods. It has been introduced to improve time to union, patient time in frame, risk of regenerate refracture, and patient function. We systematically review studies to assess whether integrated limb lengthening methods are superior to classic limb lengthening.

Methods: A total of 457 patients had classic limb lengthening, whereas 488 underwent integrated limb lengthening. The primary outcome measures were total length achieved (cm), external fixator index (month/cm) and bone healing index (month/cm). Problems, obstacles, and sequelae were compared using random effects meta-analyses of all available cases. Kaplan-Meier curves were generated to compare the time spent in frame.

Results: Integrated limb lengthening demonstrated a superior external fixator index ( = 0.0001) and bone healing index ( = 0.0146). The mean time spent in frame for integrated lengthening was significantly shorter ( = 0.0015). Significantly fewer problems ( = 0.000) and sequelae ( = 0.001) were observed with integrated lengthening. Deep infections were more common in the integrated cohort. The lengthening over a nail deep infection rate was significantly higher than with the lengthening and then nailing and lengthening and then plating techniques ( = 0.005).

Conclusions: Integrated methods of limb lengthening are superior to classic methods. We suggest the integration of plates and nails with circular frames to improve outcomes in patients undergoing limb lengthening procedures.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322778PMC
June 2020

Comparison and Validation of Preoperative Planning Techniques for Distal Femoral Osteotomies and Proximal Tibial Osteotomies.

J Knee Surg 2020 May 19. Epub 2020 May 19.

Department of Orthopedic Surgery, Limb Lengthening and Complex Reconstruction Service (LLCRS), Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, New York.

Preoperative planning is important for accurate intraoperative execution in many surgical fields. Planning for distal femoral osteotomies (DFOs) and proximal tibial osteotomies (PTOs) consists of choosing the level of the osteotomy, measuring the angle of the osteotomy based on hip-knee-ankle alignment, and choosing a proper osteotomy wedge size. Medical imaging IT solutions company Sectra has implemented a new osteotomy tool in their radiographic system that is simpler than the accepted standard of modified center of rotation of angulation (mCORA) technique, yet unvalidated. In this study, we aim to compare the Sectra osteotomy tool versus the mCORA technique to measure the osteotomy angles as well as wedge sizes in both DFOs and PTOs to validate this new tool.We enrolled  = 30 consecutive patients with DFOs and  = 30 PTOs from the last year. The Pearson correlation coefficient (PCC) along with descriptive statistics was used to evaluate for similarity between the two techniques. We also compared interobserver and intraobserver reliability using intraclass correlation coefficients (ICC).The PCC for osteotomy angles in DFOs and PTOs were both 0.998 ( < 0.001 for both). For wedge sizes, the PCC in DFOs was 0.993 and 0.980 in PTOs ( < 0.001 for both). ICCs were high for both interobserver measurements in osteotomy angles and wedge sizes (range: 0.989-0.999) as well as intraobserver measurements (0.994-0.999).The Sectra osteotomy tool is a validated tool for preoperative measurements of DFOs and PTOs. It is reliable and simpler than the current practice of the mCORA technique. We suggest future studies to analyze this Sectra osteotomy tool in other settings as to incorporate it into widespread clinical use.
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http://dx.doi.org/10.1055/s-0040-1710372DOI Listing
May 2020

The Variable Effects of NSAIDs on Osteotomy Healing and Opioid Consumption.

J Am Acad Orthop Surg Glob Res Rev 2020 04 6;4(4). Epub 2020 Apr 6.

Department of Clinical Orthopaedics, Weill Medical College of Cornell University, The Hospital for Special Surgery (Dr. Fragomen and Dr. Rozbruch); Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery (Dr. Fragomen and Dr. Rozbruch); Hospital for Special Surgery (Ms. Suh), New York, NY; Geisinger Commonwealth School of Medicine, Scranton, PA (Ms. Matta); Department of Medicine and Psychiatry, Harvard Medical School, Center for Quantitative Health, Simches Research Building, Massachusetts General Hospital and Harvard Medical School (Dr. McCoy); and Center for Quantitative Health, Simches Research Building, Massachusetts General Hospital and Harvard Medical School (Ms. Hart), Boston, MA.

In an effort to fight the opioid epidemic, an NSAID pain protocol was created for osteotomy patients. The study asked if NSAIDs negatively affect bone healing or reduce the need for opioids.

Methods: This was a retrospective review of 155 limbs that underwent osteotomy of a long bone with fixation. Patients received an NSAID-free protocol or an NSAID protocol. Time to union and bone healing index were recorded.

Results: There was not a significant difference in the time to union ( = 0.89) or bone healing index ( = 0.07). In the deformity correction group, the total milligrams of morphine equivalents prescribed after discharge was significantly less in patients receiving NSAIDs ( < 0.001).

Conclusions: The use of NSAIDs after osteotomy surgery did not negatively affect bone healing and resulted in a dramatic decrease in narcotic consumption for deformity correction patients.

Level Of Evidence: Level III retrospective cohort study.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188274PMC
April 2020

Effect of Microfracture on Functional Outcomes and Subchondral Sclerosis Following Distraction Arthroplasty of the Ankle Joint.

Foot Ankle Int 2020 06 1;41(6):631-638. Epub 2020 May 1.

Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.

Background: Treatment for post-traumatic osteoarthritis (PTOA) of the ankle remains challenging. Distraction arthroplasty (DA) is an alternative for patients who are averse to or poor candidates for arthrodesis or joint replacement. The purpose of this study was to examine the role of microfracture (MFX) and concentrated bone marrow aspirate (CBMA) on the outcome of patients undergoing DA for end-stage PTOA of the ankle joint.

Methods: Ninety-five patients who underwent DA for the treatment of end stage PTOA from 2009 to 2014 were selected from the hospital ankle registry. Demographic data, functional activity levels, complications, and radiographs taken at 6, 12, 24, and 36 months postoperatively were reviewed. Foot and Ankle Outcome Scores (FAOS) were obtained at the same time intervals. A total of 78 patients were included in this study. Interventions were divided into 4 groups for comparison: DA+MFX (n = 8), DA+MFX+CBMA (n = 35), DA+CBMA (n = 22), and DA alone (n = 13).

Results: Patients undergoing DA+MFX or DA+MFX+CBMA had significantly worse motion ( = .003) when compared with DA alone. Patients undergoing MFX had significantly reduced postoperative joint space and a greater length of time to return to activity when compared to subgroups not using MFX ( = .01). The use of MFX was associated with significantly lower FAOS scores.

Conclusion: The current study showed no benefit from MFX when combined with DA in the treatment of PTOA. CBMA may have helped mitigate the adverse effect of MFX but conferred no benefit when used with DA alone. DA remains a useful alternative to ankle arthrodesis and arthroplasty in patients with PTOA. However, MFX and biologic augmentation using CBMA appeared to have no additional benefit.

Level Of Evidence: Level III, comparative study.
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http://dx.doi.org/10.1177/1071100720917144DOI Listing
June 2020

Distraction arthroplasty in osteoarthritis of the foot and ankle.

World J Orthop 2020 Mar 18;11(3):145-157. Epub 2020 Mar 18.

Limb Lengthening and Complex Reconstruction Service, Weill Cornell Medical College Department of Orthopaedic Surgery, Hospital for Special Surgery New York, NY 10021, United States.

Post-traumatic osteoarthritis (PTOA) is a complex and painful problem in the foot and ankle. Ninety percent of osteoarthritis cases in the foot and ankle can be classified as post-traumatic. PTOA can affect any of the 33 joints in the foot and the ankle. Distraction arthroplasty is a method for treatment of early arthritic joints without fusing or replacing them and its effectiveness has been well documented. The purpose of this case series is to present our successful experiences and positive results using distraction arthroplasty to treat PTOA in the ankle, subtalar, first metatarsophalangeal, and second tarsometatarsal joints, and to present distraction arthroplasty as a viable alternative to invasive joint sacrificing procedures such as arthrodesis or arthroplasty. Distraction Arthroplasty effectively and safely treats PTOA and improves the stability of joints in the Foot and Ankle. Additionally, the use of bone marrow aspirate concentrate as an adjuvant can improve the long-term functional and structural outcomes of the joint, and can prolong the need for further, more aggressive surgical interventions such as fusion or arthroplasty.
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http://dx.doi.org/10.5312/wjo.v11.i3.145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138864PMC
March 2020

Subtalar distraction arthroplasty with bone marrow aspirate concentrate (BMAC), preliminary results of a new joint preservation technique.

Foot Ankle Surg 2021 Jan 24;27(1):87-92. Epub 2020 Feb 24.

Hospital for Special Surgery, United States.

Introduction: Isolated subtalar osteoarthritis (OA) is a debilitating condition usually occurring after trauma and particularly in the setting of an intraarticular calcaneal fracture. Currently, subtalar (talo-calcaneal joint) fusion surgery is the treatment of choice in managing subtalar OA after failure of conservative treatment. Unfortunately, subtalar fusion eliminates joint motion and increases the load over the adjacent midfoot and ankle joints, which affects the outcome of the surgery over time. Popular in the ankle, distraction arthroplasty offers another joint-preserving option, particularly important for active patients. In contrast to fusion as a salvage procedure, subtalar distraction arthroplasty allows the possibility of maintaining the function of the arthritic subtalar joint while reducing pain and improving the overall function of the foot and ankle.

Methods: We performed subtalar distraction arthroplasty using a circular external fixator combined with BMAC on seven patients with symptomatic and refractory subtalar OA. All these patients were interested in an alternative to fusion. We obtained clinical and radiographic data before and after surgery. Ankle Osteoarthritis Score (AOS) and the Marijnissen Distraction Clinical Score (MDCS) were obtained before surgery, after one year, and at latest follow-up.

Results: The average age was 56 years (range 45-69). The mean duration of post-operative follow-up was 35.4 months (range 15.2-53.5). The inversion of the ankle joint changed from 16.9° (10°-25°) pre-operatively to 14.3° (10°-20°) post-operatively (P = 0.28), and the eversion from 5.6° (0°-10°) to 10.0° (0°-20°) (P = 0.17). We found an increase in subtalar joint space from 1.4 mm (0-3) to 2.6 mm (2-4) before and after surgery (P = 0.01), respectively. Finally, Pixel Density Ratio (PDR) increased from 0.87 (0.66-1.30) to 1.01 (0.89-1.18) (P = 0.19). Compared to pre-operative conditions, we observed a decrease in subchondral sclerosis on X-ray in all cases post-operatively. The AOS score for ankle pain improved from 58.8 (47-74) to 15.1 (0-31) (p < 0.01). The AOS score for ankle disability improved from 68.2 (57-81) to 16.1 (0-43.5) (p < 0.001). We found improvement in the MDCS over time for all measured parameters. The clinical condition improved from 1.4 (0-2) to 0.8 (0-2) after one year and to 0.3 (0-2) at the latest follow-up (p < 0.001). Mobility was measured as ROM in the treated ankle relative to each patient's contralateral ankle. This increased from 35% (0-100) to 66% (15-120) to 76% (15-100) (p = 0.059). Function improved from 2.3 (0-3) to 1.3 (0-3) to 0.6 (0-3) (p < 0.001). Pain decreased from 7.4 (2-10) to 4.4 (2-8) to 2.1 (0-7) (p < 0.01). Complications include one patient with sensory neuralgia.

Conclusions: Preliminarily, results of subtalar distraction arthroplasty as a new joint preservation technique are encouraging. Our research suggests the possibility of subtalar distraction arthroplasty as an effective treatment for symptomatic subtalar OA. Furthermore, this new operation does not eliminate the possibility of a future surgery like fusion. Subtalar distraction arthroplasty can be helpful in the management of subtalar OA in active patients who desire preservation of foot and ankle motion.
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http://dx.doi.org/10.1016/j.fas.2020.02.009DOI Listing
January 2021

Biomechanical and Functional Improvements Gained by Proximal Tibia Osteotomy Correction of Genu Varum in Patients with Knee Pain.

HSS J 2020 Feb 19;16(1):30-38. Epub 2019 Mar 19.

1Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Mechanical axis malalignment contributes to abnormal forces across the knee joint. Genu varum, or increased medial mechanical axis deviation (MAD), increases force transmission and contact pressures to the medial compartment. With increasing MAD and femoral-tibial mechanical axis angle (MAA), contact forces within the medial or lateral compartment of the knee significantly increase with increasing deformity. This may lead to knee pain, further deformity, and medial compartment degenerative joint disease, which can interfere with participation in sports and diminish quality of life.

Purposes/questions: We sought to evaluate patients with knee pain with bilateral genu varum and determine the effect of bilateral proximal tibial osteotomies on knee biomechanics, deformity correction, and functional outcomes.

Methods: This was a single-center, prospective study of eight limbs in four patients. Consecutive patients presenting with knee pain and bilateral genu varum originating from the proximal tibia were included. All patients underwent staged bilateral proximal tibial osteotomies with gradual deformity correction with an external fixator. Subjects underwent a three-dimensional (3D) instrumented motion analysis during level walking. A 3D lower extremity model was built and bilateral knee frontal plane kinematics and kinetics during the stance phase of gait were determined. Radiographic analysis was performed including assessment of MAD, MAA, and medial proximal tibial angle (MPTA). Functional outcomes were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS), the 36-item Short-Form Survey (SF-36), the Lower Limb Questionnaire (LLQ), and a visual analog scale (VAS) for pain.

Results: The average time in the external fixator for a single limb was 97 days. The average follow-up period was 310 days. All biomechanical outcomes significantly improved, including knee adduction angle (7.8° to 1.8°), knee adduction moments (first peak, - 0.450 to - 0.281 nm/kg, and second peak, - 0.381 to - 0.244 nm/kg), and knee adduction moment impulse (- 0.233 to - 0.150 nm s/kg). There was a significant improvement in MAA, MAD, and MPTA. All patients showed qualitative improvement in mean scores on VAS (11.8 to 0.0), LLQ (77 to 93), KOOS (64 to 84), and SF-36 (71 to 88).

Conclusion: These findings suggest that bilateral proximal tibial osteotomy may be effective in improving knee biomechanics during gait and correcting mechanical alignment in patients with bilateral genu varum. Patients also demonstrated improvement in functional outcome scores. This technique should thus be considered in patients with varus knee osteoarthritis in the setting of genu varum to alleviate symptoms and potentially decrease further clinical deterioration.
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http://dx.doi.org/10.1007/s11420-019-09670-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6973828PMC
February 2020

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction.

J Bone Jt Infect 2019 10;4(6):306-313. Epub 2019 Dec 10.

Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA.

To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle. Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions. Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate. Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success. Prognostic Level IV.
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http://dx.doi.org/10.7150/jbji.40337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960027PMC
December 2019

Evidence-Based Recommendations for Local Antimicrobial Strategies and Dead Space Management in Fracture-Related Infection.

J Orthop Trauma 2020 Jan;34(1):18-29

The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom.

Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903381PMC
January 2020

Carbon-Fiber-Reinforced Polymer Intramedullary Nails Perform Poorly in Long-Bone Surgery.

HSS J 2019 Jul 12;15(2):109-114. Epub 2018 Oct 12.

1Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Carbon-fiber-reinforced (CFR) polymer has produced great excitement in the orthopedic community as a material that will reduce bone healing times and provide improved image quality. Osteotomy stabilized with an intramedullary (IM) nail has become a common technique to address post-traumatic malalignment of the lower extremity.

Purposes/questions: The following questions were asked: (1) Did CFR polymer nails provide a rapid healing time after long bone osteotomy, shortening, or fracture? (2) Did the CFR polymer nails produce unexpected complications?

Methods: A retrospective review was conducted in patients who received CFR polymer IM nails for various indications, from April 2016 to January 2017 in a deformity and trauma practice, using patient charts and radiographs. The primary outcomes were time to union and incidence of complications including nonunion, hardware failure, neurovascular injury, venous thromboembolism, and infection.

Results: Twelve patients who received CFR polymer IM nails in 16 limbs for various indications were included in our analysis. Patients were followed for an average of 16.9 months. Eleven limbs underwent realignment and were corrected an average of 23° through a diaphyseal osteotomy. Three limbs underwent limb-shortening surgery, an average of 25 mm, through an open, excisional osteotomy of the femoral diaphysis. Two diaphyseal, closed tibia fractures underwent routine IM nailing. The average time to union was 107.6 days, which included all limbs that united (11/16, 69%). Nonunion occurred in 5/16 (31%) of limbs. Complications recorded included nonunion and hardware failure, most of which resulted in unplanned surgery.

Conclusions: The use of the CFR polymer IM nail was associated with loss of fixation and nonunion after surgeries that have traditionally healed uneventfully. The increased elasticity of the CFR polymer allows for more motion at the osteotomy/fracture interface than the stiffer titanium counterparts, exposing long-bone osteotomies to delayed union and nonunion, a finding seen with CFR polymer plates. The overwhelmingly poor early results of this device applied to a long-bone deformity practice have led these authors to abandon the use of this implant.
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http://dx.doi.org/10.1007/s11420-018-9634-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609670PMC
July 2019

The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report.

Arch Orthop Trauma Surg 2019 Nov 19;139(11):1551-1560. Epub 2019 Jun 19.

Weill Medical College of Cornell University, New York, USA.

Introduction: The magnetic intramedullary (IM) compression nail is capable of providing sustained compression for the treatment of nonunions of long bones. This ability was previously only possible with the use of external fixation. We asked the following questions: How effective is the IM compression nail at achieving union? How do we know when adequate compression has been attained? Which types of nonunions are good candidates for this treatment?

Materials And Methods: Fourteen patients with nonunions of the tibia (5) or femur (9) were treated with the PRECICE IM compression nail. The average age was 49 years number of previous surgeries was 1.9, 7 were atrophic and 7 normotrophic, 3 were metaphyseal and 11 diaphyseal. All PRECICE IM nails were pre-distracted prior to implantation. Compression was applied post-operatively until the locking bolts were seen on X-ray to be bending or the nail was no longer shortening despite applying the external magnet.

Results: Union was achieved in 13/14 cases. The time to union was 24.5 weeks (range 11-60). The two proximal tibia metaphyseal nonunions, both deformed into varus (4°) and flexion (10°) after compression was applied with one failing to unite. The distal tibia metaphyseal and diaphyseal nonunions did not deform upon compression. Three patients had positive cultures and were treated with IV antibiotics for 6 weeks followed by 3 months of oral suppression without subsequent infection. No mechanical nail failures were seen.

Conclusions: The IM compression nail was successful at applying compression, preventing deformity, and obtaining union in all diaphyseal and in distal tibia metaphyseal nonunions. Signs of active compression are bending of the locking bolts and failure of the nail to shorten. Proximal tibia metaphyseal nonunion may not be suited for this treatment.
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http://dx.doi.org/10.1007/s00402-019-03225-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797666PMC
November 2019

Effects of a Medial Knee Unloading Implant on Tibiofemoral Joint Mechanics During Walking.

J Orthop Res 2019 10 19;37(10):2149-2156. Epub 2019 Jun 19.

Medical Engineering Research Group, Faculty of Science and Engineering, Anglia Ruskin University, Chelmsford, United Kingdom.

The Atlas™ unicompartmental knee system is a second-generation extra-articular unloading implant for patients with mild to moderate medial knee osteoarthritis. The technology acts to reduce a portion of the weight-bearing load exerted on the medial knee during physical activity thereby, reducing the mechanical stress imposed on a degenerative joint. The purpose of the present study was to evaluate the effects of the Atlas™ on tibiofemoral joint mechanics during walking. A computer-aided design assembly of the Atlas™ was virtually implanted on the medial aspect of a previously validated finite element tibiofemoral joint model. Data for knee joint forces and moments from an anthropometrically matched male were applied to the model to quasi-statically simulate the stance phase of gait. Predictions of tibiofemoral joint mechanics were computed pre- and post-virtual implantation of the Atlas™. Compressive force in the medial tibiofemoral compartment was reduced by a mean of 53%, resulting in the decrement of mean cartilage-cartilage and cartilage-meniscus von Mises stress by 31% and 32%, respectively. The Atlas™ was not predicted to transfer net loading to the lateral compartment. The tibiofemoral joint model exhibited less internal-external rotation and anterior-posterior translation post-Atlas™, indicating a change in the kinematic environment of the knee. From a biomechanical perspective, extra-articular joint unloading may serve as a treatment option for patients recalcitrant to conservative care. Evaluation of mechanical changes in the tibiofemoral joint demonstrate the potential treatment mechanism of the Atlas™, in accordance with the available clinical data. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2149-2156, 2019.
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http://dx.doi.org/10.1002/jor.24379DOI Listing
October 2019

Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction.

Strategies Trauma Limb Reconstr 2019 May-Aug;14(2):77-84

Department of Orthopaedic Surgery, Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, New York, USA; Department of Orthopaedic Surgery, Weill Medical College of Cornell University, The Hospital for Special Surgery, New York, USA.

Introduction: Historically, blocking screws have been used to assist in acute reduction of fractures during intramedullary (IM) nailing. The reverse-rule-of-thumbs (RROT) for blocking screws was introduced to facilitate internal lengthening nail use in deformity correction and limb lengthening. Our study investigated the ability of blocking screws, using same principle, to accurately correct long-bone deformity with and without lengthening and to prevent lengthening-induced deformity.

Materials And Methods: This is an institutional review board (IRB)-approved retrospective study on 86 patients who had IM nail-assisted limb reconstruction of femur or tibia with blocking screws. Surgeries were performed for deformity correction, limb lengthening, or deformity correction and limb lengthening. Data on the following variables were collected: number of blocking screws, distance of each blocking screw to osteotomy, distance of osteotomy from joint line, and amount of lengthening. Mechanical axis deviation (MAD) and joint alignment parameters were measured preoperatively and at the final postoperative follow-up. The primary outcome was the ability to obtain desired MAD and joint orientation angles. Accuracies were reported as postoperative measurements relative to goal. Association for the Study and Applications of the Methods of Ilizarov (ASAMI) scores were collected.

Results: The accuracy of deformity correction was within 6 mm from goal, while joint orientation was corrected to within 1.5° of goal. Number of blocking screws did not significantly impact accuracy. Distance of blocking screw to osteotomy and amount of lengthening did not affect accuracy. In femurs, osteotomies greater than 10 cm from the joint line were more accurate in MAD goal ( = 0.017). This result was not replicated in tibias. ASAMI scores were excellent or good.

Conclusion: Using RROT configuration, blocking screws were effective in correcting deformities of lower extremity long bones and in preventing deformity during limb lengthening. If positioned correctly, number of screws and their distance to osteotomy did not affect accuracy. Amount of lengthening did not impact accuracy. Distal femoral osteotomy less than 10 cm from knee joint may be challenging even with using blocking screws.

How To Cite This Article: Dabash S, Zhang DT, Rozbruch SR, Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction. Strategies Trauma Limb Reconstr 2019;14(2):77-84.
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http://dx.doi.org/10.5005/jp-journals-10080-1430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376586PMC
August 2020

Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis.

Strategies Trauma Limb Reconstr 2019 May-Aug;14(2):65-71

Department of Orthopaedic Surgery, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, USA.

Aim: The treatment algorithm for end-stage ankle arthritis is imperfect. Young or active patients are challenging to treat as fusion and replacement carry predictable consequences. Ankle distraction arthroplasty is a less commonly utilized surgical procedure for the treatment of osteoarthritis of the ankle. The purpose of this study was to report intermediate-term survival of ankle distraction and to identify factors associated with earlier time to failure.

Materials And Methods: A single-centre, multi-surgeon cohort of 258 cases of ankle arthritis, treated with ankle distraction or ankle distraction with supramalleolar osteotomy (SMO), was identified. Patients were contacted by phone to determine the status of the ankle (natural vs fused/replaced). Data were collected through chart review. This included patient demographics, medical comorbidities, surgical procedure, and X-ray characteristics including pattern and severity. A Cox regression model was used to determine factors associated with failure during 10 years of follow-up. Risk factors were analysed as hazard ratios (HRs) and 95% confidence intervals (CIs). Time to failure was illustrated with Kaplan-Meier (KM) curves.

Results: In total, 144 cases were successfully contacted with median follow-up of 4.57 years. In total, 16.7% of ankles failed (24/144). The 5-year survival was 84% (95% CI: 78-91%). In adjusted Cox regression, female sex (HR = 2.68, = 0.049) and avascular necrosis (AVN) of the talus (HR = 3.77, = 0.041) were significantly associated with failure risk.

Conclusion: Avascular necrosis of the talus and male/female gender differences in survival were found to be significant. Our experience shows that ankle distraction is a valid and effective operation for the treatment of end-stage ankle arthritis.

Clinical Significance: This work is clinically significant in that it demonstrates excellent intermediate-term survival data for hinged ankle distraction for treatment of osteoarthritis of the ankle. Additionally, it evaluated patient and disease characteristics allowing improved patient counselling with regard to survival longevity.

Level Of Evidence: IV cohort study.

How To Cite This Article: Greenfield S, Matta KM, McCoy TH, Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis. Strategies Trauma Limb Reconstr 2019;14(2):65-71.
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http://dx.doi.org/10.5005/jp-journals-10080-1429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376580PMC
August 2020

Knee Arthrodesis After Failed Total Knee Arthroplasty.

J Bone Joint Surg Am 2019 Apr;101(7):650-660

Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY.

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http://dx.doi.org/10.2106/JBJS.18.00191DOI Listing
April 2019

Tranexamic Acid Reduces Postoperative Blood Loss in Distal Femoral Osteotomy.

J Knee Surg 2020 May 12;33(5):440-444. Epub 2019 Feb 12.

Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.

Blood loss remains a significant source of morbidity and mortality in orthopaedic surgery, with transfusions associated with an increased risk of infection, length of stay, delayed rehabilitation, and significantly increased hospitalization costs. The purpose of this study was to assess whether the use of tranexamic acid (TXA) is effective in reducing postoperative blood loss in patients undergoing distal femoral osteotomy (DFO). A retrospective review was performed of all patients undergoing DFO by a single surgeon from 2010 to 2017, with a change in protocol occurring in 2014, after which all patients received TXA. Patients in the TXA group ( = 24) received 1-g TXA immediately prior to incision followed by a second dose of 1-g TXA 4 hours after the administration of the first dose. Patients in the control group ( = 28) did not receive TXA. Drainage was recorded through a subfascial drain that remained for 24 hours postoperatively. Postoperative hemoglobin, hematocrit, and transfusions, as well as demographic factors, including age, gender, body mass index (BMI), medical comorbidities, and ASA (American Society of Anesthesiologists) class, were recorded. Multivariate regression analysis adjusting for potential confounding variables was performed. With the exception of gender, the two groups did not differ significantly in baseline characteristics, including age, BMI, and ASA class. There was a significant difference in postoperative blood loss, with those receiving TXA having a mean drain output of 184.2 versus 242.1 mL for the control group ( = 0.02), which persisted after regression analysis ( < 0.005). Blood loss differed between patients who received one (250 mL) dose and those who received two (162.2 mL) doses of TXA, although this difference was insignificant ( = 0.489). There were no differences in postoperative hemoglobin and hematocrit levels. One patient (control group) required blood transfusion postoperatively. There were no complications related to TXA. In conclusion, TXA results in less postoperative blood loss in DFO, with the most pronounced effect in those who receive two doses. Future research should involve a larger, prospective study to assess for differences in postoperative hemoglobin/hematocrit levels and transfusion rates.
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http://dx.doi.org/10.1055/s-0039-1678540DOI Listing
May 2020

Standardization of torsional CT measurements of the lower limbs with threshold values for corrective osteotomy.

Arch Orthop Trauma Surg 2019 Jun 8;139(6):795-805. Epub 2019 Feb 8.

Department of Trauma Surgery, University Hospitals Leuven, 3000, Leuven, Belgium.

Introduction: Re-establishing anatomic rotational alignment of shaft fractures of the lower extremities remains challenging. Clinical evaluation in combination with radiological measurements is important in pre- and post-surgical assessment. Based on computed tomography (CT), a range of reference values for femoral torsion (FT) and tibial torsion (TT) have historically been reported, which require standardization to optimize the significant intra- and inter-observer variability. The aims of this study were (re-)evaluation of the reference FT and TT angles, determination of the normal intra-individual side-to-side torsional differences to aid the surgical decision-making process for reoperation, and development of a novel 3D measurement method for FT.

Materials And Methods: In this retrospective study, we included 55 patients, without any known torsional deformities of the lower extremities. Two radiologists, independently, measured the rotational profile of the femora using the Hernandez and Weiner CT methods for FT, and the tibiae using the bimalleolar method for TT. The intra-individual side-to-side difference in paired femora and paired tibiae was determined. A 3D technique for FT assessment using InSpace was designed.

Results: FT and TT demographic values were lower than previously reported, with mean FT values of 5.1°-8.8° and mean TT values of 25.5°-27.7°. Maximal side-to-side differences were 12°-13° for FT and 12° for TT. The Weiner method for FT was less variable than the Hernandez method. The new 3D method was equivocal to the conventional CT measurements.

Conclusion: The results from this study showed that the maximal side-to-side tolerance in asymptomatic normal adult lower extremities is 12°-13° for FT and 12° for TT, which could be a useful threshold for surgeons as indication for revision surgery (e.g., derotational osteotomy). We developed a new 3D CT method for FT measurement which is similar to 2D and could be used in the future for virtual 3D planning.
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http://dx.doi.org/10.1007/s00402-019-03139-1DOI Listing
June 2019

Genomewide Association Study of Fracture Nonunion Using Electronic Health Records.

JBMR Plus 2019 Jan 20;3(1):23-28. Epub 2018 Jun 20.

Center for Quantitative Health Massachusetts General Hospital and Harvard Medical School Boston MA USA.

Nonunion is a clinically significant complication of fracture associated with worse outcomes, including increased pain, disability, and higher healthcare costs. The risk for nonunion is likely to be complex and multifactorial, and as such, the biology underlying such risk remains poorly understood. Genetic studies represent one approach to identify implicated biology for further investigation, but to date the lack of large cohorts for study has limited such efforts. We utilized the electronic health records of two large academic medical centers in Boston to identify individuals with fracture nonunion and control individuals with fracture but no evidence of nonunion. We conducted a genomewide association study among 1760 individuals of Northern European ancestry with upper or lower extremity fracture, including 131 with nonunion, to examine whether common variants were associated with nonunion in this cohort. In all, one locus in the Calcyon (CALY) gene exceeded a genomewide threshold for statistical significance ( = 1.95e-8), with eight additional loci associated with < 5e-7. Previously reported candidate genes were not supported by this analysis. Electronic health records should facilitate identification of common genetic variations associated with adverse orthopedic outcomes. The loci we identified in this small cohort require replication and further study to characterize mechanism of action, but represent a starting point for the investigation of genetic liability for this costly outcome.
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http://dx.doi.org/10.1002/jbm4.10063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6339539PMC
January 2019