Systematic Review of Patient Outcomes and Associated Predictors After Microfracture in the Patellofemoral Joint Background: We summarized the clinical outcomes and predictors of clinical outcomes after microfracture for chondral lesions in the patellofemoral joint (PFJ). Methods: Embase, PubMed, CENTRAL, BIOSIS, and CINAHL databases were searched between January 1, 1980, and January 1, 2019, to identify all articles that examined outcomes or predictors of outcomes of microfracture in patients with patellofemoral chondral lesions. Studies of full-thickness chondral lesions in the PFJ were included, whereas those involving adolescents, partial-thickness chondral lesions, and underlying patellar instability were excluded. Results: We found a total of 257 articles, of which 8 articles (174 patients) met our inclusion criteria. All studies found improvement in clinical outcomes after microfracture in the PFJ. Younger patients showed greater improvement in clinical outcomes than older patients. However, the effect of size, severity (grade), or location of chondral lesions on clinical outcomes after microfracture is unclear. Conclusion: We found improvement in clinical outcomes after microfracture in the PFJ at midterm follow-up. Age may be a predictor of successful outcomes and longevity of the repair; however, there is insufficient evidence regarding the influence of defect size, severity, and location on clinical outcomes.

Timing of Lumbar Spinal Fusion Affects Total Hip Arthroplasty Outcomes Background: Many patients are affected by concurrent disease of the hip and spine, undergoing both total hip arthroplasty (THA) and lumbar spinal fusion (LSF). Recent literature demonstrates increased prosthetic dislocation rates in patients with THA done after LSF. Evidence is lacking on which surgery to do first to minimize complications. The purpose of this study was to evaluate the effect of timing between the two procedures on postoperative outcomes. Methods: We queried the Medicare standard analytics files between 2005 and 2014. Four groups were identified and matched by age and sex: THA with previous LSF, LSF with previous THA, THA with spine pathology without fusion, and THA without spine pathology. Revision THA or LSF and bilateral THA were excluded. Comorbidities and Charlson Comorbidity Index were identified. Postoperative complications at 90 days and 2 years were calculated after the most recent surgery. Four-way chi-squared and standard descriptive statistics were calculated. Results: Thirteen thousand one hundred two patients had THA after LSF, 10,482 patients had LSF after THA, 104,820 had THA with spine pathology, and 492,654 had THA without spine pathology. There was no difference in the Charlson Comorbidity Index score between the THA after LSF and LSF after THA groups. There was a statistically significant difference in THA dislocation rate, with LSF after THA at 1.7%, THA without spine pathology at 2.3%, THA with spine pathology at 3.3%, and THA after LSF at 4.6%. There was a statistically significant difference in THA revision rate, with THA without spine pathology at 3.3%, LSF after THA at 3.7%, THA with spine pathology at 4.2%, and THA after LSF at 5.7%. Conclusion: LSF after THA is associated with a reduced dislocation rate compared with THA after LSF. Reasons may include decreasing pelvic mobility in a stable, well-healed THA or early postoperative spine precautions after LSF restricting positions of dislocation.

Achieving Validated Thresholds for Clinically Meaningful Change on the Knee Injury and Osteoarthritis Outcome Score After Total Knee Arthroplasty: Findings From a University-based Orthopaedic Tertiary Care Safety Net Practice Introduction: A lack of knowledge exists about which patient characteristics predict failure to meet validated thresholds for clinically meaningful change on the Knee Injury and Osteoarthritis Outcome Score (KOOS) after total knee arthroplasty (TKA). Methods: A retrospective chart review was performed on patients who underwent primary TKA by a single surgeon between January 2013 and June 2018. Variables included demographics (age, sex, race, and insurance type), comorbidities, body mass index, and preoperative KOOS subscale scores. Multivariate logistic regression was performed to identify characteristics associated with failing to meet or exceed the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) on each KOOS subscale 6 months after TKA. Results: A total of 159 patients were included. At 6 months after TKA, approximately one-third of patients (21% to 32%) failed to meet or exceed the MCID and 27% to 39% failed to meet or exceed the SCB on all KOOS subscales. Better preoperative KOOS Symptoms, quality of life, and activities of daily living subscale scores were statistically significantly associated with failing to meet the MCID and SCB on each respective subscale. Demographics, comorbidities, and body mass index were not notable predictors of either outcome for any of the KOOS subscales. Discussion: About one-third of TKA patients in this single-site, single-surgeon sample failed to achieve a clinically meaningful outcome, and up to 4 in 10 patients had a less-than-ideal outcome 6 months after surgery. Surgeons should take care to set realistic expectations for patients with the least severe knee problems before TKA because this subgroup is especially at a high risk of failing to achieve a satisfactory outcome.

Narcotic-Free, Over-the-Counter Pain Management After Wide-Awake Hand Surgery Introduction: Prescribing opioids for postoperative pain has increased steadily, and hand surgery has been no exception. Current hand surgery literature does not describe the efficacy of pain self-management postoperatively. The purpose of this study is to describe our experience with over-the-counter (OTC), narcotic-free, postoperative pain management. Methods: We have done a retrospective chart review at an academic tertiary-care facility. Patients who underwent soft-tissue hand surgery in an office-based procedure room between January 1, 2018, and March 1, 2019, done using wide-awake local anesthesia only with no tourniquet were included. Results: Eighty-one continuous patients met the inclusion and exclusion criteria. The procedures included carpal tunnel release, cubital tunnel release, trigger finger release, first dorsal compartment release, dorsal wrist ganglion cyst excision, hand or finger mass excision, percutaneous needle fasciotomy, flexor tendon repair, and extensor tendon repair. Two patients (2.4%) received a prescription for pain medication within 1 day and 4 within 1 week after discharge (total 5.6%). Nine patients were already on chronic narcotics, and four were on short-term narcotics before the surgery date. No other patients requested or received opioid prescriptions after surgery, and no complaints were reported. Discussion: This study indicates that patients can successfully self-manage their postoperative pain with OTC analgesics. They rarely request prescriptions for pain control after soft-tissue hand surgery. Our findings support current literature suggesting that narcotic prescriptions can be eliminated in select hand and upper extremity procedures and suggest that OTC postoperative pain management is sufficient.

A Retrospective Study Comparing a Patient-specific Design Total Knee Arthroplasty With an Off-the-Shelf Design: Unexpected Catastrophic Failure Seen in the Early Patient-specific Design Background: Patient-specific design (PSD) total knee arthroplasty implants are marketed to restore neutral mechanical-axis alignment (MAA) and provide better anatomic fit compared with standard off-the-shelf (OTS) total knee arthroplasty designs. The purpose was to compare the Knee Society scores, radiographic outcomes, and complications of PSD and OTS implants. Methods: Retrospective study analyzing PSD and OTS by a single surgeon. Implant design change in PSD occurred during the period of data collection leading to PSD-1 and PSD-2 subgroups. Radiographic data including MAA, femorotibial angle, coronal-tibial angle, tibial slope and patella-sulcus angle, and complications were analyzed. Minimum follow-up was 2 years or until revision, and patients completed Knee Society scores preoperatively and postoperatively at 3, 6, 12, 24 weeks, and final follow-up. Results: There were 136 patients (154 knees), average age (62.76 +/− 8.4 years), and follow-up (3.1 +/− 1.5 years). The groups included PSD-1 (77 knees), PSD-2 (36 knees), and OTS (41 knees). The PSD-2 group had better Knee Society function scores compared with PSD-1 and OTS at all timepoints except final follow-up. PSD-2 had significantly shorter hospital stay (P = 0.000012) and less hemoglobin drop (P = 0.032) compared with PSD-1 and OTS. No differences were observed in MAA (P = 0.349) or final range of motion (P = 0.629) between the 3 groups. PSD-2 had more normal femorotibial angle, coronal-tibial angle, and tibial slope compared with PSD-1 and OTS. Failures requiring revision were 23% (18/77) PSD-1, 0% PSD-2, and 3% (1/35) OTS. Most common modes of failure were tibial subsidence (56%) and polyethylene locking mechanism failure (22%) in PSD-1. Conclusion: Catastrophic failure was seen in the PSD-1 group with tibial subsidence and polyethylene locking mechanism failure. PSD-2 had better early Knee Society function scores, shorter hospital stay, lower hemoglobin drop, radiographic alignment, and no failures compared with PSD-1 and OTS.

Lumbar Spine Fusion Rates With Local Bone in Posterolateral and Combined Posterolateral and Interbody Approaches Purpose: Posterolateral lumbar fusion (PLF) used to treat degenerative lumbar conditions still faces pseudarthrosis. Bone graft choice is a key factor; a traditional choice has been autologous iliac crest bone graft (ICBG), but complication rates are quoted up to 39%. Local bone from laminectomy eliminates ICBG harvesting complications. Methods: Two hundred forty-one patients underwent either PLF or PLF with interbody at a single lumbar level with a prospective, multicenter, randomized controlled trial only using local bone graft. Fusion was assessed with radiographs and CT. Results: PLF fused bilaterally in 18% and unilaterally in 28.8% at 6 months and 35.7% and 50.3% at 12 months, respectively. At 6-month PLF + interbody, 1.1% fused bilaterally and 11.7% unilaterally; at 12 months, 5.4% fused all three areas, and 50.8% fused at least one area. Discussion: Local bone fused substantially less than the “benchmark” ICBG.

Clinical Features of Thoracic Myelopathy: A Single-Center Study Introduction: Thoracic myelopathy is relatively uncommon because few degenerative changes occur as a result of the restricted range of motion surrounding the rib cage. Methods: A retrospective study was performed in 300 consecutive surgical cases of thoracic disorders with myelopathy treated in our department from 2000 to 2015. Girdle pain, back pain, low back pain, leg numbness, leg pain, gait disturbance, leg paresis, and bowel bladder disturbance as initial and preoperative symptoms; patellar tendon reflex, ankle tendon reflex, and ankle clonus as preoperative neurologic findings; MRI and CT findings; and surgical procedure, intraoperative findings, and postoperative recovery were investigated. Results: The disease distribution included ossification of the ligamentum flavum (OLF) (n = 48), ossification of the posterior longitudinal ligament (OPLL) (n = 30), OPLL with OLF (n = 27), intradural extramedullary tumor (n = 98), intramedullary spinal cord tumor (n = 64), vertebral tumor (n = 17), spinal cord herniation (n = 7), vertebral fracture (n = 4), and thoracic disk herniation (n = 5). There were notable associations of gait disturbance with OPLL and OPLL + OLF; back pain at initial diagnosis with disease at upper levels; and low back pain with disease at a lower level. Conclusion: These findings suggest that patients with gait disturbance, back pain, and low back pain on physical examination may have thoracic disease that results in myelopathy.

Multiple Cultures and Extended Incubation for Upper Extremity Revision Arthroplasty Affect Clinical Care: A Cohort Study Introduction: Skin flora organisms (SFOs) isolated from 1 to 2 tissue samples during shoulder and elbow revision arthroplasty are difficult to distinguish as contamination or infection. We examined the change in clinical care after implementation of an Arthroplasty Infection Protocol by increasing the number of intraoperative samples held for 10-day incubation to a minimum of 5. Methods: Infection was defined as ≥3 cultures growing the same SFO or any one culture growing any other virulent organism. SFOs growing in 1 to 2 samples were defined as skin flora contaminant. All cases were compared with pre–Arthroplasty Infection Protocol institution standard to determine changes in microbiological diagnosis and resultant antibiotic treatment. Results: Forty cases fulfilled the inclusion criteria: 50% of these were culture negative, and 35% grew Propionibacteria. When compared with the standard of obtaining one sample, this protocol altered the microbiological diagnosis and subsequent antibiotic treatment in 45% of cases (95% confidence interval 29% to 62%). This protocol had a predictive value of joint sterility in 95% of culture-negative cases (95% confidence interval 74% to 99%). Discussion: The addition of 5 or more samples held for 10-day incubation reliably differentiated between joint infection, contamination, and sterility, which changed the course of care in 45% of surgical cases.

A Novel Approach to Lower-limb Axial Alignment Analysis: A CT Study Purpose: To analyze the torsion of the lower extremities in a healthy cohort and to determine the contribution of different segments of the femur and tibia to the torsion of both bones. Methods: In this cross-sectional study, 32 patients with nonjoint or bone-related symptoms were analyzed by CT angiography. Lower-limb torsion, femoral torsion, proximal femoral torsion, femoral shaft torsion, distal femoral torsion, tibial torsion, proximal tibial torsion, and distal tibial torsion were measured. Results: The median total limb torsion was 25° external torsion, with the median femoral torsion being −9° and the median tibial torsion 30°. Both femoral metaphyses had internal torsion, with the internal torsion of the proximal metaphysis being approximately three times greater than that of the distal femoral metaphysis. The shaft was found to compensate with an external torsion of approximately two-thirds of the internal torsion of both femoral metaphyses. The proximal metaphysis of the tibia accounted for approximately one-third of the external torsion, with the segment from the distal to the tibial tubercle accounting for the remaining two-thirds of the tibial torsion. Conclusions: The diaphysis and distal metaphysis are the major contributors to external torsion of the tibia, whereas the proximal metaphysis is the major contributor to the internal torsion of the femur.

Relationship Between Pain Alleviation and Disease-specific Health-related Quality of Life Measures in Patients With Chronic Low Back Pain Receiving Duloxetine: Exploratory Post Hoc Analysis of a Japanese Phase 3 Randomized Study Background: This post hoc analysis of a Japanese phase 3 randomized study (ClinicalTrials.gov identifier: NCT01855919) investigated relationships between pain severity (assessed by the Brief Pain Inventory [BPI]) and disease-specific health-related quality of life (assessed by the 24-item Roland-Morris Disability Questionnaire [RDQ-24]) in duloxetine-treated patients with chronic low back pain (CLBP). Methods: Patients with CLBP duration >6 months and BPI average score ≥4 received duloxetine 60 mg/d (N = 230) or placebo (N = 226) for 14 weeks. Spearman rank correlation coefficients were calculated for (1) BPI change from baseline and RDQ item change from baseline and (2) BPI change from baseline and the RDQ item baseline score in duloxetine-treated patients. Results: Duloxetine treatment significantly improved the RDQ-24 total score compared with placebo; the greatest improvements were observed for RDQ02, RDQ17, and RDQ13. The strongest correlations between BPI change from baseline and RDQ item change from baseline were for RDQ13, RDQ23, and RDQ10. The correlation coefficients for the correlations between BPI change from baseline and the RDQ item baseline score were generally small. Discussion: This post hoc analysis suggested that improvement in pain severity was associated with improvement in the RDQ-24 total score and in some individual RDQ items in duloxetine-treated patients with CLBP. Furthermore, positive responses to duloxetine in terms of the RDQ13, RDQ23, and RDQ10 items may correlate with better pain responses. Clinical Trial Registry: The study described in this manuscript was registered at www.clinicaltrials.gov (NCT01855919).