bluuebunny/crossref_metadata_2025_split huggingface dataset:
Modeled Wide-Awake, Local-Anesthetic, No-Tourniquet Surgical Procedures Do Not Impair Driving Fitness
Authors: Thompson Orfield Noah J. , Badger Ariel E. , Tegge Allison N. , Davoodi Maryam , Perez Miguel A. , Apel Peter J. 
Published: August 2020

Background:
The use of wide-awake, local-anesthetic, no-tourniquet (WALANT) surgical techniques is increasingly common, and patients commonly ask whether they may drive home following these procedures. The impact of a numb hand and bulky dressing on driving fitness is unknown, and there is no literature to guide surgeons when counseling these patients. Thus, the primary objective of the present study was to determine driving fitness following a modeled-WALANT procedure.

Methods:
Twelve right-handed individuals (6 male and 6 female) with an average age of 50 years (range, 38 to 64 years) were enrolled. An instrumented vehicle was used to obtain driving kinematic and behavioral data, thus allowing for a multidimensional assessment of driving fitness. Participants first performed a drive to establish baseline kinematic metrics. The route included both public streets and a closed course. Several driving tasks were assessed, including reverse parking, parallel parking, and perpendicular parking. The total course length was 18 miles (29 kilometers) and took 45 to 55 minutes to complete. After the first drive, 10 mL of 1% lidocaine was injected in the volar aspect of the right wrist and another 10 mL was injected into the right carpal tunnel to model the anesthetic used for a WALANT carpal tunnel release, and a bulky soft dressing was applied. The modeled-WALANT drive included an identical route and tasks, in addition to a surprise event to evaluate emergency responsiveness. Driving metrics were analyzed for noninferiority of the modeled-WALANT state to baseline driving.

Results:
The modeled-WALANT state showed noninferiority to baseline driving on all 11 analyzed dimensions of driving behavior compared with the control drives. In the modeled-WALANT state, participants drove more conservatively, braked harder, and steered more smoothly. All participants safely performed the 3 parking tasks and emergency response maneuver. Driving fitness in the modeled-WALANT state was noninferior to driving fitness in the preoperative drive.

Conclusions:
A modeled-WALANT state has no clinically relevant negative impact on driving fitness, and thus surgeons should not discourage patients from driving home after unilateral WALANT surgical hand procedures.

Level of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
The Impact of Early Epidural Discontinuation on Pain, Opioid Usage, and Length of Stay After Periacetabular Osteotomy
Authors: Cunningham Daniel J. , Kovacs Daniel , Norcross William , Olson Steven , Lewis Brian 
Published: August 2020

Background:
Periacetabular osteotomy (PAO) is the standard of care for treatment of symptomatic acetabular dysplasia. Patients undergoing PAO for acetabular dysplasia have postoperative pain that can be managed with epidural analgesia. The purpose of this study was to evaluate the impact of the timing of the discontinuation of epidural analgesia on pain, opioid usage, and hospital length of stay (LOS). The study hypothesis was that removal of the epidural catheter on postoperative day 1 (POD1) would lead to reduced overall opioid usage and LOS compared with removal on POD2.

Methods:
This is a retrospective before-and-after observational review of the impact of discontinuing epidural analgesia on POD1 versus POD2 in terms of in-hospital pain, opioid usage, and LOS. Baseline patient factors such as age, sex, and body mass index (BMI) as well as outcomes including mean and median of daily pain, total oral morphine milligram equivalents (MMEs) used per day, and LOS were recorded. Descriptive and comparative statistical analyses including multivariable main-effects linear regression modeling were performed to evaluate the impact of the timing of epidural removal on outcomes.

Results:
Directly comparing outcomes for the day of epidural removal, patients with removal on POD1 had significantly less pain (mean of 4.6 versus 5.1 on the numeric rating scale [NRS], p = 0.033) and opioid usage (130.7 versus 200.4 MMEs, p < 0.001) than patients with removal on POD2. Additionally, LOS (3.3 versus 4.6 days, p < 0.001) and total opioid usage (333.0 versus 674.8 MMEs, p < 0.001) were significantly reduced in patients with epidural removal on POD1. These results persisted in multivariable analyses that were adjusted for age, sex, and BMI.

Conclusions:
This study demonstrated that patients with epidural removal on POD1 have significantly lower pain and an overall decrease in opioid usage on the date of epidural removal compared with patients undergoing epidural removal on POD2. Additionally, they have a shorter LOS as well as lower total opioid usage. Decreasing the duration of epidural usage may reduce pain, opioid usage, and LOS in patients undergoing PAO.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Selecting the “Touched Vertebra” as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves
Authors: Beauchamp Eduardo C. , Lenke Lawrence G. , Cerpa Meghan , Newton Peter O. , Kelly Michael P. , Blanke Kathy M. ,   Harms Study Group Investigators*
Published: August 2020

Background:
The selection of the lowest instrumented vertebra (LIV) in patients with adolescent idiopathic scoliosis (AIS) is still controversial. Although multiple radiographic methods have been proposed, there is no universally accepted guideline for appropriate selection of the LIV. We developed a simple and reproducible method for selection of the LIV in patients with Lenke type-1 (main thoracic) and 2 (double thoracic) curves and investigated its effectiveness in producing optimal positioning of the LIV at 5 years of follow-up.

Methods:
The radiographs for 299 patients with Lenke type-1 or 2 AIS curves that were included in a multicenter database were evaluated after a minimum duration of follow-up of 5 years. The “touched vertebra” (TV) was selected on preoperative radiographs by 2 independent examiners. The LIV on postoperative radiographs was compared with the preoperative TV. The final LIV position in relation to the center sacral vertical line (CSVL) was assessed. The CSVL-LIV distance and coronal balance in patients who had fusion to the TV were compared with those in patients who had fusion cephalad and caudad to the TV. The sagittal plane was also reviewed.

Results:
In 86.6% of patients, the LIV was selected at or immediately adjacent to the TV. Among patients with an “A” lumbar modifier, those who had fusion cephalad to the TV had a significantly greater CSVL-LIV distance than those who had fusion to the TV (p = 0.006) or caudad to the TV (p = 0.002). In the groups with “B” (p = 0.424) and “C” (p = 0.326) lumbar modifiers, there were no differences among the TV groups.

Conclusions:
We recommend the TV rule as a third modifier in the Lenke AIS classification system. Selecting the TV as the LIV in patients with Lenke type-1 and 2 curves provides acceptable positioning of the LIV at long-term follow-up. The position of the LIV was not different when fusion was performed caudad to the TV but came at the expense of fewer motion segments. Patients with lumbar modifier “A” who had fusion cephalad to the TV had greater translation of the LIV, putting these patients at risk for poor long-term outcomes.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Factors Affecting Subjective Symptoms in Children with Pes Planovalgus Deformity
Authors: Min Jae Jung , Kwon Soon-Sun , Sung Ki Hyuk , Lee Kyoung Min , Chung Chin Youb , Park Moon Seok 
Published: August 2020

Background:
Idiopathic pes planovalgus is one of the most common foot deformities in children and adolescents. However, there is a discrepancy between subjective symptoms and radiographic severity in idiopathic planovalgus deformity, and very few studies have investigated this aspect. Further, the assessment of subjective symptoms in patients with pes planovalgus requires a quantitative scoring system for making meaningful comparisons, such as the Oxford Ankle Foot Questionnaire for Children (OxAFQ-c) and that for parents (OxAFQ-p). Therefore, the purpose of this study was to evaluate the factors affecting the symptoms of idiopathic planovalgus using the OxAFQ.

Methods:
All patients who were ≤18 years of age, had visited our clinic for the evaluation of pes planovalgus deformity, and had completed the OxAFQ were included in this study. The anteroposterior talo-first metatarsal, lateral talo-first metatarsal, and hallux valgus angles were measured on weight-bearing radiographs. The data were analyzed using a multiple regression model, with age, sex, and radiographic indices as explanatory variables.

Results:
Overall, 123 patients were enrolled in this study, and 246 standing foot radiographs were evaluated along with scores in each domain of the OxAFQ. The factors affecting physical domain scores in the OxAFQ-c were female sex (p = 0.047) and the anteroposterior talo-first metatarsal angle (p = 0.033). Age of ≥10 years was a significant factor (p < 0.05) affecting all domains in both the OxAFQ-c and OxAFQ-p other than the physical domain score.

Conclusions:
Although pes planovalgus deformity is 3-dimensional, the forefoot abduction component of the deformity should be carefully assessed as it is closely related to subjective symptoms. Further, in female patients with a more severe anteroposterior talo-first metatarsal angle, an aggravation of symptoms with aging should be expected when managing pes planovalgus deformity.

Level of Evidence:
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
A Small Amount of Retraction Force Results in Inadvertent Piriformis Muscle Damage During a Piriformis-Sparing Approach to the Hip
Authors: Amanatullah Derek F. , Shah Harsh N. , Barrett Andrew A. , Storaci Hunter W. 
Published: August 2020

Background:
Piriformis-sparing approaches to the hip allow surgeons to avoid releasing the piriformis tendon during total hip arthroplasty; however, the consequences of retracting an intact piriformis tendon during such an approach remain ill-defined. The present study aimed to determine the upper limit of force that can be applied during retraction of the piriformis tendon to expose the hip, and to quantify the resultant damage to the piriformis musculotendinous complex.

Methods:
A patent-pending instrumented retractor was designed to record the applied force, duration, and angle of retraction during a piriformis-sparing posterior approach to the hip. In addition to the data collected with use of the instrumented retractor, damage to the piriformis muscle and tendon was quantified by a blinded observer.

Results:
There was no damage to the piriformis tendon in 22 (96%) of 23 hips during piriformis retraction for visualization of the hip capsule; however, there was complete or partial damage to the piriformis muscle at the sacral origin, belly, or musculotendinous junction (i.e., outside the surgical field) noted in 21 (91%) of 23 hips. The mean peak force to failure of the piriformis muscle was exceedingly small (29.0 ± 9.4 N; range, 10.1 to 44.9 N).

Conclusions:
The mean peak force applied to the piriformis retractor is much less than the force required for several common daily activities, such as opening a door or crushing an empty aluminum can. Soft-tissue damage that occurs outside the surgical field during the retraction of unreleased muscles, like the piriformis muscle, is common and remains an uncontrolled surgical variable. This inadvertent soft-tissue damage is not routinely accounted for when accessing the invasiveness of a procedure. Hence, it is no longer adequate to define a minimally invasive surgical procedure simply as an approach that involves the limited release of anatomical structures.

Clinical Relevance:
The use of instrumented retractors may redefine surgical invasiveness by providing data that could alter our understanding of the soft-tissue damage caused by retraction and open the possibility of robot-assisted or damage-limiting retractor systems.
The Impact of Heterotopic Ossification on Self-Reported Outcomes After Total Hip Arthroplasty Using the Direct Anterior Approach
Authors: Rüdiger Hannes A. , Dittrich Michael , Robinson Jonathan , Mansour Toni , Schwab Tobias , Stadelmann Vincent A. , Leunig Michael 
Published: August 2020

Background:
Heterotopic ossification (HO) is a known finding after total hip arthroplasty (THA) that potentially affects clinical outcomes. The incidence of HO is related to various factors, including soft-tissue trauma, postoperative medication, surgical approach, and the surgeon’s experience. Because use of the direct anterior approach (DAA) is gaining popularity, we aimed (1) to determine the incidence of HO after DAA-THA and (2) to evaluate the impact of HO on patient-reported outcomes (PROs).

Methods:
We retrospectively reviewed 401 THAs (67 ± 10 years old, 210 men). The incidence and grade of HO were evaluated using the Brooker classification with anteroposterior and lateral radiographs. PROs were collected with use of the Oxford Hip Score (OHS) and the Core Outcome Measures Index (COMI)-Hip and were correlated with HO grades using generalized multiple regression models.

Results:
The incidence of HO was 29.9% on the anteroposterior radiographic views (Brooker grade 1, 14.5%; grade 2, 11.1%; grade 3, 2.7%; and grade 4, 0.57%); the lateral radiographic views detected 9% additional HO when compared with the anteroposterior radiographs alone (Brooker grade 1, 8%, and grade 2, 1%). HO was more frequent in men. The American Society of Anesthesiologists (ASA) grade, age in women, and higher body mass index (BMI) in men were associated with higher HO grades. A transverse “bikini” incision was associated with a lower rate (4%) of Brooker grades 3 and 4 HO when compared with a longitudinal incision (12%). A Brooker grade of 0 to 3 HO did not impact outcomes. Only Brooker grade-4 HO was associated with significantly worse PROs; however, pain was not affected.

Conclusions:
Low-grade HO after DAA-THA is not uncommon, and its rate is underestimated when anteroposterior radiographic views are evaluated without lateral views. The risk factors for developing HO in our cohort were an ASA grade of >3, male sex (especially with a high BMI), older age in women, and use of longitudinal incisions. With use of the bikini incision, patients had lower rates of severe HO, but mostly senior surgeons with more experience performed their surgery. Age, ASA grade, experience level of the surgeon, and Brooker grade-4 HO all had a significant influence on PROs. Clinically important HO (Brooker grade 4) remains rare after DAA-THR.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Periacetabular Osteotomy as a Salvage Procedure
Authors: Brusalis Christopher M. , Peck Jeffrey , Wilkin Geoffrey P. , Robustelli Stacy , Buly Robert L. , Nawabi Danyal H. , Ranawat Anil S. , Kelly Bryan T. , Sink Ernest L. 
Published: August 2020

Background:
A periacetabular osteotomy (PAO) can reduce pain and improve quality of life in patients with hip dysplasia. While its utility for patients without traditional radiographic parameters for hip dysplasia has not been previously established, the PAO may help treat patients with hip instability that does not improve following single or multiple hip arthroscopic procedures, or when such procedures lead to hip instability.

Methods:
A single-surgeon registry of patients at a single institution was queried to identify patients with a lateral center-edge angle (LCEA) of ≥24° and a Tönnis angle of <10° who underwent PAO because of hip pain and/or instability that failed treatment with hip arthroscopy. Descriptive summary statistics were reported on patient demographics, mean change in LCEA, and patient-reported outcome measures, including the modified Harris hip score (mHHS) and the International Hip Outcome Tool-33 (iHOT-33), at a minimum of 6 months of follow-up.

Results:
Among 25 patients (mean age, 27.3 ± 6.9 years; 100% women), the mean LCEA increased from 27.2° (range, 24° to 37°) preoperatively to 39.0° ± 5.1° postoperatively (net increase, 11.8° ± 4.5°). Overall, the mean improvement in the mHHS was 11.5 ± 16.9 (preoperative, 59.4 ± 11.6; postoperative, 70.9 ± 20.6) and the mean improvement in the iHOT-33 was 23.8 ± 23.6 (preoperative, 32.2 ± 17.2; postoperative, 56.0 ± 30.0). Eighteen patients (72%) achieved a minimal clinically important improvement in mHHS (mean improvement, 17.4 ± 12.9) and iHOT-33 (mean improvement, 32.4 ± 19.1) scores. In comparison with 7 patients who did not show improvement, the 18 patients who showed improvement had significantly greater mean baseline patient-reported outcome scores.

Conclusions:
To our knowledge, these findings provide the first report on outcomes of PAO in patients with hip pain following arthroscopy who do not meet the traditional criteria for acetabular dysplasia. Early benefits in clinical outcomes suggest a novel surgical indication for PAO as a potential salvage option for selected patients; however, longer-term studies are needed.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Combination Tests in the Diagnosis of Chronic Periprosthetic Joint Infection
Authors: Abdelbary Hesham , Cheng Wei , Ahmadzai Nadera , Carli Alberto V. , Shea Beverley J. , Hutton Brian , Fergusson Dean A. , Beaulé Paul E. 
Published: August 2020

Background:
Our objective was to identify combination tests used to diagnose chronic periprosthetic joint infection (PJI) and develop a stepwise decision-making tool to facilitate diagnosis.

Methods:
We conducted a systematic review of existing combinations of serum, synovial, and tissue-based tests for diagnosing chronic PJI after hip or knee replacement. This work is an extension of our systematic review of single tests, from which we chose eligible studies that also described the diagnostic performance of combination tests.

Results:
Thirty-seven eligible articles described the performance of 56 combination tests, of which 8 combinations had at least 2 studies informing both sensitivity and specificity. We also identified 5 types of combination tests: (1) a type-I Boolean combination, which uses Boolean logic (AND, OR) and usually increases specificity at the cost of sensitivity; (2) a type-II Boolean combination, which usually increases sensitivity at the cost of specificity; (3) a triage-conditional rule, in which the value of 1 test serves to triage the use of another test; (4) an arithmetic operation on the values of 2 tests; and (5) a model-based prediction rule based on a fitted model applied to biomarker values.

Conclusions:
Clinicians can initiate their diagnostic process with a type-II Boolean combination of serum C-reactive protein (CRP) and interleukin-6 (IL-6). False negatives of the combination can be minimized when the threshold is chosen to reach 90% to 95% sensitivity for each test. Once a joint infection is suspected on the basis of serum testing, joint aspiration should be performed. If joint aspiration yields a wet tap, a leukocyte esterase (LER) strip is highly recommended for point-of-care testing, with a reading of ++ or greater indicating PJI; a reading below ++ should be followed by one of the laboratory-based synovial tests. If joint aspiration yields a dry tap, clinicians should rely on preoperative tissue culture and histological analysis for diagnosis. Combinations based on triage-conditional, arithmetic, and model-based prediction rules require further research.

Level of Evidence:
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Reduced Risk of Reoperation Using Intramedullary Nailing with Femoral Neck Protection in Low-Energy Femoral Shaft Fractures
Authors: Bögl Hans Peter , Zdolsek Georg , Michaëlsson Karl , Höijer Jonas , Schilcher Jörg 
Published: August 2020

Background:
In Sweden, approximately 1 in 4 women who are ≥50 years of age will sustain a hip fracture. Patients treated for a femoral shaft fracture are likely to have an even higher risk. We hypothesized that intramedullary nails protecting the femoral neck reduce the risk of subsequent hip fracture and allow the patient to avoid a challenging reoperation.

Methods:
Between 2008 and 2010, 5,475 fractures of the femoral shaft, in patients who were ≥55 years of age, were registered in a national registry in Sweden. Of these patients, 897 fulfilled the inclusion criteria. We used radiographs and register data to identify the reasons for and the types of reoperation that occurred between the index surgical procedure and December 31, 2014. The categories of implants were determined through a review of radiographs as intramedullary nails with and without femoral neck protection. Reoperations related to peri-implant fractures (including hip fractures) were analyzed as a subgroup of all major reoperations. Multivariable-adjusted, cause-specific hazard ratios (HRs) were calculated to compare the risk of reoperation between cases with nails with and without femoral neck protection.

Results:
Among the 897 patients, a total of 82 reoperations were performed. In 640 patients who were treated with intramedullary nails with femoral neck protection, there were 7 peri-implant fractures (no hip fractures) and 27 major reoperations. Among the 257 patients who were treated with intramedullary nails without femoral neck protection, 14 peri-implant hip fractures and 24 major reoperations were identified. Patients who received nails with femoral neck protection had a lower hazard for any peri-implant fracture (multivariable-adjusted cause-specific HR, 0.19 [95% confidence interval (CI), 0.07 to 0.5]) and major reoperation (multivariable-adjusted cause-specific HR, 0.51 [95% CI, 0.28 to 0.92]).

Conclusions:
Intramedullary nails with femoral neck protection in the treatment of low-energy femoral shaft fractures prevent secondary hip fractures and decrease the overall risk of reoperation for 4 to 6 years postoperatively.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.