Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 473 | Issue 6 | Jun, 2015

Future Patient Demand for Shoulder Arthroplasty by Younger Patients: National Projections

Eric M. Padegimas MD, Mitchell Maltenfort PhD, Mark D. Lazarus MD, Matthew L. Ramsey MD, Gerald R. Williams MD, Surena Namdari MD, MSc

The outcomes of shoulder arthroplasties in younger patients (55 years or younger) are not as reliable compared with those of the general population. Greater risk of revision and higher complication rates in younger patients present direct costs to the healthcare system and indirect costs to the patient in terms of quality of life. Previous studies have suggested an increased demand for shoulder arthroplasties overall, but to our knowledge, the demand in younger patients has not been explored.

Art In Science: The Stage of the Human Body—The Anatomical Theatre of Bologna

Berardo Di Matteo MD, Vittorio Tarabella MA, Giuseppe Filardo MD, PhD, Anna Viganò MA, Patrizia Tomba MA, Laura Bragonzoni MA, Maurilio Marcacci MD

A History of Lumbar Disc Herniation From Hippocrates to the 1990s

Eeric Truumees MD In ancient times, a supernatural understanding of the syndrome of lumbar radiculopathy often involved demonic forces vexing the individual with often crippling pain. The ancient Greeks and Egyptians began to take a more naturalistic view and, critically, suspected a relationship between lumbar spinal pathology and leg symptoms. Relatively little then changed for those with sciatica until the classic works by Cotugno and Kocher arrived in the late 18th century. Early lumbar canal explorations were performed in the late 1800s and early 1900s by MacEwen, Horsley, Krause, Taylor, Dandy, and Cushing, among others. In these cases, when compressive pathologies were found and removed, the lesions typically were (mis-)identified as enchondromas or osteochondritis dissecans. To better understand the history, learn more about the first treatments of lumbar disc herniation, and evaluate the impact of the early influences on modern spine practice, searches of PubMed and Embase were performed using the search terms discectomy, medical history, lumbar spine surgery, herniated disc, herniated nucleus pulposus, sciatica, and lumbar radiculopathy. Additional sources were identified from the reference lists of the reviewed papers. Many older and ancient sources including De Ischiade Nervosa are available in English translations and were used. When full texts were not available, English abstracts were used. The first true, intentional discectomy surgery was performed by Mixter and Barr in 1932. Early on, a transdural approach was favored. In 1938, Love described the intralaminar, extradural approach. His technique, although modified with improved lighting, magnification, and retractors, remains a staple approach to disc herniations today. Other modalities such as chymopapain have been investigated. Some remain a part of the therapeutic armamentarium, whereas others have disappeared. By the 1970s, CT scanning after myelography markedly improved the clinical evaluation of patients with lumbar disc herniation. In this era, use of discectomy surgery increased rapidly. Even patients with very early symptoms were offered surgery. Later work, especially by Weber and Hakelius, showed that many patients with lumbar disc herniation would improve without surgical intervention. In the ensuing decades, the debate over operative indications and timing continued, reaching another pivotal moment with the 2006 publication of the initial results of Spine Patient Outcomes Research Trial.

How Should We Grade Lumbar Disc Herniation and Nerve Root Compression? A Systematic Review

Yiping Li MD, Vance Fredrickson MD, Daniel K. Resnick MD

MRI is the gold standard for evaluating the relationship of disc material to soft tissue and neural structures. However, terminologies used to describe lumbar disc herniation and nerve root compression have always been a source of confusion. A clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers is vital for patient care and future research.

Molecular Basis of Intervertebral Disc Degeneration and Herniations: What Are the Important Translational Questions?

Tiffany Kadow MD, Gwendolyn Sowa MD, PhD, Nam Vo PhD, James D. Kang MD

Intervertebral disc degeneration is a common condition with few inexpensive and effective modes of treatment, but current investigations seek to clarify the underlying process and offer new treatment options. It will be important for physicians to understand the molecular basis for the pathology and how it translates to developing clinical treatments for disc degeneration. In this review, we sought to summarize for clinicians what is known about the molecular processes that causes disc degeneration.

Experimental Disc Herniation in the Rat Causes Downregulation of Serotonin Receptor 2c in a TNF-dependent Manner

Daniel Jonsson MS, Oscar Finskas MS, Yuki Fujioka MD, Anders Ståhlberg PhD, Kjell Olmarker MD, PhD

During recent decades, the knowledge of the pathophysiology of disc herniation and sciatica has drastically improved. What previously was considered a strict biomechanical process is now considered a more complex interaction between leaked nucleus pulposus and the tissue in the spinal canal. An inflammatory reaction, with tumor necrosis factor (TNF) playing an essential role, has been demonstrated. However, the exact mechanisms of the pathophysiology of disc herniation remain unknown.

What Are Long-term Predictors of Outcomes for Lumbar Disc Herniation? A Randomized and Observational Study

Dana Kerr MD, Wenyan Zhao PhD, Jon D. Lurie MD, MS

Although previous studies have illustrated improvements in surgical cohorts for patients with intervertebral disc herniation, there are limited data on predictors of long-term outcomes comparing surgical and nonsurgical outcomes.

Nonoperative Treatment for Lumbosacral Radiculopathy: What Factors Predict Treatment Failure?

Pradeep Suri MD, MS, M. Jake Carlson MD, James Rainville MD

Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery.

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

Laxmaiah Manchikanti MD, Ramsin M. Benyamin MD, Frank J. E. Falco MD, Alan D. Kaye MD,PhD, Joshua A. Hirsch MD

As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.

Is Sequestrectomy a Viable Alternative to Microdiscectomy? A Systematic Review of the Literature

Bahram Fakouri MD, Nitin R. Shetty MPhil, FRCS(Orth), Thomas C. H. White MRCS

Traditionally, lumbar discectomy involves removal of the free disc fragment followed by aggressive or conservative excision of the intervertebral disc. In selected patients, however, it is possible to remove only the free fragment or sequester without clearing the intervertebral disc space. However, there is some controversy about whether that approach is sufficient to prevent recurrent symptoms and to provide adequate pain relief.

Does Surgical Timing Influence Functional Recovery After Lumbar Discectomy? A Systematic Review

Andrew J. Schoenfeld MD, Christopher M. Bono MD

The impact of the duration of preoperative symptoms on outcomes after lumbar discectomy has not been sufficiently answered in a single study but is a potentially important clinical variable.

Outcomes of Lumbar Discectomy in Elite Athletes: The Need for High-level Evidence

Rueben Nair MD, Cynthia A. Kahlenberg BA, Wellington K. Hsu MD

Although lumbar discectomy for treatment of lumbar disc herniation in the general population generally improves patients’ pain, function, and validated outcomes scores, results of treatment in elite athletes may differ because of the unique performance demands required of competitive athletes.

Recurrent Versus Primary Lumbar Disc Herniation Surgery: Patient-reported Outcomes in the Swedish Spine Register Swespine

Peter Fritzell MD, PhD, Björn Knutsson MD, Bengt Sanden MD, PhD, Björn Strömqvist MD, PhD, Olle Hägg MD, PhD

Lumbar disc herniation (LDH) is a common indication for lumbar spine surgery. The proportion of patients having a second surgery within 2 years varies in the literature between 0.5% and 24%, with recurrent herniation being the most common cause. Several studies have not found any relevant outcome differences between patients undergoing surgery for primary LDH and patients undergoing reoperation for a recurrent LDH, but these studies have limitations, including small sample size and retrospective design.

Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes

Scott L. Parker MD, Stephen K. Mendenhall BS, Saniya S. Godil MD, Priya Sivasubramanian BS, Kevin Cahill MD, MPH, John Ziewacz MD, MPH, Matthew J. McGirt MD

Long-term postdiscectomy degenerative disc disease and low back pain is a well-recognized disorder; however, its patient-centered characterization and quantification are lacking.

Which Variables Are Associated With Patient-reported Outcomes After Discectomy? Review of SPORT Disc Herniation Studies

John D. Koerner MD, Jordan Glaser MD, Kristen Radcliff MD

The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for lumbar intervertebral disc herniation (IDH), among other pathologies. Multiple subgroup analyses have been completed since the initial publications, which have further defined which patient factors lead to better or worse patient-reported outcomes; however, the degree to which these factors influence patient-reported outcomes has not been explored.

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5 Years

James I. Cameron MD, Julie C. McCauley MPHc, Arash Y. Kermanshahi MD, William D. Bugbee MD

Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship.

Is There an Advantage to Knotless Barbed Suture in TKA Wound Closure? A Randomized Trial in Simultaneous Bilateral TKAs

Alexander P. Sah MD

Effective wound closure is critical to minimizing wound complications and withstanding the forces associated with early knee motion after TKA. Barbed sutures allow for knotless fixation, have been used successfully in other specialties, and may provide for more even distribution of tension along the length of the incision; however, data regarding unidirectional barbed sutures from randomized trials have raised important concerns about their use. Bidirectional barbed sutures offer a potential alternative, but have not been studied extensively in orthopaedic surgery.

There Are No Differences in Short- to Mid-term Survivorship Among Total Hip-bearing Surface Options: A Network Meta-analysis

Cody C. Wyles BS, Jose H. Jimenez-Almonte BS, Mohammad H. Murad MD, MPH, German A. Norambuena-Morales MD, Miguel E. Cabanela MD, Rafael J. Sierra MD, Robert T. Trousdale MD

Total hip arthroplasty (THA) is increasingly being performed in patients with long life expectancies and active lifestyles. Newer implant bearing surfaces, with superior wear characteristics, often are used in this cohort with the goal of improving longevity of the prosthesis, but comparisons across the numerous available bearing surfaces are limited, so the surgeon and patient may have difficulty deciding which implants to use.

Increased Risk of Periprosthetic Femur Fractures Associated With a Unique Cementless Stem Design

Chad D. Watts MD, Matthew P. Abdel MD, David G. Lewallen MD, Daniel J. Berry MD, Arlen D. Hanssen MD

Postoperative periprosthetic femur fractures are an increasing concern after primary total hip arthroplasty (THA). Identifying and understanding predisposing factors are important to mitigating future risk. Femoral stem design may be one such factor.

Does Radiographic Coxa Profunda Indicate Increased Acetabular Coverage or Depth in Hip Dysplasia?

Masanori Fujii MD, PhD, Tetsuro Nakamura MD, Toshihiko Hara MD, Yasuharu Nakashima MD, PhD, Yukihide Iwamoto MD, PhD

Although radiographic coxa profunda has been considered an indicator of acetabular overcoverage, recent studies suggest that radiographic coxa profunda is a nonspecific finding seen even in hip dysplasia. The morphologic features of coxa profunda in hip dysplasia and the frequency with which the two overlap are not well defined.

Is the Induced-membrane Technique Successful for Limb Reconstruction After Resecting Large Bone Tumors in Children?

Frank Fitoussi MD, PhD, Brice Ilharreborde MD, PhD

Resection of primary malignant tumors often creates large bony defects. In children, this creates reconstructive challenges, and many options have been described for limb salvage in this setting. Studies have supported the use of an induced-membrane technique after placement of a cement spacer to aid in restoration of bone anatomy.

Total Femur Replacement After Tumor Resection: Limb Salvage Usually Achieved But Complications and Failures are Common

Florian Sevelda MD, Reinhard Schuh MD, Jochen Gerhard Hofstaetter MD, Martina Schinhan MD, Reinhard Windhager MD, Philipp Theodor Funovics MD

Primary bone or soft tissue tumors of the femur sometimes present with severe and extensive bone destruction, leaving few limb-salvage options other than total femur replacement. However, there are few data available regarding total femur replacement and, in particular, regarding implant failures.

Can the Ream and Run Procedure Improve Glenohumeral Relationships and Function for Shoulders With the Arthritic Triad?

Frederick A. Matsen MD, Winston J. Warme MD, Sarah E. Jackins PT

The arthritic triad of glenoid biconcavity, glenoid retroversion, and posterior displacement of the humeral head on the glenoid is associated with an increased risk of failure of total shoulder joint replacement. Although a number of glenohumeral arthroplasty techniques are being used to manage this complex pathology, problems with glenoid component failure remain. In that the ream and run procedure manages arthritic pathoanatomy without a glenoid component, we sought evidence that this procedure can be effective in improving the centering of the humeral head contact on the glenoid and in improving the comfort and function of shoulders with the arthritic triad without the risk of glenoid component failure.

What Are Risk Factors for 30-day Morbidity and Transfusion in Total Shoulder Arthroplasty? A Review of 1922 Cases

Chris A. Anthony MD, Robert W. Westermann MD, Yubo Gao PhD, Andrew J. Pugely MD, Brian R. Wolf MD, MS, Carolyn M. Hettrich MD, MPH

Total shoulder arthroplasty (TSA) is an effective treatment for end-stage glenohumeral joint pathology with good long-term results. Previous descriptions of morbidity and blood transfusion in TSA are limited by preoperative risk factors and postoperative complications considered and single-center studies.

Modified Dunn Procedure is Superior to In Situ Pinning for Short-term Clinical and Radiographic Improvement in Severe Stable SCFE

Eduardo N. Novais MD, Mary K. Hill BA, Patrick M. Carry BA, Travis C. Heare MD, Ernest L. Sink MD

In situ pinning is the conventional treatment for a stable slipped capital femoral epiphysis (SCFE). However, with a severe stable SCFE the residual deformity may lead to femoroacetabular impingement and articular cartilage damage. A modified Dunn subcapital realignment procedure has been developed to allow for correction at the level of the deformity while preserving the blood supply to the femoral head.

What Factors Influence the Production of Orthopaedic Research in East Africa? A Qualitative Analysis of Interviews

Iain S. Elliott MD, Daniel B. Sonshine MD, Sina Akhavan BA, Angelique Slade Shantz MBA, Amber Caldwell MSc, Jesse Slade Shantz MD, MBA, Richard A. Gosselin MD, MPH, R. Richard Coughlin MD, MSc

Research addressing the burden of musculoskeletal disease in low- and middle-income countries does not reflect the magnitude of the epidemic in these countries as only 9% of the world’s biomedical resources are devoted to addressing problems that affect the health of 90% of the world’s population. Little is known regarding the barriers to and drivers of orthopaedic surgery research in such resource-poor settings, the knowledge of which would help direct specific interventions for increasing research capacity and help surgeons from high-income countries support the efforts of our colleagues in low- and middle-income countries.

Comparative Epidemiology of Revision Arthroplasty: Failed THA Poses Greater Clinical and Economic Burdens Than Failed TKA

Kevin J. Bozic MD, MBA, Atul F. Kamath MD, Kevin Ong PhD, Edmund Lau MS, Steve Kurtz PhD, Vanessa Chan MPH, Thomas P. Vail MD, Harry Rubash MD, Daniel J. Berry MD

Revision THA and TKA are growing and important clinical and economic challenges. Healthcare systems tend to combine revision joint replacement procedures into a single service line, and differences between revision THA and revision TKA remain incompletely characterized. These differences carry implications for guiding care and resource allocation. We therefore evaluated epidemiologic trends associated with revision THAs and TKAs.

Cationic Nanogel-mediated Runx2 and Osterix siRNA Delivery Decreases Mineralization in MC3T3 Cells

Arun R. Shrivats PhD, Eric Hsu PhD, Saadyah Averick PhD, Molly Klimak, April C. S. Watt MS, Marlene DeMaio MD, Krzysztof Matyjaszewski PhD, Jeffrey O. Hollinger DDS, PhD

Heterotopic ossification (HO) may occur after musculoskeletal trauma, traumatic brain injury, and total joint arthroplasty. As such, HO is a compelling clinical concern in both military and civilian medicine. A possible etiology of HO involves dysregulated signals in the bone morphogenetic protein osteogenic cascade. Contemporary treatment options for HO (ie, nonsteroidal antiinflammatory drugs and radiation therapy) have adverse effects associated with their use and are not biologically engineered to abrogate the molecular mechanisms that govern osteogenic differentiation.

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