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The Efficacy of Tranexamic Acid for the Treatment of Traumatic Hip Fractures: A Network Meta-Analysis

Bloom, David A; Lin, Charles C; Manzi, Joseph E; Mojica, Edward S; Telgheder, Zachary L; Chapman, Cary B
OBJECTIVES/OBJECTIVE:Network meta-analysis to compare the efficacy of different dosages of intravenous(IV) acid(TXA) in the treatment of traumatic hip fractures against the control group of no TXA. DATA SOURCES/METHODS:This study utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform a network meta-analysis on the use of TXA for the treatment of hip fractures. The study team utilized Ovid MEDLINE, Cochrane Reviews, Scopus, Embase, and Web of Science databases to perform the search. Studies were selected that were published in English between the years 2010 and 2020. STUDY SELECTION/DATA EXTRACTION/METHODS:For inclusion in this study, selected manuscripts were required to be randomized controlled trials with at least one control group had no anti-fibrinolytic intervention to serve as a control, IV formulations of TXA were utilized as part of the treatment group. Furthermore, all study participants must have undergone surgical intervention for traumatic hip fractures. Studies that did not immediately meet criteria for inclusion were saved for review by the full investigating team and were included based on consensus. DATA SYNTHESIS/RESULTS:All statistical analyses conducted for this study were performed using R (R Foundation for Statistical Computing, Vienna, Austria). Network meta-analyses were conducted with a frequentist approach with a random effects model using the netmeta package version 0.9-6 in R. The frequentist equivalent to surface under the cumulative ranking (SUCRA) probabilities, termed "P-Score" was used to rank different treatments. CONCLUSION/CONCLUSIONS:The use of TXA in the surgical management of traumatic hip fractures reduces the number of transfusions and perioperative blood loss, with minimal to no increased incidence of thrombotic events when compared to control. When comparing formulations, no route of administration is clearly superior in reducing perioperative blood loss.
PMID: 36821447
ISSN: 1531-2291
CID: 5434012

Long-term Patient-Reported Outcome Measures Following Particulated Juvenile Allograft Cartilage Implantation for Treatment of Difficult Osteochondral Lesions of the Talus[Formula: see text]

Manzi, Joseph; Arzani, Artine; Hamula, Mathew J; Manchanda, Kshitij; Dhanaraj, Dinesh; Chapman, Cary B
BACKGROUND/UNASSIGNED:Conventional methods are not suitable for difficult to treat osteochondral lesions of the talus (OCLTs). The role of particulated juvenile allograft articular cartilage implantation is not well elucidated for long-term patient outcomes. METHODS/UNASSIGNED:or greater, (2) shoulder lesions, (3) patients who failed microfracture, (4) patient aged ≥40 years, or (5) patient body mass index (BMI) >25. Patients were evaluated using physical examination, patient interviews, and outcome score measures. Patients had follow-up at 2 years, 4 years, and between 6 and 10 years at their most recent follow-up. Differences in functional outcome scores were compared before and after surgery. RESULTS/UNASSIGNED:Patients (age: 46.5 ± 11.8 years, BMI: 28.5 ± 6.1) had, on average, most recent follow-up of 8.0 years (range 72-113 months). Average visual analog scale for pain score decreased for patients by 3.9 points (95% confidence interval [CI] 2.18-5.60), when compared to preoperative assessment. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscale scores also improved from 46.5 to 80.9 (95% CI 21.35-47.43), and from 18.8 to 57.9 (95% CI 21.05-57.10), respectively. Short Form-36 Health Survey physical component scores showed significant improvement by an average of 45.5 points (95% CI 32.42-58.50). American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores improved from 55.2 to 80.3 (95% CI 12.459-37.741). CONCLUSION/UNASSIGNED:These results demonstrate positive patient-reported long-term outcomes for a cohort of patients with difficult OCLTs, followed over the course of 6-10 years after treatment with arthroscopy-assisted particulated juvenile articular cartilage implantation. LEVEL OF EVIDENCE/UNASSIGNED:Level II, prospective cohort study.
PMID: 34112022
ISSN: 1944-7876
CID: 4907142

Juvenile Particulate Osteochondral Allograft for Treatment of Osteochondral Lesions of the Talus: Detection of Altered Repair Tissue Biochemical Composition Using 7 Tesla MRI and T2 Mapping

Vira, Shaleen; Ramme, Austin J; Chapman, Cary; Xia, Ding; Regatte, Ravinder R; Chang, Gregory
During the previous 2 decades, numerous surgical procedures have become available to treat osteochondral lesions of the talus. The objective of the present study was to use 7 Tesla (7T) magnetic resonance imaging (MRI) to quantify and compare T2 values (a marker of collagen architecture) of native tibiotalar cartilage and cartilage repair tissue in patients treated with a juvenile particulate allograft for osteochondral lesions of the talus. The institutional review board approved the present study, and all subjects provided written informed consent. We scanned the ankles of 7 cartilage repair patients using a 7T MRI scanner with a multi-echo spin-echo sequence to measure the cartilage T2 values. We assessed the cartilage T2 values in the talar repair tissue, adjacent native talar cartilage, and overlying tibial cartilage. We compared the differences between groups using the paired t test. The talar cartilage repair tissue demonstrated greater mean T2 relaxation times compared with the native adjacent talar cartilage (64.88 +/- 12.23 ms versus 49.56 +/- 7.82 ms; p = .043). The tibial cartilage regions overlying these talar cartilage regions demonstrated a trend toward greater T2 relaxation times (77.00 +/- 31.29 ms versus 59.52 +/- 7.89 ms; p = .067). 7T MRI can detect differences in T2 values in cartilage repair tissue compared with native cartilage and could be useful for monitoring the status of cartilage health after surgical intervention.
PMID: 27989341
ISSN: 1542-2224
CID: 2372402

Evaluation and Management of Osteochondral Lesions of the Talus

Looze, Christopher A; Capo, Jason; Ryan, Michael K; Begly, John P; Chapman, Cary; Swanson, David; Singh, Brian C; Strauss, Eric J
Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options.
PMCID:5154424
PMID: 27994717
ISSN: 1947-6035
CID: 2372432

Osteochondral Lesions of the Talus Revisited Emerging Technologies

Dhanaraj, Dinesh; Chapman, Cary
Osteochondral lesions of the talus are becoming an increasinglyrecognized source of chronic ankle pain followinginjury. Although, once thought to be attributed to ischemicnecrosis, acute or repetitive trauma is the contemporary theoryregarding their etiology. Presently, there is no clear-cutconsensus among surgeons on the best algorithm to managethese challenging injuries. Arthroscopic techniques alongwith emerging technologies in the field of cartilage repair arebecoming increasingly popular treatment modalities. Theseinnovative methods have potential to provide a new directionfor the future and deliver improved clinical outcomes. Thecurrent review discusses opinions regarding the developmentof these lesions and also the approach to management, includingthe latest surgical modalities, such as osteochondralgrafts and juvenile chondrocyte implantation.
PMID: 26517167
ISSN: 2328-5273
CID: 1873792

Ilizarov external fixator for stump salvage in infected nonunions

Onyekwelu, Ikemefuna; Hasan, Saqib; Chapman, Cary B
Infected nonunions are potentially difficult complications to treat in the context of complex tibial fractures. Often, such complications necessitate amputation to prevent further sequelae, such as fulminant sepsis and complete loss of the limb. As such, the eradication of infection, the decision regarding when to amputate, and the length of the residual stump are important factors to optimize patient outcome. The authors present a unique scenario whereby an Ilizarov external fixation device was used to treat an infected tibial nonunion while simultaneously salvaging stump length to enable fitting for a below-knee prostheses. The use of the Ilizarov device can prevent abrupt dissemination of infection, stabilize the fracture, and bridge nonunion gaps. This is augmented by the unique ability of the construct to be periodically readjusted and realigned where needed to permit osteogenesis and proper alignment. The result in this case was complete eradication of infection, with the use of continuous antibiotics as a pharmacological adjunct, union of the tibial fragments, and a below-knee amputation with adequate stump length and prosthetic fit. The success of this treatment strategy was predicated on the above factors, with an emphasis on amputation level and its effect on function. The Ilizarov external fixator is a device that has been widely used to treat limb-length discrepancies, correct deformities, and induce osseous growth in bony nonunion. The authors present the Ilizarov device as a viable option for the treatment of infected tibial nonunions and stump length salvage.
PMID: 23937764
ISSN: 0147-7447
CID: 540252

Response [Letter]

Weatherall, Justin M; Chapman, Cary; Shapiro, Steven
PMID: 23743786
ISSN: 1071-1007
CID: 540282

Postoperative second metatarsal fractures associated with suture-button implant in hallux valgus surgery

Weatherall, Justin M; Chapman, Cary B; Shapiro, Steven L
BACKGROUND: The purpose of this study was to perform a retrospective review of a nonosteotomy technique for the reduction of the intermetatarsal (IM) angle in hallux valgus (HV) surgery using a modified nonabsorbable suture-button implant previously described for ankle syndesmotic injuries and to report on the outcomes and complications associated with this technique. METHODS: A retrospective review was performed of consecutive patients with a minimum follow-up of 1 year. Twenty-five patients, a total of 25 feet, were identified with a mean follow-up of 22.5 months. The mean age was 60 years. The pre- and postoperative HV and IM angles were compared. Each postoperative radiograph was assessed for loss of correction, implant failure, and second metatarsal (MT) stress fracture. The postoperative hallux American Orthopaedic Foot & Ankle Society (AOFAS) scores were obtained at the patient's final follow-up visit. Statistics were performed using the paired Student t test with the P value set at .05 to determine statistical differences. RESULTS: The preoperative mean IM and HV angles were 15.1 and 30.5 degrees, respectively. The postoperative mean IM and HV angles were 8.2 and 10.2 degrees, respectively. The reductions in the IM and HV angles were statistically significant (P < .05). The average postoperative AOFAS hallux score was 85. Two patients developed hallux varus (8%). Eight patients (32%) developed second metatarsal stress fractures. One patient (4%) with a second metatarsal stress fracture had a failure of the implant that required implant removal. The remaining stress fractures healed uneventfully. CONCLUSION: Suture-button fixation in hallux valgus achieved a satisfactory reduction in the first-second intermetatarsal angle compared with first metatarsal osteotomies but was associated with a high rate of second metatarsal stress fractures. LEVEL OF EVIDENCE: Level IV, retrospective case series.
PMID: 23386769
ISSN: 1071-1007
CID: 349012

Lower-limb amputations in patients with diabetes mellitus

Pino, Alejandro E; Taghva, Samantha; Chapman, Cary; Bowker, John H
It is estimated that approximately 23.6 million people in the United States have diabetes mellitus. With adequate control of this disease and appropriate foot care and basic surveillance, many patients can lead active and healthy lifestyles. However, some patients experience complications associated with poorly controlled glucose levels, including lower-extremity ulcerations and infections. When conservative measures have failed in treating these conditions, a lower-extremity amputation is an option for patients seeking to gain maximal functional recovery. A complete preoperative workup includes assessment of healing potential and preoperative ambulatory status, control or optimization of comorbidities when possible, and determination of amputation level using modern diagnostic modalities. Once the decision to proceed with an amputation has been made, it is important to choose an appropriate level of amputation and practice sound surgical technique. This article describes the preoperative evaluation and operative techniques involved in performing amputations on diabetic patients and reviews the current literature on the most common lower-extremity amputations performed in the care of infections in the feet of patients with diabetes mellitus.
PMID: 22146206
ISSN: 0147-7447
CID: 540292

Charcot neuroarthropathy of the foot and ankle

van der Ven, Alexander; Chapman, Cary B; Bowker, John H
Charcot neuroarthropathy is a common cause of morbidity in persons with diabetes mellitus and sensory neuropathy. Although Charcot neuroarthropathy is rare, it likely will become more prevalent in conjunction with increased incidence of diabetes mellitus. Prevention of disease progression remains the mainstay of treatment, with surgical intervention usually reserved for refractory cases. Late deformities are often complicated by chronic ulceration, infection, and osteomyelitis. The clinical presentation is best summarized with the Eichenholtz classification, and progression often follows a predictable pattern. Although Charcot neuroarthropathy is a clinical diagnosis, recent advances in diagnostic imaging have eased the clinical challenge of deciphering infection from Charcot changes. Advances in surgical treatment have demonstrated new options for limb salvage. Pharmacologic therapies directed toward decreasing bone resorption have also shown promise for treatment, but clinical application remains theoretical.
PMID: 19726740
ISSN: 1067-151x
CID: 540302