Operating Room Traffic in Total Joint Arthroplasty: One Simple Measure Toward Solving a Complex Problem.

BACKGROUND: Periprosthetic joint infection remains a devastating complication of total joint arthroplasty (TJA). The literature suggests that unnecessary operating room (OR) traffic increases the risk of surgical site infection by increasing bacterial load in the OR. We attempted to determine whether the posting of "restricted access" signs on the outside and inside of OR doors during primary TJA procedures would result in a reduction of OR door openings. METHODS: This prospectively designed, 2-phase study investigated the number of door openings per case for primary TJA. An independent observer collected data for each TJA case; the OR staff were blinded to the data collection to avoid bias. The first phase of this study recorded OR traffic without the use of "restricted access" signs. In the second, interventional phase of the study, OR traffic was monitored with the concomitant application of "restricted access" signs on the doors. The number of openings per case, from the time of incision to the time of dressing application, was collected. RESULTS: The average number of openings per case during the first phase was 75, with 0.59 door openings per minute. The average number of openings per case during the second phase was 40, with 0.28 door openings per minute. Therefore, a 47% reduction in openings per case and a 53% reduction in the number of openings per minute during primary TJA cases were observed. CONCLUSIONS: We demonstrated that the simple addition of "restricted access" signs on the outside and inside of OR doors produced a significant reduction (p < 0.001) in OR traffic during primary TJA. CLINICAL RELEVANCE: Posting signs can decrease door openings, potentially decreasing infection.

Direct Visualization of the Femoral Cortical Button in Anterior Cruciate Ligament Reconstruction Helps Ensure Proper Positioning.

This study sought to postoperatively compare femoral cortical button (FCB) placement in anterior cruciate ligament (ACL) reconstruction performed using an adjustable loop cortical femoral fixation button under direct arthroscopic visualization vs indirect methods. The authors conducted a retrospective review of postoperative knee radiographs from 76 patients who had undergone ACL reconstruction with an adjustable loop cortical femoral fixation button. Operative reports were reviewed to determine the technique used for graft placement. Two sports fellowship-trained surgeons reviewed the collected radiographs, and the position of the FCB in each patient was subsequently graded. Of the 76 patients reviewed, 42 cases were performed using direct visualization, whereas 34 cases used indirect methods. This analysis showed that FCBs placed with direct visualization were more likely to have optimal position directly on the femoral cortex compared with indirect methods (chi-square test, P=.046). The grading scores demonstrated moderate strength of interobserver reliability (kappa coefficient=0.62). Direct arthroscopic visualization while placing an FCB during ACL reconstruction with an adjustable loop cortical fixation button can help ensure optimal button placement. [Orthopedics. 2020;43(3):191-195.].

Diagnosis and management of primary malignant tumors in the upper extremity.

Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.

Neurogenic heterotopic ossification: a pictorial review.

Neurogenic heterotopic ossification is a condition whereby bone forms in an extra-skeletal site. It may occur in the context of major neurological insult involving the brain or spinal cord. It causes pain and restricts movement, most commonly at the hip joints. Although neurogenic heterotopic ossification is associated with significant morbidity, the diagnosis is not always considered when referring for imaging in susceptible individuals. This article highlights its key features to promote better awareness and recognition, by reviewing clinical findings and imaging of patients across various modalities including plain radiographs, ultrasound and computed tomography. The management of neurogenic heterotopic ossification is limited by late identification and consequently clinicians should always be aware of this potentially significant diagnosis. Recognition in the acute hospital setting before transfer to rehabilitation services may prevent further clinical sequelae including urinary tract infection and pressure ulcers.

Metabolic encephalopathy secondary to diabetic ketoacidosis: a case report.

INTRODUCTION: Metabolic encephalopathy is a rare but potentially devastating complication of diabetic ketoacidosis (DKA). This case highlights the dramatic cognitive decline of a young man due to metabolic encephalopathy complicating DKA. The aims of this case report are to highlight metabolic encephalopathy as a complication of DKA and to explore the current research in diabetic related brain injury. The importance of investigation and treatment of reversible causes of encephalopathy is also demonstrated. CASE PRESENTATION: A 35-year-old man with a background of type 1 diabetes mellitus (T1DM) and relapsing remitting multiple sclerosis (RRMS) presented to the emergency department (ED) in a confused and agitated state. Prior to admission he worked as a caretaker in a school, smoked ten cigarettes per day, took excess alcohol and smoked cannabis twice per week. Following initial investigations, he was found to be in DKA. Despite timely and appropriate management his neurological symptoms and behavioural disturbance persisted. Neuroimaging revealed temporal lobe abnormalities consistent with an encephalopathic process. The patient underwent extensive investigation looking for evidence of autoimmune, infective, metabolic, toxic and paraneoplastic encephalopathy, with no obvious cause demonstrated. Due to persistent radiological abnormalities a temporal lobe biopsy was performed which showed marked astrocytic gliosis without evidence of vasculitis, inflammation, infarction or neoplasia. A diagnosis of metabolic encephalopathy secondary to DKA was reached. The patient's cognitive function remained impaired up to 18 months post presentation and he ultimately required residential care. CONCLUSIONS: Metabolic encephalopathy has been associated with acute insults such as DKA, but importantly, the risk of cerebral injury is also related to chronic hyperglycaemia. Mechanisms of cerebral injury in diabetes mellitus continue to be investigated. DKA poses a serious and significant neurological risk to patients with diabetes mellitus. To our knowledge this is the second case report describing this acute complication.

Use of a Safety Clamp When Performing Arthroscopic Knot Tying Preserves the Suture When It Is Placed Under Excessive Tension.

The purpose of this study was to compare the location of the suture breakage between tying by hand vs with a safety clamp, needle driver. FiberWire No. 2 and 2-0 (Arthrex, Naples, Florida) were fastened onto the hook attachment of the digital force gauge. Sutures were placed under excessive strain using a hand tying technique vs a safety clamp, or instrument tying. Peak forces at which the sutures failed under tension along with locations of the suture breakage, measured from the site of the knot, were recorded. For FiberWire No. 2, the mean load to failure was 142.60±2.33 N for hand tying and 78.79±1.97 N for the safety clamp (P<.0001). For FiberWire 2-0, the mean load to failure was 62.98±4.90 N for hand tying and 34.43±2.46 N for the safety clamp (P<.0001). For FiberWire No. 2, the mean location of suture breakage was 0 cm, at the site of the knot, for hand tying and at the clamping point (10.45±0.34 cm from the knot) for the safety clamp (P<.0001). For FiberWire 2-0, the mean location of suture breakage was 0 cm, at the site of the knot, for hand tying and at the clamping point (10.47±0.22 cm from the knot) for the safety clamp (P<.0001). Use of a safety clamp while mastering arthroscopic suture technique preserves the suture knot when placed under excessive tension. [Orthopedics. 2019; 42(1):e25-e28.].

Physician Training Ultrasound and Accuracy of Diagnosis in Rotator Cuff Tears.

INTRODUCTION: Ultrasonography offers a fast and inexpensive method to evaluate the rotator cuff in the office setting. However, the accuracy of ultrasound is highly user dependent. The purpose of this study is to investigate the learning curve of an orthopaedic surgeon in using ultrasound to diagnose rotator cuff tears. METHODS: A sports medicine fellowship trained orthopaedic surgeon was taught how to perform and interpret an ultrasound examination of the shoulder by a musculoskeletal radiologist. In this prospective study, subjects were patients who presented to the office with shoulder pain suspected to be consistent with rotator cuff pathology, either complete or partial tears. The surgeon was blinded to magnetic resonance imaging (MRI) results and performed the ultrasound after performing a physical exam. Based on ultrasound and exam, the surgeon assessed if the rotator cuff was intact (no tear) or torn (having a partial or full thickness tear). Results were compared to MRI findings and arthroscopic findings (when available), and accuracy was evaluated over time to determine overall accuracy and if significant learning and improvement in accuracy took place over the time period studied. RESULTS: Eighty patients were enrolled in the study; seventy-four had an MRI within 3 months of the ultrasound and were available for evaluation. Nineteen patients underwent ultrasound, MRI, and arthroscopy. Ultrasound was able to accurately diagnose the correct rotator cuff pathology (no tear, a partial thickness tear, or a full thickness tear) in 61% of patients. Ultrasound accurately diagnosed simply the presence or absence of a tear in 74% of patients. There was a general trend toward improved accuracy as the investigator gained experience, with accuracy rates of approximately 51% for the first 40 patients, and 69% for the last 40 patients evaluated, although this difference was not statistically significant (p = 0.154). DISCUSSION: Ultrasound imaging requires significant training and practice to provide a clinically useful level of diagnostic accuracy. The applicability of this procedure for diagnosing primary rotator cuff tears in an orthopaedic office setting may be limited by the time and volume required for the practitioner to approach the accuracy reported for diagnostic ultrasound and MRI in the literature.

Calcaneonavicular Coalition with Naviculocuneiform and Cuneiform-First Metatarsal Coalitions A Case Report.

Coalitions involving three joints of the midfoot are rare. To our knowledge, this is the first report of a patient having fibrocartilaginous coalition of the calcaneonavicular joint along with partial osseous fusion of the naviculocuneiform (Chopart's joint) and medial cuneiform-first metatarsal joints. These multi-coalition pathologies are challenging to address operatively as pain can persist even after recognizing and surgically addressing each coalition in a patient.

Deformation T-Cup: a new multi-anvil apparatus for controlled strain-rate deformation experiments at pressures above 18 GPa.

A new multi-anvil deformation apparatus, based on the widely used 6-8 split-cylinder, geometry, has been developed which is capable of deformation experiments at pressures in excess of 18 GPa at room temperature. In 6-8 (Kawai-type) devices eight cubic anvils are used to compress the sample assembly. In our new apparatus two of the eight cubes which sit along the split-cylinder axis have been replaced by hexagonal cross section anvils. Combining these anvils hexagonal-anvils with secondary differential actuators incorporated into the load frame, for the first time, enables the 6-8 multi-anvil apparatus to be used for controlled strain-rate deformation experiments to high strains. Testing of the design, both with and without synchrotron-X-rays, has demonstrated the Deformation T-Cup (DT-Cup) is capable of deforming 1-2 mm long samples to over 55% strain at high temperatures and pressures. To date the apparatus has been calibrated to, and deformed at, 18.8 GPa and deformation experiments performed in conjunction with synchrotron X-rays at confining pressures up to 10 GPa at 800 °C .

Biologic augmentation in rotator cuff repair--should we do it, who should get it, and has it worked?

Rotator cuff tears are a common pathologic entity, and rotator cuff repairs are a frequently performed procedure. Given the high rate of structural failure of repair, biological augmentation of repairs is increasingly important. Biological augmentation primarily enhances the healing response and secondarily provides a mechanical bridge for tension free repair. Understanding biology of tendons and tendon healing aids in determining an optimal environment for repair. The basic principles of rotator cuff repair are aimed at achieving high initial fixation strength of the repair, restoring the anatomic footprint of the cuff tendon, minimizing gap formation, and maintaining mechanical stability until biologic healing occurs. Methods of augmentation come in many different forms and can be categorized by cell type and mechanism of delivery. Cell types include individual growth factors, stem cells, or a combination of both. Vehicles range from in situ delivery, such as microfracture, direct injection, or scaffold materials that are biologic or synthetic.

Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data.

The rate of unplanned 30-day readmissions to the hospital after discharge is being used as a marker to compare the quality of care across hospitals and to set reimbursement levels for care. While the readmission rate can be reported using administrative data, the accuracy of these data is variable, and defining which readmissions are unplanned and preventable is often difficult. The purpose of this study was to review readmissions to a single orthopedic hospital to identify the causes for readmission and, in particular, which readmissions are planned versus unplanned. Using that hospital's administrative database of patient records from 2007 to 2009, we identified all patients who were readmitted to the hospital within 30 days of a previous hospitalization for a procedure. Readmissions were broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined as either surgical or nonsurgical complications (medical conditions not directly related to the procedure). Almost 30 percent of readmissions were planned. Of the unplanned readmissions, close to 60 percent were triggered by an infection or a concern for an infection. Nonsurgical complications accounted for 18.2 percent of unplanned readmissions. This study highlights the importance of careful data collection and abstraction when calculating early readmission rates. Preventing surgical site infection and better coordinating care between orthopedic surgeons and primary care and medical subspecialty physicians may significantly reduce readmission rates.

An analysis of causes of readmission after spine surgery.

STUDY DESIGN: Retrospective review of medical records. OBJECTIVE: We reviewed all early readmissions after elective spine surgery at a single orthopedic specialty hospital to analyze the causes of unplanned readmissions. SUMMARY OF BACKGROUND DATA: Recent advances in techniques and instrumentation have made more complex spinal surgeries possible, although sometimes with more complications. Early readmission rate is being used as a marker to evaluate quality of care. There is little data available regarding the causes of early readmissions after spine surgery. METHODS: Using the hospital's administrative database of patient records from 2007 to 2009, all patients who underwent spine surgery and were readmitted to the hospital within 30 days were identified and broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Analysis was focused on 12 common spine procedures based on the principle procedure International Classification of Diseases, Ninth Revision, Clinical Modification code for the patient's initial admission. The readmission rate was calculated for each procedure. RESULTS: A total of 156 early readmissions were identified, of which 141 were unplanned. Of the unplanned readmissions, the most common causes were infection or a concern for an infection (45 patients, 32% of unplanned readmissions), nonsurgical complications (31 patients, 22% of readmissions), complications requiring surgical revision (21 patients, 15% of readmissions), and wound drainage (12 patients, 9% of readmissions). Fifty-seven percent of unplanned readmissions required a return to the operating room (76% of infections or concern for infection). The average length of stay for the unplanned readmissions was 6.5 days. When using the 12 most common procedures based on the International Classification of Diseases, Ninth Revision, Clinical Modification, the early readmission rate was 3.8% (141 early readmissions in 3673 procedures). CONCLUSION: Infection, medical complications after surgery, and surgical complications requiring revision of implants are the primary causes of unplanned early readmissions and spine surgery. Further studies are necessary to identify patients and procedures most associated with readmission.

Management of failed arthroscopic rotator cuff repair.

Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms postoperatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge. A thorough patient history, physical examination, and imaging studies (eg, plain radiography, MRI, magnetic resonance arthrography, ultrasonography) are required for diagnosis. Management is determined based on patient age, functional demands, rotator cuff competence, and the presence or absence of glenohumeral arthritis. Treatment options include revision repair, nonanatomic repair with or without biologic or synthetic augmentation, tendon transfer, and arthroplasty.

Diagnosis and management of pelvic fractures.

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specific treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause significant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, including the identification of associated injuries and emergency methods of provisional pelvic stabilization.

Characteristics of the Flexor Carpi Radialis Brevis Tendon on Magnetic Resonance Imaging and its Use in Basal Joint Arthroplasty.

We report the incidental discovery of a flexor carpi radialis brevis tendon, a rare anatomical variant identified during a surgical procedure. Magnetic resonance imaging of the contralateral side helped to delineate the anatomy of the flexor carpi radialis tendon and to differentiate the flexor carpi radialis brevis tendon from it. We describe the use of this rare tendon in ligament reconstruction of the basal joint of the thumb.

Phase II trials of dolastatin-10 in advanced pancreaticobiliary cancers.

BACKGROUND: Pancreaticobiliary malignancies respond poorly to conventional chemotherapy, and novel agents are needed. Dolatstatin-10 is a potent antimitotic pentapeptide isolated from the marine mollusk Dolabella auricularia that inhibits microtubule assembly. We conducted 2 parallel phase II trials of dolastatin-10 in patients with advanced hepatobiliary cancers and pancreatic adenocarcinoma. PATIENTS AND METHODS: Eligible patients had histologically-confirmed metastatic pancreatic adenocarcinoma or metastatic, locally advanced or recurrent cancer of the liver, bile duct or gallbladder, and had received no prior chemotherapy for advanced disease. Dolastatin-10 400 microg/m(2) was administered intravenously by bolus every 21 days. Restaging CT scans were obtained every 2 cycles. RESULTS: Twenty-eight patients (16 hepatobiliary, including 7 hepatomas, 6 cholangiocarcinomas, 2 gallbladder carcinomas, and 12 pancreatic carcinomas) enrolled; 27 were evaluable for response. There were no objective responses. Grade 3/4 neutropenia occurred in 59% of patients and neutropenic fever in 18%. Median and 1-year survival were 5.0 months and 17% for the pancreatic cancer patients, and 3.0 months and 29% for the hepatobiliary patients. Median time to progression was 1.3 months for the pancreatic cancer patients and 1.6 months for the hepatobiliary patients. CONCLUSIONS: Dolastatin-10 is inactive against hepatobiliary and pancreatic carcinomas.

Percutaneous reduction and Kirschner-wire fixation of impacted intra-articular fractures and volar lip fractures of the proximal interphalangeal joint.

We retrospectively review the cases of 5 men with closed, impacted intra-articular fractures of the middle phalanx at the proximal interphalangeal joint and describe a new technique-involving percutaneous reduction and Kirschner-wire fixation-that minimizes surgical trauma, allows fixation for early range of motion, and provides results as good as, if not superior to, those obtained with existing techniques.

Long-term outcome of surgically treated Crohn's colitis: a prospective study.

PURPOSE: Although bowel-sparing techniques have been published for treatment of Crohn's disease of the small bowel because of its relentless nature, extent of resection in Crohn's colitis is still a topic of debate. This study was designed to prospectively evaluate the long-term outcomes of patients with isolated Crohn's colitis to identify patients that may benefit from initial more aggressive resection. METHODS: We identified 179 patients with Crohn's disease operated on for primary colonic disease. They were divided into segmental colectomy, total abdominal colectomy, and total proctocolectomy groups, based on their initial operation. They were further characterized by extent and location of colonic involvement. Long-term outcome variables evaluated included colonic and small-bowel surgical recurrences, postoperative complications and long-term sequelae, long-term need for medical therapy, and need for permanent fecal diversion. RESULTS: Fifty-five patients underwent segmental colectomy, 49 total abdominal colectomy, and 75 total proctocolectomy. Patients with diffuse colonic involvement were significantly less likely to undergo segmental colectomy than total abdominal colectomy (P < 0.0001) or total proctocolectomy (P < 0.0001). Patients with distal involvement or pancolitis were significantly less likely to undergo segmental colectomy than total abdominal colectomy (P < 0.0001) or total proctocolectomy (P < 0.0001). Overall there were 31 patients (24.4 percent) with surgical Crohn's recurrences during follow-up: 19 (38.8 percent) in the segmental colectomy, 8 (22.9 percent) in the total abdominal colectomy, and 4 (9.3 percent) in the total proctocolectomy group. There was a significant difference in time to recurrence between the three groups by log-rank test (P = 0.017). Segmental colectomy patients had a significantly shorter time to first recurrence than total proctocolectomy patients (P = 0.014). After adjusting for extent of disease, the segmental colectomy group had a significantly greater risk of surgical recurrence than the total proctocolectomy group (P = 0.006). Total proctocolectomy patients were significantly less likely to be still taking medications one year after the index operation than total abdominal colectomy patients (P = 0.003) and segmental colectomy patients (P = 0.0003). During follow-up, patients with isolated distal disease were significantly more likely to require a permanent stoma than patients with isolated proximal disease (P = 0.004). CONCLUSIONS: A more aggressive approach should be considered in patients with diffuse and distal Crohn's colitis. Total proctocolectomy in the properly selected patients is associated with low morbidity, lower risk of recurrence, and longer time to recurrence. Patients after total proctocolectomy are more likely to be weaned off all Crohn's-related medications. Long-term rate of permanent fecal diversion is significantly higher in patients with distal disease.