What Is a Surgical Site Infection After Carpal Tunnel Release?

PURPOSE: Considerable variation exists in the literature on published rates of surgical site infection (SSI) after carpal tunnel release, ranging over 20-fold, from 0.28% to 6.4%. The reason for this variability is unknown. METHODS: A retrospective review was conducted on 748 open carpal tunnel releases performed under wide-awake local anesthetic no tourniquet in an in-office procedure room. The following three different definitions of infection were used for analysis: definition A: prescription of an oral antibiotic; Definition B: SSI definition by the Centers for Disease Control and Prevention; Definition C: infection that required reoperation. RESULTS: Infection rate by definition A was 8.9% (67/748), by definition B was 2.3% (17/748), and by definition C was 0.4% (3/748), resulting in a 22-fold range. CONCLUSIONS: The infection rate after carpal tunnel release is heavily influenced by the definition of SSI. The definition of SSI needs to be considered when making comparisons, either in research or quality assurance/quality improvement applications. CLINICAL RELEVANCE: When analyzing SSI rates, the exact definition of infection must be ascertained to accurately compare an individual's practice or institutional data to the literature.

Distal Radius Fractures and Bone Health: A Survey of Hand Surgeons.

Following low-energy distal radius fractures (DRF) patients rarely receive a bone health evaluation. The purpose of this survey was to investigate the attitudes and practices of American Society for Surgery of the Hand (ASSH) members regarding osteoporosis and low-energy DRF. An electronic survey was sent to 4,125 members of the ASSH. Physicians were asked about referral patterns, comfort level with labs and imaging related to bone health, and barriers. There were 475 responses (response rate 11.5%). Most respondents always (33.1%) or often (32.8%) talk about osteoporosis risk after low-energy DRF. Most respondents (87.6%) do not routinely order metabolic labs. Less than half knew of an available Fracture Liaison Service. Barriers to discussion included not enough time (32.6%), not comfortable with the topic (12.6%), and not within practice scope (33.3%). Respondents reported variable comfort levels discussing and implementing osteoporosis care in the setting of low-energy DRF. (Journal of Surgical Orthopaedic Advances 31(3):155-160, 2022).

The outcomes of quadriceps tendon autograft for anterior cruciate ligament reconstruction in adolescent athletes: a retrospective case series.

BACKGROUND: Multiple graft options exist for anterior cruciate ligament (ACL) reconstruction in an adolescent athlete. Patellar tendon harvest can lead to anterior knee pain, while hamstring tendon harvest can affect knee flexion strength and alter mechanics. Allograft is less desirable in pediatric patients due to the higher failure rate and slight risk of disease transmission. Quadriceps tendon autograft has rarely been reported for adolescent ACL reconstruction in the USA, but is an excellent option due to its large size, low donor site morbidity, and versatility. The purpose of this study is to report the outcomes of adolescents who have undergone ACL reconstruction using quadriceps tendon autograft. METHODS: Twenty-two ACL reconstructions using the quadriceps autograft were performed on 21 pediatric patients by the senior author between 2010 and 2017. The patient's demographics, injury characteristics, imaging, physical examination findings, operative findings, outcomes and sports were recorded. RESULTS: The average age at the time of surgery was 15 years. Two patients had open physes; the remainder had closing physes. 64% of patients had additional meniscal tears and 76% had bony contusions. The average duration of follow-up was 2.8 years (range 2-5 years). At final follow-up, there were no angular deformities or leg length discrepancies. The average quadriceps atrophy of the operative leg was 4 mm. The average Lysholm score was 98. 86% of patients returned to sports. No patients had re-rupture of their operative ACL. No incidences of infections, numbness, or anterior knee pain were reported. Two patients had a second arthroscopy for re-injury, revealing new meniscal tears but intact ACL grafts. CONCLUSIONS: Use of quadriceps tendon autograft for ACL reconstruction in adolescent patients allows reliable return to sport with minimal complications. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Individual Patient-reported Activity Levels Before and After Joint Arthroplasty Are Neither Accurate nor Reproducible.

BACKGROUND: Patients often are asked to report walking distances before joint arthroplasty and when discussing their results after surgery, but little evidence demonstrates whether patient responses accurately represent their activity. QUESTIONS/PURPOSES: Are patients accurate in reporting distance walked, when compared with distance measured by an accelerometer, within a 50% margin of error? METHODS: Patients undergoing THA or TKA were recruited over a 16-month period. One hundred twenty-one patients were screened and 66 patients (55%) were enrolled. There were no differences in mean age (p = 0.68), proportion of hips versus knees (p = 0.95), or sex (p = 0.16) between screened and enrolled patients. Each patient wore a FitBit Zip accelerometer for 1 week and was blinded to its measurements. The patients reported their perceived walking distance in miles daily. Data were collected preoperatively and 6 to 8 weeks postoperatively. Responses were normalized against the accelerometer distances and Wilcoxon one-tailed signed-rank testing was performed to compare the mean patient error with a 50% margin of error, our primary endpoint. RESULTS: We found that patients' self-reported walking distances were not accurate. The mean error of reporting was > 50% both preoperatively (p = 0.002) and postoperatively (p < 0.001). The mean magnitude of error was 69% (SD 58%) preoperatively and 93% (SD 86%) postoperatively and increased with time (p = 0.001). CONCLUSIONS: Patients' estimates of daily walking distances differed substantially from those patients' walking distances as recorded by an accelerometer, the accuracy of which has been validated in treadmill tests. Providers should exercise caution when interpreting patient-reported activity levels. LEVEL OF EVIDENCE: Level III, diagnostic study.

Patients undergoing surgical treatment for low-energy distal radius fractures are more likely to receive a referral and participate in a fracture liaison service program.

INTRODUCTION: Patients often do not receive osteoporosis screening after a low-energy distal radius fracture (DRF). The effect of osteoporosis on the healing of DRFs remains a debate, and it is unclear if surgical treatment of this injury affects the referral and participation rates in a fracture liaison service (FLS) program. The purpose of this study is to report on a large cohort of low-energy DRFs and identify demographic, clinical, and treatment factors that affect referral and participation rates in an FLS program. METHODS: A retrospective review identified patients over 50 years old who sustained a low-energy DRF between 2013 and 2018. Patients with high-energy or unknown injury mechanisms were excluded. The primary outcome was the effect of DRF surgical treatment on referral and participation rates in an FLS program. Secondary outcomes included patient demographic and clinical characteristic effects on referral and participation rates in an FLS program. RESULTS: In total, 950 patients met inclusion criteria. Two hundred thirty patients (24.2%) were referred and 149 (15.7%) participated in the FLS program. Patients who underwent surgery were more likely to be referred to the FLS (OR 1.893, CI 1.403-2.555, p < 0.001) and participate in the FLS program (OR 2.47, CI 1.723-3.542, p < 0.001) compared to patients who received non-operative treatment of their DRF. CONCLUSIONS: Patients who undergo surgical treatment of a low-energy DRF are more likely to be referred and participate in a FLS program. Further study is needed to identify why surgical treatment may affect referral and participation rates.

Decellularized peripheral nerve as an injectable delivery vehicle for neural applications.

Damage to the nervous system can result in loss of sensory and motor function, paralysis, or even death. To facilitate neural regeneration and functional recovery, researchers have employed biomaterials strategies to address both peripheral and central nervous system injuries. Injectable hydrogels that recapitulate native nerve extracellular matrix are especially promising for neural tissue engineering because they offer more flexibility for minimally invasive applications and provide a growth-permissive substrate for neural cell types. Here, we explore the development of injectable hydrogels derived from decellularized rat peripheral nerves (referred to as "injectable peripheral nerve [iPN] hydrogels"), which are processed using a newly developed sodium deoxycholate and DNase (SDD) decellularization method. We assess the gelation kinetics, mechanical properties, cell bioactivity, and drug release kinetics of the iPN hydrogels. The iPN hydrogels thermally gel when exposed to 37°C in under 20 min and have mechanical properties similar to neural tissue. The hydrogels demonstrate in vitro biocompatibility through support of Schwann cell viability and metabolic activity. Additionally, iPN hydrogels promote greater astrocyte spreading compared to collagen I hydrogels. Finally, the iPN is a promising delivery vehicle of drug-loaded microparticles for a combinatorial approach to neural injury therapies.

The structure of photosystem I from a high-light-tolerant cyanobacteria.

Photosynthetic organisms have adapted to survive a myriad of extreme environments from the earth's deserts to its poles, yet the proteins that carry out the light reactions of photosynthesis are highly conserved from the cyanobacteria to modern day crops. To investigate adaptations of the photosynthetic machinery in cyanobacteria to excessive light stress, we isolated a new strain of cyanobacteria, Cyanobacterium aponinum 0216, from the extreme light environment of the Sonoran Desert. Here we report the biochemical characterization and the 2.7 Å resolution structure of trimeric photosystem I from this high-light-tolerant cyanobacterium. The structure shows a new conformation of the PsaL C-terminus that supports trimer formation of cyanobacterial photosystem I. The spectroscopic analysis of this photosystem I revealed a decrease in far-red absorption, which is attributed to a decrease in the number of long- wavelength chlorophylls. Using these findings, we constructed two chimeric PSIs in Synechocystis sp. PCC 6803 demonstrating how unique structural features in photosynthetic complexes can change spectroscopic properties, allowing organisms to thrive under different environmental stresses.

Intravenous Regional Anesthesia Using a Forearm Tourniquet: A Safe and Effective Technique for Outpatient Hand Procedures.

Background: Bier block provides anesthesia of an entire extremity distal to the tourniquet without necessitating direct injection at the surgical site. This avoids obscuring anatomy with local anesthetic and anesthetizes a wide area, allowing for multiple procedures and incisions. We hypothesize that a low-volume Bier block with forearm tourniquet, rather than a traditional brachial tourniquet, is a safe, well-tolerated, and effective anesthesia technique. Methods: All cases in which adult patients underwent hand procedures using Bier block anesthesia by a single surgeon over a 4-year period were reviewed. Data collected included patient demographics, procedure(s) performed, complications, tourniquet time and settings, procedure and in-room time, and supplemental medications administered. Results: In all, 319 patients were included, 103 from a university hospital and 216 from an ambulatory surgery center. The most commonly performed procedures were carpal tunnel release (205 cases) and trigger digit release (83 cases). Most patients received a 125-mg dose of lidocaine for the Bier block; many also received additional sedatives. Twenty-three patients received no additional medications. No patients required conversion to general anesthesia. One complication (0.3%) occurred, with paresthesias and tinnitus that resolved without intervention. The average tourniquet time was 24 minutes (SD = 4.3 minutes). Patients were discharged at a median of 49 minutes postoperatively, and 9.1% of patients received supplemental analgesics prior to discharge. Conclusions: Regional anesthesia achieved with a forearm tourniquet and intravenous local anesthetic provides adequate pain control, permits timely discharge home, and has a low complication rate. It should be considered for use in outpatient hand procedures.

Novel Sodium Deoxycholate-Based Chemical Decellularization Method for Peripheral Nerve.

Decellularized peripheral nerve has been proven to be an effective clinical intervention for peripheral nerve repair and a preclinical cell carrier after spinal cord injury. However, there are currently a lack of decellularization methods for peripheral nerve that remove cells and maintain matrix similar to the previously established, clinically translated technique (the Hudson method) that relies on the discontinued Triton X-200 detergent. Therefore, the aim of this study was to optimize a novel chemical decellularization method for peripheral nerves based on the currently available anionic detergent sodium deoxycholate. Sprague Dawley rat sciatic nerves were isolated, frozen in buffered solution, and then subject to sequential washes in water, salt buffer, zwitterionic detergents sulfobetaines -10 and -16, and varying concentrations of sodium deoxycholate (SDC). To optimize DNA removal after SDC decellularization, nerves were subjected to deoxyribonuclease (DNase) incubation and salt buffer washes. Immunohistochemical results demonstrated that utilization of 3% SDC in the decellularization process preserved extracellular matrix (ECM) components and structure while facilitating significantly better removal of Schwann cells, axons, and myelin compared with the Hudson method. The addition of a 3-h DNase incubation to the 3% SDC decellularization process significantly removed cellular debris compared with the Hudson method. Proteomic analysis demonstrated that our novel decellularization method based on 3% SDC +3-h DNase used in conjunction with zwitterionic detergents, and salt buffers (new decellularization method using 3% SDC + 3-h DNase, zwitterionic detergents, and salt buffers [SDD method]) produced a similar proteomic profile compared with the Hudson method and had significantly fewer counts of cellular proteins. Finally, cytotoxicity analysis demonstrated that the SDD decellularized scaffolds do not contain significant cytotoxic residuals as eluted media supported metabolically active Schwann cells in vitro. Overall, this study demonstrates that SDD decellularization represents a novel alternative utilizing currently commercially available chemical reagents. Impact Statement Decellularized nerves are clinically relevant materials that can be used for a variety of regenerative applications such as peripheral nerve and spinal cord injury repair. However, discontinuation of key detergents used in a proven chemical decellularization process necessitates the optimization of an equivalent or better method. This research presents the field with a novel chemical decellularization method to replace the previous validated standard. Scaffolds generated from this method provide an extracellular matrix-rich material that can be used in a variety of in vitro applications to understand cellular behavior and in vivo applications to facilitate regeneration after neural injury.

Important Elements in the Quality Improvement Curriculum for Orthopaedic Residents.

BACKGROUND: Orthopaedic residency education requires trainees to participate not only in clinical and research endeavors but also in quality improvement (QI) projects. To our knowledge, little has been published on how to implement a structured QI curriculum as part of an orthopaedic residency program. This article describes a single institution's experience with developing a longitudinal, integrated, and collaborative resident QI curriculum. METHODS: The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process was taught to residents as a formal curriculum at our institution beginning in 2014. A structured integrated process was developed for residents to work in teams and meet on a monthly basis. Since then, residents have developed multiple QI projects with measured outcomes. Serial surveys have been administered to the residents to collect feedback. RESULTS: Seven major QI projects have been implemented by residents since the program's initiation. The resident surveys revealed significant improvement in comfort level with organizing QI projects. Residents also reported being comfortable working in interprofessional teams and incorporating patient safety techniques into clinical practice. CONCLUSIONS: There are few guidelines that reflect how to initiate a formal QI curriculum in an orthopaedic residency program to promote a standardized and systematic way to approach QI projects. With a structured DMAIC education plan, an emphasis on graded responsibilities within a team setting, and responsiveness to resident feedback, orthopaedic programs can develop an effective QI program to allow residents to learn valuable patient safety practices, which allows residents to have a meaningful and impactful effect on QI initiatives that will serve them well as they enter clinical practice.

X-ray Emission Spectroscopy at X-ray Free Electron Lasers: Limits to Observation of the Classical Spectroscopic Response for Electronic Structure Analysis.

X-ray free electron lasers (XFELs) provide ultrashort intense X-ray pulses suitable to probe electron dynamics but can also induce a multitude of nonlinear excitation processes. These affect spectroscopic measurements and interpretation, particularly for upcoming brighter XFELs. Here we identify and discuss the limits to observing classical spectroscopy, where only one photon is absorbed per atom for a Mn2+ in a light element (O, C, H) environment. X-ray emission spectroscopy (XES) with different incident photon energies, pulse intensities, and pulse durations is presented. A rate equation model based on sequential ionization and relaxation events is used to calculate populations of multiply ionized states during a single pulse and to explain the observed X-ray induced spectral lines shifts. This model provides easy estimation of spectral shifts, which is essential for experimental designs at XFELs and illustrates that shorter X-ray pulses will not overcome sequential ionization but can reduce electron cascade effects.

Adventitial Cystic Disease of the Radial Artery.

Upper extremity adventitial cystic disease is rare, but the characteristic findings of this lesion should be known to the hand surgeon and used to guide treatment. We present a case of a young adult male who developed a painless mass in his distal forearm. Diagnostic imaging workup revealed a cystic mass that extended within and encased the radial artery. Both MRI and direct intraoperative visualization confirmed the presence of a stalk connecting the intra-mural radial artery mass to the radiocarpal joint. The mass and stalk were excised en bloc with fenestration of the volar capsule to prevent recurrence. This case demonstrates a less common example of upper extremity adventitial cystic disease and supports the articular theory of origin of these lesions. When surgical excision is performed, an attempt should be made to identify and excise the articular stalk in an effort to minimize risk of recurrence.

Genetic Factors in Tendon Injury: A Systematic Review of the Literature.

BACKGROUND: Tendon injury such as tendinopathy or rupture is common and has multiple etiologies, including both intrinsic and extrinsic factors. The genetic influence on susceptibility to tendon injury is not well understood. PURPOSE: To analyze the published literature regarding genetic factors associated with tendon injury. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review of published literature was performed in concordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify current evidence for genetic predisposition to tendon injury. PubMed, Ovid, and ScienceDirect databases were searched. Studies were included for review if they specifically addressed genetic factors and tendon injuries in humans. Reviews, animal studies, or studies evaluating the influence of posttranscription factors and modifications (eg, proteins) were excluded. RESULTS: Overall, 460 studies were available for initial review. After application of inclusion and exclusion criteria, 11 articles were ultimately included for qualitative synthesis. Upon screening of references of these 11 articles, an additional 15 studies were included in the final review, for a total of 26 studies. The genetic factors with the strongest evidence of association with tendon injury were those involving type V collagen A1, tenascin-C, matrix metalloproteinase-3, and estrogen-related receptor beta. CONCLUSION: The published literature is limited to relatively homogenous populations, with only level 3 and level 4 data. Additional research is needed to make further conclusions about the genetic factors involved in tendon injury.

Metal Hypersensitivity and Orthopedic Implants: Survey of Orthopedic Surgeons.

BACKGROUND: There is no clear consensus among orthopedic surgeons concerning metal hypersensitivity screening and orthopedic implants. OBJECTIVE: This study investigated practices and opinions about metal hypersensitivity and orthopedic implants via a survey administered to practicing orthopedists. METHODS: A questionnaire was sent to members of the Pennsylvania Orthopaedic Society electronically. Respondents were asked about preoperative and postoperative screening habits concerning metal hypersensitivity and implants. RESULTS: Forty-four physicians completed the survey. Only 11% of respondents reported that they always or often screen patients for metal hypersensitivity. Fifty percent of respondents stated that they only rarely refer patients for patch testing (and the remainder never do). If, however, patients were found to have a positive patch test, most providers were very likely to use a different implant. Other respondents were skeptical of the relationship between metal hypersensitivity and implant failure. Dermatitis, pain, and loosening were common reasons for postoperative testing. Seventy percent of respondents said that patch testing rarely or never changed their decision making. CONCLUSIONS: This study is reflective of the lack of consensus between orthopedists regarding patch testing. It demonstrates the diversity of opinions among orthopedists, the need for additional dialogue between orthopedic and dermatology specialties, and the need for larger studies investigating outcomes and metal hypersensitivity.

Leiomyoma presenting as a massive calcified circumferential esophageal mass.

Esophageal leiomyoma is the most common benign esophageal neoplasm and often presents as an incidental finding or with nonspecific symptoms such as dysphagia or chest pain. Surgical enucleation is the mainstay of treatment and may be accomplished using both open and thoracoscopic approaches. We present a case of a 57-year-old man who presented with a massive circumferential calcified leiomyoma.

Prevalence of baby bottle versus breastfeeding graphics on products in national chain stores.

OBJECTIVE: This study surveyed the prevalence of bottle versus breastfeeding graphic images on products marketed for pregnant mothers and young children available for purchase in national chain stores. STUDY DESIGN AND METHODS: This was a product survey/content analysis. Eighteen national chain stores located in a 10-mile radius of Charlottesville, VA were visited. In total, 2,670 individual items in 11 categories of baby shower and baby gift merchandise (shower invitations, greeting cards, gift wrap, shower decorations, baby dolls, baby books, infant clothing, bibs, nursery decorations, baby blankets, and disposable diapers) were assessed. The main outcome measures were prevalences of baby bottle and breastfeeding graphic images. RESULTS: Baby bottle images were found on products in eight of the 11 categories of items surveyed. Thirty-five percent of baby dolls were marketed with a baby bottle. The prevalence of bottle images on items in all other categories, however, was low. Of the 2,670 items surveyed, none contained a breastfeeding image. CONCLUSIONS: The low prevalence of baby bottle images on commonly purchased baby gift and baby shower items is encouraging. However, the absence of breastfeeding images and the relatively high prevalence of baby dolls marketed with a baby bottle demonstrate that breastfeeding is not portrayed as the physiologic norm on these products. Product designers should explore ways to promote breastfeeding, consumers should make informed choices in product selection, and advocacy groups should promote guidelines for these products.