Neuromuscular Dysfunction in Clubfeet Associated With Constriction Band Syndrome.

INTRODUCTION: Constriction band syndrome (CBS) is a congenital limb anomaly frequently associated with clubfoot. Clubfeet in CBS patients may be associated with peroneal nerve dysfunction in the involved lower extremity; however, the etiology of this neuromuscular dysfunction is not clear. We sought to characterize the distribution of constriction bands on lower extremities with clubfoot and determine if neuromuscular deficit (NMD), defined here as having absent ankle dorsiflexion, was associated with ipsilateral proximal bands. Our secondary aim was to compare the treatment and outcomes of clubfeet with NMD to those without NMD. METHODS: We performed a retrospective review of all patients with CBS and clubfoot presenting to our facility between January 1, 1998 and December 31, 2018. Treatment with the Ponseti method, at least 1 year of follow-up at this facility, and a detailed physical exam describing lower extremity neuromuscular function and the presence and location of constriction bands were required for inclusion in the study cohort. RESULTS: Twenty children with 26 clubfeet were included. Forty-six percent (12/26) of the clubfeet had NMD. Clubfeet with and without NMD had ipsilateral thigh or leg constriction bands at similar rates [42% (5/12) vs. 43% (6/14), P =0.106], and the majority (7/12) of clubfeet with NMD did not have an ipsilateral thigh or leg band. While children with an NMD clubfoot tended toward more casts, relapses, and surgical procedures, these differences did not reach statistical significance. The use of a daytime AFO beyond age four was higher in the NMD clubfeet [58% (7/12) vs. 14% (2/14), P =0.04]. CONCLUSION: Clubfeet with neuromuscular deficits may occur in the absence of proximal ipsilateral constriction bands, suggesting they may be caused by mechanisms other than direct damage from visible constriction bands to underlying nerves. They can also coexist with arthrogrypotic conditions. Clubfeet with an NMD tended toward more casts, relapses, and surgeries than those without NMD, but these differences did not reach statistical significance. These patients often elect long-term use of a daytime AFO.

Histopathological assessment of OASIS Ultra on critical-sized wound healing: a pilot study.

BACKGROUND: Dermatopathologists assess wounds secondary to trauma, infection, or oncologic resection that can be challenging to reconstruct. OASIS Ultra, an extracellular matrix, has been described for use in chronic and burn wounds. The aim of this pilot study is to assess wound healing in post-traumatic and infective wounds treated with OASIS using histological markers of repair. MATERIALS AND METHODS: Adults with traumatic, infective or iatrogenic wound defects with size precluding primary closure were eligible. Half the wound was randomly assigned to receive OASIS plus standard therapy; the other half received standard of care (SOC) therapy. During dressing changes, standardized-scale photographs were taken and biopsies obtained. Histologic sections were reviewed for degree of acute inflammation and extent of tissue repair. Neutrophils, edema, hemorrhage, necrosis, fibroblasts, collagen density and neovascularization were semi-quantitatively assessed. RESULTS: Forty-four skin biopsies from 7 patients with 10 acute wounds met eligibility criteria. Histologically, OASIS samples demonstrated improved acute inflammation scores compared to SOC. No patients experienced OASIS-related complications. OASIS-treated wound halves trended toward more wound contraction and improved tissue repair. CONCLUSION: Our scoring system aids histopathological wound assessment. Treatment of critical-sized, post-traumatic, acute wounds with OASIS resulted in decreased inflammation, and potentially more advanced wound healing, compared to SOC.

Developmental Dysplasia of the Hip: Controversies in Management.

PURPOSE OF REVIEW: Many aspects of developmental hip dysplasia (DDH) care and evaluation are still active areas of debate. Recent studies have provided more insight into these topics such as strategies for reducing osteonecrosis, assessing hip reduction after closed and open reduction, and the management of residual acetabular dysplasia. RECENT FINDINGS: The presence of the ossific nucleus at the time of reduction does not alter the risk of osteonecrosis. The risk of osteonecrosis may be higher when hips are immobilized in excessive abduction. Limited sequence MRI may be the best choice for assessing hip reduction after closed and open reduction; however, new technologies are emerging such as 3D fluoroscopy and perfusion MRI. The treatment of residual acetabular dysplasia with bracing has been shown to be effective and the decision to perform a pelvic osteotomy is based on patient-specific factors. The spectrum of DDH treatment has evolved over the past several decades. Recent studies have provided insights into strategies for osteonecrosis prevention, hip evaluation during after reduction, and the management of residual acetabular dysplasia. However, there is ample room for additional and more rigorous studies guiding advanced imaging for assessing hip reduction such as 3D fluoroscopy and perfusion MRI, as well as the management of residual acetabular dysplasia.

Clinical Manifestations of Constriction Band Syndrome.

BACKGROUND: Constriction band syndrome (CBS) is a congenital limb anomaly with varying presentation. We sought to characterize the clinical manifestations of CBS by analyzing a large cohort of patients. Our secondary aim was to evaluate potential risk factors for CBS. METHODS: We retrospectively reviewed the records for all patients with CBS who had presented to our tertiary medical center between 1998 and 2018. Examination by a pediatric orthopaedic surgeon and the presence of pathognomonic features were inclusion criteria. Clinical notes, photographs, and radiographs were reviewed to determine the pattern of limb involvement and associated conditions. Demographic data were compared with population averages to assess for possible risk factors. RESULTS: One hundred and twenty-eight children were included. The most prevalent feature was constriction bands (96%), followed by limb or digit amputations (88%) and syndactyly/acrosyndactyly (69%). Children without constriction bands presented with either acrosyndactyly or growth of an osseous spike from a congenital diaphyseal limb or digit amputation. There was a strong predilection for involvement of central digits of the hands and feet, with sparing of the thumb/great toe and small finger/toe. The average number of involved limbs per child was 2.6; 23% of the children had involvement of only 1 limb. Children with at least 1 additional diagnosis had more limbs affected by CBS than those who were otherwise healthy (2 limbs [interquartile range (IQR), 1-3 limbs] versus 3 limbs [IQR, 2-4 limbs]; p = 0.006), suggesting a more severe phenotype. Children with more limbs involved underwent more surgical procedures (p < 0.001). CBS was associated with gestational trauma, prematurity, low birth weight, young and old maternal age, and higher social deprivation. CONCLUSIONS: Children with CBS can be categorized as having either mild or extensive involvement based on the number of involved limbs and associated conditions. Future investigation of prenatal risk factors is necessary to further elucidate the etiology of this heterogenous condition. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Case-Based Learning and Traditional Lectures in an Orthopedic Residency Anatomy Course.

OBJECTIVE: The impact of new pedagogical methods such as case-based learning (CBL) rather than traditional lectures in graduate medical education is poorly defined. We hypothesized that using CBL in lieu of lectures in an orthopedic surgery residency anatomy course would lead to increased resident engagement, improved resident satisfaction, and similar knowledge acquisition. DESIGN: A prospective, observational study design was used. CBL sessions were developed for an orthopedic surgery residency anatomy course. Content was delivered in 6 sessions (3 traditional lecture-based and 3 CBL) taught by the same attending surgeon. Engagement was measured every 10 minutes by 2 trained observers using a standardized protocol. Resident satisfaction was surveyed and knowledge acquisition tested. Data from the course were scored separately for CBL verses lectures and compared statistically. SETTING: Orthopedic surgery residency program at the University of California, San Francisco. PARTICIPANTS: Orthopedic surgery interns and residents (n = 35). RESULTS: No significant differences were measured in resident engagement (83% vs 85%, p = 0.664) or in knowledge acquisition (84% vs 78%, p = 0.056) in CBL verses lecture sessions, respectively. CBL sessions were judged equally valuable compared to lectures with high satisfaction rates across all survey measures. CONCLUSIONS: Residents demonstrated similar engagement and satisfaction with CBL compared to lectures with equivalent knowledge acquisition, suggesting both pedagogical methods are effective for a highly motivated group of learners.

Management of Metadiaphyseal Proximal Radius Fractures.

Metadiaphyseal proximal radius fractures blur the distinction between the radial neck and radial shaft fractures. Operative management presents unique technical challenges both in terms of surgical approach and fixation method. We discuss relevant anatomy, safe surgical approach, and options and techniques for fracture fixation. We describe 6 patients who achieved satisfactory functional outcomes, even in cases of severe bone loss secondary to ballistic trauma. An extensile dorsal approach with exposure of the posterior interosseous nerve is recommended when normal soft tissue intervals have not already been extensively disrupted. Robust fixation can be achieved by contouring and repurposing a variety of plates such as a variety of mini fragment plates (2.4 mm T or Y-plates), flexible nails, or even distal radius plates.

Long-term Patient-Reported Outcomes After Surgery for Hypothenar Hammer Syndrome.

Background: This study aims to describe the long-term patient-reported outcomes after surgery for hypothenar hammer syndrome (HTHS) and to identify factors associated with inferior outcomes. Methods: We retrospectively identified 27 patients who underwent surgical intervention for HTHS from 2002 to 2016. Fifteen patients (56%) completed outcome questionnaires: Quick Disabilities of the Arm, Shoulder, and Hand, Cold Intolerance Symptom Severity (CISS) survey, Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test, and Patient-Reported Outcomes Measurement Information System Pain Interference Computer Adaptive Test. The median questionnaire follow-up was 7.2 years (interquartile range, 3.1-9.9). Outcomes were compared across different surgical techniques, and the influence of patient-related factors on outcomes was also evaluated. Results: Six (40%) patients experienced complete symptom resolution, 6 (40%) had improvement without complete resolution, 1 (7%) had resolution followed by recurrence, and 2 (13%) reported no improvement. The most common symptom after surgical intervention was cold intolerance. Questionnaire scores were similar across ligation, direct repair, and vein graft vascular reconstruction. Patients had better CISS scores if they had surgery on their nondominant hand (13.2 vs 38.6) and did not have a manual labor job (18.1 vs 40.5). Conclusions: Surgery for HTHS leads to moderate long-term improvement in patient-reported outcomes. Different surgical techniques yield similar symptomatic relief. Manual labor and surgery of the dominant hand are associated with worse CISS scores.

Is observation for traumatic hemothorax safe?

BACKGROUND: Eastern Association for the Surgery of Trauma guidelines suggest tube thoracostomy (TT) be considered for all traumatic hemothoraces. However, previous research has suggested that some traumatic hemothoraces may be observed safely. We sought to (1) determine the safety of selective observation for traumatic hemothorax and (2) identify predictors of failed observation. METHODS: All patients with traumatic hemothorax from 2000 to 2014 at a Level I trauma center were identified and categorized by size as small (<300 cc) or large (≥300 cc) based on chest computed tomography (CT) scan measurements. Patients with no CT or with TT placement before CT were excluded. Patients were categorized into four intervention groups: (i) early TT (<24 hours after CT), (ii) failed observation (TT ≥24 hours after CT), (iii) successful observation (no TT), and (iv) inevaluable due to early mortality (no TT but died within 7 days). Univariate analyses compared outcomes between groups. Multivariate analyses identified independent predictors of failed observation. RESULTS: Three hundred forty patients met the inclusion criteria. 156 (46%) patients received early TT. Of the 184 patients that were initially observed, 121 (66%) were successfully observed, 53 (29%) failed observation, and 10 (5%) were inevaluable due to early mortality. Most of the successfully observed hemothoraces were small (119/121, 98%). Four independent predictors of failed observation were identified: older age, fewer ventilation-free days, large hemothorax, concurrent pneumothorax. Patients, who received TT were more likely than non-TT patients to receive tissue plasminogen activator, develop an empyema, have fewer hospital-free days, and are discharged to rehabilitation rather than home. When compared to early TT, failed observation was associated with a higher likelihood of discharge to rehabilitation but no difference in mortality, hospital-free days, or rate of empyema. CONCLUSION: Initial observation in select patients is safe and may result in better outcomes. The identified predictors of failed observation can help in clinical decision making regarding the need for TT in patients with traumatic hemothorax. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

High-Fidelity Emergency Department Thoracotomy Simulator With Beating-Heart Technology and OSATS Tool Improves Trainee Confidence and Distinguishes Level of Skill.

OBJECTIVE: Resuscitative Thoracotomy or Emergency Department Thoracotomy (EDT) is a time-sensitive and potentially life-saving procedure. Yet, trainee experience with this procedure is often limited in both clinical and simulation settings. We sought to develop a high-fidelity EDT simulation module and assessment tool to facilitate trainee education. DESIGN: Using the Kern model for curricular development, a group of expert trauma surgeons identified EDT as a high-stakes, low-frequency procedure. Task analysis identified 5 key steps of EDT: (1) opening chest/rib spreader utilization; (2) pericardiotomy/cardiac repair; (3) open cardiac massage; (4) clamping aorta; and (5) control of pulmonary hilum. A high-fidelity simulator with beating-heart technology was built. The previously validated Objective Structured Assessment of Technical Skills (OSATS) was adapted to create the "EDT-OSATS" which assessed performance along several domains: (1) Surgical technique (key steps); (2) general skills; and (3) global rating. A pilot test was performed to compare board-certified trauma surgeons (i.e., Experts) with categorical general surgery interns (i.e., Novices). Each subject received preparatory materials, completed a presimulation quiz, performed a videotaped procedure on the EDT simulator, and completed a postmodule survey. Two independent raters scored performances using the EDT-OSATS. Groups were compared in descriptive and unadjusted analyses. We hypothesized that our EDT simulation module would distinguish between expert vs novice performance and improve trainee confidence. SETTING: Simulation laboratory at Massachusetts General Hospital in Boston, MA. PARTICIPANTS: Trauma surgeons (Experts, n = 6) and categorical general surgery interns (Novices, n = 8). RESULTS: Experts scored significantly higher than Novices on nearly all components of the EDT-OSATS, including: (1) surgical technique: pericardiotomy (4.2 vs 3.4, p = 0.040), cardiac massage (3.6 vs 2.4, p = 0.028), clamping aorta (4.1 vs 3.3, p = 0.035), control of pulmonary hilum (4.8 vs 3.4, p < 0.001); (2) general skills: time/motion (4.1 vs 2.9, p = 0.011), knowledge and handling of instruments (4.3 vs 3.1, p = 0.004), and (3) global rating (3.9 vs 2.9, p = 0.026). There was no statistical difference between groups on opening chest/rib spreader utilization (3.8 vs 3.3, p = 0.352) or procedure time (204sec vs 227sec, p = 0.401), though Experts scored numerically higher than Novices on every measure. Novices reported significantly increased confidence after the simulation (3.1 vs 1.4, p = 0.001). Ninety-three percent (13/14) of participants found the simulator realistic. CONCLUSIONS: Our novel high-fidelity beating-heart EDT simulator is realistic and improves trainee confidence in this low-frequency, high-stakes emergency procedure. The EDT-OSATS tool differentiates between performances of experienced surgeons vs novice trainees on the beating-heart simulator. This training module and accompanying assessment instrument hold promise as a learning tool for clinicians who may perform emergency department thoracotomy.