A Systematic Review of the Management of Upper Extremity Orthopaedic Injuries in Epileptic Patients.

Background: During seizures, injury of the upper extremities may occur. Standardized guidelines are deficient for diagnosis and perioperative care. Methods: PubMed, Embase, Cochrane, Scopus, and Web of Science databases were systematically screened using predefined search terms. Results: Of the 59 patients included, 36 (61.0%) involved a posterior shoulder dislocation. Associated fractures were observed in 34 (57.6%) cases with surgical procedures performed in 30 (50.8%) patients. Functional outcomes were reported in 44 patients, with over half (23 of 44, [52.2%]) endorsing range of motion deficits. Conclusion: Standardized guidelines, to guarantee timely management of injury in post-seizure patients, are needed with a customized treatment approach that accommodates the various aspects of their condition.

Relationship Between Patellar Morphology and Known Anatomic Risk Factors for Patellofemoral Instability.

BACKGROUND: Patellar instability (PI) is a common problem among pediatric, adolescent, and young adult patients. Recent literature has shown a correlation between pathoanatomy and PI. PURPOSE/HYPOTHESIS: The purpose of this study was to determine if there is any difference in patellar shape in patients with and without PI and if there is any association between the shape of the patella and the shape of the trochlea. Our hypothesis was that there would be no association between the shape of the patella and the likelinhood of having PI and that the shape of the trochlea would not be associated with patellar morphology. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Magnetic resonance imaging (MRI) scans were analyzed for 97 study patients with PI and 100 control patients with anterior cruciate ligament tears. Radiologic measurements of trochlear morphology were collected via MRI; 15 measurements of patellar morphology were then measured using axial MRI scans. Comparisons between the control and PI groups were performed using a 2-tailed t test. Regression analysis was performed to determine if associations existed between the 15 patellar morphology measurements and the trochlear dysplasia measurements. RESULTS: There were no statistically significant differences between the PI and control groups for the majority of patellar morphology measurements. With regression analysis, there were no statistically significant associations between the majority of patellar morphology measurements and the trochlear dysplasia measurements. CONCLUSION: Patellar morphology is highly variable in knees with and without PI. There was a minimal association between measurements of patellar morphology and trochlear dysplasia.

Retroarticular Core Decompression with Biologic Augmentation for Juvenile Osteochondritis Dissecans of the Knee.

Juvenile osteochondritis dissecans (OCD) of the knee is a rare condition of subchondral bone that has secondary effects on articular cartilage as the condition advances. Traditional treatment for early-stage OCD involves different types of drilling procedures that work to stimulate healthy bone formation via creeping substitution. This article describes a technique that involves a complete removal, or decompression of an early-stage OCD, while preserving the overlying articular cartilage that is augmented with bone grafting and bone marrow aspirate concentrate. This allows for quicker and more reliable healing of early-stage OCD and can minimize the chance for reoperation.

Preoperative Patient Education May Decrease Postoperative Opioid Use After Meniscectomy.

PURPOSE: To identify the current opioid prescribing and use practices after arthroscopic meniscectomy and to evaluate the role of preoperative patient education in decreasing postoperative opioid consumption. METHODS: Patients undergoing arthroscopic meniscectomy were prospectively identified for inclusion. They were placed into 1 of 2 groups: Group 1 received no education regarding opioid use after surgery, whereas group 2 received a standardized overview on postoperative opioid use. Patients were assigned to the groups consecutively: Patients treated at the beginning of the study were assigned to group 1, and patients treated at the end of the study were assigned to group 2. Data from group 1 were used to identify "normal" opioid prescribing and use practices and to guide patients in group 2 regarding normal postoperative opioid use. Patients were surveyed weekly for 4 weeks after surgery to determine the number of opioids taken. Postoperative opioid consumption was analyzed and compared between the 2 groups. RESULTS: A total of 62 patients completed the study (32 in group 1 and 30 in group 2). Patients in group 1 were prescribed an average of 42.0 opioid pills (95% confidence interval [CI], 34.0-51.0 pills) and used an average of 15.84 pills (95% CI, 9.26-22.4 pills) after surgery, whereas patients in group 2 used an average of 4.00 pills (95% CI, 2.12-5.88 pills) after surgery. Patients in group 2 used 11.84 fewer opioid pills (P = .001), a 296% decrease in postoperative opioid consumption. The number of patients who continued to take opioid pills 4 weeks after surgery was 7 patients (21.9%) in group 1 and 1 patient (3.3%) in group 2. CONCLUSIONS: Preoperative patient education regarding opioids may decrease postoperative opioid consumption and the duration for which patients take opioid pills after arthroscopic meniscectomy. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Acellular dermal matrix augmentation significantly increases ultimate load to failure of pectoralis major tendon repair: a biomechanical study.

BACKGROUND: Biomechanical studies have demonstrated that standard pectoralis major tendon (PMT) repairs have inferior strength compared with native tendon. HYPOTHESIS: Augmentation of PMT repair with an acellular dermal matrix (ADM) will increase the ultimate load to failure. METHODS: Eighteen cadaveric specimens were allocated to 3 repair groups: standard repair (SR); augmented repair (AR) with ADM; and intact, native tendon (NT). Specimens were tested for cyclic elongation, linear stiffness, load to 5 mm displacement, maximum load to failure, and method of failure. RESULTS: Maximum load to failure in AR (1450 ± 295 N) was significantly higher than SR (921 ± 159 N; P = .0042) and equivalent to NT (1289 ± 240 N; P = .49). NT required the highest load to displace 5 mm (709 ± 202 N), which was higher than AR (346 ± 95 N; P < .001) and SR (375 ± 55; P = .0015). NT stiffness (125 ± 42 N/mm) was greater than the AR (69 ± 19 N/mm; P = .0073) or SR (75 ± 11 N/mm; P = .015). The mode of failure for SR was suture pullout from the PMT as opposed to button pullout from the humerus (fracture) for AR. CONCLUSION: ADM augmentation of PMT repair significantly increases ultimate load to failure.

Is Wikipedia a complete and accurate source for musculoskeletal anatomy?

PURPOSE: Wikipedia is a popular online encyclopedia generating over 5.4 billion visits per month, and it is also a common resource for the general public and professionals for medical information. The goal of this study is to determine the accuracy and completeness of Wikipedia as a resource for musculoskeletal anatomy. METHODS: The origin, insertion, innervation, and function of all muscles of the upper and lower extremities as detailed on Wikipedia was compared to the available corresponding information in Grant's Atlas of Anatomy (14th edition). Entries were scored for both accuracy and completeness. Descriptive statistics were calculated and associations between and within entries for accuracy and completeness were assessed by McNemar's tests. Information on Wikipedia's references was also collected. RESULTS: Overall, data on Wikipedia was 97.6% complete and 98.8% accurate when compared to Grant's Atlas of Anatomy. 78.6% of all entries were fully complete and accurate, with 15.3% of entries containing one error and 6.1% containing two errors. There were no associations between or within entries' accuracy and completeness. Only 62% of references from Wikipedia included were from academic sources. CONCLUSIONS: Musculoskeletal anatomy entries on Wikipedia are imperfect; they have inaccurate and missing information. Furthermore, a considerable proportion of references cited in entries are from poorly identified sources. While Wikipedia is an easily accessible resource for a large number of people and much of the anatomic information is appropriate, it cannot be considered to be an equivalent resource when compared to anatomic texts.

Treatment of Traumatic Elbow Instability With an Internal Joint Stabilizer.

PURPOSE: Current options for treating elbow instability include bony and/or ligamentous fixation with orthosis or cast immobilization, transarticular cross-pinning, temporary bridge plating, and hinged or rigid external fixation. Our purpose was to evaluate the recently developed internal joint stabilizer (IJS), which acts as an internal external fixator of the elbow. Our primary end point was to assess whether use of the device results in a stable and congruent reduction of the ulnohumeral and radiocapitellar joints in patients with acute or chronic elbow instability as a result of trauma. In our series, patients with elbow instability as a result of acute or chronic trauma were treated with an IJS. METHODS: This retrospective study reviewed 20 patients who underwent placement of a U.S. Food and Drug Administration (FDA)-approved IJS for elbow instability. Serial physical examinations and radiographs were performed to verify stability. Patients were instructed that, if they are dissatisfied with their postoperative motion, a secondary contracture release operation will be offered to them. Patients were asked to complete outcome-scoring questionnaires including the Disabilities of the Arm, Shoulder, and hand (DASH) and Mayo Elbow Performance (MEP) score. Complications were monitored for all patients. RESULTS: Twenty patients who underwent placement of an IJS for persistent elbow instability were reviewed. Patients with a flexion-extension arc of 70° or less at 12 weeks were offered a staged arthroscopic contracture release. The average MEP score improved from 12.2 ± 12.4 to 82.5 ± 14.3 and the average DASH score improved from 85.3 ± 23.0 to 37.26 ± 29.3. The average postoperative flexion-extension arc at most recent follow-up was 124.3° ± 14.9°, with a median follow-up of 17 months (8 weeks-25 months). CONCLUSIONS: Use of an IJS allows for early, congruent, and stable ulnohumeral and radiocapitellar range of motion in instances of persistent elbow instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic Elbow Contracture Release in the Pediatric Patient.

BACKGROUND: Elbow contracture is a sequelae of elbow trauma in pediatric patients. Arthroscopic contracture release has been shown to provide equivalent results to open contracture release with less associated morbidity and complications in the adult population. However, open contracture release is still commonly utilized in pediatric patients. The goal of this study is to determine the clinical results and safety profile of arthroscopic elbow contracture release in the pediatric population. METHODS: A retrospective review of all patients 18 years of age and younger who underwent arthroscopic elbow contracture release was performed. Demographic statistics, indication for surgery, preoperative and postoperative flexion-extension and pronation-supination range of motion, and all complications were recorded and analyzed. RESULTS: Twenty-five patients were identified as having undergone 29 arthroscopic elbow contracture releases. The most common index injury was elbow contracture after radial head fracture. The flexion-extension arc of motion improved from 93.0±39.9 degrees to 128.0±19.2 degrees for a total improvement of 35.2 degrees (P=0.0002), whereas the pronation-supination arc of motion improved from 141.0±58.6 degrees to 153±49.3 degrees for a total improvement of 12.2 degrees (P=0.097). There were 7 total complications. CONCLUSIONS: Arthroscopic elbow contracture release allows for restoration of range of motion with an acceptable safety profile and can be considered as a less invasive alternative to open contracture release in the pediatric population. LEVEL OF EVIDENCE: Level IV.

Return to Play in Elite Contact Athletes After Anterior Cervical Discectomy and Fusion: A Meta-Analysis.

STUDY DESIGN: Systematic literature review and meta-analysis of studies published in English language. OBJECTIVE: Return to play after anterior cervical discectomy and fusion (ACDF) in contact athletes remains a controversial topic with no consensus opinion in the literature. Additional information is needed to properly advise and treat this population of patients. This study is a meta-analysis assessing return to competitive contact sports after undergoing an ACDF. METHODS: A literature search of Medline, Embase, and Cochrane Reviews was performed to identify investigations reporting return to play following ACDF in professional contact athletes. The pooled results were performed by calculating the effect size based on the logic event rate. Studies were weighted by the inverse of the variance, which included both within and between-study error. Confidence intervals (CIs) were reported at 95%. Heterogeneity was assessed using the Q statistic and I2. Sensitivity analysis and publication bias calculations were performed. RESULTS: The initial literature search resulted in 166 articles, of which 5 were determined relevant. Overall, return to play data was provided for 48 patients. The pooled clinical success rate for return to play was 73.5% (CI = 56.7%, 85.8%). The logit event rate was calculated to be 1.036 (CI = 0.270, 1.802), which was statistically significant (P = .008). The studies included in this meta-analysis demonstrated minimal heterogeneity with Q value of 4.038 and I2 value of 0.956. CONCLUSIONS: Elite contact athletes return to competition 73.5% of the time after undergoing ACDF. As this is the first study to pool results from existing studies, it provides strong evidence to guide decision making and expectations in this patient population.

Bilateral C5 Motor Palsy after Anterior Cervical Decompression and Fusion: A Case Report and Review of the Literature.

BACKGROUND: Bilateral C5 motor palsy is a rare but potentially debilitating complication after cervical spine decompression with very few reports in the published literature. PURPOSE: To present a case of bilateral C5 motor palsy after anterior cervical decompression and fusion and discuss the incidence and risk factors of this complication. STUDY DESIGN/SETTING: We report a case of a 57-year-old male who underwent a three level C3-C6 anterior cervical discectomy and fusion with instrumentation who developed a postoperative bilateral C5 motor palsy. METHODS: A review of the literature was performed regarding reports on and incidence of post-operative bilateral C5 palsy following either anterior or posterior cervical spine decompression. RESULTS: Bilateral C5 motor palsy is a rare complication of cervical spine decompression with an overall incidence of 0.38%. Although a group of risk factors have been suggested no single cause has been identified. CONCLUSIONS: Bilateral C5 motor palsy is a rare but debilitating complication of cervical decompression.

Pediatric elbow arthroscopy: indications and safety.

BACKGROUND: Elbow arthroscopy is a minimally invasive means by which to treat a variety of acute and chronic elbow conditions. Although the safety and efficacy is well documented in the adult population, comparatively little information is available about the role of elbow arthroscopy in the pediatric population. This study reports the indications for and safety of elbow arthroscopy in a series of pediatric patients. METHODS: A retrospective review was performed from 2001 to 2015 of a surgical database at a single institution. All elbow arthroscopies performed in patients aged 18 years and younger were reviewed. Indications for surgery, perioperative and postoperative complications, further surgical intervention, and descriptive demographic information were recorded. RESULTS: We identified 64 elbow arthroscopic procedures in 59 patients. The average age at the time of surgery was 11.8 years. Indications for the arthroscopic surgery included contracture release (45.3%), closed reduction and fixation for fracture (20.3%), treatment of osteochondritis dissecans (20.3%), diagnostic arthroscopy (7.8%), and débridement (6.3%). The overall complication rate was 17.2%, with a major and minor complication rate of 6.3% and 10.9%, respectively. CONCLUSION: Elbow arthroscopy has applications in the pediatric population with an acceptable safety profile. The techniques and indications continue to evolve.

Age-Based Normative Measurements of the Pediatric Pelvis.

OBJECTIVES: Pediatric pelvic trauma is associated with high rates of morbidity and mortality. Current classifications do not take into account age-dependent quantitative differences of the pediatric pelvis making accurate diagnosis of pathologic diastasis of the pubic symphysis, sacroiliac (SI) joints, and triradiate cartilage difficult. The purpose of this study was to establish age-based normative values for the width of the pubic symphysis, SI joints, and the triradiate cartilage of the pediatric pelvis. METHODS: All computed tomographic (CT) scans of the abdomen and pelvis from patients between the ages 2 and 16 years over a 3-year period at a single institution were evaluated. Patients were excluded if the CT was performed as part of a trauma evaluation or for a history of neuromuscular disease or spinopelvic instrumentation. A total of 821 CT were included. The width of pubic symphysis, right and left SI joints, and each limb of the triradiate cartilages was measured using the PACS digital measurement tool. Left and right measurements of the SI joints and triradiate cartilage were combined and reported together. RESULTS: From age 2 to 16 years, the average widths of the SI joint and pubic symphysis decreased from 3.11 to 1.80 mm and 5.55 to 3.69 mm, respectively. The average widths of the 3 limbs of the triradiate cartilage also slightly decreased from age 2 until closure: ilioischial, iliopubic, and ischiopubic cartilages decreasing from 3.72 to 2.74 mm, 4.42 to 3.52 mm, and 3.08 to 2.97 mm, respectively. CONCLUSIONS: This study demonstrates an age-dependent decrease in width of the pubic symphysis and left and right SI joints. By contrast, the widths of the triradiate cartilage remain relatively stable until closure. We believe that these age-based normative values will aid in future diagnosis of pathologic diastasis of these areas of the pediatric pelvis.

Acute Hand Ischemia Following Elective Venous Sclerotherapy for Dorsal Hand Varicose Veins.

Venous sclerotherapy is an emerging cosmetic treatment option for dorsal hand varicose veins. Although venous sclerotherapy is considered a safe and effective procedure for treatment of venous malformations and varicosities in both the upper and lower extremities, inadvertent injection of the sclerosing agent into the arterial system has led to reported instances of acute ischemic events and distal limb necrosis. This is a rare but well-documented complication of lower-extremity venous sclerotherapy. Only 2 cases have been reported in upper-extremity venous sclerotherapy, both of which occurred during treatment of complex vascular malformations. We report an instance of acute, distal digit ischemia after elective venous sclerotherapy for a dorsal hand varicosity. As this procedure grows in popularity, it is essential for hand surgeons to be aware of this rare but potentially devastating complication.

Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Prior database studies have shown that complication rates following surgical treatment of proximal humerus fractures are low. However, diabetes has been shown across orthopedics to have significantly increased risks of postoperative complications. The purpose of our study was to identify complications for which diabetic patients are at increased risk following operative treatment of proximal humerus fractures. METHODS: The National Surgical Quality Improvement Program database from 2005 to 2014 identified patients >18 years undergoing open reduction-internal fixation for proximal humerus fractures. Patients with incomplete perioperative data were excluded. Patients with non-insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were compared with nondiabetic patients using multivariate logistic regression analysis. Odds ratio (OR) was calculated with a 95% confidence interval, and the significance level was held at P < .05. RESULTS: There were 1391 patients identified; 1147 (82%) were not diabetic, 91 (7%) had IDDM, and 153 (11%) had NIDDM. Of these, 39.68% (550) were obese (body mass index >30.0). Hypertension, dyspnea, and chronic obstructive pulmonary disease were the most frequent concurrent patient factors in diabetic patients. Postoperatively, patients with diabetes had a statistically significant higher risk of pneumonia (OR, 217.80; P = .002) and length of stay >4 days (OR, 2.05; P = .010). Among diabetics, non-insulin-dependent diabetics had a greater risk of sepsis (OR, 25.84; P = .022) and pneumonia (OR, 12.19; P = .013) than insulin-dependent diabetics. CONCLUSION: Both NIDDM and IDDM were associated with a number of adverse postoperative events. Importantly, NIDDM was found to be an independent risk factor for postoperative sepsis and pneumonia, whereas IDDM was identified as an independent risk factor for pneumonia and prolonged length of stay (≥4 days).

The heat-resistant agglutinin family includes a novel adhesin from enteroaggregative Escherichia coli strain 60A.

Heat-resistant agglutinin 1 (Hra1) is an accessory colonization factor of enteroaggregative Escherichia coli (EAEC) strain 042. Tia, a close homolog of Hra1, is an invasin and adhesin that has been described in enterotoxigenic E. coli. We devised a PCR-restriction fragment length polymorphism screen for the associated genes and found that they occur among 55 (36.7%) of the enteroaggregative E. coli isolates screened, as well as lower proportions of enterotoxigenic, enteropathogenic, enterohemorrhagic, and commensal E. coli isolates. Overall, 25%, 8%, and 3% of 150 EAEC strains harbored hra1 alone, tia alone, or both genes, respectively. One EAEC isolate, 60A, produced an amplicon with a unique restriction profile, distinct from those of hra1 and tia. We cloned and sequenced the full-length agglutinin gene from strain 60A and have designated it hra2. The hra2 gene was not detected in any of 257 diarrheagenic E. coli isolates in our collection but is present in the genome of Salmonella enterica serovar Heidelberg strain SL476. The cloned hra2 gene from strain 60A, which encodes a predicted amino acid sequence that is 64% identical to that of Hra1 and 68% identical to that of Tia, was sufficient to confer adherence on E. coli K-12. We constructed an hra2 deletion mutant of EAEC strain 60A. The mutant was deficient in adherence but not autoaggregation or invasion, pointing to a functional distinction from the autoagglutinin Hra1 and the Tia invasin. Hra1, Tia, and the novel accessory adhesin Hra2 are members of a family of integral outer membrane proteins that confer different colonization-associated phenotypes.