Pediatric Lateral Humeral Condyle Fractures: Reliability of a Modified Jakob Classification System and its Impact on Treatment Planning With or Without Arthrography.

BACKGROUND: Various lateral humeral condyle fracture (LHCF) classification systems have been in use since the 1950s, but limited research exists on their reliability. The most widely utilized, yet un-validated system is that of Jakob and colleagues. The purpose of the current study was to analyze the reliability of a modified Jakob classification system and its value in guiding treatment either with or without arthrography. METHODS: Interrater and intrarater reliability studies were performed using radiographs and arthrograms from 32 LHCFs. Radiographs were presented to 3 pediatric orthopaedic surgeons and 6 pediatric orthopaedic surgery residents who were asked to classify the fractures according to a modified Jakob classification system, enunciate their treatment plan, and whether they would utilize arthrography. Classification was repeated within 2 weeks to assess intrarater reliability. The treatment plan using radiographs only and radiographs with arthrography were compared at both rating points. RESULTS: The modified Jakob system had excellent interrater reliability using only radiographs with a kappa value of 0.82 and an overall agreement of 86%. The average kappa for intrarater reliability using only radiographs was 0.88 with a range of 0.79 to 1.00 and an average overall agreement of 91% with a range of 84% to 100%. Interrater and intrarater reliability was poorer using both radiographs and arthrography. On average, arthrography changed the treatment plan in 8% of cases. CONCLUSIONS: The modified Jakob classification system proved to be a reliable classification system for LHCFs, independent of arthrography, given the excellent free-marginal multirater kappa values. LEVEL OF EVIDENCE: Level III-diagnostic.

Adolescent Baseball Pitchers With Ulnar Collateral Ligament Tears Exhibit a High Proportion of Partial Tears.

BACKGROUND: Ulnar collateral ligament (UCL) tears in the throwing elbow are classified according to grade and location using magnetic resonance arthrography (MRA). However, the frequency of each tear type and the association to age, competition level, and radiographic findings in adolescent baseball pitchers are unknown. PURPOSES: The primary purpose of this study was to use MRA to characterize the severity, location, and UCL tear type in adolescent pitchers. The second aim was to describe the relationship between the UCL tear type and age, competition level, and plain radiographic findings. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Records of adolescent pitchers with a UCL tear treated by the senior author between 2007 and 2016 were retrospectively reviewed. MRA scans were reviewed and tears were classified according to the Joyner-Andrews classification. Low-grade partial tears are classified as type I, high-grade partial tears as type II, complete full-thickness tears as type III, and tear pathology in >1 region in the UCL as type IV. Each type of tear also has a location designated at the midsubstance, ulna (U), or humerus (H). Patient characteristics, competition level, and associated plain radiographic abnormalities were recorded. Univariate analyses were performed to examine the relationships between tear types and age, competition level, and plain radiographic findings. RESULTS: A total of 200 adolescent pitchers (mean ± SD age, 17.2 ± 1.5 years) with MRA scans were reviewed. Type II-H (n = 62), type II-U (n = 51), and type III-U (n = 28) were the most common tear types observed. Type II tears comprised 64.5% of adolescent UCL tears, with type II-H being the most common. Plain radiographs were abnormal in 32% of patients, with calcifications (10.5%) and olecranon osteophytes (12.5%) being the most common findings. There were no significant relationships between tear type and age (P = .25), competition level (P = .23), or radiographic abnormalities (P = .75). CONCLUSION: Humeral-sided high-grade partial tears were the most common tear type in adolescent pitchers. There was no relationship between UCL tear type and age competition level, and plain radiographic abnormalities.

Joining the Navy to Become a Physician: The Typical Experience.

INTRODUCTION: The decision to enter the Navy as a physician is a major career choice. However, there are no published studies that address the typical Navy physician's experience in the Health Professions Scholarship Program (HPSP) and Uniformed Services University of the Health Sciences (USUHS) programs. The purpose of this qualitative study is to describe the typical Navy physician's experience in the HPSP and USUHS programs. MATERIALS AND METHODS: An anonymous online survey containing 47 questions was distributed to 63 Navy HPSP and USUHS physicians who started internships from 2008 to 2015. Participants were chosen by using purposeful, criterion, and snowball sampling methods with whom the author had a professional relationship during his military experience. The survey data were plotted in Excel spreadsheets and graphs according to six sub-research questions. Mean, SD, Likert scale 1-5, and grouping of free text responses were recorded. RESULTS: A total of 54 out of 63 Navy physicians (85.7%) responded to the survey. Navy physicians got their first-choice residency selection of 67.3% of the time, 34.6% went straight through residency without interruptions, 44.2% answered definitely or probably that military match changed their residency selection compared to them applying for civilian residency, and 46.2% answered definitely or probably that it was more difficult to get into military versus civilian residency. Participants answered definitely or probably that military experience puts them ahead of civilians in terms of leadership (82.7%), prior medical experience (46.2%), and applying for civilian residency (76.2%). Common positive themes of free-text answers included having financial stability, unique life experiences, and serving their country. Common negative themes included lack of career control, lack of knowledge regarding HPSP/USUHS programs, and delay in residency and career. CONCLUSIONS: The principal findings in this study are that most Navy physicians favored paid medical school/financial support, working overseas and in unique operational climates, having unique life experiences, leadership skills, and prior military experience put them ahead of their civilian colleagues, thought the Navy experience was worth it, and would join again if given the opportunity. However, most Navy physicians had a lack of career control due to needs of the Navy, lack of knowledge regarding residency selection, operational billets, and active duty service obligation, had more difficulty getting into a military residency of their choice versus civilians, and had interrupted residency training/training delays. The Navy would possibly benefit from a nationwide HPSP/USUHS physician mentorship program and an educational seminar to increase medical student applicant knowledge, which may improve recruiting and retention.

Orthopedic Surgery and Flight Surgery: Income Differences Between the Navy Health Professions Scholarship Program and Civilian Orthopedic Surgery.

INTRODUCTION: The purpose of this study to analyze the financial impact of choosing a civilian or military orthopedic surgery career. It will examine the most common scenarios to become an orthopedic surgeon in the Navy Health Professions Scholarship Program to include becoming a flight surgeon. To the authors' knowledge, there is no peer-reviewed literature that financially analyzes the most common scenarios for a Navy Health Professions Scholarship Program scholarship recipient to become an orthopedic surgeon. MATERIALS AND METHODS: Salaries for Navy orthopedic surgeons, residents, and flight surgeons were recorded using the 2020 Defense Finance and Accounting Service pay tables and Navy Fiscal Year 2019 Medical Corps Special Pay Guidance. The median income of civilian orthopedic surgeons was recorded using Salary.com. The present value (PV) and future value (FV) were calculated using the Consumer Price Index-U and average Department of Defense pay increases over the past 20 years. Six common scenarios were utilized to calculate the PV and FV of civilian compared to Navy orthopedic surgeons. RESULTS: The two highest earning net FVs among all Navy scenarios were those surgeons who kept their Navy tour to 5 years or less (flight surgeon tour/separate or civilian deferment/separate). The civilian throughout scenario had the highest net FV of $19,974,673 after retiring at the age of 65. Flight surgeon tour/separate and civilian deferment/separate scenarios only made $843,751 and $1,401,630 less respectively than a pure civilian career due to the tax shelter afforded by the military pay. All Navy retirement scenarios to include Navy throughout, civilian deferment/Navy throughout, flight surgeon tour/Navy throughout resulted in a net FV less than $17,700,000. Civilian residency/deferment and retiring in the Navy had the worst net FV among all scenarios. CONCLUSIONS: It was found that the shorter tours in the Navy had a higher net FV than those who made the Navy a career in orthopedic surgery. Flight surgery is a rewarding operational experience with among the highest net FV among Navy scenarios and is only slightly less than the net FV of a pure civilian career. However, it can be more difficult to apply for civilian orthopedic surgery after serving a flight surgeon tour. Lastly, the net FV was very similar between a civilian orthopedic surgeon career and the shorter tours served in the Navy. Factors such as higher civilian income with associated loan repayment/signing bonuses makes the civilian orthopedic surgery route the best financial option. This study will help those medical students considering a military versus a civilian career in orthopedic surgery and aid in Department of Defense recruitment/retention.

Sensorineural hearing loss after spine surgery treated with hyperbaric oxygen therapy: two case reports.

Acute idiopathic sudden sensorineural hearing loss (ISSNHL) following lumbar spinal surgery is an exceedingly rare phenomenon. This paper presents a case of ISSNHL presenting acutely after lumbar spine decompression and fusion treated with transtympanic steroids and hyperbaric oxygen (HBO2) therapy. It also presents the ironic case of SSNHL secondary to presumed viral pathology sustained by the patient's operative surgeon who was treated with transtympanic steroids and HBO2 as well. Proposed etiologies of the patient's ISSNHL include: hypotension, prone operative position, malfitted/malpositioned headrest, microemboli from a cell-saver, and nitrous oxide anesthesia. The role of systemic hypotension as an etiology of ISSNHL is discussed given the fact that there are no reported cases of ISSNHL in orthopedic procedures performed with permissive hypotension. The initiation of steroids and HBO2 therapy has been shown to be an effective treatment for ISSNHL when started within 14 days of symptom onset. HBO2 and transtympanic steroids were initiated 10 days earlier in the operative surgeon, which showed to be a better treatment modality compared to the postoperative patient. ISSNHL in the acute postoperative period of lumbar spinal fusion surgery presents a unique treatment dilemma because systemic steroids are routinely avoided over concerns of pseudarthrosis. Of the seven documented cases of ISSNHL following lumbar spine surgery, none underwent HBO2 as a treatment modality.

Separating large microscale particles by exploiting charge differences with dielectrophoresis.

Dielectrophoresis (DEP), the migration of particles due to polarization effects under the influence of a nonuniform electric field, was employed for characterizing the behavior and achieving the separation of larger (diameter >5 µm) microparticles by exploiting differences in electrical charge. Usually, electrophoresis (EP) is the method of choice for separating particles based on differences in electrical charge; however, larger particles, which have low electrophoretic mobilities, cannot be easily separated with EP-based techniques. This study presents an alternative for the characterization, assessment, and separation of larger microparticles, where charge differences are exploited with DEP instead of EP. Polystyrene microparticles with sizes varying from 5 to 10 µm were characterized employing microdevices for insulator-based dielectrophoresis (iDEP). Particles within an iDEP microchannel were exposed simultaneously to DEP, EP, and electroosmotic (EO) forces. The electrokinetic behavior of four distinct types of microparticles was carefully characterized by means of velocimetry and dielectrophoretic capture assessments. As a final step, a dielectropherogram separation of two distinct types of 10 µm particles was devised by first characterizing the particles and then performing the separation. The two types of 10 µm particles were eluted from the iDEP device as two separate peaks of enriched particles in less than 80 s. It was demonstrated that particles with the same size, shape, surface functionalization, and made from the same bulk material can be separated with iDEP by exploiting slight differences in the magnitude of particle charge. The results from this study open the possibility for iDEP to be used as a technique for the assessment and separation of biological cells that have very similar characteristics (shape, size, similar make-up), but slight variance in surface electrical charge.

A Case of Non-simultaneous Bilateral Partial Triceps Tendon Repair.

A partial triceps tendon tear is an uncommon injury. Even rarer is a bilateral partial triceps tendon tear in which there has been one documented case. This case report illustrates a 37-yr-old African-American male who sustained non-simultaneous bilateral partial triceps tendon avulsions. He sustained a traumatic right partial triceps tendon avulsion after a fall onto an outstretched right arm that required operative repair after failure of conservative treatment. Five months later, he sustained a similar injury after falling on an outstretched left arm that was repaired 9 d later. His post-operative courses were uncomplicated. He returned to full duty at his 6 mo and remained symptom free at 12 mo. The case demonstrates that operative treatment of partial triceps tendon avulsions using bone tunnels yields good outcomes in high-demand patients who have failed conservative treatment and who have had an operative repair of the contralateral extremity.

A Case of Cutaneous Leishmaniasis guyanensis Mimicking Otitis Externa.

Cutaneous leishmaniasis typically presents as a painless papule progressing to an ulcer or plaque. In this case study of the ear, the disease manifested as a small painful bump progressing into redness and swelling about the ear with purulent drainage. After multiple oral/intravenous antipseudomonal, antistaphylococcal, and antifungal treatments, there was no improvement. The skin progressed to an erythematous plaque and hemorrhagic ulcer; punch biopsy and speciation revealed Leishmaniasis guyanensis. The patient was switched to a seven-dose course of intravenous L-amphotericin B (visceral leishmaniasis protocol). Within 21 days, pain and edema resolved and the ulcers healed. Three-month follow-up demonstrated no recurrence. Further studies are needed to evaluate the use of L-amphotericin B in Leishmaniasis guyanensis.

Assessment of Sub-Micron Particles by Exploiting Charge Differences with Dielectrophoresis.

The analysis, separation, and enrichment of submicron particles are critical steps in many applications, ranging from bio-sensing to disease diagnostics. Microfluidic electrokinetic techniques, such as dielectrophoresis (DEP) have proved to be excellent platforms for assessment of submicron particles. DEP is the motion of polarizable particles under the presence of a non-uniform electric field. In this work, the polarization and dielectrophoretic behavior of polystyrene particles with diameters ranging for 100 nm to 1 µm were studied employing microchannels for insulator based DEP (iDEP) and low frequency (<1000 Hz) AC and DC electric potentials. In particular, the effects of particle surface charge, in terms of magnitude and type of functionalization, were examined. It was found that the magnitude of particle surface charge has a significant impact on the polarization and dielectrophoretic response of the particles, allowing for successful particle assessment. Traditionally, charge differences are exploited employing electrophoretic techniques and particle separation is achieved by differential migration. The present study demonstrates that differences in the particle's surface charge can also be exploited by means of iDEP; and that distinct types of nanoparticles can be identified by their polarization and dielectrophoretic behavior. These findings open the possibility for iDEP to be employed as a technique for the analysis of submicron biological particles, where subtle differences in surface charge could allow for rapid particle identification and separation.