Antimicrobial effects of blue light therapy against cutibacterium acnes: optimal dosing and impact of serial treatments.

Background: Blue light therapy (BLT) is a Food and Drug Administration cleared modality used in dermatology as an effective treatment of acne. The primary purpose of this study is to determine if there are dose-dependent antimicrobial effects of BLT against Cutibacterium acnes (C. acnes). Methods: A known strain of C. acnes was grown on chocolate agar in a controlled laboratory environment under anaerobic conditions for 1 week. After 1 week, 2-3 colonies of C. acnes were isolated and transferred to broth medium to incubate for 2 or 7 days. Broth vials (treatment arm) then underwent 1 of 6 different blue light dosing treatment regimens and a duplicate broth vial served as a control left open to the same environment. The BLT regimens were a single treatment of 25 J/cm2, 50 J/cm2, 75 J/cm2, 100 J/cm2, 2 serial treatments of 50 J/cm2 separated by 24 hours, or 2 serial treatments of 75 J/cm2 separated by 24 hours. The Omnilux Blue device (415 nm wavelength) was used for all BLT treatments and delivered, on average, 1.68 ± 0.004 J/min. Following treatment, the control and treatment broth samples were plated on chocolate agar and allowed to grow for 7 days. After 7 days, plates were counted and colony forming units (CFUs) were calculated. Six trials were completed for each BLT dosing regimen based on an a priori power analysis of 6 individual 2-sided t-tests. Comparisons in the primary outcome were made via mixed-effects analysis of variance with replicate as a random effect. Results: All BLT treatment regimens resulted in significantly fewer CFUs than their aggregate control plate CFUs (P < .05 for all). Furthermore, in 2-way comparison of CFUs between BLT treatment groups, a single treatment of 75 J/cm2 did lead to significantly less growth than 25 J/cm2 (P = .017) and 50 J/cm2 (P = .017). There were no improved antimicrobial effects with serial treatments when comparing 2 doses of 50 J/cm2 with a single dose of 100J/cm2, nor were 2 doses of 75 J/cm2 more efficacious than 100 J/cm2. Using the Omnilux Blue device, it took 44.8 minutes to deliver a 75 J/cm2 dose. Conclusion: BLT is an effective antimicrobial agent against this single virulent strain of C. acnes. Treatment dosing of 75 J/cm2 was identified to be the most effective dose per unit time. Serial treatments did not lead to superior antimicrobial effects over a single, high-dose treatment.

Bone quality in total shoulder arthroplasty: a prospective study correlating computed tomography Hounsfield units with thumb test and fracture risk assessment tool score.

Background: To evaluate if Hounsfield units (HU) measured on preoperative computed tomography (CT) scans at the anatomic neck of the proximal humerus correlates with intraoperative findings of the "thumb test" in assessment of bone quality in shoulder arthroplasty patients. Methods: Primary anatomic total shoulder and reverse total shoulder arthroplasty patients from 2019-2022 with an available preoperative CT scan of the operative shoulder were prospectively enrolled at a single center with 3 surgeons who perform shoulder arthroplasty. The "thumb test" was performed intraoperatively; a positive test signified "good bone." Demographic information, including prior dual x-ray absorptiometry scans, was extracted from the medical record. HU at the cut surface of the proximal humerus were calculated, as was cortical bone thickness on preoperative CT. Fracture risk assessment tool (FRAX) scores were calculated for 10-year risk of osteoporotic fracture. Results: A total of 149 patients were enrolled. Mean age was 67.6 ± 8.5 years with 69 (46.3%) being males. Patients with a negative thumb test were significantly older (72.3 ± 6.6 vs. 66.5 ± 8.6 years; P < .001) than those with a positive thumb test. Males were more likely to have a positive thumb test than females (P = .014). Patients with a negative thumb test had significantly lower HUs on preoperative CT (16.3 ± 29.7 vs. 51.9 ± 35.2; P < .001). Patients with a negative thumb test had a higher mean FRAX score (14.1 ± 7.9 vs. 8.0 ± 4.8; P < .001). Receiver operator curve analysis was performed to identify a cut-off value for CT HU of 36.67, above which the thumb test is likely to be positive. Furthermore, receiver operator curve analysis also identified optimal cut-off values for 10-year risk of fracture by FRAX score of 7.75 HU, below which the thumb test is likely to be positive. Fifty patients were at high risk based on FRAX and HU; surgeons classified 21 (42%) as having "poor bone" quality through a negative thumb test. High-risk patients had a negative thumb test 33.8% (23/68) and 37.1% (26/71) of the time for HU and FRAX, respectively. Conclusions: Surgeons are poor at identifying suboptimal bone quality at the anatomic neck of the proximal humerus based on intraoperative thumb test when referencing against CT HU and FRAX scores. The objective measures of CT HU and FRAX scoring may be useful metrics to incorporate into surgeons' preoperative plans for humeral stem fixation using readily available imaging and demographic data.

Current State of Research Gap-Years in Orthopedic Surgery Residency Applicants: Program Directors' Perspectives.

Background: The purpose of this study was to determine how orthopedic residency program directors (PDs) evaluate residency applicants who participated in a research gap-year (RGY). Methods: A 23 question electronically administered survey was created and emailed to all Accreditation Council for Graduate Medical Education (ACGME) orthopedic residency PDs for the 2020-21 application cycle. PDs were emailed directly if active contact information was identifiable. If not, program coordinators were emailed. The survey contained questions regarding the background information of programs and aimed at identifying how PDs view and evaluate residency applicants who participated in a RGY. Descriptive statistics for each question were performed. Results: Eighty-four (41.8%) of 201 PDs responded. Most respondent programs (N=62, 73.8%) identified as an academic center. The most common geographic region was the Midwest, N=33 (39.3%). Few programs (N=3, 3.8%) utilize a publication "cut-off" when screening residency applicants. When asked how many peer-reviewed publications were necessary to deem a RGY as "productive," responses ranged from 0-15 publications (median interquartile range 4.5 [3-5]). Forty-one (53.3%) PDs stated they would council medical students to take a RGY with USMLE Step 1 scores being the #1 factor guiding that advice. More PDs disagree than agree (N=35, 43.6%; vs N=22, 28.2%) that applicants who complete a RGY are more competitive applicants, and 35 PDs (45.5%) agree research experiences will become more important in resident selection as USMLE Step 1 transitions to Pass/Fail. Conclusion: Program directors have varying views on residency applicants who did a RGY. While few programs use a publication cutoff, the median number of publications deemed as being a "productive" RGY was approximately 5. Many PDs agree that research experiences will become more important as USMLE Step becomes Pass/Fail. This information can be useful for students interested in pursuing a RGY and for residency programs when evaluating residency applicants. Level of Evidence: IV.

Patient compliance and satisfaction with topical benzoyl peroxide gel prior to shoulder surgery.

Background: Cutibacterium acnes is a common pathogen leading to postoperative shoulder infections. Many centers are utilizing 5% topical benzoyl peroxide (BPO) gel to decrease cutibacterium acnes bioburden prior to surgery. The purpose of this study was to evaluate patient compliance, tolerance, and side effects of applying BPO to the shoulder prior to surgery. Our hypothesis was that BPO would be well tolerated with few, minor side effects, and patients would comply with a regimen of 5 treatments spanning 48 hours prior to surgery. Methods: All patients undergoing operative intervention, either open or arthroscopic, about the shoulder from August 7, 2020, through July 15, 2021, by a single surgeon were instructed to apply BPO to the shoulder after showering, on dry skin, in the morning and evening, starting 48 hours before their surgical date. Patients were instructed to apply a half-dollar-sized quantity for each treatment. There were a total of 5 topical applications. On the day of surgery, patients were given a 6-question survey regarding side effects experienced, BPO treatments missed, ease of treatment, and a scenario question. Demographic information was collected, and a satisfaction survey was administered upon study completion. Results: A total of 183 patients out of a possible 284 eligible patients (64.4%) completed the survey. The median (interquartile range) age at surgery was 59.9 years. Sixty-four participants (35%) in the study cohort were female. One-hundred thirteen (61.7%) had an arthroscopic surgical approach, whereas 70 (38.3%) underwent open shoulder surgery. Most patients (N = 152, 83.5%) experienced no side effects from the topical 5% BPO gel treatments. Twenty-two (12.0%) patients missed 1 treatment, 10 (5.5%) missed 2 treatments, 1 (0.5%) missed 3 treatments, 3 (1.6%) missed 4 treatments, and 4 (2.2%) missed all 5 treatments. The majority of patients, 143 (78.1%), completed all 5 treatments. When prompted to choose between serial skin preparation treatments at home leading up to surgery or a single light-based decolonization procedure in the preoperative holding area on the day of surgery, 111 (60.7%) preferred to undergo antimicrobial treatment at home and arrive for surgery as otherwise scheduled. Conclusion: Serial preoperative applications of topical 5% BPO gel are well tolerated by the majority of patients. Over 20% of patients missed at least one application of BPO. Most patients prefer home-based antimicrobial treatments compared with arriving earlier on the day of surgery for a single light-based antimicrobial treatment.

Incidence of Research Gap Years in Orthopaedic Residency Applicants: The New Standard?

INTRODUCTION: The purpose of this study was to (1) determine the incidence of a research gap year (RGY) in orthopaedic residency applicants at a single institution over a seven-year span; (2) compare applicant characteristics between applicants who did a RGY with those who did not, and (3) report variables associated with match success for RGY applicants. METHODS: Applicants who reported taking a year out from medical school to pursue research on their Electronic Residency Application Service to a single institution from 2014 to 2015 through 2020 to 2021 were reviewed. RESULTS: A strong positive correlation was noted between the percentage of applicants who participated in a RGY and time (Pearson correlation: r = 0.945 [95% confidence interval (CI), 0.666-0.992], P = 0.001). Over the study period, 11% of applicants had done a RGY, most commonly after their third year of medical school (82.7%). Most RGY applicants matched orthopaedics (72.8%) and 19.4% matched at the same institution they did their RGY. CONCLUSION: The percentage of RGY applicants to the study institution nearly doubled between 2014 to 2015 and 2020 to 2021. RGY applicants had a higher match rate than nationally published match rates. Further study is needed on a national level.

Efficacy of combinational therapy using blue light and benzoyl peroxide in reducing Cutibacterium acnes bioburden at the deltopectoral interval: a randomized controlled trial.

BACKGROUND: The purpose of this study was to compare the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) preparation in eradicating Cutibacterium acnes at the deltopectoral interval measured by positive, quantitative culture findings. METHODS: Adult male volunteers were randomized to 1 of 3 treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. In the BLT group, a single 23-minute treatment was administered at an estimated irradiance of 40 mW/cm2 (radiant exposure, 55.2 J/cm2). In the BPO-BLT group, volunteers received both treatments as described earlier. After treatment with either BPO, BLT, or both, a single swab culture was taken from the treatment shoulder. Next, control and treatment shoulders were prepared with CHX, and cultures were taken from each shoulder. Cultures were sent for anaerobic quantitative growth analysis with both polymerase chain reaction and Sanger sequencing confirmation of presumptive C acnes colonies. RESULTS: This study enrolled 60 male volunteers, 20 per group, with no loss to follow-up. After treatment but prior to CHX administration, all culture samples in the BPO group and BLT group grew C acnes. Prior to CHX, 16 samples (80%) in the BPO-BLT group grew C acnes. On quantitative analysis, the BPO group and BPO-BLT group had significantly less growth of C acnes compared with the BLT group after treatment but prior to CHX (P < .05 for each). Following CHX administration, the BPO and BPO-BLT groups had significantly fewer positive culture findings (odds ratios of 0.03 and 0.29, respectively) and less quantity of growth compared with their control arms (P < .05). This was not seen in the BLT group. For quantitative between-group analysis, no significant synergistic effects were seen with BPO-BLT compared with BPO alone (P = .688). There was no difference in side effects between groups. CONCLUSION: The combination of topical BPO and CHX was effective at eliminating C acnes in most cases. BLT alone did not demonstrate effective antimicrobial properties against C acnes at the radiant exposure administered in this study. Combining BPO and BLT did not lead to significant synergistic antimicrobial effects. Both BPO and BLT are safe with few, transient side effects reported. More work is needed to determine whether BLT at higher radiant exposures or serial treatment results in bactericidal effects against C acnes in vivo.

Osteoporosis Screening Is Often Indicated but Overlooked Prior to Rotator Cuff Repair.

PURPOSE: To (1) report the percentage of patients undergoing rotator cuff repair (RCR) who were appropriately screened with dual-energy X-ray absorptiometry testing prior to surgery, if indicated, and (2) determine the percentage of patients properly prescribed osteoporosis medications within 6 months of surgery. METHODS: Consecutive patients aged 50 years or older who underwent elective RCR at a single tertiary-care center over a 1-year period were reviewed. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density. The U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Patients with acute fractures or revision surgery were excluded. RESULTS: Of the 218 patients included, 129 were women (58.1%). The mean age was 61.5 ± 7.2 years. One hundred thirty-one RCRs (60.1%) occurred within 3 months of injury. A total of 69 patients (31.7%) met the NOF criteria for bone mineral density screening. Of these patients, 23 (33.3%) were appropriately screened with a dual-energy X-ray absorptiometry scan. Primary care providers initiated bone health assessment in 18 of the 23 appropriately screened patients, with orthopaedic providers initiating the workup in 3 patients (13.0%). Thirty-two patients (14.7%) met the NOF criteria for pharmacologic management of osteoporosis. Of these patients, 5 (15.6%) were treated. Patients meeting the medication criteria were older (69.1 ± 7.7 years vs 60.2 ± 6.3 years, P < .001), had a lower body mass index (28.8 ± 6.1 vs 31.5 ± 6.5, P = .028), and had chronic rotator cuff tears (P = .015). CONCLUSIONS: Patients aged 50 years or older undergoing RCR are often not appropriately screened for osteoporosis. Even when appropriately screened, only 15.6% of patients meeting the indications for pharmacologic intervention for bone health optimization were prescribed appropriate medications. Although bone health optimization may or may not affect surgical timing, patient encounters related to rotator cuff tears can be used as an opportunity for providers to initiate osteoporosis screening and treatment protocols. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

INTRODUCTION: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. METHODS: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. RESULTS: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). CONCLUSION: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Creation of a Custom-Length, Humeral Antibiotic Cement Spacer for Use in Treatment of Shoulder Periprosthetic Joint Infection.

Periprosthetic joint infection of the shoulder is a challenging clinical situation to manage owing to the fastidious organisms often present and delayed clinical presentation. While several treatment options have been described, the mainstay of treatment remains a staged revision with the use of a humeral antibiotic cement spacer. Such spacers are commercially available or can be made by hand. When an extended humeral osteotomy is required to remove a well-fixed long stem humeral component, it may be advantageous to place an antibiotic spacer with a stem length approximately as long as the hardware being removed. This technique demonstrates creation of a custom length, humeral antibiotic cement spacer for use in treatment of shoulder periprosthetic joint infection.

Factors considered in ranking orthopedic shoulder and elbow fellowship applicants: a survey of program directors.

Background: Orthopedic fellowship positions continue to be increasingly competitive, with most orthopedic residency graduates pursuing fellowship after completion of residency. Shoulder and elbow fellowship training represents an increasingly competitive and relatively smaller cohort of applicants than other subspecialties; there are only 29 programs with a total of 40 offered positions. The purpose of this survey is to identify and rank factors considered most important by shoulder and elbow fellowship directors when identifying potential fellowship candidates. Methods: A web-based survey was emailed to all 29 orthopedic shoulder and elbow fellowship directors recognized by American Shoulder and Elbow Surgeons. Demographic information was collected regarding program size, total number of applicants interviewed, and total number of applicants subsequently ranked. The survey also included a list of twelve applicant characteristics which each program director was asked to rank in a sequential order (most important to least). The median score of each factor was calculated, and a weighted score was applied to the top five (of twelve) categories selected by each program. Five points were given to the top-ranked factor. Four points were given to factors ranked 2nd, three points to factors ranked 3rd, two points to factors ranked 4th, and one point to factors ranked 5th. The weighted scores were then used to determine the most highly desired applicant characteristics. Results: Twenty-two of 29 (76%) orthopedic shoulder and elbow fellowship programs responded to the survey. Fourteen of 22 (64%) programs interview 20 or fewer applicants each year. No programs ranked more than 25 applicants. Twelve of 22 (55%) of program directors rated the interview as the most important factor, whereas 6 of 22 (27%) selected letters of recommendation. Based on the weighted score calculation, interviews, letters of recommendation, and personal connections to the applicant/letter writers comprised the top three categories, respectively, and captured 193 of 330 (58%) of the total available points in the weighted score. Strength of shoulder/elbow experience in residency, ties to the geographical area, and comments made regarding technical competence scored among the lowest factors. Conclusion: Orthopedic shoulder and elbow fellowship directors consistently ranked interviews, letters of recommendation, and personal connection to applicant/letter writer higher than other factors when ranking applicants. This information provides both program directors as well as applicants with important information to consider when navigating the shoulder and elbow fellowship application process.

Role of pre-revision tissue biopsy in evaluation of painful shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Pre-revision tissue biopsy (PTB) for culture has been used as a diagnostic tool in the evaluation for periprosthetic joint infection among patients with a painful shoulder arthroplasty. The purpose of this study was to (1) determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of PTB culture results compared with results of "gold-standard" tissue biopsy for culture taken at the time of subsequent revision surgery (TBR), and (2) report the current indications and protocols described for use of PTB. The hypothesis was that PTB culture results would correlate highly with results of TBR and that protocols for PTB would vary by institution. METHODS: By use of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis of English-language literature were performed using the Embase, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases from inception through March 2020. Methodological Index for Non-randomized Studies (MINORS) validated grading criteria were used to summarize the quality and bias of included studies. Studies were included if an arthroscopic or open tissue biopsy was performed in patients who had previously undergone anatomic total shoulder arthroplasty, shoulder hemiarthroplasty, or reverse total shoulder arthroplasty as a separate procedure prior to revision of components, if applicable. Meta-analysis to identify the sensitivity, specificity, NPV, and PPV of PTB was performed. Analysis was performed by first defining 1 positive PTB culture result as infection and then defining 2 positive culture results as infection. RESULTS: A total of 1751 titles were screened, and 66 full-text articles were reviewed for inclusion. Four total studies encompassing 72 cases met the inclusion criteria. All studies were small (N = 13 to N = 23), retrospective series, with all but 12 biopsies performed arthroscopically. Sixty-five patients (90.2%) underwent subsequent revision surgery and TBR. Of these patients, 23 (35.4%) had ≥1 positive culture result with PTB and TBR. By this definition, the sensitivity of PTB was 92.0% (95% confidence interval [CI], 72.5%-98.6%); specificity, 70.0% (95% CI, 53.3%-82.9%); PPV, 65.7% (95% CI, 47.7%-80.3%); and NPV, 93.3% (95% CI, 76.5%-98.8%). For 2 positive PTB results, the sensitivity of PTB was 100% (95% CI, 51.7%-100%); specificity, 50.0% (95% CI, 31.4%-68.6%); PPV, 33.3% (95% CI, 14.4%-58.8%); and NPV, 100% (95% CI, 69.9%-100%). No complications of PTB were reported. The mean Methodological Index for Non-randomized Studies (MINORS) grade was 11.4 (range, 8.5-14). CONCLUSION: PTB is a sensitive diagnostic modality with a high NPV that may aid in the diagnosis of shoulder periprosthetic joint infection in patients with a painful shoulder arthroplasty. Given the disparate biopsy protocols, greater standardization of clinical best practices and broader prospective studies are necessary to define the future role of PTB in dictating treatment.

The Effect of an Orthopaedic Surgeon's Attire on Patient Perceptions of Surgeon Traits and Identity: A Cross-Sectional Survey.

INTRODUCTION: In orthopaedic surgery, limited research is available addressing how attire, including white coats (WC) and feminine attire such as skirts, affects patient perceptions. It is unknown how surgeon appearance is associated with identification as a surgeon and perception of clinical skills, nor whether this differs between male and female surgeons. METHODS: An image-based survey was offered to all adult patients in four orthopaedic surgeons' sport medicine or foot and ankle clinics. Respondents viewed 10 photos of male and female models in varying attire and identified that individual's most likely role on the healthcare team. Then, in 10 photos pairs, respondents selected which surgeon showed more competence, ability to excel in performing the physical components of surgery, likelihood to provide a good surgical outcome, and trustworthiness. RESULTS: Two hundred thirty-eight patients participated in the survey. Men were identified as surgeons significantly more frequently than women in similar clothing (P < 0.05) for all attire except a business attire without a WC (men: 18.2% vs women: 11.2%; P = 0.252). Patients ranked physicians wearing a WC with any attire as more competent and more likely to give a good surgical outcome than those without (all P < 0.005). Patients found women in feminine attire significantly less likely to excel in performing the physical parts of surgery than women in scrubs (P = 0.001). DISCUSSION: Women surgeons who wear feminine business attire instead of scrubs may be perceived less able to perform the physical work of operating, but are otherwise rated comparably with their peers, both male and female. Surgeons wearing WC are generally perceived more favorably than those without WC, an effect that is magnified for perceptions of competence for female surgeons. Men are more readily identified as surgeons than women when wearing a similar attire, except for a business attire without WC. There are continuing differences in how patients perceive male and female orthopaedic surgeons based on their attire.

Prevalence and Treatment of Osteoporosis Prior to Elective Shoulder Arthroplasty.

INTRODUCTION: The rate of preoperative osteoporosis in lower extremity arthroplasty is 33%. The prevalence of osteoporosis in shoulder arthroplasty patients is inadequately studied. The purpose of this study was to (1) determine the prevalence of osteoporosis in patients undergoing elective shoulder arthroplasty, (2) report the percentage of patients having dual-energy x-ray absorptiometry (DEXA) testing before surgery, and (3) determine the percentage of patients who have been prescribed osteoporosis medications within 6 months before or after surgery. METHODS: This retrospective case series included all adults aged 50 years and older who underwent elective shoulder arthroplasty at a single tertiary care center over an 8-year period. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. RESULTS: Two hundred fifty-one patients met the inclusion criteria; 171 (68%) met the criteria for DEXA testing, but only 31 (12%) had this testing within 2 years preoperatively. Eighty patients (32%) met the NOF criteria for receipt of pharmacologic osteoporosis treatment, and 17/80 (21%) received a prescription for pharmacotherapy. DISCUSSION: Two-thirds of elective shoulder arthroplasty patients meet the criteria to have bone mineral density measurement done, but less than 20% have this done. One in three elective shoulder arthroplasty patients meet the criteria to receive osteoporosis medications, but only 20% of these patients receive therapy.

Effect of Microfracture on Meniscal Tear Healing in a Goat (Capra hircus) Model.

Meniscal injuries are an extremely common cause of knee pain. Meniscal repairs performed with concomitant anterior cruciate ligament reconstruction appear to heal at a higher rate than meniscal repairs performed in isolation. This may be due in part to the release of marrow elements into the knee and the time of meniscal repair. In cases of isolated meniscal repair, some orthopedic surgeons use microfracture to release marrow elements into the joint as an adjunct to enhance meniscal healing. This study evaluated rates of meniscal tear healing with or without the performance of microfracture in a goat (Capra hircus) model. Forty castrated young adult male goats underwent either a horizontal or a longitudinal 1.0-cm meniscal tear with or without microfracture. All procedures were performed open, in a bloodless field. Meniscal tears were created in the peripheral half of the body of the medial meniscus. The goats were euthanized at 6 months, and meniscal tears were analyzed and classified as complete healing, partial healing, or no healing by direct visualization. A probe was used as an aid to evaluate and classify the meniscal tears. Twenty (87%) of 23 goat meniscal tears showed at least partial healing when performed with concomitant microfracture. Only 5 (29%) of 17 menisci showed any healing in goats that did not receive microfracture. This difference in healing rates was statistically significant (P<.001). Fifteen (65%) meniscal tears accomplished with microfracture were completely healed, whereas only 2 (12%) menisci showed complete healing without microfracture (P<.001). The results of this study suggest that the release of bone marrow elements into the knee by microfracture improves meniscal healing rates.

2014 Fort Hood, Texas, mass casualty incident: reviews and perspectives.

On April 2, 2014, in Fort Hood, Texas, an active shooter incident occurred where four active duty soldiers were tragically killed. Active shooter incidents are becoming alarmingly more frequent over the last decade in the USA. The authors provide a detailed account of the events that occurred within the hospital and an evaluation of the triage decisions made on that day. A detailed review of mass casualty preparedness and the general approach to triage processes are also described.

Exposure of the distal humerus using a triceps hemi-peel approach.

This study evaluates the exposure of the distal humerus articular surface obtained using a triceps hemi-peel approach versus the triceps-flexor carpi ulnaris (TRIFCU) approach. Twelve cadaveric upper extremity specimens were dissected using a lateral-to-medial hemi-peel modification of the TRIFCU approach to the elbow. After completing the hemi-peel exposure, the visible border of the articular surface was marked with a permanent ink pen. The dissection was continued to complete a standard TRIFCU approach, and the visible border of the exposure was again marked. The elbow was disarticulated, and calibrated digital images were taken to quantify the humeral surface area exposed through each approach. During both approaches, the surgeon's ability to visualize the intertrochlear groove, medial crista anterior crest, medial crista posterior crest, anterior capitulum, and posterior capitulum was recorded. No difference was found in the surgeons' ability to identify the 5 designated anatomic landmarks using the hemi-peel versus the TRIFCU approach. The TRIFCU exposed an average of 6.68 cm(2) of the trochlear articular surface, whereas the hemi-peel approach exposed an average of 5.93 cm(2). The average difference between the exposures was 0.75 cm(2) (P<.001), or 12.5%. The hemi-peel and TRIFCU approaches to the elbow both allow excellent visualization of the distal humerus articular surface. The hemi-peel exposure is a useful approach for the accurate reduction and fixation of displaced intra-articular distal humerus fractures.

Do protective lead garments harbor harmful bacteria?

This study attempted to identify and characterize bacteria present on shared-use protective lead shielding garments worn in the operating room. Those worn at the authors' institution were collected and swabbed in designated 5×5-cm areas. Swabs were sent to the clinical laboratory for bacterial isolation and identification. All isolates were identified using standard microbiological methods. Isolates then underwent antimicrobial susceptibility testing as per standard hospital procedures. Of 182 total collected swabs, bacteria were isolated on only 5 (2.7%) samples. Coagulase-negative Staphylococci was identified on 3 samples and the remaining 2 grew coagulase-negative Staphylococci and gram-positive rods. The collection sites for these isolates were the lead apron, midline, bottom outer surface (n=3), thyroid shield midline, inner surface (n=1), and skirt midline, bottom inner surface (n=1). Of the collected samples, 98.3% were negative for bacterial growth. The remaining isolates were consistent with common skin flora. No multi-drug resistant organisms were identified on any garments. Standard cleaning procedures at the institution are an effective way to prevent growth of bacteria on shared-use protective lead shielding garments worn in the operating room.

Volumetric muscle loss.

Prevention of infection, as well as bone covering and healing, is paramount in the management of limb injury with associated muscle injury. Volumetric muscle loss (VML) is the traumatic or surgical loss of skeletal muscle with resultant functional impairment. No standardized evaluation protocol exists for the characterization and quantification of VML. Clinical photographs and video recordings, range of motion measurements, manual muscle strength testing, and isokinetic muscle function testing may prove to be useful in documenting VML. Current treatment options include functional free muscle transfer and the use of advanced bracing designs. Advances in powered bracing and regenerative medicine may one day provide additional therapeutic options. Further research on VML is warranted.