Approaching "Elective" Surgery in the Era of COVID-19.

The coronavirus disease 2019 pandemic created unprecedented challenges for the health care system. To meet capacity demands, hospitals around the world suspended surgeries deemed to be elective. In hand surgery, numerous pathologies are treated on an elective basis, but a delay or absence of care may result in poorer outcomes. Here, we present an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term "elective," we define procedures that can be safely delayed on the basis of 3 considerations. First, a safe delay is possible only if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, 3 case examples are discussed considering individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crisis that may strain resources, but further considerations may be important if an operation requires hospital admission.

Design and synthesis of a bis-macrocyclic host and guests as building blocks for small molecular knots.

The thread-link-cut (TLC) approach has previously shown promise as a novel method to synthesize molecular knots. The modular second-generation approach to small trefoil knots described herein involves electrostatic interactions between an electron-rich bis-macrocyclic host compound and electron-deficient guests in the threading step. The bis-macrocyclic host was synthesized in eight steps and 6.6% overall yield. Ammonium and pyridinium guests were synthesized in 4-5 steps. The TLC knot-forming sequence was carried out and produced a product with the expected molecular weight, but, unfortunately, further characterization did not produce conclusive results regarding the topology of the product.

Diagnosis and Management of Thoracic Myelopathy.

Thoracic myelopathy can be a challenging condition to diagnose and treat. Successful outcomes depend on early recondition of the pathology and appropriate surgical referral in cases of progressive neurologic deterioration. The thoracic cord is tethered in kyphosis by the dentate ligaments and contains a tenuous blood supply. These conditions make the thoracic cord particularly susceptible to external compression and ischemic damage. Careful preoperative planning with specific attention to the location and source of thoracic stenosis is critical to successful decompression and complication avoidance. The purpose of this discussion is to outline the common sources of thoracic myelopathy and current recommendations regarding diagnosis and management. The review concludes with an overview of the most up-to-date literature regarding clinical outcomes.

Cervical Myelopathy: An Update on Posterior Decompression.

STUDY DESIGN: This was a narrative review. OBJECTIVE: The aim was to discuss current methods and review updated outcome studies regarding posterior decompression in the management of cervical myelopathy. SUMMARY OF BACKGROUND DATA: Progressive myelopathy in the cervical segments is an indication for urgent surgical management. Although nonoperative treatment is an option in mild to moderate cases, the majority of patients will experience deterioration in neurological function requiring surgical decompression. METHODS: A review of the literature was performed using PubMed to provide updated information regarding posterior cervical decompression in the management of myelopathy. RESULTS: There are numerous studies comparing outcome data between cervical laminectomy and fusion with laminoplasty. While each technique has advantages and disadvantages, both provide adequate decompression and good long-term outcomes in patients meeting appropriate criteria. CONCLUSIONS: Posterior decompression is an important approach for spine surgeons to have in their toolkits when treating cervical myelopathy.

Wound care practices after orthopaedic trauma surgery are highly variable and not evidence based.

OBJECTIVE: Given the tremendous medical, social and financial costs of surgical site infections, the pressure to minimize these complications has been mounting. There remains a substantial gap in evidence-based practice for postoperative wound care after orthopaedic trauma surgery. The purpose of this study is to determine what standards are currently in practice for postoperative wound management. METHODS: A 16-question web-based survey was published on the Orthopaedic Trauma Association website and disseminated to members through the association's quarterly email. The survey gathered data on postoperative wound care practices; specifically, when wound checks are performed, and when providers allow patients to get the incisions wet. RESULTS: 102 Orthopaedic surgeons completed the survey. Ninety-one percent were trauma fellowship trained, and 95% worked at either a Level I (76%) or Level II (19%) trauma center. There were over 100 different proposed protocols captured by the survey. The majority of surgeons (54%) perform a wound check within the first three days after surgery. Additionally, half of surgeons (50%) do not permit patients to get their incisions wet until sutures and staples are removed. CONCLUSION: Wound care routines following surgical management of orthopaedic trauma injuries are highly variable. Diverse protocols are performed at the discretion of the treating surgeon without scientific basis. This study defines immense variability in one aspect of peri-operative care that could play an important role in surgical site infections and provides a foundation for future studies to explore the potential influence of standardized wound care routines on post-operative infections and wound healing.

Accuracy of magnetic resonance imaging in predicting anterior cruciate ligament tear location and tear degree.

PURPOSE: The purpose of this study is to evaluate the reliability of magnetic resonance imaging (MRI) in predicting the location of ACL tears in preoperative planning for anterior cruciate ligament (ACL) repair. METHODS: Thirty-four patients who underwent ACL repair were retrospectively analyzed to compare intraoperative arthroscopic findings with preoperative MRIs. RESULTS: For identifying type I tears, the sensitivity of MRI was 9.0% and the accuracy of MRI was 8.8%. There was moderate interrater agreement between MRI findings for tear location and tear degree. CONCLUSION: MRI alone may not necessarily be accurate in identifying which ACL tears are amenable to repair. STUDY DESIGN: Retrospective case series; Level of Evidence: IV.

Historical Perspective: Thomas E. Whitesides, Jr.

: Dr. Thomas Whitesides was a pioneer in general orthopedics and spine surgery. He brought the anterior approach to the United States in the management of thoracolumbar trauma, a revolutionary step at the time. At Emory, he taught 100s of residents and fellows using the Socratic method. Dr. Whitesides remains a valuable consultant for complex spine cases to this day.

Secondhand smoke and traffic exhaust confer opposing risks for asthma in normal and overweight children.

OBJECTIVE: Exposure to ultrafine particles (UFP) in secondhand smoke (SHS) and traffic-related air pollution (TRAP) may elicit chronic inflammation. It was hypothesized that the association between these exposures would be potentiated in overweight versus normal-weight children. METHODS: Average lifetime exposure to TRAP and SHS and objective, physician-diagnosed asthma were determined for 575 children at age 7. Overweight was defined as having a body mass index (BMI) >85th percentile for age and gender. The association between TRAP and SHS exposure and asthma was examined by logistic regression stratified by BMI. RESULTS: A total of 131 children were overweight; the prevalence of asthma was 24.4% and 14.2% among overweight and normal-weight children, respectively. Exposure to SHS was significantly associated with asthma among overweight (adjusted odds ratio [adjOR] = 3.0; 95% confidence interval [CI] = 1.2, 7.4) but not normal-weight children (adjOR = 1.1; 95% CI = 0.4, 2.7). In contrast, TRAP was significantly associated with asthma among normal-weight (adjOR = 1.8; 95% CI = 1.0, 3.4) but not overweight children (adjOR = 0.7; 95% CI = 0.4, 2.7). CONCLUSIONS: The association between SHS and TRAP exposure and asthma is modified by children's weight. Children's time-activity patterns, including time spent indoors or outdoors, may vary by weight and play an important role in these UFP exposures.