Factors affecting risk of recurrence with periprosthetic infection in shoulder arthroplasty.

BACKGROUND: The goal of treating periprosthetic infection, besides its eradication, is to avoid recurrence. The purpose of this study was to evaluate the impact of increasing Infection Severity (IS) score (based on the 2018 International Consensus Meeting on Orthopedic Infections statement), single-stage revision, and pathogenicity of the infective organism on the risk of infection recurrence. METHODS: A database of 790 revisions performed by a single surgeon from 2004-2020 was reviewed for patients with minimum 2-year follow-up and ≥1 positive culture finding and/or pathology result from the revision surgical procedure. In total, 157 cases performed in 144 patients met the inclusion criteria. These cases were then categorized by infection probability (IS score) according to the 2018 consensus statement. Of 157 cases, 46 (29%) were classified as definitely or probably infected; 25 (16%), possibly infected; and 86 (55%), unlikely to be infected. Additionally, patients were grouped by single-stage surgery and pathogenicity of the infective organism. RESULTS: A recurrence in this study was classified as the growth of the same organism in any patient requiring revision surgery. The 86 cases in the group with unlikely infection showed a recurrence rate of 2.3%. The 25 cases in the group with possible infection showed a recurrence rate of 12%. The 46 cases in the group with definite or probable infection showed a recurrence rate of 17.4%. Patients in the definite/probable infection group had a higher rate of recurrence than those in the groups with possible infection and unlikely infection (P = .009). The IS score was higher in the recurrence group than the non-recurrence group (7.5 ± 4.3 vs. 3.9 ± 3.4, P < .001). Overall, patients who underwent 1-stage revision had a 5.0% recurrence rate, but among the 34 patients with an infection classification of definite or probable who underwent 1-stage revision, the recurrence rate was 5.9%. Cases of highly virulent methicillin-resistant Staphylococcus aureus also showed a recurrence rate of 30.8% compared with 4.0% and 5.9% for Cutibacterium acnes and coagulase-negative staphylococci, respectively (P = .005). CONCLUSION: Recurrent infection after treatment of a periprosthetic infection is associated with increasing severity scores, as defined in the 2018 consensus statement, and more aggressive microorganisms. However, a single-stage surgical procedure, even in patients with higher IS scores, did not impart a significantly increased risk of recurrence.

Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures.

PURPOSE: To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS: In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS: Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION: Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

Impact of Residents on Hand Surgery Fellows' Educational Experience: A Cross-Sectional Survey.

PURPOSE: To survey current hand surgery fellows on the perceived impact of residents on their fellowship educational experience. METHODS: Electronic surveys were distributed to 177 hand surgery fellows in the United States. The survey was designed to elucidate details of their fellowship programs, percentage of time working with, and in competition with, residents in differing clinical settings, perception of the impact of residents on their education, and strategies for resolving conflicts with attending physicians and residents. RESULTS: Of the 177 hand surgery fellows, 72 (40.1%) responded to the survey, of which 61 (84.7%) were orthopedic surgery-trained, 11 (15.3%) were plastic surgery-trained, and 0 (0%) were general surgery-trained. As fellows, 56 (78%) respondents reported working alongside a dedicated resident on their service. The median percentage of time spent working with the residents was 50% or higher for all clinical environments. The median perceived percentage time in competition with residents was 25% in the operating room and 0% for all other clinical environments. Fifty-one (71%) respondents agreed or strongly agreed that residents enhanced their educational experience, and 55 (76%) respondents stated that these interactions will positively or somewhat positively affect their abilities to practice as a future hand surgeon. A plurality of fellows reported that they resolved conflicts cooperatively with residents (n = 34, 47.2%) and that this was their preference (n = 36, 50.0%). The majority of fellows were comfortable with discussing educational conflicts with their attending and/or program director (n = 67, 93.1%). CONCLUSIONS: Hand surgery fellows frequently work with residents. The operating room is the most frequent site for competition between fellows and residents. Fellows responded positively when asked if residents should be involved in their fellowship. When conflicts do arise, fellows have the skills to manage conflicts with residents collaboratively. CLINICAL RELEVANCE: This study evaluates the relationship between residents and fellows to improve the postgraduate educational experience.

Open Reduction And Internal Fixation of Tarsometatarsal (Lisfranc) Fracture Dislocations-Is Arthrodesis Necessary?

INTRODUCTION: Controversy remains regarding the optimal management of tarsometatarsal (Lisfranc) fracture dislocations. Open reduction and internal fixation (ORIF) and ORIF with primary arthrodesis (PA) have been described in the treatment of these injuries, although adverse sequelae remain problematic. Previous work has yielded small cohorts with heterogenous results. We aimed to describe the outcomes of Lisfranc fracture dislocations managed with ORIF and/or PA to identify risk factors for complications, such as nonunion and revision surgery. METHODS: A retrospective review of 206 consecutive tarsometatarsal fracture dislocations that underwent surgical repair between 2015 and 2021 was performed. Time to radiographic union was noted. Complications were recorded, including revision surgery, infection, symptomatic implant removal, posttraumatic arthritis, secondary arthrodesis, and nonunion. A comparative subgroup analysis of outcomes by treatment modality (ie, PA versus ORIF) and by injury severity (isolated injury versus concomitant lower extremity fracture) were performed. Logistic regression analysis was performed to assess factors associated with revision surgery. RESULTS: 104 patients met the inclusion criteria with a mean 13-month follow-up. Ninety-three (n = 93) patients underwent ORIF, and 11 patients underwent PA. Radiographic union was achieved in 94.2% of cases (98/104) at an average 106 days. Complications included superficial infection (3.8%), deep infection (7.7%), symptomatic implant removal (19.2%), posttraumatic arthritis (12.5%), secondary arthrodesis (4.8%), and nonunion (2.9%). No difference existed in the complication rates between those who underwent ORIF and those who underwent PA ( P = 0.50). Revision surgery rates were similar between patients who sustained isolated injuries and those with concomitant lower extremity fractures ( P = 0.31). Risk factors for revision surgery included open fractures (OR 4.01, P = 0.042) and previous psychiatric illness (OR 5.77, P = 0.016). DISCUSSION: The vast spectrum of injury in Lisfranc fracture dislocations makes uniform treatment challenging. In this large consecutive series, few failed to achieve union or required secondary arthrodesis. Open fractures and previous psychiatric illness portended worse clinical outcomes. ORIF without PA remains a viable treatment in these injuries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Effect of 3rd Carpometacarpal Arthrodesis in the Outcomes of Total Wrist Fusion Using Modern Plate Technology.

Background The inclusion of the third carpometacarpal (CMC) joint in the fusion mass in total wrist fusion (TWF) remains controversial. Our goal was to evaluate the clinical outcomes and effects of third CMC joint arthrodesis compared with bridging the CMC joint during TWF. A retrospective chart review was performed. Outcomes assessed included hardware loosening, hardware failure, symptomatic hardware necessitating removal, and need for revision arthrodesis. Case Description/Literature Review We found that concomitant third CMC joint arthrodesis was associated with a significantly reduced rate of radiocarpal and midcarpal joint nonunion, hardware loosening, and symptomatic hardware removal when compared to bridging of the CMC joint. There was no significant difference in hardware failure rates or the need for revision arthrodesis. Clinical Relevance When using a contoured dorsal spanning plate, concomitant CMC joint arthrodesis should be considered during TWF to mitigate against hardware loosening and symptomatic hardware. Level of Evidence Level IV.

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia.

BACKGROUND: Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia. METHODS: Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures. RESULTS: Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management. CONCLUSIONS: Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Assessment of 30-Day Adverse Events in Single-Event, Multilevel Upper Extremity Surgery in Adult Patients with Upper Motor Neuron Syndrome.

BACKGROUND: Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome. METHODS: A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery. RESULTS: All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1). CONCLUSIONS: With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome. LEVEL OF EVIDENCE: Level IV.

Distal Radius Fracture Treatment Outcomes in Patients With Ipsilateral Hemiplegia or Hemiparesis.

BACKGROUND: Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia. METHODS: Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union. RESULTS: There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries. CONCLUSIONS: Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.

Effect of Trapeziectomy on Carpal Stability.

Background: The scaphoid-trapezoid-trapezium (STT) articulation stabilizes the scaphoid and links the proximal and distal carpal rows. The purpose of the study was to determine whether trapezium excision in the treatment of trapeziometacarpal (TM) arthritis affects carpal stability. Methods: A retrospective chart and radiographic review was performed on all wrists that underwent trapeziectomy with suspensionplasty or ligament reconstruction, and tendon interposition for TM arthritis between 2004 and 2016. Radiographic outcome measures included the modified carpal height ratio (MCHR) and radioscaphoid (RS), radiolunate (RL), and scapholunate (SL) angles. Degenerative change at the TM and STT joints was classified according to the Eaton-Littler, and Knirk and Jupiter classification systems. Radiographic parameters were compared between preoperative and final follow-up time points. Results: A total of 122 wrists were included in the study with a mean follow-up of 3.5 years (range: 1.0-13.0 years). The mean RL (range: -2.2° ± 11.8° to -10.7° ± 16.5°) and RS angles (range: 52.6° ± 13.8° to 44.4° ± 17.8°) decreased significantly (<.001) without significant change in SL angle, indicating progressive lunate and scaphoid extension after trapeziectomy. The mean MCHR decreased significantly (range: 1.6 ± 0.1 to 1.5 ± 0.1) following trapeziectomy, indicating progressive carpal collapse. Progressive scaphoid-trapezoid arthrosis was observed following trapeziectomy. No other preoperative radiographic factors investigated were associated with significant differences in preoperative and postoperative values for radiographic outcome measures. Conclusions: Trapeziectomy can lead to loss of carpal height, coordinated extension of both the lunate and scaphoid, and progressive scaphotrapezoid arthrosis. As such, in wrists with dynamic or static carpal instability, trapeziectomy should be performed with caution due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability.

Does Proximal Row Carpectomy Improve Union in Wrist Arthrodesis? A Retrospective Cohort Study.

Background Some surgeons advocate for concomitant proximal row carpectomy (PRC) with total wrist arthrodesis (TWA), though there are limited data to support or oppose this view. Questions/Purposes Does concomitant PRC improve rates of union, revision, hardware loosening, hardware failure, and hardware removal in TWA? Patients and Methods A retrospective cohort study of patients who underwent TWA with and without concomitant PRC between January 2008 and December 2018 was undertaken. Patients were included if they underwent TWA using a dorsal spanning plate. Patients were excluded if they underwent partial wrist arthrodesis, revision TWA, or TWA with nondorsal spanning plate fixation. Results A total of 183 wrists in 180 patients were included in the study, 96 (52.5%) in the TWA only and 87 (47.5%) in the TWA + PRC groups. Median clinical and radiographic follow-up was 18.0 months (3.0-133.0 months) in the TWA + PRC group and 18.5 months (2.0-126.0 months) in the TWA only group ( p = 0.907). No difference in nonunion (TWA + PRC: 13/87 [14.9%], TWA only: 18/96 [18.8%], odds ratio: 0.76, p = 0.494), revision (TWA + PRC: 5/87 [5.75%], TWA only: 8/96 [8.33%], hazard ratio [HR]: 0.73, p = 0.586), loosening (TWA + PRC: 4/87 [4.60%], TWA only: 6/96 [6.25%], HR: 0.74, p = 0.646), failure (TWA + PRC: 5/87 [5.75%], TWA only: 4/96 [4.17%], HR: 1.55, p = 0.530), and removal (TWA + PRC: 12/87 [13.8%], TWA only: 16/96 [16.7%], HR: 0.84, p = 0.634) were identified. Conclusion Concomitant PRC might not improve rates of union or diminish complications in patient undergoing TWA. The role of PRC and the rationale for its use in TWA need to be individualized and discussed with patients prior to surgery. Level of Evidence This is a Level IV, therapeutic study.

Adverse events of radioimmunotherapy for non-Hodgkin lymphoma: A systematic review and meta-analysis.

Non-Hodgkin's lymphoma continues to be a highly prevalent entity in the general population. Currently, there are multiple treatment schemes based on chemotherapeutic agents with a great success rate. However, there is a non-negligible percentage of patients who may relapse or be refractory. In this sense, new therapeutic options have emerged in the search for adequate responses, such as monoclonal antibodies that target the CD20 molecule. Another valid option is radioimmunotherapy (RIT), which combines using monoclonal antibodies for the specific targeting of malignant cells and radiation to destroy these cells. Despite the promising results that favor RIT in several clinical studies in different target populations and types of NHL, one situation to consider is the association of this therapy and second neoplasms (acute myeloid leukemia (AML) or myelodysplastic syndrome (MSD)). In this sense, we have proposed this meta-analysis to analyze the published information and determine the incidence of this association and determine this therapy's safety.

Quality of Reduction of Displaced Intra-articular Calcaneal Fractures Using a Sinus Tarsi Versus Extensile Lateral Approach.

OBJECTIVE: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs). DESIGN: Retrospective. SETTING: Level 1 and level 2 academic centers. PATIENTS: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs. METHODS: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): <1 mm step, <5 mm gap, and/or <5° of angulation, fair (F): 1-3 mm step, 5-10 mm gap, and/or 5-15° angulation; and poor (P): >3 mm step, >10 mm gap, and/or >15° angulation. RESULTS: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18-74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P < 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P < 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06). CONCLUSIONS: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Team Approach: Multidisciplinary Perioperative Care in Upper-Extremity Reconstruction for Adults with Spasticity and Contractures.

* Spasticity is the heightened motor tone that occurs as a result of damage to upper motor neurons in the central nervous system from brain or spinal cord injuries. * Nonoperative interventions for upper-extremity spasticity include chemodenervation or orthotic use, but their efficacy may be limited in correcting severe deformities. In such cases, surgical reconstruction may be necessary. * A single-event multilevel surgery (SEMLS) is a method of addressing deformities involving the entire extremity under 1 anesthetic episode. * It is the responsibility of the surgeon to assemble and communicate with the appropriate health-care team members during the patient's hospitalization to prevent perioperative complications and to optimize outcomes after surgery. Team entities integral to successful SEMLS for patients with spasticity include respiratory therapy, nutrition, neuropalliative care, internal medicine, occupational therapy, and anesthesiology. * The goal of upper-extremity reconstruction in patients with spasticity is to improve the patient's quality of life, reduce pain, improve hygiene, restore functionality, and correct disfiguring joint contractures.

An adaptable soft-mold embossing process for fabricating optically-accessible, microfeature-based culture systems and application toward liver stage antimalarial compound testing.

Advanced cell culture methods for modeling organ-level structure have been demonstrated to replicate in vivo conditions more accurately than traditional in vitro cell culture. Given that the liver is particularly important to human health, several advanced culture methods have been developed to experiment with liver disease states, including infection with Plasmodium parasites, the causative agent of malaria. These models have demonstrated that intrahepatic parasites require functionally stable hepatocytes to thrive and robust characterization of the parasite populations' response to investigational therapies is dependent on high-content and high-resolution imaging (HC/RI). We previously reported abiotic confinement extends the functional longevity of primary hepatocytes in a microfluidic platform and set out to instill confinement in a microtiter plate platform while maintaining optical accessibility for HC/RI; with an end-goal of producing an improved P. vivax liver stage culture model. We developed a novel fabrication process in which a PDMS soft mold embosses hepatocyte-confining microfeatures into polystyrene, resulting in microfeature-based hepatocyte confinement (µHEP) slides and plates. Our process was optimized to form both microfeatures and culture wells in a single embossing step, resulting in a 100 µm-thick bottom ideal for HC/RI, and was found inexpensively amendable to microfeature design changes. Microfeatures improved intrahepatic parasite infection rates and µHEP systems were used to reconfirm the activity of reference antimalarials in phenotypic dose-response assays. RNAseq of hepatocytes in µHEP systems demonstrated microfeatures sustain hepatic differentiation and function, suggesting broader utility for preclinical hepatic assays; while our tailorable embossing process could be repurposed for developing additional organ models.