Access to heart disease and stroke care in Tennessee.

Tennessee is ranked fourth-worst in the United States for deaths caused by stroke and third-worst in the nation for cardiovascular deaths. Two recent surveys provide information about the geographic distribution of hospital-based, primary and secondary care promotion, and of emergency medical services for these disease conditions. This article is a synthesis of selected findings from these surveys to identify priority populations for interventions to reduce cardiac and stroke mortality in Tennessee. Twenty-three counties have a medical facility with a formal clinical pathway or system for implementing cardiovascular disease prevention strategies. Sixty-three of the state's 95 counties have no designated specialty center for an EMS service to transport cardiac and stroke patients. Fifty-six counties, comprising 38 percent of the state's population, lie between 20 and 50 miles from the nearest state-of-the-art stroke care. Twenty-one counties, containing nearly 10 percent of the state's population, are greater than 50 miles from advanced stroke care facility. Some health districts are faring better than the state proportion (86.8 percent) for people indicating they would call 911 for a suspected cardiac or stroke emergency, while many are performing much poorer. The Shelby district (Memphis) is much higher (p < 0.01), while Madison and South Central districts are well below the state's prevalence (p < 0.001). The fact that these "less-likely-to-call-911" areas are also in mostly rural settings poses priority challenges for public education. To combat this trend, coordinated efforts are in progress to incentivize the development of cardiac and stroke centers or, alternatively, the formation of regional collaborative networks affiliated with a specialty center.

Flexor Tenosynovectomy for Recurrent Carpal Tunnel Syndrome: A Retrospective Case Series of 108 Hands.

Background: The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery. Fibrosis and hypertrophy have been identified in the flexor tenosynovium in these patients. The authors use flexor tenosynovectomy (FTS) for recurrent CTS after primary carpal tunnel release and present a review of these patients. Methods: A retrospective chart review was performed of 108 cases of FTS for recurrent CTS from 1995 to 2015 by 4 attending surgeons at one institution. Demographic information, symptoms, and outcomes were among the data recorded. A phone survey was conducted on available patients where the shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and satisfaction were assessed. Results: Average office follow-up was 12 months. Average age was 57.5 years. A total of 104 (96%) reported symptom improvement and 48 (44%) reported complete symptom resolution. Forty patients were available for long-term follow-up at an average 6.75 years postoperatively via phone interview. Average QuickDASH score was 31.2 in these patients. Thirty-six (90%) of 40 patients were initially satisfied at last office visit, and 31 (78%) of 40 were satisfied at average 6.9 years, a maintenance of satisfaction of 86%. Satisfied patients were older (58 years) than unsatisfied patients (51 years). Conclusion: Both long-term satisfaction and QuickDASH scores in our cohort are consistent with or better than published results from nerve-shielding procedures. The authors believe a decrease in both carpal tunnel volume and potential adhesions of fibrotic or inflammatory synovium contributes to the benefits of this procedure. This remains our procedure of choice for recurrent CTS.

Treatment of Ipsilateral Femoral Neck and Shaft Fractures With Cannulated Screws and Antegrade Reconstruction Nail.

Ipsilateral femoral neck and shaft fractures are challenging injuries, and there are different fixation options but no consensus on a superior construct. Our preferred method is cannulated screw fixation of the femoral neck and antegrade reconstruction nailing of the shaft. Compressive fixation of the femoral neck fracture with cancellous lag screws followed by reconstruction nail placement provides compressive fixation and fixed angle support of the neck fracture while allowing for more optimal treatment of femoral shaft fractures at or above the isthmus. The purpose of this submission is to describe the surgical decision-making, surgical technique, and all surgically related complications of this technique.

Colon adenocarcinoma with metastases to the scaphoid: a case report and review of the literature.

Metastases to the hand and wrist are extremely rare, with <250 cases described in the literature. We present a case of acrometastasis of colon adenocarcinoma to the scaphoid in an 81-year-old male. Adenocarcinoma of the colon metastasizes to bone in an estimated 10% of cases; however, we are unaware of reports of this tumor metastasizing to the scaphoid or to any of the other carpal bones. We were able to identify only two cases of scaphoid metastases in the literature. This case highlights the potential for metastatic disease and other lesions to develop in the scaphoid and carpus.

Trampoline-Related Injuries: A Comparison of Injuries Sustained at Commercial Jump Parks Versus Domestic Home Trampolines.

INTRODUCTION: The nature of trampoline injuries may have changed with the increasing popularity of recreational jump parks. METHODS: A retrospective review was performed evaluating domestic trampoline and commercial jump park injuries over a 2-year period. RESULTS: There were 439 trampoline injuries: 150 (34%) at jump parks versus 289 (66%) on home trampolines. Fractures and dislocations accounted for 55% of jump park injuries versus 44% of home trampoline injuries. In adults, fractures and dislocations accounted for 45% of jump park injuries versus 17% of home trampoline injuries. More lower extremity fractures were seen at jump parks versus home trampolines in both children and adults. Adults had a 23% surgical rate with jump park injuries versus a 10% surgical rate on home trampolines. DISCUSSION: Trampoline-related injury distribution included a higher percentage of fractures/dislocations, lower extremity fractures, fractures in adults, and surgical interventions associated with jump parks versus home trampolines. LEVEL OF EVIDENCE: Level III.

Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial.

OBJECTIVE: To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur. DESIGN: Prospective, randomized controlled trial. SETTING: Single Level 1 trauma center. PATIENTS: Forty-seven patients were randomized to the study group, and 46 patients comprised the control group. INTERVENTION: The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose. MAIN OUTCOME MEASUREMENTS: Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)]. RESULTS: TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57). CONCLUSION: The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness.

OBJECTIVES: Evaluate the safety and efficacy of manipulation under anesthesia (MUA) for posttraumatic elbow stiffness. DESIGN: Retrospective, case series. SETTING: Single institution; level 1 trauma center. PATIENTS/PARTICIPANTS: Chart review of 45 patients over a 10-year period treated with MUA for posttraumatic elbow stiffness after elbow injuries treated both operatively and nonoperatively. INTERVENTION: None. MAIN OUTCOME MEASURES: Change in total flexion arc pre- to postmanipulation; time to manipulation; complications. RESULTS: Average time from most recent surgical procedure or date of injury to MUA was 115 days. Average premanipulation flexion arc was 57.9 degrees; average flexion arc at the final follow-up was 83.7 degrees. The improvement in elbow flexion arc of motion was statistically significant (P < 0.001). Post hoc analysis of the data revealed 2 distinct groups: 28 patients who underwent MUA within 3 months of their most recent surgical procedure (early manipulation), and 17 patients who underwent MUA after 3 months (late manipulation). Average improvement in elbow flexion arc in the early MUA group was 38.3 degrees (P < 0.001); improvement in the late MUA group was 3.1 degree. Comparison of improvement between the early and late MUA groups found a significant difference (P < 0.001) in mean flexion arc improvement from premanipulation to postmanipulation, favoring the early group. One patient had a complication directly attributable to MUA. Nineteen patients required additional procedures on the injured extremity after MUA. CONCLUSIONS: MUA is a safe and effective adjunct to improving motion in posttraumatic elbow stiffness when used within 3 months from the original injury or time of surgical fixation. After 3 months, MUA does not reliably increase elbow motion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Analysis of Cervical and Spinal Alignment in Multilevel ACDF with Lordotic Interbody Device.

BACKGROUND: Restoration and maintenance of cervical lordosis is an important clinical parameter in spine surgery. The purpose of this study was to determine the extent to which a multilevel anterior cervical discectomy and fusion (ACDF: greater than 3 levels) procedure restores cervical lordosis and the affect of increasing lordosis on sagittal vertical axis. METHODS: We performed a retrospective radiographic analysis of 69 patients who underwent multilevel ACDF by 2 surgeons between 2013 and 2014. We measured the global and segmental sagittal alignment of the cervical spine using the cobb method at 4 time intervals (preop, post op 4wks, 10wks and 6 months) as well as the sagittal vertical axis (SVA) using both a C1-S1 and C7-S1 plumb line methods at 2 time intervals (preop and post op 4wks). Radiographs were measured by three reviewers. RESULTS: Interrater reliability was good to excellent for all measurements. Cervical lordosis significantly increased from preop 10.26° to 4 weeks postop 19.44° and was maintained up to 6 months 19.34 (p<0.0005). Segmental cervical lordosis was also significantly increased from preop 8.22° to post op at 4 weeks (20.26°) and was maintained at post op 10weeks 20.30° and post op 6 months 19.56° (p<0.0005). C7-S1 SVA and C1-S1 SVA also significantly increased from 12.04mm preop to 27.49mm post op 4 wks (p<0.0005) and -1.93mm preop to 8.67mm post op (p<0.0005) respectively. A change in C2-C7 lordosis positively correlated with a change in C7-SVA and C1-SVA (r=0.37, P<0.005, and r=0.312, p<0.05 respectively). CONCLUSIONS: Multilevel ACDF significantly increases and maintains both segmental and global cervical lordosis up to 6 months after surgery. Increasing C2-C7 global lordosis is correlated with increasing positive sagittal vertical axis. Level of evidence: IV.

Generating stability in elderly acetabular fractures-A biomechanical assessment.

BACKGROUND & OBJECTIVES: As the overall health and life expectancy increases in the United States, the incidence of fragility fractures in elderly patients also continues to increase. Given their medical comorbidities and decreased bone mineral density, acetabular fractures in the elderly population present a significant challenge to the orthopaedic trauma surgeon. The anterior column posterior hemitransverse (ACPHT) fracture pattern is a common fracture pattern in this population, and is often associated with central subluxation/dislocation of the femoral head with articular impaction. This study sought to delineate the most stable fixation construct in ACPHT fracture patterns in the elderly population. MATERIALS AND METHODS: The sample consisted of 3 groups of synthetic hemipelves (N=15), which were tested in order to compare stiffness by measuring motion at fracture lines under applied loads. The three groups of unique quadrilateral plate fixation were as follows: a specialty quadrilateral surface plate; 4 long peri-articular screws parallel to the quadrilateral surface into the ischium,; and an 8 hole infrapectineal buttress plate. Digital imaging system measured construct motion under load. Construct stiffness was estimated by linear regression of load between 50 and 850N versus average relative motion (average of relative motion at 200 points along the line of the osteotomy). Permanent deformation was estimated as the magnitude of relative motion upon unloading. RESULTS: Using ANOVA with Tukey's test to determine construct stiffness in loading, the group long peri-articular screws was found to have significantly higher stiffness than either of the other groups. Maximal fracture displacement was located at the intersection of the low transverse fracture line in the posterior column and the free quadrilateral surface fragment. CONCLUSIONS: Results indicate that the best fixation construct for this ACPHT acetabular fracture pattern includes independent lag screws across the anterior column and a pelvic brim plate with long periarticular screws maximizing posterior column fixation and preventing medialization of the free quadrilateral fragment. Although there are potential patient considerations that may complicate the placement of all 4 long screws, in most patients one or more of these screws can be safely placed in order to help prevent secondary displacement.

Modified Iliac Oblique-Outlet View: A Novel Radiographic Technique for Antegrade Anterior Column Screw Placement.

Percutaneous fixation of acetabular fractures can be challenging because of the complex anatomy of the anterior column. We have used a modified iliac oblique-outlet image view in conjunction with more traditional radiographic views to place antegrade anterior column screws. This technique does not replace the pelvic inlet but is a good alternative in the lateral decubitus position because it helps to mitigate the difficulties of obtaining the pelvic inlet radiograph in this position. The purpose of this study is to describe the radiographic technique, demonstrate proper and aberrant screw placement using Sawbones, and present a review of patients in which this technique was used in clinical practice.

The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications.

OBJECTIVES: This study was performed to compare patient outcomes after Reamer-Irrigator-Aspirator (RIA)-harvested bone grafting with the current gold standard, either anterior or posterior iliac crest bone graft (ICBG). DESIGN: Prospective randomized controlled trial. SETTING: Multicenter study at 3 geographically separate Level 1 trauma centers. PATIENTS/PARTICIPANTS: One hundred thirty-three patients with nonunion or posttraumatic segmental bone defect requiring operative intervention. INTERVENTION: Patients were prospectively randomized to receive ICBG or RIA autograft. Supplemental internal fixation was performed per surgeon preference. MAIN OUTCOME MEASUREMENTS: Operative data included amount of graft, time of harvest, and associated surgical costs. The Short Musculoskeletal Functional Assessment and the Visual Analog Scale were used to document baseline and postoperative function and pain. Clinical and radiographic union was the defined end point; patients considered to have failed treatment if they either developed an infection requiring operative treatment or had a persistent nonunion of the grafted extremity. RESULTS: One hundred thirteen of the 133 enrolled patients were followed until union and included in the final analysis. Intraoperative data showed anterior ICBG to yield 20.7 ± 12.8 (5-60) cm of autograft with an average harvest time of 33.2 ± 16.2 minutes, posterior ICBG yielded 36.1 ± 21.3 (20-100) cm of autograft in 40.6 ± 11.2 minutes, and RIA yielded 37.7 ± 12.9 (5-90) cm in 29.4 ± 15.1 minutes. Anterior ICBG produced significantly less bone graft than either RIA or posterior ICBG (P < 0.001). The RIA harvest was completed in significantly less operative time compared with posterior ICBG (P = 0.005). At $738, the RIA setup was considerably more expensive than the ∼$100 cost of a bone graft tray; however, when compared with posterior ICBG, the longer operative time required for a posterior harvest came at an additional incremental cost of $990-1880, making RIA the less expensive option. Patients were followed for an average of 56.9 ± 42.1 (11-250) weeks. Forty-nine of 57 patients (86.0%) who received ICBG united in an average of 22.5 ± 13.2 weeks; 46 of 56 patients (82.1%) who received RIA healed in an average of 25.8 ± 17.0 weeks. Union rates and time to union were comparable between the 2 procedures. There was no difference in complications requiring reoperation for persistent nonunion or infection at the grafted site, nor there was any difference in donor-site complications. Postoperative follow-up showed that RIA patients had significantly lower donor-site pain scores throughout follow-up. CONCLUSIONS: When compared with autograft obtained from the iliac crest, autograft harvested using the RIA technique achieves similar union rates with significantly less donor-site pain. RIA also yields a greater volume of graft compared with anterior ICBG and has a shorter harvest time compared with posterior ICBG. For larger volume harvests, cost analysis favors using RIA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.