Cervical Spinal Immobilization: A Head-to-Head Comparison of a One-Step Spray-on Foam Splint Versus Structural Aluminum Malleable Splint Immobilization.

INTRODUCTION: Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine. METHODS: This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient. RESULTS: Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01). CONCLUSION: The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application.

Robotic-Assisted Versus Conventional Posterior Lumbar Fusion-An Analysis of 90-Day Complications and Readmissions.

OBJECTIVE: To evaluate medical and surgical complication rates between robotic-assisted versus conventional elective posterior lumbar fusions. METHODS: The Symphony Integrated DataVerse was queried using International Classification of Diseases, 10th Edition, Clinical Modification procedure codes to identify patients undergoing elective posterior lumbar fusions for degenerative spine pathologies between 2015 and 2018. International Classification of Diseases, 10th Edition, Clinical Modification procedure codes (8E0W4CZ, 8E0W0CZ, 8E0W3CZ) were used to identify patients undergoing a robotic-assisted spinal fusion. Outcome measures were 90-day medical and surgical complications, 1-year pseudarthrosis, and 1-year revision surgery rates. Multivariate logistic regression analyses were used to assess whether undergoing a robotic-assisted fusion (vs. conventional fusion) was associated with differences in wound complications, medical complications, pseudarthrosis, revision surgery, and readmissions within 90 days of surgery. RESULTS: A total of 39,387 patients undergoing elective posterior lumbar fusions were included in the cohort-of whom 245 (0.62%) patients underwent a robotic-assisted fusion. Multivariate analysis showed that robotic-assisted fusion (vs. conventional fusion) was not associated with significant differences in 90-day rates of wound complications (P = 0.299), urinary tract infections (P = 0.648), acute myocardial infarctions (P = 0.209), acute renal failure (P = 0.461), pneumonia (P = 0.214), stroke (P = 0.917), deep venous thrombosis (P = 0.562), pulmonary embolism (P = 0.401), and readmissions (P = 0.985). In addition, there were no significant differences in the 1-year rates of revision fusions (P = 0.316) and pseudarthrosis (P = 0.695). CONCLUSIONS: Patients who underwent a robotic-assisted fusion had similar rates of surgical and medical complications compared with those who underwent a conventional fusion. Further studies are warranted to better understand the future role of robots in spine surgery.

Red painful nodules in a hospitalized patient.

Was the patient's treatment, or his underlying condition, to blame?

Surgeon Specialty Influences Referral Rate for Osteoporosis Management following Vertebral Compression Fractures.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To evaluate the referral rate for long-term osteoporosis management following vertebral compression fracture treated by different specialties at a single academic institution. METHODS: Patients undergoing vertebral cement augmentation for painful osteoporotic compression fractures from 2009 to 2014 were identified. Medical records were reviewed to determine if the treating surgeon discussed and/or referred the patient for long-term osteoporosis management. Any referral for or mention of medical long-term osteoporosis management was counted as a positive response. Results were statistically analyzed with chi-square test. RESULTS: Two hundred fourteen patients underwent vertebral cement augmentation; 150 met inclusion criteria. Orthopedic surgeons treated 88 patients, neurosurgeons treated 39, and interventional radiology or pain management physicians treated 23. Orthopedic surgeons referred 82% of patients for osteoporosis management, neurosurgeons referred 36%, and interventional radiology/pain management referred 17%. The referral rate was significantly higher for orthopedic surgeons compared with either of the other two groups; there was no significant difference between neurosurgery and interventional radiology/pain management. CONCLUSIONS: Among physicians who treat osteoporotic vertebral compression fractures, orthopedic surgeons more frequently address osteoporosis or refer patients for osteoporosis management compared with neurosurgeons and interventional radiologists or pain management physicians. The results of this study shed light on the disparity in how different specialties approach treatment of osteoporosis in patients with fractures painful enough to require surgery and highlight potential areas for improvement in osteoporosis awareness training.

Large plaques on a baby boy.

This newborn's prenatal lab work and delivery were normal. So, too, were his Apgar scores and neurologic exam. So why was he covered in brown and black plaques?

A novel co-culture model of murine K12 osteosarcoma cells and S. aureus on common orthopedic implant materials: 'the race to the surface' studied in vitro.

Infection is a major cause of orthopedic implant failure. There are few studies assessing both tissue cell and bacterial adherence on common orthopedic implant materials in a co-culture environment. An in vitro co-culture model was created using K12 osteosarcoma cells and Staphylococcus aureus in a medium incubated over metal disks for 48 h. The results showed that, in the presence of S. aureus, there were fewer osteosarcoma cells attached to the disks for all substrata tested. There were significantly more osteosarcoma cells adhering to the cobalt chrome than the stainless steel and titanium disks. Overall, in the presence of osteosarcoma cells, there were more bacteria adhering to the disks for all the substrata tested, with significantly more bacteria adhering to the stainless steel disks compared to cobalt chrome and titanium disks. Scanning electron microscopy verified that osteosarcoma cells and bacteria were adherent to the metal disks after incubation for 48 h. Furthermore, the observation that more bacteria were in the co-culture than in the control sample suggests that the osteosarcoma cells serve as a nutrient source for the bacteria. Future models assessing the interaction of osteogenic cells with bacteria on a substratum would be improved if the model accounted for the role of the immune system in secondary bone healing.

Multiple roles of tumor necrosis factor-alpha in fracture healing.

This review presents a summary of basic science evidence examining the influence of tumor necrosis factor-alpha (TNF-α) on secondary fracture healing. Multiple studies suggest that TNF-α, in combination with the host reservoir of peri-fracture mesenchymal stem cells, is a main determinant in the success of bone healing. Disease states associated with poor bone healing commonly have inappropriate TNF-α responses, which likely contributes to the higher incidence of delayed and nonunions in these patient populations. Appreciation of TNF-α in fracture healing may lead to new therapies to augment recovery and reduce the incidence of complications.

Plaques on dorsal hands & arms.

This patient's slow-growing lesions hadn't responded to topical steroids or antifungals. Careful consideration of her work environment led us to a curious diagnosis.

Management of external genital warts.

Genital warts affect 1% of the sexually active U.S. population and are commonly seen in primary care. Human papillomavirus types 6 and 11 are responsible for most genital warts. Warts vary from small, flat-topped papules to large, cauliflower-like lesions on the anogenital mucosa and surrounding skin. Diagnosis is clinical, but atypical lesions should be confirmed by histology. Treatments may be applied by patients, or by a clinician in the office. Patient-applied treatments include topical imiquimod, podofilox, and sinecatechins, whereas clinician-applied treatments include podophyllin, bichloroacetic acid, and trichloroacetic acid. Surgical treatments include excision, cryotherapy, and electrosurgery. The quadrivalent human papillomavirus vaccine is active against virus subtypes that cause genital warts in men and women. Additionally, male circumcision may be effective in decreasing the transmission of human immunodeficiency virus, human papillomavirus, and herpes simplex virus.

Is orthopedics more competitive today than when my attending matched? An analysis of National Resident Matching Program data for orthopedic PGY1 applicants from 1984 to 2011.

OBJECTIVE: This study evaluated supply and demand trends for orthopedic postgraduate year 1 (PGY1) positions from 1984 to 2011 for the purpose of estimating national intercandidate competition over time. DESIGN: National Resident Matching Program (NRMP) data for orthopedic surgery from 1984 to 2011 were collected. Proxy variables including (total number of orthopedic applicants/number of orthopedic PGY1 positions), (number of US senior applicants to orthopedics/number of orthopedic PGY1 positions), (number of US seniors matching into orthopedics/number of US senior orthopedic applicants), (total number of matched orthopedic applicants/total number of orthopedic applicants), and (total number of US applicants who fail to match into orthopedics/total number of US senior applicants into orthopedics) as well as average United States Medical Licensing Examination Step 1 scores were used to gauge the level of competition between candidates and were compared over time. SETTING: Academic medical center in the Midwestern United States. PARTICIPANTS: Medical professors and medical students. RESULTS: The NRMP data suggested that the number of positions per applicant decreased or remained stable since 1984 and that the percentage of applicants who did not match was no higher now than in the past. This finding was primarily because of the relative decrease in the ratio of applicants to available PGY1 positions, which stems from the number of positions increasing more rapidly than the number of applicants. CONCLUSIONS: The NRMP data from 1984 to 2011 supported our hypothesis that intercandidate competition intensity for orthopedic PGY1 positions has not increased over time. The misconception that orthopedics is becoming more competitive likely arises from the increased number of applications submitted per candidate and the resulting relative importance placed on objective criteria such as United States Medical Licensing Examination Step 1 scores when programs select interview cohorts.

Continuous passive motion following cartilage surgery: does a common protocol exist?

Continuous passive motion (CPM) devices have the potential to improve the histological content as well as the rate and volume of chondrogenesis in repair tissue following chondral injury. However, clinical evidence is lacking to support broad implementation of CPM following cartilage restoration procedures. We searched PubMed, CINAHL, SPORTDiscus, and Cochrane for such terms as knee, continuous passive motion, CPM, ACI, ACT, autologous chondrocyte implantation, autologous chondrocyte transplantation, microfracture, marrow-stimulation technique, mosaicplasty, osteochondral autograft, and osteochondral allograft. Inclusion criteria were all English-language studies of human subjects, evidence levels I to IV, reporting the use of CPM following cartilage repair or restoration surgery in the knee. One hundred and seven studies met inclusion criteria. Sixty-three studies reported the use of CPM following autologous chondrocyte implantation; 28 reported the use of CPM following microfracture; 13 reported the use of CPM following osteochondral autograft; and 15 reported the use of CPM following osteochondral allograft (several studies reported > 1 type of cartilage procedure, which explains why the sum of all studies reporting a particular procedure [119] is greater than the number of studies included in the review [107]). Of the 5723 patients included, 60.8% were treated with autologous chondrocyte implantation, 23.1% were treated with microfracture, 6.4% were treated with osteochondral autograft, and 9.7% were treated with osteochondral allograft. Of the 6612 total defects, 5043 (76.3%) were tibiofemoral and 1569 (23.7%) were patellofemoral. Most reports of CPM use after cartilage restoration procedures did not include specific information on how it was implemented. Overall, the description of CPM protocols in published knee articular cartilage surgery studies was disappointing. The majority of studies did not describe common variables such as the duration of CPM therapy, the initiation of CPM therapy, and the initial range of motion used. The most commonly prescribed parameters within a CPM regimen are initiated on the first postoperative day, with an initial range-of-motion of 0 to 30 degrees and a frequency of 1 cycle per minute, and for 6 to 8 hours daily over 6 weeks. The lack of consistent standardized reporting of postoperative CPM protocols provides an impetus to researchers and clinicians to more clearly define and describe their use following knee articular surgery.

Factors influencing the outcome of autologous chondrocyte implantation: a systematic review.

Autologous chondrocyte implantation (ACI) is an effective method of treatment of chondral defects of the knee. ACI outcomes are influenced by patient-, knee-, and lesion-specific factors. We compiled subject-level data from current studies on ACI and quantitatively analyzed this data set for associations between patient-, knee-, and lesion-specific factors and the outcome of ACI surgery. A systematic review of studies investigating ACI treatment outcomes in the knee was performed. Only studies that published subject-level data were included. Data on patient and lesion characteristics, as well as clinical outcome scores, were collected. Thirteen studies (305 defects) were included in this review. These studies showed that ACI treatment improves clinical outcomes in different patient populations. However, subject-specific variables such as patient age, gender, body mass index, duration of preoperative symptoms, as well as defect size and location were not associated with International Knee Documentation Committee score or visual analog scale score changes (p > 0.05 for all). Covariate analysis showed that patient age was related to symptom duration prior to surgery (p = 0.009). ACI surgery has been shown to improve outcomes in patients with chondral lesions of the knee. Despite evidence in the literature showing that multiple patient-, knee-, and lesion-specific factors may influence treatment outcomes, our review shows that these factors, solely, do not affect outcomes. However, together, they may synergistically affect outcomes.

Observational study of buprenorphine treatment of opioid-dependent pregnant women in a family medicine residency: reports on maternal and infant outcomes.

PURPOSE: Within a family medicine residency, an outpatient buprenorphine treatment program was provided for pregnant women who were dependent on opioids. The purpose of this study was to investigate the outcomes of infants who were exposed to a range of doses of buprenorphine in utero and to determine how closely observed maternal/fetal outcomes (eg, method of delivery and infants requiring treatment for neonatal abstinence syndrome [NAS]) match those previously reported in the literature. METHODS: This study consists of a retrospective case series of 23 infants born to 22 pregnant women who were dependent on opioids and who were treated with buprenorphine during a 31-month period. RESULTS: Thirty-five percent of infants (8 of 23) required treatment for NAS. There was no significant relationship between maternal dose of buprenorphine and birth weight, NAS severity (ie, peak NAS score), or time to first peak NAS score. Infants born to tobacco users had a significantly lower birth weight (P = .0136) than infants born to nonusers. Seventy percent of infants (16 of 23) were breastfeeding at the time of discharge from the hospital. CONCLUSIONS: The observations made in this case series are consistent with data previously reported in the literature. Infants in this study were more likely to be breastfed than those previously described by others, but further analysis is necessary to determine whether this finding is significant.