Extracorporeal measurement of femoral nail length in the treatment of trochanteric hip fractures: the "box" technique.

Intramedullary nails, long and short, are widely used for fixation of trochanteric femur fractures. In theory, long nails may be able to protect the entire length of the femur from a future periprosthetic fracture, providing that the nail spans the length of the entire femoral canal. The described technique for long nail insertion calls for the use of an intramedullary guidewire and depth gauge for premeasurement of the length of the canal, as well as the use of a reamer. However, compared with short nails, this technique may add cost, operating time, and blood loss. We describe a safe technique for long nail measurement that reliably spans the length of the femur while potentially reducing surgical cost, time, and blood loss. We also describe 21 cases in which the technique was applied.

A dual-sensor ultrasound based method for detecting elevated muscle compartment pressures: A prospective clinical pilot study.

BACKGROUND: Acute compartment syndrome (ACS) is a limb-threatening condition associated with elevated muscle compartment pressures (MCPs). The only existing treatment of ACS is to reduce MCP by fasciotomy; however, a reliable clinical method for detecting elevated MCPs is lacking. A dual-sensor (ultrasound and pressure) technology to detect elevated MCPs was previously tested on cadavers. Our goal was to examine the use of this technology in the clinical setting. METHODS: Patients with tibia fractures were prospectively enrolled. Observers used a dual-sensor probe to measure the amount of pressure required to flatten the anterior compartment fascia (CFFP). Direct-MCP measurements and 4-compartment fasciotomy were done for suspected ACS. RESULTS: Fifty-two patients were enrolled into the study. Nine patients underwent fasciotomy for a clinical diagnosis of ACS. Both CFFP (p-value = 8.395e-08) and delta-CFFP (p-value = 4.114e-05) were significantly larger in the fasciotomy group compared to the non-fasciotomy group. CFFP measurements showed very strong correlations to the direct MCP measurements (p-value = 0.006746, rho = 0.9285714), and delta-CFFP showed strong correlation (p-value = 0.06627, rho = 0.75). CFFP measurements had good inter-observer variability, with an interclass correlation (ICC) of 0.814 (95%-Confidence Interval: 0.631-0.907) and excellent intra-observer variability with an ICC of 0.942 (95%-Confidence Interval: 0.921-0.958). CONCLUSION: The results of this pilot study suggest that the proposed ultrasound-based method is useful in detecting elevated MCPs and may be helpful in the diagnosing ACS or ruling out the need for urgent fasciotomy. Large-scale clinical trials are needed to validate these claims.

The WORC Index and Predicting Treatment Failure in Patients Undergoing Primary Arthroscopic Rotator Cuff Repair.

BACKGROUND: Rotator cuff tears are common injuries that are reliably treated with arthroscopic repair, producing good to excellent results. The Western Ontario Rotator Cuff (WORC) index is a validated disease-specific instrument used to assess patient outcomes; however, no study to date has correlated WORC index with treatment failure. PURPOSE: To evaluate the WORC index as a predictor for successful treatment in arthroscopic rotator cuff repair. An additional purpose was to identify patient and tear characteristics associated with risk of treatment failure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study reviewed a total of 500 patients who underwent arthroscopic rotator cuff repair with a minimum of 2-year follow-up. Patient charts were reviewed for treatment failures, defined as persistent or recurrent shoulder pain or weakness, leading to further workup and identification of a failure to heal or recurrent tear by magnetic resonance imaging. Patient demographic and comorbidity data were gathered and correlated with risk of failure. All patients completed WORC questionnaires, and scores were correlated with risk of treatment failure. RESULTS: There were 28 (5.6%) treatment failures at a median 28 weeks (SD, 42 weeks) postoperatively. Patients claiming workers' compensation were 3.21 times more likely (odds ratio; P = .018) to fail treatment. Posterior interval tears (those including infraspinatus) were 3.14 times more likely (P = .01) to fail than anterior interval tears. Tear size was associated with treatment failure; the odds of failure was 3.24 for a 2-tendon tear and 5.83 for a 3-tendon tear (P = .03). Tears involving the nondominant arm were associated with an increased risk of failure by a factor of 3.04 (95% CI, 1.01-9.11; P = .047). A WORC score ≥80 was associated with a 95% probability of treatment success at 1 year. CONCLUSION: After arthroscopic rotator cuff repair, patients with WORC scores ≥80 at 1 year have a 95% probability of successful treatment and likely do not benefit from continued follow-up visits. Furthermore, several risk factors were identified that may influence outcomes after rotator cuff repair, including workers' compensation, location of tear, tear size, and hand dominance.

Open Reduction, Bone Grafting, and Internal Fixation of Osteochondritis Dissecans Lesion of the Knee.

Osteochondritis dissecans (OCD) of the femoral condyle is an idiopathic focal bone abnormality affecting the subchondral bone and can result in unstable osteochondral lesions. The treatment of unstable OCD lesions with open reduction and internal fixation with metallic compression screws is well documented in the literature. Fixation is performed to prevent dislodgement of unstable OCD lesions or fix displaced fragments that have been surgically reduced. The procedure is performed by approaching the knee through a midline incision and medial parapatellar arthrotomy. The lesion is identified, and a scalpel is used to incise the cartilage circumferentially, leaving 1 side intact, to create a "trap door" flap. The OCD fragment is lifted from the bed, and the bed is prepared by debriding the fibrocartilage scar and bone-grafting the bed. The osteochondral fragment is reduced back to the bed, and guidewires are placed to secure the reduction and plan screw trajectories. Guide pins are overdrilled and Herbert compression screws are placed to secure the OCD fragment. The wound is irrigated and closed. Complications are rare, but later screw removal is typically recommended. Reported outcomes are satisfactory, with an 80% rate of radiographic healing and good-to-excellent patient-reported outcomes.

A Novel Non-invasive Method for the Detection of Elevated Intra-compartmental Pressures of the Leg.

Acute Compartment Syndrome is a devastating consequence of musculoskeletal trauma. Currently the diagnosis is based on clinical signs and symptoms, and while adjuncts such as invasive intra-compartmental pressure measurements are often used to corroborate the physical exam findings, there remains no reliable objective test to aid in the decision to perform a decompressive fasciotomy. In a cadaver model of compartment syndrome, an ultrasound (US) based method has been shown to be a reliable measurement of increased intra-compartmental pressure. An absolute pressure of >100 mbar or a difference of 50 mbar in the CFFP between the legs can be considered pathologic. Using an ultrasound transducer, coupled with a pressure sensor, the pressure needed to flatten the superficial fascia of the anterior compartment of lower legs (Compartment Fascia Flattening Pressure [CFFP]) can be measured. The CFFP of the injured leg is compared to the CFFP of the uninjured leg. This US measured index can then serve as an adjunct to the physical exam in evaluating injured lower extremities and assessing the need for decompressive fasciotomy. The advantages of this protocol include: being a non-invasive method and an easily reproducible technique.

The fission yeast DNA structure checkpoint protein Rad26ATRIP/LCD1/UVSD accumulates in the cytoplasm following microtubule destabilization.

BACKGROUND: DNA structure checkpoints are conserved eukaryotic signal transduction pathways that help preserve genomic integrity. Upon detecting checkpoint signals such as stalled replication forks or double-stranded DNA breaks, these pathways coordinate appropriate stress responses. Members of the PI-3 kinase related kinase (PIKK) family are essential elements of DNA structure checkpoints. In fission yeast, the Rad3 PIKK and its regulatory subunit Rad26 coordinate the detection of checkpoint signals with pathway outputs. RESULTS: We found that untreated rad26Delta cells were defective for two microtubule-dependent processes: chromosome segregation and morphogenesis. Interestingly, cytoplasmic accumulation of Rad26-GFP occurred following treatment with microtubule destabilizing drugs, but not during treatment with the genotoxic agent Phleomycin. Cytoplasmic accumulation of Rad26-GFP depended on Rad24, a 14-3-3 protein also required for DNA structure checkpoints and morphogenesis. Results of over expression and epistasis experiments confirm that Rad26 and Rad24 define a response to microtubule destabilizing conditions. CONCLUSION: Two DNA structure checkpoint proteins with roles in morphogenesis define a response to microtubule destabilizing conditions.

Autologous Chondrocyte Implantation Using a Bilayer Collagen Membrane with Bone Graft and Anteromedialization of the Tibial Tubercle for the Treatment of a Large Osteochondral Defect in the Lateral Knee Trochlea: A Case Report.

CASE: Autologous chondrocyte implantation (ACI) is an established technique for the treatment of osteochondral lesions of the knee. For larger lesions with a substantial amount of bone loss, ACI using a bilayer collagen membrane with bone-grafting has been demonstrated to offer good to excellent results in the tibiofemoral joint, but little has been reported on its use in the patellofemoral joint. We report on the 2-year follow-up of this technique of ACI with bone-grafting used for the treatment of a large osteochondral defect in the lateral aspect of the trochlea of the knee in an 18-year-old, active female patient. CONCLUSION: This case illustrates that ACI with bone-grafting using such a "sandwich" technique can be an effective treatment option for osteochondral lesions of the trochlea in the knee.