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PURPOSE: To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone. METHODS: Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement. RESULTS: All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up. CONCLUSIONS: In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications. LEVEL OF EVIDENCE: Therapeutic level IV.
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Fracturas del Fémur , Fijación Intramedular de Fracturas , Fracturas Espontáneas , Fracturas de Cadera , Humanos , Fijación Intramedular de Fracturas/efectos adversos , Fijación Intramedular de Fracturas/métodos , Fracturas de Cadera/cirugía , Fracturas de Cadera/etiología , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Resultado del Tratamiento , Fracturas del Fémur/cirugía , Fracturas del Fémur/etiología , Clavos Ortopédicos/efectos adversosRESUMEN
BACKGROUND: Cryoanalgesia is a tool being used by interventional radiology to treat chronic pain. Within a certain cold temperature range, peripheral nerve function is interrupted and recovers, without neuroma formation. Cryoanalgesia has most often been applied to the intercostal nerve. Cryoanalgesia has applications to peripheral nerve surgery, yet is poorly understood by reconstructive microsurgeons. METHODS: Histopathology of nerve injury was reviewed to understand cold applied to peripheral nerve. Literature review was performed utilizing the PubMed and MEDLINE databases to identify comparative studies of the efficacy of intraoperative cryoanalgesia versus thoracic epidural anesthesia following thoracotomy. Data were analyzed using Fisher's exact and analysis of variance tests. A similar approach was used for pudendal cryoanalgesia. RESULTS: Application of inclusion and exclusion criteria resulted in 16 comparative clinical studies of intercostal nerve for this review. For thoracotomy, nine studies compared cryoanalgesia with pharmaceutical analgesia, with seven demonstrating significant reduction in postoperative opioid use or postoperative acute pain scores. In these nine studies, there was no association between the number of nerves treated and the reduction in acute postoperative pain. One study compared cryoanalgesia with local anesthetic and demonstrated a significant reduction in acute pain with cryoanalgesia. Three studies compared cryoanalgesia with epidural analgesia and demonstrated no significant difference in postoperative pain or postoperative opioid use. Interventional radiology targets pudendal nerves using computed tomography imaging with positive outcomes for the patient with pain of pudendal nerve origin. CONCLUSION: Cryoanalgesia is a term used for the treatment of peripheral nerve problems that would benefit from a proverbial reset of peripheral nerve function. It does not ablate the nerve. Intraoperative cryoanalgesia to intercostal nerves is a safe and effective means of postoperative analgesia following thoracotomy. For pudendal nerve injury, where an intrapelvic surgical approach may be difficult, cryoanalgesia may provide sufficient clinical relief, thereby preserving pudendal nerve function.
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Dolor Agudo , Analgesia , Humanos , Analgésicos Opioides , Dolor Agudo/tratamiento farmacológico , Crioterapia , Analgesia/métodos , Dolor Postoperatorio/terapia , Nervios IntercostalesRESUMEN
BACKGROUND: The purpose of this study is to evaluate the effects of Florida lae House Bill 21 (HB21) on opioid prescribing patterns by a single orthopedic hand surgeon after outpatient hand and upper extremity surgery. METHODS: The following variables were evaluated with retrospective chart review before and after implementation of HB21: type of opioid, number of pills, morphine milligram equivalents (MMEs), emergency department visits, and readmissions. In addition, the Florida Prescription Drug Monitoring Program (E-FORCSE [Electronic-Florida Online Reporting of Controlled Substance Evaluation]) was queried to determine the number of pills and MMEs prescribed and sold for the latter cohort. Student t tests, Fisher exact tests, and binary logistic regression were used for statistical analysis. P < .05 was considered significant. RESULTS: We reviewed 231 consecutive patients who underwent hand or upper extremity surgery from July 2017 to July 2018 and 207 consecutive patients from January 2020 to January 2021. The average age was significantly different between the cohorts (48.41 vs 44.98 years, P = .025); however, there were no significant differences across other demographic variables. After controlling for age, the average number of pills prescribed per patient decreased significantly after HB21 (25.11 vs 21.6 pills, P < .001). The number of MMEs prescribed per patient decreased as well, but the decrease was not statistically significant (167.8 vs 154.1 MMEs, P = .054). There was an association between preoperative opioid prescriptions filled and prolonged opioid use (odds ratio 6.438, P = .003). CONCLUSION: Florida law HB21 resulted in significantly fewer pills prescribed per patient, suggesting that legislation likely changed prescriber behavior and/or patient demand regarding postoperative opioid prescriptions after outpatient hand and upper extremity surgery.
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Introduction: While commonly caused by traumatic injury and fracture, compartment syndrome can also result from reperfusion injury. Very few cases of prophylactic fasciotomy are mentioned when considering time to revascularization after prolonged vascular ischemia. We present a case of a patient who underwent multiple compartment prophylactic fasciotomies following reperfusion injury in the upper extremity. Case Report: We report a 72-year-old male that suffered from an anterior shoulder dislocation after a ground-level fall. After reduction, pulses were not measurable, and angiography indicated an axillary artery occlusion. Immediately after operative reperfusion, compartments became tense. Orthopedic surgeons subsequently performed arm anterior, posterior, and forearm volar and mobile wad compartment fasciotomies, after 13 h of ischemia. The patient tolerated the procedure, and at the latest follow-up, was working to improve strength in the extremity. Conclusion: Even when the circumstances of injury seem to be less traumatic as in this case of a ground-level fall, we document the importance of prompt recognition and intervention of suspected compartment syndrome following prolonged ischemia and revascularization of the upper extremity.
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Background: Curative treatment of bone sarcoma is primarily based on operative management. The Orthopedic Oncology approach towards this disease has evolved greatly to the breakthrough in systemic treatment options as well as unique implant designs favoring limb salvage over amputations. The purpose of this study was to perform a bibliometric analysis of the top 50 most cited papers related to the orthopedic the approach to bone sarcomas. Methods: We queried the ISI Web of Knowledge database in July 2022. Keywords utilized were: ""Bone Sarcoma" OR "Osteosarcoma" OR "Ewing Sarcoma" OR "Chondrosarcoma" OR "Chordoma". The top 50 articles pertaining to the orthopedic approach to bone sarcoma were included for analysis and included manuscript title, authors, citation count, journal and publication year. Results: The mean number of citations are 187.06 (Range 125-400; SD 67.83). The average citations per year is 10.03 (Range 47.86-3.43; SD 8.05). Many articles were published from 2000 to 2009 (n = 20) and 1990-1999 (n = 13). The majority of the articles were published by institutions within the United States (n = 32). The most common level of evidence was level IV (n = 37). Majority of the articles focused on treatment outcome (n = 22). Conclusion: This study offers a comprehensive review of the most cited literature regarding orthopedic approaches to bony sarcomas. Modern treatment approaches for bone sarcoma has resulted in an increased focus within the literature on achieving disease free survival wide tissue margins. Understanding the trends of available studies allows for physicians and researchers to target and innovate future areas of study.
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PURPOSE: Clavicle fractures are among the most common orthopedic fractures, and treatment methods, operative versus nonoperative, have been a point of contention. The purpose of this study was to evaluate the 50 most influential articles regarding clavicle fractures to better understand past focuses of research and to identify any gaps in knowledge. METHODS: A review of the most cited articles related to clavicle fractures was conducted using Web of Science database. A search was conducted in April 2022 by one trained researcher. Two independent researchers evaluated each article based on relevance to clavicle fracture. RESULTS: The mean number of citations was 179.1, ranging from 576 to 81 citations, and collectively cited 8954 times. The decade from 2000 to 2009 contributed the greatest portion of articles, with only a small portion coming from before 1980. The Journal of Bone and Joint Surgery-American Volume contributed the greatest number of articles (20%). The majority of the articles were therapeutic (n = 37) and focused on treatment and outcome (n = 32). Most of the clinically focused articles had a level of evidence of IV (n = 26). CONCLUSION: There is an increased influence of recent articles focused on clavicle fracture and management, due to the idea that conventional nonoperative treatment has a high rate of nonunion. Many of the most influential studies evaluate the outcomes of various treatments. Many of these studies, however, are lower levels of evidence, leaving a paucity of high level of evidence articles to support these conclusions. LEVEL OF EVIDENCE: V.
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Clavícula , Fracturas Óseas , Humanos , Clavícula/cirugía , Curación de Fractura , Resultado del Tratamiento , Fracturas Óseas/cirugía , Fijación de Fractura/métodosRESUMEN
OBJECTIVE: The Internet is a source of health information for patients. Quality of information available to patients is varied and uncontrolled. Physicians should be familiar with the overall quality of the information. This review provides an evaluation of YouTube's current patient accessible health information on the topic of lumbar disc herniation (LDH). METHODS: YouTube was queried using 3 different search strings: (1) "disc herniation", (2) "lumbar disc herniation", or (3) "lower back disc herniation". Video duplicates, non-English, or those that contained no audio or were not relevant to LDH were excluded. The first 50 videos per search string were evaluated. Two reviewers independently assessed videos. Parameters included duration, upload date, number of views, number of likes, views per day, and likes per day. A scoring system was used to grade the videos for their performance on diagnosis and treatment of LDH. RESULTS: The first 50 videos produced a total number of hits of 50,500, 29,100, and 22,100, respectively. Strong agreement, assessed using intraclass correlation coefficient (ICC), was demonstrated between readers for both diagnostic scores (ICC 0.921, 95% CI 0.866-0.953) and treatment scores (ICC 0.916, 95% CI 0.855-0.951). Educational Physician videos had significantly greater diagnostic and treatment scores compared to non-physician videos (9.54 vs. 7.05, P = 0.048, and 6.53 vs. 5.3, P = 0.004). CONCLUSIONS: YouTube videos pertaining to LDH were found to have low overall quality. Physicians should be cognizant about information sources readily available to patients as they may influence patient expectations and preconceptions.
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Medios de Comunicación Sociales , Humanos , Fuentes de Información , Grabación en Video , Pacientes , Difusión de la InformaciónRESUMEN
Introduction: Septic arthritis is an orthopaedic emergency, with permanent cartilage damage possible within hours of the onset of symptoms. Diagnostic criteria for septic arthritis in immunocompetent patients are well established, however, there is a paucity of literature evaluating diagnostic criteria in immunocompromised patients. The purpose of this retrospective case-control study was to evaluate the laboratory and clinical information of immunocompromised patients with septic arthritis and compare them to immunocompetent patients with septic arthritis to enable physicians to diagnose septic arthritis more accurately in this population. Methods: All patients at our institution, a level I trauma center, with a clinical diagnosis of septic arthritis between January 1, 2006 and November 1, 2021 were identified and reviewed retrospectively. Patients 18 years old or older were screened for immunocompromised status and those meeting criteria were included for review. The control cohort was matched by the joint affected and age. Data were analyzed using the Shapiro-Wilk test, Turkey's test, Mann-Whitney U test, independent sample t-test, and chi-square analysis. A p-value of <0.05 was considered significant. Results: A total of 36 patients with positive joint aspirate cultures were compared (18 immunocompetent and 18 immunocompromised). The immunocompromised group had a significantly longer length of hospital stay than the immunocompetent group (p = 0.044). There was no significant difference in erythrocyte sedimentation rate (ESR) (p = 0.852), peripheral white blood cell count (pWBC) (p = 0.696), joint aspirate white blood cell count (aWBC) (p = 0.901), polymorphonuclear cell percentage (PMN%) (p = 0.325), or total operations performed per patient (p = 0.365). Conclusion: At our institution, immunocompromised patients with septic arthritis did not have significantly different diagnostic laboratory values when compared to immunocompetent patients. This suggests that immunocompromised patients with suspicion of septic arthritis can be assessed with similar diagnostic criteria as immunocompetent individuals; however, a larger cohort study is needed to assess the difference more precisely in laboratory values.
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Background It is generally believed that trauma to fat grafts is detrimental and affects the survival of the graft. In addition, it has been shown that smaller fat particle size corresponds to better survival; however, smaller cannula openings correspond to slower and more difficult fat graft harvesting. Objectives This study documents the relationship between cannula size, harvested fat cell size, and injection needle size. A means of reducing fat particle size following aspiration with larger diameter cannulas is also discussed. Methods Fat was harvested from five patients undergoing elective liposuction. Each fat sample was placed in a syringe and injected through progressively smaller needles until obstruction under low pressure was obtained. The minimal needle size was documented for each sample. Results Fat harvested with a liposuction cannula results in different size fat particles ranging up to the size of the cannula. Particles obtained from 3- and 4-mm cannulas can be injected without obstruction through a 16-gauge needle. Particles obtained from a 2-mm cannula can be injected without obstruction through an 18-gauge needle. Particles obtained from a 1-mm cannula can be injected without obstruction through a 20-gauge needle. Particles obtained from a 1-mm cannula could not be injected without obstruction through a 22-gauge needle. Conclusions There is a relationship between cannula opening size and the resultant fat graft size. Fat particles are somewhat compressible but should not be forced through needles or cannulas that are too narrow. It may be beneficial to harvest fat with larger cannulas and cut the particles to smaller sizes for injection.