Lower Extremity Assistive Devices (LEADs): A Contemporary Literature Review.

Lower extremity ambulatory assistive devices (LEADs) are important augments that provide mobility and stability when weightbearing is restricted in the setting of injury, surgery, or balance disorders. In order to optimize patient safety and function when prescribing these devices, it is essential for the orthopaedic surgeon to have a firm understanding of their specific indications, proper fitting, energy demand, biomechanical advantages, and potential complications. Comprehension of normal gait cadence, identification of the functional deficit present and knowledge of available options will assist in safely prescribing the proper device. Over the last decade, newer alternatives to traditional LEADs (canes, crutches, walkers) have become available, including the rolling knee scooter and hands-free single crutch. These have been developed to improve mobility and independence; however, it is necessary to appreciate their limitations when prescribing them to patients. This review will provide an update on normal and pathologic gait biomechanics as well as the most common types of LEADs currently available to the orthopaedic surgeon, their indications, important considerations, proper fitting, associated energy expenditure, and complications.

Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. MATERIALS AND METHODS: This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. RESULTS: This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. CONCLUSIONS: ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

Management of Isolated Greater Trochanter Fractures Associated With Total Hip Arthroplasty.

Periprosthetic hip fractures are recognized complications associated with total hip arthroplasty. Over the past decade, there has been a 2.5-fold increase in the incidence of periprosthetic fractures which is expected to grow exponentially in the future. Most of these fractures require surgical fixation or revision arthroplasty. Fractures of the greater trochanter represent a subset of periprosthetic fractures for which there is currently no consensus in the literature regarding the optimal management. The purpose of this review was to outline the management strategies available to address these fractures, with formulation of recommendations for fractures sustained intraoperatively, postoperatively, and in the setting of primary and revision total hip arthroplasty.

Osteomyelitis in Sickle Cell Anemia: Does Age Predict Risk of Salmonella Infection?

BACKGROUND: Osteomyelitis is a condition that disproportionately affects those with sickle cell anemia (SCA). Despite the frequency of osteomyelitis in this population, there are reports of increasing life expectancy and rates of Staphylococcus aureus infections, which contrasts the belief that Salmonella is the most common organism identified. The purpose of this systematic review is to determine the most commonly identified organism and identify whether age is associated with the development of Salmonella osteomyelitis in homozygous sickle cell patients. METHODS: A search of PubMed, EMBASE Cochrane and databases was performed for studies of all levels of evidence pertaining to osteomyelitis in SCA. Reasons for exclusion included non-English language, case reports, literature reviews, isolated septic arthritis without bony involvement and isolated oral-facial bony involvement. RESULTS: The most common pathogen cultured was nontyphoid Salmonella , which occurred in 117 of 192 (60.9%) of cases identified. This was followed by S. aureus 41 of 192 (21.8%) and other enteric bacteria 14 of 192 (7.2%). Subgroup analysis demonstrated differences at the age of initial presentation with Salmonella cohort at 6.8 years and S. aureus cohort at 22.1 years ( P = 0.0001). On geographic analysis, African countries had an older average age of diagnosis at 13.1 years with decreased rates of Salmonella infections and increased rates of infections from other organisms compared with the US, Middle East and Europe. CONCLUSIONS: This systematic review suggests that Salmonella is most commonly identified in patients with SCA (HbSS phenotype) especially those <12 years old presenting with acute osteomyelitis. Sub-Saharan African countries had later ages of diagnosis compared with the US, Middle East and Europe with bacterial profiles that favors a diagnosis of chronic osteomyelitis and missed acute initial presentation. Therefore, age of presentation is likely a surrogate for geographic and socioeconomic factors such as availability of medical screening and treatment.

Incidence and Management of Radial Nerve Palsies in Humeral Shaft Fractures: A Systematic Review.

Radial nerve palsies in closed humeral shaft fractures are common, with an incidence of 7%-17%. The management of radial nerve palsies in closed fractures is often expectant, with 70.7% spontaneously recovering within six months. A literature search was conducted for studies on radial nerve palsies in humeral shaft fractures from 2000-2018. A total of 4972 humeral shaft fractures were identified, with an incidence of 12.2% of primary radial nerve palsies. During the exploration, no neurological intervention was performed in nearly 41% of cases, and the most common finding was no evidence of any nerve lesion (35%). Those who underwent neurolysis were more likely to resolve when compared to primary repair or nerve grafting. Overall, there was a high rate of spontaneous radial nerve palsy recovery (85%) with radial nerve exploration increasing rates of resolution. While exploration demonstrates increased resolution, it is yet to be determined which fractures are indicated for nerve exploration.

Evaluation of Virulence Gene Expression Patterns in Acinetobacter baumannii Using Quantitative Real-Time Polymerase Chain Reaction Array.

According to the Centers for Disease Control's recently devised National Strategy for Combating Antibiotic-Resistant Bacteria, Acinetobacter baumannii is a "serious" threat level pathogen. A. baumannii's notoriety stems from the fact that a large number of modern strains are multidrug resistant and persist in the hospital setting, thus causing numerous deaths per year. It is imperative that research focus on a more fundamental understanding of the factors responsible for the success of A. baumannii. Toward this end, our group investigated virulence gene expression patterns in a recently characterized wound isolate, AB5075, using quantitative real-time polymerase chain reaction array. Notably, several genes showed statistically significant upregulation at 37°C compared to 25°C; MviM, Wbbj, CarO, and certain genes of the Bas, Bar, and Csu operons. Additionally, we found that in vitro biofilm formation by Csu transposon insertion mutant strains is attenuated. These findings validate previous reports that suggest a link between the Csu operon and biofilm formation. More importantly, our results demonstrate a successful method for evaluating the significance of previously identified virulence factors in a modern and clinically relevant strain of A. baumannii, thereby providing a path toward a more fundamental understanding of the pathogenicity of A. baumannii.