Musculoskeletal function following bariatric surgery.

OBJECTIVE: Bariatric surgery is an effective method for acute weight loss. While the impact of bariatric surgery on general medical conditions (e.g., type 2 diabetes) is well documented, few studies focus on physical functional outcomes following weight-loss induced by bariatric surgery. DESIGN AND METHODS: We report on 50 women aged 20-74 scheduled for Roux-en-Y gastric bypass (RYGB) procedure who were enrolled for a prospective 1-year study. Height, weight, and waist circumference were recorded preoperatively and at 6 and 12 months, postoperatively. To track musculoskeletal/physical function changes, the timed-get-up-and-go (TGUG) and short-form health survey-36 (SF-36) and short musculoskeletal function assessment (SFMA) questionnaires were administered. RESULTS: Patients had significant weight loss and functional improvement. At 1 year mean weight loss was 48.5 kg and mean TGUG improvement was 3.1 s. SMFA and SF-36 also showed improvement in functional components with weight loss at 6 months and 1-year post surgery. Significant associations were observed between TGUG and SMFA measures at all time points. Final weight at 1 year post bariatric surgery was also significantly correlated with most functional outcomes and changes in these outcomes. Partial correlations controlling for age revealed additional associations between body weight and functional outcomes, especially at the 6-month visit. CONCLUSION: Our results suggest that significant rapid weight loss, such as that attained by bariatric surgery, acutely improves musculoskeletal function in morbidly obese patients. Additionally, for patients with musculoskeletal disease or injury, weight loss resulting from bariatric surgery may serve as an adjunct for improving global functional outcome, and enhancing the rehabilitation potential.

Incidence of bilateral scapholunate dissociation in symptomatic and asymptomatic wrists.

PURPOSE: Scapholunate dissociation (SLD) is thought to be a common cause of both acute and chronic wrist pain. Classically, this condition is attributed to a traumatic event and is thought to inevitably lead to the development of degenerative arthritis. Bilateral findings should thus be infrequent. The purpose of the present study was to determine the incidence of bilateral radiographic SLD and associated arthritic changes. METHODS: Demographic, radiographic, and clinical data were obtained from 124 patients with abnormal x-ray findings in at least 1 wrist. Radiographs reviewed included posteroanterior, lateral, and Moneim views of both symptomatic and asymptomatic wrists. Pathology was defined as a scapholunate gap ≥ 5 mm and/or a scapholunate angle ≥ 60°. Arthritic changes were assessed. RESULTS: A majority of the 124 patients (51%) were unable to recall any specific injury to their wrist. On the symptomatic side, 101 (81%) patients had a pathologic measurement for their scapholunate gap, and 109 (88%) had an abnormal angle measurement. On the asymptomatic side, 64 (52%) of the gap measurements and 87 (70%) of the angle measurements were pathologic. Ninety-nine patients (80%) had abnormal radiographic findings bilaterally for at least 1 variable on each side. Only 13 patients (11%) had a clinical instability pattern typical of SLD. Half the patients had radiographic degenerative changes at presentation. CONCLUSIONS: Bilateral radiographic SLD is much more common than previously assumed, is often asymptomatic, and does not inevitably lead to degenerative arthritis. These findings should call into question the assumption of a uniquely traumatic etiology. Further, most patients presented with pathologies unrelated to the scapholunate articulation. Surgical intervention chosen on the basis of radiologic findings, in the absence of clinical instability, might not be the best course of action, unless criteria are established to determine which patients eventually develop arthritic changes or become symptomatic. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Assuring the research competence of orthopedic graduates.

OBJECTIVES: To assure that orthopaedic residents have the knowledge needed to critically appraise the medical/surgical literature and the skills needed to design and conduct musculoskeletal and orthopaedic research. SETTING: Residency program of the Department of Orthopaedic Surgery, Sports Medicine and Rehabilitation at Wright State University Boonshoft School of Medicine, Dayton, Ohio. PARTICIPANTS: Established in 2005, members of the residency program's Research Team (RT) include orthopaedic faculty and residents, university faculty and graduate students, community scientists, and department staff. METHODS: The membership and responsibilities of the Research Team are described. The goals of the three-month research rotation during the second year of residency and the activities of the assigned resident are reported. The work of the two research residents during the second year of their six-year program is explained. Helpful educational resources are noted, the role of the faculty research mentor defined, funding sources listed, and the financial support for RT members and research staff presented. RESULTS: The scholarly activity of orthopaedic surgery residents increased substantially from the five-year period before the implementation of the Research Team (September 2000 through August 2005) to the four-year period after initiation of the RT (September 2005 through November 2009). For peer-reviewed scholarship activity, publications on which residents were authors increased from 1 to 10 per year, national presentations at professional meetings increased from 6 to 11 per year, and local and regional presentations increased from 2 to 4 per year. CONCLUSIONS: The Research Team is an effective strategy for assuring that orthopaedic residents have the knowledge and skills to evaluate clinical care evidence and to conduct musculoskeletal and orthopaedic research.

Healing of iatrogenic skeletal muscle wounds is affected by incision device.

Orthopedic joint procedures frequently require extensive dissection of skeletal muscles resulting in tissue injury, formation of scar tissue, pain, and potentially, functional impairment. The authors hypothesized that using a low-temperature ultrasonic cutting and coagulating device (Harmonic Blade, Ethicon Endo-Surgery, Cincinnati, OH) would result in reduction in tissue trauma in terms of reducing acute and chronic inflammation during healing. Bilateral longitudinal incisions were made into the tibialis cranialis muscles of rabbits with either a Harmonic Blade or a standard monopolar electrosurgical scalpel. At 3, 7, and 21 days postoperatively, necropsy and histological evaluations indicated a significant attenuation of acute inflammation (P = .011) for the Harmonic incisions compared with electrosurgery. No significant differences were observed for chronic inflammation, necrosis, or fibrosis. Use of a Harmonic scalpel during dissection of skeletal muscle in orthopedic surgery may result in reduced influx of neutrophils, reducing acute inflammation, and potentially aid in reducing postoperative pain and functional impairment.

Biomechanical comparison of a proximal humeral locking plate using two methods of head fixation.

HYPOTHESIS: Locking plates have emerged as the implant of choice for stabilization of proximal humeral fractures. The biomechanical properties of a locked plating system using smooth pegs vs threaded screws for fixation of the humeral head were compared to test the hypothesis that there would be no biomechanical difference between pegs and threaded screws. MATERIALS AND METHODS: Sixteen pairs of fresh frozen cadaveric humeri were randomized to have a surgical neck gap osteotomy stabilized with a locked plate using threaded screws (n=8) or smooth pegs (n=8). The intact contralateral humerus served as a control. Each specimen was tested with simultaneous cyclic axial compression (40 Nm) and torsion (both +/-2 Nm and +/-5 Nm) for 6000 cycles. All specimens were loaded to failure. Interfragmentary motion and load-displacement curves were analyzed to identify differences between the groups. Our data were then compared to previously published forces across the glenohumeral joint to provide evidence based recommendations for postoperative use of the shoulder. RESULTS: There was a statistically significant difference between test specimens and their paired control (P < .001) in cyclic testing and load to failure. Differences between the smooth pegs and threaded screws were not statistically significant. DISCUSSION: There is no biomechanical difference between locked smooth pegs and locked threaded screws for proximal fragment fixation in an unstable 2-part proximal humeral fracture model. CONCLUSION: Our study contributes to the published evidence evaluating forces across the glenohumeral joint and suggests that early use of the affected extremity for simple activities of daily living may be safe. Use of the arm for assisted ambulation requiring a crutch, cane, walker, or wheelchair should be determined on a case-by-case basis.

Total dislocation of the talus and the navicular: a case report.

Total dislocation of the talonavicular joint is rare. Detection of a major tarsal bone extrusion is simple. However, its management and treatment are not. We present a case of a total extrusion of the talus and navicular of an open dislocation and the reconstruction options that subsequently followed. In spite of a well-perfused foot, our patient decided to undergo a below the knee amputation after an infection.

Lateral compartment syndrome of the lower extremity in a recreational athlete: a case report.

There are a limited number of reported cases of acute-onset isolated lateral compartment syndrome. We report a case of a 28-year-old recreational athlete who was erroneously diagnosed as having a muscle strain of his right lower extremity and discharged home. The patient over the course of the next day developed increasing leg pain and returned to the same emergency department where measurement of the peroneal compartment was 122 mm Hg. The patient had an emergent fasciotomy of the peroneal compartment of the right leg. The remainder of his hospital course was unremarkable. Although not commonly encountered, lateral compartment syndrome is important to consider in all patients who present with increasing pain out of proportion to injury and a tense swollen compartment after physical activity.

Correlation of pain scores, analgesic use, and beck anxiety inventory scores during hospitalization in lower extremity amputees.

Post amputation pain can be debilitating for patients and families. Chronic pain is a common phenomenon after lower extremity amputation, occurring in up to 80% of this population. The purpose of this pilot study was to correlate post amputation pain scores to opioid analgesic consumption and Beck Anxiety Inventory (BAI) scores. Twenty-three patients with lower extremity amputation at an 827-bed acute care inner-city hospital were surveyed pre-operatively and post-operatively to determine if there was a significant correlation between anxiety and pain. A numeric scale was utilized by patients to rate their pain level, while the BAI was utilized to measure their anxiety levels.A significant correlation was found between the pre-operative BAI levels and the BAI levels identified at time of discharge. Patients were found to have a higher than normal level of anxiety pre-operatively. No significant correlations were found between anxiety and pain.

Uniplanar external fixation for care of circumferential extremity burn wounds in adults.

The optimal management of circumferential extremity burns remains a challenge. Elevation of the extremity to decrease wound swelling and avoid pressure at the point of contact on new skin grafts is a standard objective but can be frequently difficult to accomplish. Although various forms of elevation have been proposed, our purpose was to evaluate the safety and efficacy of the uniplanar external fixation (UEF) device in providing extremity elevation and stabilization while optimizing skin grafting. Intraoperative application of either upper or lower extremity UEF was performed at the time of eschar excision and application of split-thickness autografts. Inclusion criterion was that patients should be over 16 years of age with third-degree circumferential extremity burns that were planned for autologous skin grafting within 48 hours after their injury. Patient consent was obtained in every case. Eight patients aged 17 to 62 with circumferential extremity burns were reviewed. No pin-tract infections were observed, nor were any of the skin grafts lost due to shearing. Peripheral nerve and arterial injuries were not encountered. Only one patient with an oversized arm secondary to morbid obesity had a pin pull-out. No other patient developed adverse sequelae from the surgery or from the placement of the UEF device. The UEF device provides a safe and effective means for elevation of extremites in patients with circumferential extremity burns undergoing skin grafting. This allows for optimal access for skin grafting, dressing changes, and postoperative positioning. Shear injury and pressure necrosis of the fresh grafts is minimized. Increasing the number of pins in obese patients should be considered to avoid the complications of pin pull-out.

Follow-up on misrepresentation of research activity by orthopaedic residency applicants: has anything changed?

BACKGROUND: In our previous study, published in 1999, we showed that 18% of research citations listed as published by orthopaedic residency applicants were misrepresented. Since our last report, we sought to determine whether there had been any change in the behavior of applicants wishing to pursue the field of orthopaedic surgery. METHODS: We evaluated the research citations that were identified after a review of the Publications section of the Common Application Form from the Electronic Residency Application Service for all applicants to our orthopaedic residency program for 2005 and 2006. Inclusion and exclusion criteria were established for citations listed on candidate applications. Citations were required to be from journals listed in Ulrich's Periodicals Directory. The PubMed-MEDLINE database engine was used to search for citations. If searching failed to yield the cited publication, a review of the journal of alleged publication was undertaken and an interlibrary search was conducted with the use of several research databases. When no match was found, the citation was labeled as misrepresented. Misrepresentation was defined as either (1) nonauthorship of an existing article or (2) claimed authorship of a nonexistent article. RESULTS: One hundred and forty-two (35.9%) of 396 applicants during the 2005 and 2006 application periods listed publications. A total of 304 citations were claimed from these 142 applicants. Listings included articles that were in press or in print (thirty-four citations), articles in journals not found in Ulrich's Periodicals Directory (twenty-eight citations), book chapters (twenty-three citations), and articles recorded as having been submitted (eighty-eight citations). These 173 works were excluded from our analysis. One hundred and thirty-one citations were referenced as appearing in journals per our search criteria, and all were verified. Twenty-seven or 20.6% (95% confidence interval, 14.2% to 28.7%) of 131 citations were misrepresented. CONCLUSIONS: The prevalence of misrepresented research publications from orthopaedic surgery residency applicants increased modestly to 20.6% compared with that found in our original report (18%). As we recommended in our last report, we strongly urge residency programs to require applicants to submit reprints of their publications with their residency applications. Perhaps standardized guidelines should be developed to help to prevent misrepresentation through the Electronic Residency Application Service.

Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective.

More than 200,000 people in the United States are diagnosed annually with compartment syndrome. This condition is commonly established based on clinical parameters. Determining its presence, however, can be challenging in obtunded patients or those with an altered mental status. A delay in diagnosis and treatment of these injuries can result in significant morbidity. Surgical release of the enveloping fascia remains the acceptable standard treatment for compartment syndrome. This article reviews the evaluation and treatment of compartment syndrome.