Acute Correction of Leg Length Discrepancy and Severe Femoral Malalignment: A Case Report.

Introduction: Approximately 70% of the population have a leg length discrepancy, with 2 cm being the threshold for surgical treatment. Although there are reports of patient outcomes after incremental leg-lengthening, there is a paucity of data regarding acute lengthening procedures. We present a unique case of acute leg lengthening and correction of severe malalignment in an adult patient after femoral malunion treated with multiple modified Sofield-Millar osteotomies and intramedullary nailing, a technique that has only previously been performed in pediatric long bone deformities. To the author's knowledge, there have been no previous reports of acute lengthening in an adult patient to correct for such a severe deformity in a single operation. Case Report: A 48-year-old woman with a 35-year history of a right femur fracture malunion presented with a 5 cm leg length discrepancy and severe malalignment associated with pain and ambulatory dysfunction. Multiple modified Sofield-Millar osteotomies followed by placement of an intramedullary nail were performed and resulted in successful acute correction of limb length discrepancy and anatomical alignment. There was a complete union of bone with callus formation at osteotomy sites at 9 months postoperatively, and the patient reported minimal pain and improved ambulation. The patient was followed for 2 years postoperatively and experienced an improvement in ambulatory function with no pain. No post-operative complications were observed. Conclusion: Multiple modified Sofield-Millar osteotomies with intramedullary nailing were utilized for successful acute correction of limb length discrepancy and severe malalignment with improvement in pain and ambulatory function in this case of femoral leg length discrepancy in an adult patient.

The Clinical Utility of Maceration Dressings in the Treatment of Inpatient Hand Infections: An Evaluation of Treatment Outcomes Compared to Standard Care.

Background: In cases of oral antibiotic-resistant infection of the hand, we propose utilizing a heated, moist maceration dressing to help shorten and simplify the in-hospital clinical course by increasing the efficacy of antibiotic deliverance to infection sites, increasing the success of nonoperative management, and decreasing eradication time of infection of the hand. Methods: Fifty-six patients older than 18 years of age who presented with hand infections requiring inpatient intravenous antibiotics at our suburban academic hospital over a 30-month period were included and randomly assigned to either the maceration dressing group or the standard treatment group. Maceration dressings included warm and moist gauze, kerlix, webril, Orthoglass, Aqua K Pad, and sling. Results: Fifty-two patients who were mostly male and younger than 60 years of age were included. Patients who used the maceration dressing had significantly shorter hospital lengths of stay (P = .02) and intravenous antibiotics duration before transition to oral antibiotics (P = .04), and decreased need for formal operating room irrigation and debridement to obtain source control (P = .02) compared to patients treated with the standard dressing. Post-hoc analysis yielded improved outcomes when using the maceration dressing regardless of whether initial bedside incision and drainage was needed to decompress a superficial abscess or not. Conclusion: The maceration dressing can be used along with proper intravenous antibiotic treatment to improve the treatment course of patients with hand infections regardless of whether the patient needs an initial bedside incision and drainage or not. Level of Evidence: Therapeutic Level II.

Review of Physician Referrals to Orthopedic Spine versus Neurosurgery.

BACKGROUND: Previous studies have reported what patients value while choosing their surgeon, but there are no studies exploring the patterns of referral to spine surgeons among primary care physicians (PCPs). This study aims to identify any trends in PCPs' referral to orthopedic surgery versus neurosurgery for spinal pathology. METHODS: In total, 450 internal medicine, family medicine, emergency medicine, neurology, and pain management physicians who practice at one of three locations (suburban community hospital, urban academic university hospital, and urban private practice) were asked to participate in the study. Consenting physicians completed our 24-question survey addressing their beliefs according to pathologies, locations of pathologies, and surgical interventions. RESULTS: Overall, 108 physicians (24%) completed our survey. Fifty-seven physicians (52.8%) felt that neurosurgeons would provide better long-term comprehensive spinal care. Overall, 66.7% of physicians would refer to neurosurgery for cervical spine radiculopathy; 52.8%, to neurosurgery for thoracic spine radiculopathy; and 56.5%, to orthopedics for lumbar spine radiculopathy. Most physicians would refer all spine fractures to orthopedics for treatment except cervical spine fractures (56.5% to neurosurgeons). Most physicians would refer to neurosurgery for extradural tumors (91.7%) and intradural tumors (96.3%). Most would refer to orthopedic surgeons for chronic pain. Finally, physicians would refer to orthopedics for spine fusion (61.1%) and discectomy (58.3%) and to neurosurgery for minimally invasive surgery (59.3%). CONCLUSIONS: Even though both orthopedic surgeons and neurosurgeons are intensively trained to treat a similar breath of spinal pathology, physicians vary in their referring patterns according to spinal pathology, location of pathology, and intended surgery. Education on the role of spine surgeons among PCPs is essential in ensuring unbiased referral patterns.

The Effect of an Orthopedic Hand Surgeon's Attire on Patient Confidence and Trust.

Background: Multiple studies have concluded that patients are more likely to understand and trust physicians who dress in more formal attire (shirt and tie) as opposed to casual attire (t-shirts and jeans). The white coat has repeatedly been reported as a major source of trust and confidence in a patient's eyes. Methods: This study explores the effect an orthopedic hand surgeon's attire has on a patient's perception of their surgeon's clinical values. All patients 18 years of age and older who visited our orthopedic hand surgeon's suburban outpatient practice were asked to participate in our survey-based study. Results: Ninety-seven surveys were completed and included. A majority of our responders are female (n = 59, 60.8%), Caucasian (n = 83, 85.6%) between the ages of 55 and 74 years (n = 40, 41.2%), currently employed (n = 59, 60.8%) with private health insurance (n = 69, 71.1%), and married (n = 64, 66.0%). Patients rated male and female hand surgeons wearing a white coat highest using the Likert scale and when asked about their perceived clinical qualities. Patients consistently poorly rated their surgeons wearing casual attire. Patients did note that the white coat, or any specific attire, was not necessary during the initial encounter to build a strong patient-surgeon relationship. Finally, goatees and beards do not positively or negatively impact a surgeon's patient-constructed image. Conclusions: Combining strong clinical skills with appropriate clinical attire highlighted by the physician wearing a white coat appears to be an effective way to enhance patient satisfaction while ultimately gaining the trust and respect needed to properly care for patients.

Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach.

BACKGROUND: When critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. METHOD: A multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). RESULTS: In total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). CONCLUSION: By implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.