Avive Soft Tissue Membrane Improves Outcomes of Revision Upper-extremity Nerve Decompression Surgery.

Revision nerve decompression remains a challenge for surgeons. Avive Soft Tissue Membrane is processed human umbilical cord membrane that may reduce inflammation and scarring, thereby improving tissue gliding. Although synthetic conduits have been reported in revision nerve decompression, the use of Avive has not. Methods: Prospective study of revision nerve decompression with Avive application. VAS pain, two-point discrimination, Semmes-Weinstein, pinch and grip strength, range of motion, Quick Disability of Arm, Shoulder & Hand (QuickDASH), and satisfaction were recorded. Using a propensity-matched cohort, VAS pain and satisfaction were retrospectively collected to compare with cohort outcomes. Results: In the Avive cohort, 77 patients (97 nerves) were included. Mean follow-up was 9.0 months. Avive was applied to the median nerve in 47.4%, ulnar nerve in 39.2%, and radial nerve in 13.4%. VAS pain was 4.5 preoperatively and 1.3 postoperatively. S4 sensory recovery was achieved in 58% of patients, S3+ in 33%, S3 in 7%, S0 in 2%, and improvement from baseline in 87%. Strength improved in 92%. Mean total active motion was 94.8%. Mean QuickDASH score was 36.1, and 96% reported improved or resolved symptoms. Preoperative pain was not significantly different between Avive cohort and controls (P = 0.618). Postoperative pain was significantly lower in cohort patients (1.3 ± 2.2 versus 2.7 ± 3.0, P = 0.001). In the Avive cohort, more had improved or resolved symptoms (P < 0.0001). Clinically important improvement in pain was reported in 64.9% of Avive group patients versus 40.8% of controls (P = 0.002). Conclusion: Avive contributes to improved outcomes in revision nerve decompression.

Bony hypertrophy of the forearm in bareback rodeo athletes.

OBJECTIVE: Activities that require increased load bearing are known to cause bony hypertrophy. This phenomenon has been documented in the dominant arm of athletes in sports requiring significant utilization of a single limb. The literature addressing this effect in rodeo athletes, however, is minimal. Studies evaluating rodeo athletes are primarily focused on acute injury management rather than chronic symptoms resulting from changes in bone and soft tissue. We designed a study to evaluate bony hypertrophy in athletes without acute injury. METHOD: Rodeo bareback riders presented with frequent pain in their grip arm, no radiographic evidence of injury, and clinical signs of peripheral nerve compression. Anteroposterior and lateral X-rays taken for initial evaluation in 17 bareback rodeo athletes were retrospectively reviewed. The diameter of bilateral ulnas was measured at its longitudinal midpoint. Ratio of Ulnar Diameters (grip arm/free arm) and Percentage Diameter Difference were calculated. An independent samples t-test was used to assess differences in diameters of grip and non-grip arms. RESULT: The mean ulnar diameter was 18.4 ± 3.5 in the grip arm and 16.6 ± 3.5 in the non-grip arm (p < 0.001). The mean ratio of grip to free arm ulnar diameter was 1.42 ± 0.21 (range = 1.05-1.92). The mean diameter percent difference measured 42.3% (range = 4.7%-92.0%), and the grip arm was observed to have a greater ulnar diameter compared to the non-grip arm. CONCLUSION: There are significant anatomic differences in the grip arm of bareback rodeo athletes compared to the contralateral arm. In cases of persistent pain in the grip arm and no evidence of acute injury, these differences may be relevant to pain symptoms and should be considered as part of the assessment and treatment algorithm.

Preoperative Angiography Can Guide Treatment of Post-Femoral Neck Fracture Capital Femoral Physeal Separation and Displacement: A Case Report.

CASE: A 13-year, 6-month-old boy sustained a Delbet type III femoral neck fracture with postoperative femoral head avascular necrosis (AVN) and subsequent capital femoral physeal separation (CFPS). Preoperative angiography revealed a patent artery of the ligamentum teres to the femoral head epiphysis, allowing our patient to undergo a modified Dunn procedure to maintain this artery and preserve his native hip. CONCLUSION: Preoperative angiography allows for real-time identification of femoral head epiphyseal blood supply in patients with femoral head AVN complicated by CFPS and guides surgical treatment for hip preservation.

THE CONSTRAINING EFFECT OF THE LATERAL FEMORAL INTERMUSCULAR SEPTUM ON PASSIVE HIP ADDUCTION IN UN-EMBALMED CADAVERS.

BACKGROUND: Due to the lack of verifiable iliotibial band elongation in response to stretching, the anatomical, biomechanical, and physiological responses to treatment of iliotibial band syndrome remain unclear. The lateral intermuscular septum, consisting of multiple myofibroblasts, firmly anchors the iliotibial band to the femur. PURPOSE AND HYPOTHESIS: The purpose of this in-situ study was to examine the constraining effect of the lateral intermuscular septum on available passive hip adduction range of motion in un-embalmed cadavers. It was hypothesized that an iliotibial band-septum-complex release would significantly increase passive hip adduction. DESIGN: Within-specimen repeated measures in-situ design. SETTING: Anatomy laboratory. METHODS: Metal markers were inserted into selected anatomical landmarks in eleven (11) un-embalmed human cadavers. With the specimen supine, the test-side lower limb was passively adducted until maximum passive hip adduction was reached. This movement was repeated three times each within two conditions: (1) band-septum-complex intact and (2) band-septum-complex dissected. Digital video of marker displacement was captured throughout each trial. Still images from a start and an end position were extracted from each video sequence. A custom Matlab program was used to calculate frontal plane hip adduction angle changes from obtained images. RESULTS: Mean change in passive hip adduction after band-septum-complex release was -0.3 ° (SD 1.6 °;95% CI: -1.33,0.76). A paired samples t-test revealed a non-significant difference (t=-.611; p=.555) in passive hip adduction for the band-septum-dissected condition (18.8 ± 3.9 °) versus the band-septum-intact condition (18.5 °±4.7 °). CONCLUSION: The lateral intermuscular septum does not appear to have a constraining effect on passive hip adduction in un-embalmed cadavers. Future research should evaluate the constraining effect of other selected tissues and conditions on hip adduction. Furthermore, inflammatory, metabolic, viscoelastic, and sensorimotor control properties within the iliotibial band in response to stretching should be investigated. LEVEL OF EVIDENCE: 3.

Effects of powdered rifampin and vancomycin solutions on biofilm production of staphylococcus aureus on orthopedic implants.

PURPOSE: Hardware infections in orthopedic surgery, specifically those involving biofilm producing bacteria, are troublesome and are highly resistant to systemic antibiotics. The purpose of this study was to demonstrate the power of rifampin and vancomycin solutions in inhibiting as well as eliminating in vitro on staphylococcus aureus (S. aureus) biofilm in vitro on stainless-steel implants. METHODS: A suspension of either S. aureus or a S. aureus containing a plasmid that cods for the green fluorescence protein containing fluorescent protein plasmid was applied to 1 × 1cm sterile stainless steel orthopedic plating material (coupon). Biofilm development was confirmed by; the quantitative assay (colony forming unit [CFU/coupon]) and visualized using confocal laser scanning microscopy. With this established method of biofilm development, we determined the minimum biofilm inhibitory concentration (MBIC) and the minimum biofilm eradication concertation (MBEC) of Rifampicin and Vancomycin. To determine the MBIC, stainless steel plates were subjected to different concentrations of antibiotic solution and inoculated with overnight cultures of S. aureus. After 24 h of incubation at 37 °C, the biofilms on the untreated and antibiotic-treated coupons were quantified. To determine the MBEC, partial S. aureus biofilms were developed on the coupons and then treated with the different concentrations of each antibiotic for 24 h. The number of bacteria within the control untreated as well as treated coupons was determined. RESULTS: Both rifampin and vancomycin solutions inhibited biofilm production of S. aureus on stainless steel mediums; the MBIC for rifampin and vancomycin were 80 ng/mL and 1 µg/mL respectively. The MBEC for Rifampicin was similar to the MBIC. However, the MBEC for Vancomycin was 6 mg/ml. CONCLUSIONS: When applied to orthopedic stainless steel hardware in vitro, solutions of rifampin and vancomycin powder separately or in combination can completely prevent and eliminate biofilm produced by S. aureus. LEVEL OF EVIDENCE: II.

Periprosthetic Fracture through a Unicortical Tracking Pin Site after Computer Navigated Total Knee Replacement.

A rare complication from computer-navigated total knee arthroplasty is a fracture through the insertion site of a tracking pin. These pins are inserted across the femoral and tibial shafts either bicortically, transcortically, or unicortically and have a reported fracture incidence of 1.38%, with all published cases occurring after bicortical pin placement. In this case, a 60-year-old female suffered a femoral shaft fracture through a unicortically inserted computer navigation tracking pin 6 weeks after total knee arthroplasty. Her fracture was successfully fixated with an intramedullary nail with retention of the knee prosthesis. This case is important as it records the risk for a postoperative fracture through a unicortically inserted computer navigation pin.

Bosworth Dislocation without Associated Fracture.

One of the rarest ankle injuries is the Bosworth fracture-dislocation, whereby the distal fibula fractures and is lodged behind the tibia and is often unable to be reduced in a closed fashion. Even more rarely, a Bosworth dislocation without any accompanying fractures may occur. In this case, a 19-year-old male presented with a Bosworth dislocation, with the ipsilateral tibia having previously undergone intramedullary nailing. After closed reduction was attempted, open reduction and fixation was performed, directly reducing the fibula and fixing the unstable syndesmosis with 2 quadricortical screws. Bosworth injuries are rare, yet severe, and should be treated in a timely manner. We were able to provide good reduction and fixation without requiring removal of the intramedullary nail, and we support the use of 2 quadricortical screws as a valid treatment option for the fixation of Bosworth dislocations.