A localized laminar flow device decreases airborne particulates during shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Although the rate of periprosthetic joint infection following shoulder arthroplasty is low, it is a morbid and costly complication. Airborne particulates have long been recognized as a potential source of wound contamination, and operating room-mounted and smaller localized laminar airflow devices have been developed to minimize airborne particulates. This randomized controlled trial evaluated the effectiveness of a localized laminar flow device in reducing the intrusion of ambient airborne particles and bacteria into the surgery site during shoulder arthroplasty as measured by overall particle counts and colony-forming units (CFUs). METHODS: Patients undergoing primary anatomic or reverse shoulder arthroplasty were eligible for participation. After providing informed consent, patients were randomly assigned to the Air Barrier System (ABS) group or control group. For all patients, the ABS was placed on the surgical field; however, it was only turned on by the technician for those randomized to the ABS. Study participants, surgeons, and surgical staff were blinded to group assignment. Bacterial CFUs were collected from within 5 cm of the surgical wound every 10 minutes, whereas airborne particulates were collected every minute. Poisson regression models were used to determine whether differences existed in CFUs and particulate counts between the ABS and control groups. RESULTS: A total of 43 patients were randomized into the ABS (n = 21) or control (n = 22) group. Surgical time (P = .53) and the average staff count (P = .16) in the operating room did not differ between groups. Poisson regression showed that the ABS group had significantly lower CFUs (ß = -0.583, P < .001) along with surgical time and particulates with a diameter ≥ 5 µm. Staff count and particulates with a diameter < 5 µm were not significant predictors of CFUs. Infection was not a primary outcome; however, no postoperative infections have been reported in either study group with a minimum of 1-year follow-up for all patients. DISCUSSION: This double-blinded, randomized trial demonstrated that a localized laminar flow device dramatically reduced the count of CFUs in the air directly above the wound and beneath the ABS (adjusted for the number of operating room personnel and surgical time). The use of the device was not associated with a longer case duration; however, some additional setup time was required prior to surgical incision to place the device. Further study is required to determine the clinical implications of this finding-specifically, whether such devices result in lower rates of periprosthetic joint infection after shoulder arthroplasty.

Osteochondral Reconstruction of the Capitellum.

Osteochondritis dissecans (OCD) of the capitellum is a relatively rare condition, with a higher incidence in adolescents who participate in repetitive overhead sports. The surgical treatment approach for this uncommon problem has varied from microfracture, loose body removal, abrasion chrondroplasty, lesion fixation, osteochondral allograft transplantation surgery, and osteochondral autologous transplantation surgery. The purpose of this study is to present the authors' preferred surgical technique for the treatment of unstable OCD lesions of the capitellum with osteochondral autologous transplantation surgery using autograft from the ipsilateral knee.

Florid Suprascapular Neuropathy after Primary Rotator Cuff Repair Attributed to Suprascapular Notch Constriction in the Setting of Double Crush Syndrome.

This report describes a patient who had an open repair of a small supraspinatus tendon tear performed 6 months after an arthroscopic acromioplasty with debridement had failed to provide pain relief. Three months prior to the tendon repair, he had a two-level cervical spine discectomy and fusion (C4-5, C5-6) that improved his neck pain. Florid suprascapular neuropathy was detected 10 weeks after the open rotator cuff repair. Evidence of some nerve recovery resulted in a long period of observation. But unsatisfactory improvement warranted decompression of the suprascapular notch, which was found to be very stenotic. At surgery, there was no evidence of neuroma, cyst, or other compressing lesion or tissue. Therefore, it was ultimately hypothesized that there was an exacerbation of a preexisting, but clinically unrecognized, entrapment of the suprascapular nerve in the suprascapular notch in the setting of cervical radiculopathy (primarily C5). Retrospectively it was also concluded that had this compressive etiology been recognized, it would have favored prompt decompression rather than the long observation period. Three years was required to achieve a good result following suprascapular notch decompression. The underlying C5 radiculopathy may have created a "double crush syndrome" that contributed to the propensity for injury and the prolonged recovery. There should be heightened awareness of this problem in patients who do not have satisfactory improvement in shoulder pain from previous shoulder and neck surgery.

Development of Clostridium septicum gas gangrene as an adverse effect of clindamycin-induced Clostridium difficile infection in a pediatric patient.

Clostridium myonecrosis or gas gangrene is a life-threatening infection characterized by either traumatic or atraumatic etiology. It has been widely described in patients with traumatic open wounds and in immunocompromised patients, including malignancy. A third source can result from natural flora in the gastrointestinal tract after bowel ischemia. This is a rare occurrence and is even less commonly described in the pediatric population. We present a pediatric patient who developed Clostridium septicum myonecrosis as an iatrogenic complication from clindamycin-induced Clostridium difficile ischemic colitis.

Secondary osteon size and collagen/lamellar organization ("osteon morphotypes") are not coupled, but potentially adapt independently for local strain mode or magnitude.

In bone, matrix slippage that occurs at cement lines of secondary osteons during loading is an important toughening mechanism. Toughness can also be enhanced by modifications in osteon cross-sectional size (diameter) for specific load environments; for example, smaller osteons in more highly strained "compression" regions vs. larger osteons in less strained "tension" regions. Additional osteon characteristics that enhance toughness are distinctive variations in collagen/lamellar organization (i.e., "osteon morphotypes"). Interactions might exist between osteon diameter and morphotype that represent adaptations for resisting deleterious shear stresses that occur at the cement line. This may be why osteons often have a peripheral ring (or "hoop") of highly oblique/transverse collagen. We hypothesized that well developed/distinct "hoops" are compensatory adaptations in cases where increased osteon diameter is mechanically advantageous (e.g., larger osteons in "tension" regions would have well developed/distinct "hoops" in order to resist deleterious consequences of co-existing localized shear stresses). We tested this hypothesis by determining if there are correlations between osteon diameters and strongly hooped morphotypes in "tension", "compression", and "neutral axis" regions of femora (chimpanzees, humans), radii (horse, sheep) and calcanei (horse, deer). The results reject the hypothesis-larger osteons are not associated with well developed/distinct "hoops", even in "tension regions" where the effect was expected to be obvious. Although osteon diameter and morphotype are not coupled, osteon diameters seem to be associated with increased strain magnitudes in some cases, but this is inconsistent. By contrast, osteon morphotypes are more strongly correlated with the distribution of tension and compression.

Prolonged Dyspnea after Interscalene Block: Attributed to Undiagnosed Addison's Disease and Myasthenia Gravis.

This report describes a patient who had a series of daily interscalene nerve blocks to treat pain following a shoulder manipulation for postsurgical stiffness. She experienced acute respiratory compromise that persisted for many weeks. All typical and unusual causes of these symptoms were ruled out. Her treating pulmonologist theorized that the ipsilateral carotid body had been injured. However, it was subsequently determined that the constellation of symptoms and their prolonged duration were best explained by a poor stress response from Addison's disease coupled with exacerbation of early onset myasthenia gravis. This patient's case is not a typical reaction to interscalene nerve blocks, and thus preoperative testing would not be recommended for myasthenia gravis or Addison's disease without underlying suspicion. We describe this report to inform physicians to consider a workup for these diagnoses if a typical workup rules out all usual causes of complications from an interscalene block.

Analysis of osteon morphotype scoring schemes for interpreting load history: evaluation in the chimpanzee femur.

Osteon morphotype scores (MTSs) allow for quantification of mechanically important collagen/lamellar variations between secondary osteons when viewed in circularly polarized ight (CPL). We recently modified the 6-point MTS method of Martin et al. (Martin RB, Gibson VA, Stover SM, Gibeling JC, Griffin LV (1996a) Osteonal structure in the equine third metacarpus. Bone 19, 165-71) and reported superiority of this modified method in correlating with 'tension' and 'compression' cortices of both chimpanzee proximal femoral diaphyses and diaphyses of other non-anthropoid bones that are loaded in habitual bending (Skedros et al. 2009, 2011). In these studies, the 'tension' and 'compression' cortices differed significantly in predominant collagen fiber orientation (CFO) based on weighted-mean gray levels (CFO/WMGLs) in CPL images. In chimpanzee femora, however, some osteons were difficult to score with the 6-point method; namely, 'hybrids' with peripherally bright 'hoops' and variability in alternating rings within the osteon wall. We hypothesized that some of these hybrids would be more prevalent in regions subject to torsion than bending. In this perspective the present study was aimed at expanding our 6-point scoring method (S-6-MTS) into two 12-point methods with six additional morphotypes that considered these hybrids. Three- and 4-point methods were also evaluated. We hypothesized that at least one of these other methods would out-perform the S-6-MTS in terms of accuracy, reliability, and interpreting torsion vs. bending load histories. Osteon morphotypes were quantified in CPL images from transverse sections of eight adult chimpanzee femora (neck, proximal diaphysis, mid-diaphysis), where the mid-diaphysis and base- and mid-neck locations have relatively more complex loading (e.g. torsion + bending) than the proximal diaphysis, where bending predominates. Correlation coefficients between CFO/WMGL and MTSs showed that the S-6-MTS method was either stronger or equivalent to the 12-point methods, and typically stronger than the 3- and 4-point methods for all load environments. In nearly all instances the S-6-MTS is more reliable and accurate when it is applied to cases where interpreting load history requires distinguishing habitual bending from torsion. Consequently, in studies of osteonal adaptations for these load histories the 3- and 4-point methods are not stronger correlates, and the extra time required to assign additional scores in the 12-point methods is both unnecessary and can be highly unreliable.

A weighted osteon morphotype score outperforms regional osteon percent prevalence calculations for interpreting cortical bone adaptation.

Using circularly polarized light microscopy,we described a weighted-scoring method for quantifying regional distributions of six secondary osteon morphotypes(Skedros et al.: Bone 44 (2009) 392-403). This osteon morphotype score (MTS) strongly correlated with "tension" and "compression" cortices produced by habitual bending. In the present study, we hypothesized that the osteon MTS is superior to a relatively simpler method based on the percent prevalence (PP) of these osteon morphotypes. This was tested in proximal femoral diaphyses of adult chimpanzees and habitually bent bones: calcanei from sheep, deer, and horses, radii from sheep and horses, and third metacarpals (MC3s) from horses. Sheep tibiae were examined because their comparatively greater torsion/shear would not require regional variations in osteon morphotypes. Predominant collagen fiber orientation (CFO), a predictor of regionally prevalent/predominant strain mode, was quantified as image gray levels (birefringence). Ten PP calculations were conducted. Although PP calculations were similar to the osteon MTS in corroborating CFO differences between "tension" and "compression" cortices of the chimpanzee femora and most of the habitually bent bones, PP calculations failed to show a compression/tension difference in equine MC3s and sheep radii. With the exception of the prevalence of the "distributed" osteon morphotype, correlations of PP calculations with CFO were weak and/or negative. By contrast, the osteon MTS consistently showed positive correlations with predominant CFO. Compared with the osteon MTS and predominant CFO, regional variations in PP of osteon morpho types are not stronger predictors of nonuniform strain distributions produced by bending.

Interpreting cortical bone adaptation and load history by quantifying osteon morphotypes in circularly polarized light images.

Birefringence variations in circularly polarized light (CPL) images of thin plane-parallel sections of cortical bone can be used to quantify regional differences in predominant collagen fiber orientation (CFO). Using CPL images of equine third metacarpals (MC3s), R.B. Martin, V.A. Gibson, S.M. Stover, J.C. Gibeling, and L.V. Griffin. (40) described six secondary osteon variants ('morphotypes') and suggested that differences in their regional prevalence affect fatigue resistance and toughness. They devised a numerical osteon morphotype score (MTS) for quantifying regional differences in osteon morphotypes. We have observed that a modification of this score could significantly improve its use for interpreting load history. We hypothesized that our modified osteon MTS would more accurately reveal differences in osteon MTSs between opposing "tension" and "compression" cortices of diaphyses of habitually bent bones. This was tested using CPL images in transverse sections of calcanei from sheep, deer, and horses, and radii from sheep and horses. Equine MC3s and sheep tibiae were examined as controls because they experience comparatively greater load complexity that, because of increased prevalence of torsion/shear, would not require regional mechanical enhancements provided by different osteon morphotypes. Predominant CFO, which can reliably reflect adaptation for a regionally prevalent strain mode, was quantified as mean gray levels from birefringence of entire images (excluding pore spaces) in anterior, posterior, medial, and lateral cortices. Results showed that, in contrast to the original scoring scheme of Martin et al., the modified scheme revealed significant anterior/posterior differences in osteon MTSs in nearly all "tension/compression" bones (p<0.0001), but not in equine MC3s (p=0.30) and sheep tibiae (p=0.35). Among habitually bent bones, sheep radii were the exception; relatively lower osteon populations and the birefringence of the primary bone contributed to this result. Correlations between osteon MTSs using the scoring scheme of Martin et al. with CFO data from all regions of each bone invariably demonstrated weak-to-moderate negative correlations. This contrasts with typically high positive correlations between modified osteon MTSs and regional CFO. These results show that the modified osteon MTS can be a strong correlate of predominant CFO and of the non-uniform strain distribution produced by habitual bending.