Early Mobilization After Basal Joint Arthroplasty: Clinical Results.

Background: Traditional rehabilitation for basal joint arthroplasty involves postoperative immobilization. We hypothesize that early motion is safe and will result in equivalent clinical outcomes to traditional rehabilitation. Methods: Patients undergoing ligament reconstruction and tendon interposition were randomized into 2 rehabilitation protocols. All patients were immobilized postoperatively in a thumb-spica splint for 2 weeks. The accelerated group (Group 1) was transitioned into a removable Carpometacarpal (CMC)-wrap with activity as tolerated, while the traditional group (Group 2) were immobilized for an additional 4 weeks. Patients were examined preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, a visual analog scale for pain (VAS), pinch and grip strength and thumb range of motion. Results: Ninety-three thumbs were randomized, 48 in group 1 and 45 in group 2. There were no statistically significant differences between the 2 groups preoperatively. DASH scores were significantly lower in the accelerated rehabilitation group at 6 weeks postoperatively compared to the traditional rehabilitation group, but these became equivalent by 12 weeks postoperatively. There were no statistically significant differences between the 2 groups with respect to postoperative VAS, key, pinch, or grip strength or thumb range of motion at all time points postoperatively. Conclusions: Early (12-week and 1-year) outcomes suggest early mobilization of patients following CMC arthroplasty does not compromise clinical results. Long-term data will determine the lasting effects of accelerated rehabilitation but may offer earlier return to function than traditional rehabilitation.

Pedicle Screw Track Augmentation With Fibular Allograft for Significant Bone Loss in Revision Fixation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To report the clinical and radiological outcomes for screw track augmentation with fibular allograft in revision of loose pedicle screws associated with significant bone loss along the screw track. METHODS: Thirty consecutive patients, 18 men (60%) and 12 women (40%), with a mean age 52 years (range 34- 68). Fibular allograft was prepared by cutting it into longitudinal strips 50 mm in length. Three allograft struts were inserted into the screw track. Six mm tap used to tap between the 3 fibular struts. Eight- or 9-mm diameter, and 45 or 50 mm in length screw was then inserted. The clinical outcomes were assessed by means of the Oswestry Disability Index (ODI), and visual analog scale (VAS) for back and leg pain for clinical outcome. Computed tomography scan (CT) performed at 12 months postoperative visit to assess fibular graft incorporation along the pedicle screw track, any screw loosening and the interbody as well as posterolateral fusion. RESULTS: At a mean follow up of 29 months, there were statically significant improvement in the ODI and VAS for back and leg pain. CT scan obtained at last follow-up showed incorporation of fibular allograft and solid fusion in all patients except one. CONCLUSION: The fibular allograft augmentation of the pedicle screw track in revision of loose pedicle screws associated with significant bone loss is a viable option. It allows for biologic fixation at the screw-bone interface and has some key advantages when compared to currently available methods.

Chronic exertional compartment syndrome of the thenar musculature.

We present the case of a 44-year-old male with complaints of activity-induced, debilitating bilateral hand pain that had been undiagnosed for approximately six years. After extensive evaluation, intra-compartmental pressure monitoring confirmed the diagnosis of chronic exertional compartment syndrome of both the adductor pollicis and the thenar compartments (abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis). A two-incision decompressive fasciotomy was performed and post-operative intra-compartmental pressure measurements pre- and post-exercise were obtained confirming successful treatment of the condition.

Fracture of allograft interbody spacer resulting in post-operative radiculopathy: A case report.

BACKGROUND: Allograft interbody spacers are utilized during transforaminal lumbar interbody fusion (TLIF) to reestablish anterior column support and disc height. While the TLIF technique offers many improvements over previous surgical methods, instrumentation and bone graft-related complications such as spacer misplacement or migration, screw fracture or misplacement, or rod breakage continue to be reported. The objective of this manuscript is to report on a fractured allograft interbody spacer that displaced into the neural foramen and resulted in impingement on the exiting nerve root that required revision. CASE SUMMARY: A 50-year-old male had two-level TLIF with immediate post-operative right L5 radiculopathy. Computed tomography scan demonstrated a fractured allograft interbody spacer that displaced into the right neural foramen and impinged on the exiting L5 nerve root. Revision surgery was performed to remove the broken allograft fragments from the right L5 foramen and the intact portion of the spacer was left in place. The right leg L5 radicular pain resolved. At the last follow up 12 mo after the index procedure, computed tomography scan confirmed sound interbody and posterolateral fusion. CONCLUSION: Displacement of broken allograft interbody spacer following TLIF procedures can result in neurological sequelae that require revision. To avoid such an occurrence, the authors recommend allowing sufficient time for the reconstitution of the graft in saline prior to use to decrease brittleness, to use an impactor size that is as close as possible to the spacer size and meticulous inspection of the cortical allograft spacer for any visible imperfection prior to insertion.

Total hip arthroplasty for the management of hip fracture: A review of the literature.

Total hip arthroplasty (THA) is indicated for completely displaced femoral neck fractures (FNF) in elderly community ambulators. Compared to open reduction internal fixation (ORIF) and hemiarthroplasty (HA), THA has favorable outcomes in this population. Cementless fixation with prophylactic cabling is the technique of choice. THA is costlier for hip fractures than for osteoarthritis, but is cost effective for FNF given its lower rate of revision than HA or ORIF. Postoperative home discharge with a home exercise program in appropriate patients may effectively control costs while optimizing outcome.

A standard universal C-arm language: Assessing its need and its likelihood of acceptance.

Intraoperative fluoroscopy has facilitated improvements in surgical procedures across various subspecialties but has resulted in increased radiation exposure to the patient and surgeon. The results of a survey administered to 447 orthopedic surgeons and radiological technologists show that there is no standard universal c-arm language, that significant confusion and miscommunication exists between surgeons and technologists because of this, that unnecessary radiation exposure occurs as a direct consequence of this miscommunication, and that the vast majority of respondents would accept a standardized language similar to the one proposed in this study. This could potentially lead to less miscommunication and radiation exposure.

Editorial Commentary: Is the Key to Successful Revision Anterior Cruciate Ligament Reconstruction Addressing the Anterolateral Complex With a Lateral Extra-articular Tenodesis?

As the overall incidence of anterior cruciate ligament (ACL) ruptures continues to rise, the failure rates in reconstructive surgery remain relatively stable. Despite advances in our understanding of graft selection, anatomic reconstruction, addressing concomitant injuries, and the importance of rehabilitation, we continue to see failure rates in primary ACL reconstructions of up to 15%. Thus as the number of primary ACL reconstructions rises, so too does the number of revision ACL surgeries. This rising need for revision ACL reconstructions presents an even more daunting task because failure rates of up to 25% have been reported. Much of the current literature's focus is on improving outcomes and lowering these failure rates. Could adding a lateral extra-articular tenodesis to revision ACL surgery be the magic bullet we have been searching for to lower our failure rates? We question whether it is that simple.

Empiric treatment is less costly than Staphylococcus aureus screening and decolonization in total joint arthroplasty patients.

The aim of our study was to compare the cost of preoperative empiric mupirocin treatment of all total joint arthroplasty patients with a standard Staphylococcus aureus screening and decolonization protocol. The cost of empiric mupirocin treatment is $24.65 per patient, whereas the cost of a standard S. aureus screening and decolonization protocol is $60.32 per patient. Given that more than 1,051,000 total joint arthroplasties are performed annually, the cost savings with empiric treatment is nearly $40 million per year. Empiric treatment allows for more efficient workflow, minimizes potential for clerical error, eliminates risk of undertreatment, and has not been shown to increase antibiotic resistance.

Lateral intermuscular septum as cause of radial nerve compression: case report and review of the literature.

Multiple sites of compression of the radial nerve have been described, some more commonly than others. In this case report we describe a case of radial nerve compression at the lateral intermuscular septum in a patient with a history of open reduction and internal fixation of a mid-shaft humerus fracture 10 years prior. To our knowledge, only one previous case of chronic radial nerve compression by the lateral intermuscular septum associated with a humeral shaft fracture has been described. Our patient's clinical presentation with specific electrodiagnostic abnormalities, operative findings and post-operative symptom relief point towards the rare diagnosis of compression of the radial nerve at the level of the lateral intermuscular septum as the cause of his symptoms.

Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures.

AIM: To analyze the literature on efficacy of dynamamization vs exchange nailing in treatment of delayed and non-union femur fractures. METHODS: Ultimately, 31 peer-reviewed articles with 644 exchanged nailing patients and 131 dynamization patients were identified and analyzed. The following key words were inputted in different combinations in order to search the field of publications in its entirety: "non-union", "delayed union", "ununited", "femur fracture", "femoral fracture", "exchange nailing", "dynaiz(s)ation", "secondary nailing", "dynamic", "static", and "nail revision". The initial search yielded over 150 results, and was refined based on the inclusion criteria: Only studies reporting on humans, non-unions and delayed unions, and the usage of exchange nailing and/or dynamization as a secondary treatment after failed IM nailing. The resulting 66 articles were obtained through online journal access. The results were filtered further based on the exclusion criteria: No articles that failed to report overall union rates, differentiate between success rates of their reported techniques, or articles that analyzed less than 5 patients. RESULTS: Exchange nailing lead to fracture union in 84.785% of patients compared to the 66.412% of dynamization with statistically comparable durations until union (5.193 ± 2.310 mo and 4.769 ± 1.986 mo respectively). Dynamically locking exchange nails resulted in an average union time of 5.208 ± 2.475 mo compared to 5.149 ± 2.366 mo (P = 0.8682) in statically locked exchange nails. The overall union rate of the two procedures, statically and dynamically locked exchange nailing yielded union rates of 84.259% and 82.381% respectively. Therefore, there was no significant difference between the different locking methods of exchange nailing for union rate or time to union at a significance value of P < 0.05. The analysis showed exchange nailing to be the more successful choice in the treatment of femoral non-unions in respect to its higher success rate (491/567 EN, 24/57 dynam, P < 0.0001). However, there was no significant difference between the success rates of the two procedures for delayed union fractures (25/27 EN, 45/55 dynam, P = 0.3299). Nevertheless, dynamization was more efficient in the treatment of delayed unions (at rates comparable to exchange nailing) than in the treatment of non-unions. CONCLUSION: In conclusion, after examination of factors, dynamization is recommended treatment of delayed femur fractures, while exchange nailing is the treatment of choice for non-unions.

A Case Report of an Isolated Dislocation of the Scaphoid in a Lesser Arc Injury and a Review of the Literature.

Isolated dislocations of the scaphoid are extremely uncommon injuries and are often associated with significant ligamentous failures. Since scaphoid dislocations typically present with associated carpal fractures, few cases of isolated dislocations of the scaphoid exist in the literature. The proposed treatment options in the literature range from closed reduction and casting to open reduction and internal fixation. We present the case of a 41-year-old male with an isolated scaphoid dislocation in whom open reduction and internal fixation was performed with K-wires. At five months follow-up, the patient had returned to work and all desired activities.

Iliopsoas Abscess Presenting With Sacral Fracture and Gluteal Abscess: A Clinical Conundrum.

Abscess of the iliopsoas muscle is a rare condition that requires a high degree of clinical suspicion for diagnosis. High mortality rates highlight the need for prompt recognition. We report the case of a 26-year-old man, with a history of intravenous drug use, who was referred from an outside facility with sacral fracture and gluteal abscess. Sacral trauma occurred 3 weeks before presentation, with progressive worsening of buttock pain. The patient was treated with irrigation and débridement of the gluteal abscess. Follow-up MRI revealed a communicating iliopsoas abscess that initially had been undiagnosed. After a prolonged hospital stay requiring additional irrigation and débridement procedures, the patient was discharged in a stable condition. Five-month follow-up has demonstrated no evidence of recurrence of infection. To our knowledge, this is the first reported case of Staphylococcus aureus gluteal abscess with pelvic extension into the iliopsoas secondary to sacral trauma and intravenous drug use.

Antibiotic bone cement's effect on infection rates in primary and revision total knee arthroplasties.

AIM: To compare infection rates in primary and revision total knee arthroplasty (TKA) procedures using antibiotic impregnated bone cement (AIBC) to those rates in procedures not using AIBC. METHODS: A systematic review and meta-analysis was conducted in search for randomized controlled trials/studies (RCTs) pertaining to the field of antibiotic AIBC vs non-AIBC groups in both primary and revision TKA procedures. The primary literature search performed was to identify all RCTs that assessed AIBC in primary and revision TKA procedures. This search was done strictly through the PubMed database using the article "filters" setting that identified and separated all RCTs from the overall search. The original search was "Primary/revision total knee arthroplasty using AIBC". Other key terms and phrases were included in the search as well. Eligible articles that were used in the "results" of this review met the following criteria: (1) Involved primary or revision TKA procedures (for any reason); (2) included TKA outcome infection rate information; (3) analyzed an AIBC group vs a non-AIBC control group; (4) were found through the RCT filter or hand search in PubMed; and (5) published 1985-2017. Exclusion criteria was as follows: (1) Patients that were not undergoing primary or revision TKA procedures; (2) articles that did not separate total hip arthroplasity (THA) vs TKA results if both hip and knee revisions were evaluated; (3) papers that did not follow up on clinical outcomes of the procedure; (4) extrapolation of data was not possible given published results; (5) knee revisions not done on human patients; (6) studies that were strictly done on THAs; (7) articles that were not found through the RCT filter or through hand search in PubMed; (8) articles that did not evaluate AIBC used in a prosthesis or a spacer during revision; (9) articles that did not compare an AIBC group vs a non-AIBC control group; and (10) articles that were published before 1985. RESULTS: In total, 11 articles were deemed eligible for this analysis. Nine of the 11 studies dealt with primary TKA procedures comparing AIBC to non-AIBC treatment. The other two studies dealt with revision TKA procedures that compared such groups. From these papers, 4092 TKA procedures were found. 3903 of these were primary TKAs, while 189 were revision TKAs. Of the 3903 primary TKAs, 1979 of these used some form of AIBC while 1924 were part of a non-AIBC control group. Of the 189 revision TKAs, 96 of these used some form of AIBC while 93 were part of a non-AIBC control group. Average follow-up times of 47.2 mo and 62.5 mo were found in primary and revision groups respectively. A two-tailed Fisher's exact test was done to check if infection rates differed significantly between the groups. In the primary TKA group, a statistically significant difference between AIBC and non-AIBC groups was not found (AIBC infection rate = 23/1979, non-AIBC infection rate = 35/1924, P = 0.1132). In the revision TKA group, a statistically significant difference between the groups was found (AIBC infection rate = 0/96, non-AIBC infection rate = 7/93, P = 0.0062). No statistically significant differences existed in Knee Society Scores, Hospital for Special Surgery Scores, or Loosening Rates. CONCLUSION: AIBC did not have a significant effect on primary TKA infection rates. AIBC did have a significant effect on revision TKA infection rates.

Loss of Follow-up in Orthopaedic Trauma: Who Is Getting Lost to Follow-up?

OBJECTIVES: Noncompliance with postoperative follow-up visits remains a common problem in orthopaedic trauma. The aim of this study was to identify risk factors for loss of follow-up after orthopaedic trauma. DESIGN: Retrospective review. SETTING: Urban level 1 academic trauma center. PATIENTS: A total of 307 (226 men/81 women) patients undergoing surgical treatment of their orthopaedic injuries were included in this study. The average age was 40.4 ± 17 years. INTERVENTION: All patients were treated surgically for their orthopaedic injuries and were instructed to follow-up in the orthopaedic trauma clinic after hospital discharge. MAIN OUTCOME MEASUREMENTS: Noncompliance with follow-up appointment at 6 months after injury. RESULTS: Over a 6-month postoperative period, a total of 215 patients were noncompliant with at least one of their follow-up appointments between hospital discharge and the 6-month follow-up. A logistic regression showed male gender, uninsured or government insurance, and smoker to be statistically significant risk factors for noncompliance with the 6-month follow-up (P < 0.05). Noncompliance with any follow-up appointment was significantly increased in patients with illicit drug abuse (P = 0.02) as per logistic regression analysis. CONCLUSIONS: Loss of follow-up is a common problem in orthopaedic trauma. Our study suggests different risk factors for noncompliance, including male gender, smoker, lack of commercial health insurance, and illicit drug abuse. Health care providers may consider establishing protocols for facilitating follow-up appointments to patients who are at risk for noncompliance.

Medial peritalar fracture dislocation of the talar body.

Peritalar fracture dislocations typically involve the talar neck and are classified according to Hawkins. To our knowledge, peritalar fracture dislocation involving the talar body has not been formally reported. In this article, we describe a case of peritalar fracture dislocation of the talar body.