Temporary Botulinum Immobilization of Residuum Muscles for Facilitation of the Initial Ingrowth of Skin to the Porous Skin and Bone Integrated Pylon in the Technology of Direct Skeletal Attachment: Large Animal Model.

Enhancing the technology of bone-anchored limb prosthetics, we present a modified porcine model for developing an infection-free integration between the skin and a percutaneous bone implant. The deeply porous Skin and Bone Integrated Pylon (SBIP) presented an infection-free skin-implant interface both after implantation into the dorsum and after implantation into the residuum after below-knee amputation. However, deep ingrowth of skin into the porous cladding of the SBIP was achieved better in the dorsal procedure, while implantation to the residuum sometimes developed a stoma, probably due to the high mobility of the skin and soft tissues in the pig's thigh. Uncontrolled high skin mobility during the first week after implantation constituted a limitation for the porcine animal model, which we tried to address in the current study. As our previous studies showed that casting of the leg residuum did not sufficiently limit the skin's movement around the implant, we tested a modified protocol of the implantation, which included injection of botulinum toxin into the thigh muscles. During the course of the study, we identified proper botulinum toxin componentry, dosage, and the period after injections to achieve a maximal effect of immobilization of the muscles affecting skin movements. To verify the immobilization, we used kinetic data on the asymmetry of loading during gait with the Strideway System, Tekscan, Inc., Boston, MA, USA. We found that injections in the four muscles of the distal thigh of the left hind leg with MYOBLOC® (rimabotulinumtoxinB; 5,000 units/muscle) were sufficient to provide noticeable immobilization by the fourth week after the procedure. This conclusion was made based on the analysis of the dynamics of asymmetry in vertical ground reactions on the injected (left hind) and uninvolved (right hind) legs during gait over an instrumented walkway.

Variation in the Profit Margin for Different Types of Total Joint Arthroplasty.

BACKGROUND: As health care shifts to a value-based model with bundled-payment methods, it is important to understand the costs and reimbursements of arthroplasty procedures that represent the largest expenditure of Medicare. The aim of the present study was to characterize the variation in (1) total hospital costs, (2) reimbursement, and (3) profit margin for different arthroplasty procedures. METHODS: The total hospital costs of total knee arthroplasty (TKA), total hip arthroplasty (THA), anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and total ankle arthroplasty (TAA) were calculated with use of time-driven activity-based costing at an orthopaedic institution from 2018 to 2020. The average reimbursement for each type of procedure was determined. Profit margin, defined as the reimbursement profit after direct costs, was calculated by deducting the average time-drive activity-based total hospital costs from the reimbursement value. Multivariate analyses were performed to evaluate the associations between costs, reimbursement, and profit margins. RESULTS: There were 13,545 arthroplasty procedures analyzed for this study, including 6,636 TKAs, 5,902 THAs, 346 TSAs, 577 RSAs, and 84 TAAs. Costs and reimbursement were highest for TAA. THA and TKA resulted in the highest profit margins, whereas RSA resulted in the lowest. The strongest associations with profit margin were private insurance (0.46547), age (-0.22732), and implant cost (-0.19240). CONCLUSIONS: THA and TKA had greater profit margins overall than TAA and upper-extremity arthroplasty in general. Profit margins for RSA, TSA, and TAA were all at least 28% lower than those for TKA or THA. Lower-volume arthroplasty procedures were associated with decreased profit margins. Study findings suggest that optimizing implant costs and length of stay are important for sustaining institutional fiscal health when performing shoulder and ankle arthroplasty surgery.

Recent Progress in Animal Studies of the Skin- and Bone-integrated Pylon With Deep Porosity for Bone-Anchored Limb Prosthetics With and Without Neural Interface.

INTRODUCTION: The three major unresolved problems in bone-anchored limb prosthetics are stable, infection-free integration of skin with a percutaneous bone implant, robust skeletal fixation between the implant and host bone, and a secure interface of sensory nerves and muscles with a prosthesis for the intuitive bidirectional prosthetic control. Here we review results of our completed work and report on recent progress. MATERIALS AND METHODS: Eight female adult cats received skin- and bone-integrated pylon (SBIP) and eight male adult cats received SBIP-peripheral neural interface (PNI) pylon into the right distal tibia. The latter pylons provided PNI for connection between a powered sensing transtibial prosthesis and electrodes in residual soleus muscle and on residual distal tibial nerve. If signs of infection were absent 28-70 days after implantation, cats started wearing a passive prosthesis. We recorded and analyzed full-body mechanics of level and slope locomotion in five cats with passive prostheses and in one cat with a powered sensing prosthesis. We also performed histological analyses of tissue integration with the implants in nine cats.Four pigs received SBIPs into the left hindlimb and two pigs-into the left forelimb. We recorded vertical ground reaction forces before amputation and following osseointegration. We also conducted pullout postmortem tests on the implanted pylons. One pig received in dorsum the modified SBIPs with and without silver coating. RESULTS: Six cats from the SBIP groups had implant for 70 days. One cat developed infection and did not receive prosthesis. Five cats had pylon for 148 to 183 days, showed substantial loading of the prosthesis during locomotion (40.4% below presurgery control), and demonstrated deep ingrowth of skin and bone tissue into SBIP (over 60%). Seven of eight cats from the SBIP-PNI group demonstrated poor pylon integration without clinical signs of infection. One cat had prosthesis for 824 days (27 months). The use of the bidirectionally controlled prosthesis by this animal during level walking demonstrated increased vertical loading to nearly normal values, although the propulsion force was significantly reduced.From the study on pigs, it was found that symmetry in loading between the intact and prosthetic limbs during locomotion was 80 ± 5.5%. Skin-implant interface was infection-free, but developed a stoma, probably because of the high mobility of the skin and soft tissues in the pig's thigh. Dorsal implantation resulted in the infection-free deep ingrowth of skin into the SBIP implants. CONCLUSIONS: Cats with SBIP (n = 5) and SBIP-PNI (n = 1) pylons developed a sound interface with the residuum skin and bone and demonstrated substantial loading of prosthetic limb during locomotion. One animal with SBIP developed infection and seven cats with SBIP-PNI demonstrated poor bone integration without signs of infection. Future studies of the SBIP-PNI should focus on reliability of integration with the residuum. Ongoing study with pigs requires decreasing the extra mobility of skin and soft tissues until the skin seal is developed within the SBIP implant.

Most Orthopaedic Studies Using the National Inpatient Sample Fail to Adhere to Recommended Research Practices: A Systematic Review.

BACKGROUND: The National Inpatient Sample (NIS) database is accessible, inexpensive, and increasingly used in orthopaedic research, but it has complex design features that require nuanced methodological considerations for appropriate use and interpretation. A recent study showed poor adherence to recommended research practices for the NIS across a broad spectrum of medical and surgical fields, but the degree and patterns of nonadherence among orthopaedic publications remain unclear. QUESTIONS/PURPOSES: In this study, we sought: (1) to quantify nonadherence to recommended research practices provided by the Agency for Healthcare Research and Quality (AHRQ) for using the NIS data in orthopaedic studies from 2016-2017; and, (2) to identify the most common nonadherence practices. METHODS: We evaluated all 136 manuscripts published across the 74 orthopaedic journals listed on Scimago Journal & Country Rank that used the NIS from January 2016 through December 2017. Of those studies, 2% (3 of 136) were excluded because NIS was not used for analysis. The studies were evaluated for adherence to seven recommended research practices by the AHRQ: (1) identifying observations as hospitalization events rather than unique patients; (2) not performing state-level analyses; (3) limiting hospital-level analyses to data from year 1988-2011; (4) not performing physician-level analyses; (5) avoiding the use of nonspecific secondary diagnosis codes to infer in-hospital events; (6) using survey-specific analysis methods that account for clustering, stratification, and weighting; and (7) accounting for data changes in trend analyses spanning major transition periods in the data set (1997-1998 and 2011-2012). RESULTS: Overall, 93% (124 of 133) of the studies did not adhere to one or more practices. For each of the research practices assessed, 80% (106 of 133) of the studies did not account for the clustering and stratification in survey design; 56% (75 of 133) implied records were unique patients rather than hospitalization events; 41% (54 of 133) inappropriately used secondary diagnosis codes to infer in-hospital events. CONCLUSIONS: Nearly all manuscripts published in orthopaedic journals using the NIS database in 2016 and 2017 failed to adhere to recommended research practices. Future research quantifying variations in study results on the basis of adherence to recommended research practices would be of value. CLINICAL RELEVANCE: With the ubiquitous presence of large-database studies in orthopaedic journals, our work points to the importance of rigorous methodological appraisal when evaluating results, and encourages journals to require the use of the methodology checklists upon submission of such studies. More research is needed to determine whether deviations from recommended research practices actually lead to biased conclusions that affect patient care and policy-related decisions.

Comparing Reported Complication Rates in Shoulder Arthroplasty Between 2 Large Databases.

Large databases are commonly used to analyze surgical outcomes. Recent studies have suggested that there are differences in complication rates between databases across certain procedures, but the reasons for these differences are not fully understood. The goal of this study was to compare complications of shoulder arthroplasty across databases as well as to interpret the causes of any differences. The authors compared complication rates for shoulder arthroplasty as reported by the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2010. The authors then restricted NIS data solely to hospitals that also contributed to NSQIP to provide a more direct comparison of the patient populations. The authors identified 48,287 discharges reported in NIS and 1679 discharges reported in NSQIP for patients who underwent shoulder arthroplasty. The complication rate for shoulder arthroplasty was significantly higher in the NIS population (12.6%; 95% confidence interval, 12.0%-13.2%) than in the NSQIP population (5.60%; 95% confidence interval, 4.59%-6.81%). When NIS data were restricted solely to hospitals that also participated in NSQIP, the rate of complications remained higher, at 13.4% (95% confidence interval, 11.2%-15.8%), and the rate increased relative to the nonrestricted data. The databases compared in this study had statistically significant differences in reported complication rates for shoulder arthroplasty. This difference persisted when NIS data were restricted to hospitals that also participated in NSQIP, suggesting that differences in database design contribute to important differences in data. Orthopedic surgeons and administrators must use caution when using complication rates derived from large database studies. [Orthopedics. 2020;43(2):113-118.].

The New Science of Practical Wisdom.

Wisdom has been discussed for centuries in religious and philosophical texts. It is often viewed as a fuzzy psychological construct analogous to consciousness, stress, and resilience. This essay provides an understanding of wisdom as a scientific construct, based on empirical research starting in the 1970s. The focus is on practical rather than theoretical wisdom. While there are different conceptualizations of wisdom, it is best defined as a complex human characteristic or trait with specific components: social decision-making, emotional regulation, prosocial behavior (such as empathy and compassion), self-reflection, acceptance of uncertainty, decisiveness, and spirituality. These psychological processes involve the fronto-limbic circuitry. Wisdom is associated with positive life outcomes including better health, well-being, happiness, life satisfaction, and resilience. Wisdom tends to increase with active aging, facilitating a contribution of wise grandparents to promoting fitness of younger kin. Despite the loss of their own fertility and physical health, older adults help enhance their children's and grandchildren's well-being, health, longevity, and fertility-the "grandmother hypothesis" of wisdom. Wisdom has important implications at individual and societal levels and is a major contributor to human thriving. We need to place a greater emphasis on promoting wisdom through our educational systems from elementary to professional schools.

The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort.

BACKGROUND: Orthopedic surgeons utilize the 22-modifier when billing for complex procedures under the American Medical Association's Current Procedural Terminology (CPT) for reasons such as excessive blood loss, anatomic abnormality, and morbid obesity, cases that would ideally be reimbursed at a higher rate to compensate for additional physician work and time. We investigated how the 22-modifier affects physician reimbursement in knee and hip arthroplasty. METHODS: We queried hospital billing data from 2009 to 2016, identifying all cases performed at our urban tertiary care orthopedic center for knee arthroplasty (CPT codes 27438, 27447, 27487, and 27488) and hip arthroplasty (CPT codes 27130, 27132, 27134, 27236). We extracted patient insurance status and reimbursement data to compare the average reimbursement between cases with and without the 22-modifier. RESULTS: We analyzed data from 2605 procedures performed by 10 providers. There were 136 cases with 22-modifiers. For knee arthroplasty (n = 1323), the 22-modifier did not significantly increase reimbursement after adjusting for insurer, provider, and fiscal year (4.2% dollars higher on average, P = .159). For hip arthroplasty (n = 1282), cases with a 22-modifier had significantly higher reimbursement than those without the 22-modifier (6.2% dollars more, P = .049). For hip arthroplasty cases with a 22-modifier, those noting morbid obesity were reimbursed 29% higher than those cases with other etiology. CONCLUSIONS: The effect of the 22-modifier on reimbursement amount is differential between knee and hip arthroplasty. Hip arthroplasty procedures coded as 22-modifier are reimbursed more than those without the 22-modifier. Providers should consider these potential returns when considering submitting a 22-modifier.

Functional Outcomes of 24-Hour Thumb Immobilization in Healthy Volunteers: Prospective Comparative Study.

Background Immobilization is often needed for the treatment of wrist and hand injuries. The current best method of immobilization for several types of injuries has yet to be elucidated with little being reported on the functional differences of each type of immobilization. Purpose The purpose of this study is to compare the functional outcome between healthy young volunteers with a 24-hour short arm cast (SAC) versus thumb spica cast (TSC) immobilization. Methods A total of 50 healthy volunteers completed a baseline typing assessment and a Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity functional scoring assessment. Participants in group 1 were randomly initially assigned to a TSC of their dominant hand followed by an SAC, whereas participants in group 2 were randomly initially assigned to a TSC of their nondominant hand followed by an SAC. The volunteers completed the typing assessment and PROMIS assessment at the end of the 24-hour casting period. Results A total of 50 participants were enrolled in the study with 25 in group 1 and 25 in group 2. There was a 24.3-point difference between the average PROMIS score for participants with SAC compared with participants with TSC (93 vs. 68.7; p = 0.0001). There was a significant difference between the typing speed and accuracy of participants with SAC compared with participants with TSC ( p = 0.0001). Conclusion There is a significant difference in functionality of a TSC immobilization versus an SAC immobilization according to the PROMIS functional outcome score and typing speed in a 24-hour casting period. SAC immobilization should be considered to have a possible similar effect in pathologic conditions instead of TSC immobilization given these findings even though a 24-hour period is not enough to provide adequate long-term conclusions. Level of Evidence I, prospective comparative study.

Subperiosteal transmission of intra-articular pressure between articulated and stationary joints.

Hydrostatic pressures can be transmitted between synovial capsules. In each of ten rabbits, we simultaneously measured pressure in two joints, one of which was passively ranged, and the other of which was kept stationary. The intra-articular pressure inside the stationary joint changed every time its companion joint was ranged. But the pressure in the stationary joint did not change when the periosteum was transected above the ranged joint. This phenomenon was observed in all four animals that served as their own controls. The study suggests that the intra-articular pressure was transmitted through the space between the periosteum and the bone surface. Alternative explanations, like measurements of venous blood pressure, did not show correlation with hydrostatic pressure changes in the joints. The Floating Skeleton concept suggests a biomechanical rationale for this newly observed phenomenon: that there exists a subperiosteal hydrostatic connection of synovial joints, and that this "net" distributes excess pressures among joints through the periosteal sheath to sustain the integrity of the joint contacting surfaces over a lifetime.

Factors used by program directors to select hand surgery fellows.

PURPOSE: To identify factors and attributes hand surgery fellowship program directors consider important in selecting applicants for interview and ranking. METHODS: A web-based questionnaire was sent to all hand fellowship program directors in the United States. The questionnaire was designed to identify the most important criteria in granting an interview, sources of letters of recommendation, the interview process, and factors used to rank a candidate. Each criterion was ranked in importance on a 1 to 5 Likert scale, with 1 being not important and 5 being critical. All responses were anonymous. The most important criterion for each section of the survey was determined by comparing the average Likert scores. RESULTS: Fifty-two of 76 program directors responded (68%). The criteria with the highest mean Likert scores for offering an applicant an interview were, in order, quality letters of recommendation from hand surgeons, completion of an orthopedic surgery residency, comments regarding the applicant's technical competence, applicant having an MD degree (as opposed to a DO degree), and residency program reputation. The letters of recommendation with the highest value were from the division chief of hand surgery and another hand surgeon in the division/department. The most important features of the interview were maturity of applicant, ability of applicant to articulate thoughts, ability to listen well, self-confidence, and relevant questions asked. The most important factors in ranking a candidate were applicant integrity, commitment to hard work, quality of letters of recommendation, quality of the interview, and ability to work well with other members of the hand surgery team. CONCLUSIONS: There are identifiable factors considered important by hand surgery fellowship directors when selecting and ranking an applicant. This information may be valuable to medical students and residents contemplating careers in hand surgery.

Total joint arthroplasty surgery: does day of surgery matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

Effect of applied force and blade speed on histopathology of bone during resection by sagittal saw.

A sagittal saw is commonly used for resection of bone during joint replacement surgery. During sawing, heat is generated that can lead to an increase in temperature at the resected surface. The aim of this study was to determine the effect of applied thrust force and blade speed on generating heat. The effect of these factors and their interactions on cutting temperature and bone health were investigated with a full factorial Design of Experiments approach for two levels of thrust force, 15 N and 30 N, and for two levels of blade oscillation rate, 12,000 and 18,000 cycles per minute (cpm). In addition, a preliminary study was conducted to eliminate blade wear as a confounding factor. A custom sawing fixture was used to crosscut samples of fresh bovine cortical bone while temperature in the bone was measured by thermocouple (n=40), followed by measurements of the depth of thermal necrosis by histopathological analysis (n=200). An analysis of variance was used to determine the significance of the factor effects on necrotic depth as evidenced by empty lacunae. Both thrust force and blade speed demonstrated a statistically significant effect on the depth of osteonecrosis (p<0.05), while the interaction of thrust force with blade speed was not significant (p=0.22). The minimum necrotic depth observed was 0.50mm, corresponding to a higher level of force and blade speed (30 N, 18,000 cpm). Under these conditions, a maximum temperature of 93°C was measured at 0.3mm from the kerf. With a decrease in both thrust force and blade speed (15N, 12,000 cpm), the temperature in the bone increased to 109°C, corresponding to a nearly 50% increase in depth of the necrotic zone to 0.74 mm. A predictive equation for necrotic depth in terms of thrust force and blade speed was determined through regression analysis and validated by experiment. The histology results imply that an increase in applied thrust force is more effective in reducing the depth of thermal damage to surrounding bone than an increase in blade speed.

Scapula fractures: interobserver reliability of classification and treatment.

OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Comprehensive Look at Blood Transfusion Utilization in Total Joint Arthroplasty at a Single Academic Medical Center under a Single Surgeon.

The utilization of autologous and allogeneic transfusions in total joint arthroplasties was to characterize patients who may benefit from giving preoperative blood donations. We conducted a retrospective chart review of 525 patients to document preoperative hematocrit, estimated blood loss, length of stay, transfusions, and medical comorbidities. Results of our review showed that total hip arthroplasty revision (THA-R) had the highest prevalence of transfusions (60%) followed by total hip arthroplasty (THA, 53%), total knee arthroplasty-revision (TKA-R, 33%), and total knee arthroplasty (TKA, 23%). There was significant waste of autologous donations: 92% of TKA patients, 64% of THA, and 33% of THA-R patients wasted on average 1.527, 1.321, and 1.5 autologous units, respectively. Pre-operative hematocrit was the strongest predictor of future transfusion need across all procedures, and primary THA had additional predictors in age and gender.

New method of fixation of in-bone implanted prosthesis.

This article presents results on the effectiveness of a new version of the titanium porous composite skin and bone integrated pylon (SBIP). The SBIP is designed for direct skeletal attachment of limb prostheses and was evaluated in a preclinical study with three rabbits. In accordance with the study protocol, a new version of the pylon (SBIP-3) was implanted into the hind leg residuum of three rabbits. The SBIP-3 has side fins that are designed to improve the bond between the bone and pylon. The fins are positioned inside two slots precut in the bone walls; their length can be adjusted to match the thickness of the bone walls. After 13 (animal 1) or 26 (animals 2 and 3) wk, the animals were sacrificed and samples collected for histopathological analysis. The space between the fins and the bone into which they were fit was filled with fibrovascular tissue and woven bone. No substantial inflammation was found. We suggest that if further studies substantiate the present results, the proposed method can become an alternative to the established technique of implanting prostheses into the medullary canal of the hosting bone.

Unrecognized acute exertional compartment syndrome of the leg and treatment.

Acute-on-chronic exertional compartment syndrome is rare and may be easily missed without a high degree of awareness and clinical suspicion. We report a case of unrecognized acute-on-chronic exertional compartment syndrome in a recreational soccer player. The late sequela of this condition, foot drop, was successfully treated with transfer of the peroneus longus tendon.

Spontaneous hemothorax in multiple exostoses: a case report and review of literature.

Abstract Multiple hereditary exostoses is a rare autosomal dominant disorder characterized by the growth of multiple osteochondromas. We describe the thoracoscopic remodeling of a spiculated costal exostotic lesion responsible for spontaneous recurrent hemothoraces in a 17-year-old male patient with multiple hereditary exostoses.

Basal joint arthroplasty and carpal tunnel release through a single incision: an in vitro study.

PURPOSE: Carpal tunnel syndrome coexists with basal joint arthritis in a large percentage of patients. These 2 conditions are often treated surgically through separate incisions. The purpose of this cadaver study is to show the effect of trapeziectomy and transverse carpal ligament release from the scaphoid tubercle on carpal canal pressures. This technique may permit both problems to be addressed through the same Wagner incision. METHODS: In 4 fresh frozen cadaver limbs pressures in the carpal canal were elevated to 30 mm Hg through a percutaneously placed balloon. Pressures were measured using an 18-gauge sideport needle via a transducer. Trapeziectomy and release of the transverse carpal ligament from the scaphoid were performed in succession through a Wagner incision with canal pressures measured after each step. RESULTS: Carpal canal pressures decreased after trapeziectomy (mean, 7 mm Hg; range, 3-14 mm Hg) but did not return to baseline (0 mm Hg) until complete release of the ligament. CONCLUSIONS: Decompression of the carpal tunnel can be performed effectively through a Wagner incision during basal joint arthroplasty. This cadaver model shows reduction in the canal pressures after trapeziectomy and release of the transverse carpal ligament. This single-incision approach is attractive because it may decrease morbidity compared with a 2-incision approach in patients with concomitant carpal tunnel syndrome and basal joint arthritis.

Rapidly advancing necrotizing fasciitis caused by Photobacterium (Vibrio) damsela: a hyperaggressive variant.

OBJECTIVE: To describe the first case of Vibrio damsela necrotizing fasciitis in New England, emphasizing the importance of very early operative intervention to achieve source control in this extremely aggressive infection. DESIGN: Case report. SETTING: Surgical intensive care unit at Tufts-New England Medical Center in Boston, MA. PATIENT: A 69-yr-old retired fisherman with rapidly progressive necrotizing fasciitis from Photobacterium (Vibrio) damsela infection and ensuing multiple-system organ failure. INTERVENTIONS: Surgical debridement, ventilator support, vasopressors, continuous veno-venous hemofiltration, and blood product transfusions. MEASUREMENTS AND MAIN RESULTS: Death. CONCLUSIONS: A high index of suspicion is necessary for the diagnosis of this specific pathogen and concordant infection. The willingness to surgically debride and amputate without hesitation at a very early point may be the only intervention capable of saving the lives of patients affected by Photobacterium (Vibrio) damsela.

Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study.

BACKGROUND: A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral. METHODS: A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded. RESULTS: Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months. CONCLUSIONS: Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.