The Syringe External Fixator: Short- and Medium-Term Functional Outcomes From This Inexpensive and Customizable Treatment for Comminuted Intra-Articular Fractures of the Hand.

PURPOSE: Comminuted intra-articular fractures and fracture dislocations of the metacarpophalangeal (MCP) and interphalangeal joints are challenging. Dynamic external fixation, permitting early joint motion while still minimizing forces across the healing joint, can result in acceptable postoperative active range of motion (AROM). However, some fractures are not initially stable enough for early dynamic motion; further, many available dynamic external fixation systems are costly and cumbersome. We reviewed our experience using an external fixator made from a 1-mL syringe and K-wires and report outcomes using it as a static fixator, dynamic fixator, or configured as a static fixator and then converted to a dynamic fixator in the clinic. METHODS: Patients with intra-articular fractures and fracture dislocations of the MCP and proximal interphalangeal (PIP) joints treated between 2014 and 2020 using syringe external fixators were retrospectively reviewed. We reviewed demographics, mechanisms, treatment types and durations, and postoperative AROM, as well as complications including infection, pin loosening, nonunion, hardware failure, and need for further surgery. Patients were analyzed by the level of joint injury (MCP versus PIP) and by treatment pattern. RESULTS: After excluding 23 patients with 25 joint injuries who were lost to follow-up or had inadequate outcome data, 27 patients with 29 joint injuries were reviewed. The average follow-up was 171 days after surgery. The postoperative AROM at the MCP level averaged 55° for static fixation and 30° for static-to-dynamic fixation. The postoperative AROM at the PIP level averaged 64° for static fixation, 66° for static-to-dynamic fixation, and 80° for dynamic fixation. Three pin site infections and 2 loose pins were reported. CONCLUSIONS: The syringe external fixator is an inexpensive, effective, and customizable treatment for intra-articular MCP and interphalangeal fractures and fracture dislocations, and results in acceptable postoperative AROM outcomes and complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Rare Cause of Pedunculated Polyps Caused by Strongyloides.

Introduction: Strongyloidiasis is a systemic disease caused by the nematode Strongyloides stercoralis. Strongyloides is unique among parasites in that it can remain undetected for decades. Although patients may present with the typical symptoms of a skin rash, cough or diarrhoea, a rare manifestation of infection is pseudopolyposis in the colon. This case highlights the unique finding of pseudopolyposis in a patient with strongyloidiasis with negative stool studies. Case description: We present the case of an 81-year-old man with a delayed diagnosis of strongyloidiasis. The patient initially presented to the clinic for evaluation of productive cough and was treated empirically for bronchitis. He subsequently developed vomiting and diarrhoea with imaging revealing circumferential wall thickening of the ascending colon, consistent with colitis. Although stool tests were negative, the patient was treated with antibiotics, and then underwent a colonoscopy which revealed multiple polyps. Biopsy results confirmed Strongyloides infection. The patient was treated with ivermectin and improved. Discussion: This case describes the unique finding of colonic pseudopolyposis in a patient infected with Strongyloides in rural southwest Virginia. Strongyloidiasis is often misdiagnosed due to its non-specific gastrointestinal symptoms and the chronic nature of the disease. Although stool studies are routinely negative for parasitic infection, CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context. Determining the definitive diagnosis in a timely manner is crucial for establishing the specific treatment and for resolution of the disease. LEARNING POINTS: CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context; stool studies may be negative, as in this case.Internists should know the incidence, even if it is low, of certain parasitic infections in their local area.Strongyloides infection in the colon can mimic colitis and initiating the wrong treatment can lead to worse outcomes.

Patient Satisfaction After Discharge Is Discordant With Reported Inpatient Experience.

Patient satisfaction measures are commonly used to evaluate clinical performance. However, research on the correlation between patient satisfaction scores and actual patient experience is limited. This study aimed to determine the concordance between patient satisfaction reported as an inpatient and patient satisfaction reported after discharge. The study enrolled 231 adult orthopedic patients at least 48 hours after admission to an academic hospital. Study participants rated their overall inpatient experience on a scale of 0 to 10, followed by open-ended questions on their hospital experience. Participants were then randomized to a second survey by either phone or mail at 4 to 6 weeks after discharge. Statistical and qualitative techniques were used to assess concordance in satisfaction scores and the agreement and association between patient experiences and patient satisfaction scores. The median overall patient satisfaction scores were 9.5 as inpatients (interquartile range [IQR], 8-10) and 10 at follow-up (IQR, 8-10), with a poor concordance between the inpatient and follow-up satisfaction scores (ρc=0.28). This study raises concerns regarding the validity of patient satisfaction measures to accurately quantify inpatient experience and the limitations related to its modes of administration. The authors observed poor agreement between the reported experience as an inpatient and the recollection of the inpatient experience after discharge. [Orthopedics. 2021;44(3):e427-e433.].

Syringe External Fixator: An Inexpensive Static-to-Dynamic Treatment for Comminuted Intra-Articular Phalangeal Fractures.

Comminuted intra-articular phalanx fractures are complicated injuries often treated with external fixation. The ideal external fixation system should be affordable, readily available, adaptable, and easy to use. The use of dynamic external fixation has advanced the care of these injuries but can be difficult to implement. The authors present a case example of a patient with a comminuted intra-articular phalangeal fracture of the left small finger treated using a syringe as a static uniplanar fixator that was converted to a dynamic fixator during postoperative recovery.

Can Liposomal Bupivacaine Be Safely Utilized in Elective Spine Surgery?

STUDY DESIGN: Single-blinded prospective randomized control trial. OBJECTIVES: To compare the incidence of adverse events (AEs) and hospital length of stay between patients who received liposomal bupivacaine (LB) versus a single saline injection, following posterior lumbar decompression and fusion surgery for degenerative spondylosis. METHODS: From 2015 to 2016, 59 patients undergoing posterior lumbar decompression and fusion surgery were prospectively enrolled and randomized to receive either 60 mL injection of 266 mg LB or 60 mL of 0.9% sterile saline, intraoperatively. Outcome measures included the incidence of postoperative AEs and hospital length of stay. RESULTS: The most common AEs in the treatment group were nausea (39.3%), emesis (18.1%), and hypotension (18.1%). Nausea (23%), constipation (19.2%), and urinary retention (15.3%) were most common in the control group. Patients who received LB had an increased risk of developing nausea (relative risk [RR] = 1.7; 95% confidence interval [CI] = 0.75-3.8), emesis (RR = 2.3; 95% CI = 0.51-10.7), and headaches (RR = 2.36; 95% CI = 0.26-21.4). Patients receiving LB had a decreased risk of developing constipation (RR = 0.78; 95% CI = 0.25-2.43), urinary retention (RR = 0.78; 95% CI = 0.21-2.85), and pruritus (RR = 0.78; 95% = 0.21-2.8) postoperatively. Relative risk values mentioned above failed to reach statistical significance. No significant difference in the hospital length of stay between both groups was found (3.9 vs 3.9 days; P = .92). CONCLUSION: Single-dose injections of LB to the surgical site prior to wound closure did not significantly increase or decrease the incidence or risk of developing AEs postoperatively. Furthermore, no significant difference was found in the hospital length of stay between both groups.

The Utility of In-Hospital Postoperative Radiographs Following Surgical Treatment of Traumatic Thoracolumbar Injuries.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The objective of this study was to assess the utility of routine in-hospital postoperative radiographs for identifying hardware failure following surgical treatment of traumatic thoracolumbar (TL) injuries. BACKGROUND: Postoperative radiographs following spine surgery are considered standard of care despite a lack of evidence supporting their utility. Previous studies have concluded that postoperative radiographs following lumbar fusion for degenerative conditions have limited clinical value. MATERIALS AND METHODS: A retrospective chart review was performed on patients who underwent surgical treatment of traumatic TL injuries between December 2006 and October 2015 at a level I trauma center. Before discharge, postoperative upright anteroposterior and lateral radiographs were obtained and reviewed by 1 surgeon and 1 radiologist as per protocol. Patients who subsequently underwent revision surgery during their initial hospital stay were identified. These patients were further analyzed to identify the indications for surgery and determine if the results of the radiographs obtained led to the subsequent revision surgery. RESULTS: A total of 463 patients were identified who underwent surgical treatment following TL trauma. The rate of revision surgery during the initial hospitalization was 1.3% (6/463). Three patients underwent revision surgery due to worsening neurological status. One patient underwent reoperation because of advance imaging obtained for abdominal trauma. Two patients underwent revision surgery due to abnormal findings on postoperative radiographs. The overall sensitivity and specificity of routine postoperative radiographs was 33.3% and 100%, respectively. CONCLUSIONS: In the absence of new clinical signs and symptoms, obtaining routine in-hospital postoperative radiographs following surgical treatment of TL injuries provides minimal value. Clinical assessment should help determine if additional imaging is indicated for the patient. Avoiding unnecessary inpatient tests such as routine postoperative radiograph may offer multitude of benefits including lowering patient radiation exposure, reducing health care costs and better allocation of hospital resources. LEVEL OF EVIDENCE: Level III.

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery.

BACKGROUND: Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis. METHODS: Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay. RESULTS: LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, P = .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, P = .048). Additionally, pre- and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline. CONCLUSIONS: In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations. LEVEL OF EVIDENCE: 2.