Early Results of Surgical Management of Camptodactyly.

BACKGROUND: We hypothesize that surgery for moderate-to-severe camptodactyly (>50 degrees) results in modest gains in range of motion and improved digital position. METHODS: A retrospective analysis of patients undergoing surgery for camptodactyly at a tertiary children's hospital between 2000 and 2014 was performed. Surgery was indicated for patients with persistent, functionally limiting flexion contractures despite observation, therapy, and splinting. Data were collected on demographics, clinical history and presentation, nonoperative management, surgery, and clinical follow-up, focusing on range of motion at the involved joint. Total passive motion (TPM) and total active motion (TAM) at the proximal interphalangeal (PIP) joint was calculated at presentation, preoperative visit, first postoperative visit out of the cast, and last follow-up visit. Average postoperative follow-up was 1.4 years. RESULTS: In total, 31 digits in 22 patients were reviewed. There were 13 males; average age at surgery was 9.6 years. There were 7 type I (infantile), 8 type II (adolescent), and 7 type III (syndromic) patients. All cases involved the PIP joint; 55% involved the small finger. All patients underwent sequential release of contracted structures until maximal extension without compromising vascularity or joint stability was obtained. Z-plasty of the volar skin was performed in 68% of digits, flexor digitorum superficialis tenotomy in 77%, volar plate release in 58%, and collateral ligament release in 48%. All patients were casted postoperatively for an average of 31 days, and 71% of digits had temporary transarticular pin fixation. At initial presentation, mean TPM and TAM were 34 and 24 degrees, respectively. TPM and TAM were 32 and 19 degrees immediately preoperatively, 30 and 13 at the first postoperative visit, and 35 and 25 at the final follow-up. Furthermore, the position of PIP arc of motion was in a more extended position postoperatively. Average TPM arc of motion was from 50 to 82 degrees preoperatively and 28 to 63 degrees at final follow-up; average TAM arc of motion was 62 to 81 degrees preoperatively and 30 to 55 degrees at final follow-up. There were no clinically meaningful differences in results based on camptodactyly type, preoperative motion, or age at surgery. There were no cases of wound infection or dehiscence. Two patients with recurrent contractures opted for subsequent PIP arthrodesis. CONCLUSIONS: Total motion of the PIP joint was similar both preoperatively and postoperatively following surgical release of camptodactyly. However postoperatively, the digit was in a more extended position over this arc of motion. For patients with functionally limiting flexion contractures, surgical release may be beneficial by providing a more extended position, for improved digital release, hygiene, and esthetics. LEVEL OF EVIDENCE: Level IV.

Biochemical, biophysical, and mutational analyses of subunit interactions of the human cytomegalovirus nuclear egress complex.

Nuclear egress, the trafficking of herpesvirus nucleocapsids from the nucleus to the cytoplasm, involves two conserved viral proteins that form a complex at the nuclear envelope, referred to as the nuclear egress complex. In human cytomegalovirus, these two proteins are called UL50 and UL53. To study UL50 and UL53 in molecular detail, these proteins were expressed in bacteria and purified. To obtain highly expressed, pure proteins, it was necessary to truncate both constructs based on sequence conservation and predicted secondary structural elements. Size exclusion chromatography and analytical ultracentrifugation studies indicated that the truncated form of UL50 is a monomer in solution, that the truncated form of UL53 is a homodimer, and that, when mixed, the two proteins form a heterodimer. To identify residues of UL53 crucial for homodimerization and for heterodimerization with UL50, we constructed and expressed mutant forms of UL53 containing alanine substitutions in a predicted helix. Isothermal titration calorimetry was used to measure the binding affinities of the UL53 mutants to UL50. UL53 residues, the replacement of which reduced binding to UL50, form a surface on one face of the predicted helix. Moreover, most of the substitutions that reduce UL53-UL50 interactions also reduced homodimerization. Substitutions that reduced the interaction between UL50 and UL53 in vitro also reduced colocalization of full-length UL50 and UL53 at the nuclear rim in transfected cells. These results demonstrate direct protein-protein interactions between these proteins that are likely to be mediated by a helix, and they have implications for understanding nuclear egress and for drug discovery.

Best Approaches in Distal Radius Fracture Malunions.

PURPOSE OF REVIEW: Malunion remains a common complication in the treatment of distal radius fractures. The purpose of this review was to discuss the various approaches in planning and surgical management for extra- and intra-articular distal radius malunions. RECENT FINDINGS: Several recent studies have reported good results with surgical correction of distal radius malunions utilizing a number of preoperative planning methods and surgical approaches. Three-dimensional models and custom cutting guides have recently become more popular, but their benefit in comparison to other methods remains unclear. Regardless of preoperative planning method or surgical approach, good results can be achieved with correction of distal radius malunion with careful attention to patient selection, indications, and surgical technique.

Surgical Decision-Making in Median Neuropathy Associated with Distal Radius Fractures.

Objectives A lack of conclusive evidence on the treatment of acute median neuropathy (AMN) in patients with distal radius fractures has led to inconsistent surgical guidelines and recommendations regarding AMN in distal radius fractures. There is a wide variation in surgical decision-making. We aimed to evaluate international differences between surgical considerations and practices related to carpal tunnel release (CTR) in the setting of distal radius fractures. Methods We approached surgeons who were a member of the Orthopaedic Trauma Association (United States) or of the Dutch Trauma Society (the Netherlands) and asked them to provide sociodemographic information and information on their surgical practice regarding CTR in the setting of distal radius fractures. After applying our exclusion criteria, our final cohort consisted of 127 respondents. Results Compared with Dutch surgeons, surgeons from the United States are more of the opinion that displaced distal radius fractures are at risk of developing acute carpal tunnel syndrome (ACTS), consider persistent paresthesia in the median nerve distribution after closed reduction to be a surgical emergency less often, and are more likely to perform a CTR if there are signs of ACTS in the setting of a distal radius fracture. Conclusion A lack of conclusive evidence has led to international differences in surgical practice regarding the treatment of ACTS in the setting of distal radius fractures. Future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures. Level of Evidence This is a Level V study.

Intra-articular findings during the modified Brostrom procedure for lateral instability of the pediatric ankle.

The purpose of this study was to identify the rates of chondral injury, soft tissue impingement, and bony impingement in pediatric patients undergoing the modified Brostrom procedure with ankle arthroscopy for lateral ankle instability. A retrospective review of all patients undergoing a modified Brostrom procedure with ankle arthroscopy performed by two surgeons at a tertiary care children's hospital between October 2002 and April 2014 was performed. Data were collected regarding demographics, history and initial presentation, nonoperative management, surgical procedure and arthroscopic findings, and clinical follow-up. All patients had symptoms of ankle instability and had failed nonoperative management before surgery. A total of 69 patients were reviewed (75 ankles), of whom 54 (78%) were female and six underwent bilateral surgery. The mean±SD age was 15.2±2.6 years, and the mean BMI was 23.6±5.0 kg/m. All patients had preoperative radiography and MRI. Preoperative imaging within 1 year before surgery was available for review of 57 (76%) ankles, with 16 (28%) having open physes, 28 (49%) having closing physes, and 13 (23%) having closed physes. All patients reviewed underwent the Brostrom procedure with Gould modification and routine concurrent arthroscopy. During arthroscopy, anterior soft tissue impingement was noted in 49 (65%) ankles, synovitis in 40 (53%), chondral defect in eight (11%), loose body in three (4%), and none were found to have bony impingement. Soft tissue impingement (65%) is common in pediatric patients undergoing surgery for lateral ankle instability. Bony impingement (0%) and chondral injury (11%) are uncommon. This is in contrast to the adult population where bony impingement and chondral injury are more common. LEVEL OF EVIDENCE: Level IV Case Series.

Economic implications of the Society for Assisted Reproductive Technology embryo transfer guidelines: healthcare dollars saved by reducing iatrogenic triplets.

OBJECTIVE: To estimate the national cost savings resulting from reductions in higher-order multiple (HOM) live births (defined as three or more fetuses), following the initial publication of the Society for Assisted Reproductive Technology (SART) guidelines on ET in 1998. DESIGN: Descriptive use and cost analysis. SETTING: Not applicable. PATIENT(S): Not applicable. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Estimates of the total number of HOM deliveries prevented (from 1998-2012) following the publication of SART guidelines; the associated healthcare savings (2014 US dollars). RESULT(S): A singleton live birth was estimated to cost $17,100-$24,200. A twin live birth was estimated at $66,000-$117,500. A triplet live birth was estimated at $190,800-$456,300. The percentage of HOM gestations among all ART pregnancies decreased from 11.4% in 1997 to 2.0% in 2012, with the sharpest year-over-year decline of 20.3% occurring in the year following the publication of the guidelines. The number of prevented HOM deliveries from 1998 through 2012 was estimated to be between 13,500 and 16,300, corresponding to cost savings of $6.02B (billion) (range, $2.35B-$7.03B, 2014 US dollars). CONCLUSION(S): Iatrogenic HOM gestations represent a substantial economic burden to our healthcare system. The introduction of guidelines for ET in 1998 coincided with a dramatic decrease in the HOM rate in subsequent years and an associated cumulative cost savings of more than $6B. Further reductions in HOM gestations could save up to an additional $2B annually.

Surgical site infection in orthopaedic oncology.

BACKGROUND: This study addressed risk factors for surgical site infection in patients who had undergone orthopaedic oncology surgical procedures. METHODS: We retrospectively reviewed data on 1521 orthopaedic oncologic surgical procedures in 1304 patients. We assessed patient demographics, updated Charlson comorbidity index, surgery-specific data, and treatment-related data and attempted to identify predictors of surgical site infection with bivariate and multivariable analysis. RESULTS: Eight factors independently predicted surgical site infection: body mass index (odds ratio [OR]:, 1.03, 95% confidence interval [CI]: 1.00 to 1.07), age (OR: 1.18, 95% CI: 1.05 to 1.33), total number of preceding procedures (OR: 1.19, 95% CI: 1.07 to 1.34), preexisting implants (OR: 1.94, 95% CI: 1.17 to 3.21), infection at another site on the date of the surgery (OR: 4.13, 95% CI: 1.57 to 10.85), malignant disease (OR: 1.46, 95% CI: 0.94 to 2.26), hip region affected (OR: 1.96, 95% CI: 1.35 to 2.84), and duration of the procedure (OR: 1.16, 95% CI: 1.07 to 1.25). CONCLUSIONS: These factors can inform patients and surgeons of the probability of surgical site infection after orthopaedic oncologic surgery. While most risk factors are unmodifiable or related to the complexity of the case, infection at another site on the date of the surgery is one factor amenable to intervention.

Fatigue optimization scheduling in graduate medical education: reducing fatigue and improving patient safety.

BACKGROUND: Medical error is a major cause of preventable morbidity and mortality. Resident fatigue is likely to be a significant contributor. OBJECTIVES: We calculated and compared predicted fatigue impairment in surgical residents on varying schedules by using the validated Sleep, Activity, Fatigue, and Task Effectiveness model and Fatigue Avoidance Scheduling Tool; we identified specific times of day and rotations during which residents were most affected, instituted countermeasures, and measured the predicted response. METHODS: We compared 4 scheduling patterns: day shift, trauma shift, night shift, and prework hour restriction Q3 call (or every-third-night call). The dependent variables were mean daily effectiveness while at work and the percentage of time residents worked with critical fatigue impairment (defined as an effectiveness score of less than 70 correlated with an increased risk for error and a blood alcohol content of 0.08). Fatigue countermeasures (ie, a 30-minute nap, eliminating 24-hour shifts) were applied to rotations with significant impairment to determine impairment plasticity. RESULTS: CALCULATED MEAN EFFECTIVENESS SCORES AND PERCENTAGE OF TIME SPENT IMPAIRED AT WORK WERE AS FOLLOWS: day shift, 90.3, 0%; trauma shift, 82.0, 7.5%; prework hour restriction Q3 call shift, 80.7, 23%; and night shift, 68.0, 50% (P < .001). Fatigue optimization countermeasures for night shift rotation improved mean daily effectiveness to 87.1 with only 1.9% of time working while impaired (P < .001). CONCLUSIONS: There is a significant potential for fatigue impairment in residents, with work schedule a significant factor. Once targeted, fatigue impairment may be minimized with specific countermeasures. Fatigue optimization tools provide data for targeted scheduling interventions, which reduce fatigue and may mitigate medical error.