Stenosing synovitis of the extensor pollicis longus tendon.

There are only a few published cases of extensor pollicis longus (EPL) tenosynovitis in patients without rheumatoid arthritis. Even less common are cases of stenosing tenosynovitis of the EPL associated with triggering. This article presents 2 cases of EPL stenosing tenosynovitis with triggering of the thumb in the area of Lister's tubercle and addresses how to treat them.

Nexplanon removal from intramuscular implantation in biceps: case report.

Contraceptive implant devices are relatively safe devices, but complications arise when implants become nonpalpable, and cannot be safely removed. In this case report, we describe the location of an implant in the subfascial plane of the upper arm, the diagnostic imaging findings we encountered during the workup, and the procedure necessary to remove it. We demonstrated that if the device is in close proximity to the fascia, it may be difficult to distinguish from the fascia on magnetic resonance imaging. Nonetheless, fluoroscopy and ultrasound easily distinguished the device from the surrounding tissue and allowed localization intraoperatively.

Four Anchor Repair of Jersey Finger.

Background: Various surgical techniques for treating avulsions of the flexor digitorum profundus tendon at the distal phalanx have been published but no ideal technique has emerged. We introduce a new all-internal 4-anchor flexor tendon repair technique and evaluate outcomes in three clinical cases. Methods: In this retrospective case series, we reviewed three patients that sustained an avulsion of the flexor digitorum profundus tendon at the distal phalanx. All patients were surgically treated with the four-anchor repair technique. Two titanium anchors were inserted into the distal phalanx and two all-suture anchors were inserted distal to the first set of anchors. The tendon was then attached to these four anchors using a Krackow stitch pattern and the anchors were sown to each other. Active flexion and extension of the proximal and distal interphalangeal joint were measured at 3-month, 12-month, and 5-year follow-up. Postoperative complications were documented. Results: All patients achieved excellent clinical outcomes according to assessment criteria. At 3-month follow-up, all patients regained full flexion; two patients had full extension, while one patient was 3 degrees short of full extension. At 12-month follow-up, all patients had full flexion and extension. Five-year follow-up demonstrated the same results with no loss of function, sensation or grip strength. The repairs healed without rupture, and no complications were reported. Conclusion: The 4-anchor flexor tendon repair is a viable surgical technique for zone 1 flexor digitorum profundus tendon repair or reconstruction. Further studies are needed to replicate these promising results and biomechanically validate this technique.Level of Evidence: IV.

Vacuum-assisted closure complicated by erosion and hemorrhage of the anterior tibial artery.

We report an erosion and hemorrhage of a left anterior tibial artery associated with a vacuum-assisted closure device. To our knowledge, this report represents the first arterial erosion associated with a vacuum-assisted closure device. We estimate our patient lost 6 units of blood. The hemorrhage was complicated by anticoagulation and a traumatic setting. Based on our complication, we believe great care should be taken when placing a vacuum-assisted closure device adjacent to an exposed artery.

White spotting variant mouse as an experimental model for ovarian aging and menopausal biology.

OBJECTIVE: Menopause is a unique phenomenon in modern women, as most mammalian species possess a reproductive period comparable with their life span. Menopause is caused by the depletion of germ cell-containing ovarian follicles and in laboratory studies is usually modeled in animals in which the ovarian function is removed through ovariectomy or chemical poisoning of the germ cells. Our objective was to explore and characterize the white spotting variant (Wv) mice that have reduced ovarian germ cell abundance, a result of a point mutation in the c-kit gene that decreases kinase activity, as a genetic model for use in menopause studies. METHODS: Physiological and morphological features associated with menopause were determined in female Wv/Wv mice compared with age-matched wildtype controls. Immunohistochemistry was used to evaluate the presence and number of follicles in paraffin-embedded ovaries. Bone density and body composition were evaluated using the PIXImus x-ray densitometer, and lipids, calcium, and hormone levels were determined in serum using antigen-specific enzyme immunoassays. Heart and body weight were measured, and cardiac function was evaluated using transthoracic echocardiography. RESULTS: The ovaries of the Wv/Wv females have a greatly reduced number of normal germ cells at birth compared with wildtype mice. The remaining follicles are depleted by around 2 months, and the ovaries develop benign epithelial lesions that resemble morphological changes that occur during ovarian aging, whereas a normal mouse ovary has numerous follicles at all stages of development and retains some follicles even in advanced age. Wv mice have elevated plasma gonadotropins and reduced estrogen and progesterone levels, a significant reduction in bone mass density, and elevated serum cholesterol and lipoprotein levels. Moreover, the Wv female mice have enlarged hearts and reduced cardiac function. CONCLUSIONS: The reduction of c-kit activity in Wv mice leads to a substantially diminished follicular endowment in newborn mice and premature depletion of follicles in young mice, although mutant females have a normal life span after cessation of ovarian function. The Wv female mice exhibit consistent physiological changes that resemble common features of postmenopausal women. These alterations include follicle depletion, morphological aging of the ovary, altered serum levels of cholesterol, gonadotropins and steroid hormones, decreased bone density, and reduced cardiac function. These changes were not observed in male mice, either age-matched male Wv/Wv or wildtype mice, and are improbably caused by global loss of c-kit function. The Wv mouse may be a genetic, intact-ovary model that mimics closely the phenotypes of human menopause to be used for further studies to understand the mechanisms of menopausal biology.

Upper extremity fractures in pedestrian versus motor vehicle accidents: an underappreciated concern.

BACKGROUND: Though pedestrian versus motor vehicle (PVMV) accidents are a common cause of trauma admission and subsequent orthopaedic consult, the prevalence of upper extremity fracture (UEF) in such events and its association with lower extremity injury (LEI) is unknown. We sought to describe UEF in PVMV accident patients at the time of orthopaedic consult. METHODS: A retrospective chart review was conducted for all pedestrian hit by motor vehicle cases for which an orthopaedic consult was performed at Jackson Memorial Hospital between July 2006 and January 2008. Fractures were recorded by location along with relevant clinical information. Logistic regression was used to calculate odds ratios (O.R.) and 95% confidence intervals (C.I.) for variables associated with UEF. RESULTS: 336 cases were identified and reviewed. LEI was the most frequent injury type (67% of cases). UEF was also common, found in 25% of cases (humerus 11%, ulna 7%, radius 6%, hand 4%, and wrist 2%). Tibia or fibula fracture, femur fracture, and spine fracture were negatively associated with UEF in univariate analyses and after controlling for other associated factors. CONCLUSIONS: In PVMV accident populations, UEF is a frequent injury often seen in the absence of any LEI. These findings emphasize the importance of carefully screening all PVMV accident patients for UEF and may call into question the usefulness of currently discussed injury pattern.

Prevalence of methicillin resistant Staphylococcus aureus in upper extremity soft tissue infections at Jackson Memorial Hospital, Miami-Dade County, Florida.

PURPOSE: Methicillin resistant Staphylococcus aureus (MRSA) has been a hospital based problem since first being reported in the 1960s. Recent increases in outpatient MRSA infections suggest that there may be increased incidence of MRSA in upper extremity soft tissue infections (UESTIs). The aim of this study is to describe the current microbial flora responsible for UESTIs at an urban, tertiary care, teaching hospital. METHODS: A retrospective chart review was performed of all orthopaedic consultations for UESTIs from June 2006 to December 2007. The only exclusion criterion was a diagnosis of osteomyelitis. Logistic regression was used to describe the association between demographic and clinical characteristics identified on univariate analysis, and a MRSA positive culture. Odds ratios and confidence intervals are reported. RESULTS: There were 432 orthopaedic consultations for UESTIs. Twelve cases of osteomyelitis were excluded per protocol. Therefore, 420 patients comprised our study population, ranging in age from 4 months to 95 years, (mean: 40 years), with 327 (77.9%) men and 93 (22.1%) women. Wound cultures were available in 335 of 420 patients (79.8%). Positive cultures were found in 292 patients with a 53.4% MRSA rate (156 of 292). Methicillin sensitive Staphylococcus aureus was the second most prevalent microbe, found in 73 of 292 patients (25.0%). All MRSA isolates were susceptible to gentamicin and linezolid, and 98% or more were sensitive to vancomycin, rifampin, and trimethoprim-sulfamethoxazole combination. Univariate analyses and logistic regression identified infection location proximal to the wrist (Odds Ratio = 1.81, 95% Confidence Interval = 1.06-3.09, p<0.03) and diagnosis of abscess or felon (Odds Ratio = 3.22, 95% Confidence Interval = 1.84-5.63, p<0.001) as significantly associated with a MRSA positive culture. CONCLUSIONS: This is the largest study examining the prevalence of microbial flora in UESTIs. We found that MRSA has become the most common microbe in UESTIs comprising 53.4%, consistent with current trends at other urban medical centers.

Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial.

BACKGROUND: Although osteoporosis is strongly associated with hip fractures, the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5% and 30%. Currently, most patients receiving treatment have been referred back to their primary care physician for osteoporosis management. The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months. METHODS: A prospective randomized trial was conducted to assess the difference in the rate of osteoporosis treatment when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and "usual" care. RESULTS: Sixty-two patients were enrolled in the study. Thirty-one patients each were in the control and intervention groups. The percentage of patients who were on pharmacologic treatment for osteoporosis at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic (58%) than when treatment was managed by a primary care physician (29%) (p = 0.04). CONCLUSIONS: An active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture.

Necrotizing infection of the spine.

STUDY DESIGN: Case report of multifocal necrotizing fasciitis with lumbar involvement. OBJECTIVES: To raise awareness of an unusual, but potential, focus of a multifocal necrotizing infection in a diabetic patient. SUMMARY OF BACKGROUND DATA: Necrotizing fasciitis is a rapidly spreading infection of the soft tissue and fascia. These infections can be polymicrobial, are challenging to treat, and often have grave consequences. The spine may rarely be involved in such infections. METHODS: We describe a patient with long-standing diabetic foot ulcers, which evolved to a necrotizing infection. This infection spread hematogenously to several noncontiguous locations, including the lumbar spine, and was heralded by gas production at the sites of involvement. The spine was treated aggressively and infection eradicated at this site. RESULTS: Despite eradicating the spinal component of this infection, other sites were challenging to clear, and the patient went on to die of multisystem organ failure. CONCLUSIONS: Necrotizing infections rarely involve the spine. Heightened awareness of this potential focus of infection may facilitate its detection. As with other sites, aggressive surgical debridement of this potentially fatal condition is imperative.