bluuebunny/crossref_metadata_2025 huggingface dataset:
Oropharyngeal Bacterial Colonization after Chlorhexidine Mouthwash in Mechanically Ventilated Critically Ill Patients
Authors: La Combe Béatrice , Mahérault Anne-Claire , Messika Jonathan , Billard-Pomares Typhaine , Branger Catherine , Landraud Luce , Dreyfuss Didier , Dib Fadia , Massias Laurent , Ricard Jean-Damien
Published: September 2018

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Oropharyngeal care with chlorhexidine to prevent ventilator-associated pneumonia is currently questioned, and exhaustive microbiologic data assessing its efficacy are lacking. The authors therefore aimed to study the effect of chlorhexidine mouthwash on oropharyngeal bacterial growth, to determine chlorhexidine susceptibility of these bacteria, and to measure chlorhexidine salivary concentration after an oropharyngeal care.

Methods

This observational, prospective, single-center study enrolled 30 critically ill patients under mechanical ventilation for over 48 h. Oropharyngeal contamination was assessed by swabbing the gingivobuccal sulcus immediately before applying 0.12% chlorhexidine with soaked swabs, and subsequently at 15, 60, 120, 240, and 360 min after. Bacterial growth and identification were performed, and chlorhexidine minimal inhibitory concentration of recovered pathogens was determined. Saliva was collected in 10 patients, at every timepoint, with an additional timepoint after 30 min, to measure chlorhexidine concentration.

Results

Two hundred fifty bacterial samples were analyzed and identified 48 pathogens including Streptococci (27.1%) and Enterobacteriaceae (20.8%). Oropharyngeal contamination before chlorhexidine mouthwash ranged from 103 to 107 colony-forming units (CFU)/ml in the 30 patients (median contamination level: 2.5·106 CFU/ml), and remained between 8·105 (lowest) and 3·106 CFU/ml (highest count) after chlorhexidine exposure. These bacterial counts did not decrease overtime after chlorhexidine mouthwash (each minute increase in time resulted in a multiplication of bacterial count by a coefficient of 1.001, P = 0.83). Viridans group streptococci isolates had the lowest chlorhexidine minimal inhibitory concentration (4 [4 to 8] mg/l); Enterobacteriaceae isolates had the highest ones (32 [16 to 32] mg/l). Chlorhexidine salivary concentration rapidly decreased, reaching 7.6 [1.8 to 31] mg/l as early as 60 min after mouthwash.

Conclusions

Chlorhexidine oropharyngeal care does not seem to reduce bacterial oropharyngeal colonization in critically ill ventilated patients. Variable chlorhexidine minimal inhibitory concentrations along with low chlorhexidine salivary concentrations after mouthwash could explain this ineffectiveness, and thus question the use of chlorhexidine for ventilator-associated pneumonia prevention.
Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks
Authors: Siddiqui Naveed , Yu Eugene , Boulis Sherif , You-Ten Kong Eric
Published: September 2018

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Success of a cricothyrotomy is dependent on accurate identification of the cricothyroid membrane. The objective of this study was to compare the accuracy of ultrasonography versus external palpation in localizing the cricothyroid membrane.

Methods

In total, 223 subjects with abnormal neck anatomy who were scheduled for neck computed-tomography scan at University Health Network hospitals in Toronto, Canada, were randomized into two groups: external palpation and ultrasound. The localization points of the cricothyroid membrane determined by ultrasonography or external palpation were compared to the reference midpoint (computed-tomography point) of the cricothyroid membrane by a radiologist who was blinded to group allocation. Primary outcome was the accuracy in identification of the cricothyroid membrane, which was measured by digital ruler in millimeters from the computed-tomography point to the ultrasound point or external-palpation point. Success was defined as the proportion of accurate attempts within a 5-mm distance from the computed-tomography point to the ultrasound point or external-palpation point.

Results

The percentage of accurate attempts was 10-fold greater in the ultrasound than external-palpation group (81% vs. 8%; 95% CI, 63.6 to 81.3%; P < 0.0001). The mean (SD) distance measured from the external-palpation to computed-tomography point was five-fold greater than the ultrasound to the computed-tomography point (16.6 ± 7.5 vs. 3.4 ± 3.3 mm; 95% CI, 11.67 to 14.70; P < 0.0001). Analysis demonstrated that the risk ratio of inaccurate localization of the cricothyroid membrane was 9.14-fold greater with the external palpation than with the ultrasound (P < 0.0001). There were no adverse events observed.

Conclusions

In subjects with poorly defined neck landmarks, ultrasonography is more accurate than external palpation in localizing the cricothyroid membrane.
Vaginal Cuff Dehiscence and Evisceration
Authors: Nezhat Camran , Kennedy Burns Megan , Wood Michelle , Nezhat Ceana , Nezhat Azadeh , Nezhat Farr
Published: September 2018

Vaginal cuff dehiscence is an infrequent complication of hysterectomy, with the potential for evisceration and additional morbidity. This review aims to describe the incidence, risk factors, preventative measures, and management. Identification of specific risk factors is problematic because many studies either lack comparison groups or are underpowered as a result of the rarity of this complication. Good surgical technique to optimize vaginal cuff healing and minimize the risk of postoperative cuff infection are important as is avoidance of early intercourse, traumatic vaginal penetration, or excess strain on the vaginal cuff during the postoperative period. Judicious use of electrocautery or other thermal energy, use of delayed absorbable sutures, and adequate tissue bites can further decrease the risk of dehiscence. Prompt recognition and management are critical to achieve best outcomes.
Patient and Health Care Provider Factors Associated With Prescription of Opioids After Delivery
Authors: Badreldin Nevert , Grobman William A. , Chang Katherine T. , Yee Lynn M.
Published: September 2018

OBJECTIVE:

To identify patient and health care provider characteristics associated with receipt of a high amount of prescribed opioids at postpartum discharge.

METHODS:

This was a retrospective case–control study of all opioid-naïve women delivering at a single, high-volume tertiary care center between December 1, 2015, and November 30, 2016. Inpatient, outpatient, pharmacy, and billing records were queried for clinical, prescription, and health care provider (training, age, gender) data. The discharging health care provider, whether an opioid prescription was provided, and the details of any opioid prescription were determined. A high amount of prescribed opioids was defined as morphine milligram equivalents greater than the 90th percentile (determined as 300 morphine milligram equivalents for vaginal and 500 morphine milligram equivalents for cesarean delivery). Multivariable logistic regression models with random effects were used to identify patient and health care provider factors independently associated with receipt of a high amount of prescribed opioids at discharge. Findings were analyzed separately by mode of delivery.

RESULTS:

The analysis included 12,362 women. High amounts of opioids were prescribed for 636 of 9,038 (7.0%) women who delivered vaginally and 241 of 3,288 (7.3%) of those delivering by cesarean. In multivariable analysis, patient factors associated with receipt of a high amount of prescribed opioids at discharge after a vaginal delivery included nulliparity, intrapartum neuraxial anesthesia, major laceration, and infectious complication. Discharge by a trainee physician was associated with decreased odds of receiving a high amount of opioids (8.5% vs 1.9%; adjusted odds ratio [OR] 0.08, 95% CI 0.01–0.53). For women who underwent cesarean delivery, the only patient factor associated with receipt of a high amount of prescribed opioids was hemorrhage. Discharge by a trainee physician was associated with decreased odds of being provided a high-amount opioid prescription (7.9% vs 0.4%; adjusted OR 0.01, 95% CI 0.00–0.36).

CONCLUSION:

Even after adjusting for patient factors, discharge by a trainee physician is significantly associated with decreased odds of a high amount of prescribed opioids at postpartum discharge.
Maternal Outcomes Associated With Lower Range Stage 1 Hypertension
Authors: Sutton Elizabeth F. , Hauspurg Alisse , Caritis Steve N. , Powers Robert W. , Catov Janet M.
Published: September 2018

OBJECTIVE:

To evaluate maternal and neonatal outcomes in healthy, nulliparous women classified with stage 1 hypertension under the revised American College of Cardiology and American Heart Association Guidelines and to evaluate the effects of low-dose aspirin on maternal and neonatal outcomes in this population.

METHODS:

We conducted a secondary analysis of data from a multicenter randomized, double-blind, placebo-controlled trial of low-dose aspirin for prevention of preeclampsia in nulliparous, low-risk women recruited between 13 and 25 weeks of gestation. Of the 3,134 nulliparous women enrolled in the original study, 2,947 women with singleton pregnancies and without missing data were included in this analysis. Blood pressure was measured at enrollment between 13 and 25 weeks of gestation and outcomes were adjudicated from the medical record.

RESULTS:

One hundred sixty-four participants were identified with lower range stage 1 hypertension (5.6%), systolic blood pressure 130–135 mm Hg, diastolic blood pressure 80–85 mm Hg, or both by the new American College of Cardiology–American Heart Association guidelines. Within the placebo group (n=1,482), women with stage 1 hypertension had a significantly increased incidence of preeclampsia compared with normotensive women, 15.3% (15/98) vs 5.4% (75/1,384) (relative risk 2.66, 95% CI 1.56–4.54,P<.001). Moreover, women with stage 1 hypertension had an increased incidence of gestational diabetes mellitus (6.1% vs 2.5%,P=.03) and more indicated preterm deliveries (4.2% vs 1.1%,P=.01). Comparing women with stage 1 hypertension and normotensive women receiving low-dose aspirin during pregnancy (n=1,465), no differences in rates of preeclampsia (7.6% vs 4.4%, respectively,P=.2), gestational diabetes mellitus, or indicated preterm deliveries were observed. Rates of placenta abruption, small for gestational age, and spontaneous preterm birth did not differ significantly between groups.

CONCLUSION:

Application of the new American College of Cardiology–American Heart Association guidelines in a pregnant population identifies a cohort of women who are at increased risk for preeclampsia, gestational diabetes mellitus, and preterm birth.
Delivery-to-Delivery Weight Gain and Risk of Hypertensive Disorders in a Subsequent Pregnancy
Authors: Dude Annie M. , Shahawy Sarrah , Grobman William A.
Published: September 2018

OBJECTIVE:

To estimate whether weight gain between deliveries is associated with an increased risk of hypertensive disorders in a subsequent pregnancy.

METHODS:

This is a case–control study of women who had two live singleton births of at least 24 weeks of gestation at a single maternity hospital from January 1, 2005, to December 31, 2015, with no hypertensive disorder documented in the index pregnancy. Maternal weight gain between deliveries was measured as the change in body mass index (BMI) at delivery. Women who were diagnosed with any hypertensive disorder in the subsequent pregnancy were compared with those who experienced no hypertensive disorder in the subsequent pregnancy using χ2 statistics for categorical variables and t tests for continuous variables. Logistic regression was used to determine whether weight gain remained independently associated with hypertensive disorders after adjusting for potential confounders.

RESULTS:

Of 1,033 women, 188 (18.2%) were diagnosed with a hypertensive disorder in the subsequent pregnancy. Of these, 166 (88.3%) had a hypertensive disorder specific to pregnancy (gestational hypertension; preeclampsia; superimposed preeclampsia; or hemolysis, elevated liver enzymes, and low platelet count syndrome), and 22 (11.7%) had chronic hypertension only. Greater weight gain between deliveries was significantly associated with a higher frequency of hypertensive disorders, which remained significant for a BMI increase of at least 2 kg/m2 in multivariable analyses (adjusted odds ratio [OR] 1.76, 95% CI 1.14–2.74 for 2 to less than 4 kg/m2, adjusted OR 3.19, 95% CI 1.86–5.47 for 4 kg/m2 or more). Conversely, weight loss of 2 kg/m2 or more was associated with a decreased risk of a hypertensive disorder (adjusted OR 0.41, 95% CI 0.21–0.81).

CONCLUSION:

Among women with no hypertensive disorder noted in an index pregnancy, an increase in BMI of at least 2 kg/m2 between deliveries was independently associated with an increased risk of a hypertensive disorder in a subsequent pregnancy.
Mozart for Reducing Patient Anxiety During Colposcopy
Authors: Hilal Ziad , Alici Ferizan , Tempfer Clemens B. , Rath Katrin , Nar Kirnjit , Rezniczek Günther A.
Published: September 2018

OBJECTIVE:

To test whether music by Mozart reduces anxiety among patients undergoing colposcopy.

METHODS:

In a randomized multicenter trial, we measured the reduction of the situation-specific anxiety of women hearing Mozart’s Symphony No. 40 during colposcopy compared with women not hearing music using the State-Trait Anxiety Inventory. Secondary endpoints were reduction of heart rate (beats per minute), pain during and 10 minutes after colposcopy, general unpleasantness, anxiety during colposcopy, and overall satisfaction (11-item visual analog scales). Analysis was by intention to treat. A sample size of 104 per group (N=208) was calculated to achieve 80% power to detect a difference of 4.8 with a SD of 12.3 in anxiety scores.

RESULTS:

Between February 2017 and May 2018, 212 women were randomized. The mean anxiety reduction was −9.4±10.8 SD in 103 women in the music group and −9.0±10.6 in 102 women in the control group (P=.40). The secondary endpoints reduction of heart rate (−16.3±16.9 vs −15.4±17.1; P=.37), pain during procedure (median 2 [interquartile range 1–4] vs 2 [1–3.5]; P=.80), pain 10 minutes after examination (1 [0–1.75] vs 1 [0–2]; P=.42), general unpleasantness (3 [1–5.75] vs 4 [1–5.5]; P=.35), anxiety during examination (2 [1–5] vs 2 [1–6]; P=.28), and overall satisfaction (10 [9–10] vs 10 [9–10]; P=.81) were also not different between the two study groups.

CONCLUSION:

Mozart’s Symphony No. 40 does not reduce anxiety in women undergoing colposcopy.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT03005795.
New insights in myositis-specific autoantibodies
Authors: Ghirardello Anna , Doria Andrea
Published: September 2018

Purpose of review

The aim of this study was to provide the most recent evidence on clinical utility of myositis-specific autoantibodies (MSAs) in the management of patients with myositis.

Recent findings

In the last few years, several evidences have emerged on the clinical and pathogenetic role of established and novel MSA. Antisynthetase antibodies represent a reliable biomarker for pulmonary involvement also in patients with connective tissue diseases other than myositis. Antisignal recognition particle and antihydroxy-3-methylglutaryl coenzyme A reductase autoantibodies are able to induce complement-dependent muscle damage. Dermatomyositis-specific antibodies are useful indicators of clinical diversity. The pivotal role of antitranscription intermediary factor 1γ autoimmune response in adult-age paraneoplastic dermatomyositis has been further asserted. AnticN1A and antifour-and-a-half LIM protein 1 antibodies are newly conceived myositis-related antibody specificities, which can contribute to patients’ stratification into more homogeneous groups.

Distinct autoantibody-associated clinical phenotypes can be predicted by extended MSA testing in serum. Standardization and validation of MSA laboratory detection methods is strongly recommended for better supporting myositis diagnosis, management and prognosis definition.
Understanding the Opioid Epidemic: Factors Predictive of Inpatient and Postdischarge Prescription Opioid Use After Orthopaedic Trauma
Authors: Flanagan Christopher D. , Wysong Elena F. , Ramey James Scott , Vallier Heather A.
Published: September 2018

Objective:

The purpose of this study was to determine which factors influence inpatient and postdischarge opioid use after orthopaedic trauma.

Design:

Retrospective cohort study.

Setting:

Single Level 1 trauma center.

Participants:

The study included 235 adult trauma patients treated operatively for fracture with minimum 1 overnight hospital stay.

Intervention:

Operative fracture management.

Main Outcome Measurement:

Total opioid pain medication use, in oral morphine equivalents, in inpatient and postdischarge settings.

Results:

Controlling for length of stay, inpatient opioid use was negatively correlated with age and positively correlated with Injury Severity Score, intensive care unit (ICU) admission, and baseline tobacco use (P < 0.0001, adjusted R2 = 0.274). Discharge opioid prescription amount was negatively correlated with age, the presence of a complication, and ICU admission and positively correlated with inpatient opioid use (P < 0.0001, adjusted R2 = 0.201). Postdischarge opioid use was associated with larger amounts of opioids prescribed at discharge, a patient history of alcohol use at baseline, and ICU admission (P < 0.0001, R2 = 0.123).

Conclusion:

Nonmodifiable factors accounted for the level of inpatient opioid use in a trauma population. Higher inpatient use predicts larger opioid prescriptions at discharge, whereas larger discharge prescription predicts greater postdischarge opioid use. Strategies to reduce postdischarge opioid use should begin with reductions in inpatient opioid use. Multimodal pain strategies may be needed to achieve this goal.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Importance of Mechanoreceptors and Other Neural Structures Within the Anterior Intermeniscal Ligament in the Etiology of Anterior Knee Pain After Tibial Nailing
Authors: Franke Jörg , Brobeil Alexander , Lips Katrin Susanne , Gattenloehner Stefan , Franke Anissa Paulina , Hohendorff Bernd , Alt Volker , Schnettler Reinhard
Published: September 2018

Background:

Anterior knee pain is the most common complication after intramedullary tibial nailing. The cause is often multifactorial and varies among individuals. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible source of postsurgical anterior knee pain. Although there is a certain ambiguity regarding the importance and function of the AIL, neural structures in the AIL tissue might play a significant role with respect to functional purposes and pain perception.

Methods:

We subjected 6 AIL specimens to histologic examination to identify the neural structures that are a mandatory requirement as a source of anterior knee pain. Specifically, we performed three-dimensional immunohistochemical investigation of subtyping, orientation, and detailed characterization of neural structures within the AIL tissue.

Results:

Histologic and three-dimensional immunohistochemical examinations confirmed the presence of neural structures in all 6 AIL specimens. We identified myelinated and unmyelinated nerve fibers, as well as all types of mechanoreceptors.

Conclusions:

Free nerve endings are a mandatory requirement for pain perception as a result of AIL violation during tibial nailing. Our verification of all different types of mechanoreceptors in the AIL tissue makes a role of the ligament in knee joint function and proprioception highly probable. Further investigations are necessary to clarify possible correlations between neural supply and function of the AIL. Violation of the ligament during operative procedures should be avoided, although the significance of the AIL is still debated.
Radiographic and Clinical Outcomes of Periprosthetic Distal Femur Fractures Treated With Open Reduction Internal Fixation
Authors: Christ Alexander B. , Chawla Harshvardhan , Gausden Elizabeth B. , Villa Jordan C. , Wellman David S. , Lorich Dean G. , Helfet David L.
Published: September 2018

Objectives:

To report outcomes and complications of periprosthetic distal femur fractures (PPDFF) treated with open reduction internal fixation (ORIF) using a plate construct, with or without endosteal augmentation.

Design:

Retrospective Case Series.

Setting:

One Level I trauma center and one tertiary care hospital.

Patients/Participants:

Forty patients with PPDFFs, treated by 3 surgeons, were identified using an institutional trauma registry. Thirty-two patients with 12 months of clinical and radiographic follow-up were included, and 8 patients were lost to follow-up before 12 months.

Intervention:

All patients underwent ORIF of the PPDFF with lateral locked plating, and 11 received additional endosteal augmentation using allograft fibula.

Results:

Thirty-two patients were available for the final follow-up. Ninety-four percent of patients achieved union at an average of 6.5 months postoperatively. Twenty-one percent of patients underwent subsequent surgery, with more than half of those being for removal of implants. Anatomic limb alignment was achieved in all cases (no malunions). Almost half of the patients required assistive devices for ambulation in the long term.

Conclusions:

ORIF of PPDFF with direct visualization using periarticular locking plates ± endosteal strut allograft resulted in a 94% union rate and no deep infections. There was no difference in outcomes between groups treated with or without additional endosteal fibular allograft. However, these are catastrophic injuries in frail patients, and 20% of patients either died or were lost to follow-up, and almost half required an assistive device for ambulation after surgery despite restoration of limb alignment.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Consortium of Orthopaedic Academic Traumatologists: A Model for Collaboration in Orthopaedic Surgery
Authors: Miclau Theodore , MacKechnie Madeline C. , Shearer David W. ,   on behalf of the COACT group
Published: September 2018

In March 2016, North American academic leaders with an interest in and commitment to the field of global orthopaedics met in Orlando, Florida, to gauge each institution's clinical, research, and educational programs in developing countries, establish the main limitations to participating in global health efforts, and assess areas of need for both the participating institutions and their international partners. After this inaugural meeting, a needs assessment survey was distributed to the group to better understand how to organize and unify the individual institutional global efforts. The results revealed that surgeons believed there was a vital need for improved communication, mentorship, and infrastructural support between North American universities. To this end, the Consortium of Orthopaedic Academic Traumatologists (COACT) was founded. The COACT seeks to promote a novel framework geared toward improving trauma care capacity by building collaborative partnerships among leading academic centers across the United States and Canada. The consortium represents a comprehensive partnership that promotes communication, collaboration, and advocacy through a central network to facilitate investigative, educational, and clinical services. Academic partners share best practices, resources, and opportunities in their international outreach projects in low- and middle-income countries in the field of orthopaedic trauma. Over the course of the past 2 years, the COACT has grown to more than 80 faculty, fellow, resident, and student members, representing over 20 orthopaedic institutions across North America.
Practical Guide to Delivering Surgical Skills Courses in a Low-Income Country: Knowledge Gained From a Surgical Education Partnership in Haiti
Authors: Furey Andrew , O'Hara Nathan N. , Marshall Erin , Pollak Andrew N.
Published: September 2018

Routine surgical skills training is known to advance a surgeon's technical proficiency. However, orthopaedic providers in low-income countries have limited access to skills training programs. International academic partnerships can augment locally available orthopaedic education, improving the quality of and capacity to deliver orthopaedic care in low-income countries. The objective of this study is to provide a practical guide to delivering an orthopaedic skills training course in a low-resource setting. The information provided is based on the experiences of the authors, along with specific feedback from previous course participants in Haiti.
Haitian Annual Conference on Orthopaedic Traumatology: Building Surgical Capacity Through Academic Collaboration
Authors: Dyer George S. M.
Published: September 2018

The Assemblée Annuelle Haitienne de Traumatologie Orthopedique (Haitian Annual Conference on Orthopaedic Traumatology) is an international orthopaedic conference, conducted each Spring in Haiti in French and English. It brings together most of Haiti's practicing orthopaedic surgeons, trainees from Haiti's 3 residency training programs, and a visiting faculty from overseas. The Haitian Annual Conference on Orthopaedic Traumatology has become an unexpected cornerstone of 1 program to support and nurture the development of orthopaedic surgery in that country.
Conducting a Randomized Controlled Trial in Tanzania: Institute for Global Orthopaedics and Traumatology and the Muhimbili Orthopaedic Institute
Authors: Ibrahim John , Liu Max , Yusi Kurt , Haonga Billy , Eliezer Edmund , Shearer David W. , Morshed Saam
Published: September 2018

Introduction:

Low- and middle-income countries (LMICs) experience a large volume of orthopaedic trauma, but limited research exists to evaluate effective treatments using locally available means. Academic partners can help design and implement research studies through collaborative efforts with local investigators. We will describe the study design and lessons learned from a randomized controlled trial in Tanzania comparing outcomes of 2 operative treatments for open tibia fractures.

Study Design:

The Institute for Global Orthopaedics and Traumatology at the University of California, San Francisco, and the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania, partnered to design a prospective, randomized controlled trial. Adult patients with open tibia fractures were randomized to receive either intramedullary nailing or external fixation as definitive fixation. Our primary outcome was the rate of reoperation, and secondary outcomes included EQ-5D, pain, function, radiographic union, and return to work.

Results:

We enrolled 40 patients in a pilot study that informed improvements in the study design and standard operating procedures. These modifications included development of a specific outline of the technical standards for each surgical intervention and held training workshops to disseminate this knowledge among operative surgeons. This resulted in the successful enrollment and standardized treatment of our target sample of 240 patients.

Discussion:

There are several challenges in conducting high-quality, international research. Keys for success include maintaining a strong relationship between partners, having local research coordinators, simplifying data collection and storage, and incentivizing patients to attend follow-up visits.
Developing Sustainable Orthopaedic Care in Northern Tanzania: An International Collaboration
Authors: Sheth Neil P. , Hardaker W. Mack , Zakielarz Kevin S. , Rudolph Michele , Massawe Honest , Levin L. Scott , Premkumar Ajay
Published: September 2018

There is a devastating lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries. Similar to other low- and middle-income countries, Tanzania has a severe shortage of trained orthopaedic surgeons. The surgeons available are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise annually. Over the past several years, our interdisciplinary team of both American and Tanzanian members has worked to understand the current local cultural and economic barriers to increasing surgical capacity, ensuring surgical safety, delivering affordable care, providing adequate patient follow-up, and improving surgical education. We propose a new paradigm for the delivery of musculoskeletal care and creation of sustained surgical capacity in this setting by building an Orthopaedic Center of Excellence in Moshi, Tanzania, augmented by international partner institutions year-round. This initiative is a public–private partnership led by the University of Pennsylvania in conjunction with Kilimanjaro Christian Medical Center. A growing number of contributors, including the Tanzanian Health Ministry, several universities, and industry partners, including general electric (GE) Health Care Africa, are currently helping to advance this concept into reality. Through our model, we aim to increase surgical capacity and quality, as well as enhance local surgical education, with the ultimate objective of training the next generation of African surgeons in the latest surgical techniques and equipment.
Can a 2-Day Course Teach Orthopaedic Surgeons Rotational Flap Procedures? An Evaluation of Data From the Nepal SMART Course Over 2 years
Authors: Challa Sravya , Conway Devin , Wu Hao-Hua , Bisht Rishi , Sherchan Binod , Lamichhane Arjun , Shearer David W. , Terry Michael , Gillenwater Justin
Published: September 2018

Introduction:

Traumatic lower extremity injuries requiring multidisciplinary treatment pose a challenge in low- and middle-income countries, where access to specialists may be limited. The surgical management and reconstructive training (SMART) course teaches orthopaedic surgeons muscle and fasciocutaneous flap procedures to address this scarcity. The purpose of this study is to assess the effectiveness of the SMART course in improving competency and comfort in performing common lower extremity flap procedures among participants.

Methods:

Sixty-four orthopaedic surgeons from different regions of Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. A competency test—consisting of questions from US in-training plastic and orthopaedic surgery examinations—was administered to attendees before and after the course. Thirty-two participants from 2016 were asked to rate their comfort level in performing flap procedures both pre- and postcourse.

Results:

Overall competency test scores, as well as scores in the plastic surgery section, increased significantly after the course (P < 0.01). The precourse competency test scores were higher in 2016 compared with 2017 (P = 0.02). There was a higher increase in overall competency test scores after the course in 2016 compared with 2017 (P = 0.03). The procedure comfort levels reported by attendees increased for all flaps (P < 0.01).

Conclusions:

These results demonstrate the ability of the SMART course to improve the competency and comfort levels of orthopaedic surgeons in performing common lower extremity flap procedures. Despite the differences in years in practice and previous experience in performing flaps, the course yielded significantly better results in 2017 compared with 2016, showing that the implementation of the course has been improving.
Using a corkscrew-tipped telescopic nail in the treatment of osteogenesis imperfecta: a biomechanical study and preliminary results of 17 consecutive cases
Authors: Sarikaya Ilker , Seker Ali , Erdal Ozan Ali , Gunay Huseyin , Inan Muharrem , Guler Beril
Published: September 2018

High complication rates were reported with the telescopic nail technique systems. To overcome such technical difficulties, we designed a corkscrew-tipped telescopic nail (CTTN). We biomechanically compared its pullout strength with that of two other tip designs. We used CTTN in 17 patients with osteogenesis imperfecta and reported their preliminary results. Average patient age was 82.6 months, and mean follow-up was 32.0±6 months. Telescoping and osteotomy site healing were assessed using radiological studies. Successful telescoping with event-free osteotomy site healing was achieved in 94.1% of patients; limited telescoping and delayed union were detected in one case each. Our results show that CTTN provides sufficient pullout strength and reduced complication rates compared with other designs.
Proposal of an innovative casting technique for correction of clubfoot according to Ponseti method: a pilot study
Authors: Gigante Cosimo , Pedrotti Luisella , Guido Davide
Published: September 2018

A total of 70 clubfeet were treated by a posterior above-knee cast (pressure points on the talus and on the first metatarsal) according to Ponseti method. At diagnosis, average Pirani score was 4.44, and mean time of treatment was 50.32 days. Overall, 27 (38.6%) clubfeet had only conservative treatment (5.29 casts) and 43 (61.4%) also had Achilles tenotomy (6.38 casts). At the end 61/70 feet (87.14%) had Pirani score 0; 10/70 feet (5.71%) had Pirani score 0.5. The Pirani score gain/cast was β=–0.432 (P<0.001). This new casting technique is safe and effective at avoiding some adverse issues related to the removal of the conventional cast.
Dupuytren’s disease in a child: a long-term evolution after surgery
Authors: García-Mata Serafin , Duart-Clemente Julio
Published: September 2018

We report the case of a 13-year-old girl who presented with a fibrous nodular lesion on the palm of her hand. After ultrasonographic examination, surgical resection of the skin (dermofasciectomy) was performed, and a nodular phase mass was recovered, characterized as fusocellular fibroblast proliferation in a dense collagenous stroma with a cell population consisting of parallel fascicles of densely packed fusiform cells of a fibroblast strain. No signs of encapsulation or malignant changes were observed, all of which was consistent with Dupuytren’s disease. This lesion is exceptional in childhood. Sixteen years later, the patient has not relapsed, and retains full active and passive mobility. Dupuytren’s disease in childhood must be considered in the differential diagnosis of any hard palmar lesion. Diagnostic uncertainty and the fact that a hard palmar lesion in children may be clinically indistinguishable from a malignant process mean that resection of the lesion and histological examination are required.
Costs and complications of increased length of stay following adolescent idiopathic scoliosis surgery
Authors: Boylan Matthew R. , Riesgo Aldo M. , Chu Alice , Paulino Carl B. , Feldman David S.
Published: September 2018

Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84–4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162–14 904; P<0.001) in insurance charges, $5198 (95% CI=4144–6252; P<0.001) in hospital costs, 28% increased risk (odds ratio=1.28; 95% CI=1.01–1.63; P=0.041) of all-cause 90-day readmission, and a 57% increased risk (odds ratio=1.57; 95% CI=1.13–2.17; P=0.007) of returning to the operating room within 90 days. Increased LOS during the index admission scoliosis surgery is associated with higher costs and an increased risk of 90-day postoperative complications. Protocols to decrease LOS for this surgery have potential benefits to patients, hospitals, and insurers. Level of Evidence: Level III, retrospective comparative study.
Severity of ulnar deficiency and its relationship with lower extremity deficiencies
Authors: Walker Janet L. , Hosseinzadeh Pooya , Lea Justin , White Hank , Bell Sheila , Riley Scott A.
Published: September 2018

To assess the characteristics of ulnar deficiency (UD) and their relationship to lower extremity deficiencies, we retrospectively classified 82 limbs with UD in 62 patients, 55% of whom had femoral, fibular, or combined deficiencies. In general, UD severity classification at one level (elbow, ulna, fingers, thumb/first web space) statistically correlated with similar severity at another. Ours is the first study to show that presence of a lower limb deficiency is associated with less severe UD on the basis of elbow, ulnar, and thumb/first web parameters. This is consistent with the embryological timing of proximal upper extremities developing before the lower extremities.
Surgical site infection following elective nonspinal paediatric orthopaedic surgery: a prospective review
Authors: Jones Stanley , Shepherd John , Robinson Karen , Khandekar Sumukh A.
Published: September 2018

The aim of this study was to determine the rate of surgical site infection (SSI) and the factors that predispose to it in children undergoing nonspinal orthopaedic surgery. Over a 6-month period, 326 children who underwent 334 nonspinal elective orthopaedic surgical procedures were prospectively reviewed for the development of surgical site infections. A total of 14 sites became infected, with an overall infection rate of 4.19%. All the infections were superficial, and the only causative organism detected was Staphylococcus aureus. Operating times longer than 1 h and surgical wounds greater than 10 cm in length were positively associated with SSIs. Although there were differences between male and females, type of admission, the use of prophylactic antibiotics, degree of wound contamination and the grades of surgeons, these differences were not statistically significant. The results of this prospective study provide valuable information that was not previously available to the practicing paediatric orthopaedic surgeon.
The long-term outcomes of posteromedial limited surgery for developmental dysplasia of the hip: a mean 17.3-year follow-up
Authors: Bicimoglu Ali , Caliskan Emrah
Published: September 2018

The objectives of this retrospective study were to evaluate long-term functional and radiological outcomes of 102 dislocated hips of 79 patients treated with the modified medial approach and to compare them with respect to both of our short-term and mid-term outcomes and also with the current literature. The mean age at operation was 11.3±4.3 months (range: 3–18 months), with a minimum follow-up of 15 years (range: 15–23 years). It was determined that 94.1% of mean hip scores were either good or excellent. Avascular necrosis, subluxation/redislocation, and secondary surgeries were 14.8, 6.9, and 7.8%, respectively. We believe this modified procedure requiring no routine arthrotomy is safe and effective.
Loss of Midline Function in Brachial Plexus Birth Palsy Patients
Authors: Abzug Joshua M. , Wyrick-Glover Theresa O. , Case Alexandria L. , Zlotolow Dan A. , Kozin Scott H.
Published: September 2018

Background:

Loss of midline function impairs the child’s ability to perform certain activities of daily living such as dressing, buttoning, and perineal care. The purpose of this study was to assess brachial plexus birth palsy (BPBP) patients with loss of midline function with respect to etiology and treatment.

Methods:

A retrospective review of all BPBP patients with loss of midline function was performed. The modified Mallet scale was used with internal rotation assessed via hand on spine and hand to belly. Demographics, extent of BPBP, prior surgical intervention, procedure(s) performed to correct the loss of midline function, complications, and outcomes were assessed.

Results:

In total, 20 patients were identified with loss of midline function as defined by the inability to reach midline and touch their umbilicus. Nineteen patients had previously undergone tendon transfers about the shoulder with or without arthroscopic capsular release to improve external rotation. After the initial surgery, modified Mallet scores improved 1 grade for abduction, hand to mouth, hand to neck, and external rotation without altering the hand to spine category. However, the internal rotation category (hand to umbilicus) decreased from an average 2.71 preoperatively to an average 2.15 postoperatively. Nine patients underwent a derotational humeral osteotomy to improve midline function. The average correction of internal rotation was 47.8 degrees (range, 20 to 85 degrees). After this surgery, modified Mallet scores remained unchanged for hand to spine; however, the scores improved back to 2.7 for the internal rotation category. Two complications were noted including 1 plate fracture and 1 fracture through a screw hole.

Conclusions:

BPBP patients who undergo surgical procedures to improve shoulder external rotation and/or obtain joint reduction may inadvertently lose midline function. Derotational humeral osteotomy can effectively restore midline function, which is needed to perform activities of daily living. Surgical procedures to improve external rotation should be performed in a manner that minimizes limitation of midline functions.

Level of Evidence:

Level III—therapeutic.
Financial Analysis of Closed Femur Fractures in 3- to 6-Year-Olds Treated With Immediate Spica Casting Versus Intramedullary Fixation
Authors: Lewis Robert B. , Hariri Omar , Elliott Marilyn E. , Jo Chan-Hee , Ramo Brandon A.
Published: September 2018

Background:

Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds.

Methods:

An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room.

Results:

A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention.

Conclusions:

Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes.

Level of Evidence:

Level III—retrospective comparative study.
Removal of Metaphyseal Screw Only After Hemiepiphysiodesis Correction of Coronal Plane Deformities Around the Knee Joint: Is This a Safe and Advisable Strategy?
Authors: Keshet Doron , Katzman Alexander , Zaidman Michael , Eidelman Mark
Published: September 2018

Purpose:

Correcting lower limb angular deformities in the skeletally immature patient with guided growth is a very common procedure. Using an 8-plate construct to produce reversible hemiepiphysiodesis allows correction of the mechanical axis of the limb. It has become routine strategy to remove only the metaphyseal screw from the 8-plate construct after desired correction is achieved, in order to ease its reinsertion in case of deformity recurrence. In this study, we evaluated the efficacy and safety of this technique.

Methods:

We reviewed the results of 80 patients (133 limbs) who were treated by guided growth using 8-plate hemiephisiodesis around the knee. After achievement of the correction goal, both screws and plate were removed in 78 limbs while only the metaphyseal screw was removed in 55 limbs.

Results:

The mean age of patient was 8.9 years at the time of surgery. Within the group whose metaphyseal screw was removed, 12 limbs showed radiographic signs of deformity recurrence and underwent reinsertion of the metaphyseal screw. In 9 of the cases of metaphyseal screw reinsertion, the plate or its location had to be changed (mean follow-up after screw removal was 14 mo). There were 2 cases where leaving the plate with an epiphyseal screw caused a radiographic bone bar and undesired clinical growth arrest.

Conclusions:

On the basis of our experience, leaving the 8-plate construct with an epiphyseal screw in place exposes the patient to risks of bony bar, growth arrest, and an additional surgery for hardware removal. The majority of 8-plate constructs are not suitable for reinsertion of the metaphyseal screw.