Bennet A. Butler

Total ankle arthroplasty versus ankle arthrodesis—a comparison of outcomes over the last decade

BackgroundThe surgical treatment of end-stage tibiotalar arthritis continues to be a controversial topic. Advances in surgical technique and implant design have lead to improved outcomes after both ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet a clear consensus regarding the most ideal form of treatment is lacking. In this study, the outcomes and complications following AA and TAA are compared in order to improve our understanding and decision-making for care and treatment of symptomatic tibiotalar arthritis.MethodsStudies reporting on outcomes and complications following TAA or AA were obtained for review from the PubMed database between January 2006 and July 2016. Results from studies reporting on a minimum of 200 total ankle arthroplasties or a minimum of 80 ankle arthrodesis procedures were reviewed and pooled for analysis. All studies directly comparing outcomes and complications between TAA and AA were also included for review. Only studies including modern third-generation TAA implants approved for use in the USA (HINTEGRA, STAR, Salto, INBONE) were included.ResultsA total of six studies reporting on outcomes following TAA and five reporting on outcomes following AA met inclusion criteria and were included for pooled data analysis. The adjusted overall complication rate was higher for AA (26.9%) compared to TAA (19.7%), with similar findings in the non-revision reoperation rate (12.9% for AA compared to 9.5% for TAA). The adjusted revision reoperation rate for TAA (7.9%) was higher than AA (5.4%). Analysis of results from ten studies directly comparing TAA to AA suggests a more symmetric gait and less impairment on uneven surfaces after TAA.ConclusionsPooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. Based on the existing literature, the decision to proceed with TAA or AA for end-stage ankle arthritis should be made on an individual patient basis.

First carpometacarpal arthroplasty with ligamentous reconstruction: a long-term follow-up.

BackgroundThe purpose of the present study is to evaluate a single surgeon’s short, intermediate, and long-term clinical, functional, and radiographic outcomes with a trapeziectomy with flexor carpi radialis (FCR) suspension arthroplasty without tendon interposition (LRSA).MethodsTwenty-one patients underwent 26 FCR suspension arthroplasties without tendon interposition by a single senior surgeon. All patients had Eaton stage III and IV carpometacarpal (CMC) osteoarthritis. The Patient-Rated Wrist and Hand Evaluation (PRWHE) and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) were used to evaluate functional outcomes. A comprehensive strength and range of motion evaluation was performed to evaluate clinical outcomes. Plain radiographs at rest and with maximal pinch were performed to evaluate for arthroplasty space subsidence.ResultsThe LRSA exhibited consistent clinical and functional outcomes throughout postoperative follow-up. As the average patient age and time from surgery increased, range of motion (ROM) and PRWHE scores stayed relatively constant, while lateral tip and tip pinch strength deteriorated with time. The LRSA prevented the proximal migration of the first metacarpal in all but one patient. No patients required revision arthroplasty following LRSA.ConclusionsThis study demonstrates the consistent short, intermediate, and long-term clinical, functional, and radiographic outcomes following a trapeziectomy with FCR suspension arthroplasty.

Multifaceted aseptic protocol decreases surgical site infections following hip arthroplasty

Introduction: We investigate the effectiveness of a comprehensive aseptic protocol in reducing surgical site infection (SSI) after hip arthroplasty in a single medical centre with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA). Methods: A prospectively collected database of all patients undergoing hip arthroplasty in a single centre between 2005 and 2011 was reviewed for SSI using Centers for Disease Control (CDC) criteria and AAOS guidelines. All patients were administered an aseptic protocol consisting of: preoperative 2% mupirocin nasal ointment and 0.4% chlorhexidine surgical-site wipes; modified instrument care; perioperative prophylactic vancomycin and cefazolin; and surgical-site skin preparation with chlorhexidine, alcohol and iodophor. We compare our protocol hip arthroplasty SSI rate to our institutional historical control and to contemporary literature. Results: Among 774 patients, 69% were ASA>2, 45% had BMI≥30 and 10.3% had rheumatoid arthritis. We found an overall 0.39% infection rate; significantly lower than our institutional historical control (0.39% vs. 2.60%, p<0.001, OR 0.15, NNT 200) and significantly lower than 6 published reports (p<0.001-0.022, OR 0.16-0.22). Compared to these cohorts, significantly more of our patients were ASA>2, had BMI≥30 or had rheumatoid arthritis. Patients with 3 or more identifiable risk factors were at an increased risk of SSI compared to those with 2 or fewer risk factors. Conclusions: Our aseptic protocol decreases SSI in a high-risk population undergoing hip arthroplasty in a medical centre and community with a high prevalence of MRSA.

Long leg splinting for pediatric femur fractures

Background Pediatric femur fractures are frequently encountered injuries frequently treated with spica casting. Spica casting may, however, be expensive and burdensome to patients. A possible alternative is a long leg splint. Methods Patients aged 6 months to 5 years old who were treated for a femoral shaft fracture with a long leg splint extending above the waist were matched with a patient treated with a spica cast. Results At the time of healing, the alignment in the spica cast group was only significantly better than the alignment of the splint group with respect to coronal angulation.

Early diagnosis of septic arthritis in immunocompromised patients

OBJECTIVES Septic arthritis results in rapid joint destruction if not properly diagnosed and treated. A work up for septic arthritis includes a peripheral white blood cell count, inflammatory markers, and a joint aspiration. In the general population, the interpretation of these labs has been well-defined by prior studies. To this point, no study has determined how immunosuppressive states affect this work up. METHODS Patients with immunosuppressive conditions who received a joint aspiration for a painful joint were retrospectively identified. Laboratory results from their work up were gathered and analyzed. RESULTS 216 patients were included in the study, 21 of whom were diagnosed with septic arthritis. The average aspiration WBC count was 74,190 with 88% PMNs. 81% had a positive gram stain. DISCUSSION Laboratory values for immunosuppressed patients with septic arthritis were similar to those associated with septic arthritis in historical general population controls.

Deltoid Ligament Repair for Tibiotalar Stabilization and Reduction of Syndesmosis: A Cadaveric Study

Category: Ankle Introduction/Purpose: Ankle fractures with combined deltoid ligament/syndesmotic injuries are common. Proper reduction of these injuries may be deceptively difficult due to the complexity of the tibiotalar and syndesmotic articulations. The syndesmosis, in particular, has been shown to have a fairly high rate of malreduction with traditional techniques and intraoperative imaging. Additionally, the deltoid ligament has important contributions to tibiotalar alignment and stability which cannot be replaced with laterally based fixation alone. Deltoid ligament repair has the potential to address both of the proceeding issues, but has fallen out of favor due to a lack of clinical evidence supporting its use. Here we provide cadaveric data showing that deltoid ligament repair can assist with accurate syndesmotic reduction and stabilize the talus in all planes of motion. Methods: 21 lower limbs disarticulated at the knee were obtained for testing. A material testing machine capable of exerting known axial and rotational forces was utilized for testing. A motion capture system was used to accurately track the tibia, talus, and fibula in all planes of translational and rotational movement. The relative positions of each bone with respect to each other were tracked with the ankle hanging under gravitational forces only and with a modest axial force. This was done in intact ankles, ankles following creation of a combined deltoid ligament/syndesmotic injury state, and subsequently after deltoid ligament repair (Figure 1). Results: Compared to the intact state, after injury creation there was a significant increase in talar eversion with respect to the tibia when hanging which corrected with axial loading. Additionally, there was a significant increase in talar internal rotation with respect to the tibia with axial loading. Finally, there was a trend towards increased anterior translation of the fibula with respect to the tibia with axial loading which corrected with hanging. All of these rotational/translational issues were corrected with deltoid ligament repair. Conclusion: This study provides cadaveric evidence that after a combined deltoid ligament/syndesmotic injury, deltoid ligament repair can help ensure accurate syndesmotic reduction and stabilize the tibiotalar joint, especially with respect to inversion/eversion.

Novel intramedullary device for lengthening transfemoral residual limbs.

BackgroundLower limb loss is a highly disabling medical condition that can severely impact a person’s quality of life. Recovery becomes especially challenging if an amputee has a short residual limb, which can complicate proper prosthetic fitting, causing discomfort, difficulties in suspension, and reduced mobility. Current limb lengthening techniques such as the Ilizarov apparatus and external fixators are cumbersome, uncomfortable, and have high complication rates. In this study, we investigated the effectiveness of a novel limb-lengthening device that uses intramedullary bone lengthening and requires only one percutaneous rod at the end of the limb during the distraction phase. Only the intramedullary nail remains after the distraction phase, and no external components are required during the consolidation phase. We hypothesize that this system would create a much easier experience for the patient.MethodsThe system was first tested in a mock surgical implantation using plastic femur bones. The device was then tested in a series of cadaveric experiments using pelvis-to-knee specimens by a group of surgeons. Surgeons evaluated the surgical insertion technique, soft tissue considerations, hardware fixation strategies, and the effectiveness of the distraction mechanism. Revisions and improvements to the device and surgical procedure were made based on the results from the cadaveric experiments.ResultsA questionnaire was given to two visiting surgeons following the final iteration of the device. The surgeons reported that the system effectively lengthened the limb, was sturdy, and could be installed efficiently. However, there remains a risk of infection and soft tissue imbalances, similar to that introduced by an external fixator device. Suggestions on how to improve the design of the device and mitigate infection through postoperative management and surgical standard of care will be considered for future clinical trials.ConclusionsThe described intramedullary residual limb-lengthening device has evolved from a prototype to a mature model tested in six cadaveric experiments to date. Further mechanical and functional testing is needed to finalize the device before testing in patients.

Recombinant human bone morphogenetic protein-2 versus iliac crest bone graft in anterior cervical discectomy and fusion: Dysphagia and dysphonia rates in the early postoperative period with review of the literature

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a growth factor utilized to stimulate bone development in several clinical scenarios. Although the U.S. Food and Drug Administration approved this therapeutic modality for only two applications, it is frequently used off-label in anterior cervical discectomy and fusion (ACDF) procedures as an alternative to iliac crest bone graft (ICBG), the prior standard of care. This usage has been a source of controversy in the medical community due to evidence of increased rates of postoperative edema and dysphagia. This retrospective cohort study investigates two groups of 200 patients having undergone ACDF, one using rhBMP-2 and the other using ICBG, to evaluate the incidence of complications in the early postoperative period. A significant reduction in average length of stay was found in the rhBMP-2 cohort (1.40days) compared to the ICBG cohort (1.85days) as well as a significantly increased rate of dysphagia (25.5% in rhBMP-2 vs. 15% in ICBG; p=0.01). An increased rate of dysphonia was observed among patients undergoing revision surgery (25.0%) compared to primary surgery (1.6%), but stratification by number of levels, gender, and smoking status yielded no differences in complication rates. Our evaluation of two large cohorts along with review of the literature on the topic sheds light on potential benefits and risks of rhBMP-2 in ACDF procedures. Further investigation is warranted to determine if clinical gains outweigh the potential harms of rhBMP-2 use in this setting.

Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures.

Background: Simulation-based education has been integrated into many orthopaedic residency programs to augment traditional teaching models. Here we describe the development and implementation of a combined didactic and simulation-based course for teaching medical students and interns how to properly perform a closed reduction and percutaneous pinning of a pediatric supracondylar humeral fracture. Methods: Subjects included in the study were either orthopaedic surgery interns or subinterns at our institution. Subjects all completed a combined didactic and simulation-based course on pediatric supracondylar humeral fractures. The first part of this course was an electronic (e)-learning module that the subjects could complete at home in approximately 40 minutes. The second part of the course was a 20-minute simulation-based skills learning session completed in the simulation center. Subject knowledge of closed reduction and percutaneous pinning of supracondylar humeral fractures was tested using a 30-question, multiple-choice, written test. Surgical skills were tested in the operating room or in a simulated operating room. Subject pre-intervention and post-intervention scores were compared to determine if and how much they had improved. Results: A total of 21 subjects were tested. These subjects significantly improved their scores on both the written, multiple-choice test and skills test after completing the combined didactic and simulation module. Prior to the module, intern and subintern multiple-choice test scores were significantly worse than postgraduate year (PGY)-2 to PGY-5 resident scores (p < 0.01); after completion of the module, there was no significant difference in the multiple-choice test scores. After completing the module, there was no significant difference in skills test scores between interns and PGY-2 to PGY-5 residents. Both tests were validated using the scores obtained from PGY-2 to PGY-5 residents. Conclusions: Our combined didactic and simulation course significantly improved intern and subintern understanding of supracondylar humeral fractures and their ability to perform a closed reduction and percutaneous pinning of these fractures.

Illinois trauma centers and community violence resources.

Background: Elder abuse and neglect (EAN), intimate partner violence (IPV), and street-based community violence (SBCV) are significant public health problems, which frequently lead to traumatic injury. Trauma centers can provide an effective setting for intervention and referral, potentially interrupting the cycle of violence. Aims: To assess existing institutional resources for the identification and treatment of violence victims among patients presenting with acute injury to statewide trauma centers. Settings and Design: We used a prospective, web-based survey of trauma medical directors at 62 Illinois trauma centers. Nonresponders were contacted via telephone to complete the survey. Materials and Methods: This survey was based on a survey conducted in 2004 assessing trauma centers and IPV resources. We modified this survey to collect data on IPV, EAN, and SBCV. Statistical Analysis: Univariate and bivariate statistics were performed using STATA statistical software. Results: We found that 100% of trauma centers now screen for IPV, an improvement from 2004 (P = 0.007). Screening for EAN (70%) and SBCV (61%) was less common (P < 0.001), and hospitals thought that resources for SBCV in particular were inadequate (P < 0.001) and fewer resources were available for these patients (P = 0.02). However, there was lack of uniformity of screening, tracking, and referral practices for victims of violence throughout the state. Conclusion: The multiplicity of strategies for tracking and referring victims of violence in Illinois makes it difficult to assess screening and tracking or form generalized policy recommendations. This presents an opportunity to improve care delivered to victims of violence by standardizing care and referral protocols.