David Gendelberg

A Radiation Safety Training Program Results in Reduced Radiation Exposure for Orthopaedic Residents Using the Mini C-arm

BackgroundFluoroscopy during fracture reduction allows a physician to assess fractures and immediately treat a pediatric patient. However, concern regarding the effects of radiation exposure has led us to find ways to keep radiation exposures as low as reasonably achievable. One potentially simple way, which to our knowledge has not been explored, to decrease radiation exposure is through formal education before mini C-arm use.Questions/purposesWe questioned whether a radiation safety educational program decreases radiation (1) time and (2) exposure among residents and patients.Patients and MethodsThis is a retrospective study in which second-year residents underwent a 3-hour educational program regarding mini C-arm use and radiation safety taught by our institution’s health physics department. We evaluated the records of all patients who underwent a pediatric both-bone forearm or distal radius fracture reduction in the emergency department 3 months before the educational program or after the program. To be included in the study, records included simple both-bone forearm fractures, simple distal radius fractures, and patient age younger than 18 years, and could not include patients with multiple fractures in the same limb. This resulted in study groups of 53 and 45 patients’ records in the groups before and after the educational session, respectively. Radiation emission from the mini C-arm between both groups were compared.ResultsExposure time with the mini C-arm was longer in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 41.2, SD = 24.7, 95% CI, 23.14–59.26 vs mean = 28.9, SD = 14.4, 95% CI, 15.91–41.89, p = 0.066; patients with distal radius fractures: mean = 38.1, SD = 26.1, 95% CI, 25.1–51.1 vs mean = 26.7, SD = 15.8, 95% CI, 16.44–36.96, p = 0.042). Calculated radiation exposure with the mini C-arm was larger in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 90.9, SD = 60.9, 95% CI, 51.06–130.74 vs mean = 30.4, SD = 18.5, 95% CI, 16.73–44.07, p < 0.001; patients with distal radius fractures: mean = 83.1, SD = 58.9, 95% CI, 54.75–111.45 vs mean = 32.6, SD = 26.4, 95% CI, 20.07–45.13, p < 0.001).ConclusionsA radiation-safety program resulted in decreased radiation exposure to residents and patients, and in decreased mini C-arm exposure time during pediatric fracture reductions.Level of EvidenceLevel III, therapeutic study.

Operative and Nonoperative Treatment Approaches for Lumbar Degenerative Disc Disease Have Similar Long-Term Clinical Outcomes Among Patients with Positive Discography

OBJECTIVE It remains unclear whether fusion for lumbar degenerative disc disease with positive discography produces better outcomes compared with nonoperative treatment. The aim of this study was to compare outcomes of patients with discography-concordant lumbar degenerative disc disease electing for fusion versus nonoperative treatment. METHODS We retrospectively reviewed consecutive patients with back pain and concordant lumbar discogram who were offered fusion. Follow-up questionnaires included pain score, Oswestry disability index, short form-12, and satisfaction scale. Patients were stratified based on whether they elected for fusion or nonoperative treatment. RESULTS Overall follow-up was 48% (96/200). Patients lacking follow-up were slightly older (P = 0.021) and less likely to be smokers (P = 0.013). Between patients with and without follow-up, there were no significant differences in pain score at initial visit, body mass index, or gender (P ≥ 0.40). The 96 patients for whom follow-up was obtained included 53 in the operative and 43 in the nonoperative groups. At baseline, there were no significant differences between these groups based on age, pain score, body mass index, smoking, or gender (P ≥ 0.25). Mean follow-up was 63 months for operative and 58 months for nonoperative patients (P = 0.20). The mean pain score at last follow-up improved significantly for operative and nonoperative patients (P < 0.001). At follow-up, operative and nonoperative groups did not differ significantly with regard to pain scores, Oswestry disability index, short form-12, or satisfaction scale. CONCLUSIONS Comparison of long-term outcomes for patients with back pain and concordant discography did not demonstrate a significant difference in outcome measures of pain, health status, satisfaction, or disability based on whether the patient elected for fusion or nonoperative treatment.

Distinguishing Pseudomeningocele, Epidural Hematoma, and Postoperative Infection on Postoperative MRI.

Study Design:Retrospective case series. Objective:To identify specific magnetic resonance imaging (MRI) characteristics of epidural fluid collections associated with infection, hematoma, or cerebrospinal fluid (CSF). Summary of Background Data:Interpretation of postoperative MRI can be challenging after lumbar fusion. The purpose of this study was to identify specific MRI characteristics of epidural fluid collections associated with infection, hematoma, or CSF. Methods:The study population includes consecutive patients between 2006 and 2010 who had MRIs performed within 2 weeks after elective surgery for evaluation of possible CSF fluid collection, hematoma, or infection. Patients with known previous infection (discitis/osteomyelitis) or inadequate MRIs were excluded from the study. Medical records were reviewed to determine the diagnosis (infection, hematoma, or pseudomeningocele) underlying the fluid collection. MRIs were retrospectively evaluated by a musculoskeletal radiologist and orthopedic spine attending who were blinded to the pathologic diagnosis for characteristics of the fluid collection. MRI characteristics include location of lesion: osseous involvement, disk location, anterior versus posterior versus anteroposterior, soft-tissue involvement, and iliopsoas involvement. Characteristics of the lesion include: volume of lesion, loculation, satellite lesions, multiple loci, destructive characteristics, and mass effect upon thecal sac. Enhancement was scored based upon the following variables: rim enhancement, smooth versus irregular, thin versus thick, heterogeneity, diffuse enhancement, nonenhancement, and rim thickness. General fluid collection intensity and complexity on T1, T2, and T1 postcontrast images was scored as high, medium, and low. The &khgr;2 test was used to compare the incidence of imaging characteristics between patient groups (infection, hematoma, and CSF). Results:Thirty-three patients were identified who met inclusion criteria. There were 13 (39%) with infection, 9 (27%) with hematoma, and 11 (33%) with CSF collection. Factors that were associated with infection were osseous involvement (R=0.392, P=0.024) and destructive characteristics (R=0.461, P=0.007). Factors that were correlated with hematoma include mass effect (R=0.515, P=0.002) and high T1-signal intensity (R=0.411, P=0.019), absence of thecal sac communication (R=−0.389, P=0.025), and absence of disk involvement (R=−0.346, P=0.048). Pseudomeningocele was associated with thecal sac communication (R=0.404, P=0.02), absence of mass effect (R=−0.48, P=0.005), low T1 signal (R=−0.364, P=0.04), and low T2 complexity (R=−0.479, P=0.005). Conclusion:Specific characteristics of the postoperative MRI can be used to distinguish infection from noninfectious fluid collections. The strongest predictors of infection were osseous involvement and destructive bony changes. Hematoma was associated with mass effect on the thecal sac, high T1-signal intensity, and absence of thecal sac communication and disk involvement. CSF collections were distinguished by absence of mass effect, low T2-signal complexity, low T1-signal intensity, and communication with the thecal sac.

Restoring Volar Tilt in AO Type C2 Fractures of the Distal Radius With Unilateral External Fixation

PURPOSE To determine whether unilateral external fixation using a staged multiplanar reduction technique restores anatomic volar tilt in a distal radius fracture model. METHODS We used radiographic images to obtain baseline measurements in 20 fresh-frozen cadaveric wrists. Through a standard dorsal approach to the radius, we performed osteotomies to simulate displaced AO/ASIF type C2 fractures. After placement of a unilateral external fixator, a stepwise technique of applying longitudinal traction followed by a volar translational maneuver was performed. Radiographic imaging was obtained after each step of the multiplanar reduction technique. RESULTS Standard longitudinal traction did not restore volar tilt angles to their baseline measurements. The addition of a volar translation maneuver had a significant effect on restoring baseline volar tilt. There was a statistically significant difference in volar tilt measurements between straight longitudinal traction and volar translation. Radial inclination, radial height, and ulnar variance did not differ significantly between longitudinal traction and the addition of volar translation. CONCLUSIONS A criticism of traditional external fixation is the inability of longitudinal ligamentotaxis to attain sagittal plane (volar tilt) reduction of the articular surface. This study demonstrates that a multiplanar reduction technique using unilateral external fixation devices on cadaveric distal radius fractures can achieve an acceptable reduction. CLINICAL RELEVANCE External fixation of distal radius fractures may be favorable in situations where soft tissue loss, wound contamination, and comorbid medical factors preclude the use of internal fixation techniques. A multiplanar reduction technique using a unilateral external fixation device may facilitate fracture reduction in acceptable alignment.

Management of Simple Clavicle Fractures by Primary Care Physicians

The clavicle is the most commonly fractured bone. Children with simple fractures are often referred to orthopedic surgeons by primary care physician to ensure adequate care. The objective of this study was to show that simple clavicle fractures have excellent outcomes and are within the scope of primary care physician’s practice. We performed a retrospective chart review of 16 adolescents with simple clavicle fractures treated with a sling. Primary outcomes were bony union, pain, and function. The patients with simple clavicle fractures had excellent outcomes with no complications or complaints of pain or restriction of their activities of daily living. The outcomes are similar whether treated by an orthopedic surgeon or a primary care physician. The cost to society and the patient is less when the primary care physician manages the fracture. Therefore, primary care physicians should manage simple clavicle fractures.

Utility of a long arm extension cast in management of pediatric fractures: A technique revisited

A long arm cast with the elbow extended is a useful but often forgotten technique to manage some pediatric fractures. Specifically, proximal forearm fractures of both the radius and ulna, olecranon fractures, flexion-type supracondylar fractures and type II Monteggia fractures are well managed in this manner. Although some of these fractures are seen infrequently, timely diagnosis and treatment are essential to prevent complications. In this article, we present a review of the evaluation and management of these fractures in children, and a description of the technique used to apply a long arm cast in extension.

Lyme Arthritis of the Pediatric Elbow: A Case Series

Most patients with untreated Lyme disease will experience joint symptoms. Owing to their resemblance in clinical presentation, Lyme arthritis and septic arthritis are often difficult to differentiate. However, their treatment is different. The elbow is rarely the first joint to present with symptoms. Therefore, Lyme disease is not commonly included in the differential diagnosis for children presenting with isolated elbow pain. The authors report 4 cases of monoarticular Lyme arthritis presenting in the elbow. There was an average delay of diagnosis of 4.75 days. Three cases were treated with oral antibiotics alone; 1 case was treated with unnecessary surgery due to uncertainty of the diagnosis and the delay in the laboratory performing the Lyme serology tests. The authors strongly recommend that Lyme serology be performed on an emergent basis to prevent unneeded surgery. [Orthopedics. 2018; 41(4):e511-e515.].

Dry Catheter Technique in Shoulder Arthroplasty

Introduction Interscalene regional anesthesia is effective for pain management but is not without complications. To determine whether postoperative neurologic findings were related to the surgery versus the regional catheter, we developed the dry catheter technique where patients could be examined after the surgery prior to dosing the catheter. The purpose of the study was to assess the utility of the dry catheter block in recognizing neurological deficits associated with regional anesthesia. Methods An interscalene catheter was placed but not started. After the surgery, a neurovascular examination was performed. If the examination was normal, the regional anesthesia was started. Throughout the patient’s hospitalization, pain levels were collected. Results A total of 125 shoulders were studied. There were 9 postoperative nerve-related complications. The patients experienced the most pain relief in the first 12 hours. Conclusion The dry catheter technique allows differentiation between complications associated with regional anesthesia versus those associated with the surgery. Although interscalene anesthesia provided effective pain control, we stopped using it because we felt its complication rate was too high.

Self-Reported Outcomes for Patients Undergoing Revision Carpal Tunnel Surgery With or Without Hypothenar Fat Pad Transposition

Background: Carpal tunnel surgery is the most common surgical procedure performed on the hand. Although complications are rare, recurrent or persistent carpal tunnel syndrome can be a significant problem after primary decompression. Various procedures have been described for the treatment of these patients including repeat decompression and hypothenar fat pad transposition. The purpose of this study is to compare the outcomes of patients undergoing revision carpal tunnel decompression with and without hypothenar fat pad transposition. Methods: We performed a retrospective review of all patients undergoing revision carpal tunnel surgery at our institution between 2002 and 2014. Identified patients were contacted by telephone. A Boston Carpal Tunnel Questionnaire (BCTQ) was administered to all participants. Results: Seventy-six patients underwent revision carpal tunnel surgery over the study period. Twenty-nine of 45 potential participants provided a survey response (64.9%) representing a total of 33 carpal tunnel revision surgeries. Seventeen hands underwent repeat decompression alone, and 16 hands underwent repeat decompression with hypothenar fat pad transposition. A trend toward improved overall BCTQ score was noted for patients undergoing decompression alone; however, no significant difference was determined for total survey score by procedure type. Similarly, total symptom severity and functional scores were not statistically significant between groups; however, a trend toward significance for improved symptom severity score was observed in patients undergoing decompression alone. Conclusions: Our results reveal no difference in self-reported symptom severity and functional scores between patients undergoing revision carpal tunnel surgery with repeat decompression alone or decompression with fat pad transposition.

Complex clavicle fractures in children: Kids are not little adults

Background The clavicle is the most commonly fractured bone in the body and accounts for 10–15% of all pediatric fractures. Adult patients with complete midshaft clavicle fractures often undergo surgical management. Pediatric patients have a thicker periosteum, more robust blood supply and a greater healing potential. Controversy exists as to whether to treat adolescents with surgery similar to adults versus with a sling as children are treated. Some orthopaedic surgeons are now operating on adolescent clavicle fractures. Objective The objective of the study was to evaluate the outcomes of displaced midshaft clavicle fractures in adolescent who were treated conservatively with a sling. Methods We performed a retrospective chart review of 25 pediatric patients aged 12–16 with complete midshaft clavicle fracture. The outcomes of the study were bony union and functional outcomes such as pain, problems with ADL measured by the modified Disability of Arm, Shoulder, and Hand (DASH) score. Results All patients in our cohort had excellent outcomes at follow-up visits with no complaints of pain or limitations of activities of daily living. Mean follow-up time was 12 months. All patients had perfect modified DASH score of 18. Injury radiographs demonstrated an average of 13 mm shortening initially and 8 mm shortening in final follow-up. Average fracture angulation at final follow-up was 15°. Normal clavicle angulation at the mid shaft is 8°. All clavicles healed completely with no case of malunion or non-union reported. Conclusion Clavicle fractures are common. Although operative treatment of clavicle fractures in the adult population is gaining popularity due to issues in adults with non-union and malunion, the adolescent population is different. The adolescent clavicle fracture demonstrates robust healing and remodeling and complete return to full function. We therefore recommend that adolescent patients aged 12–16 with complete clavicle fracture be treated conservatively with a sling.