Garet C. Comer

Cancer risk after use of recombinant bone morphogenetic protein-2 for spinal arthrodesis.

BACKGROUND Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a growth factor known to have in vitro effects on the growth and invasiveness of cancer. It has been approved by the U.S. Food and Drug Administration in limited doses for single-level anterior spinal arthrodesis, but it is commonly used off-label and at high doses. The effect of rhBMP-2 on the risk of cancer has been a concern. We sought to evaluate the risk of new cancers in patients receiving high-dose rhBMP-2. METHODS We used publicly available data from a pivotal, multicenter, randomized controlled trial of patients with degenerative lumbar spine conditions who underwent a single-level instrumented posterolateral arthrodesis with either high-dose rhBMP-2 in a compression-resistant matrix (CRM) (rhBMP-2/CRM; n = 239) or autogenous bone graft (control group; n = 224). We compared the risks of new cancers in the rhBMP-2/CRM and control groups at two and five years after surgery. RESULTS At two years, with 86% follow-up, there were fifteen new cancer events in eleven patients in the rhBMP-2/CRM group compared with two new cancer events in two patients in the control group treated with autogenous bone graft. The incidence rate of new cancer events per 100 person-years was 3.37 (95% confidence interval [CI], 1.89 to 5.56) in the rhBMP-2/CRM group at two years compared with 0.50 (95% CI, 0.06 to 1.80) in the control group. The incidence rate ratio was 6.75 (95% CI, 1.57 to 60.83; p = 0.0026) at two years. Calculated in terms of the number of patients with one or more cancer events two years after the surgery, the incidence rate per 100 person-years was 2.54 (95% CI, 1.27 to 4.54) in the rhBMP-2/CRM group compared with 0.50 (95% CI, 0.06 to 1.82) in the control group at two years; the incidence rate ratio was 5.04 (95% CI, 1.10 to 46.82; p = 0.0194). At five years, there was a 37% loss of follow-up, but a significantly greater incidence of cancer events was still observed in the rhBMP-2/CRM group. CONCLUSIONS A high dose of 40 mg of rhBMP-2/CRM in lumbar spinal arthrodesis was associated with an increased risk of new cancer.

Local bone graft harvesting and volumes in posterolateral lumbar fusion: a technical report

BACKGROUND CONTEXT In lumbar surgery, local bone graft is often harvested and used in posterolateral fusion procedures. The volume of local bone graft available for posterolateral fusion has not been determined in North American patients. Some authors have described this as minimal, but others have suggested the volume was sufficient to be reliably used as a stand-alone bone graft substitute for single-level fusion. PURPOSE To describe the technique used and determine the volume of local bone graft available in a cohort of patients undergoing single-level primary posterolateral fusion by the authors harvesting technique. STUDY DESIGN Technical description and cohort report. PATIENT SAMPLE Consecutive patients undergoing lumbar posterolateral fusion with or without instrumentation for degenerative processes. OUTCOME MEASURE Local bone graft volume. METHODS Consecutive patients undergoing lumbar posterolateral fusion with or without instrumentation for degenerative processes of were studied. Local bone graft was harvested by a standard method in each patient and the volume measured by a standard procedure. RESULTS Twenty-five patients were studied, and of these 11 (44%) had a previous decompression. The mean volume of local bone graft harvested was measured to be 25 cc (range, 12-36 cc). Local bone graft was augmented by iliac crest bone in six of 25 patients (24%) if the posterolateral fusion bed was not well packed with local bone alone. There was a trend to greater local bone graft volumes in men and in patients without previous decompression. CONCLUSION Large volumes of local bone can be harvested during posterolateral lumbar fusion surgery. Even in patients with previous decompression the volume harvested is similar to that reported harvested from the posterior iliac crest for single-level fusion.

Hand Therapy Modalities for Proximal Interphalangeal Joint Stiffness

ASSH Disclaimer: The material presented in this CME activity is mad ASSH for educational purposes only. This material is not intended to methods or the best procedures appropriate for the medical situation rather it is intended to present an approach, view, statement, or opinion may be helpful, or of interest, to other practitioners. Examinees agree to medical education activity, sponsored by the ASSH, with full knowledge a they waive any claim they may have against the ASSH for reliance o presented. The approval of the US Food and Drug Administration is requ and drugs that are considered experimental. Instrumentation systems dis during this educational activity may not yet have received FDA approv

Management of Complications of Congenital Hand Disorders

This article reviews treatment and presents complications seen in the treatment of 7 common congenital hand differences, including syndactyly, camptodactyly, ulnar and radial polydactyly, thumb hypoplasia, radial longitudinal deficiency, and epidermolysis bullosa. The management of these conditions is challenging but has evolved over the last several decades with refined understanding of the disease processes and treatments. The goal of this article is to synthesize prior knowledge and provide further insights into these conditions that will help the surgeon avoid treatment complications.

Instability after reverse total shoulder arthroplasty

BACKGROUND This study evaluated patients with and without a prosthetic dislocation after reverse total shoulder arthroplasty (RTSA) to identify risk factors for instability. METHODS Dislocation and nondislocation cohorts were established for analysis in 119 patients who had undergone RTSA at our institution between 2011 and 2014. Preoperative history and parameters pertaining to RTSA design were evaluated for correlation with instability. A logistic regression model was used to analyze independent predictors. RESULTS Eleven patients (9.2%) demonstrated instability in the early postoperative period. Dislocations occurred at an average of 8 weeks postoperatively (range, 3 days-5 months). The mean follow-up of all patients was 28 months (range, 6-106 months). Postoperative instability was associated with male gender, history of prior open shoulder surgery, and preoperative diagnoses of fracture sequelae, particularly proximal humeral or tuberosity nonunion. Absence of subscapularis repair was an independent predictor of instability. In addition, 5 of the 11 patients (45%) in the instability cohort sustained a second dislocation requiring another operation. CONCLUSIONS Redislocation after revision surgery for the initial dislocation was an unexpected and alarming finding. Treatment for the initial dislocation event by placement of a thicker polyethylene insert was inadequate in 45% of patients of our cohort and required another revision with a larger glenosphere and thicker humeral inserts. Initial instability after RTSA must be carefully managed, especially in the revision and post-traumatic setting. Exchange to a thicker polyethylene insert only carries a higher risk of recurrent instability.

Simultaneous bilateral resection total shoulder arthroplasty with anatomic antibiotic cement spacer retention

Periprosthetic shoulder infection (PSI) is a challenging problem that may lead to shoulder pain, dysfunction, and even death. The reported incidence of infection after shoulder arthroplasty ranges from 0% to 4%.7,14,16 Recent developments have improved our ability to diagnose and to treat this condition. To date, there is no consensus on the optimal treatment of patients with PSI. To our knowledge, no reports of simultaneous bilateral resection total shoulder arthroplasty (TSA) and cement spacer placement exist in the literature. We report one such case with a 25-month follow-up.

A Biomechanical Comparison of Shape Design and Positioning of Transforaminal Lumbar Interbody Fusion Cages

Study Design Cadaveric biomechanical analysis. Objective The aim of this study was to compare three interbody cage shapes and their position within the interbody space with regards to construct stability for transforaminal lumbar interbody fusion. Methods Twenty L2–L3 and L4–L5 lumbar motion segments from fresh cadavers were potted in polymethyl methacrylate and subjected to testing with a materials testing machine before and after unilateral facetectomy, diskectomy, and interbody cage insertion. The three cage types were kidney-shaped, articulated, and straight bullet-shaped. Each cage type was placed in a common anatomic area within the interbody space before testing: kidney, center; kidney, anterior; articulated, center; articulated, anterior; bullet, center; bullet, lateral. Load-deformation curves were generated for axial compression, flexion, extension, right bending, left bending, right torsion, and left torsion. Finally, load to failure was tested. Results For all applied loads, there was a statistically significant decrease in the slope of the load-displacement curves for instrumented specimens compared with the intact state (p < 0.05) with the exception of right axial torsion (p = 0.062). Among all instrumented groups, there was no statistically significant difference in stiffness for any of the loading conditions or load to failure. Conclusions Our results failed to show a clearly superior cage shape design or location within the interbody space for use in transforaminal lumbar interbody fusion.

Reconstruction of the Unsalvageable Proximal Pole in Scaphoid Nonunions Utilizing Rib Osteochondral Autograft

The patient was a 19-year-old right-hand-dominant collegiate football lineman who sustained a left scaphoid proximal pole fracture during a game. He was treated with closed reduction and percutaneous fixation with placement of a cannulated headless compression screw (Mini-Acutrak 2, Acumed, Hillsboro, OR). Postoperative radiographs demonstrated maintained reduction and appropriate fixation of the compression screw. Five months after surgery, the patient noted resolution of pain, excellent range of motion, and apparent radiographic union. He was allowed to return to sport, but subsequently reported pain with wrist motion and lifting that limited his functional ability.