John M. Bednar

Prosthetic nerve grafts: A resorbable tube as an alternative to autogenous nerve grafting

The use of a prosthetic nerve graft, composed of a resorbable polyorthoester tube, as an alternative to free autogenous nerve grafting for the treatment of a gap in a peripheral nerve was studied, with a cat sciatic nerve as the model. The results demonstrate that regeneration will occur through a resorbable tube spanning a 1.5 cm gap and reinnervate end organ muscle. In those muscles showing evidence of reinnervation, nerve regeneration through the tubes as assayed by electrophysiologic examination demonstrated no difference compared with autogenous nerve grafts, with the exception that the initial rate of regeneration was delayed by 4 to 6 weeks.

Workers compensation. Effect of state law on treatment cost and work status.

Workers compensation legislation is regulated at a state level resulting in different benefits based on the state of employment. The negative effect of workers compensation on the results of surgical treatment has been established previously. A comparison of the results of treatment of patients receiving workers compensation from different states has not been reported. This study prospectively evaluated the effect of the difference in state workers compensation laws on the number of postoperative visits, amount of postoperative therapy, time off from work, and return to work status. The study group consisted of 275 patients. The results indicated a significant increase in the number of postoperative visits, amount of therapy, time off from work, and number of patients who remained out of work in the compensation versus the noncompensation group. A significant increase in these parameters also was present in the Pennsylvania compensation group as compared with the New Jersey compensation group. This study shows that differences in workers compensation benefits have a significant effect on the results of medical treatment, return to work status, and the cost of medical care.

Dynamic computerized tomography of the occiput-atlas-axis complex in trauma patients with odontoid lateral mass asymmetry

Over a 23-month period, 25 patients aged 11 to 74 years presented to our Level I trauma center with odontoid lateral mass asymmetry of 2 to 5 mm on properly centered AP open-mouth X-rays: 32% of patients were asymptomatic, 68% had cervical pain, and 32% had limited range of motion. Patients with cervical spine fractures or dislocations and those with fixed deformity were excluded. The clinical significance of asymmetry was determined utilizing dynamic axial CT scanning of the occiput (C0), atlas (C1) and axis (C2) with the head neutral and with 15 degrees to 30 degrees active rotation. Nineteen patients demonstrated greater than 5 degrees of relative motion of C1 on C2 bilaterally. Three patients had less than 5 degrees of relative motion bilaterally and three patients had less than 5 degrees relative motion with left rotation only. No patient had formal treatment and all had nearly normal cervical range of motion on clinical examination at the time of hospital discharge. The finding of an asymmetric odontoid-lateral mass interspace on properly centered open-mouth AP X-rays in the presence of otherwise normal cervical spine X-rays, in conscious patients without fixed deformity, appears to be incidental and requires no further evaluation or treatment.

Lunatocapitate and Triquetrohamate Arthrodeses for Degenerative Arthritis of the Wrist

PURPOSE Proximal row carpectomy and 4-corner arthrodesis are 2 well-established motion-preserving treatment strategies for scapholunate advanced collapse. In this study, we present an arthrodesis technique involving the capitolunate and triquetrohamate joints as another potential treatment option. METHODS From 2000 to 2009, 27 consecutive patients with degenerative scapholunate advanced collapse and scaphoid nonunion advanced collapse were evaluated prospectively and treated with scaphoid excision and intercarpal arthrodesis between the capitate and lunate and between the hamate and triquetrum. This cohort consisted of 18 men and 9 women, involving dominant-sided surgery in 20 of 27 patients. Two patients were active smokers, and 3 cases were work related. Average age at time of surgery was 55 ± 3 years, and average follow-up was 51 ± 7 months. Preoperative and postoperative range of motion, grip strength, and radiographic evidence of osseous union were documented. Standardized Patient-Rated Wrist Evaluation scores for both pain and function were collected. RESULTS Wrist extension and flexion were decreased after surgery by 17% and 25% respectively, yielding a 21% decrease in mean flexion-extension arc. There was no significant difference with regard to postoperative radial and ulnar deviation or mean coronal plane arc compared to preoperative values. Compared to the contralateral side, preoperative and postoperative grip strength were 53% and 70%, respectively. The average operative-sided grip strength increased by 27%. The mean Patient-Rated Wrist Evaluation pain score was 11 ± 3 (of 50). The mean Patient-Rated Wrist Evaluation functional score was 17 ± 5 (of 100). Complications included 1 nonunion (yielding a 96% fusion rate), 1 median neuropathy (which resolved), and 2 superficial wound infections (treated successfully with oral antibiotics). CONCLUSIONS Arthrodesis of the capitolunate and triquetrohamate joints offers a motion-preserving strategy with a high union rate and good clinical function and pain outcomes for the treatment for scapholunate advanced collapse and scaphoid nonunion advanced collapse. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Bipolar femoral endoprosthesis: a study correlating component movement with clinical outcome.

Fifty-five bipolar femoral hemiarthroplasties performed between January 1979 and February 1986 were reviewed to correlate component movement with clinical outcome. Fourteen of these patients were examined clinically using the Harris Hip Score and radiographically by the method of Drinker and Murray to determine the per cent of total motion in abduction present at the inner bearing surface. The average followup was 19.7 months. The data demonstrate that the clinical result is related to inner bearing motion. The inner bearing motion is significantly decreased by weight bearing and may be influenced by the size of the femoral component.

Arthroscopic Repairs of Triangular Fibrocartilage Complex Tears

Technical advancements in arthroscopic wrist procedures have improved our knowledge of normal and abnormal intraarticular wrist function. Triangular fibrocartilage complex (TFCC) tears from trauma injuries are a common source of ulnar-sided wrist pain. Fortunately, the TFCC is a structure that can be evaluated and treated arthroscopically with results that are comparable to open surgical procedures. Successful arthroscopic repairs of TFCC tears depend on a coordinated team effort between perioperative nurses, orthopedic surgeons, nurse practitioners, and occupational hand therapists, as well as cooperation from patients and family members. This article reviews the anatomy and physiology of the TFCC, the biomechanics of the wrist and mechanisms of injury, and arthroscopic repairs of TFCC tears.

Acute Scapholunate Ligament Injuries: Arthroscopic Treatment

Wrist arthroscopy is an effective technique for treating acute scapholunate instability. It allows an accurate assessment of the degree and extent of the ligament injury. Partial injuries are effectively treated with arthroscopic debridement and electrothermal ligament tightening. Complete ligament injuries treated arthroscopically allow direct visualization of the torn ligament and assessment of the degree of scaphoid displacement and rotation. The use of arthroscopy allows a more accurate reduction of the scaphoid and lunate at the time of fixation than can be obtained using just fluoroscopy.

Lessons in flying: crew resource management as a quality improvement method for acute coronary syndromes care.

Providing timely, high-quality, guideline-based care to patients with acute coronary syndromes (ACS) who present to the emergency department is critically dependent on cooperation, coordination, and communication between emergency medicine physicians and cardiologists. However, to achieve sustained improvement at the individual institution level, consistent implementation of quality improvement (QI) activities is needed. We describe a QI initiative for ACS care in the emergency setting that combined clinical education with a curriculum based on crew resource management (CRM) principles-a set of tools and techniques for communication, teamwork, and error avoidance used in the aviation industry and with proven applicability in the healthcare setting. Educational training sessions were open to multidisciplinary healthcare teams at 3 hospital sites, and participants were provided practical tools and resources to enhance communication, teamwork, and patient-centered care. Through patient chart reviews, participant surveys, and clinician interviews, baseline assessments of clinical performance measures and team communication-, logistics-, and skills-based efficiencies were performed and reported before the educational training was delivered at each QI site. Reviews of pre- and postinitiative participant surveys demonstrated improvement in knowledge and confidence in the delivery of appropriate and effective ACS care; however, reviews of pre- and postinitiative patient charts revealed limited process improvements. Altogether, this multicenter study of a continuing medical education program based on CRM principles was associated with improvements in provider knowledge and confidence regarding the delivery of appropriate ACS care, but had limited impact on clinical performance measures.

Gentamicin-induced ototoxicity complicating treatment of chronic osteomyelitis.

Ototoxicity, though a significant disabling complication of aminoglycoside antibiotic therapy, is monitored infrequently. Chronic osteomyelitis patients treated with an aminoglycoside are in a group at higher risk due to the length of therapy and large total dose of drug required for treatment. Serum levels of gentamicin should be maintained within therapeutic ranges but below toxic levels. Gentamicin ototoxicity is vestibular in two thirds of patients and cochlear in one third. One half of the patients with cochlear toxicity also have vestibular symptoms. Symptoms are often vague, insidious in onset, and masked by the critical presentation of the primary infectious process. Symptoms may occur immediately upon initiation of therapy, any time during the course of treatment, or after administration has been completed. The development of toxicity should be monitored on a regular basis by specifically asking the patient whether there has been any subjective hearing loss, ear fullness, tinnitus, or vertigo supplemented by pretreatment and follow-up audiogram and electronystagmogram (ENG). Therapy should be discontinued at the first sign of alteration of cochlear or vestibular function. Ototoxic recovery occurs in only about 50% of the patients affected.

Internal Fixation of Distal Metacarpal Fractures: New Uses for an Old Plate

Certain metacarpal fracture patterns require operative fixation to restore anatomy and optimize results. Compared with dorsal plating, the width of the minicondylar blade plate buttresses the deforming volar pull of the intrinsics and provides a stronger construct. The implant provides firm fixation in the juxta-articular fragment with minimal space requirements. Therefore, the purpose of this study was to examine the outcomes following the use of a minicondylar blade plate for the treatment of distal metacarpal fractures. Twenty-two distal metacarpal fractures in 20 patients treated with a minicondylar blade plate were retrospectively reviewed. Outcome measures collected included postoperative grip strength, range of motion, return to work, and radiographic evidence of osseous union. Average range of motion of the metacarpophalangeal joint was 62° postoperatively. Eighty-two percent (18/22) of fractures were able to flex their digits to their distal palmar crease. Seventy-one percent (12/17) of patients had at least 75% return to grip strength compared with the contralateral side. Seventeen patients returned to full activity at a mean of 2.5 months (range, 1-3 months) postoperatively; 1 patient was on disability, and data were not available for the final 2 patients. No major complications occurred. The minicondylar blade plate is a safe and effective technique for stabilizing unstable periarticular metacarpal fractures. Stable fixation allows for early range of motion, rapid return to strength, and a relatively quick return to full work duty.