Nathaniel C. Wingert

Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture.

OBJECTIVE Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application. METHODS From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded. RESULTS The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage. CONCLUSIONS The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.

Sonication of Antibiotic Spacers Predicts Failure during Two-stage Revision for Prosthetic Knee and Hip Infections

BackgroundPeriprosthetic joint infection is a leading cause of failure after two-stage reimplantation. One cause of relapse may be persistent subclinical infection. Difficulty exists in detecting biofilm-forming infections. Sonication disrupts biofilm and has led to higher rates of positive intraoperative cultures.Questions/purposesOur aims in this study were to determine (1) if sonication results were predictive of failure, including reinfection, at 2-year followup; and (2) whether sonication of antibiotic spacers at the time of reimplantation improves sensitivity of intraoperative cultures.MethodsWe prospectively followed 36 consecutive patients undergoing two-stage reimplantation for periprosthetic hip or knee infection. Minimum followup was 19 months (mean, 29.9 months; range, 19–38 months). Results of intraoperative cultures and sonicated antibiotic spacers were analyzed.ResultsPositive sonication results were predictive of failure as defined by reinfection at 2-year followup. Among the 18 patients who had positive sonication results, reinfection developed in nine patients (50%) compared with two of 18 patients (11%) with negative sonication results (odds ratio, 8.0; 95% CI, 1.2–69.0). Sonication of antibiotic spacers improved the sensitivity of intraoperative cultures from 36% to 82%.ConclusionsSonication of antibiotic spacers appears to be useful in predicting failure attributable to recurrent infection after two-stage reimplantation. For patients with positive sonication cultures during reimplantation, more aggressive antimicrobial treatment may be indicated after reimplantation.Level of EvidenceLevel III, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

The ACS NSQIP Risk Calculator Is a Fair Predictor of Acute Periprosthetic Joint Infection

BackgroundPeriprosthetic joint infection (PJI) is a severe complication from the patient’s perspective and an expensive one in a value-driven healthcare model. Risk stratification can help identify those patients who may have risk factors for complications that can be mitigated in advance of elective surgery. Although numerous surgical risk calculators have been created, their accuracy in predicting outcomes, specifically PJI, has not been tested.Questions/Purposes(1) How accurate is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Site Infection Calculator in predicting 30-day postoperative infection? (2) How accurate is the calculator in predicting 90-day postoperative infection?MethodsWe isolated 1536 patients who underwent 1620 primary THAs and TKAs at our institution during 2011 to 2013. Minimum followup was 90 days. The ACS NSQIP Surgical Risk Calculator was assessed in its ability to predict acute PJI within 30 and 90 days postoperatively. Patients who underwent a repeat surgical procedure within 90 days of the index arthroplasty and in whom at least one positive intraoperative culture was obtained at time of reoperation were considered to have PJI. A total of 19 cases of PJI were identified, including 11 at 30 days and an additional eight instances by 90 days postoperatively. Patient-specific risk probabilities for PJI based on demographics and comorbidities were recorded from the ACS NSQIP Surgical Risk Calculator website. The area under the curve (AUC) for receiver operating characteristic (ROC) curves was calculated to determine the predictability of the risk probability for PJI. The AUC is an effective method for quantifying the discriminatory capacity of a diagnostic test to correctly classify patients with and without infection in which it is defined as excellent (AUC 0.9–1), good (AUC 0.8–0.89), fair (AUC 0.7–0.79), poor (AUC 0.6–0.69), or fail/no discriminatory capacity (AUC 0.5–0.59). A p value of < 0.05 was considered to be statistically significant.ResultsThe ACS NSQIP Surgical Risk Calculator showed only fair accuracy in predicting 30-day PJI (AUC: 74.3% [confidence interval {CI}, 59.6%–89.0%]. For 90-day PJI, the risk calculator was also only fair in accuracy (AUC: 71.3% [CI, 59.9%–82.6%]). Conclusions The ACS NSQIP Surgical Risk Calculator is a fair predictor of acute PJI at the 30- and 90-day intervals after primary THA and TKA. Practitioners should exercise caution in using this tool as a predictive aid for PJI, because it demonstrates only fair value in this application. Existing predictive tools for PJI could potentially be made more robust by incorporating preoperative risk factors and including operative and early postoperative variables.Level of EvidenceLevel III, diagnostic study.

Clinical Outcomes of Endoscopic Carpal Tunnel Release in Patients 65 and Over

PURPOSE To examine outcomes of endoscopic carpal tunnel release (ECTR) in patients 65 and older. We hypothesized that this population could expect relief of pain, night pain/numbness, and numbness. METHODS A retrospective review was conducted of all patients 65 years of age and over who had ECTR for nerve conduction study-confirmed carpal tunnel syndrome (CTS) from October 2007 to July 2010. The charts were reviewed for demographic data, symptoms and physical findings, patient satisfaction, and 3 patient-reported outcome scores. Preoperative and postoperative results for pain, night pain/numbness, and numbness were compared. Logistic regression analysis was used to assess whether age influenced symptom resolution. Boston carpal tunnel, Short Form-36 and Disabilities of the Arm, Shoulder, and Hand scores were compared between patients with mild, moderate, or severe CTS. RESULTS A total of 78 patients had ECTR. Their ages ranged from 65 to 93 years (mean, 73 y). Before surgery 69% of patients had constant numbness. Night pain/numbness was present in 65 patients before surgery, and 61 had complete resolution. All 70 patients who presented with pain reported complete relief by the 6-month follow-up. Following ECTR, the average Boston carpal tunnel symptom severity, functional status, and Disabilities of the Arm, Shoulder, and Hand scores were 1.5,1.5, and 13, respectively. At final evaluation, 79% of patients were very satisfied or satisfied with their outcome. A significant number of patients were found to have improvement in pain, night pain/numbness, and numbness following ECTR. CONCLUSIONS This study has demonstrated relief of symptoms in a statistically significant number of patients following ECTR. We found that preoperative CTS severity, based on nerve conduction study result, did not significantly correlate with patient outcome following ECTR. Advanced symptoms at presentation do not preclude symptom resolution and should not be a contraindication to ECTR. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Serotonin Reuptake Inhibitors and Bleeding Risks in Major Orthopedic Procedures

BACKGROUND Risk of abnormal bleeding in surgery patients prescribed serotonin reuptake inhibitors (SRIs) is unclear. Considering the quantity of literature on abnormal gastrointestinal (GI) bleeding with SRIs, relatively little exists on SRI bleeding risks in surgical procedures. We investigated whether SRIs increase the risk of surgical bleeding in patients undergoing knee and hip total joint replacement. METHODS RA retrospective case-control study was conducted among subjects undergoing primary total hip and knee replacement surgeries from January 2005 to March 2011 at a single institution. The experimental group was defined by utilization of SRIs at the time of surgery (the independent variable). The control group was matched for age, sex, ethnicity, and type of surgery (hip or knee). Any case with preoperative hematocrit <30, platelets <100,000; abnormal prothrombin time, partial-prothrombin time, and international normalized ratio (INR), primary bleeding disorder, medical conditions, or medications associated with increased bleeding was excluded. All cases were randomly selected. RESULTS RA total of 194 subjects (hip 104, knee 90) were included. Statistical analysis was performed on the SRI group (n = 71) and the control, non-SRI group (n = 123). No difference was found between the groups in estimated blood loss, hemoglobin, hematocrit, platelets, PT, PTT, and INR from preoperative to postoperative day 1, 2, and 3. Furthermore, no subjects in either group required blood transfusions. CONCLUSION SRIs were not associated with increased risk of bleeding in primary knee or hip replacement surgeries in this study. The hypothesis that SRIs increase the risk of bleeding based on presumptions about their action on platelet aggregation is uncertain and warrants further study.

Single-incision lateral approach for triple arthrodesis.

Background: Triple arthrodesis is a powerful hindfoot corrective procedure involving fusion of the talonavicular (TN), calcaneocuboid (CC), and subtalar (ST) joints. A 2-incision approach, a single-incision medial triple arthrodesis, and a single-incision medial double arthrodesis are well described. We present a single-incision lateral approach to triple arthrodesis. Methods: We retrospectively reviewed 70 patients who underwent triple arthrodesis at our institution from 2007 to 2011. Patients had either double-incision (n = 33) or single-incision lateral (n = 37) triple arthrodesis. A single surgeon performed all procedures. The most common diagnosis was stage III planovalgus deformity. Deformity correction, union rate, time of surgery, complications, wound healing, reoperations, and pre- and postoperative visual analog scale (VAS) pain scores were analyzed for both groups. Results: There were no statistical differences in deformity correction, wound healing, complications, reoperations, or improvement in VAS pain scores. Operation time was significantly shorter in the single-incision lateral group (86 minutes vs 95 minutes, P = .0395). There was no difference in union rates with regard to the TN, ST, or CC joints. Five patients had radiographic nonunions of the CC joint between both groups. Conclusions: This is the first study that presents outcomes of a single lateral approach for triple arthrodesis. The single-incision approach was faster. The low rate of symptomatic nonunions suggests that fusion of the CC joint may not be important in symptomatic relief or deformity correction. Level of Evidence: Level III, retrospective comparative study.

Role of Sonication for Detection of Infection in Explanted Orthopaedic Trauma Implants.

Objectives: Sonication is a new technology that uses high-frequency sound waves to mechanically dislodge bacteria adherent in biofilms. Unlike arthroplasty, its role in orthopaedic trauma has not been described. The goal of this study was to explore the utility of sonication in orthopaedic trauma. Design: Retrospective review. Setting: Level I trauma center. Patients: One hundred forty-six sonicated metallic orthopaedic devices from September 2010 to May 2013 were included. Patients were divided into 3 groups: clinically infected, elective implant removals, and nonunion. Intervention: Sonication culture results were retrospectively reviewed for all patients undergoing implant removal. Outcomes: Sonication results were the primary study outcome and were considered positive for culture growth if equal to or greater than 20 colony-forming units per plate. Results: In 32 patients with clinical infection, tissue cultures were positive in 30 (94%) and negative in 2 (6%). In contrast, sonication cultures were positive in 19 patients (59%) and did not identify additional organisms. Of the 72 patients who underwent elective implant removal, 52 had pain. Sonication cultures were positive in 5 of these 52 patients (10%) and in 0 of 20 patients with no pain. Sonication culture results were negative in all 42 patients who underwent nonunion surgery. Conclusions: Sonication of orthopaedic trauma implants in patients with clinically apparent infection or “aseptic” nonunion offered negligible additional information. Sonication demonstrated a positive microbiologic yield in a subset of patients with painful implants; further research is required to better establish the frequency of subclinical infection and to determine the diagnostic role of traditional cultures and sonication. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Recurrent synovial chondromatosis of the wrist: a case report of 13-years ongoing disease

S ynovial chondromatosis is an uncommon condition in which joint synovial tissues undergo metaplastic cartilage formation. Typically, a benign, monoarticular, self-limiting process, synovial chondromatosis most commonly affects large joints with a predilection for the knee. Rare instances of hand and wrist involvement exist, reported as 2% of all cases. Disease recurrence after excision has been sporadically documented in the wrist. Symptomatic peripheral nerve compression at the wrist associated with synovial chondromatosis has been reported in five patients. We describe a patient with synovial chondromatosis of the wrist, with 13 yr of ongoing disease. Established treatment principles, namely excision of pathologic synovium and tumor, have failed to definitively rid this patient of disease. Informed consent was obtained from the patient.