Ross Feller

Nail Dynamization for Delayed Union and Nonunion in Femur and Tibia Fractures

Femoral and tibial shaft fractures are common injuries in the United States. Since their introduction, reamed intramedullary nails have become the treatment of choice for most of these fractures. However, delayed union and nonunion can complicate treatment in up to 10% of patients. Removal of interlocking screws, or dynamization, can promote fracture healing in cases of delayed union or nonunion. The efficacy of nail dynamization has been reported to range from 19% to 82%. This study was conducted to evaluate the efficacy of dynamization, identify the factors associated with its success or failure, and analyze the cost compared with exchange nailing. The authors retrospectively reviewed charts from 2011 to 2014 and searched billing records for Current Procedural Terminology codes 27506 and 27759, for intramedullary nailing of femoral and tibial shaft fractures, and code 20680, for removal of deep hardware. This search identified 34 patients with 35 fractures treated with dynamization for delayed union or nonunion. Dynamization was effective in creating union in 54% of patients. The factor that best correlated with the success of dynamization was the diameter of the fracture callus at the time of dynamization. Direct costs associated with dynamization were nearly

Atypical Fractures of the Femur: Evaluation and Treatment

10,000 less than those associated with exchange nailing. Dynamization can be an effective first-line treatment for delayed union and nonunion of femoral and tibial shaft fractures. The union rate in the current study is similar to previously published rates, and cost data suggest that dynamization is a viable alternative to exchange nailing for some patients with delayed union or nonunion. [Orthopedics. 2016; 39(6):e1117-e1123.].

Examination of cervical spine kinematics in complex, multiplanar motions after anterior cervical discectomy and fusion and total disc replacement

Bisphosphonates are widely used as a primary treatment modality for osteoporosis. These agents prevent bone resorption via both the inhibition of osteoclast function and the promotion of osteoclast apoptosis1,2. The Fracture Intervention Trial Research Group investigated the effectiveness of bisphosphonates for the reduction of fragility fractures of the hip, distal part of the radius, and vertebrae3. Their research demonstrated that, compared with calcium supplementation alone, bisphosphonates with calcium supplementation …

Degenerative Arthritis of the Hand and Wrist

Background The biomechanical behavior of total disc replacement (TDR) and anterior cervical discectomy and fusion (ACDF) incomplex multiplanar motion is incompletely understood. The purpose of this study was to determine whether ACDF or TDR significantly affects in vitro kinematics through a range of complex, multiplanar motions. Methods Seven human cervical spines from C4-7 were used for this study. Intact cervical motion segments with and without implanted TDR and ACDF were tested by use of unconstrained pure bending moment testing fixtures in 7 mechanical modes: axial rotation (AR); flexion/extension (FE); lateral bending (LB); combined FE and LB; combined FE and AR; combined LB and AR; and combined FE, LB, and AR. Statistical testing was performed to determine whether differences existed in range of motion (ROM) and stiffness among spinal segments and treatment groups for each mechanical test mode. Results ACDF specimens showed increased stiffness compared with the intact and TDR specimens (P < .001); stiffness was not found to be different between TDR and intact specimens. ACDF specimens showed decreased ROM in all directions compared with TDR and intact specimens at the treated level. For the coupled motion test, including AR, LB, and FE, the cranial adjacent level (C4/C5) for the intact specimens (2.7°) showed significantly less motion compared with both the TDR (6.1°, P = .009) and ACDF (6.8°, P = .002) treatment groups about the LB axis. Testing of the C4/C5 and C6/C7 levels in all other test modes yielded no significant differences in ROM comparisons, although a trend toward increasing ROM in adjacent levels in ACDF specimens compared with intact and TDR specimens was observed. Conclusions This study compared multiplanar motion under load-displacement testing of subaxial cervical motion segments with and without implanted TDR and ACDF. We found a trend toward increased motion in adjacent levels in ACDF specimens compared with TDR specimens. Biomechanical multiplanar motion testing will be useful in the ongoing development and evaluation of spinal motion–preserving implants.

Complex Regional Pain Syndrome

Degenerative arthritis (OA) of the hand and wrist is commonly encountered and can involve the interphalangeal, carpometacarpal (CMC), midcarpal, radiocarpal, and distal radioulnar articulations. In all cases of degenerative arthritis, it is key to assess the functional impairment and pain that a patient is experiencing when deciding treatment; one must not succumb to treating a patient based on a radiograph. Both the operative and nonoperative treatment options for these conditions are numerous. Nonoperative modalities include splinting, corticosteroid injections, and non-steroidal anti-inflammatories (NSAIDs). Surgical treatment options for interphalangeal (PIP, DIP) and metacarpophalangeal (MCP) joint OA arthritis include fusion and several athroplasty options. Similarly, there are a multitude of procedures for thumb CMC OA, with trapeziectomy with ligament reconstruction and tendon interposition (LRTI) being the most common. In terms of the radiocarpal joint, the student must be aware of the commonly encountered patterns of degenerative wrist OA, i.e., scapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC). Finally, the management of DRUJ OA includes several reconstructive options, which will be reviewed.

Rheumatoid Arthritis and Other Inflammatory Arthritides

Complex regional pain syndrome (CRPS) is a neuropathic disorder marked by pain, autonomic and vasomotor instability, and sensory abnormalities. Typically, the syndrome presents after surgery or trauma and is characterized by continuing pain which is disproportionate to the inciting event. Although some cases will resolve within the first year of presentation, many patients progress to a chronic form of the disease. CRPS type I (formerly known as reflex sympathetic dystrophy, or RSD) and CRPS II (formerly known as causalgia) are distinguished by the latter being associated with damage to a specific peripheral nerve. The diagnosis of CRPS is based mainly on history and physical examination. Multiple treatment options have been discussed in the literature, and some as discussed below show potential benefit. However, there is still no clear consensus regarding diagnosis and therapeutic algorithms.

Other Compressive Neuropathies

Although the end-stage sequelae of rheumatoid arthritis (RA) are nowhere near as frequently encountered since the advent of DMARDs (Disease Modulating Anti-Rheumatic Drugs), RA is still the most commonly encountered inflammatory arthropathy affecting the upper extremity. This is a disease marked by chronic synovitis and articular destruction, oftentimes accompanied by tenosynovitis and involvement of other soft tissue structures. Deformity can be managed with soft tissue and bony reconstruction, arthroplasty, and arthrodesis. Tendon rupture is common in untreated or longstanding cases and can be addressed with a multitude of tendon transfer options. Other autoimmune and inflammatory conditions such as systemic lupus erythematosus (SLE) and psoriasis can involve the upper extremity, producing characteristic physical signs and patterns of arthropathy. Many options for medical management exist, and the student should be familiar with the various mechanisms of action of these drugs as well as their side effects. One should also have an understanding of the management of immunomodulating medications in the preoperative and perioperative period.

Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

Although carpal tunnel syndrome (median nerve compression at the wrist) and cubital tunnel syndrome (ulnar nerve compression at the elbow) represent the vast majority of compressive neuropathies of the upper extremity, there are a host of other compression neuropathies that may affect the shoulder, upper arm, forearm, wrist, and hand. Although less frequent, it is vital to understand these alternative sites of compression and the corresponding syndromes in order to provide a patient with an accurate diagnosis and treatment plan. Keen history taking and a detailed physical examination is paramount in differentiating between different sites of nerve compression, as nerve conduction and electromyographic testing will often fail to identify a subset of etiologies and results can be ambiguous at times. A failure to interpret the true site of nerve compression can lead to erroneous surgical treatment and failure to alleviate symptoms. Questions in this chapter deal with the following less common compressive neuropathies such as suprascapular nerve entrapment, pronator syndrome, radial tunnel syndrome, and Guyon’s canal compression.

Arthroscopic Quantification of Syndesmotic Instability in a Cadaveric Model

Surgical site infections remain a dreaded complication of orthopaedic surgery, affecting both patient economics and quality of life. It is important to note that infections are multifactorial, involving both surgical and patient factors. To decrease the occurrence of infections, surgeons frequently use local modalities, such as methicillin-resistant Staphylococcus aureus screening; preoperative bathing; intraoperative povidone-iodine lavage; and application of vancomycin powder, silver-impregnated dressings, and incisional negative-pressure wound therapy. These modalities can be applied individually or in concert to reduce the incidence of surgical site infections. Despite their frequent use, however, these interventions have limited support in the literature.