Timothy I. Carter

Fresh stored allografts for the treatment of osteochondral defects of the knee.

BACKGROUND Osteochondral allograft reconstruction of articular cartilage defects is a well-established cartilage repair strategy. Currently, fresh osteochondral allograft tissue is commercially available to clinicians approximately thirty days following graft harvest. Little clinical information is available on the outcome of patients who have been treated with fresh allografts stored for several weeks or more. The purpose of this study was to prospectively analyze the clinical outcome and graft morphology of patients who received fresh, hypothermically stored, allograft tissue for the treatment of symptomatic chondral and osteochondral defects of the knee. METHODS Nineteen patients with symptomatic chondral and osteochondral lesions of the knee who were treated with fresh osteochondral allografts between 1999 and 2002 were prospectively followed. The mean age at the time of surgery was thirty-four years. Validated outcomes instruments (the Activities of Daily Living Scale and the Short Form-36) were used; all patients must have had a baseline functional score prior to surgery and a minimum two-year follow-up evaluation. All grafts were obtained from commercial vendors; the mean preimplantation storage time of the graft was thirty days (range, seventeen to forty-two days). The mean lesion size was 602 mm(2). Magnetic resonance imaging was used to evaluate the morphologic characteristics of the implanted grafts. RESULTS The mean duration of clinical follow-up was forty-eight months (range, twenty-one to sixty-eight months). The mean score (and standard deviation) on the Activities of Daily Living Scale increased from a baseline of 56 +/- 24 to 70 +/- 22 at the time of the final follow-up (p < 0.05). The mean Short Form-36 score increased from a baseline of 51 +/- 23 to 66 +/- 24 at the time of final follow-up (p < 0.005). With the numbers studied, we could not correlate graft storage time, body mass index, lesion size, lesion location, or patient age with the functional outcome scores. At a mean follow-up interval of twenty-five months, cartilage-sensitive magnetic resonance imaging demonstrated that the normal articular cartilage thickness was preserved in eighteen implanted grafts, and allograft cartilage signal properties were isointense relative to normal articular cartilage in eight of the eighteen grafts. Osseous trabecular incorporation of the allograft was complete or partial in fourteen patients and poor in four patients. Complete or partial trabecular incorporation positively correlated with Short Form-36 scores at the time of follow-up (r = 0.487, p < 0.05). CONCLUSIONS Fresh osteochondral allografts that were hypothermically stored between seventeen and forty-two days were effective in the short term both structurally and functionally in reconstructing symptomatic chondral and osteochondral lesions of the knee. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Accuracy and Reliability of Three Different Techniques for Manual Goniometry for Wrist Motion: A Cadaveric Study

PURPOSE Despite the ubiquitous use of manual goniometry in measuring objective outcomes of hand surgery and therapy, there are limited data concerning its accuracy or repeatability for wrist motion. The purpose of this study was to evaluate the accuracy and reliability (both inter- and intra-rater) in measuring wrist flexion and extension using 3 manual goniometric alignment techniques (ulnar, radial, and dorsal-volar) in cadaveric upper extremities, using fluoroscopic verification of posture as a gold standard. In addition, we sought to assess the accuracy and reliability of the dorsal-volar technique for measurement of radioulnar deviation. METHODS External fixators were applied to 10 cadaveric wrists with intramedullary cannulated rods in the radius and third metacarpal for gold-standard fluoroscopic verification of posture. Manual goniometric measurements with each technique were captured by 2 raters (a hand surgeon and a hand therapist) for reliability measurements and by a single rater for accuracy. Wrists were positioned at angles of maximum flexion, extension, and radial and ulnar deviation for reliability testing and at preselected angles across the range of motion for accuracy testing. At each position, wrist angle was measured with a 1 degrees increment goniometer, and fluoroscopic angles were measured digitally. Intraclass correlation coefficients and root mean square values were calculated for all combinations, and analysis of variance was used to test differences between techniques. RESULTS No technique was statistically less accurate than any other (6 degrees to 7 degrees ). Each method was found to have high intra-rater reliability. For measurement of wrist flexion and extension, the dorsal-volar technique demonstrated the greatest inter-rater reliability, as compared to ulnar and radial, respectively. CONCLUSIONS Although each measurement technique demonstrated a similar degree of accuracy and intra-rater reliability, the dorsal-volar technique demonstrates the greatest level of inter-rater reliability for measurement of wrist flexion and extension. This information is important clinically, as measurements are regularly exchanged between hand surgeons and therapists as a basis for decisions regarding patient care.

The HYSLAR trial: a prospective randomized controlled trial of the use of a restrictive fluid regimen with 3% hypertonic saline versus lactated Ringers in patients undergoing pancreaticoduodenectomy.

Objective:This study was designed to determine whether the volume and type of fluid administered for pancreaticoduodenectomy impacts postoperative outcomes. Background:Three percent hypertonic saline (HYS) has been suggested as a means of reducing the volume of fluid required to sustain tissue perfusion in the perioperative period. Methods:Between May 2011 and November 2013, patients undergoing pancreaticoduodenectomy were enrolled in an institutional review board–approved, single-center, prospective, parallel, randomized controlled trial (NCT 01428050), comparing lactated Ringers (LAR) (15 mL/kg/hr LAR intraoperation, 2 mL/kg/hr LAR postoperation) with HYS (9 mL/kg/hr LAR and 1 mL/kg/hr HYS intraoperation, 1 mL/kg/hr HYS postoperation). Results:A total of 264 patients were randomized. Demographic variables between groups were similar. The HYS patients had a significantly reduced net fluid balance (65 vs 91 mL/kg, P = 0.02). The overall complication rate was reduced in the HYS group (43% vs 54%), with a relative risk of 0.79 [95% confidence interval (CI), 0.62–1.02; P = 0.073], factoring stratification for pancreas texture. After adjustment for age and weight, the relative risk was 0.75 [95% CI (0.58–0.96); P = 0.023]. The total number of complications was significantly reduced in the HYS group (93 vs 123), with an incidence rate ratio of 0.74 [95% CI (0.56–0.97); P = 0.027]. After adjustment for age and weight, the incidence rate ratio was 0.69 [95% CI (0.52–0.90); P = 0.0068]. Reoperations, length of stay, readmissions, and 90-day mortality were similar between groups. Conclusions:A moderately restrictive fluid regimen with HYS resulted in a statistically significant 25% reduction in complications when adjusted for age, weight, and pancreatic texture.

Outcome of organs procured from donors on extracorporeal membrane oxygenation support: an analysis of kidney and liver allograft data.

Extracorporeal membrane oxygenation has become rescue therapy for adults with overwhelming cardiac and/or respiratory failure. Not all patients are saved, creating a new cohort of potential organ donors. This study examines the outcomes of liver and kidney allografts procured from donors on extracorporeal membrane oxygenation (ECMO).

Development of an anatomical wrist joint coordinate system to quantify motion during functional tasks

The purpose of this study was to develop a three-dimensional (3D) motion analysis based anatomical wrist joint coordinate system for measurement of in-vivo wrist kinematics. The convergent validity and reliability of the 3D motion analysis implementation was quantified and compared with manual and electrogoniometry techniques on 10 cadaveric specimens. Fluoroscopic measurements were used as the reference. The 3D motion analysis measurements (mean absolute difference [MAD] = 3.6°) were significantly less different (P < .005) than manual goniometry (MAD = 5.7°) but not (P = .066, power = 0.45) electrogoniometry (MAD = 5.0°) compared with fluoroscopy. The intraclass correlation coefficient (ICC[2,1]) was highest for 3D motion analysis compared with manual and electrogoniometry, suggesting better reliability for this technique. To demonstrate the utility of this new wrist joint coordinate system, normative data from 10 healthy subjects was obtained while throwing a dart.

Patellofemoral Osteochondral Autologous Transfer

| ABSTRACT Osteochondral autograft transfer is a cartilage repair technique in which an osteochondral plug is transferred from an area of less contact pressure to the full- thickness, focal chondral defect. Although the osteo- chondral autograft transfer has been described for the treatment of femoral condylar chondral lesions, the application to the patellofemoral joint has not been described. The purpose of the article is to describe the technical aspects involved in osteochondral autograft transfer for isolated chondral lesions of the patella.

Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery

Management of anemic patients refusing blood transfusion remains challenging. Concomitant coronary artery disease further complicates management. We sought to decrease the likelihood of cardiac events by employing hypothermia and neuromuscular blockade, in addition to limited phlebotomy, in a critically anemic Jehovahs Witness patient following emergent colectomy. The patients hemoglobin concentrations were trended with serial blood gases. Neuromuscular blockade was instituted with cisatracurium, followed by hypothermia to a target of 32°C. The patients lowest hemoglobin levels occurred on postoperative day 3 before beginning to rise. There were no postoperative cardiac events reported during the patients course of stay. She recovered well with no evidence of anemia or cardiac events at 1-year follow-up. We conclude that targeted hypothermia with neuromuscular blockade, as an adjunct to accepted techniques, may be an alternative for critically anemic patients with coronary artery disease refusing blood transfusion.

Fluid Restriction During Pancreaticoduodenectomy: Is It Effective in Reducing Postoperative Complications?

Timothy I. Carter, MD, Charles J. Yeo, MD, Harish Lavu, MD* Department of Surgery, SUNY Downstate Medical Center, 450 Clarkson Avenue Brooklyn, New York, NY 11203, USA; Department of Surgery, The Jefferson Pancreas Biliary and Related Cancer Center, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 620, Philadelphia, PA 19107, USA; Department of Surgery, The Jefferson Pancreas Biliary and Related Cancer Center, Thomas Jefferson University, 1025 Walnut Street, College Building, Suite 605, Philadelphia, PA 19107, USA

AN EXTENSION TO THE ISB WRIST JOINT COORDINATE SYSTEM: AN IN VITRO ACCURACY STUDY

INTRODUCTION Investigators have used a variety of marker sets and methods to describe upper extremity kinematics. However, without a standard set of anatomical and joint coordinate system definitions for 3-D motion analysis (3DMA), data sets cannot be compared between investigators. In an effort to summarize the descriptions of upper extremity motion, Wu and colleagues [1] published a set of joint coordinate system recommendations. This proposed kinematic solution is an extension from that standard. The purpose of this investigation is to develop an anatomically based wrist joint coordinate system (WJCS) and appropriate tracking frames. To test this new WJCS a comparison between the 3-D motion analysis (3DMA) implementation, manual goniometry (MG), and electro-goniometry (EG) was performed. We hypothesize that 3DMA would provide increased accuracy over the other methods.