The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

Clinical Utilization of DiaSorin Molecular Polymerase Chain Reaction in Pneumocystis Pneumonia.

BACKGROUND: Pneumocystis jirovecii polymerase chain reaction (PCR) testing is a sensitive diagnostic tool but does not distinguish infection from colonization. Cycle threshold (CT) may correlate with fungal burden and could be considered in clinical decision making. Clinical use of PCR and significance of CT values have not previously been examined with the DiaSorin Molecular platform. METHODS: Retrospective review of P jirovecii PCR, CT values and clinical data from 18 months in a multihospital academic health system. The diagnostic performance of PCR with respect to pathology and correlation of CT with severity were examined. RESULTS: Ninety-nine of 1006 (9.8%) assays from 786 patients in 919 encounters were positive. Among 91 (9.9%) encounters in which P jirovecii pneumonia (PJP) was treated, 41 (45%) were influenced by positive PCR. Negative PCR influenced discontinuation of therapy in 35 cases. Sensitivity and specificity of PCR were 93% (95% CI, 68%-100%) and 94% (95% CI, 91%-96%) with respect to pathology. CT values from deep respiratory specimens were significantly different among treated patients (P = .04) and those with positive pathology results (P < .0001) compared to patients not treated and those with negative pathology, respectively, and was highly predictive of positive pathology results (area under the curve = 0.92). No significant difference was observed in comparisons based on indicators of disease severity. CONCLUSIONS: Pneumocystis jirovecii PCR was a highly impactful tool in the diagnosis and management of PJP, and use of CT values may have value in the treatment decision process in select cases. Further investigation in a prospective manner is needed.

Validation of High-Sensitivity Severe Acute Respiratory Syndrome Coronavirus 2 Testing for Stool-Toward the New Normal for Fecal Microbiota Transplantation.

INTRODUCTION: Mounting evidence demonstrates potential for fecal-oral transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The US Food and Drug Administration now requires SARS-CoV-2 testing of potential feces donors before the use of stool manufactured for fecal microbiota transplantation. We sought to develop and validate a high-sensitivity SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) procedure for testing stool specimens. METHODS: A modified extraction method was used with an RT-PCR assay adapted from the Centers for Disease Control and Prevention PCR protocol for respiratory specimens. Contrived specimens were created using pre-COVID-19 banked stool specimens and spiking in known concentrations of SARS-CoV-2-specific nucleic acid. The highest transcript concentration at which 2/2 or 1/2 SARS-CoV-2 targets were detected in 9/10 replicates was defined as the dual-target limit and single-target limit of detection, respectively. The clinical performance of the assay was evaluated with stool samples collected from 17 nasopharyngeal swab RT-PCR-positive patients and 14 nasopharyngeal RT-PCR-negative patients. RESULTS: The dual-target and single-target limit of detection were 56 copies/µL and 3 copies/µL, respectively. SARS-CoV-2 was detected at concentrations as low as 0.6 copies/µL. Clinical stool samples from known COVID-19-positive patients demonstrated the detection of SARS-CoV-2 in stool up to 29 days from symptom onset with a high agreement with nasopharyngeal swab tests (kappa statistic of 0.95, P value < 0.001). DISCUSSION: The described RT-PCR test is a sensitive and flexible approach for the detection of SARS-CoV-2 in stool specimens. We propose an integrated screening approach that incorporates this stool test to support continuation of fecal microbiota transplantation programs.

Comparison of Antibody Class-Specific SARS-CoV-2 Serologies for the Diagnosis of Acute COVID-19.

Accurate diagnosis of acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is critical for appropriate management of patients with this disease. We examined the possible complementary role of laboratory-developed class-specific clinical serology in assessing SARS-CoV-2 infection in hospitalized patients. Serological tests for immunoglobulin G (IgG), IgA, and IgM antibodies against the receptor binding domain (RBD) of SARS-CoV-2 were evaluated using samples from real-time reverse transcription-quantitative PCR (qRT-PCR)-confirmed inpatient coronavirus disease 2019 (COVID-19) cases. We analyzed the influence of timing and clinical severity on the diagnostic value of class-specific COVID-19 serology testing. Cross-sectional analysis revealed higher sensitivity and specificity at lower optical density cutoffs for IgA in hospitalized patients than for IgG and IgM serology (IgG area under the curve [AUC] of 0.91 [95% confidence interval {CI}, 0.89 to 0.93] versus IgA AUC of 0.97 [95% CI, 0.96 to 0.98] versus IgM AUC of 0.95 [95% CI, 0.92 to 0.97]). The enhanced performance of IgA serology was apparent in the first 2 weeks after symptom onset and the first week after PCR testing. In patients requiring intubation, all three tests exhibit enhanced sensitivity. Among PCR-negative patients under investigation for SARS-CoV-2 infection, 2 out of 61 showed clear evidence of seroconversion IgG, IgA, and IgM. Suspected false-positive results in the latter population were most frequently observed in IgG and IgM serology tests. Our findings suggest the potential utility of IgA serology in the acute setting and explore the benefits and limitations of class-specific serology as a complementary diagnostic tool to PCR for COVID-19 in the acute setting.

Results after radial head arthroplasty in unstable fractures.

BACKGROUND: Whereas most radial head fractures are stable injuries, they sometimes occur as part of complex injury patterns with associated elbow instability. Radial head arthroplasty has been favored in patients with unreconstructable radial head fractures and unstable elbow injuries. The purpose of this study was to review radiographic outcomes, functional outcomes, and complications after radial head arthroplasty for radial head fracture in unstable elbow injuries. METHODS: This study was a retrospective review of radial head fractures treated with radial head arthroplasty by a single surgeon during a 15-year period. Demographics of the patients, injury details, operative reports, radiographic and clinical outcomes, and any complications were recorded. Patients were divided into stable and unstable elbow injury groups. RESULTS: A total of 68 patients were included. There were 50 unstable fractures that were compared with 18 stable fractures. Patients with unstable radial head fractures with associated elbow dislocation achieved mean flexion and mean forearm rotational arc of motion similar to that of patients with stable radial head fractures. However, supination loss was greater in the unstable group than in the stable fracture group, with a mean difference of 10°. Radiographic outcomes and complication rates did not differ between injury groups. There was no observed decrease in implant longevity in patients with unstable elbow injuries. CONCLUSIONS: Radial head arthroplasty is an effective option for treatment of unstable elbow injuries, with recovery of functional elbow range of motion and no difference in complication rate or implant survivorship compared with those patients with stable injuries.

Repair of Displaced Partial Articular Fracture of the Distal Femur: The Hoffa Fracture.

PURPOSE: The Hoffa fracture is a rare fracture pattern consisting of a unicondylar posterior fracture of the distal femur. This video demonstrates a case of Hoffa fracture repair using headless screw compression. METHODS: Hoffa fractures are intra-articular in nature. Given that isolated Hoffa fractures are rare, there is little information available as to the best management of this injury. However, several small studies have demonstrated good-to-excellent functional results after anatomical reduction and rigid fixation of the Hoffa fracture, followed by early mobilization. RESULTS: This video presents a case of surgical repair of a Hoffa fracture, and contaminant meniscal repair, in a 25-year-old man. Partially threaded, headless compression screws provide for independent compression of the fracture after placement. CONCLUSIONS: The Hoffa fracture is a rare injury typically seen after high-energy trauma. The surgical technique for treatment of the Hoffa fracture as seen in this video provides good stabilization and enables for early range of motion.

Percutaneous Repair of a Schatzker III Tibial Plateau Fracture Assisted by Arthroscopy.

PURPOSE: Tibial plateau fractures are articular fractures that sometimes prove difficult to effectively manage and treat. Although fluoroscopy is frequently used to assess the articular reduction in the surgical repair of tibial plateau fractures, this video demonstrates the additional benefit of arthroscopy in assisting with the articular reconstruction of a Schatzker III tibial plateau fracture. METHODS: The goal of operative treatment of tibial plateau is reconstruction of the articular surface followed by reestablishment of tibial alignment. Arthroscopy has been advocated as a possible supplement to the operative treatment of tibial plateau fractures. Arthroscopy-assisted fracture reduction has been shown to provide a significantly improved visualization of fracture fragment displacement when compared with traditional fluoroscopy use in select cases. RESULTS: This video demonstrates the use of arthroscopy to visualize the articular surface and aid in reduction during fixation of a tibial plateau fracture. Initially, arthroscopic visualization confirms depression of lateral tibial plateau and the elevation of the fractured segment. After fixation with 2 partially threaded cancellous screws, arthroscopy confirms articular reduction and normal relation of lateral meniscus to the articular surface. CONCLUSIONS: Arthroscopic visualization is a reliable technique for assessing articular reduction during surgical repair of a tibial plateau fracture. In addition, this technique enables the surgeon to assess for soft tissue injuries that could potentially go undiagnosed.

Management of Proximal Humerus Fractures with the Equinoxe® Locking Plate System.

There is no consensus on surgical fixation and treatment of proximal humerus fractures, even though they are common fractures with several fixation techniques. This retrospective study quantifies the outcomes of patients who sustained a proximal humerus fracture and were treated with open reduction and internal fixation by at a single academic center between December 2010 and December 2014 using the Equinoxe® proximal humerus locking plate. Following enrollment, injury and surgical data was recorded. Forty-nine patients (31 female, 18 male) with 50 fractures were identified who met the inclusion criteria. Mean follow-up period was 16.8 months (range: 6 to 44 months). Mean age was 60.7 years with no significant difference in mean age by gender. Mean age-adjusted Charlson Comorbidity Index (CCI) was 2.9 (range: 0 to 6). The overall complication rate was 10% (N = 5) with the most common complication being osteonecrosis (N = 3). Four patients required reoperation. At final follow-up, mean active forward flexion for the cohort was 140.8º ± 30.1º, mean passive forward flexion was 155.7º ± 25.2º, and mean active external rotation was 50.1º ± 17.9º. For patients with postoperative complications, mean active forward flexion was 106.0º ± 23.0º, mean passive forward flexion was 136.7º ± 23.1º, and mean active external rotation was 34.2º ± 24.4. Active forward flexion and external rotation were significantly different in the presence of a complication (p = 0.005 and p = 0.038, respectively). Mean DASH score for the cohort was 19.1 ± 20.9. Mean DASH score for patients who developed complications or underwent reoperations was 34.2 ± 24.3. This study demonstrates that the Equinoxe® proximal humerus locking plate provides stable fracture treatment with excellent clinical results and a low complication rate when performed by experienced orthopaedic traumatologists.