Salvage of a recalcitrant humeral shaft septic nonunion using a linked nail-plate fixation construct with intercalary allograft.

Open humeral shaft fractures comprise approximately 2% of all fractures of the humerus. Nearly 20% of open humeral shaft fractures will develop deep infection, increasing the risk of nonunion regardless of treatment method. Recalcitrant septic nonunion of the humeral shaft is a complex and challenging problem. Operative treatment should aim to eradicate infection, address bony defects, and establish a stable construct that affords early motion. We describe the case of a 38-year-old male with a recalcitrant humeral shaft septic nonunion following fixation of an open humeral shaft fracture. Management of the infection consisted of periodic surgical debridement and IV antibiotics, resulting in a 10 cm segmental defect. Definitive fixation was achieved using the combination of an antegrade intramedullary nail, intercalary femoral shaft allograft, compression plating, and autologous bone graft. In addition to achieving bony union, the patient regained his pre-injury ROM and function, which was clinically sustained at 2-year follow-up.

The "Double Washer" Technique Is an Effective Strategy for Bicortical Fixation in Periprosthetic Fractures About a Femoral Stem: A Technical Trick and Case Series.

SUMMARY: Periprosthetic fractures about the hip and knee are challenging injuries to treat for the orthopaedic surgeon. The pre-existing femoral implant and poor bone quality provide for difficulties in achieving stable fixation. We present a surgical technique and clinical series of 5 patients describing the use and outcomes of a 3.5 screw with a "double washer" technique to achieve bicortical fixation around a femoral prosthesis.

Radiographic Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraobserver Reliability in Assessing Humeral Shaft Fracture Healing.

BACKGROUND: Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively. PURPOSE: The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing. METHODS: A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen's kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed. RESULTS: ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979). CONCLUSIONS: This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.

Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion.

BACKGROUND: The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion. MATERIALS AND METHODS: Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment. RESULTS: Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745). CONCLUSIONS: RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage.

Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap's major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap's favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.

A Comparison of Assessment Tools: Is Direct Observation an Improvement Over Objective Structured Clinical Examinations for Communications Skills Evaluation?

BACKGROUND: Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. OBJECTIVE: We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. METHODS: We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. RESULTS: There were 28 of a possible 59 residents (47%) included. A total of 89% (25 of 28) of residents passed the communications skills OSCE; only 54% (15 of 28) of residents passed the direct observation communications assessment. There was a positive, moderate correlation between OSCE and direct observation scores overall (r = 0.415, P = .028). There was no agreement between OSCE and direct observation in categorizing residents into passing and failing scores (κ = 0.205, P = .16), after adjusting for chance agreement. CONCLUSIONS: Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

Ultralow-Dose CT (REDUCTION Protocol) for Extremity Fracture Evaluation Is as Safe and Effective as Conventional CT: An Evaluation of Quality Outcomes.

OBJECTIVES: To assess clinical and hospital quality outcomes of patients receiving the previously reported Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) imaging protocol. DESIGN: Retrospective Chart review. SETTING: Level I Trauma Center and affiliated Tertiary Care Hospital Center. PATIENTS/PARTICIPANTS: Fifty patients who received this protocol for acute traumatic fracture evaluation and met the inclusion criteria were compared with a cohort of 50 patients matched for age and fracture type who previously received conventional CT scanning for acute traumatic fracture evaluation. INTERVENTION: Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol for diagnostic fracture evaluation. MAIN OUTCOME MEASURES: Estimated effective radiation doses were calculated and compared using Digital Imaging and Communications in Medicine (DICOM) information from all included studies. Patient outcomes between groups were compared with time to fracture union as the primary outcome. Secondary outcome measures included the presence of complication defined as infection, malunion, nonunion, failure of nonoperative treatment, painful implants, and implant failure. Other secondary quality outcomes that were recorded included readmission within 30 days and hospital length of stay. Functional quality measures included joint range of motion. Statistical analyses were conducted to identify significant differences between cohorts (significance designated as P < 0.05). RESULTS: Patient characteristics between cohorts were not significantly different with respect to age, sex, body mass index, comorbidities, injury mechanism, or injury location. Fractures of the elbow, hip, knee, and foot/ankle were evaluated. Mean clinical follow-up was 9.5 ± 4.9 months for the REDUCTION cohort and 12.4 ± 5.3 months for the conventional CT cohort. Mean estimated effective dose for all REDUCTION scans was 0.15 milliSieverts (mSv) as compared to 1.50 mSv for the conventional CT cohort (P = 0.037). Preoperative diagnosis was confirmed intraoperatively in 49/50 cases in the REDUCTION cohort compared with 48/50 cases in the conventional CT cohort (P = 0.79). Outcomes including time to union, range of motion, complications, readmission, treatment failure, reoperation, and length of stay were not significantly different between groups. CONCLUSIONS: The REDUCTION protocol represents ultralow-dose CT developed for minimizing radiation exposure to patients presenting with traumatic fractures. This protocol resulted in a 10-fold reduction in radiation exposure. No difference in clinical or hospital quality outcomes was detected between patients who received this protocol as compared to those receiving automated dose CT. The REDUCTION protocol is a safe and effective method of performing CT for extremity fractures with significantly reduced radiation risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Short-Term Outcomes of Geriatric Distal Femur and Femoral Neck Fractures: Results From the NSQIP Database.

PURPOSE: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. METHODS: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. RESULTS: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 ± 7.93 vs 82.11 ± 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 ± 1.32 vs 4.49 ± 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 ± 6.73 days vs 7.02 ± 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates. CONCLUSION: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

A mammalian melanopsin in the retina of a fresh water turtle, the red-eared slider (Trachemys scripta elegans).

A mammalian-like melanopsin (Opn4m) has been found in all major vertebrate classes except reptile. Since the pupillary light reflex (PLR) of the fresh water turtle takes between 5 and 10 min to achieve maximum constriction, and since photosensitive retinal ganglion cells (ipRGCs) in mammals use Opn4m to control their slow sustained pupil responses, we hypothesized that a Opn4m homolog exists in the retina of the turtle. To identify its presence, retinal tissue was dissected from seven turtles, and total RNA extracted. Reverse transcriptase-polymerase chain reactions (RT-PCRs) were carried out to amplify gene sequences using primers targeting the highly conserved core region of Opn4m, and PCR products were analyzed by gel electrophoresis and sequenced. Sequences derived from a 1004-bp PCR product were compared to those stored in GenBank by the basic local alignment search tool (BLAST) algorithm and returned significant matches to several Opn4ms from other vertebrates including chicken. Quantitative real-time PCR (qPCR) was also carried out to compare expression levels of Opn4m in different tissues. The normalized expression level of Opn4m in the retina was higher in comparison to other tissue types: iris, liver, lung, and skeletal muscle. The results suggest that Opn4m exists in the retina of the turtle and provides a possible explanation for the presence of a slow PLR. The turtle is likely to be a useful model for further understanding the photoreceptive mechanisms in the retina which control the dynamics of the PLR.