Technical Tips for Reduction and Stable Fixation of Proximal Humerus Fractures.

The surgical treatment of proximal humerus fractures, though common, is associated with surprisingly high complication rates upward of 34%. Obtaining a reduction and placing a stable fixation can be challenging because many fractures treated surgically are comminuted and occur in osteoporotic bone. Nevertheless, innovations in technique and implant design are mitigating some failures. These innovations include the use of fibular strut allograft and other fixation adjuncts, the correct placement of calcar screws and other locking fixation, and having a systematic approach to reduction and intraoperative imaging to ensure the restoration of anatomy. This review and accompanying video highlight various technical strategies to maximize the success of surgical treatment for these challenging injuries.

Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks.

The incidence of pertrochanteric hip fractures continues to rise as the aging population expands. Despite advancements in techniques and implants, failure rates remain up to 16% in the literature. The recognition of challenging fracture patterns and the use of meticulous preoperative planning can help to avoid common pitfalls. Understanding fluoroscopic views for reduction assessment and implant placement is instrumental in preventing fixation failure. In addition, adjunctive techniques including the use of a bone hook, cerclage wire, and colinear clamps can facilitate reduction efforts. It is imperative for the surgeon to recognize common pitfalls and to consider a wide array of techniques to manage these challenging and common fractures.

Surgical Tips and Tricks for Distal Femur Plating.

Distal femur fractures are challenging fractures to treat, with nonunion rates as high as 22%. Precontoured locking plates have mitigated some earlier causes of failure, while introducing new challenges. The recognition of troublesome injury patterns and appropriate preoperative planning can avoid common pitfalls. Adjunctive techniques, including the use of a radiolucent triangle, an external fixator, unicortical plates, and crossing K-wires, can assist with fracture reduction and maintenance. It is important to understand the common pitfalls involved with distal femur plating and to consider a wide array of techniques to combat these challenges.

Staying Out of Trouble With Intramedullary Nailing of Distal Tibia Fractures.

As the biologically friendly and biomechanically sound technique of intramedullary fixation has been increasingly applied to distal tibia diaphyseal fractures, challenges with the technique have emerged. Malalignment, most often valgus and recurvatum, is more common than with mid-diaphyseal patterns, given the lack of endosteal fit, and this can be challenging to prevent. Key technical steps can ensure success. These include recognition and initial fixation of intra-articular fracture planes, the use of percutaneous clamps, a slightly lateral terminal nail position, and the use of blocking wires or screws to prevent malalignment after nail passage. With thorough preoperative planning and early recognition of troublesome patterns, a variety of techniques can be applied to obtain and maintain a stable reduction throughout the procedure.

Correlation of Single-Photon Emission Computed Tomography Results With Clinical and Intraoperative Findings in Painful Total Ankle Replacement.

BACKGROUND: Evaluating pain after total ankle replacement (TAR) is often difficult, and traditional imaging modalities do not always adequately assess potential etiologies of failure. Our study adds to the current understanding of single-photon emission computed tomography combined with conventional computed tomography (SPECT-CT) as a diagnostic tool for painful TAR. We hypothesized that SPECT-CT would be predictive of clinical and intraoperative findings and would be more useful than magnetic resonance imaging (MRI) in our cohort. METHODS: A retrospective review of SPECT-CT imaging performed at our institution in patients with painful TAR from January 2014 to November 2018 was conducted. A total of 37 patients were identified, and 28 of them underwent revision surgery. Additionally, 19 patients had an MRI during the same time frame. Imaging results were compared to the documented clinical findings and intraoperative findings during revision surgery. RESULTS: Of the 37 patients included, 89.2% (33/37) had SPECT-CT results that were consistent with the ultimate diagnosis documented in the medical record. Aseptic loosening (12/33) and impingement (11/33) were the most common diagnoses. Among patients who underwent revision surgery, SPECT-CT results were consistent with intraoperative findings in 26 of the 28 (92.9%) cases. In the 19 patients who also underwent MRI, the findings were consistent with clinical findings 36.8% (7/19) of the time. CONCLUSION: In our cohort, there was high consistency between SPECT-CT results and documented clinical diagnoses. SPECT-CT also demonstrated high consistency with intraoperative findings during revision surgery. Compared with MRI, SPECT-CT proved more useful in establishing a diagnosis of pain after TAR. LEVEL OF EVIDENCE: Level III, comparative series.

Relationship of ACL Injury and Posterior Tibial Slope With Patient Age, Sex, and Race.

BACKGROUND: Posterior tibial slope (PTS) has been proposed as a potential risk factor for anterior cruciate ligament (ACL) injury; however, studies that have examined this relationship have provided inconclusive and sometimes contradictory results. Further characterization of this relationship may enable the medical community to identify individuals at greater risk for ACL injury and possibly characterize an anatomic target during surgical reconstruction. PURPOSE: The primary goal was to investigate the relationship between PTS and ACL injury. The secondary goal was to determine whether there are any patient factors, such as age, race, or sex, that correlate with ACL injury and PTS. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Medical records of 221 patients who underwent magnetic resonance imaging (MRI) of the knee between January 2003 and December 2009 were reviewed. Patients were separated into 2 groups: a study group of those subjects who had undergone surgery for ACL injury (n = 107) and a control group of patients diagnosed with patellofemoral syndrome (n = 114). Demographic data were collected, and MRI images from both groups were analyzed using imaging software to obtain medial and lateral tibial slope measurements. Data were then analyzed using analysis of variance (ANOVA) comparison and a multivariable regression model to determine which, if any, patient factors were related to probability of having an ACL injury. RESULTS: ANOVA comparison demonstrated that the study group had significantly greater values for lateral PTS (6° ± 4°; P < .001) and medial PTS (7° ± 4°; P = .002) compared with controls (5° ± 3° and 5° ± 4°, respectively). After stepwise elimination of nonsignificant variables, the final multivariable logistic regression model determined that age (odds ratio [OR], 0.94; P < .001) and lateral PTS (OR, 1.12; P = .002) had statistically significant relationships with ACL injury. Medial PTS, race, and sex were not demonstrated to be significant predictors of ACL injury in this final model. CONCLUSION: This study demonstrates a relationship between increased lateral PTS and ACL injury, which corroborates the findings of previously published studies. The findings presented in this article may help identify patients who are at greater risk of ACL injury and could potentially benefit from treatments aimed at modification of PTS.

Stigmatizing attitudes and low levels of knowledge but high willingness to participate in HIV management: a community-based survey of pharmacies in Pune, India.

BACKGROUND: The World Health Organization (WHO) recommends that the role of pharmacists in low-income settings be expanded to address the increasing complexity of HIV antiretroviral (ARV) and co-infection drug regimens. However, in many such settings including in India, many pharmacists and pharmacy workers are often neither well trained nor aware of the intricacies of HIV treatment. The aims of our study were; to determine the availability of ARVs, provision of ARVs, knowledge about ARVs, attitudes towards HIV-infected persons and self-perceived need for training among community-based pharmacies in an urban area of India. METHODS: We performed a survey of randomly selected, community-based pharmacies located in Pune, India, in 2004-2005 to determine the availability of ARVs at these pharmacies, how they were providing ARVs and their self-perceived need for training. We also assessed knowledge, attitudes and perceptions on HIV and ARVs and factors associated with stocking ARVs. RESULTS: Of 207 pharmacies included in the survey, 200 (96.6%) were single, private establishments. Seventy-three (35.3%) pharmacies stocked ARVs and 38 (18.4%) ordered ARVs upon request. The reported median number of ARV pills that patients bought at one time was 30, a two week supply of ARVs (range: 3-240 pills). Six (2.9%) pharmacy respondents reported selling non-allopathic medicines (i.e. Ayurvedic, homeopathy) for HIV. Ninety (44.2%) pharmacy respondents knew that ARVs cannot cure HIV, with those stocking ARVs being more likely to respond correctly (60.3% vs. 34.8%, p = 0.001). Respondents of pharmacies which stocked ARVs were also more likely to believe it was a professional obligation to provide medications to HIV-infected persons (91.8% vs. 78.8%, p = 0.007) but they were also more likely to believe that HIV-infected persons are unable to adhere to their medicines (79.5% vs. 40.9%, p < 0.01). Knowledge of the most common side effects of nevirapine, abnormal liver enzyme profile and skin rash, was reported correctly by 8 (3.9%) and 23 (11.1%) respondents, respectively. Seven (3.4%) respondents reported that they had received special training on HIV, 3 (1.5%) reported receipt of special training on ART and 167 (80.7%) reported that they believed that pharmacy staff should get special training on ART. CONCLUSION: There is a high willingness to participate in HIV management among community-based pharmacies but there is a tremendous need for training on HIV therapies. Furthermore, stigmatizing attitudes towards HIV-infected persons persist and interventions to reduce stigma are needed, particularly among those that stock ARVs.