Parallel K-Wire Placement Leads to Fusion and Midcarpal Settling in Scaphoid Excision Four-Corner Fusion.

BACKGROUND: Scaphoid excision 4-corner fusion is a motion-sparing procedure in patients with advanced radioscaphoid arthritis. This study introduces an alternate technique for scaphoid excision 4-corner fusion using a parallel Kirschner wire (K-wire) construct across the midcarpal joints that leads to reliable fusion rates, and good patient outcomes. METHODS: This is a single-surgeon, retrospective study of patients who underwent scaphoid excision 4-corner fusion, using a parallel K-wire construct across the midcarpal joints. Once fusion was achieved, K-wires were removed. Radiographic union rate, time to union, capitolunate angle, capitolunate coverage, and amount of midcarpal settling are measured. Patient-reported outcome measures and descriptive statistics are presented. RESULTS: Sixty-five wrists were included in this study with a mean age of 50.1 years. One patient was lost to follow-up. All 64 wrists (100%) fused at an average of 2.6 months. The mean capitolunate angle was 7°, and capitolunate coverage was 99.2%. Fifty-two patients (81%) had adequate radiographs for measurement. Average midcarpal settling was 1.1 mm. Thirty-two patients (51%) were available for long-term follow-up at an average of 5.3 years (0.7-10.2 years), and participated in patient reported outcomes (PRO) surveys. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 16.6, and numeric pain rating scale score was 1.8. CONCLUSIONS: Parallel K-wire placement across the midcarpal joints with scaphoid leads to a high rate of fusion with good patient outcomes long term. Midcarpal settling that occurs through dynamic compression around the K-wires may have contributed to bony fusion. This technique may provide an alternative approach to achieving reliable fusion across the midcarpal joints.

"Post-Decompressive Neuropathy": New-Onset Post-Laminectomy Lower Extremity Neuropathic Pain Different from the Preoperative Complaint.

STUDY DESIGN: Level III retrospective cross-sectional study. PURPOSE: To define and characterize the presentation, symptom duration, and patient/surgical risk factors associated with 'postdecompressive neuropathy (PDN).' OVERVIEW OF LITERATURE: PDN is characterized by lower extremity radicular pain that is 'different' from pre-surgical radiculopathy or claudication pain. Although it is a common constellation of postoperative symptoms, PDN is incompletely characterized and poorly understood. We hypothesize that PDN is caused by an intraoperative neuropraxic event and may develop early (within 30 days following the procedure) or late (after 30 days following the procedure) within the postoperative period. METHODS: Patients who consented to undergo lumbar laminectomy with or without an instrumented fusion for degenerative lumbar spine disease were followed up prospectively from July 2013 to December 2014. Relevant data were extracted from the charts of the eligible patients. Patient demographics and surgical factors were identified. Patients completed postoperative questionnaires 3 weeks, 3 months, 6 months, and 1 year postoperatively. Questions were designed to characterize the postoperative pain that differed from preoperative pain. A diagnosis of PDN was established if the patient exhibited the following characteristics: pain different from preoperative pain, leg pain worse than back pain, a non-dermatomal pain pattern, and nocturnal pain that often disrupted sleep. A Visual Analog Scale was used to monitor the pain, and patients documented the effectiveness of the prescribed pain management modalities. Patients for whom more than one follow-up survey was missed were excluded from analysis. RESULTS: Of the 164 eligible patients, 118 (72.0%) completed at least one follow-up survey at each time interval. Of these eligible patients, 91 (77.1%) described symptoms consistent with PDN. Additionally, 75 patients (82.4%) described early-onset symptoms, whereas 16 reported symptoms consistent with late-onset PDN. Significantly more female patients reported PDN symptoms (87% vs. 69%, p=0.03). Patients with both early and late development of PDN described their leg pain as an intermittent, constant, burning, sharp/stabbing, or dull ache. Early PDN was categorized more commonly as a dull ache than late-onset PDN (60% vs. 31%, p=0.052); however, the difference did not reach statistical significance. Opioids were significantly more effective for patients with early-onset PDN than for those with late-onset PDN (85% vs. 44%, p=0.001). Gabapentin was most commonly prescribed to patients who cited no resolution of symptoms (70% vs. 31%, p=0.003). Time to symptom resolution ranged from within 1 month to 1 year. Patients' symptoms were considered unresolved if symptoms persisted for more than 1 year postoperatively. In total, 81% of the patients with earlyonset PDN reported complete symptom resolution 1 year postoperatively compared with 63% of patients with late-onset PDN (p=0.11). CONCLUSIONS: PDN is a discrete postoperative pain phenomenon that occurred in 77% of the patients who underwent lumbar laminectomy with or without instrumented fusion. Attention must be paid to the constellation and natural history of symptoms unique to PDN to effectively manage a self-limiting postoperative issue.

Vancomycin Powder Regimen for Prevention of Surgical Site Infection in Complex Spine Surgeries.

STUDY DESIGN: In total, 496 patients of a single surgeon cohort examining the surgical-site infection (SSI) rates with the addition of vancomycin powder in both diabetic and revision spine surgery cases. A historical control group of 652 patients were compared from the same surgeon over an earlier time period before the inception of using vancomycin powder prophylaxis. OBJECTIVE: The objective of this study was to describe and compare the rates of infection in high-risk patient populations while using vancomycin powder. SUMMARY OF BACKGROUND DATA: Vancomycin powder may not decrease an already low rate of infection. Therefore, use of vancomycin powder in high-risk patients with a higher rate of infection would potentially show benefit of vancomycin powder. MATERIALS AND METHODS: In total, 496 patient charts were collected from a database of cases. Patients were included in the cohort if they had revision spinal operation or if they were diabetic. Patients in the time period July 2010 to August 2013 were included in the vancomycin protocol where 1 g of vancomycin powder was added to the wound before wound closure. Cases were considered positive if there was a positive culture or if there was sufficient clinical suspicion to treat. As a control to this cohort, 692 charts were reviewed from a earlier time period of the same surgeon and institution. RESULTS: In total, 28 patients of 496 (5.6%) patients in the cohort returned to the operating room for seroma, hematoma, draining wound, or infection. Sixteen of these patients (16/496, 3.2%) had a culture positive infection or were treated as an infection. This rate was significantly lower than the historical rate before the protocol. CONCLUSIONS: Although vancomycin does seem to be useful in decreasing SSIs, it is not a panacea. SSIs in high-risk patients were not completely eliminated by the vancomycin protocol.

Outcomes of revision total knee arthroplasty after methicillin-resistant Staphylococcus aureus infection.

BACKGROUND: The incidence of infection by methicillin-resistant Staphylococcus aureus (MRSA) in total knee arthroplasty (TKA) is becoming a more frequent concern, as increased morbidity following TKA has been reported for infections by resistant organisms. This study investigates whether MRSA infections are associated with decreased functional scores. QUESTIONS/PURPOSES: We therefore compared the functional scores, operative times, and rates of reinfection of revision TKA following MRSA infection versus other indications for revision. METHODS: We retrospectively reviewed charts of 101 patients (103 knees) who underwent mobile bearing TKA revision from January 2003 to September 2006, with a minimum clinical followup of 2 years in 45 knees (44%). We obtained the following indices: WOMAC, Activities of Daily Living Score (ADLS), SF-36, and Knee Society scores (KSS). Three groups of revisions were compared: MRSA infection (n = 6), non-MRSA infection (n = 9), and aseptic failure (n = 30). The three groups were similar in demographics and comorbidities. RESULTS: The MRSA (166 minutes) and non-MRSA groups (149 minutes) had longer operative times than the aseptic group (121 minutes). With numbers available, there were no differences in ROM, WOMAC, ADLS, KSS, and SF-36, with MRSA separate or combined with all infections. Infection recurrence between MRSA-infected knees and non-MRSA-infected knees was similar. CONCLUSIONS: While our study was underpowered to detect functional differences between MRSA-infected knees and non-MRSA-infected knees it does add data to the literature. Knees revised for infection have longer operative times and more frequent infection after revision. The reason for increased operative times is unclear. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care.

BACKGROUND: Our previous Delphi study identified several audit filters considered sensitive to deviations in prehospital trauma care and potentially useful in conducting performance improvement, a process currently recommended by the American College of Surgeons Committee on Trauma. This study validates 2 of those proposed audit filters. STUDY DESIGN: We studied 4,744 trauma patients using the electronic records of the Central Region Trauma registry and Emergency Medical Services (EMS) patient logs for the period January 1, 2002, to December 31, 2004. We studied whether requests by on-scene Basic Life Support (BLS) for Advanced Life Support (ALS) assistance or failure by EMS personnel to record basic patient physiology at the scene was associated with increased in-hospital mortality. We performed multivariate analyses, including a propensity score quintile approach, adjusting for differences in case mix and clustering by hospital. RESULTS: Overall mortality was 6.1%. A total of 28.2% (n = 1,337) of EMS records were missing patient scene physiologic data. Multivariate analysis revealed that patients missing 1 or more measures of patient physiology at the scene had increased risk of death (adjusted odds ratio = 2.15; 95% CI, 1.13 to 4.10). In 17.4% (n = 402) of cases BLS requested ALS assistance. Patients for whom BLS requested ALS had a similar risk of death as patients for whom ALS was initially dispatched (odds ratio = 1.04; 95% CI, 0.51 to 2.15). CONCLUSIONS: Failure of EMS to document basic measures of scene physiology is associated with increased mortality. This deviation in care can serve as a sensitive audit filter for performance improvement. The need by BLS for ALS assistance was not associated with increased mortality.