Fence-Line Spectroscopic Measurements Suggest Carry-Over of Salt-Laden Aerosols into Flare Systems Is Common.

Pollutant emissions from gas flares in the upstream oil and gas (UOG) industry can be exacerbated by aerosols of coproduced liquid hydrocarbons and formation water that survive separation and enter the flare. Of noteworthy concern is the potential impact of salt-laden aerosols, since the associated chlorine may adversely affect combustion and emissions. Here, we use a novel approach to remotely detect carry-over of salt-laden aerosols into field-operational flares via flame emission spectroscopy targeting two of the most abundant species in produced water samples, sodium and potassium. Ninety-five UOG flares were examined during field campaigns in the Bakken (U.S.A. and Canada) and Amazon (Ecuador) basins. For the first time, carry-over of salt species into flares is definitively detected and further found to be concerningly common, with 74% of studied flares having detectable sodium and/or potassium signatures. Additional analysis reveals that carry-over strongly correlates with reported flared gas volume (positive) and well age (negative), but carry-over was also observed in flares linked to older wells and those flaring relatively little gas. Given the scale of global UOG flaring and the risk of salt-laden aerosols affecting emissions, these findings emphasize the need to review separation standards and re-evaluate pollutant emissions from flares experiencing carry-over.

Analysis of factors that drives arthrocentesis for suspected septic joint.

INTRODUCTION: This study aims to develop a simple diagnostic criterion that could be used to justify arthrocentesis in adults with suspected septic arthritis. Our hypothesis is that no single factor will be predictive for a decision to aspirate a questionable septic joint. METHODS: A prospective observational cohort study was performed at a Level 1 Trauma institution including all patients over the age of 18 years referred to Orthopaedics through the Emergency Department or inpatient orthopaedic consultations for a suspected septic joint. Patient information recorded was age, laboratory markers (white blood cell count, erythrocyte sedimentation rate, C-reactive protein, physical exam findings (fever, pain with range-of-motion), and presence of smoking, diabetes, end-stage renal disease (ESRD) on dialysis, and body mass index > 30. Continuous data was analyzed using logistic regression, and nominal data was analyzed using a two-tailed Fisher's exact test. RESULTS: A total of 128 patients met inclusion criteria for this study; 71 patients underwent arthrocentesis for suspected septic joint. On analysis of risk factors, the demographics, laboratory markers, physical exam and comorbidities were not significant between the two groups. On subset analysis of the septic joints, we found the only risk factor to be significantly predictive of whether a joint was septic was the presence of ESRD on dialysis (p = 0.042). CONCLUSION: Past data have looked solely at predictive risk factors for septic arthritis; however, this study aims to predict what drives physicians towards aspirating a joint even before it is determined to be septic. We found no single factor was predictive of joint aspiration. Only ESRD on dialysis is predictive of whether a joint with concern for septic arthritis would ultimately be septic in our institution. The decision to aspirate continues to be best determined by clinician judgment in light of experience and available clinical information.

Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice.

PURPOSE: The goal of this study was to determine whether the type of anesthesia (monitored anesthesia care [MAC] vs wide-awake local anesthesia no tourniquet technique [WALANT]) or the surgical technique (mini-open vs endoscopic) would affect patient satisfaction with postoperative pain control, postoperative pain, or opioid use after carpal tunnel release (CTR). The hypothesis was that endoscopic and open CTR surgery would have the same patient satisfaction with postoperative pain control, postoperative pain, and opioid use, but WALANT surgery would have higher patient satisfaction with postoperative pain control, postoperative pain, and opioid use than MAC. METHODS: This prospective study examined all patients undergoing carpal tunnel surgery by 4 hand surgeons at our institution. Two surgeons perform primarily 1-incision endoscopic CTR and the other 2 perform mini-open CTR. Two surgeons perform all procedures under WALANT; the other 2 employ MAC with a local anesthetic. Postsurgical questionnaires were completed at the 2-week postoperative visit. Patients reported remaining pills, average pain, highest pain, lowest pain, and overall satisfaction with postoperative pain control. RESULTS: A total of 93 patients underwent CTR by the 4 participating hand surgeons. Of these, 43 underwent open CTR and 50 underwent endoscopic CTR. Sixty-two were performed under MAC and 31 with WALANT. With regard to anesthesia type, overall there was 5.5 mean morphine equivalents (MME) less prescribed and an average of 3.6 MME more remaining on the first postoperative visit with WALANT compared with MAC. Patient satisfaction with postoperative pain control was an average score of 7.9 for MAC and 7.4 for WALANT. With regard to surgical technique, overall, there was 15.2 MME less prescribed and an average of 1.03 MME more remaining on the first postoperative visit with endoscopic CTR compared with open CTR. Patient satisfaction with postoperative pain control between endoscopic and open release demonstrated an average score of 7.1 and 8.0, respectively. CONCLUSIONS: This study demonstrates minimal differences in opioid pain medication use, patient satisfaction with postoperative pain control, and pain scores in a comparison of surgical technique as well as anesthesia type. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Analysis of surgical options for patients with bilateral carpal tunnel syndrome.

BACKGROUND: Bilateral endoscopic carpal tunnel release is a modality offered for the treatment of the median nerve compression neuropathy. This retrospective study compares outcomes for patients undergoing open carpal tunnel release versus bilateral endoscopic carpal tunnel release. We hypothesized that there is no significant difference in postoperative complication rates between unilateral open and bilateral endoscopic carpal tunnel release surgery. METHODS: The authors identified all patients who underwent open carpal tunnel release, unilateral endoscopic carpal tunnel release and bilateral endoscopic carpal tunnel release at a university hospital from 2012 to 2014. Cases were identified using CPT billing codes and the data was assessed using an analysis of variance (ANOVA). All endoscopic carpal tunnel releases were done by the same surgeon (AP), and greater than 90% of open procedures were done by a different same surgeon (DF). RESULTS: The total combined complication rate was 24.7% with no significant difference (p > .05) between techniques. There were no major complications necessitating a return to the operating room. Variables that had a statistically significant difference between groups (p < .05) included mean tourniquet time, mean total procedure time, and return to work as determined from the number of follow-up appointments. CONCLUSIONS: The study demonstrates equivocal complication profiles and decreased cost associated with bilateral endoscopic tunnel release as compared to sequential open carpal tunnel release. Endoscopic bilateral carpal tunnel release for patients with bilateral carpal tunnel syndrome offers a safe and effective alternative to open carpal tunnel release.

National trends, 90-day readmission and subsequent knee surgery following multi-ligament knee reconstruction.

INTRODUCTION/BACKGROUND: Given the uncommon nature of the multi-ligament injured knee, a better understanding of its outcomes may be achieved by contemporary evaluation of a national administrative database. We aim to identify risk factors for 90-day major complications, 90-day readmissions, and subsequent knee surgery after a multi-ligament knee reconstruction. METHODS: The Humana Claims Database was queried for all patients undergoing a multi-ligament knee reconstruction procedure from 2007 to 2016 using International Classification of Diseases (ICD)-9 procedure codes and Current Procedural Terminology (CPT) codes. Outcomes of interest included Center of Medicaid and Medicare Services (CMS)- reportable 90-day complications, 90-day readmission and subsequent ligament reconstruction or total knee arthroplasty. Predictive factors studied included demographics (ie. age, sex, tobacco use) comorbidity burden and operative factors (ie. surgical setting, diagnosis of knee dislocation, concomitant meniscal repair or meniscectomy). RESULTS: 588 multi-ligament knee reconstruction procedures were identified. The 90-day readmission rate 8.3%. The rate of subsequent ligament surgery was 7.1%. On multivariate regression analysis, a diagnosis of knee dislocation was associated with a four times greater likelihood of readmission and a two and a half greater likelihood of subsequent ligament surgery. Concomitant meniscectomy was associated with higher likelihood of subsequent total knee arthroplasty (9.1, 1.4-67.0) and outpatient setting of surgery compared to inpatient hospital setting was associated with reduced likelihood of readmission. CONCLUSION: While uncommon, the patient population undergoing multi-ligament knee surgery is relatively diverse. Understanding common factors predisposing this population to adverse events following surgery may assist in improved outcomes.

Comparison of Hand Drills for the Insertion of Skeletal Traction Pins.

Skeletal traction pins are inserted as part of emergent stabilization of lower extremity fractures. The purpose of this study is to compare two drill options: a reusable store-bought drill and a single-use, sterilely packaged drill. The reusable drill and disposable drill were compared by having volunteers insert traction pins within a foam bone, fully encased, knee joint model using both systems. The two drill types were evaluated on three measures: user satisfaction, time required for insertion of the pins, and cost. The disposable drill received a statistically significant higher user satisfaction score and a statistically significant faster time to pin insertion. The per-use cost of the disposable system was found to be higher. For skeletal traction pin insertion, the disposable, single-use drill was found to be superior to the reusable drill in user satisfaction and time required for traction pin insertion. Institutional cost analysis favors the disposable system because of the more predicable charge capture, while the per-use cost of the disposable system remains higher. (Journal of Surgical Orthopaedic Advances 27(4):274-276, 2018).

Endoscopic Thermal Fasciotomy for Chronic Exertional Compartment Syndrome.

Chronic exertional compartment syndrome is an activity-induced condition that occurs when intracompartmental pressures within an osteofascial envelope increase during exercise, leading to reversible ischemic symptoms such as pain, cramping, numbness, or weakness. Nonoperative treatment options for this condition have shown limited success and are often undesirable for the patient given the requirement for activity modification. Traditional surgical treatment options involving open or subcutaneous fasciotomies have more favorable results, but these techniques are associated with significant morbidity. Endoscopically assisted fasciotomy techniques afford the advantages of being minimally invasive, providing excellent visualization, and allowing accelerated rehabilitation. The purpose of this article is to describe a technique for performing endoscopically assisted fasciotomies for chronic exertional compartment syndrome of the lower leg using an entirely endoscopic thermal ablating device. The endoscopic thermal fasciotomy technique is associated with minimal morbidity, ensures excellent hemostasis, and affords an early return to sports.