An Orthopedic-Hospitalist Comanaged Hip Fracture Service Reduces Inpatient Length of Stay.

INTRODUCTION: Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States, representing a health-care cost of US$9 to 20 billion. Hip fracture incidence is projected to increase dramatically. Hospitals must modify clinical models to accommodate this growing burden. Comanagement strategies are reported in the literature, but few have addressed orthopedic-hospitalist models. An orthopedic-hospitalist comanagement (OHC) service was established at our hospital to manage hip fracture patients. We sought to determine whether the OHC (1) improves the efficiency of hip fracture management as measured by inpatient length of stay (LOS) and time to surgery (TTS) and (2) whether our results are comparable to those reported in hip fracture comanagement literature. METHODS: A comparative retrospective-prospective cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before (n = 45) and 10 months after implementation (n = 54) of the OHC at a single academic hospital. Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours, 30-day readmission rates, and mortality. Outcomes were compared to comanagement study results published in MEDLINE-indexed journals. RESULTS: Patient cohort demographics and comorbidities were similar. Inpatient LOS was reduced by 1.6 days after implementation of the OHC (P = .01) without an increase in 30-day readmission rates or mortality. Time to surgery was insignificantly reduced from 27.4 to 21.9 hours (P = .27) and surgery within 48 hours increased from 86% to 96% (P = .15). DISCUSSION: The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution. CONCLUSION: Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly expanding patient population.

Treatment of posttraumatic cubitus varus with corrective supracondylar humeral osteotomies using the methyl methacrylate external fixator.

BACKGROUND: In upper and lower extremity fractures and osteotomy fixation, the use of methyl methacrylate (MM) as an external fixator presents an alternative method. The primary aim of this retrospective study was to evaluate the midterm outcome of pediatric patients who underwent corrective humeral supracondylar lateral closing-wedge osteotomy, with the external fixation system composed of MM and multiplane K-wires. METHODS: Fourteen consecutive cases with cubitus varus, who underwent corrective osteotomy with a limited lateral approach stabilized with MM and the multiplane K-wires external fixator system between January 2006 and May 2010, were retrospectively evaluated. Time of union, preoperative and postoperative elbow range of motion, and humeroulnar angle were measured. Results were rated as excellent, good, or poor, according to Bellemore criteria. RESULTS: There were a total of 6 female patients and 8 male patients with a mean age of 5.7 years (range, 3 to 9 y). The mean follow-up period was 28.2 months (range, 24 to 48 mo). The mean humeroulnar angle was (-) 18.6 degrees preoperatively, and (+) 16.3 degrees at the final follow-up. Thirteen patients were evaluated as excellent and 1 patient as good, according to Bellemore criteria. Union was seen in all patients at mean 7 weeks (range, 6 to 8 wk). Pin tract infection was observed in 1 patient and treated with oral antibiotics. Loss of correction was not observed in any patient during follow-up. CONCLUSIONS: External fixation of corrective supracondylar humeral osteotomy with MM and multiplane K-wires is a practical, effective, reliable, and cheap alternative method that can be applied. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Transverse carpal ligament and forearm fascia release for the treatment of carpal tunnel syndrome change the entrance angle of flexor tendons to the A1 pulley: the relationship between carpal tunnel surgery and trigger finger occurrence.

PURPOSE: The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers. METHODS: The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other. RESULTS: We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger. DISCUSSION: Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area. CLINICAL RELEVANCE: This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

Relevance of an academic GMP Pan-European vector infra-structure (PEVI).

In the past 5 years, European investigators have played a major role in the development of clinical gene therapy. The provision of substantial funds by some individual member states to construct GMP facilities makes it an opportune time to network available gene therapy GMP facilities at an EU level. The integrated coordination of GMP production facilities and human skills for advanced gene and genetically-modified (GM) cell therapy, can dramatically enhance academic-led "First-in-man" gene therapy trials. Once proof of efficacy is gathered, technology can be transferred to the private sector which will take over further development taking advantage of knowledge and know-how. Complex technical challenges require existing production facilities to adapt to emerging technologies in a coordinated manner. These include a mandatory requirement for the highest quality of production translating gene-transfer technologies with pharmaceutical-grade GMP processes to the clinic. A consensus has emerged on the directions and priorities to adopt, applying to advanced technologies with improved efficacy and safety profiles, in particular AAV, lentivirus-based and oncolytic vectors. Translating cutting-edge research into "First-in-man" trials require that pre-normative research is conducted which aims to develop standard assays, processes and candidate reference materials. This research will help harmonise practices and quality in the production of GMP vector lots and GM-cells. In gathering critical expertise in Europe and establish conditions for interoperability, the PEVI infrastructure will contribute to the demands of the advanced therapy medicinal products* regulation and to both health and quality of life of EU-citizens.

Is the rabbit knee a suitable model for the human interphalangeal and metacarphophalangeal joints of the hand?

OBJECTIVES: The purpose of this study was to assess the suitability of the rabbit knee as a small joint model for the human interphalangeal and metacarphophalangeal joints of the hand. METHODS: The proximal joint surface areas of 47 middle phalanges, the proximal and distal joint surface areas of 90 proximal phalanges, and the distal joint surface areas of 42 metacarpals of various human cadavers were calculated and compared with the distal femoral and proximal tibial joint surface areas of 20 knee of 10 New Zealand white rabbits by a photogrammetric method. RESULTS: The mean joint surface area of the rabbit proximal tibia was larger than the proximal joint surface area of the middle phalanx, the distal joint surface area of the proximal phalanx, the proximal joint surface area of the proximal phalanx, and the distal joint surface area of the metacarpal. The mean joint surface area of the rabbit distal femur was larger than that of the middle phalanx, but similar to the proximal joint surface area of the proximal phalanx, and that of the distal metacarpal and distal proximal phalanx. CONCLUSION: The rabbit knee is not suitable model for the human interphalangeal and metacarphophalangeal joints of the hand. There is still a lack of an appropriate animal model for the small joints of the hand.

Gabapentin is a first line drug for the treatment of neuropathic pain in spinal cord injury.

STUDY DESIGN: Prospective, randomized, double blind, placebo-controlled, crossover clinical trial. OBJECTIVES: To determine the efficacy of gabapentin in the treatment of neuropathic pain related to spinal cord injury. SUMMARY OF BACKGROUND DATA: Neuropathic pain is initiated or caused by a primary lesion or dysfunction in the nervous system. Neuropathic pain associated with spinal cord injury is quite refractory, and current treatments are not effective. Gabapentin, an anticonvulsant, has become the first choice in the treatment of neuropathic pain. The place of gabapentin in the treatment of spinal cord injury-related neuropathic pain was questioned in only a few recent reports; however, they are retrospectively designed, nonstandardized, and uncontrolled studies, or involve a very small series of patients using less than optimum doses. METHODS: A total of 18-week study period included a 4-week medication/placebo titration period. This was followed by a 4-week stable dosing period when the patients continued to receive maximum tolerated doses, a 2-week washout period, then a crossover of 4 weeks of medication/placebo titration, and another 4 weeks of stable dosing period. Twenty paraplegic patients (female/male: 7/13) with complete spinal cord injury at the thoracic and lumbar level, aged between 20 and 65 years, with neuropathic pain for more than 6 months were recruited for the study. RESULTS: All patients completed the study. Gabapentin reduced the intensity as well as the frequency of pain, relieved all neuropathic pain descriptors except the itchy, sensitive, dull, and cold types, and improved the quality of life (P < 0.05). CONCLUSIONS: Gabapentin can be added to the list of first-line medications for the treatment of chronic neuropathic pain in spinal cord injury patients. It is a promising new agent and offers advantages over currently available treatments.

Intracortical epidermoid cyst of the tibia.

Epidermoid cyst in a long bone is an extremely rare condition. The authors describe such a tumor located in the cortex of the tibia in a 21-year-old woman. She was successfully treated with curettage and autogenous bone grafting.

End-to-side neurorrhaphy as a salvage procedure for irreparable nerve injuries. Technical note.

After a few reports on end-to-side nerve repair at the beginning of the last century, the technique was put aside until its recent reintroduction. The authors present their results in three patients with median nerve defects that were between 15 and 22 cm long and treated using end-to-side median-to-ulnar neurorrhaphy through an epineurial window. The follow-up times were between 32 and 38 months. Sensory evaluation involved superficial touch, pinprick, and two-point discrimination tests. Motor evaluation was completed by assessing the presence of opposition and by palpating the abductor pollicis brevis muscle. Sensory recovery was observed in all patients in the median nerve dermatome, and motor recovery was absent, except in Case 1. End-to-side nerve repair can be a viable alternative to nerve grafting in patients with long gaps between the ends of the injured nerve.