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1.
Hand Clin ; 39(3): 427-434, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37453769

RESUMO

The proper technique for flexor tendon repair has been well established through numerous bench science and clinical studies. However, less is known about strategies to avoid and manage postoperative complications. This article discusses the common complications after flexor tendon repair, such as repair site rupture and adhesion formation. This article also addresses strategies to prevent and manage these complications. The foundation for preventing many of these complications is ensuring a strong repair without gapping at time zero, which will enable the accrual of tensile strength through early initiation of motion.


Assuntos
Traumatismos dos Tendões , Humanos , Traumatismos dos Tendões/cirurgia , Tendões/cirurgia , Ruptura/cirurgia , Amplitude de Movimento Articular , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/cirurgia , Resistência à Tração , Técnicas de Sutura , Fenômenos Biomecânicos
2.
J Arthroplasty ; 38(6S): S7-S13, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-37019311

RESUMO

BACKGROUND: The impact of tourniquet use on recovery after total knee arthroplasty (TKA) remains controversial. The purpose of this prospective, single blinded, randomized controlled trial was to investigate the effect of tourniquet use on early recovery after TKA using a smartphone app-based patient engagement platform (PEP) with a wrist-based activity monitor to obtain more robust data on early recovery. METHODS: There were 107 patients undergoing primary TKA for osteoarthritis who were enrolled (54 tourniquet [TQ+]; 53 no tourniquet [TQ-]). All patients utilized a PEP and wrist-based activity sensor for 2 weeks preoperatively and 90 days postoperatively to collect Visual Analog Scale (VAS) pain scores and opioid consumption, as well as weekly Oxford Knee Score (OKS) and monthly Forgotten Joint Score (FJS). There was no difference in demographics between groups. Formal physical therapy assessments were performed preoperatively and 3 months postoperatively. Independent sample t-tests were used for continuous data and Chi-square and Fisher's exact tests were used for discrete data. RESULTS: Tourniquet use did not have a statistically significant impact on daily VAS pain or opioid consumption during the first 30 days postoperatively (P > .05). Tourniquet use did not have a significant impact on OKS or FJS at 30 or 90 days postoperatively (P > .05), or on performance of formal physical therapy testing at 3 months postoperatively (P > .05). CONCLUSION: Using a digital technology to collect daily patient data, we found that tourniquet use has no clinically significant negative impact on pain and function in the first 90 days after primary TKA.


Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/reabilitação , Articulação do Joelho/cirurgia , Analgésicos Opioides/uso terapêutico , Estudos Prospectivos , Resultado do Tratamento , Recuperação de Função Fisiológica , Osteoartrite do Joelho/cirurgia , Dor Pós-Operatória/cirurgia , Torniquetes
3.
Hand Clin ; 39(2): 131-139, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-37080645

RESUMO

Flexor tendon repair techniques and rehabilitation have advanced tremendously in the past 50 years. However, the attributes of the ideal tendon repair articulated by Dr Strickland in 1995 hold true today. The ideal repair requires sutures easily placed in the tendon, secure suture knots, a smooth juncture of the tendon ends, minimal gapping, least interference with tendon vascularity, and sufficient strength throughout healing. When accomplished, the modern flexor tendon repair is a stout repair, sufficient for early mobilization and intrinsic tendon healing.


Assuntos
Procedimentos de Cirurgia Plástica , Traumatismos dos Tendões , Humanos , Traumatismos dos Tendões/cirurgia , Tendões/cirurgia , Suturas , Técnicas de Sutura , Resistência à Tração , Fenômenos Biomecânicos
4.
J Orthop Trauma ; 37(2): 57-63, 2023 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-36048739

RESUMO

OBJECTIVE: To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group. DESIGN: Multicenter Retrospective Cohort. SETTING: Three Urban Level I Academic Trauma Centers. PATIENTS: Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria. MAIN OUTCOME MEASUREMENTS: Transfusion and postoperative complication rates. RESULTS: Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications. CONCLUSIONS: Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fraturas do Quadril , Varfarina , Humanos , Varfarina/efeitos adversos , Estudos Retrospectivos , Anticoagulantes/efeitos adversos , Pontuação de Propensão , Fraturas do Quadril/cirurgia , Fraturas do Quadril/tratamento farmacológico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle
5.
J Orthop Trauma ; 36(4): 172-178, 2022 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-34456312

RESUMO

OBJECTIVES: To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups. DESIGN: Multicenter retrospective cohort. SETTING: Three tertiary care, academic, Level I trauma centers. PATIENTS: Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching. MAIN OUTCOME MEASUREMENTS: The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality. RESULTS: One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179). CONCLUSIONS: This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Anticoagulantes , Fraturas do Quadril , Anticoagulantes/uso terapêutico , Transfusão de Sangue , Humanos , Estudos Retrospectivos , Centros de Traumatologia
6.
J Am Acad Orthop Surg ; 30(1): 19-26, 2022 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-34932506

RESUMO

INTRODUCTION: Pilon fractures occur through high-energy axial-loading trauma and are frequently associated with complications. The goal of this study was to assess whether anterior impaction (AI) tibial pilon fractures are associated with increased rates of posttraumatic osteoarthritis (PTOA), secondary surgeries, and lower patient-reported outcomes compared with patients with non-AI pilon fractures. METHODS: In this retrospective cohort study, 52 pilon fractures in 50 patients were included. The average follow-up was 25 months (range, 12 to 62 in non-AI and 12 to 66 in AI). The Kellgren and Lawrence (KL) score for PTOA, tibiotalar ratio for anterior-posterior talar subluxation, coronal tibiotalar angle, Patient-Reported Outcomes Measurement Information System score, and rates of secondary surgeries and infection were assessed. RESULTS: The AI group showed radiographic evidence of more advanced PTOA at the final follow-up (KL score 3.1 vs. 2.5, P = 0.021) and a higher rate of implant removal for pain (39% vs. 13%, P = 0.030). AI also had greater anterior talar subluxation on preoperative (P < 0.001) and final follow-up radiographs (P = 0.026). A higher KL score was associated with greater anterior talar displacement on preoperative (r = -0.421, P = 0.003) and final follow-up radiographs (r = -0.359, P < 0.009). No differences were seen in 1-year Patient-Reported Outcomes Measurement Information System scores. DISCUSSION: AI pilon fractures are associated with recurrent anterior talar subluxation, more severe PTOA, and a higher rate of implant removal for pain compared with non-AI fractures.


Assuntos
Fraturas do Tornozelo , Fraturas da Tíbia , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas , Humanos , Estudos Retrospectivos , Tíbia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Resultado do Tratamento
7.
J Orthop Trauma ; 35(4): 167-170, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32931686

RESUMO

OBJECTIVE: To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS: Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization. INTERVENTION: Percutaneous posterior pelvic fixation and pelvic arterial embolization. MAIN OUTCOME MEASUREMENTS: Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients. RESULTS: Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group. CONCLUSION: Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fraturas Ósseas , Ossos Pélvicos , Ferida Cirúrgica , Fixação Interna de Fraturas/efeitos adversos , Fraturas Ósseas/cirurgia , Humanos , Ossos Pélvicos/diagnóstico por imagem , Ossos Pélvicos/cirurgia , Estudos Retrospectivos
8.
Bone Joint J ; 102-B(6_Supple_A): 163-169, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32475280

RESUMO

AIMS: The aim of this study was to determine if the local delivery of vancomycin and tobramycin in primary total knee arthroplasty (TKA) can achieve intra-articular concentrations exceeding the minimum inhibitory concentration thresholds for bacteria causing acute prosthetic joint infection (PJI). METHODS: Using a retrospective single-institution database of all primary TKAs performed between January 1 2014 and May 7 2019, we identified patients with acute PJI that were managed surgically within 90 days of the initial procedure. The organisms from positive cultures obtained at the time of revision were tested for susceptibility to gentamicin, tobramycin, and vancomycin. A prospective study was then performed to determine the intra-articular antibiotic concentration on postoperative day one after primary TKA using one of five local antibiotic delivery strategies with tobramycin and/or vancomycin mixed into the polymethylmethacrylate (PMMA) or vancomycin powder. RESULTS: A total of 19 patients with acute PJI after TKA were identified and 29 unique bacterial isolates were recovered. The mean time to revision was 37 days (6 to 84). Nine isolates (31%) were resistant to gentamicin, ten (34%) were resistant to tobramycin, and seven (24%) were resistant to vancomycin. Excluding one Fusobacterium nucleatum, which was resistant to all three antibiotics, all isolates resistant to tobramycin or gentamicin were susceptible to vancomycin and vice versa. Overall, 2.4 g of tobramycin hand-mixed into 80 g of PMMA and 1 g of intra-articular vancomycin powder consistently achieved concentrations above the minimum inhibitory concentrations of susceptible organisms. CONCLUSION: One-third of bacteria causing acute PJI after primary TKA were resistant to the aminoglycosides commonly mixed into PMMA, and one-quarter were resistant to vancomycin. With one exception, all bacteria resistant to tobramycin were susceptible to vancomycin and vice versa. Based on these results, the optimal cover for organisms causing most cases of acute PJI after TKA can be achieved with a combination of tobramycin mixed in antibiotic cement, and vancomycin powder. Cite this article: Bone Joint J 2020;102-B(6 Supple A):163-169.


Assuntos
Antibacterianos/administração & dosagem , Artroplastia do Joelho , Bactérias/efeitos dos fármacos , Prótese do Joelho/efeitos adversos , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/etiologia , Tobramicina/administração & dosagem , Vancomicina/administração & dosagem , Administração Tópica , Cimentos Ósseos , Combinação de Medicamentos , Humanos , Testes de Sensibilidade Microbiana , Polimetil Metacrilato , Estudos Retrospectivos , Tobramicina/farmacologia , Vancomicina/farmacologia
9.
Muscle Nerve ; 60(5): 629-636, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31397919

RESUMO

INTRODUCTION: Neuroenhancing therapies are desired because repair of nerve injuries can fail to achieve recovery. We compared two neuroenhancing therapies, electrical stimulation (ES) and systemic tacrolimus (FK506), for their capabilities to enhance regeneration in the context of a rat model. METHODS: Rats were randomized to four groups: ES 0.5 mA, ES 2.0 mA, FK506, and repair alone. All groups underwent tibial nerve transection and repair, and outcomes were assessed by using twice per week walking track analysis, cold allodynia response, relative muscle mass, and nerve histology. RESULTS: Electrical stimulation and FK506 groups demonstrated improved functional recovery and myelinated axon counts distal to the repair compared with repair alone. Electrical stimulation provided improvements in nerve regeneration that were not different from optimized FK506 systemic administration. DISCUSSION: Providing ES after nerve repair improved regeneration and recovery in rats, with minimal differences in therapeutic efficacy to FK506, further demonstrating its clinical potential to improve management of nerve injuries.


Assuntos
Estimulação Elétrica/métodos , Imunossupressores/farmacologia , Regeneração Nervosa/efeitos dos fármacos , Recuperação de Função Fisiológica/efeitos dos fármacos , Tacrolimo/farmacologia , Nervo Tibial/lesões , Animais , Músculo Esquelético/efeitos dos fármacos , Músculo Esquelético/inervação , Músculo Esquelético/patologia , Músculo Esquelético/fisiopatologia , Regeneração Nervosa/fisiologia , Procedimentos Neurocirúrgicos , Traumatismos dos Nervos Periféricos , Ratos , Recuperação de Função Fisiológica/fisiologia , Nervo Tibial/patologia , Nervo Tibial/cirurgia
10.
Exp Neurol ; 318: 216-231, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31085199

RESUMO

Repair of traumatic nerve injuries can require graft material to bridge the defect. The use of alternatives to bridge the defect, such as acellular nerve allografts (ANAs), is becoming more common and desired. Although ANAs support axon regeneration across short defects (<3 cm), axon regeneration across longer defects (>3 cm) is limited. It is unclear why alternatives, including ANAs, are functionally limited by length. After repairing Lewis rat nerve defects using short (2 cm) or long (4 cm) ANAs, we showed that long ANAs have severely reduced axon regeneration across the grafts and contain Schwann cells with a unique phenotype. But additionally, we found that long ANAs have disrupted angiogenesis and altered leukocyte infiltration compared to short ANAs as early as 2 weeks after repair. In particular, long ANAs contained fewer T cells compared to short ANAs. These outcomes were accompanied with reduced expression of select cytokines, including IFN-γ and IL-4, within long versus short ANAs. T cells within ANAs did not express elevated levels of IL-4, but expressed elevated levels of IFN-γ. We also directly assessed the contribution of T cells to regeneration across nerve grafts using athymic rats. Interestingly, T cell deficiency had minimal impact on axon regeneration across nerve defects repaired using isografts. Conversely, T cell deficiency reduced axon regeneration across nerve defects repaired using ANAs. Our data demonstrate that T cells contribute to nerve regeneration across ANAs and suggest that reduced T cells accumulation within long ANAs could contribute to limiting axon regeneration across these long ANAs.


Assuntos
Regeneração Tecidual Guiada/métodos , Regeneração Nervosa/fisiologia , Nervo Isquiático/lesões , Nervo Isquiático/transplante , Linfócitos T/imunologia , Aloenxertos , Animais , Ratos , Ratos Endogâmicos Lew , Ratos Sprague-Dawley , Alicerces Teciduais
11.
Clin Orthop Relat Res ; 477(5): 1249-1255, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30998643

RESUMO

BACKGROUND: Transverse patella fractures are often treated with cannulated screws and a figure-of-eight anterior tension band. A common teaching regarding this construct is to recess the screws so that their distal ends do not protrude beyond the patella because doing so may improve biomechanical performance. However, there is a lack of biomechanical or clinical data to support this recommendation. QUESTION: In the treatment of transverse patella fractures, is there a difference between prominent and recessed cannulated screw constructs, supplemented by tension banding, in terms of gap formation from cyclic loading and ultimate load to failure? METHODS: Ten pairs of fresh-frozen cadaver legs (mean donor age, 72 years; range, 64-89 years) were randomized in a pairwise fashion to prominent or standard-length screws. In the prominent screw group, screw length was 15% longer than the measured trajectory, resulting in 4 to 6 mm of additional length. Each patella was transversely osteotomized at its midportion and fixed with screws and an anterior tension band. Gap formation was measured over 40 loaded flexion-extension cycles (90° to 5°). Ultimate load to failure was assessed with a final monotonic test after cyclic loading. Areal bone mineral density (BMD) of each patella was measured with dual energy x-ray absorptiometry (DEXA). There was no difference in BMD between the recessed (1.06 ± 0.262 g/cm) and prominent (1.03 ± 0.197 g/cm) screw groups (p = 0.846). Difference in gap formation was assessed with a Wilcoxon Rank Sum Test. Ultimate load to failure and BMD were assessed with a paired t-test. RESULTS: Patella fractures fixed with prominent cannulated screws demonstrated larger gap formation during cyclic loading. Median gap size at the end of cyclic loading was 0.13 mm (range, 0.00-2.92 mm) for the recessed screw group and 0.77 mm (range, 0.00-7.50 mm) for the prominent screw group (p = 0.039; 95% confidence interval [CI] difference of geometric means, 0.05-2.12 mm). There was no difference in ultimate failure load between the recessed screw (891 ± 258 N) and prominent screw (928 ± 268 N) groups (p = 0.751; 95% CI difference of means, -226 to 301 N). Ultimate failure load was correlated with areal BMD (r = 0.468; p = 0.046). CONCLUSIONS: In this cadaver study, when using cannulated screws and a figure-of-eight tension band to fix transverse patella fractures, prominent screws reduced the construct's ability to resist gap formation during cyclic loading testing. CLINICAL RELEVANCE: This biomechanical cadaver study found that the use of prominent cannulated screws for the fixation of transverse patella fractures increases the likelihood of interfragmentary gap formation, which may potentially increase the risk of fracture nonunion and implant failure. These findings suggest that proximally and distally recessed screws may increase construct stability, which may increase the potential for bony healing. The findings support further laboratory and clinical investigations comparing recessed screws supplemented by anterior tension banding with other repair methods that are in common use, such as transosseous suture repair.


Assuntos
Fixação de Fratura/métodos , Fraturas Ósseas/cirurgia , Patela/cirurgia , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos , Cadáver , Humanos , Pessoa de Meia-Idade , Patela/lesões
12.
J Craniofac Surg ; 30(1): 127-132, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30376506

RESUMO

BACKGROUND: Early management of unilateral coronal synostosis (UCS) aims to treat the cranial abnormality with the hope of improving middle and lower facial morphology. This study analyzed osseous volume and 3-dimensional distances in the midface and mandible of patients with UCS to assess changes in facial symmetry following a cranial vault procedure. METHODS: Patients who underwent fronto-orbital advancement for UCS repair between 1981 and 2012 with follow-up of at least 3 years were included. Computed tomography-based 3-dimensional reconstructions of the mandible and LeFort III midface were divided by 3 midline osseous landmarks and measured for volume. Distances between 11 osseous landmarks were measured in the midface and mandible. Ratios between the measurements on synostotic and nonsynostotic sides were calculated. Presurgical to postsurgical changes were evaluated with paired samples t tests. The study was powered to detect differences between preoperative and postoperative ratios of at least 3%. RESULTS: Eleven patients were included. Mean age at initial imaging was 4.7 ± 3.2 months (range, 0.4-9.2 months) with postoperative follow-up of 9.0 ±â€Š5.3 years (range, 3.3-17.0 years). Midfacial symmetry of osseous volume improved following surgery (synostotic to nonsynostotic ratio, 94.1% vs 98.9%, P = 0.044). The width (P < 0.001), height (P = 0.039), and anterior-posterior depth of the midface (P = 0.011) also became more symmetric. In the mandible, however, volumetric and linear symmetry did not improve. CONCLUSIONS: Symmetry of the midface, but not the mandible, improves significantly following the cranial procedure in patients with UCS.


Assuntos
Craniossinostoses/cirurgia , Face/diagnóstico por imagem , Face/patologia , Mandíbula/diagnóstico por imagem , Mandíbula/patologia , Adolescente , Pontos de Referência Anatômicos , Cefalometria , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Imageamento Tridimensional , Lactente , Recém-Nascido , Masculino , Período Pós-Operatório , Tomografia Computadorizada por Raios X
13.
Case Rep Neurol Med ; 2015: 812035, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26609456

RESUMO

Autoantibodies to the γ-aminobutyric acid receptor, subtype B (GABAB), are a known cause of limbic encephalitis. The spectrum of clinical manifestations attributable to this antibody is not well defined at the present time. Here we present a case of GABAB encephalitis presenting with encephalopathy, status epilepticus, dysautonomia, and acute heart failure. To our knowledge, heart failure and dysautonomia have not yet been reported with this syndrome.

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