Fluoroscopy and Radiographs for Detecting Retained Surgical Needles in the Hand.

When a surgical needle is lost, the protocol is to explore the surgical field and to obtain a plain radiograph if the needle cannot be located. The size of the needle that can be detected with imaging is debated. Plain-film radiographs, C-arm, and mini C-arm fluoroscopy imaging was obtained of a cadaveric hand with retained needle of varying lengths (suture sizes 4-0 - 10-0). The authors performed analyses to determine the sensitivity and specificity of the imaging modalities. There were no differences in diagnostic area under the receiver operating characteristic curve between the three modalities. For plain film, optimal cutoff for needle size was 5.2 mm (sensitivity 0.87, specificity 0.75), for C-arm 6.8 mm (sensitivity 0.84, specificity 0.87), and for mini C-arm 5.9 mm (sensitivity 0.82, specificity 0.86). In the hand, the use of C-arm fluoroscopy is as sensitive as plain-film radiography at detecting retained needles greater than 5.9 mm. (Journal of Surgical Orthopaedic Advances 33(1):026-028, 2024).

Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy.

PURPOSE: To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. METHODS: This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. RESULTS: A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n = 45; primary, n = 404) than in the group that did not receive TXA (n = 25; primary, n = 388) (P = .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P = .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P = .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5 minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n = 27) than in the group that did (n = 10) (P = .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P = .24). CONCLUSIONS: There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. LEVEL OF EVIDENCE: Level III, retrospective multicenter consecutive series.

Patient Outcomes Are Not Improved by Platelet-Rich Plasma Injection Onto the Capsule at the Time of Closure During Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Purpose: To determine the effect of platelet-rich plasma (PRP) injection onto the capsule at time of closure on outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Methods: Patients who underwent hip arthroscopy between January 2014 and December 2021 were retrospectively identified. The first cohort included patients who received PRP injection onto the capsule following capsular closure at the conclusion of the case. The second cohort did not receive PRP. Pain scores on a visual analog scale, Modified Harris Hip Scores, Single Assessment Numeric Evaluation (SANE), as well as Patient-Reported Outcomes Measurement Information System Physical Function scores were obtained preoperatively as well as at multiple time points postoperatively up to 2 years. Results: In total, 345 patients were included in the study, with 293 in the PRP cohort and 52 in the non-PRP cohort. There was no significance difference in age (P = .69), sex, or preoperative pain (P = .92) and patient-reported outcome scores between the 2 groups (modified Harris Hip Score, P = .38; Patient-Reported Outcomes Measurement Information System Physical Function, P = .48), except for preoperative SANE scores, which had a greater baseline in the PRP group (P < .001). Using both observed data as well as repeated measure analysis of variance model to estimate for missing data after baseline, we found there were no differences in visual analog scale pain scores nor patient-reported outcome scores at any time point. There was similarly no difference in change from baseline for SANE scores. There was no difference in rate of revision surgery between the 2 cohorts (P = .66). Conclusions: Based on the results of this study, intraoperative PRP injection onto the capsule at the time of capsular closure does not improve outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Level of Evidence: Level III, retrospective comparative study.

Visual Estimation of Length by Orthopaedic Surgeons: How Accurate Are Lengths Estimated in Digital Images Compared to In-Person Estimations?

Orthopaedic surgeons are frequently required to make estimations, often without the use of measuring tools, including the lengths of wounds, incisions, bone fragments, and soft tissue defects. To evaluate the accuracy of these estimations, simulated wounds of randomized lengths were drawn on a healthy volunteer. Resident and attending physicians estimated the length of each wound via digital photograph and subsequently in person. Comparison of digital photograph versus in-person estimation was completed with paired t-test. The accuracy of estimation by experience level was assessed using Spearman rank. Accuracy was higher with in-person measurement compared with digital photographs, but overall low in both settings. There was no correlation between better accuracy and more experience in either setting. In order to properly guide treatment decisions and document physical exam findings, a ruler should be used rather than visual estimation alone. Likewise, clinical photographs used for patient care should always include a ruler. (Journal of Surgical Orthopaedic Advances 30(2):108-111, 2021).

Chondrotoxicity of Local Anesthetics: Liposomal Bupivacaine Is Less Chondrotoxic than Standard Bupivacaine.

OBJECTIVE: The purpose of this study is to determine whether (1) liposomal bupivacaine is chondrotoxic; (2) the chondrotoxicity of liposomal bupivacaine differs from standard bupivacaine; and (3) chondrotoxic effects are time dependent. MATERIALS AND METHODS: We obtained 72 10 mm articular cartilage plugs from 12 fresh bovine distal femoral knee joints and exposed them to either saline, 0.5% bupivacaine, or liposomal bupivacaine for either 30 or 90 minutes. Twenty-four hours after treatment, chondrocyte viability was measured with the use of a fluorescent live/dead assay. An ANOVA test of variance was performed followed by a Holm-Sidak test to make pairwise comparisons across conditions. Student's t-test was used to compare means. RESULTS: Percent viability of cells exposed to liposomal bupivacaine for 30 minutes was less versus saline control (53.9% ± 21.5% vs. 73.7 ± 18.4%, p=0.035), and this remained significant at 90 minutes (49.1% ± 20.3% vs. 67.2% ± 25.6%, p < 0.001). Liposomal bupivacaine had less chondrotoxic effects when compared with bupivacaine after 90 minutes, with greater viability (49.1% ± 20.3% vs. 21.4% ± 14.0%, p=0.003). Chondrotoxicity was found to be time dependent within the bupivacaine group (percent viability at 30 min: 45.5 ± 18.2%, 90 min: 21.4 ± 14.0%, p=0.001); however, liposomal bupivacaine did not demonstrate a significant time-dependent chondrotoxic relationship (p=0.583). CONCLUSIONS: Bupivacaine and liposomal bupivacaine are both toxic to chondrocytes. Liposomal bupivacaine is less chondrotoxic than standard bupivacaine and does not demonstrate a time-dependent toxicity.

Limb Salvage for Musculoskeletal Tumors in the Austere Environment: Review of the Literature With Illustrative Cases Regarding Considerations and Pitfalls.

Although there is literature discussing the treatment of acute and chronic trauma in austere environments, no literature or guidelines for the treatment of musculoskeletal tumors exist. This series discusses case examples with considerations and pitfalls of performing limb-salvage surgery in an underserved location. Cases of limb-salvage surgery performed by the same orthopaedic oncologist in Haiti and the Dominican Republic are discussed with a review of the literature on limb salvage for musculoskeletal tumors in developing nations. All patients successfully underwent limb-salvage surgery after considering multiple factors including tumor type and location. Patients with metastatic disease, likelihood of substantial blood loss, and poor health were not candidates for limb-salvage surgery. Medical missions and the development of partnerships with established training programs make limb salvage a greater possibility. Knowledge of the facility, anesthesia support, and instrumentation available is vital. Advanced imaging, blood products, and allograft are likely unavailable or difficult to obtain. Established continuity of care is necessary, and training of the local surgeon should be provided. Surgery should only be considered if it is safe and provides more of a benefit to the patient than an amputation.

Slipped Capital Femoral Epiphysis in an Adult Patient With Kabuki Syndrome.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is a condition which predominantly occurs in adolescents. SCFE is extremely rare in adults, and nearly all previous reported cases have been associated with an endocrine disorder. METHODS: We present a case of a 19-year-old man with Kabuki syndrome who was diagnosed with an unstable SCFE requiring surgical fixation. A literature search on PubMed and Google Scholar was done looking for all published cases of delayed-onset SCFE. All previous reported cases were reviewed to determine the likely cause of the SCFE. RESULTS: No previous cases of SCFE were described in patients with Kabuki syndrome. Literature review revealed 27 articles describing 32 cases of delayed-onset SCFE. Thirty-one of these cases were associated with endocrine disorders or pituitary tumors. Endocrine disorders associated with delayed-onset SCFE included hypothyroidism, hypogonadism, and panhypopituitarism. Pituitary adenomas and craniopharyngiomas were also associated with delayed-onset SCFE. DISCUSSION: This is the first reported case of SCFE in a patient with Kabuki syndrome. Kabuki syndrome is a genetic disorder known to cause delayed growth, resulting in delayed physeal closure, placing the patients at risk of SCFE even into adulthood. The literature search revealed that nearly all previously described delayed-onset SCFE cases were associated with endocrine disorders or pituitary tumors. We recommend that all patients diagnosed with delayed-onset SCFE be evaluated for endocrine disorders, pituitary tumors, and/or genetic disorders which can cause delayed skeletal maturation as these disorders can range from severe endocrine disorders to intracranial tumors.

Intrapelvic Femoral Head Dislocation without Associated Proximal Femur Fracture: A Case Report and Description of Closed Reduction Technique.

Traumatic hip dislocations are potentially devastating injuries, especially in young patients, and require emergent orthopedic treatment. Given the significant amount of energy required to cause these injuries, a high index of suspicion is necessary to identify related injuries. The associated injuries, direction of dislocation, and time between injury and reduction represent the known prognostic factors, based on limited available research. Intrapelvic hip dislocations represent an uncommon variant of the traumatic hip dislocation, with all previously reported cases involving ipsilateral proximal femur fractures. We present a case of intrapelvic femoral head dislocation without an associated proximal femur fracture, as well as the maneuvers used to treat the patient via a closed reduction.

Imaging activity in astrocytes and neurons with genetically encoded calcium indicators following in utero electroporation.

Complex interactions between networks of astrocytes and neurons are beginning to be appreciated, but remain poorly understood. Transgenic mice expressing fluorescent protein reporters of cellular activity, such as the GCaMP family of genetically encoded calcium indicators (GECIs), have been used to explore network behavior. However, in some cases, it may be desirable to use long-established rat models that closely mimic particular aspects of human conditions such as Parkinson's disease and the development of epilepsy following status epilepticus. Methods for expressing reporter proteins in the rat brain are relatively limited. Transgenic rat technologies exist but are fairly immature. Viral-mediated expression is robust but unstable, requires invasive injections, and only works well for fairly small genes (<5 kb). In utero electroporation (IUE) offers a valuable alternative. IUE is a proven method for transfecting populations of astrocytes and neurons in the rat brain without the strict limitations on transgene size. We built a toolset of IUE plasmids carrying GCaMP variants 3, 6s, or 6f driven by CAG and targeted to the cytosol or the plasma membrane. Because low baseline fluorescence of GCaMP can hinder identification of transfected cells, we included the option of co-expressing a cytosolic tdTomato protein. A binary system consisting of a plasmid carrying a piggyBac inverted terminal repeat (ITR)-flanked CAG-GCaMP-IRES-tdTomato cassette and a separate plasmid encoding for expression of piggyBac transposase was employed to stably express GCaMP and tdTomato. The plasmids were co-electroporated on embryonic days 13.5-14.5 and astrocytic and neuronal activity was subsequently imaged in acute or cultured brain slices prepared from the cortex or hippocampus. Large spontaneous transients were detected in slices obtained from rats of varying ages up to 127 days. In this report, we demonstrate the utility of this toolset for interrogating astrocytic and neuronal activity in the rat brain.

Imaging activity in neurons and glia with a Polr2a-based and cre-dependent GCaMP5G-IRES-tdTomato reporter mouse.

New strategies for introducing genetically encoded activity indicators into animal models facilitate the investigation of nervous system function. We have developed the PC::G5-tdT mouse line that expresses the GCaMP5G calcium indicator in a Cre-dependent fashion. Instead of targeting the ROSA26 locus, we inserted the reporter cassette nearby the ubiquitously expressed Polr2a gene without disrupting locus integrity. The indicator was tagged with IRES-tdTomato to aid detection of positive cells. This reporter system is effective in a wide range of developmental and cellular contexts. We recorded spontaneous cortical calcium waves in intact awake newborns and evaluated concentration-dependent responses to odorants in the adult olfactory bulb. Moreover, PC::G5-tdT effectively reports intracellular calcium dynamics in somas and fine processes of astrocytes and microglial cells. Through electrophysiological and behavioral analyses, we determined that GCaMP5G expression had no major impact on nervous system performance. PC::G5-tdT will be instrumental for a variety of brain mapping experiments.