Computed Tomography Scan Versus Saline Load Test in the Detection of Traumatic Arthrotomies of the Ankle: A Cadaveric Study.

OBJECTIVE: To evaluate the sensitivity and ability of computed tomography (CT) scan for diagnosing traumatic ankle arthrotomies compared with that of the saline load test (SLT). METHODS: Eleven cadaveric ankles were included in this study. Before intervention, a CT scan was obtained to confirm the absence of intra-articular air. Arthrotomies were created at the anterolateral, posterolateral, anteromedial, and posteromedial aspects of the ankle under fluoroscopic visualization. A postarthrotomy and postrange of motion CT scan was obtained to evaluate for the presence of intra-articular air. Each ankle then underwent a SLT with 60 mL of saline, where volumes provoking extravasation were recorded. RESULTS: Of the 11 included ankles, intra-articular air was detected in all 11 ankles by CT scan. All 11 ankles also demonstrated extravasation of saline through the arthrotomy site during SLT. Thus, the sensitivity for both CT scan and SLT for detecting ankle traumatic arthrotomy was 100%. The mean volume of saline needed for extravasation was 7.7 mL, with a range of 3-22 mL and a SD of 5.4. CONCLUSIONS: Given that CT scan was equally as sensitive to the SLT, this study presents good evidence that CT scan may be used for the detection of ankle traumatic arthrotomies.

Computed Tomography Scan Versus Saline Load Test for Detection of Traumatic Shoulder Arthrotomy: A Cadaveric Study.

OBJECTIVES: Traumatic shoulder arthrotomy (TSA) is a rare injury that is commonly detected through saline load test (SLT). There are no studies that have studied the ability of computed tomography (CT) scan to detect a TSA. The purpose of this study is to determine the ability of CT scan to detect a TSA and compare it with the SLT. METHODS: Twelve cadaveric shoulders were included in the study. Before intervention, a CT scan was conducted to determine presence of intra-articular air. After confirmation that no air was present, an arthrotomy was made at the anterior or posterior portal site. A CT was obtained postarthrotomy to evaluate for intra-articular air. Each shoulder then underwent an SLT to assess the sensitivity of SLT and the volume needed for extravasation. RESULTS: Twelve shoulders were included after a pre-intervention CT scan. Six shoulders received an arthrotomy through the anterior portal and six shoulders received an arthrotomy through the posterior portal. After the arthrotomy, air was visualized on CT scan in 11 of the 12 shoulders (92%). All 12 shoulders demonstrated extravasation during SLT. The mean volume of saline needed for extravasation was 29 mL with an SD of 10 and range of 18-50 mL. CONCLUSIONS: CT scan is a sensitive modality (sensitivity of 92%) for detection of TSA. In comparison, SLT is more sensitive (sensitivity of 100%) and outperforms CT scan for the diagnosis of TSA in a cadaveric model. Further research is needed to solidify the role that CT imaging has in the diagnosis of TSAs.

Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods.

INTRODUCTION: Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically. METHODS: A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded. RESULTS: The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively. CONCLUSION: The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.

CT Scan versus Saline Load Test for Detection of Traumatic Wrist Arthrotomy.

Background Traumatic arthrotomy of the wrist is most commonly detected using the saline load test (SLT); however, little data exists on the effectiveness of the SLT to this specific joint. The use of computed tomography (CT) scan has been validated as an alternative method to detect traumatic arthrotomy of the knee, as the presence of intra-articular air can be seen when there is violation of the joint capsule. Question/Purpose The purpose of this study was to determine the ability of CT scan to identify arthrotomy of the wrist capsule and compare the diagnostic performance of CT versus traditional SLT. Materials and Methods Ten fresh frozen cadavers which had undergone transhumeral amputation were initially used in this study. A baseline CT scan was performed to ensure no intra-articular air existed prior to intervention. After baseline CT, an arthrotomy was created at the 6R radiocarpal portal site. The wrists then underwent a postarthrotomy CT to identify the presence or absence of intra-articular air. Following CT, the wrists were subjected to the SLT to detect the presence of extravasation from the arthrotomy. Results Nine cadavers were included following baseline CT scan. Following arthrotomy, intra-articular air was visualized in eight of the nine cadavers in the postarthrotomy CT scan. Air was seen in the radiocarpal joint in eight of the nine wrists; midcarpal joint in seven of the nine wrists; and distal radioulnar joint in six of the nine wrists. All wrists (nine of the nine) demonstrated extravasation during the SLT. The mean volume of extravasation occurred at 3.7 mL (standard deviation = 2.6 mL), with a range of 1 to 7 mL. Conclusion CT scan correctly identified eight of the nine simulated traumatic arthrotomies. Injection of 7 mL during the SLT was necessary to identify 100% of the arthrotomies. Clinical Relevance CT scan is a sensitive modality for detection of traumatic arthrotomy of the wrist in a cadaveric model.

Lemonade from Lemons-Using COVID Downtime to Teach Essential Telemedicine Skills.

As a result of the COVID-19 pandemic, the use of telemedicine has rapidly accelerated. Our orthopaedic department created a telemedicine educational program for residents using standardized patient scenarios. Training residents to use telemedicine will help them navigate through unforeseen issues that otherwise may have never been a consideration. This is not only useful for today's climate but also potentially for the duration of their careers.

Bilateral Ulnar Styloid Impaction Syndrome Treated with Ulnar Styloidectomy.

Background Ulnar styloid impaction syndrome (USIS) is produced by the tip of an oversized ulnar styloid inappropriately contacting the triquetrum. This condition results in chondromalacia, synovitis, and ulnar-sided wrist pain. Case Description We report a rare case of bilateral USIS that presented with a prolonged course. The patient's symptoms resolved in both wrists following two separate ulnar styloidectomy procedures. Literature Review Our case differs from previous reports in that it involves a patient whose own history of USIS led to a timelier diagnosis of the same disease in the contralateral wrist. To the best of our knowledge, there are no prior reports of bilateral USIS. Clinical Relevance USIS remains an uncommon cause of ulnar-sided wrist pain and a particularly difficult diagnosis to confirm. Here, we illustrate that this syndrome can be confidently approached using a combination of careful attention to patient history, physical examination, and various imaging methods.

Financial impact of total hip arthroplasty: a comparison of anterior versus posterior surgical approaches.

BACKGROUND: Compared to the posterior approach, the anterior approach to total hip arthroplasty (THA) offers the potential for an accelerated recovery secondary to less dissection and therefore less pain in the immediate postoperative period. This offers potential financial benefit through a reduction in length of stay. This study retrospectively reviewed 98 anterior approach and 69 posterior approach THA cases (N = 167) to compare perioperative outcomes and cost-effectiveness. METHODS: Patients who underwent anterior approach THA were discharged sooner than those who underwent posterior approach THA. RESULTS: The anterior approach was also less expensive per patient than the posterior approach. Overall, differences in perioperative outcomes between these approaches to THA are less robust than previously reported. There is a significant difference in operative cost between these surgical approaches. CONCLUSIONS: Although there are many sources for this difference in cost, the predominant contributor is surgeon implant preference.

Social and Cultural Barriers: Understanding Musculoskeletal Health Literacy: AOA Critical Issues.

The Institute of Medicine considers limited health literacy a "silent epidemic," as approximately half of Americans lack the competencies necessary for making informed decisions regarding their health. Limited health literacy substantially impedes the effective dissemination and comprehension of relevant health information, and also complicates communication, compromises care, and leads to worse patient outcomes. Poor health, early death, and worse control of chronic conditions have also been associated with limited health literacy. Unfortunately, physicians often struggle to identify those with limited health literacy, which can have adverse effects on the physician-patient relationship. In this article, we discuss the meaning of health literacy,the risk factors for and consequences of limited health literacy, orthopaedic-specific implications and investigations, and the strategies orthopaedic surgeons can utilize to improve health literacy and communication.

Musculoskeletal Health Literacy in Patients With Foot and Ankle Injuries: A Cross-Sectional Survey of Comprehension.

PURPOSE: Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle-related complaints, as these individuals may be at increased risk for inferior outcomes. METHODS: In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle-related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values <.05 were considered significant. RESULTS: The mean LiMP score was 5 ± 2.06. Limited musculoskeletal health literacy was seen in 32% of participants (18/56). Although gender (male), a current or prior employment in a health care field, and having previously seen a physician for a musculoskeletal complaint correlated with higher literacy rates, these values did not reach statistical significance (P > .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy (P = .008, P = .04, respectively). CONCLUSIONS: Approximately one third of patients presenting to the ED with foot and ankle-related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at $1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable. LEVELS OF EVIDENCE: Prognostic, Level IV study.

Preliminary trauma radiographs misrepresent pubic diastasis injuries.

The goal of this study was to evaluate the role of portable primary trauma survey radiographs in the evaluation and management of anteroposterior (AP) compression pelvic injuries. A retrospective analysis was conducted at a level I academic trauma center. Twenty-seven adults with AP compressive class pelvic ring injuries who received both portable pelvic radiographs and pelvic computed tomography (CT) imaging in an unbound pelvic state were included. Three orthopedic surgeons performed independent measurements of diastasis on portable pelvic radiographs and coronal pelvic CT reconstructions. Measurement techniques were standardized among observers and were repeated after 8 weeks to assess intraobserver reliability. Nonoperative vs operative treatments were correlated with the initial magnitude of pelvic injury on CT and portable radiographic images. Independent measurements of diastasis on both radiographs and CT scans showed excellent intraobserver reliability (average correlation coefficient, 0.986) and interobserver reliability (average correlation coefficient, 0.979). Compared with diastasis measurements on CT scans, portable pelvic radiographs overestimated diastasis by an average of 49%, or 12.6 mm (P<.0001; 95% confidence interval, 9.6-15.6). Portable pelvic films were less precise than standard pelvic radiographs in measuring the size of femoral head controls (R(2)=0.919 vs 0.759; P=.004). In 12 of the 27 patients evaluated, radiographic indications for operative pelvic fixation were met by portable radiographs but not CT scans, and 11 of these patients ultimately underwent operative fixation. Portable AP pelvic radiographs may distort and exaggerate pelvic bony injuries, especially those involving anterior pelvic structures. Surgeons should use caution when making management decisions based on preliminary portable pelvic radiographs.

Management of chronic musculoskeletal pain.

Chronic musculoskeletal pain results from a complex interplay of mechanical, biochemical, psychological, and social factors. Effective management is markedly different from that of acute musculoskeletal pain. Understanding the physiology of pain transmission, modulation, and perception is crucial for effective management. Pharmacologic and nonpharmacologic therapies such as psychotherapy and biofeedback exercises can be used to manage chronic pain. Evidence-based treatment recommendations have been made for chronic pain conditions frequently encountered by orthopaedic surgeons, including low back, osteoarthritic, posttraumatic, and neuropathic pain. Extended-release tramadol; select tricyclic antidepressants, serotonin reuptake inhibitors, and anticonvulsants; and topical medications such as lidocaine, diclofenac, and capsaicin are among the most effective treatments. However, drug efficacy varies significantly by indication. Orthopaedic surgeons should be familiar with the widely available safe and effective nonnarcotic options for chronic musculoskeletal pain.

Volar ligament repair for radiocarpal fracture-dislocation.

Radiocarpal fracture-dislocations are uncommon injuries, comprising a spectrum of trauma to the capsuloligamentous complex and osseous structures of the radiocarpal joint along with the adjacent structures. Management guidelines are derived from limited case series and expert opinions. An understanding of the relevant anatomy suggests that restoration of an anatomically reduced joint in conjunction with repair or reconstruction of the osseous and soft tissue structures optimizes outcome. Special consideration should be given to repair of the radial styloid, intercarpal ligaments, and radiocarpal capsuloligamentous complex. The authors report 2 patients with radiocarpal fracture-dislocations in which reduction and stabilization of the carpus was achieved using suture anchor fixation of the volar extrinsic radiocarpal ligaments.

Multiple oxidative stress-response members of the Adapt78 family.

Adapt78 is an oxidative and calcium stress-response gene. Its protein product is a potent natural inhibitor of the intracellular calcium signaling protein calcineurin. Much of what is known about Adapt78 protein is based on cell-transfection studies. Toward understanding natural endogenous Adapt78, we used an antibody raised against cellular Adapt78 and recently determined that endogenous Adapt78 protein, like its mRNA, is oxidative and calcium stress responsive. Here we report the identification of a second endogenous form of this protein family of 41 kDa. Subcellular fractionation of human HeLa cells revealed that in contrast to results of previous transfection studies, most endogenous Adapt78, characterized as 29 and 41 kDa electrophoretic doublets, resides in the cellular cytosol. The 41 kDa form of Adapt78 was abundant and found to exhibit many characteristics in common with the previously reported oxidative stress-responsive 29 kDa form, including hypo- and hyperphosphorylation variants, rapid loss of the hypophosphorylated form following oxidative stress, response to various kinase and phosphatase inhibitors, and localization. However, it also exhibited some unique characteristics, most notably the lack of calcium inducibility. Finally, the 29 kDa form exhibited a much shorter half-life and strong stabilization following oxidant exposure compared with the 41 kDa Adapt78 form. These data reveal the presence of a novel oxidative stress-responsive 41 kDa Adapt78 species, lend further insight into the Adapt78 family of proteins and their distribution, and challenge previous conclusions obtained using transfection protocols.