Predicting Contralateral Surgery for Trapeziometacarpal Arthrosis Within 5 Years

PURPOSE

Symptomatic trapeziometacarpal (TMC) joint arthritis is a common cause of hand pain. It is unknown how many patients ultimately elect to have bilateral surgery for TMC arthritis. In this study, we assessed the frequency and predictive factors for contralateral TMC surgery in patients who underwent prior TMC surgery.

METHODS

We identified 712 patients who underwent primary surgery for TMC arthritis with a follow-up period of 5 years. We collected demographic, surgical, and follow-up data. Prediction models for contralateral surgery using a training and testing data set were created with multivariable logistic regression and random forest classifier algorithms.

RESULTS

At the time of initial surgery, 230 patients had bilateral thumb pain (32%), but only 153 patients ultimately had an operation for TMC arthritis on the contralateral side within 5 years (21% of 712 total patients and 67% of 230 patients with bilateral pain). Common predictive factors between both models for contralateral surgery were younger age (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.93-0.98), bilateral thumb pain (OR = 3.76; 95% CI, 2.52-5.65), and anxiety disorders (OR = 1.84; 95% CI, 1.11-3.03).

CONCLUSIONS

In our study, we found that the rate of contralateral surgery was 21% in patients who underwent prior TMC surgery. Predictive factors for future contralateral surgery included younger age, bilateral thumb pain, and anxiety disorder at the time of initial surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

From Data to Decisions: How AI Is Revolutionizing Clinical Prediction Models in Plastic Surgery

SUMMARY

The impact of clinical prediction models within Artificial Intelligence (AI) and machine learning (ML) is significant. With its ability to analyze vast amounts of data and identify complex patterns, machine learning has the potential to improve and implement evidence-based plastic, reconstructive, and hand surgery. Among others, it is capable of predicting the diagnosis, prognosis, and outcomes of individual patients. This modeling aids daily clinical decision making, most commonly at the moment, as decision-support.Therefore, the purpose of this paper is to provide a practice guideline to plastic surgeons implementing AI in clinical decision-making or setting up AI research to develop clinical prediction models using the 7-step approach and the ABCD validation steps of Steyerberg et al. Secondly, we describe two important protocols which are in the development stage for AI research: 1) the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) checklist, and 2) The PROBAST checklist to access potential biases.

Complications and Unplanned Reoperation After Thumb Metacarpophalangeal Arthrodesis

PURPOSE

Arthrodesis of the metacarpophalangeal (MCP) joint of the thumb is a common procedure to treat arthritis or instability. Studies reporting hardware complications and nonunion rates after thumb MCP joint arthrodesis report on small sample sizes. We aimed to describe the hardware complication rate, the nonunion rate, and the number of thumbs that achieve union among patients undergoing thumb MCP joint arthrodesis.

METHODS

A database spanning 5 urban hospitals in a single metropolitan region in the United States was searched for patients who underwent thumb MCP joint arthrodesis between January 1, 2004 and January 1, 2020. After reviewing patient records, we identified 122 thumbs that underwent MCP joint arthrodesis and had a minimum follow-up of 90 days. The primary outcome was unplanned reoperation after hardware complications and nonunion. Second, the number of thumbs that achieved radiographic union was reported for the tension band and screw fixation arthrodesis group.

RESULTS

Twenty-two (18%) out of 122 thumbs had hardware complications after thumb MCP joint arthrodesis, and 11 (9%) out of 122 thumbs developed a nonunion. Patients who underwent screw fixation arthrodesis had no events of hardware complications and subsequent hardware removal. The nonunion rate was 9/65 (14%) in the tension band arthrodesis group and 2 (4%) of 45 in the screw fixation arthrodesis group. Of the thumbs that had available radiographs to assess the healing of the arthrodesis, 34 (81%) of 42 were radiographically united in the tension band arthrodesis group and 29 (91%) of 32 in the screw fixation group.

CONCLUSIONS

Our data suggest that screw fixation has fewer hardware complications and a lower reoperation rate than tension band arthrodesis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

DRUJ Capsular Release for Forearm Rotational Limitation: Surgical Technique and Case Series

BACKGROUND

Forearm stiffness can be caused by distal radioulnar joint (DRUJ) capsular contractures, which can occur after trauma such as a distal radius fracture. In this setting, a DRUJ capsular release may help improve forearm rotation, but the long-term functional outcomes remain unknown. The purpose of this case series is to investigate the short-term improvement in total pronosupination arc range of motion and long-term patient-reported outcomes (PROs) after DRUJ capsular release.

METHODS

We performed a retrospective review of consecutive patients who underwent DRUJ capsular release. Range of motion prior to surgery and at final short-term follow-up was collected and analyzed with a Wilcoxon signed-rank test. Patient-reported outcomes including QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores were obtained as medians with interquartile range (IQR), while patient satisfaction was measured on a 4-point Likert scale.

RESULTS

Five patients met the inclusion criteria with a median short-term follow-up of 5.5 (IQR: 4.3-10.3) months. The median preoperative supination was 25° (IQR: 0°-35°), and the median postoperative supination was 50° (IQR: 40°-60°; P = .03). The median preoperative pronation was 45° (IQR: 10°-60°), and the median postoperative pronation was 70° (IQR: 60°-80°; P = .04). After the long-term median follow-up of 10.9 (IQR 9.7-11.2) years, all the patients were satisfied or very satisfied with the results of the surgery. The median QuickDASH score was 13.6 (IQR: 9.1-20.5), and the median PROMIS UE score was 46.5 (IQR: 43.8-47.7).

CONCLUSIONS

Distal radioulnar joint capsular release can improve pronation and supination in patients with posttraumatic forearm stiffness and is associated with high long-term patient satisfaction.

Intra-abdominal bacterial growth and detection of bacteria by fluorescence in situ hybridization in patients with secondary peritonitis

Background

Patients with secondary peritonitis are treated by surgery and intravenous antibiotics depending on the micro-organisms cultured from abdominal fluid samples. However, such samples may not be representative of the origin of the intra-abdominal infection. Therefore, this study determined (1) whether different micro-organisms are cultured from abdominal fluid, peritoneum and blood samples, and (2) whether fluorescence in situ hybridization (FISH), with 16S ribosomal RNA-targeted probes applied on peritoneum samples, is more efficient than standard culturing techniques.

Methods

In a pilot study, samples of abdominal fluid, peritoneum and blood were obtained from two groups of patients: six patients with secondary peritonitis (peritonitis group) and five patients without peritonitis (control group).

Results

Standard culturing techniques revealed coagulase-negative staphylococci (CNS) and yeast in abdominal fluid samples in three of six patients; Escherichia coli, enterococci, CNS and Citrobacter in peritoneum samples in five of six patients; and no micro-organisms in the blood samples from the peritonitis group. In the control group, CNS were cultured from the abdominal fluid samples in one of five patients, while no micro-organisms were cultured from peritoneum samples and CNS were cultured from the blood samples in one of five patients. The FISH technique revealed a large number of various anaerobic bacteria in peritoneum samples in one of six patients in the peritonitis group. In the control group no bacteria were detected.

Conclusion

Micro-organisms cultured from abdominal fluid differ from those cultured from peritoneum samples. The FISH technique confirmed these findings in only one case. However, it is a promising technique for the identification and localization of bacteria causing secondary peritonitis.

Local treatment of generalised peritonitis in rats; effects on bacteria, endotoxin and mortality

OBJECTIVE

To assess the effect of debridement, intraoperative lavage with saline, and additional instillation of taurolidine or imipenem/cilastatin in rats with faecal peritonitis.

DESIGN

Laboratory study.

SETTING

University hospital, The Netherlands.

MATERIAL

60 male Wistar rats.

INTERVENTIONS

Rats were given an intraperitoneal injection of a faecal suspension containing Escherichia coli and Bacteroides fragilis. Six groups of 10: sham operation, debridement, debridement with saline lavage, debridement with saline lavage with intraperitoneal instillation of saline or taurolidine, or imipenem/cilastatin, were studied.

MAIN OUTCOME MEASURES

Bacterial growth and endotoxin concentration in abdominal exudate and plasma, abscess formation, and mortality.

RESULTS

Debridement temporarily reduced bacterial growth and the concentration of endotoxin in abdominal exudate, and delayed mortality. Lavage with saline further reduced bacterial growth and the endotoxin concentration. It also reduced the plasma endotoxin concentration, and mortality. Additional instillation of taurolidine did not reduce bacterial growth, but did initially reduce the endotoxin concentration in abdominal exudate and plasma. Instillation of imipenem/cilastatin, after debridement and lavage, significantly reduced all variables measured.

CONCLUSION

In rats with faecal peritonitis, debridement, lavage with saline, and additional instillation of imipenem/cilastatin, all have cumulatively reducing effect on bacterial growth, endotoxin concentrations, abscess formation, and mortality. Instillation of taurolidine reduces only the amount of endotoxin.

Haemophilus influenzae in lung explants of patients with end-stage pulmonary disease

In order to determine the presence and distribution of Haemophilus influenzae in lung tissue sections, we obtained lung explants from 49 lung transplant recipients with cystic fibrosis (CF) (n = 16), chronic obstructive pulmonary disease (COPD) including emphysema (n = 16), bronchiectasis (n = 5), pulmonary hypertension (n = 9), Langerhans cell histiocytosis (n = 1), and idiopathic pulmonary fibrosis (n = 2). Analysis was done by selective culturing, immunoperoxidase (IP) staining, and by polymerase chain reaction (PCR). H. influenzae was cultured from specimens of the lung explants from one CF and one COPD patient. IP staining of tissue sections was positive in 24 patients (10 CF patients, eight COPD patients, two bronchiectasis patients, and four patients with noninfectious pulmonary diseases). IP-positive tissue sections were PCR-positive, and IP-negative sections were PCR-negative. H. influenzae was more frequently detected in tissue sections of lung explants from CF and COPD patients than from patients with bronchiectasis or noninfectious pulmonary diseases. H. influenzae was diffusely present in the epithelium, the submucosa of the bronchi, the bronchioles, the interstitium, and the alveolar epithelium. H. influenzae was localized extracellularly alone and in bacterial clusters, and was also associated with macrophages in CF patients. The results of this study demonstrate that H. influenzae is often present in the lungs of patients with end-stage pulmonary disease, especially CF and COPD patients. H. influenzae is diffusely present in the respiratory epithelium and subepithelial layers of the lungs of these patients.

Effect of intraperitoneal antimicrobials on the concentration of bacteria, endotoxin, and tumor necrosis factor in abdominal fluid and plasma in rats

The efficacy of intraperitoneal instillation of antimicrobial agents in eliminating the bacterial contaminant in patients with generalized peritonitis remains controversial. We determined the effect of intraperitoneal instillation of taurolidine or imipenem on mortality, and on the concentration of bacteria, endotoxin, and tumor necrosis factor (TNF) in rats with intraperitoneally injected bacteria. Thirty rats were inoculated intraperitoneally with two enteric bacterial strains, followed by either taurolidine, saline, or imipenem. Abdominal fluid and blood were analyzed at different time intervals. The survival rate was highest in the imipenem group (p < 0.05). The bacterial concentration in abdominal fluid in the taurolidine and imipenem group was lower than in the saline group (p < 0.005), but the concentration in the imipenem group was lowest (p < 0.005). The endotoxin concentration in abdominal fluid and plasma in the taurolidine group was lower than in the other two groups (p < 0.05). The TNF concentration in abdominal fluid and plasma in the taurolidine group was lower than in the saline group (p < 0.05), whereas the concentration in the imipenem group was higher (p < 0.005). We conclude that topically applied taurolidine in rats with intraperitoneally injected bacteria may have a weak antibacterial effect, and lowered concentrations of endotoxin and TNF. Topically applied imipenem had a profound bactericidal activity but induced endotoxin and TNF release.

Gentamycin reduces bacteremia and mortality rates associated with the treatment of experimental peritonitis with recombinant tissue plasminogen activator

BACKGROUND

Recombinant tissue plasminogen activator (rtPA), administered intraperitoneally, reduces intra-abdominal abscess formation in rats with fecal peritonitis at the costs of increased mortality and early Escherichia coli bacteremia. It was determined whether or not mortality and bacteremia could be prevented by gentamycin in these rats.

STUDY DESIGN

Fecal peritonitis was induced by intraperitoneal injection of sterile feces contaminated with 10(8) (experiment 1) or 10(4) (experiment 2) colony forming units (cfu) E. coli and 10(4) cfu Bacteroides fragilis. Male Wistar rats were randomly assigned to receive either methyl hydroxy propyl cellulose (MHPC) gel alone (M) or 0.5 mg/mL rtPA dissolved in MHPC gel (M-tPA). Three hours after inoculation, one-half of the rats in each of these groups received 6 mg/kg gentamycin sulfate (G) intramuscularly (group M-G and M-tPA-G). At one, three, six, 12, and 24 hours after inoculation, blood cultures were taken. At five days after inoculation, intra-abdominal abscess formation was assessed and abscesses were cultured (experiment 2).

RESULTS

All rats in groups M and M-tPA in experiment 1 developed bacteremia and died within 24 hours. Bacteremia occurred significantly earlier in group M-tPA compared with group M (p < 0.05). Gentamycin significantly reduced the number of rats with bacteremia, the bacteria concentration in the blood, and mortality rates. Although in experiment 2 none of the rats developed bacteremia, gentamycin prevented mortality associated with the use of rtPA. The number of abscesses in groups M-tPA and M-tPA-G was significantly lower than in those in groups M and M-G (p < 0.01). Gentamycin did not influence the number of abscesses.

CONCLUSIONS

Gentamycin reduces bacteremia and mortality rates in rats with fecal peritonitis treated with rtPA intraperitoneally to prevent intra-abdominal abscess formation.

Effect of recombinant tissue plasminogen activator on intra-abdominal abscess formation in rats with generalized peritonitis

BACKGROUND

During generalized peritonitis, intraabdominal fibrin deposition is stimulated whereas fibrinolytic activity is reduced, which predisposes intra-abdominal abscess formation. We investigated the effects of increasing the intra-abdominal fibrinolytic activity on abscess formation by intra-abdominal administration of recombinant tissue plasminogen activator (rt-PA). Potential side effects, such as bacteremia and bleeding, were also assessed.

STUDY DESIGN

A rat model of generalized peritonitis, induced by intraperitoneal injection of sterile feces contaminated with 10(4) cfu per mL Escherichia coli (E. coli) and 10(4) cfu per mL Bacteroides fragilis, was used.

RESULTS

Rats treated with rt-PA dissolved in methyl hydroxy propyl cellulose (MHPC) gel (0.5 mg per mL), had significantly less intra-abdominal abscesses than rats in the control group, treated with either Ringer's lactate solution or MHPC gel alone (p < 0.01). Other than E. coli, cultures of abscesses revealed species originating from the intestine, demonstrating bacterial translocation. The mortality rate was significantly higher in the rats treated with rt-PA as compared with rats in the control group (p < 0.01), which was surprising considering the absence of bacteremia. By challenging the rats with a higher dose of E. coli, early bacteremia was observed in the rats treated with rt-PA, not related to increased mortality rates. Intraabdominal use of rt-PA was not associated with an increased incidence of bleeding events.

CONCLUSIONS

Recombinant tissue plasminogen activator prevents abscess formation in rats with generalized peritonitis. However, early bacteremia and increased mortality rates are serious drawbacks of the intra-abdominal use of rt-PA in this rat model.

Translocation of bacteria and endotoxin in organ donors

OBJECTIVE

To determine if bacterial translocation and endotoxin absorption occur in organ donors with an anatomically intact gastrointestinal tract.

DESIGN

Case series.

SETTING

Intensive care units in general and university hospitals.

PATIENTS

Twenty-one (multiple) organ donors.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Occurrence of factors that may promote bacterial translocation and/or endotoxin absorption. Bacterial concentration in mesenteric lymph nodes, abdominal fluid, blood, liver, lung, and spleen. Endotoxin level in abdominal fluid, peripheral blood, and portal blood. Anatomical integrity of the bowel wall.

RESULTS

Factors that may promote bacterial translocation and/or endotoxin absorption were present in all organ donors. Culture specimens revealed bacteria in 14 organ donors (67%). In 210 (81%) of 260 culture specimens, the bacteria isolated were identical to those isolated from the bowel content, demonstrating bacterial translocation. Endotoxin was found in nine (53%) of 17 abdominal fluid samples, in four (19%) of 21 peripheral blood samples, and in two (10%) of 21 portal blood samples. Light- and electron-microscopic examination of the bowel wall showed no anatomical abnormalities.

CONCLUSION

Bacterial translocation and endotoxin absorption are frequent among organ donors and may adversely influence organ function in transplant recipients and other critically ill patients.