Reconstructing a chronic, malunited Galeazzi fracture with distal radial ulnar joint instability: a simple, modified technique

A male in his 70s presented with a chronic malunited comminuted Galeazzi fracture dislocation, including angular malunion, radial shortening (1.3 cm ulnar-plus variance) and distal radioulnar joint (DRUJ) instability secondary to chronic dislocation with mechanical rotation block. A modified, single-stage radius corrective osteotomy with bone grafting technique to overcorrect radius length was employed, restoring normal DRUJ motion and stability by engaging the secondary DRUJ stabilisers without triangular fibrocartilage complex repair. DRUJ stability was restored via radius lengthening, engaging the DRUJ's secondary stabilisers, bypassing the need for complex ligamentous reconstruction. The patient returned to full activity. We recommend our simple yet effective approach to treat chronic, malunited Galeazzi fractures with DRUJ instability.

Multi-staged management of a mangled, exploded hand crush injury with long-term outcome: the critical link between surgery and therapy

A 38-year-old right-hand dominant man sustained a severe, work-related left-hand crushing injury. A multi-staged approach to salvage was employed in conjunction with aggressive hand therapy involvement for a successful, functional outcome. Now at approximately 5 years postinjury, the patient can perform daily activities, coaches sports and has returned to and maintained his full-time work position. Mangled, severe hand crush injuries warrant immediate treatment to debride non-salvageable tissues, stabilise and revascularise the hand in an effort to maximise reconstructive potential and functional capacity. It is critical to recognise that these cases require multiple stages of operative reconstruction with direct and ongoing involvement of hand therapy and pending degree of injury, rehabilitation often lasting months to years.

Multiple simultaneous venous flow-through free flap salvage for multifinger revascularisations

A 22-year-old man presented with traumatic crush-avulsion injuries to the left index, ring and small fingers resulting in complex soft tissue loss and acute three-finger ischaemia. The patient underwent immediate revascularisation and soft tissue resurfacing of the three digits using three separate venous flow-through free flaps performed in a single-stage operation. Continued follow-up after 9 months confirmed successful salvage of these three digits. Multiple simultaneous venous flow-through free flaps can be considered as a viable alternative reconstructive modality for traumatic multi-digit ischaemia where both graft-based digital artery reconstruction and soft tissue coverage are required for multiple digits.

Snapping Extensor Pollicis Longus Tendon Subluxation Secondary to Trapeziometacarpal Instability: Case Report and Technique

CASE

A 20-year-old woman presented with painful, snapping extensor pollicis longus (EPL) tendon subluxation and trapeziometacarpal (TMC) joint instability. Hemi-extensor carpi radialis longus (ECRL) tendon autograft stabilized the TMC joint, reconstructing the 1-2 intermetacarpal ligament. The subluxed EPL tendon was centralized over the dorsal first metacarpal by tightening the metacarpophalangeal radial sagittal band and creating a dorsal first metacarpal "neosheath" pulley using ECRL graft remnant. Postoperative rehabilitation included Spica bracing and immediate thumb interphalangeal joint exercises.

CONCLUSION

The patient's pain due to EPL tendon subluxation and TMC joint instability completely resolved. Postoperative thumb range of motion and function were equivalent to the nonaffected side.

Reconstructing Complex Open Back Wounds with a Modified Minimal-Access Keystone Flap: A Case Report

CASE

A 61-year-old patient was referred 12 days postoperative with complex, infected, and dehisced paraspinal wound. After debridement and revision of hardware, deep dead space was eliminated through bilateral paraspinal muscle flap advancement. After hardware coverage, a large skin and tissue defect remained. The defect was reconstructed using a modified Keystone flap, eliminating the lateral cutaneous incision. Our patient healed without complication.

CONCLUSION

The modified Keystone flap is an option for reconstructing spinal wound defects, yielding excellent tissue coverage and advancement, grants additional flap advancement if necessary because of elimination of the lateral cutaneous incision, and an overall pleasing aesthetic result.

Targeted muscle reinnervation following external hemipelvectomy or hip disarticulation: An anatomic description of technique and clinical case correlates

BACKGROUND

Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates.

METHODS

Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations.

RESULTS

A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft.

CONCLUSIONS

This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.

Preserving the Knee in the Setting of High Segmental Tibial Bone and Massive Soft-Tissue Loss Using Vascularized Distal Tibial Bone Docking and a Foot Fillet Flap: A Case Report

CASE

We discuss our reconstructive approach to avoid an above-knee amputation in a 33-year-old man presenting after lower extremity crush injury. We used a vascularized tibial bone flap and a foot fillet flap to restore length and joint functionality to the residual limb. The patient ambulates with good prosthetic fit on durable heel pad skin and 100° active knee motion.

CONCLUSION

This pairing of intramedullary nail with vascularized bone flap and fillet flap to address soft-tissue coverage and retain limb length is a useful tool in traumatic lower extremity injury management, providing an alternative technique for tibial bone graft stabilization with robust, sensate tissue coverage.

Cannabis Abuse or Dependence and Post-operative Outcomes After Appendectomy and Cholecystectomy

BACKGROUND

Though cannabis is gaining broader acceptance among society and a noted increase in legalization, little is known regarding its impact on post-operative outcomes. We conducted this study to quantify the relationship between cannabis abuse or dependence (CbAD) on post-operative outcomes after cholecystectomy and appendectomy.

METHODS

Using the 2013-2015 Nationwide Readmissions Database, we identified discharges associated with cholecystectomy or appendectomy from January 2013-August 2015. Patients were grouped by CbAD history. The primary outcomes were length of stay, serious adverse events, home discharge, and 30-day readmission. Propensity-score matching was used to account for differences between groups and all statistics accounted for the matched sample.

RESULTS

The final sample included 3288 patients with a CbAD history matched 1:1 to patients without a CbAD history (total sample = 6576). After matching, acceptable balance was achieved in clinical characteristics between groups. In the cholecystectomy cohort (n = 1707 pairs), CbAD patients had longer hospitalizations (3.5 versus 3.2 d, P 0.003) and similar rates of serious adverse events (6.1 versus 4.8, P 0.092), home discharge (96.1 vs 96.2, P 0.855), and readmission (8.3 versus 6.9, P 0.137). In the appendectomy cohort (n = 1581 pairs), CbAD patients had longer hospital stays (2.7 versus 2.5 d, P 0.024); more frequent serious adverse events (5.0 versus 3.5, P 0.041); and similar home discharge (96.8 vs 97.3, P 0.404) and readmission (5.4 versus 5.1, P 0.639) rates.

CONCLUSIONS

Patients with a history of CbAD in the cholecystectomy and appendectomy cohorts had slightly longer hospital stays, and patients with a history of CbAD in the appendectomy group displayed a slight increase in adverse events, but otherwise similar clinical outcomes without clinically significant increases in complications compared to patients without this history.

Outcome of Early Motion Protocol for Total Hand Replantation: 1- and 2-Year Postoperative Results

Introduction  We review the benefits of early motion protocols following replantation of a total right hand amputation at 1 and 2 years after replantation, and provide recommendations for postoperative management. Materials and Methods  Replantation of the entire right hand in zone-4 was performed and supported by rigid external fixation spanning the forearm and hand. An early active "place-and-hold" motion protocol was initiated within the first 3 postoperative days. Metacarpophalangeal joint extensors were tethered by the pins, limiting full excursion. This resulted in stiffness and extensor adhesions that required a staged extensor tenolysis; however, all joints remained supple. The early motion protocol prevented the need for significant flexor tenolysis and joint releases. Results  Early motion rehabilitation protocols can produce very successful results in complex replantation. The enhanced stability afforded by external fixation of the wrist allowed us to perform aggressive early rehabilitation. Conclusion  This case highlights the benefits of early active motion (limiting the need for complex joint and flexor tendon releases) and demonstrates the degree of extensor adhesions caused by even minor extensor tendon tethering. This aggressive rehabilitation approach can produce excellent range of motion, and likely limit the need for secondary tenolysis and joint release procedures.

Salvage of Failed Achilles Tendon Interposition Arthroplasty for DRUJ Instability After Ulnar Head Resection With Aptis Prosthesis

BACKGROUND

Historically, failed conservative treatment for irreparably damaged distal radioulnar joints (DRUJs) is treated via distal ulnar resection or DRUJ fusion; complications include disabling painful convergence of the radius and ulnar stump during lifting Various treatments for radioulnar impingement include distal radioulnar Achilles tendon allograft interpositional arthroplasty. This technique does not adequately prevent radioulnar impingement and we explore an alternative treatment.

METHODS

We report 7 adult patients who failed Achilles tendon interposition, subsequently treated with Aptis total DRUJ prostheses (mean follow-up, 26 months; range, 7-40).

RESULTS

Revision to Aptis prosthesis produced clinically stable DRUJ, improved grip strength and painless lifting capabilities, high patient satisfaction, and no major complications. All returned to daily activities and even recreational sports.

CONCLUSIONS

Tendon lacks biomechanical features key to the shock-absorbing function of cartilage-features it cannot deliver when used to prevent radioulnar convergence. We report Aptis DRUJ prosthesis as an alternative to the tendon allograft technique.

Adeno-Associated Virus 5 Transduces Adipose-Derived Stem Cells with Greater Efficacy Than Other Adeno-Associated Viral Serotypes

Adipose-derived stem cells (ASCs) have shown potential in the treatment of a myriad of diseases; however, infusion of cells alone is unlikely to provide the full range of potential therapeutic applications. Transient genetic manipulation of ASCs could increase their repair and regeneration characteristics in a disease-specific context, essentially transforming them into drug-eluting depots. The goal of this study was to determine the optimal parameters necessary to transduce ASCs with recombinant adeno-associated virus (rAAV), an approved gene therapy vector that has never been associated with disease. Transduction and duration of gene expression of the most common recombinant AAV vectors were tested in this study. Among all tested serotypes, rAAV5 resulted in both the highest and longest term expression. Furthermore, we determined the glycosylation profile of ASCs before and after neuraminidase treatment and demonstrate that rAAV5 transduction requires plasma membrane-associated sialic acid. Future studies will focus on the optimization of gene delivery to ASCs, using rAAV5 as the vector of choice, to drive biological drug delivery, engraftment, and disease correction.

The measurable cost of complications for outpatient cosmetic surgery in patients with mental health diagnoses

BACKGROUND

Mental health conditions, including psychiatric and substance abuse diagnoses, have been associated with poor postoperative outcomes, but no studies have quantified the relationship to date.

OBJECTIVE

The authors examine the association between mental health conditions and immediate postoperative outcomes as defined by further hospital-based acute care within 30 days of surgery.

METHODS

California State Ambulatory Surgery, Inpatient, and Emergency Department Databases were used to identify all adult patients undergoing outpatient cosmetic plastic surgery between January 2007 and October 2011. Patients were subgrouped by the presence of mental health or substance abuse conditions. Primary outcome was the need for hospital-based acute care (admission or emergency department visit) within 30 days after surgery. Multivariable logistic regression models compared outcomes between groups.

RESULTS

Of 116,597 patients meeting inclusion criteria, 3.9% and 1.4% had either a psychiatric or substance abuse diagnosis, respectively. Adjusting for medical comorbidities, patients with psychiatric disorders more frequently required hospital-based acute care within 30 days postoperatively than those without mental illness diagnoses (11.1% vs 3.6%; adjusted odds ratio [AOR], 1.78 [95% confidence interval, 1.59-1.99]). This was true both for hospital admissions (3.5% vs 1.1%; AOR, 1.61 [1.32-1.95]) and emergency department visits (8.8% vs 2.7%; AOR, 1.88 [1.66-2.14]). The most common acute diagnoses were surgical in nature, including postoperative infection, hemorrhage, and hematoma; the median hospital admission charge was $35 637. Similar findings were noted among patients with a substance abuse diagnosis.

CONCLUSIONS

Mental health conditions are independently associated with the need for more frequent hospital-based acute care following surgery, thus contributing to added costs of care. A patient's mental health should be preoperatively assessed and appropriately addressed before proceeding with any elective procedure.

LEVEL OF EVIDENCE

4.

Unusual presentation of hemochromatosis as isolated metacarpophalangeal joint osteoarthritis: a case report

BACKGROUND

Hemochromatosis, North America's most prevalent genetic disorder, tends to present with an insidious onset and subtle, yet characteristic findings. Patients tend to present with both constitutional symptoms and end-organ effects.

METHODS

Clinical criteria such as history, physical examination, imaging criteria with focused radiologic constellations, and laboratory findings were used for diagnosis.

RESULTS

We report the case of a man who lacked classic systemic symptoms, but instead presented with isolated metacarpophalangeal joint disease and characteristic radiologic findings. The diagnosis was confirmed by serum iron studies and subsequent genetic work-up.

CONCLUSIONS

A high index of clinical suspicion is required to diagnose early disease; better prognostic responses are expected with treatment of less severe disease. Hand surgeons should be aware of the characteristic findings for this rare presentation so proper treatment can be initiated early.

The mechanism of bone resorption by cyclosporin: involvement of the NO-cGMP pathway

Treatment with cyclosporin A (CsA) following solid organ transplantations such as heart or liver generally results in bone loss. However, in vitro studies show that CsA inhibits bone resorption. Our previous in vivo animal studies demonstrated that the effects of nitric oxide (NO) on bone are biphasic; at high doses, NO increases bone resorption. In this study, we have examined in an in vitro setting to determine whether the bone loss caused by CsA administration is dependent on the NO-cyclic guanosine monophosphate (cGMP) pathway. Freshly isolated osteoclast-rich neonatal rat long bone marrow cells were added to 100 microM thick dentin sections that had been seeded with neonatal-rat calvarial osteoblasts. These co-cultures were maintained for 48 hrs in a basal medium with CsA (1, 5, and 10 microg/ml), both alone and with either L-Arginine (NO substrate; 10-3M), L-NAME (NO synthase enzyme inhibitor; 10-4M), or the combination of the two. The cultures were then fixed in cold 95% ethanol and stained with tartrate resistant acid phosphatase (TRAP) to identify osteoclasts and sites of osteoclastic resorption. Preparations were analyzed using an automated histomorphometry software package. Scanning electron microscopy affirmed that the areas identified by light microscopy as resorption sites contained osteoclastic lacunae. CsA inhibited bone resorption dose-dependently. CsA at 10 microg/ml produced a 90% inhibition of bone resorption (control = 5.5 -/+2.0%; CsA = 0.64 -/+ 0.09=). L-Arginine reversed this inhibition by 90% (Arg + CsA = 4.23 -/+ 1.57%; CsA = 0.64 -/+ 0.09%). The application of NOS inhibitor L-NAME inhibited bone resorption by 87% (Arg + CsA + L-NAME = 0.55 -/+ 0.14%; Arg + CsA = 4.23 -/+ 1.5%). We conclude that NO-cGMP pathway is involved in the CsA induced bone loss.

A novel pharmacological approach of musculoskeletal losses associated with simulated microgravity

Exposure to microgravity (weightlessness) is known to cause rapid bone and muscle losses. We have used the hind limb-suspended (HLS) rat model to simulate microgravity-induced musculoskeletal losses in order to assess resulting hormonal changes and to develop a novel pharmacological countermeasure. Previously, we demonstrated significant decreases in circulatory hormonal levels [serum thyroxin, 1,25(OH)2 vitamin D (p<0.05), and serum testosterone (p<0.001)] in HLS rats. Both thyroxin and 1,25(OH)2 vitamin D levels returned to normal soon after removal from HLS, while testosterone levels matched normal levels only after a further 3-4 weeks. However, even by day 42, bone mineral density (BMD) remained significantly lower, although serum hormones were back to normal. Because serum testosterone levels become undetectable in HLS rats, we hypothesized that the replacement of testosterone during HLS could prevent musculoskeletal losses. Based on these data, an intervention study was carried out to assess the efficacy of testosterone and synthetic anabolic steroid, nandrolone decanoate (ND), in prevention of weightlessness-induced musculoskeletal losses. HLS rats (control) had a significant reduction of muscle volume (42.9 -/+ 3.0, versus 56 -/+ 1.8 in ground control rats; p<0.01). Both testosterone and ND treatments prevented this muscle loss (51.5 -/+ 2 cm(3) and 51.6 -/+ 1.2, respectively; a 63% improvement, p<0.05). Similarly, BMD of the placebo-treated HLS rats was significantly lower than that of ground control rats (0.416 -/+ 0.011 versus 0.354 -/+0.014, p<0.05), and testosterone and ND prevented this bone loss (0.404 -/+ 0.013 versus. 0.409 -/+ 0.011, respectively). These data suggest that both testosterone and ND therapy can minimize the musculoskeletal losses associated with exposure to simulated weightlessness. Experiments using the combination of bisphosphonate and testosterone demonstrated complete protection of both muscle and bone in these HLS rats. Therefore, considering that: 1) testosterone is anabolic to osteoblasts and muscle cells and also decreases the rate of bone turnover, 2) serum testosterone levels are markedly suppressed in simulated weightlessness, and 3) testosterone replacement therapy prevented musculoskeletal losses in HLS rats, we propose that the musculoskeletal losses observed in this animal model (i.e., simulated microgravity) are related to their testosterone deficiency. Since serum sex hormones levels are markedly reduced in this model of simulated microgravity, androgen replacement with a bisphosphonate seems to be a rational counter.

Simulated weightlessness-induced attenuation of testosterone production may be responsible for bone loss

This study examined the effects of simulated weightlessness on serum hormone levels and their relationship to bone mineral density (BMD). The tail-suspended (i.e., hindlimb suspended, HLS) rat model was used to simulate weightless conditions through hindlimb unloading to assess changes in hormonal profile and the associated bone loss. In the first study, 24 adult male rats were assigned to two groups with 12 rats being HLS for 12 d, and the remaining 12 rats serving as ground controls. On d 0, 6, and 12, blood samples were taken to estimate circulating hormone levels. HLS rats had significant reductions in testosterone, 1,25 (OH)2 vitamin D, and thyroxine levels by d 6 (p<0.01); their testosterone levels were almost undetectable by d 12 (p<0.001). Serum cortisol levels in these rats were elevated on d 6 (p<0.02), but returned to normal levels by d 12. No changes were observed with serum ionized calcium and other hormones examined, as well as the body weights, and weights of thymus, heart, and brain. In the second study, eight rats were ground controls, while an additional eight rats were HLS for 12 d before being removed from tail-suspension and maintained for a further 30 d. Blood samples were collected every 6th d for 42 d. This study showed that both serum thyroxine and 1,25(OH)2 vitamin D levels returned to normal levels soon after hind limb unweighting, while serum testosterone levels matched normal levels only after a further 3-4 wk. These studies showed a significant decrease of femur weights, but not weights of humeri in HLS rats suggesting that this is a specific effect on unloaded bones. On d 12 in both studies, a significant reduction in the lumbar spine (p<0.05) and the femoral neck (p<0.01) BMD appeared in HLS rats. This was confirmed in the second study, where HLS led to a significant decrease in BMD even extending to d 42. Previous studies have shown that space flight and tail-suspension lead to marked reductions in bone formation with little effect on bone resorption. Recently, we reported that androgen replacement can indeed prevent bone losses in this animal model. Therefore, it seems logical to propose that the significant decreases of serum testosterone observed in these tail-suspended animals are, at least in part, responsible for the losses of BMD seen in their affected weight-bearing bones (i.e., lumbar spine and the femur). Considering that 1. testosterone is anabolic to osteoblasts and also decreases the rate of bone turnover 2. serum testosterone levels are markedly suppressed in simulated weightlessness, and 3. testosterone replacement therapy prevented the bone loss in HLS rats, we propose that the testosterone deficiency in this animal model is related to their bone loss.

Reversal of weightlessness-induced musculoskeletal losses with androgens: quantification by MRI

Microgravity causes rapid decrement in musculoskeletal mass is associated with a marked decrease in circulatory testosterone levels, as we reported in hindlimb-suspended (HLS) rats. In this model which simulates microgravity, we hypothesized that testosterone supplementation should prevent these losses, and we tested this in two studies. Muscle volumes and bone masses were quantitated by using magnetic resonance imaging (MRI) on day 12. In the first study, 12-wk-old Sprague-Dawley rats that were HLS for 12 days lost 28.5% of muscle volume (53.3 +/- 4.8 vs. 74.5 +/- 3.6 cm3 in the ground control rats; P < 0.001) and had a 5% decrease in bone mineral density (BMD) (P < 0.05). In the second study, 30 male 12-wk-old Wistar rats were HLS and were administered either a vehicle (control), testosterone, or nandrolone decanoate (ND). An additional 20 rats were used as ground controls, one-half of which received testosterone. HLS rats had a significant reduction in muscle volume (42.9 +/- 3.0 vs. 56 +/- 1.8 cm3 in ground control rats; P < 0.01). Both testosterone and ND treatments prevented this muscle loss (51.5 +/- 2 and 51.6 +/- 1.2 cm3, respectively; a 63% improvement; P < 0. 05). There were no statistical differences between the two active treatment groups nor with the ground controls. Similarly, there was an 85% improvement in BMD in the testosterone group (1.15 +/- 0.04 vs. 1.04 +/- 0.04 density units in vehicle controls; P < 0.05) and a 76% improvement in the ND group (1.13 +/- 0.07 density units), whereas ground control rats had a BMD of 1.17 +/- 0.03 density units. Because serum testosterone levels are markedly reduced in this model of simulated microgravity, androgen replacement seems to be a rational countermeasure to prevent microgravity-induced musculoskeletal losses.