Faculty Bibliography

PRCIS/CONCLUSIONS:Residence in a middle-class neighborhood correlated with lower follow-up compared to residence in more affluent neighborhoods. The most common explanations for not following up were the process of making an appointment and lack of symptoms. PURPOSE/OBJECTIVE:To explore which individual and neighborhood-level factors influence follow-up as recommended after positive ophthalmic and primary care screening in a vulnerable population using novel methodologies. PARTICIPANTS/METHODS:and Methods: From 2017 to 2018, 957 participants were screened for ophthalmic disease and cardiovascular risk factors as part of the Real-Time Mobile Teleophthalmology study. Individuals who screened positive for either ophthalmic or cardiovascular risk factors were contacted to determine whether or not they followed up with a healthcare provider. Data from the Social Vulnerability Index, a novel virtual auditing system, and personal demographics were collected for each participant. A multivariate logistic regression was performed to determine which factors significantly differed between participants who followed up and those who did not. RESULTS:As a whole, the study population was more socioeconomically vulnerable than the national average (mean summary Social Vulnerability Index score=0.81). Participants whose neighborhoods fell in the middle of the national per capita income distribution had lower likelihood of follow-up compared to those who resided in the most affluent neighborhoods (relative risk ratio=0.21, P-value<0.01). Participants cited the complicated process of making an eye care appointment and lack of symptoms as the most common reasons for not following up as instructed within four months. CONCLUSIONS:Residence in a middle-class neighborhood, difficulty accessing eye care appointments, and low health literacy may influence follow up among vulnerable populations.

BACKGROUND: Fracture of the metaphyseal region of the distal ulna is an uncommon injury that has been reported to occur concomitantly with distal radius fracture. We aimed to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare outcomes in operatively versus non-operatively treated patients. METHODS: Over a 5-year period a distal radius fracture registry was maintained at our institution. Eleven of 512 consecutive patients had metaphyseal distal ulna fractures in association with distal radius fractures and at least 1-year follow-up. Baseline radiographs and functional data were obtained, and patients were followed at 1-week, 2-week, 3-week, 6-week, 3-month, 6-month, 1-year, and 2-year intervals. Patients were split into two treatment groups: Group 1 consisted of five non-operatively treated patients, and Group 2 consisted of six operatively treated patients. RESULTS: Four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head, fracture of the neck region with concomitant fracture of the tip of the ulnar styloid, simple fracture of the ulnar head, and comminuted fracture of the ulnar head. There were no statistical differences between the two groups with regard to flexion, extension, supination, pronation, and functional outcomes. CONCLUSIONS: Ulnar fracture patterns observed did not easily fall into previously described categories, and we have proposed a new classification system. Simple fractures of the ulnar neck or head often do not require operative fixation.

PURPOSE: Zone II flexor tendon repairs may create a bulging effect with resistance to tendon gliding. A biomechanical study was performed comparing the 4-strand cross-locked cruciate (CLC) to a 4-strand Strickland repair, both with and without an interlocking horizontal mattress (IHM) suture, in terms of strength characteristics and work of flexion. METHODS: Sixteen fresh-frozen human fingers were placed in a custom jig. Flexor digitorum profundus tendons were sectioned at the A3 pulley level. Fingers were separated into 2 repair groups: 4-strand CLC and 4-strand Strickland core suture. Work of flexion was determined for each group, with and without an IHM circumferential suture. Final repair including IHM was tested for 2-mm gap failure and ultimate load to failure. RESULTS: The CLC-IHM had a significantly smaller increase in work of flexion than the Strickland-IHM. For both suture types, the circumferential suture resulted in a statistically significant increase in work of flexion; however, peak entry force produced upon entry of the repair into the A2 pulley was reduced, although the decrease was not statistically significant for each group. The CLC-IHM had a significantly higher ultimate load to failure. CONCLUSIONS: (1) The CLC-IHM suture method is stronger with less work of flexion than the Strickland-IHM method. (2) This new, combination repair method of CLC core suture with IHM circumferential suture is biomechanically superior to the commonly performed Strickland-IHM technique

A retrospective study of 132 patients (63 spinal anesthesia and 69 general anesthesia) undergoing total hip arthroplasty was performed by 4 fellowship-trained adult reconstructive surgeons to determine the influence of anesthesia type on postoperative limb length and medial offset. Limb length discrepancy occurred in 87.0% of patients who received regional anesthesia as opposed to 47.6% patients who had general anesthesia (P<.001). Differences in postoperative medial offset measurements between the 2 groups were not statistically significant. It was concluded that surgeons operating on patients who receive regional anesthesia should supplement intraoperative tests for assessing hip stability with meticulous preoperative templating to avoid overlengthening the operative limb

One thousand thirty-five total hip arthroplasty (THA) cases were retrospectively reviewed, and the number and type (autologous and allogenic) of postoperative units of blood transfused were analyzed with respect to pre-, intra-, and postoperative variables. The most significant and consistent predictors of a blood transfusion after THA were advanced age and the use of low-molecular-weight heparin for deep venous thrombosis prophylaxis. Our recommendations for predonation are 1 unit for THA patients younger than 75 years if hemoglobin is 130 g/dL or greater and 2 units or a combination of 1 unit of predonated blood and 1 unit of directed or banked blood for THA patients older than 75 years

Heparin-induced thrombocytopenia (HIT) and heparin induced thrombocytopenia with thrombosis (HITT) ar rare complications associated with use of unfractionate heparin (UFH) or low-molecular-weight heparin (LMWH) HIT is a benign clinical condition characterized by a mil drop in platelet count with no clinical significance. HIT is an immune-mediated reaction associated with a wide spread 'hypercoagulable' state resulting in arterial an venous thrombosis. There is a higher incidence of HIT with UFH use than with LMWH use. Orthopedic surger patients are at higher risk for developing HITT than are patients who receive prophylactic heparin for cardiovascular surgery or medical reasons. Therapy for patients suspected of having HITT should begin with immedi ate discontinuation of heparin in any form followed by pharmacologic inhibition with thrombin (e.g., recombinant hirudin [lepirudin], argatroban, danaparoid sodium)

BACKGROUND: Prolonged wound drainage following total hip or total knee arthroplasty has been associated with an increased risk of postoperative morbidity. The purpose of this study was to determine the pharmacologic, surgical, and patient-specific factors that are associated with prolonged wound drainage and the relationship of this complication to the length of hospital stay and the rate of wound infections. METHODS: We conducted a retrospective observational study of 1211 primary total hip arthroplasties and 1226 primary total knee arthroplasties. Prospectively collected data included body mass index, intraoperative blood loss, surgical time, type of prophylaxis against deep venous thrombosis, and length of hospital stay. The association of these factors with the duration of postoperative wound drainage was analyzed. An acute infection developed after fifteen primary total hip arthroplasties and ten primary total knee arthroplasties. The patients with an acute postoperative infection were compared with their uninfected counterparts, and an odds ratio was determined to estimate the risk of prolonged wound drainage resulting in a wound infection. RESULTS: Morbid obesity was strongly associated with prolonged wound drainage in the total hip arthroplasty group (p = 0.001) but not in the total knee arthroplasty group (p = 0.590). An increased volume of drain output was an independent risk factor for prolonged wound drainage in both groups. Patients who received low-molecular-weight heparin for prophylaxis against deep venous thrombosis had a longer time until the postoperative wound was dry than did those treated with aspirin and mechanical foot compression or those who received Coumadin (warfarin); this difference was significant on the fifth postoperative day (p = 0.003) but not by the eighth postoperative day. Prolonged wound drainage resulted in a significantly longer hospital stay in both groups (p < 0.001). Each day of prolonged wound drainage increased the risk of wound infection by 42% following a total hip arthroplasty and by 29% following a total knee arthroplasty. CONCLUSIONS: Morbid obesity, the use of low-molecular-weight heparin, and a higher drain output were associated with a prolonged time until the postoperative wound was dry following a primary total hip arthroplasty, whereas a higher drain output was the only risk factor associated with prolonged drainage following a primary total knee arthroplasty. Prolonged drainage was associated with a higher rate of infection following a primary total hip arthroplasty, whereas obesity was the only identified independent risk factor for postoperative infection following a primary total knee arthroplasty

BACKGROUND: The lateral trochanteric support plate (LSP) was developed to prevent excessive sliding of unstable intertrochanteric femur fractures fixed with a sliding hip screw (SHS). This study compared the fracture stability and screw sliding characteristics of unstable intertrochanteric femur fractures fixed with either an SHS and LSP or an Intramedullary Hip Screw (IMHS). METHODS: Six matched pairs of cadaveric human femurs with simulated, unstable intertrochanteric femur fractures were stabilized with either an IMHS or a 135-degree SHS with an attached LSP. Inferior and lateral head displacements and lag screw sliding distances were measured for applied static loads of 750 N, before and after cycling. RESULTS: Four-part unstable intertrochanteric femur fractures showed comparable screw sliding characteristics and stability whether instrumented with an SHS and LSP or an IMHS. CONCLUSION: A sliding hip screw with an attached lateral support plate provides stability and ability to resist medial displacement of the femoral shaft similar to that seen with the IMHS

A retrospective study of 1,402 patients who underwent primary total knee arthroplasty (TKA) (1,194 unilateral, 208 bilateral) was performed. The strongest predictors for allogenic transfusion after surgery were advancing age (P<.001), low preoperative hemoglobin (P<.001), and the use of low-molecular-weight heparin postoperatively (P<.01). Pre-donation of 1 unit of autologous blood before TKA decreased the allogenic transfusion rate from a baseline of 38% to 11%, whereas pre-donating 2 units lowered the rate of breakthrough transfusion of allogenic blood to 7%. A patient with a preoperative hemoglobin >150 g/L or who is younger than age 65 with a preoperative hemoglobin >130 g/L may not benefit from pre-donation, and a high rate of wastage may result