Background:
Members of the military are known to experience disproportionately high rates of both glenohumeral instability and superior labrum anterior-posterior (SLAP) tears when compared with ...civilian populations. Although the outcomes after simultaneous repair of Bankart and SLAP lesions have been well described, there is a paucity of literature available regarding the operative management of posterior instability with concomitant superior labral pathology.
Purpose:
To compare outcomes of combined arthroscopic posterior labral and SLAP repair with those of isolated posterior labral repair.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
All consecutive patients younger than 35 years who underwent arthroscopic posterior labral repair from January 2011 to December 2016 with a minimum follow-up of 5 years were identified. From this cohort of eligible patients, all individuals who had undergone combined SLAP and posterior labral repair (SLAP cohort) versus posterior labral repair alone (instability cohort) were then identified. Outcome measures including the visual analog scale score, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, Rowe instability score, and range of motion were collected pre- and postoperatively and scores were compared between groups.
Results:
In total, 83 patients met the inclusion criteria for the study. All patients were active-duty military at the time of surgery. The mean follow-up was 93.79 ± 18.06 months in the instability group and 91.24 ± 18.02 months in the SLAP group (P = .5228). Preoperative SANE and ASES scores were significantly worse in the SLAP group. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no significant differences in any outcome scores or range of motion between groups. In total, 39 patients in the instability cohort and 37 in the SLAP cohort returned to preinjury levels of work (92.86% vs 90.24%, respectively; P = .7126), and 38 instability patients and 35 SLAP patients returned to preinjury levels of sporting activity (90.48% vs 85.37%, respectively; P = .5195). Two patients in the instability group and 4 patients in the SLAP group were medically discharged from the military (4.76% vs 9.76%; P = .4326), and 2 patients in each cohort had experienced treatment failure at the final follow-up (4.76% vs 4.88%; P > .9999).
Conclusion:
Combined posterior labral and SLAP repair led to statistically and clinically significant increases in outcome scores and high rates of return to active-duty military service that did not differ significantly from the results after isolated posterior labral repair. The results of this study indicate that simultaneous repair is a viable treatment option for the management of combined lesions in active-duty military patients <35 years of age.
Background:
Active-duty servicemembers are a population at risk for the development of posterior shoulder instability. While short-term outcomes after arthroscopic posterior labral repair for ...posterior shoulder instability are promising, there is a paucity of longer term follow-up data for this procedure.
Purposes:
The primary purpose was to report midterm outcomes after arthroscopic posterior labral repair in active-duty military patients for posterior shoulder instability without bone loss. The secondary purpose was to determine if outcomes varied between anchor types used.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Preoperative and postoperative outcomes, with a minimum 3-year follow-up, for a visual analog scale for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) score, and the Rowe score were collected and analyzed. A separate subgroup analysis was performed comparing the outcomes of patients who underwent repair with biocomposite anchors versus those who underwent repair with all-suture anchors.
Results:
A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months met the inclusion criteria and were available for analysis. As a whole, the cohort demonstrated statistically and clinically significant improvements in outcome scores at final follow-up. Preoperative and postoperative range of motion did not vary significantly. While the difference in final outcome scores between the 2 anchor types did not reach statistical significance, a statistically significantly larger proportion of patients who underwent repair with all-suture anchors versus those who underwent repair with biocomposite anchors met the Patient Acceptable Symptom State for the SANE (97.14% vs 78.95%, respectively; P = .0180) and the ASES score (88.57% vs 68.42%, respectively; P = .0171). The proportion of patients who achieved the substantial clinical benefit or surpassed the minimal clinically important difference, however, did not vary by anchor type. Overall, 70 patients (95.89%) remained on active duty and were able to return to preinjury work and recreational activity levels. There were 3 patients (4.11%) who had recurrent posterior instability.
Conclusion:
This population of active-duty servicemembers undergoing posterior labral repair for posterior labral instability without bone loss demonstrated a statistically and clinically significant improvement in midterm outcomes, a low recurrence rate, and a rate of return to active duty of 95.89%, regardless of the anchor type used.
STUDY DESIGN.Retrospective case series
OBJECTIVE.To characterize outcomes associated with tracheostomy timing following traumatic cervical spinal cord injury (CSCI).
SUMMARY OF BACKGROUND DATA.The ...morbidity associated with cervical spine trauma is substantially increased in the setting of concomitant CSCI. Despite recent evidence, it remains uncertain if early tracheostomy following traumatic CSCI can improve outcomes.
METHODS.From January 1, 2007, to December 31, 2015, retrospective chart review identified seventy (70) patients who presented to a single Level 1 trauma center with traumatic CSCI and received tracheostomy for management of respiratory compromise. Patients were subdivided into two groups based on time from initial intubation to tracheostomy procedureearly (tracheostomy less than or equal to 7 days from initial intubation) and late (greater than 7 days from initial intubation).
RESULTS.This series included 75.7% males and 24.3% females with mean age 50.5 years. A chest injury was present in 31.4% of patients. AIS A was the most common AIS score (41.4%), and 70.1% of patients had an injury level at C4 or above. Early tracheostomy was performed in 52.4% of patients. Factors most predictive of early tracheostomy were more severe AIS score (OR = 1.72) and higher neurological level of injury (OR = 1.91) (p < 0.001, pseudoR = 0.241). Controlling for AIS and neurological level of injury, early tracheostomy was associated with fewer ventilator days (23.9 vs 36.9, p = 0.0268), fewer days to decannulation (53.0 vs 74.3, p = 0.0075), and shorter ICU stays (20.7 vs 26.0, p = 0.0217). Rates of pneumonia, surgical site infection, in-hospital mortality, 90-day mortality, and 90-day readmission rates were not different between groups.
CONCLUSIONS.Tracheostomy within seven days of intubation may improve respiratory outcomes in patients with traumatic CSCI, regardless of level or severity of injury, without increasing complication rates.Level of Evidence4
The reliability and measurement error of several impairment measures used during the clinical examination of patients with patellofemoral pain syndrome (PFPS) has not been established. The purpose ...was to determine the inter-tester reliability and measurement error of measures of impairments associated with PFPS in patients with PFPS.
A single group repeated measures design was used. Two pairs of physical therapists participated in data collection. Examiners were blinded to each others' measurements.
Thirty patients (age 29 +/- 8; 17 female) with PFPS participated in this study. Inter-tester reliability coefficients were substantial for measures of hamstrings, quadriceps, plantarflexors, and ITB/TFL complex length, hip abductors strength, and foot pronation (ICCs from .85 to .97); moderate for measures of Q-angle, tibial torsion, hip external rotation strength, lateral retinacular tightness, and quality of movement during a step down task (ICCs from .67 to .79); and poor for femoral anteversion (ICC of .45). Standard error of measurement (SEM) for measures of muscle length ranged from 1.6 degrees to 4.3 degrees. SEM for Q-angle, tibial torsion, and femoral anteversion were 2.4 degrees, 2.9 degrees, and 4.5 degrees respectively. SEM for foot pronation was 1 mm. SEM for measures of muscle strength was 1.8 Kg for abduction and 2.4 Kg for external rotation.
Several of the impairments associated with PFPS had sufficient reliability and low measurement error. Further investigation is needed to test if these impairment measurements are related to physical function and whether or not they are useful for decision-making.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVE:The objective of this study was to characterize relationships between obesity and initial hospital stay, including complications, in patients with multiple system trauma and surgically ...treated fractures.
DESIGN:Prospective, observational.
SETTING:Level 1 trauma center.
PATIENTS:Three hundred seventy-six patients with an Injury Severity Score greater than 16 and mechanically unstable high-energy fractures of the femur, pelvic ring, acetabulum, or spine requiring stabilization.
MAIN OUTCOME MEASUREMENTS:Data for obese (body mass index ≥ 30) versus nonobese patients included presence of pneumonia, deep vein thrombosis, pulmonary embolism, infection, organ failure, and mortality. Days in ICU and hospital, days on ventilator, transfusions, and surgical details were documented.
RESULTS:Complications occurred more often in obese patients (38.0% vs. 28.4%, P = 0.03), with more acute renal failure (5.70% vs. 1.38%, P = 0.02) and infection (11.4% vs. 5.50%, P = 0.04). Days in ICU and mechanical ventilation times were longer for obese patients (7.06 vs. 5.25 days, P = 0.05 and 4.92 vs. 2.90 days, P = 0.007, respectively). Mean total hospital stay was also longer for obese patients (12.3 vs. 9.79 days, P = 0.009). No significant differences in rates of mortality, multiple organ failure, or pulmonary complications were noted. Medically stable obese patients were almost twice as likely to experience delayed fracture fixation due to preference of the surgeon and were more likely to experience delay overall (26.0% vs. 16.1%; P = 0.02). Mean time from injury to fixation was 34.9 hours in obese patients versus 23.7 hours in nonobese patients (P = 0.03).
CONCLUSIONS:Obesity was noted among 42% of our trauma patients. In obese patients, complications occurred more often and hospital and ICU stays were significantly longer. These increases are likely to be associated with greater hospital costs. Surgeon decision to delay procedures in medically stable obese patients may have contributed to these findings; definitive fixation was more likely to be delayed in obese patients. Further study to optimize the care of patients with increased body mass index may help to improve outcomes and minimize additional treatment expenses.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
This study presents patient demographics, injury characteristics, outcomes, and complications associated with dorsal bridge plating (DBP) in the treatment of distal radius fractures.
A literature ...search performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines identified 206 articles, 12 of which met inclusion criteria, accounting for 310 patients. Included articles contained the results of DBP for treatment of distal radius fractures with reported outcomes between 1988 and 2018. Data were pooled and analyzed focusing on patient demographics, as well as 3 primary outcomes of complications, range of motion (ROM), and Disabilities of the Arm, Shoulder, and Hand (DASH) and QuickDASH scores.
Average age was 55 years, median follow-up was 24 months, and the most common use was in comminuted (92%) intra-articular (92%) distal radius fracture caused by fall (58%), or motor vehicle collision or motorcycle collision (27%). A minority of patients had open fractures (16%) and most were cases of polytrauma (65%). Median time from placement to DBP removal was 17 weeks (mean, 119 days). At final follow-up, mean wrist ROM was 45° flexion, 50° extension, 75° pronation, and 73° supination. Mean DASH score was 26.1, and mean QuickDASH score was 19.8. The overall rate for any complication was 13%; the most common was hardware failure (3%) followed by symptomatic malunion or nonunion (3%), and persistent pain after hardware removal (2%).
Dorsal bridge plating was found to be used most commonly in intra-articular, comminuted distal radius fractures with overall functional wrist ROM, moderate patient-reported disability, and a 13% complication rate at follow-up.
Therapeutic IV.
The synthesis of exopolysaccharides as biofilm matrix components by pathogens is a crucial factor for chronic infections and antibiotic resistance. Many periplasmic proteins involved in polymer ...processing and secretion in Gram-negative synthase dependent exopolysaccharide biosynthetic systems have been individually characterized. The operons responsible for the production of PNAG, alginate, cellulose and the Pel polysaccharide each contain a gene that encodes an outer membrane associated tetratricopeptide repeat (TPR) domain containing protein. While the TPR domain has been shown to bind other periplasmic proteins, the functional consequences of these interactions for the polymer remain poorly understood. Herein, we show that the C-terminal TPR region of PgaA interacts with the de-N-acetylase domain of PgaB, and increases its deacetylase activity. Additionally, we found that when the two proteins form a complex, the glycoside hydrolase activity of PgaB is also increased. To better understand structure-function relationships we determined the crystal structure of a stable TPR module, which has a conserved groove formed by three repeat motifs. Tryptophan quenching, mass spectrometry analysis and molecular dynamics simulation studies suggest that the crystallized TPR module can bind PNAG/dPNAG via its electronegative groove on the concave surface, and potentially guide the polymer through the periplasm towards the porin for export. Our results suggest a scaffolding role for the TPR domain that combines PNAG/dPNAG translocation with the modulation of its chemical structure by PgaB.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
•We are unaware of any studies evaluating all calcaneus fractures, both open and closed injuries, treated operatively in the military.•Blast as mechanism of injury was the single most predictive ...variable for patients requiring separation from the military, requiring a subsequent procedure, and for requiring a below knee amputation.•Calcaneus fractures treated operatively in the military are often caused by blast injuries, and have a high rate of requiring subsequent procedures, amputation, and separation from the military.
Calcaneus fractures can be devastating injuries, and operative treatment is fraught with complications. We are unaware of any studies evaluating all calcaneus fractures, both open and closed, treated operatively in the military. The purpose of this study is to evaluate all calcaneus fractures that required open reduction internal fixation to determine soldiers’ ability to return to work and the need for additional surgeries.
All active-duty patients undergoing open reduction internal fixation of calcaneus fractures from 2010-2016 were identified utilizing the Military Health System Management Analysis and Reporting Tool (M2). Armed Forces Health Longitudinal Technology Application (AHLTA) was utilized to determine comorbid medical conditions, subsequent procedures, surgical outcomes, and duty status within the military.
Three hundred seventy-five active-duty service members who met our inclusion/exclusion criteria were identified. One hundred fifty-one patients (55.1%) sustained their calcaneus fracture as a result of a blast injury. One hundred sixty (59.3%) patients required separation from the military as a result of their injury. Among patients who required a subsequent procedure, thirty-four patients (9.1%) required a subtalar arthrodesis, and thirty-two patients (8.5%) eventually required a below knee amputation. Blast as mechanism of injury was the single most predictive variable for patients requiring separation from the military (Odds Ratio 16.2, p< .001), requiring a subsequent procedure (Odds Ratio 8.4, p < .001), and for requiring a below knee amputation (Odds Ratio 47.3, p < .001).
Calcaneus fractures treated operatively in the military are often caused by blast injuries, and have a high rate of requiring subsequent procedures, amputation, and separation from the military.
OBJECTIVES:To determine the incidence of hypovitaminosis D and to evaluate a supplementation intervention. We hypothesized that patients would exhibit high adherence with a free sample, and levels ...would become sufficient.
DESIGN:Prospective observational study.
SETTING:Level 1 trauma center.
PATIENTS:One hundred forty-four consecutive, skeletally mature patients treated for acute fractures.
INTERVENTION:All were provided 600 mg calcium and 800 IU vitamin D3 capsules twice daily.
MAIN OUTCOME MEASUREMENTS:Serum 25(OH) D levels were obtained on presentation and after supplementation. Patient surveys determined adherence, vitamin D intake, and sun exposure.
RESULTS:Ninety-one men and 53 women, mean age 45 years, mean body mass index 28.1, were studied. Mean baseline 25(OH) D level was 20.2 ng/mL, including 9 patients taking vitamin D supplements before injury. All others (mean baseline 16.9 ng/mL) were prescribed calcium and vitamin D and were offered free supplements when discharged. Seventy-seven patients completed surveys, and mean 25(OH) D level was 36.7 ng/mL after a mean of 7.0 weeks of supplementation (P < 0.0001). Seventy-nine percent reported adherence to supplement recommendations. All adherent patients achieved normal levels. Sixteen patients were nonadherent, with 10 who forgot to take the supplement, 4 choosing not to use it, 1 choosing to sell the sample, and 1 losing the sample.
CONCLUSION:Hypovitaminosis D was present in 97% of orthopaedic trauma patients who were not already taking supplements. The intervention was effective in reducing hypovitaminosis D within several weeks, with all supplemented patients achieving normal levels. Seventy-nine percent of patients adhered to recommendations. Further study to determine the long-term cost-effectiveness of this strategy seems warranted.
LEVEL OF EVIDENCE:Therapeutic, Level II. See Instructions for Authors for a complete description of levels of evidence.
Retrospective review.
The objective of this study was to evaluate the ability of the American Spinal Injury Association (ASIA) Impairment Scale and neurological level of injury to predict the need ...for mechanical ventilation as well as tracheostomy.
High-level cervical spinal cord injuries, high Injury Severity Score, and low Glasgow Coma Scale have been shown to predict tracheostomy.
A total of 383 patients with fractures, dislocations, or ligamentous injury of the cervical spine were included in the study. Charts were reviewed to determine demographics, Injury Severity Score, Glasgow Coma Scale, presence and severity of chest injuries, length of hospital stay, intensive care unit stay, mechanical ventilation time, and mortality.
Fifty-nine patients (15.4%) underwent tracheostomy. An ASIA Impairment Scale of A had a specificity of 98.8% and sensitivity of 32.2% for predicting the need for tracheostomy. This yielded a 1.2% false-positive rate. The ASIA Impairment Scale remained the most significant predictor after regression for Injury Severity Score, Glasgow Coma Scale, and Chest Abbreviated Injury Scale. Neurological level of injury was not a significant predictor of tracheostomy.
An ASIA Impairment Scale of A at any level of injury is a specific predictor of the need for tracheostomy with a low false-positive rate. Given the relatively low risk of early tracheostomy and the potential benefits, an ASIA Impairment Scale of A would be a sensible early criterion to determine the need for tracheostomy.
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