Abstract Background context Instrumentation failure is a recognized complication after complex spinal reconstruction and deformity correction. Rod fracture (RF) is the most frequent mode of hardware ...failure in long-segment spinal fusion surgery. This complication can negatively impact the clinical outcome by producing spinal pain, functional compromise, instability, and loss of deformity correction. Purpose To describe the outrigger rod surgical technique. Study design Review of literature, case review, and surgical technique description. Patient sample Two clinical cases are presented. Outcome measures Rod fracture. Methods Outrigger rod placement in posterior spinal arthrodesis is performed by supplementing primary spinal rods with outrigger rods attached with cranial and caudal side-by-side connectors providing a more robust construct. Results This technique may be beneficial for preventing RF in patients undergoing surgery for three-column osteotomy for sagittal imbalance; pseudarthrosis surgery with previous hardware failure; transforaminal lumbar interbody cage placement at multiple levels in realignment procedures, long-segment spinal arthrodesis with impaired host fusion potential; long-segment instrumented fusions that span the cervicothoracic, thoracolumbar, or lumbosacral junction; and across spinal segments at high risk for RF (eg, after extensive resection of vertebral elements in the management of metastatic malignancy). Conclusions The risk of rod failure is substantial in the setting of long-segment spinal arthrodesis and corrective osteotomy. Efforts to increase the mechanical strength of posterior constructs may reduce the occurrence of this complication. The outrigger rod technique increases spinal construct stiffness and may improve the longevity of the construct. This technique should reduce the rate of device failure during maturation of posterior fusion mass and limit the need for supplemental anterior column support.
Purpose To measure changes in upper limb work and power capacity before and after anterior scalene muscle block (ASMB) to suggest thoracic outlet syndrome caused by costoclavicular space compression. ...Methods We evaluated 34 patients disabled by symptoms suggesting thoracic outlet syndrome. An ASMB was performed via a supraclavicular injection. The sternocleidomastoid muscle was injected as a control. We captured data obtained from work simulator measurements before and after ASMB. Each patient performed a push–pull test with the forearm at waist level (test 1), an overhead bar push–pull test with the arm elevated (test 2), and the extremity abduction stress test with repetitive hand gripping during static arm elevation (test 3). We measured the work product, time to fatigue, and power generation. Sensory testing was performed after ASMB to rule out improved performance associated with possible sensory nerve block. Results In contrast to sternocleidomastoid injection controls, symptomatic and functional improvement was noted in all patients (n = 34) after ASMB. Work product measurement improved 93%, 108%, and 104% for tests 1, 2, and 3, respectively. Time to fatigue and power output also increased after the block. Conclusions Temporary symptomatic improvement after ASMB may be anticipated in patients with TOS. This study documents a significant concurrent increase in upper limb motor function after the block. Increased work and power measurements after ASMB may draw diagnostic inference regarding a dynamic change in the scalene muscle and the costoclavicular space associated with symptomatic thoracic outlet syndrome. Type of study/level of evidence Diagnostic III.
Abstract The opportunity for total joint arthroplasty (TJA) in patients with chronic infectious liver disease is rapidly expanding. This is the product of both superior survival of chronic hepatitis ...patients, evolving implant technologies, and improvement of techniques in TJA. Unfortunately, treating this group of patients is not without significant challenges that can stem from both intrahepatic and extrahepatic clinical manifestations. Moreover, many subclinical changes occur in this cohort that can alter hemostasis, wound healing, and infection risk even in the asymptomatic patient. In this review, we discuss the various clinical presentations of chronic infectious liver disease and summarize the relevant literature involving total joint arthroplasty for this population. Hopefully, through appropriate patient selection and perioperative optimization, treating surgeons should see continued improvement in outcomes for patients with chronic infectious liver disease.
Abstract Patients with afibrinogenemia or hypofibrinogenemia present a unique challenge to the arthroplasty surgeon as fibrinogen is a key contributor to hemostasis. Patients with these disorders are ...known to have a higher risk for postsurgical bleeding complications. We present the case of a patient with hypofibrinogenemia who underwent an elective total knee arthroplasty. Our colleagues in hematology-oncology guided us initially to achieve and maintain appropriate fibrinogen levels in the early perioperative period. However, the patient developed an acute joint effusion and subsequent infection 4 weeks after her initial operation. Her fibrinogen levels were noted to have fallen below the target range by that time, and it was also revealed that the patient failed to follow-up with hematology-oncology to monitor her levels. Based on our review of the available literature, we recommend that patient's fibrinogen levels be closely monitored and maintained ideally >100 mg/dL not only in the initial perioperative window but perhaps for the first 4-6 weeks postoperatively as well.
Purpose: There are minimal long-term epidemiological data focused on finger amputations in the United States (US). We sought to quantify the incidence and trends in finger amputations over a 20-year ...period, describe mechanisms of injury by age groups, and examine trends in emergency department (ED) disposition. Methods: The National Electronic Injury Surveillance System was queried over a 20-year period (1997–2016) for finger amputations presenting to US EDs. Using US Census data, national incidence rates were estimated. We evaluated specific mechanisms of injury and ranked common mechanisms for each age group. Trends in hospital admission rates were evaluated and predictors of admission were examined using logistical regression. Results: From 1997 to 2016, a weighted estimate of 464,026 patients sustained finger amputations in the US with an estimated yearly incidence of 7.5/100,000 person-years. A bimodal age distribution was seen, with the greatest incidence in children aged less than 5 years and adults over 65 years. Doors were the most common injury mechanism in children (aged less than 5 years), whereas power saws were most common in teens and adults (aged more than 15 years). Over the study period, there was a significant increase in patients admitted to the hospital; however, this increase was not seen among African Americans. Significant predictors of hospital admission included male gender, age less than 18 years, high-energy mechanisms, non–African American race, and very large hospital size, as defined by the National Electronic Injury Surveillance System. Conclusions: The incidence of finger amputations is bimodal; young children (aged less than 5 years) and the elderly (aged greater than 65 years) are at greatest risk. There is a widening disparity between African Americans and non–African Americans in relation to ED disposition. Doors and power saws are the most common mechanisms of injury; however, these affect different age ranges. This study’s results highlight the need for improved age-specific safety guidelines and device safety features. Type of study/level of evidence: Prognostic IV. Key words: epidemiology, finger amputation, NEISS database
Purpose We present our experience in using pulse oximetry as an aid in the diagnosis of thoracic outlet syndrome (TOS). Our attention was given to those symptomatic patients without objective ...confirmatory data on imaging or electrodiagnostic evaluation. Methods Using a pulse oximeter, we measured the oxygen saturation and the pulse rate during a provocative extremity abduction stress test exercise maneuver in 18 patients with symptoms and signs consistent with a diagnosis of nonspecific neurogenic TOS. The oxygen saturation and pulse rates in 18 asymptomatic subjects were used as a control. Results Resting oxygen saturation above 97% was present in both groups initially. After the provocative exercise maneuver, there was a significant reduction in the oxygen saturation levels, which dropped to 86% in the symptomatic TOS group compared with 94% in the control group. There was a significant increase in pulse rate in those subjects suspected of having TOS compared with a minimal increase in pulse rate in control subjects. Conclusions Pulse oximetry produced objective confirmatory measurements, which support a hypothesis that hypoperfusion in the upper limb during provocative activities or exercise may cause disabling symptoms associated with nonspecific neurogenic TOS. This method may be a useful, noninvasive, rapid, and inexpensive clinical tool in the diagnosis of TOS, a condition frequently lacking in objective, confirmatory diagnostic data. Type of study/level of evidence Diagnostic III.
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