•The tenets of our technique maximize the clinical benefits on K-wires in hand/wrist fractures while minimizing the concern for infection.•Percutaneous K-wire fixations can safely and effectively ...fixate fractures of the hand/wrist in fixation periods exceeding 8 weeks.•Exposed K-wires should not be bent in situ nor inserted through an incision for fixation of hand/wrist fractures.•Percutaneous K-wires should be covered with a desiccant dressing to prevent pin site infections.
Kirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection.
Patients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection.
90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation.
The specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.
None of the 28 identified point mutations in tafazzin (Taz1p), which is the mutant gene product associated with Barth syndrome (BTHS), has a biochemical explanation. In this study, endogenous Taz1p ...was localized to mitochondria in association with both the inner and outer mitochondrial membranes facing the intermembrane space (IMS). Unexpectedly, Taz1p does not contain transmembrane (TM) segments. Instead, Taz1p membrane association involves a segment that integrates into, but not through, the membrane bilayer. Residues 215-232, which were predicted to be a TM domain, were identified as the interfacial membrane anchor by modeling four distinct BTHS mutations that occur at conserved residues within this segment. Each Taz1p mutant exhibits altered membrane association and is nonfunctional. However, the basis for Taz1p dysfunction falls into the following two categories: (1) mistargeting to the mitochondrial matrix or (2) correct localization associated with aberrant complex assembly. Thus, BTHS can be caused by mutations that alter Taz1p sorting and assembly within the mitochondrion, indicating that the lipid target of Taz1p is resident to IMS-facing leaflets.
Abstract Background context Vertebral compression fractures secondary to low bone mass are responsible for almost 130,000 inpatient admissions and 133,500 emergency department visits annually, ...totaling over $5 billion of direct inpatient costs. Although most vertebral compression fractures heal within a few months with conservative therapy, a significant portion fail to improve with conservative treatment and require long-term care, conservative treatment, or both. Fractures that fail conservative therapy are treated with vertebral augmentation procedures (VAPs) such as vertebroplasty (VP) and kyphoplasty (KP). Two large randomized clinical trials published in 2009 questioned the efficacy of VP in treatment of VAPs. Purpose This study aimed to investigate trends in utilization of VP and KP between 2005 and 2010 to capture the impact of the 2009 literature on utilization of VAPs. The study also compares patient characteristics and perioperative outcomes between VP and KP to further delineate the risks of each procedure. Study design Retrospective analysis of national utilization rates, clinical outcomes, patient demographics, and patient comorbidities using a large national inpatient database. Patient sample A total of 63,459 inpatient admissions from 46 states and more than 1,000 different hospitals were included in the analysis. Outcome measures Length of stay (LOS), total direct cost, mortality, postoperative complications. Methods Data were obtained from the National Inpatient Sample database for the period between 2005 and 2010. National Inpatient Sample is the largest publicly available all payer inpatient database in the United States. Patients undergoing VP and KP were identified via corresponding the International Classification of Diseases, 9th Revision procedure codes. National utilization trends were estimated using weights supplied as part of the National Inpatient Sample dataset. Information on patient comorbidities and demographics was collected. A series of univariate and multivarariate analyses were used to identify statistically significant differences in patient characteristics, clinical outcomes, as well as cost and LOS between patients undergoing VP versus KP. Results A total of 307,050 inpatient VAPs were performed in the United States between 2005 and 2010. Of those procedures, 225,259 were KP and 81,790 were VP. Kyphoplasty utilization showed an increasing trend between 2005 and 2007, increasing from 27 to 33 procedures per 100,000 capita older than 40 years. During the same time period, VP utilization remained constant at approximately nine procedures per 100,000 capita older than 40 years. After 2007, utilization of both VP and KP decreased. The most precipitous decrease in VAP utilization occurred in 2009. Patients undergoing VP were on average older (76.7 vs. 77.8, p<.0001), more frequently women (74.48% vs. 73.15%, p=.00083), and black (1.77% vs. 1.55%, p=.004059). Patients undergoing VP had on average more comorbidities then those undergoing KP. Patients undergoing VP had a higher rate of postoperative anemia secondary to acute bleeding and higher rate of venous thromboembolic events. Those undergoing KP had a greater rate of cardiac complications; however, this difference was not statistically significant when taking into account patient age and comorbidity burden. Vertebroplasty was associated with higher mortality (0.93% vs. 0.60%, p<.001), longer LOS (6.78 vs. 5.05 days, p<.0001), and lower total cost ($42,154 vs. $46,101, p<.0001). Conclusions Overall, KP was associated with lower complication rates, shorter LOS, and a higher total direct cost compared with VP. Utilization rates showed a significant decrease since 2009 in both VP and KP, suggesting that both procedures were impacted by the two randomized controlled trials published in 2009 that suggested poor efficacy of VP.
Recent military conflicts have resulted in numerous extremity injuries requiring complex orthopaedic reconstructive procedures, which begin with a thorough débridement of all contaminated and ...necrotic tissue in the zone of injury. The site of injury is also the site of healing, and we propose that débrided muscle tissue contains cells with robust reparative and regenerative potential.
Débrided muscle from soldiers who had sustained traumatic open extremity injuries was collected during surgical débridement procedures at Walter Reed Army Medical Center. With modifications to a previously described stem-cell-isolation protocol, mesenchymal progenitor cells were harvested from traumatized muscle, enriched, expanded in culture, and exposed to induction media for osteogenesis, adipogenesis, and chondrogenesis.
The isolated mesenchymal progenitor cells stained positive for cell-surface markers (CD73, CD90, CD105), which are characteristic of adult human mesenchymal stem cells. Histological identification of lineage-specific markers demonstrated the potential of these cells to differentiate into multiple mesenchymal lineages. Reverse transcription-polymerase chain reaction analysis confirmed multilineage mesenchymal differentiation at the gene-expression level.
To our knowledge, the present report provides the first description of mesenchymal progenitor cell isolation from traumatized human muscle. These cells may play an integral role in tissue repair and regeneration and merit additional investigation as they could be useful in future cell-based tissue-engineering strategies.
Deficits in mitochondrial function result in many human diseases. The X-linked disease Barth syndrome (BTHS) is caused by mutations in the tafazzin gene TAZ1. Its product, Taz1p, participates in the ...metabolism of cardiolipin, the signature phospholipid of mitochondria. In this paper, a yeast BTHS mutant tafazzin panel is established, and 18 of the 21 tested BTHS missense mutations cannot functionally replace endogenous tafazzin. Four BTHS mutant tafazzins expressed at low levels are degraded by the intermembrane space AAA (i-AAA) protease, suggesting misfolding of the mutant polypeptides. Paradoxically, each of these mutant tafazzins assembles in normal protein complexes. Furthermore, in the absence of the i-AAA protease, increased expression and assembly of two of the BTHS mutants improve their function. However, the BTHS mutant complexes are extremely unstable and accumulate as insoluble aggregates when disassembled in the absence of the i-AAA protease. Thus, the loss of function for these BTHS mutants results from the inherent instability of the mutant tafazzin complexes.
Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis ...and non-free muscle transfers in restoring elbow flexion.
MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines.
Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0–140°), and eight articles, 215 cases, provided DASH scores (total range: 8–90.8).
Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.
Hypothesis We hypothesize that a technique for all-arthroscopic fixation of capitellum osteochondritis dissecans (OCD) lesions using suture fixation and autogenous iliac crest bone grafting offers a ...successful alternative to open internal fixation techniques as shown by 2-year validated patient-reported outcomes. Methods Our technique uses arthroscopic all-inside suture fixation with iliac crest autogenous bone grafting. The procedure was performed on 4 elite-level, adolescent athletes presenting with 5 unstable capitellum OCD lesions resulting in elbow pain, limited range of motion, and decreased ability to play. Magnetic resonance imaging showed an unstable OCD lesion, which was correlated with arthroscopy. Postoperatively, patients were evaluated by the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; Oxford Elbow and Mayo Elbow scores; visual analog scale; postoperative range of motion; and return to play. Results Three female patients and one male patient aged 13 to 15 years underwent the procedure. The mean final follow-up period was 2.8 years. Union was achieved in all patients, as seen on magnetic resonance imaging at a mean of 3 months. At follow-up, the mean loss of extension was 2°. Mean flexion was 153°. There was no loss of supination or pronation. The mean score on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire was 11. The mean Mayo Elbow score was 88. The mean Oxford Elbow score was 42. The mean visual analog scale score was 2. The mean time to return to play was 4 months. All patients continued to compete at an elite level. There were no infections or cases of fixation failure, and no patients required conversion to open surgery or needed revision surgery. Conclusion Arthroscopic all-inside fixation of unstable OCD lesions is a successful technique, facilitating athletes to return to an elite level of play.
Between 2008 and 2017, the American Pyrotechnics Association reported a 41% increase in revenue from firework sales, with 2017 showing $885 million US dollars in consumer sales. We sought to evaluate ...the epidemiology of firework-related upper extremity injuries during this 10-year period, hypothesizing that hand/upper extremity injuries from fireworks were increasing in the United States.
Observational epidemiologic assessment of a weighted cohort of patients via the National Electronic Injury Surveillance System from 2008 to 2017. The National Electronic Injury Surveillance System provides a nationwide probability sample of injuries related to consumer products based on emergency department visits collected from a cohort of about 100 US hospitals.
A total of 1,079 patients representing an estimated 41,195 firework-related upper extremity injuries presented to US emergency departments from 2008 to 2017. The number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in firework sales and the increase in injuries (rs = 0.939, P < 0.01). The overwhelming majority of firework-related injuries were seen in males (77%) aged 11 to 29 years (48%). The hand and fingers accounted for 85.8% of injuries, with the thumb being the most commonly injured body part (51.3%). Burns were the most common injury across all body sites except the wrist, where fractures were most common.
Ten-year firework-related upper extremity injuries increased, corresponding to increased consumer sales across the same period. This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated upper extremity injuries.
Level III.
In recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven ...intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research.
The authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy. The literature was reviewed to identify possible outcomes and their likelihood following CDR and ACDF. Health state utility factors were determined from the literature and assigned to each possible outcome, and procedural effectiveness was expressed in units of quality-adjusted life years (QALYs). Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample, the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio. Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology (CPT) code. Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis.
In the reference case, the model assumed a 20-year duration for the CDR prosthesis. Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years ($3042/QALY for CDR vs $8760/QALY for ACDF). Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF. Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the $50,000/QALY gained willingness-to-pay threshold is crossed. Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective.
Both CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.
The contribution of potatoes to the global food supply is increasing—consumption more than doubled in developing countries between 1960 and 2005. Understanding climate change impacts on global potato ...yields is therefore important for future food security. Analyses of climate change impacts on potato compared to other major crops are rare, especially at the global scale. Of two global gridded potato modeling studies published at the time of this analysis, one simulated the impacts of temperature increases on potential potato yields; the other did not simulate the impacts of farmer adaptation to climate change, which may offset negative climate change impacts on yield. These studies may therefore overestimate negative climate change impacts on yields as they do not simultaneously include CO
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fertilisation and adaptation to climate change. Here we simulate the abiotic impacts of climate change on potato to 2050 using the GLAM crop model and the ISI-MIP ensemble of global climate models. Simulations include adaptations to climate change through varying planting windows and varieties and CO
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fertilisation, unlike previous global potato modeling studies. Results show significant skill in reproducing observed national scale yields in Europe. Elsewhere, correlations are generally positive but low, primarily due to poor relationships between national scale observed yields and climate. Future climate simulations including adaptation to climate change through changing planting windows and crop varieties show that yields are expected to increase in most cases as a result of longer growing seasons and CO
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fertilisation. Average global yield increases range from 9 to 20% when including adaptation. The global average yield benefits of adaptation to climate change range from 10 to 17% across climate models. Potato agriculture is associated with lower green house gas emissions relative to other major crops and therefore can be seen as a climate smart option given projected yield increases with adaptation.
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