Category: Sports; Trauma; Other Introduction/Purpose: Achilles tendon ruptures are common injurie... more Category: Sports; Trauma; Other Introduction/Purpose: Achilles tendon ruptures are common injuries in the active duty US military population. Timely rehabilitation has critical importance in force readiness. There remains debate about optimal treatment of Achilles tendon ruptures. Recent studies have found decreased risk of rerupture but increased complication rates with operative management, with similar times to full recovery. The development of a minimally invasive, percutaneous Achilles tendon technique has shown lower rates of wound complications than open management, with similar re-rupture rates. However, there exists no comparative studies between the percutaneous, minimally invasive Achilles tendon surgery and nonoperative management. This was a retrospective cohort study comparing the results of the Percutaneous Achilles Repair System (PARS) and nonoperative management in the active duty military population. Methods: All Achilles tendon injuries in active duty patients wer...
BACKGROUND Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental comp... more BACKGROUND Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental complication. This retrospective study aims to identify patient and surgical factors associated with nonunion risk to help mitigate this. The authors hypothesize that patient factors and potentially modifiable surgical factors are contributory. METHODS Thirty-three patients who underwent corrective osteotomy of the distal radius for prior fracture malunion were identified. Radiographs and patient records were reviewed for demographics, comorbidities, nutritional status, plate position, angle and length of osteotomy correction, and graft used. The primary study outcome was osteotomy nonunion. Descriptive and bivariate statistics were used to identify covariates relevant to nonunion. Backward, stepwise logistic regression was applied to investigate the multivariate effects on outcome, and regression analysis was adjusted for confounders. RESULTS Seven patients (21 percent) experienced nonunion...
Introduction Pathologic fracture of the femur due to Streptococcus anginosus osteomyelitis has ra... more Introduction Pathologic fracture of the femur due to Streptococcus anginosus osteomyelitis has rarely been described. With limited evidence for treating S. anginosus osteomyelitis, the orthopaedic surgeon is presented with a difficult treatment decision at index presentation. Presented here is a case of failed conservative management, diagnostic dilemma, failed hardware stabilization, and definitive surgical treatment resulting in good clinical outcome. Case presentation A 69-year-old male experienced acute right thigh pain, edema, and erythema after dental treatment 17 days prior. He was diagnosed with right femoral diaphyseal osteomyelitis and Brodie's abscess. Blood cultures grew S. anginosus, but all site-specific tissue cultures resulted negative. Initial management consisted of intravenous antibiotic therapy and percutaneous abscess drainage. Months later, the patient sustained a displaced pathologic fracture of the diaphyseal femur and there was concern for neoplasm, but ...
OBJECTIVES This review aimed to evaluate the quality of research and reporting of randomized cont... more OBJECTIVES This review aimed to evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems. DATA SOURCE PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail". Filters were applied for the years 1991-2019, full articles, human subjects, and English language. STUDY SELECTION Inclusion criteria were (1) prospective and randomized trials (2) Studies reported >80% follow-up (3) articles were amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) included skeletally immature patients or (2) incomplete data sets DATA EXTRACTION:: Articles were assessed with Coleman Methodology Score, the Consolidated Standards of Reporting Trials (CONSORT) systems, and Cowan's Categorical Rating by two independent observers. DATA SYNTHESIS Scores for individual articles were averaged for the two observers. The total and subcategory scores for all included articles were also averaged with standard deviation from both observers. Categories from the two grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using Kappa statistic and correlation coefficient to assess agreement and reliability. CONCLUSIONS All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the Modified Coleman Score and CONSORT grading scheme ranges despite being Oxford Level 1. LEVEL OF EVIDENCE Level 1.
Background Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, promp... more Background Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, prompting surgical stabilization. Studies investigating this injury are limited by small case volumes. Our purpose is to review the surgical techniques, outcomes, and complications of ulnar CMC joint stabilization. Methods A literature search was performed of all articles published on the surgical treatment and outcomes of ulnar CMC fracture dislocations using PubMed and Google Scholar databases between the years 2014 and 2019. Data were pooled and analyzed, assessing surgical techniques and hand outcome measures: union, recurrent dislocations, range of motion, grip strength, and complications. Results Six studies met inclusion criteria. All surgical patients, regardless of technique, went on to union with no incidents of recurrent instability. Grip strength was significantly decreased postoperatively (82.7% of uninjured side). Patients with CMC dislocations of both the fourth and fifth ray h...
The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has... more The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has led to a debate regarding the relative clinical significance of fibrinolysis in the setting of trauma. The debate has centered on two camps. The one camp defines fibrinolysis in trauma by standard coagulation tests as well as fibrin split products, D-dimers, and plasmin/antiplasmin levels. This camp favors a more liberal use of tranexamic acid and attributes more significance to hyperfibrinolysis in TIC. The other camp favors a definition of fibrinolysis based on the viscoelastic tests (VET), rotational thromboelastometry (ROTEM), and thromboelastography (TEG). These whole blood assays define hyperfibrinolysis at a higher threshold than plasma-based tests. Therefore, this VET camp reserves antifibrinolytic treatment for patients who demonstrate severe coagulopathy associated with hyperfibrinolysis. This bimodal attribution of the clinical relevance of fibrinolysis in trauma suggests tha...
The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has... more The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has led to a debate regarding the relative clinical significance of fibrinolysis in the setting of trauma. The debate has centered on two camps. The one camp defines fibrinolysis in trauma by standard coagulation tests as well as fibrin split products, D-dimers, and plasmin/antiplasmin levels. This camp favors a more liberal use of tranexamic acid and attributes more significance to hyperfibrinolysis in TIC. The other camp favors a definition of fibrinolysis based on the viscoelastic tests (VET), rotational thromboelastometry (ROTEM), and thromboelastography (TEG). These whole blood assays define hyperfibrinolysis at a higher threshold than plasma-based tests. Therefore, this VET camp reserves antifibrinolytic treatment for patients who demonstrate severe coagulopathy associated with hyperfibrinolysis. This bimodal attribution of the clinical relevance of fibrinolysis in trauma suggests that there may be an underlying "Myth" of the concept of TIC that was historically defined by plasma-based tests and a future "Reality" of the concept of TIC that is grounded on an understanding of TIC based on a VET-defined "fibrinolytic spectrum" of TIC. This narrative review explores this "Myth" and "Reality" of fibrinolysis in TIC and proposes a direction that will allow a "Future" interpretation of TIC that incorporates both the past "Myth" and present "Reality" of fibrinolysis TIC.
The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been ... more The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been a subject of much debate on both sides of the Atlantic and in Australia. As a result of the large randomized controlled study called the Clinical Randomization of an Antifibrinolytic in Severe Hemorrhage (CRASH-2), there was an initial enthusiasm for the use of TXA to treat bleeding patients. However, the adoption of TXA in the United States was delayed by concerns of "knowledge and evidence gaps" of the CRASH-2 study and because of a lack of mechanistic rationale that would explain the survival benefit noted in the study. Subsequent nonrandomized controlled trials questioned the liberal use of TXA in trauma patients. This narrative review explores the historical as well as clinical and theoretical grounds for the more measured use of TXA in the United States and proposes a clinical and point-of-care guided utilization of TXA, blood components, and adjunctive hemostatic agents ...
The development of sex-specific traits, including the female-specific ability to bite humans and ... more The development of sex-specific traits, including the female-specific ability to bite humans and vector disease, is critical for vector mosquito reproduction and pathogen transmission. Doublesex (Dsx), a terminal transcription factor in the sex determination pathway, is known to regulate sex-specific gene expression during development of the dengue fever vector mosquito Aedes aegypti. Here, the effects of developmental siRNA-mediated dsx silencing were assessed in adult females. Targeting of dsx during A. aegypti development resulted in decreased female wing size, a correlate for body size, which is typically larger in females. siRNA-mediated targeting of dsx also resulted in decreased length of the adult female proboscis. Although dsx silencing did not impact female membrane blood feeding or mating behavior in the laboratory, decreased fecundity and fertility correlated with decreased ovary length, ovariole length, and ovariole number in dsx knockdown females. Dsx silencing also resulted in disruption of olfactory system development, as evidenced by reduced length of the female antenna and maxillary palp and the sensilla present on these structures, as well as disrupted odorant receptor expression. Female lifespan, a critical component of the ability of A. aegypti to transmit pathogens, was also significantly reduced in adult females following developmental targeting of dsx. The results of this investigation demonstrate that silencing of dsx during A. aegypti development disrupts multiple sex-specific morphological, physiological, and behavioral traits of adult females, a number of which are directly or indirectly linked to mosquito reproduction and pathogen transmission. Moreover, the olfactory phenotypes observed connect Dsx to development of the olfactory system, suggesting that A. aegypti will be an excellent system in which to further assess the developmental genetics of sex-specific chemosensation.
Category: Sports; Trauma; Other Introduction/Purpose: Achilles tendon ruptures are common injurie... more Category: Sports; Trauma; Other Introduction/Purpose: Achilles tendon ruptures are common injuries in the active duty US military population. Timely rehabilitation has critical importance in force readiness. There remains debate about optimal treatment of Achilles tendon ruptures. Recent studies have found decreased risk of rerupture but increased complication rates with operative management, with similar times to full recovery. The development of a minimally invasive, percutaneous Achilles tendon technique has shown lower rates of wound complications than open management, with similar re-rupture rates. However, there exists no comparative studies between the percutaneous, minimally invasive Achilles tendon surgery and nonoperative management. This was a retrospective cohort study comparing the results of the Percutaneous Achilles Repair System (PARS) and nonoperative management in the active duty military population. Methods: All Achilles tendon injuries in active duty patients wer...
BACKGROUND Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental comp... more BACKGROUND Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental complication. This retrospective study aims to identify patient and surgical factors associated with nonunion risk to help mitigate this. The authors hypothesize that patient factors and potentially modifiable surgical factors are contributory. METHODS Thirty-three patients who underwent corrective osteotomy of the distal radius for prior fracture malunion were identified. Radiographs and patient records were reviewed for demographics, comorbidities, nutritional status, plate position, angle and length of osteotomy correction, and graft used. The primary study outcome was osteotomy nonunion. Descriptive and bivariate statistics were used to identify covariates relevant to nonunion. Backward, stepwise logistic regression was applied to investigate the multivariate effects on outcome, and regression analysis was adjusted for confounders. RESULTS Seven patients (21 percent) experienced nonunion...
Introduction Pathologic fracture of the femur due to Streptococcus anginosus osteomyelitis has ra... more Introduction Pathologic fracture of the femur due to Streptococcus anginosus osteomyelitis has rarely been described. With limited evidence for treating S. anginosus osteomyelitis, the orthopaedic surgeon is presented with a difficult treatment decision at index presentation. Presented here is a case of failed conservative management, diagnostic dilemma, failed hardware stabilization, and definitive surgical treatment resulting in good clinical outcome. Case presentation A 69-year-old male experienced acute right thigh pain, edema, and erythema after dental treatment 17 days prior. He was diagnosed with right femoral diaphyseal osteomyelitis and Brodie's abscess. Blood cultures grew S. anginosus, but all site-specific tissue cultures resulted negative. Initial management consisted of intravenous antibiotic therapy and percutaneous abscess drainage. Months later, the patient sustained a displaced pathologic fracture of the diaphyseal femur and there was concern for neoplasm, but ...
OBJECTIVES This review aimed to evaluate the quality of research and reporting of randomized cont... more OBJECTIVES This review aimed to evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems. DATA SOURCE PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail". Filters were applied for the years 1991-2019, full articles, human subjects, and English language. STUDY SELECTION Inclusion criteria were (1) prospective and randomized trials (2) Studies reported >80% follow-up (3) articles were amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) included skeletally immature patients or (2) incomplete data sets DATA EXTRACTION:: Articles were assessed with Coleman Methodology Score, the Consolidated Standards of Reporting Trials (CONSORT) systems, and Cowan's Categorical Rating by two independent observers. DATA SYNTHESIS Scores for individual articles were averaged for the two observers. The total and subcategory scores for all included articles were also averaged with standard deviation from both observers. Categories from the two grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using Kappa statistic and correlation coefficient to assess agreement and reliability. CONCLUSIONS All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the Modified Coleman Score and CONSORT grading scheme ranges despite being Oxford Level 1. LEVEL OF EVIDENCE Level 1.
Background Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, promp... more Background Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, prompting surgical stabilization. Studies investigating this injury are limited by small case volumes. Our purpose is to review the surgical techniques, outcomes, and complications of ulnar CMC joint stabilization. Methods A literature search was performed of all articles published on the surgical treatment and outcomes of ulnar CMC fracture dislocations using PubMed and Google Scholar databases between the years 2014 and 2019. Data were pooled and analyzed, assessing surgical techniques and hand outcome measures: union, recurrent dislocations, range of motion, grip strength, and complications. Results Six studies met inclusion criteria. All surgical patients, regardless of technique, went on to union with no incidents of recurrent instability. Grip strength was significantly decreased postoperatively (82.7% of uninjured side). Patients with CMC dislocations of both the fourth and fifth ray h...
The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has... more The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has led to a debate regarding the relative clinical significance of fibrinolysis in the setting of trauma. The debate has centered on two camps. The one camp defines fibrinolysis in trauma by standard coagulation tests as well as fibrin split products, D-dimers, and plasmin/antiplasmin levels. This camp favors a more liberal use of tranexamic acid and attributes more significance to hyperfibrinolysis in TIC. The other camp favors a definition of fibrinolysis based on the viscoelastic tests (VET), rotational thromboelastometry (ROTEM), and thromboelastography (TEG). These whole blood assays define hyperfibrinolysis at a higher threshold than plasma-based tests. Therefore, this VET camp reserves antifibrinolytic treatment for patients who demonstrate severe coagulopathy associated with hyperfibrinolysis. This bimodal attribution of the clinical relevance of fibrinolysis in trauma suggests tha...
The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has... more The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has led to a debate regarding the relative clinical significance of fibrinolysis in the setting of trauma. The debate has centered on two camps. The one camp defines fibrinolysis in trauma by standard coagulation tests as well as fibrin split products, D-dimers, and plasmin/antiplasmin levels. This camp favors a more liberal use of tranexamic acid and attributes more significance to hyperfibrinolysis in TIC. The other camp favors a definition of fibrinolysis based on the viscoelastic tests (VET), rotational thromboelastometry (ROTEM), and thromboelastography (TEG). These whole blood assays define hyperfibrinolysis at a higher threshold than plasma-based tests. Therefore, this VET camp reserves antifibrinolytic treatment for patients who demonstrate severe coagulopathy associated with hyperfibrinolysis. This bimodal attribution of the clinical relevance of fibrinolysis in trauma suggests that there may be an underlying "Myth" of the concept of TIC that was historically defined by plasma-based tests and a future "Reality" of the concept of TIC that is grounded on an understanding of TIC based on a VET-defined "fibrinolytic spectrum" of TIC. This narrative review explores this "Myth" and "Reality" of fibrinolysis in TIC and proposes a direction that will allow a "Future" interpretation of TIC that incorporates both the past "Myth" and present "Reality" of fibrinolysis TIC.
The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been ... more The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been a subject of much debate on both sides of the Atlantic and in Australia. As a result of the large randomized controlled study called the Clinical Randomization of an Antifibrinolytic in Severe Hemorrhage (CRASH-2), there was an initial enthusiasm for the use of TXA to treat bleeding patients. However, the adoption of TXA in the United States was delayed by concerns of "knowledge and evidence gaps" of the CRASH-2 study and because of a lack of mechanistic rationale that would explain the survival benefit noted in the study. Subsequent nonrandomized controlled trials questioned the liberal use of TXA in trauma patients. This narrative review explores the historical as well as clinical and theoretical grounds for the more measured use of TXA in the United States and proposes a clinical and point-of-care guided utilization of TXA, blood components, and adjunctive hemostatic agents ...
The development of sex-specific traits, including the female-specific ability to bite humans and ... more The development of sex-specific traits, including the female-specific ability to bite humans and vector disease, is critical for vector mosquito reproduction and pathogen transmission. Doublesex (Dsx), a terminal transcription factor in the sex determination pathway, is known to regulate sex-specific gene expression during development of the dengue fever vector mosquito Aedes aegypti. Here, the effects of developmental siRNA-mediated dsx silencing were assessed in adult females. Targeting of dsx during A. aegypti development resulted in decreased female wing size, a correlate for body size, which is typically larger in females. siRNA-mediated targeting of dsx also resulted in decreased length of the adult female proboscis. Although dsx silencing did not impact female membrane blood feeding or mating behavior in the laboratory, decreased fecundity and fertility correlated with decreased ovary length, ovariole length, and ovariole number in dsx knockdown females. Dsx silencing also resulted in disruption of olfactory system development, as evidenced by reduced length of the female antenna and maxillary palp and the sensilla present on these structures, as well as disrupted odorant receptor expression. Female lifespan, a critical component of the ability of A. aegypti to transmit pathogens, was also significantly reduced in adult females following developmental targeting of dsx. The results of this investigation demonstrate that silencing of dsx during A. aegypti development disrupts multiple sex-specific morphological, physiological, and behavioral traits of adult females, a number of which are directly or indirectly linked to mosquito reproduction and pathogen transmission. Moreover, the olfactory phenotypes observed connect Dsx to development of the olfactory system, suggesting that A. aegypti will be an excellent system in which to further assess the developmental genetics of sex-specific chemosensation.
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