Optimal management of post-traumatic radioulnar synostosis

Post-traumatic radioulnar synostosis is a rare complication after forearm or elbow injury that can result in loss of motion and significant disability. Risk factors include aspects of the initial trauma and of the surgical treatment of that trauma. Surgical intervention for synostosis is the standard of care and is determined based on the location of the bony bridge. Surgical timing is recommended between 6 months and 2 years with recent advocacy for the 6- to 12-month period after radiographs demonstrate bony maturation but early enough to prevent further stiffness and contractures. For most types of synostosis, surgical resection with interposition graft is recommended. The types of materials used include synthetic, allograft, and vascularized and non-vascularized materials, but currently there is no consensus on which is the most preferable. Adjuvant therapy is not considered necessary for all cases but can be beneficial in patients with high risk factors such as recurrence or traumatic brain injury. Postoperative rehabilitation should be performed early to maintain range of motion. © 2017 Osterman and Arief

Predicting Revision Following In Situ Ulnar Nerve Decompression for Patients With Idiopathic Cubital Tunnel Syndrome.

PURPOSE: To determine the incidence of revision and potential risk factors for needing revision surgery following in situ ulnar nerve decompression for patients with idiopathic cubital tunnel syndrome (CTS). METHODS: We conducted a retrospective chart review of all patients treated at 1 specialty hand center with an open in situ ulnar nerve decompression for idiopathic CTS from January 2006 through December 2010. Revision incidence was determined by identifying patients who underwent additional surgeries for recurrent or persistent ulnar nerve symptoms. Bivariate analysis was performed to determine which variables had a significant influence on the need for revision surgery. RESULTS: Revision surgery was required in 3.2% (7 of 216) of all cases. Age younger than 50 years at the time of index decompression was the lone significant predictor of need for revision surgery. Other patient factors, including gender, diabetes, smoking history, and workers\u27 compensation status were not predictive of the need for revision surgery. Disease-specific variables including nerve conduction velocities, McGowan grading, and predominant symptom type were also not predictive of revision. CONCLUSIONS: For patients with idiopathic CTS, the risk of revision surgery following in situ ulnar nerve decompression is low. However, this risk was increased in patients who were younger than 50 years at the time of the index procedure. The findings of this study suggest that, in the absence of underlying elbow arthritis or prior elbow trauma, in situ ulnar nerve decompression is an effective, minimal-risk option for the initial surgical treatment of CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III

Evaluation and Management of Sleep Disorders in the Hand Surgery Patient.

Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition

Geographic and Age-Based Variations in Medicare Reimbursement Among ASSH Members.

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members\u27 Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). Hand-surgeons-per-capita and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state\u27s average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus number of hand surgeons per capita, and (3) total reimbursement from Medicare versus number of years in practice. Analysis of variance (ANOVA) was used to detect a difference in reimbursement based on categorical range of years as an ASSH member. Results: A total of 1667 ASSH members satisfied inclusion in this study. Although there was significant variation among states\u27 average reimbursement, reimbursement was not significantly correlated with the state\u27s hand surgeons per capita or total number of hand surgeons in that given state. Correlation between years as an ASSH member and average reimbursement was significant but non-linear; the highest reimbursements were seen in surgeons who had been ASSH members from 8 to 20 years. Conclusions: Peak reimbursement from Medicare for ASSH members appears to be related to the time of surgeons\u27 peak operative volume, rather than any age-based bias for or against treating Medicare beneficiaries. In addition, though geographic variation in reimbursement does exist, this does not appear to correlate with density or availability of hand surgeons

A laboratory study to estimate pore geometric parameters of sandstones using complex conductivity and nuclear magnetic resonance for permeability prediction

We estimate parameters from the Katz and Thompson permeability model using laboratory complex electrical conductivity (CC) and nuclear magnetic resonance (NMR) data to build permeability models parameterized with geophysical measurements. We use the Katz and Thompson model based on the characteristic hydraulic length scale, determined from mercury injection capillary pressure estimates of pore throat size, and the intrinsic formation factor, determined from multi-salinity conductivity measurements, for this purpose. Two new permeability models are tested, one based on CC data and another that incorporates CC and NMR data. From measurements made on forty-five sandstone cores collected from fifteen different formations, we evaluate how well the CC relaxation time and the NMR transverse relaxation times compare to the characteristic hydraulic length scale and how well the formation factor estimated from CC parameters compares to the intrinsic formation factor. We find: (1) the NMR transverse relaxation time models the characteristic hydraulic length scale more accurately than the CC relaxation time (R2 of 0.69 and 0.39 and normalized root mean square errors (NRMSE) of 0.16 and 0.20, respectively); (2) the CC estimated formation factor is well correlated with the intrinsic formation factor (NRMSE=0.23). We demonstrate that that permeability estimates from the joint-NMR-CC model (NRMSE=0.13) compare favorably to estimates from the Katz and Thompson model (NRMSE=0.074). This model advances the capability of the Katz and Thompson model by employing parameters measureable in the field giving it the potential to more accurately estimate permeability using geophysical measurements than are currently possible

Platelet-Rich Plasma Injection With Percutaneous Needling for Recalcitrant Lateral Epicondylitis: Comparison of Tenotomy and Fenestration Techniques.

Background: Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance. Purpose: To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction. Results: At a mean follow-up of 40 months, significant improvements in VAS-P (mean, -6.1; 95% CI, -6.8 to -5.5; P \u3c .0001), QuickDASH (mean, -46; 95% CI, -52 to -40; P \u3c .0001), and PRTEE (mean, -57; 95% CI, -64 to -50; P \u3c .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P \u3c .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group (P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course. Conclusion: A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm

Tendinosis develops from age- and oxygen tension-dependent modulation of Rac1 activity.

Age-related tendon degeneration (tendinosis) is characterized by a phenotypic change in which tenocytes display characteristics of fibrochondrocytes and mineralized fibrochondrocytes. As tendon degeneration has been noted in vivo in areas of decreased tendon vascularity, we hypothesized that hypoxia is responsible for the development of the tendinosis phenotype, and that these effects are more pronounced in aged tenocytes. Hypoxic (1% O2 ) culture of aged, tendinotic, and young human tenocytes resulted in a mineralized fibrochondrocyte phenotype in aged tenocytes, and a fibrochondrocyte phenotype in young and tendinotic tenocytes. Investigation of the molecular mechanism responsible for this phenotype change revealed that the fibrochondrocyte phenotype in aged tenocytes occurs with decreased Rac1 activity in response to hypoxia. In young hypoxic tenocytes, however, the fibrochondrocyte phenotype occurs with concomitant decreased Rac1 activity coupled with increased RhoA activity. Using pharmacologic and adenoviral manipulation, we confirmed that these hypoxic effects on the tenocyte phenotype are linked directly to the activity of RhoA/Rac1 GTPase in in vitro human cell culture and tendon explants. These results demonstrate that hypoxia drives tenocyte phenotypic changes, and provide a molecular insight into the development of human tendinosis that occurs with aging

Effect of clay content and distribution on hydraulic and geophysical properties of synthetic sand-clay mixtures

Geophysical methods show promise for detecting the spatial variability of subsurface clay content and its effect on subsurface hydraulic properties. We have developed a laboratory study that examines the influence of clay content and distribution on the relationships between hydraulic conductivity K and the physical and geophysical properties of the media. Two geophysical methods are investigated: spectral induced polarization (SIP) and nuclear magnetic resonance (NMR). We used synthetic sediment mixtures of sand and up to 10% kaolinite clay by mass; the clay was homogeneously mixed or was present as large (approximately 5 mm) clusters distributed through the sample. The K varies moderately well (normalized root-mean-square error [Nrms error] = 0.393) with the pore-volume normalized surface area S-por a proxy measure of clay content, in the homogeneous samples and poorly (Nrms error = 0.507) when the clustered samples are included in the fit. The SIP parameters indicate moderately good to excellent fits with S-por for homogeneous samples (Nrms error = 0.0783-0.139) and moderately good to good fits for clustered samples (Nrms error = 0.140-0.336), and the coefficients describing the polarizability of the samples depend on the clay distribution. NMR parameters vary moderately well with S-por in the homogeneous samples (Nrms error = 0.341-0.412) and poorly (Nrms error = 1.08-6.04) in the clustered samples. The SIP parameters vary moderately well with K (Nrms error = 0.301-0.466); however, the relationship between the SIP parameters and K is compromised by the nonnegligible polarization of the clay clusters. NMR parameters indicate good to excellent fits with K (Nrms error = 0.0789-0.116). For SIP and NMR, fitting homogeneous and clustered samples together does not compromise the fit quality. These results suggest that the geophysical measurements are better predictors of K in heterogeneous porous media than bulk measures of pore geometry such as S-por

Postpartum Mastitis and Community-acquired Methicillin-resistant Staphylococcus aureus

This single-center, case-control study documents a relative increase in methicillin resistance among 48 cases of Staphylococcus aureus–associated postpartum mastitis during 1998–2005. Of 21 cases with methicillin resistance, 17 (81%) occurred in 2005. Twenty (95%) isolates contained the Staphylococcus cassette chromosome mec type IV gene; this suggests that the increase is due to community-acquired methicillin-resistant Staphylococcus aureus

The on-orbit performance of the Orbiting Carbon Observatory-2 (OCO-2) instrument and its radiometrically calibrated products

The Orbiting Carbon Observatory-2 (OCO-2) carries and points a three-channel imaging grating spectrometer designed to collect high-resolution, co-boresighted spectra of reflected sunlight within the molecular oxygen (O_2) A-band at 0.765 microns and the carbon dioxide (CO_2) bands at 1.61 and 2.06 microns. These measurements are calibrated and then combined into soundings that are analyzed to retrieve spatially resolved estimates of the column-averaged CO_2 dry-air mole fraction, XCO_2. Variations of XCO_2 in space and time are then analyzed in the context of the atmospheric transport to quantify surface sources and sinks of CO_2. This is a particularly challenging remote-sensing observation because all but the largest emission sources and natural absorbers produce only small (< 0.25 %) changes in the background XCO_2 field. High measurement precision is therefore essential to resolve these small variations, and high accuracy is needed because small biases in the retrieved XCO_2 distribution could be misinterpreted as evidence for CO_2 fluxes. To meet its demanding measurement requirements, each OCO-2 spectrometer channel collects 24 spectra s^(−1) across a narrow ( 17 000), dynamic range (∼ 10^4), and sensitivity (continuum signal-to-noise ratio > 400). The OCO-2 instrument performance was extensively characterized and calibrated prior to launch. In general, the instrument has performed as expected during its first 18 months in orbit. However, ongoing calibration and science analysis activities have revealed a number of subtle radiometric and spectroscopic challenges that affect the yield and quality of the OCO-2 data products. These issues include increased numbers of bad pixels, transient artifacts introduced by cosmic rays, radiance discontinuities for spatially non-uniform scenes, a misunderstanding of the instrument polarization orientation, and time-dependent changes in the throughput of the oxygen A-band channel. Here, we describe the OCO-2 instrument, its data products, and its on-orbit performance. We then summarize calibration challenges encountered during its first 18 months in orbit and the methods used to mitigate their impact on the calibrated radiance spectra distributed to the science community