Nasal reconstruction with local flaps: A simple algorithm for management of small defects

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Be familiar with subunits of the nose. 2. Understand various flaps used in nasal reconstruction. 3. Be able to choose a flap for the defect depending on its location, size, shape and orientation. BACKGROUND: Management of small defects in nasal reconstruction can be quite challenging. Location, size, shape, and orientation of the defects are important factors in determining the method used in reconstruction. METHODS: In this article, the authors retrospectively examined 300 cases where local flaps were used to reconstruct small nasal defects. The authors correlated the characteristics of those defects with the techniques used to reconstruct them. RESULTS: The authors found that certain flaps were used predominantly in reconstruction of certain defects. CONCLUSIONS: The authors were able to develop a simple algorithm for management of small nasal defects that may prospectively aid the planning of reconstructive strategy in these cases. Copyright © 2008 by the American Society of Plastic Surgeons

Postoperative Complications and Impact of Gender on Operative Treatment of Distal Radius Fractures

Background: Distal Radius Fracture Repair procedures remain commonly performed. While numerous studies have attempted to differentiate gender impact on operative outcomes, the literature remains inconclusive. In particular, gender impact on orthopedic procedures is controversial. In our study, we examined the effects of gender on postoperative complications following distal radius fracture repairs. We predict that males will have increased morbidity and mortality following operative treatment of distal radius fractures than their female counterparts. Methods: Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for all operative treatments for distal radius fractures from 2007 through 2014. Data includes preoperative demographic information and risk factors, perioperative events, and complications occurring within 30 days of initial surgical intervention. Subjects were identified using Current Procedural Terminology (CPT) codes. Primary CPT codes 25607, 25608, 25609 were used to identify patients receiving operative treatment for distal radius fractures. Two cohorts were defined in this study: (1) Male and (2) Female. Data on patients’ demographics, comorbidities, and postoperative complications were analyzed with univariate and multivariate analyses on SPSS software. Univariate analysis was performed using Pearson’s Chi-square for categorical variables or one-way ANOVA for continuous variables. Variables with p\u3c0.05 were selected for multivariate analyses. For the multivariate analyses, Poisson logistic linear regression analyses were performed to determine independent associations of risk factors for postoperative complications. Multivariate analysis results were reported as odds-ratios and 95% confidence intervals. A p-value of \u3c0.05 was used. Results: A total of 6,450 subjects were included in this study. Females comprised the majority of the study, with 4,675 (72%) patients. There were 1,775 male patients included in this study (28%). In total, there were 196 postoperative complications (4.2%) amongst females, and 75 postoperative complications (4.8%) seen in the male cohort. Men have an increased likelihood of failure to wean from anesthesia (p=0.022). There was no observed difference between males and females amongst all other comorbidities. Multivariate analysis did not identify gender as an independent risk for post-operative complications. Summary: There was no difference in postoperative complications based on gender analysis. Furthermore, Gender was not determined to be an independent risk factor for any post-operative complication. Overall complications for operative treatment of distal radius fractures were low for both groups. Based upon our results, risk for postoperative complications should not be stratified based off gender. Patients who stand to benefit from operative treatment of distal radius fractures should receive treatment

Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections

© 2016, © The Author(s) 2016. Background: Hospital transfer decisions regarding pyogenic flexor tenosynovitis (PFT) are made difficult by emergency department presentations similar to other finger infections, with pain, redness, and functional limitation. Our objectives were to: (1) determine diagnostic sensitivity and specificity of Kanavel signs; and (2) identify existing factors most predictive of PFT during initial presentation. Methods: Adult patients who underwent surgical consultation for concern of PFT over a 5-year period were identified retrospectively. Bivariate screening identified clinical criteria for differentiation, and multivariate logistic regression was performed to control for confounding. We then created a prediction algorithm for diagnosis of PFT. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. Results: Patients with PFT differed significantly from those with non-PFT finger infections in regard to the 4 Kanavel signs, duration of symptoms less than 5 days, and erythrocyte sedimentation rate. Sensitivity of the Kanavel signs ranged from 91.4% to 97.1%. Specificity ranged from 51.3% to 69.2%. Logistic regression identified independent predictors for PFT as tenderness along the flexor tendon sheath, pain with passive extension, and duration of symptoms less than 5 days. A prediction algorithm incorporating these 3 factors showed an area under the ROC curve of 0.91 (95% confidence interval, 0.840-0.979). Conclusions: Kanavel signs have high sensitivity for detecting PFT but have poor specificity on an individual basis. Clinical prediction algorithms that combine the relevant factors may be helpful in the development of clinical prediction tools and educational materials for optimization of emergency hand care systems. Further prospective study is needed

Monitoring Bacterial Burden, Inflammation and Bone Damage Longitudinally Using Optical and μCT Imaging in an Orthopaedic Implant Infection in Mice

Background: Recent advances in non-invasive optical, radiographic and μCT imaging provide an opportunity to monitor biological processes longitudinally in an anatomical context. One particularly relevant application for combining these modalities is to study orthopaedic implant infections. These infections are characterized by the formation of persistent bacterial biofilms on the implanted materials, causing inflammation, periprosthetic osteolysis, osteomyelitis, and bone damage, resulting in implant loosening and failure. Methodology/Principal Findings: An orthopaedic implant infection model was used in which a titanium Kirshner-wire was surgically placed in femurs of LysEGFP mice, which possess EGFP-fluorescent neutrophils, and a bioluminescent S. aureus strain (Xen29; 1×103 CFUs) was inoculated in the knee joint before closure. In vivo bioluminescent, fluorescent, X-ray and μCT imaging were performed on various postoperative days. The bacterial bioluminescent signals of the S. aureus-infected mice peaked on day 19, before decreasing to a basal level of light, which remained measurable for the entire 48 day experiment. Neutrophil EGFP-fluorescent signals of the S. aureus-infected mice were statistically greater than uninfected mice on days 2 and 5, but afterwards the signals for both groups approached background levels of detection. To visualize the three-dimensional location of the bacterial infection and neutrophil infiltration, a diffuse optical tomography reconstruction algorithm was used to co-register the bioluminescent and fluorescent signals with μCT images. To quantify the anatomical bone changes on the μCT images, the outer bone volume of the distal femurs were measured using a semi-automated contour based segmentation process. The outer bone volume increased through day 48, indicating that bone damage continued during the implant infection. Conclusions/Significance: Bioluminescent and fluorescent optical imaging was combined with X-ray and μCT imaging to provide noninvasive and longitudinal measurements of the dynamic changes in bacterial burden, neutrophil recruitment and bone damage in a mouse orthopaedic implant infection model. © 2012 Niska et al

The Effect of BMI on Rates of Postoperative Complications after Open Reduction and Internal Fixation of Distal Radius Fractures – A Study on the National Surgical Quality Improvement Project Database

Background: A patient’s Body Mass Index (BMI) has a wide variety of correlations in the orthopedic perioperative setting including post-operative complications. With the current increasing obesity epidemic in the population, understanding the effects of BMI across surgical outcomes can help highlight specific populations that may warrant further management. This study examines the outcomes of patients categorized by BMI receiving operative treatment for distal radius fractures. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent operative management for distal radius fractures between 2007 and 2014 were identified and stratified into groups based on World Health Organization BMI guidelines: (1) \u3c18.5, (2) 18.5-24.9, (3) 25-29.9, (4) \u3e30. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after operation. Results: A total of 6,078 subjects were included in this study, with patients who were underweight having the highest percentage of complications at 4.5%. Underweight patients were seen to have an increased likelihood of developing sepsis (p=0.003), myocardial infarction (p\u3c0.001) and progressive renal insufficiency (p\u3c0.001). There were no observed differences seen between BMI groups amongst other comorbidities. Multivariate analysis did not identify BMI as an independent risk factor for any post-operative complications. Conclusion: Relative to non-obese patients (BMI\u3c30), patients with BMI\u3e30 were not observed to be at an increased risk for any post-operative complications. On the contrary patients underweight (BMI\u3c18.5) were found to be at increased risk for developing sepsis, progressive renal insufficiency, and myocardial infarction. Overall complications for operative treatment of distal radius fracture were low for all groups, and patients who stand to benefit from operative treatment should still receive treatment

Daptomycin and tigecycline have broader effective dose ranges than vancomycin as prophylaxis against a Staphylococcus aureus surgical implant infection in mice

Vancomycin is widely used for intravenous prophylaxis against surgical implant infections. However, it is unclear whether alternative antibiotics used to treat methicillin-resistant Staphylococcus aureus (MRSA) infections are effective as prophylactic agents. The aim of this study was to compare the efficacies of vancomycin, daptomycin, and tigecycline as prophylactic therapy against a methicillin-sensitive S. aureus (MSSA) or MRSA surgical implant infection in mice. MSSA or MRSA was inoculated into the knee joints of mice in the presence of a surgically placed medical-grade metallic implant. The efficacies of low- versus high-dose vancomycin (10 versus 110 mg/kg), daptomycin (1 versus 10 mg/kg), and tigecycline (1 versus 10 mg/kg) intravenous prophylaxis were compared using in vivo bioluminescence imaging, ex vivo bacterial counts, and biofilm formation. High-dose vancomycin, daptomycin, and tigecycline resulted in similar reductions in bacterial burden and biofilm formation. In contrast, low-dose daptomycin and tigecycline were more effective than low-dose vancomycin against the implant infection. In this mouse model of surgical implant MSSA or MRSA infection, daptomycin and tigecycline prophylaxis were effective over a broader dosage range than vancomycin. Future studies in humans will be required to determine whether these broader effective dose ranges for daptomycin and tigecycline in mice translate to improved efficacy in preventing surgical implant infections in clinical practice. Copyright © 2012, American Society for Microbiology. All Rights Reserved

Mouse model of chronic post-arthroplasty infection: noninvasive in vivo bioluminescence imaging to monitor bacterial burden for long-term study.

Post-arthroplasty infections are a devastating problem in orthopaedic surgery. While acute infections can be treated with a single stage washout and liner exchange, chronic infections lead to multiple reoperations, prolonged antibiotic courses, extended disability, and worse clinical outcomes. Unlike previous mouse models that studied an acute infection, this work aimed to develop a model of a chronic post-arthroplasty infection. To achieve this, a stainless steel implant in the knee joints of mice was inoculated with a bioluminescent Staphylococcus aureus strain (1 × 10(2) -1 × 10(4) colony forming units, CFUs) and in vivo imaging was used to monitor the bacterial burden for 42 days. Four different S. aureus strains were compared in which the bioluminescent construct was integrated in an antibiotic selection plasmid (ALC2906), the bacterial chromosome (Xen29 and Xen40), or a stable plasmid (Xen36). ALC2906 had increased bioluminescent signals through day 10, after which the signals became undetectable. In contrast, Xen29, Xen40, and Xen36 had increased bioluminescent signals through 42 days with the highest signals observed with Xen36. ALC2906, Xen29, and Xen40 induced significantly more inflammation than Xen36 as measured by in vivo enhanced green fluorescence protein (EGFP)-neutrophil flourescence of LysEGFP mice. All four strains induced comparable biofilm formation as determined by variable-pressure scanning electron microscopy. Using a titanium implant, Xen36 had higher in vivo bioluminescence signals than Xen40 but had similar biofilm formation and adherent bacteria. In conclusion, Xen29, Xen40, and especially Xen36, which had stable bioluminescent constructs, are feasible for long-term in vivo monitoring of bacterial burden and biofilm formation to study chronic post-arthroplasty infections and potential antimicrobial interventions. Copyright © 2011 Orthopaedic Research Society

Protective role of IL-1β against post-arthroplasty Staphylococcus aureus infection

MyD88 is an adapter molecule that is used by both IL-1R and TLR family members to initiate downstream signaling and promote immune responses. Given that IL-1β is induced after Staphylococcus aureus infections and TLR2 is activated by S. aureus lipopeptides, we hypothesized that IL-1β and TLR2 contribute to MyD88-dependent protective immune responses against post-arthroplasty S. aureus infections. To test this hypothesis, we used a mouse model of a post-arthroplasty S. aureus infection to compare the bacterial burden, biofilm formation and neutrophil recruitment in IL-1β-deficient, TLR2-deficient and wild-type (wt) mice. By using in vivo bioluminescence imaging, we found that the bacterial burden in IL-1β-deficient mice was 26-fold higher at 1 day after infection and remained 3- to 10-fold greater than wt mice through day 42. In contrast, the bacterial burden in TLR2-deficient mice did not differ from wt mice. In addition, implants harvested from IL-1β-deficient mice had more biofilm formation and 14-fold higher adherent bacteria compared with those from wt mice. Finally, IL-1β-deficient mice had ∼50% decreased neutrophil recruitment to the infected postoperative joints than wt mice. Taken together, these findings suggest a mechanism by which IL-1β induces neutrophil recruitment to help control the bacterial burden and the ensuing biofilm formation in a post-surgical joint. © 2011 Orthopaedic Research Society. Published by Wiley Periodicals, Inc