Urinary bladder matrix versus dermal regeneration template for lower extremity wound coverage

PURPOSE

To compare dermal regenerative template (DRT), with and without split-thickness skin-grafting (STSG), and urinary bladder matrix (UBM) for coverage of lower extremity wounds.

METHODS

A retrospective review of 56 lower extremity wounds treated with either DRT and STSG (DRT-S) (n = 18), DRT only (n = 17), or UBM only (n = 21). Patient characteristics, comorbidities, American Society of Anesthesiology (ASA) classification, injury characteristics, wound characteristics, use of negative pressure wound therapy, surgical details, postoperative care, and failure of primary wound coverage procedure were documented.

RESULTS

The DRT group, compared to the DRT-S group, was older [median difference (MD) 17.4 years, 95% confidence interval (CI) 9.1-25.7; p = 0.0008], more diabetic (proportional difference (PD) 54.2%, CI 21.2-76.1%; p = 0.002), had smaller wounds (MD - 91.0 cm2, CI - 125.0 to - 38.0; p = 0.0008), more infected wounds (PD 49.0%, CI 16.1-71.7%; p = 0.009), a shorter length of stay after coverage (MD - 5.0 days, CI - 29.0 to - 1.0; p = 0.005), and no difference in primary wound coverage failure (41.2% vs. 55.6%; p = 0.50). The UBM group, compared to the DRT group, was younger (MD - 6.8 years; CI - 13.5 to - 0.1; p = 0.04), had fewer patients with an ASA > 2 (PD - 35.0%, CI - 55.2% to - 7.0%; p = 0.02), diabetes (PD - 49.2%, CI - 72.4% to - 17.6%; p = 0.003), and had no difference in primary wound coverage failure (36.4% vs. 41.2%; p = 1.0). Failure of primary wound coverage was found to only be associated with larger wound surface areas (MD 22.0 cm2, CI 4.0-90.0; p = 0.01).

CONCLUSIONS

DRT and UBM coverage had similar rates of primary wound coverage failure for lower extremity wounds.

LEVEL OF EVIDENCE

Diagnostic, Level III.

Fracture displacement of lateral compression type 1 (LC1) Pelvic Ring Injuries: Which measurement methods are reliable and does displacement correlate with adverse events?

PURPOSE

To determine the interobserver reliability of perceived displacement (PD) ≥ 1 cm of lateral compression type 1 (LC1) pelvic ring fractures and to determine if PD correlated with published methods of measuring fracture displacement and adverse events.

METHODS

The injury and follow-up radiographs of 10 patients with nonoperative minimally displaced LC1 injuries were reviewed by 27 orthopaedic trauma surgeons to determine if they perceived an interval fracture displacement ≥ 1 cm. Perceived displacement (PD) was compared to 11 measurements of displacement: the difference in heights of iliac crests (IC), sourcils, and ischial tuberosities on AP/outlet radiographs; the distance from femoral head (FH) to the sacral midline and the distance between the radiographic teardrops (TD) on the AP; the distance from the TD to sacral midline and the difference in distances between the SI joints and the contralateral TD on the inlet. The interobserver reliability and correlation of PD and measured displacement was calculated. The association between PD and adverse events was also evaluated.

RESULTS

PD had weak interobserver reliability (kappa = 0.46). Many of the measurements of displacement were poorly sensitive for PD. The magnification-corrected AP TD measurement had the highest sensitivity (100%) for PD and excellent interobserver reliability (Intraclass correlation 0.97), but had a low specificity (57.1%). All three patients with PD had adverse events while patients without PD had uneventful recoveries (p = 0.008).

CONCLUSIONS

The AP TD measurement detected all cases of PD and had excellent reliability. PD was associated with adverse events, suggesting that accurate and reliable measurements of displacement are warranted.

LEVEL OF EVIDENCE III

Diagnostic.

To Beard or Not to Beard? Bacterial Shedding Among Surgeons

Beards in the operating room are controversial because of their potential to retain and transmit pathogenic organisms. Many bearded orthopedic surgeons choose to wear nonsterile hoods in addition to surgical masks to decrease contamination of the operative field. The goal of this study was to determine whether nonsterile surgical hoods reduce the risk of bacterial shedding posed by beards. Bearded (n=10) and clean-shaven (n=10) subjects completed 3 sets of standardized facial motions, each lasting 90 seconds and performed over blood agar plates, while unmasked, masked, and masked and hooded. The plates were cultured for 48 hours under aerobic and anaerobic conditions. Colony-forming units (CFUs) were quantified, expanded, and identified. Overall, the addition of surgical hoods did not decrease the total number of anaerobic and aerobic CFUs isolated per subject, with a mean of 1.1 CFUs while hooded compared with 1.4 CFUs with the mask alone (P=.5). Unmasked subjects shed a mean of 6.5 CFUs, which was significantly higher than the number of CFUs shed while masked (P=.02) or hooded (P=.01). The bearded group did not shed more than the clean-shaven group while unmasked (9.5 vs 3.3 CFUs, P=.1), masked (1.6 vs 1.2 CFUs, P=.9), or hooded (0.9 vs 1.3 CFUs, P=.6). Bearded surgeons did not appear to have an increased likelihood of bacterial shedding compared with their nonbearded counter parts while wearing surgical masks, and the addition of nonsterile surgical hoods did not decrease the amount of bacterial shedding observed.

Mini Tightrope Fixation Versus Ligament Reconstruction - Tendon Interposition for Maintenance of Post-trapeziectomy Space Height: A Biomechanical Study

PURPOSE

To test the biomechanical stability of ligament reconstruction and tendon interposition (LRTI) compared with Mini TightRope fixation for thumb metacarpal subsidence after trapeziectomy.

METHODS

Fifteen fresh human cadaveric hands underwent trapeziectomy and were divided into 3 treatment groups: LRTI using a biotenodesis screw and single versus dual Mini TightRope fixation. The thumb and index fingers were removed distal to the metacarpal; the distal ends of the metacarpals and proximal radius were potted in urethane resin and mounted onto a servohydraulic testing machine. A cyclic axial load was applied to stress the trapezial cavity. We recorded displacement of the first metacarpal via the position of the actuator head and computed the size of the trapezial space as the difference of the initial size and first metacarpal displacement. Each specimen underwent cyclical loading until the first metacarpal had collapsed completely onto the scaphoid (failure of the repair) or until 6 hours of testing had been completed. The number of cycles to failure, change in the size of the trapezium cavity, and relative change in size of the trapezium cavity were determined.

RESULTS

The trapezial space had completely closed before 6 hours of testing were completed in all biotenodesis screw-augmented LRTI specimens and remained present in all single and dual Mini TightRope specimens. Absolute (and normalized) changes in the size of the trapezial cavity in the single and dual Mini TightRope specimens were 11 ± 2 and 10 ± 2 mm, respectively.

CONCLUSIONS

Dual Mini TightRope fixation provided superior load bearing and maintenance of trapezial space height compared with single Mini TightRope or LRTI biotenodesis screw procedures.

CLINICAL RELEVANCE

This study demonstrates that patients who undergo suture suspension arthroplasty may be able to move earlier because of the immediate stability the construct affords.

Dual mini TightRope suspensionplasty for thumb basilar joint arthritis: a case series

PURPOSE

To evaluate the efficacy of the technique of dual Mini TightRope suspensionplasty for treatment of trapeziometacarpal joint arthritis.

METHODS

We conducted a retrospective study investigating the use of a dual Mini TightRope suspensionplasty technique from 2010 to 2013 at a single institution. We identified 11 patients (12 thumbs). Grip and pinch strength, thumb range of motion, and complications were reviewed. The trapezial space ratio was measured from the preoperative, postoperative, and follow-up radiographs. All patients completed the Disabilities of Arm, Shoulder, and Hand survey, Patient-Rated Wrist Evaluation, and the Michigan Hand Outcome Questionnaire at the latest follow-up.

RESULTS

Dual Mini TightRope suspensionplasty resulted in reduced pain levels, increased grip and pinch strength, and preserved range of motion. Radiographs demonstrated maintenance of trapezial space height at an average of 17 months (range, 10-26 mo). There were no cases of impingement or fracture of the first and second metacarpal bases.

CONCLUSIONS

Dual Mini TightRope suspensionplasty for the management of trapeziometacarpal joint arthritis yielded satisfactory results with improvement in strength and function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Provision of dental care for medically compromised children in the UK by General Dental Practitioners

The aim of this study was to investigate the views of General Dental Practitioners (GDPs) regarding their provision of dental treatment for medically compromised children. A questionnaire to assess confidence, experience and willingness to treat eight specific groups of medically compromised children was sent to 524 GDPs. Information is based on 271 completed questionnaires. The median number of children treated by GDPs in each of the eight groups over the previous 5 years was 0-2. Eighty percent of respondents stated that they would value further training in the provision of dental care for medically compromised children. Confidence was highest in providing dental treatment for children with three conditions: congenital heart disease (37% very confident), diabetes (39% very confident) and epilepsy (41% very confident). These were also the conditions that the GDPs reported as presenting most frequently in the dental surgery. GDPs reported least confidence in providing dental care for children with haemophilia (12% very confident) and organ transplants (14% very confident). Only 30% of GDPs wanted to be routinely involved with the provision of dental care for medically compromised children. The results indicate that medically compromised children may have problems accessing dental care and expertise. A system of integrated medical and specialised dental care is suggested.

Recognizing and caring for the medically compromised child: 1. Disorders of the cardiovascular and respiratory systems

This paper describes important disorders of the cardiovascular and respiratory systems and the management of dental treatment for patients with these diseases.