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Srinath A, Southall WGS, Nazal MR, Mechas CA, Foster JA, Griffin JT, Muhammad M, Moghadamian ES, Landy DC, Aneja A. Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis. J Orthop Trauma 2024; 38:220-224. [PMID: 38457751 DOI: 10.1097/bot.0000000000002798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). METHODS DESIGN Retrospective cohort. SETTING Single level I trauma center. PATIENT SELECTION CRITERIA Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. OUTCOME MEASURES AND COMPARISONS The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. RESULTS There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. CONCLUSIONS This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arjun Srinath
- Department of Orthopaedic Surgery, University of Miami, Miami, FL
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Mark R Nazal
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Charles A Mechas
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | | | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
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Muhammad M, Foster JA, Griffin JT, Kinchelow DL, Sierra-Arce CR, Southall WGS, Albitar F, Moghadamian ES, Wright RD, Matuszewski PE, Zuelzer DA, Primm DD, Hawk GS, Aneja A. Non-Operative Treatment of Humeral Shaft Fractures with Immediate Functional Bracing versus Coaptation Splinting and Delayed Functional Bracing: A Retrospective Study. J Orthop Trauma 2024:00005131-990000000-00361. [PMID: 38527088 DOI: 10.1097/bot.0000000000002810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
OBJECTIVES To compare radiographic and clinical outcomes in non-operative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB. METHODS Design: Retrospective cohort study. SETTING Academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA Patients with closed humeral shaft fractures managed non-operatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months follow-up were excluded.Outcome Measures and Comparisons: The primary outcome was coronal and sagittal radiographic alignment assessed at final follow-up. Secondary outcomes included rate of failure of non-operative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear. RESULTS Ninety-seven patients were managed non-operatively with delayed FB (n=58) or immediate FB (n=39). Overall, the mean age was 49.9 years (range 18-94), and 64 (66%) patients were female. The immediate FB group had less smokers (p=0.003) and lower incidence of radial nerve palsy (p=0.025), with more proximal third humeral shaft fractures (p=0.001). There were no other significant differences in demographic or clinical characteristics (p>0.05). There were no significant differences in coronal (p=0.144) or sagittal (p=0.763) radiographic alignment between groups. In total, 33 (34.0%) humeral shaft fractures failed non-operative management, with 11 (28.2%) in the immediate FB group, and 22 (37.9%) in the delayed FB group (p=0.322). There were no significant differences in fracture union (p=0.074) or skin complications (p=0.259) between groups. CONCLUSIONS This study demonstrated that non-operative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with coaptation splinting followed by delayed functional bracing. Future prospective studies assessing patient reported outcomes (PROs) will further guide clinical decision making. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Daria L Kinchelow
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Carlos R Sierra-Arce
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Wyatt G S Southall
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Ferras Albitar
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Eric S Moghadamian
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Raymond D Wright
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Paul E Matuszewski
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - David A Zuelzer
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Daniel D Primm
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA, 40507
| | - Gregory S Hawk
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, Kentucky, USA 40507
| | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
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Griffin JT, Landy DC, Mechas CA, Nazal MR, Foster JA, Moghadamian ES, Srinath A, Aneja A. The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy. J Bone Joint Surg Am 2024:00004623-990000000-01054. [PMID: 38512980 DOI: 10.2106/jbjs.23.00906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy. METHODS A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing. RESULTS In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked. CONCLUSIONS A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jarod T Griffin
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Charles A Mechas
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Mark R Nazal
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Jeffrey A Foster
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arjun Srinath
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida
| | - Arun Aneja
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts
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Foster JA, Hawk GS, Landy DC, Griffin JT, Bernard AC, Oyler DR, Southall WGS, Muhammad M, Sierra-Arce CR, Mounce SD, Borgida JS, Xiang L, Aneja A. Does Scheduled Low-Dose Short-Term NSAID (Ketorolac) Modulate Cytokine Levels Following Orthopaedic Polytrauma? A Secondary Analysis of a Randomized Clinical Trial. J Orthop Trauma 2024:00005131-990000000-00357. [PMID: 38506517 DOI: 10.1097/bot.0000000000002807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To determine whether scheduled low-dose, short-term ketorolac modulates cytokine concentrations in orthopaedic polytrauma patients. METHODS DESIGN Secondary analysis of a double-blinded, randomized controlled trial. SETTING Single Level I trauma center from August 2018 to October 2022. PATIENT SELECTION CRITERIA Orthopaedic polytrauma patients between 18-75 years with a New Injury Severity Score greater than 9 were enrolled. Participants were randomized to receive 15 mg of intravenous (IV) ketorolac every 6 hours for up to 5 inpatient days or 2 mL of IV saline similarly. OUTCOME MEASURES AND COMPARISONS Daily concentrations of prostaglandin E2 (PGE2), interleukin (IL)-1a, IL-1b, IL-6, and IL-10. Clinical outcomes included hospital and intensive care unit (ICU) length of stay (LOS), pulmonary complications, and acute kidney injury (AKI). RESULTS Seventy orthopaedic polytrauma patients were enrolled, with 35 participants randomized to the ketorolac group and 35 to the placebo group. The overall IL-10 trend over time was significantly different in the ketorolac group (p = 0.043). IL-6 was 65.8% higher at enrollment compared to Day 3 (p < 0.001) when aggregated over both groups. There was no significant treatment effect for PGE2, IL-1a, or IL-1b (p > 0.05). There were no significant differences in clinical outcomes between groups (p > 0.05). CONCLUSIONS Scheduled low-dose, short-term, IV ketorolac was associated with significantly different mean trends in IL-10 concentration in orthopaedic polytrauma patients with no significant differences in PGE2, IL-1a, IL-1b, or IL-6 levels between groups. The treatment did not have an impact on clinical outcomes of hospital or ICU LOS, pulmonary complications, or AKI. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Gregory S Hawk
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, KY
| | | | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew C Bernard
- Department of Trauma and Acute Care Surgery, University of Kentucky, Lexington, KY
| | - Douglas R Oyler
- Pharmacy Practice & Science Department, University of Kentucky, Lexington, KY
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Samuel D Mounce
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Jacob S Borgida
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Lusha Xiang
- US Army Institute of Surgical Research, San Antonio, TX
| | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
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Foster JA, Landy DC, Pectol RW, Annamalai RT, Aneja A. A multi-institutional study of short-term mortality in COVID-positive patients undergoing hip fracture surgery: is survival better than expected? Eur J Orthop Surg Traumatol 2024; 34:285-291. [PMID: 37462783 DOI: 10.1007/s00590-023-03620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/11/2023] [Indexed: 01/07/2024]
Abstract
PURPOSE Early reports of 30-day mortality in COVID-positive patients with hip fracture were often over 30% and were higher than historical rates of 10% in pre-COVID studies. We conducted a multi-institutional retrospective cohort study to determine whether the incidence of 30-day mortality and complications in COVID-positive patients undergoing hip fracture surgery is as high as initially reported. METHODS A retrospective chart review was performed at 11 level I trauma centers from January 1, 2020 to May 1, 2022. Patients 50 years or older undergoing hip fracture surgery with a positive COVID test at the time of surgery were included. The primary outcome measurements were the incidence of 30-day mortality and complications. Post-operative outcomes were reported using proportions with 95% confidence interval (C.I.). RESULTS Forty patients with a median age of 71.5 years (interquartile range, 50-87 years) met the criteria. Within 30-days, four patients (10%; 95% C.I. 3-24%) died, four developed pneumonia, three developed thromboembolism, and three remained intubated post-operatively. Increased age was a statistically significant predictor of 30-day mortality (p = 0.01), with all deaths occurring in patients over 80 years. CONCLUSION In this multi-institutional analysis of COVID-positive patients undergoing hip fracture surgery, 30-day mortality was 10%. The 95% C.I. did not include 30%, suggesting that survival may be better than initially reported. While COVID-positive patients with hip fractures have high short-term mortality, the clinical situation may not be as dire as initially described, which may reflect initial publication bias, selection bias introduced by testing, or other issues. LEVELS OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Jeffrey A Foster
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA.
| | - David C Landy
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Richard W Pectol
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Ramkumar T Annamalai
- Department of Biomedical Engineering, University of Kentucky College of Engineering, Lexington, KY, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
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Kavolus MW, Landy DC, Horan KM, Foster JA, Griffin JT, Carroll EA, Aneja A. Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point. Eur J Orthop Surg Traumatol 2024; 34:347-352. [PMID: 37523032 DOI: 10.1007/s00590-023-03654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/25/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN. METHODS A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3 cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured. RESULTS On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1 mm (SD, 1.7 mm) medial to the intercondylar notch. CONCLUSION The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1 mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.
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Affiliation(s)
- Matthew W Kavolus
- Department of Orthopaedic Surgery, Wellstar Kennestone Hospital, Atlanta, GA, USA
| | - David C Landy
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S Limestone, Lexington, KY, USA
| | - Kendall M Horan
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S Limestone, Lexington, KY, USA
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S Limestone, Lexington, KY, USA
| | - Jarod T Griffin
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S Limestone, Lexington, KY, USA.
| | - Eben A Carroll
- Wake Forest School of Medicine, Department of Orthopaedics, Winston Salem, Wake Forest, NC, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S Limestone, Lexington, KY, USA
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Pectol RW, Kavolus MW, Kiefer A, Sneed CR, Womble T, Foster JA, Kinchelow DL, Hawk GS, Matuszewski PE, Landy DC, Aneja A. Comparison of post-op opioid use and pain between short and long cephalomedullary nails in elderly intertrochanteric fractures. Eur J Orthop Surg Traumatol 2023; 33:3135-3141. [PMID: 37052677 DOI: 10.1007/s00590-023-03553-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/10/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE It remains unknown if cephalomedullary nail (CMN) length has an impact on pain and opioid use following fixation. Given the lack of level I evidence favoring a specific CMN length to prevent adverse surgical outcomes, we investigated if CMN length impacts acute postoperative pain and opioid use. The authors hypothesize that the use of longer CMNs results in increased pain scores and morphine milligram equivalents (MME) intake during the 0-24 h (h) and 24-36 h postoperative period. METHODS A retrospective chart review was performed from 2010 to 2020 of patients ≥ 65 years-old who underwent CMN for IT fractures and fractures with subtrochanteric extension (STE). We compared patients who received short and long CMNs using numeric rating scale (NRS) pain scores and MME intake at 0-24 h and 24-36 h postoperatively. RESULTS 330 patients receiving short (n = 155) and long (n = 175) CMNs met criteria. CMN length was found to not be associated with higher pain scores in the early postoperative phase. However, patients with long CMNs received higher MME from 0-24 h (25.4% estimated mean increase, p value = 0.02) and 24-36 h (22.3% estimated mean increase, p value = 0.04) postoperatively, even after adjusting for covariates, gender, and age. CONCLUSION Patients with long CMNs received greater MME postoperatively. Additionally, differences in pain and MME were not significantly different between patients with and without STE, suggesting our findings were not influenced by this pattern. These results suggest longer CMNs are associated with higher acute postoperative opioid intake among patients with IT fractures. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
- Richard W Pectol
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Matthew W Kavolus
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Axel Kiefer
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Chandler R Sneed
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Tanner Womble
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA.
| | - Daria L Kinchelow
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Gregory S Hawk
- Department of Statistics, University of Kentucky, Lexington, KY, USA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - David C Landy
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, 780 Rose St., MN508, Lexington, KY, 40536, USA
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Foster JA, Kavolus MW, Landy DC, Pectol RW, Sneed CR, Kinchelow DL, Griffin JT, Hawk GS, Aneja A. Low-Dose Short-Term Scheduled Ketorolac Reduces Opioid Use and Pain in Orthopaedic Polytrauma Patients: A Randomized Clinical Trial. J Orthop Trauma 2023:00005131-990000000-00264. [PMID: 37752630 DOI: 10.1097/bot.0000000000002703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To determine whether scheduled low-dose, short-term ketorolac is associated with reduced length of stay, opioid use, and pain in orthopaedic polytrauma patients. DESIGN Double-blinded, randomized controlled trial. SETTING One Level 1 trauma center. PATIENTS From August 2018 to October 2022, 70 orthopaedic polytrauma patients between 18-75 years-old with a New Injury Severity Score (NISS) > 9 were randomized. 70 participants were enrolled, with 35 randomized to the ketorolac group and 35 to the placebo group. INTERVENTION 15 mg of intravenous (IV) ketorolac every 6 hours for up to 5 inpatient days or 2 mL of IV saline in a similar fashion. MAIN OUTCOME MEASUREMENTS Length of Stay (LOS), Morphine Milligram Equivalents (MME), Visual Analogue Scale (VAS), and Complications. RESULTS Study groups were not significantly different with respect to age, BMI, and NISS (p>0.05). Median LOS was 8 days (interquartile range [IQR], 4.5 to 11.5) in the ketorolac group compared to 7 days (IQR, 3 to 10) in the placebo group (p = 0.275). Over the 5-day treatment period, the ketorolac group experienced a 32% reduction in average MME (p = 0.013) and a 12-point reduction in baseline-adjusted mean VAS (p = 0.037) compared to the placebo group. There were no apparent short-term adverse effects in either group. CONCLUSION Scheduled low-dose, short-term IV ketorolac was associated with significantly reduced inpatient opioid use and pain in orthopaedic polytrauma patients with no significant difference in LOS and no apparent short-term adverse effects. The results support the use of scheduled low-dose, short-term IV ketorolac for acute pain control among orthopaedic polytrauma patients. Further studies are needed to delineate lasting clinical effects and potential long-term effects, such as fracture healing. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeffrey A Foster
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | - Matthew W Kavolus
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | - David C Landy
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | - Richard W Pectol
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | - Chandler R Sneed
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | - Daria L Kinchelow
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | - Jarod T Griffin
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
| | | | - Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky
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9
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Mechas CA, Aneja A, Nazal MR, Pectol RW, Sneed CR, Foster JA, Kinchelow DL, Kavolus MW, Landy DC, Srinath A, Moghadamian ES. Association of Talar Neck Fractures With Body Extension and Risk of Avascular Necrosis. Foot Ankle Int 2023; 44:392-400. [PMID: 36999214 DOI: 10.1177/10711007231160751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures. METHODS A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs. RESULTS There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99). CONCLUSION We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Charles A Mechas
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Mark R Nazal
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Richard W Pectol
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Chandler R Sneed
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Daria L Kinchelow
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Matthew W Kavolus
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - David C Landy
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Arjun Srinath
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
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10
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Aneja A, Gal ZT, Dawson AN, Sneed CR, Kalbac T, Pectol RW, Kavolus MW, Griffin JT, Leonard EH, Foster JA, Kinchelow DL, Srinath A. Functional Outcomes of Primary Arthrodesis (PA) versus Open Reduction and Internal Fixation (ORIF) in the Treatment of Lisfranc Injuries. J Orthop Trauma 2023:00005131-990000000-00193. [PMID: 37012637 DOI: 10.1097/bot.0000000000002606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
OBJECTIVES To determine whether PA or ORIF results in better functional outcomes via patient-reported outcome measures (PROMs). Reoperation rates and surgical characteristics amongst the two groups are evaluated as well. DESIGN A retrospective cohort study. SETTING Level 1 trauma center. PATIENTS Eighty-one patients treated via PA or ORIF for Lisfranc injuries between January 2010 and January 2019. MAIN OUTCOME MEASUREMENTS PROMs were collected via the validated Foot and Ankle Ability Measure (FAAM) questionnaire. Follow-up ranged from one to ten years post-treatment. RESULTS Two hundred patients underwent ORIF and 72 patients underwent PA. Eighty-one out of 272 patients responded to the questionnaire. The FAAM revealed ADL subscores for PA and ORIF of 69.78 ± 18.61 and 73.53 ± 25.60, respectively (P = 0.48). The Sports subscore for PA (45.81 ± 24.65) and ORIF (56.54 ± 31.13) were not significantly different (P = 0.11). Perceived levels of ADL (P = 0.32) and Sports (P = 0.81) function, compared to pre-injury levels, were also not significantly different between the two groups. Rates of reoperation were nearly identical for PA (28.1%) and ORIF (30.6%) (P = 1.00). CONCLUSION Our results suggest that neither PA nor ORIF is superior with regards to functional outcomes or rates of re-operation in the surgical treatment of Lisfranc injuries when appropriately triaged by the treating surgeon.Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | | | - Ashley N Dawson
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Chandler R Sneed
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Tyler Kalbac
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Richard W Pectol
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Matthew W Kavolus
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Jarod T Griffin
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Elizabeth H Leonard
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Daria L Kinchelow
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arjun Srinath
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
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11
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Aneja A, Kavolus MW, Teasdall RJ, Sneed CR, Pectol RW, Isla AE, Stromberg AJ, Obremskey W. Does prophylactic local tobramycin injection lower open fracture infection rates? OTA Int 2022; 5:e210. [PMID: 36569107 PMCID: PMC9782352 DOI: 10.1097/oi9.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 04/14/2022] [Indexed: 06/17/2023]
Abstract
Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation. Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI. Design: Phase 3 prospective, randomized clinical trial. Setting: Two level 1 trauma centers. Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered. Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure. Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI. Results: Not applicable. Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI. Level of Evidence: Level 1.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Matthew W. Kavolus
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Robert J. Teasdall
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Chandler R. Sneed
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Richard W. Pectol
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Alexander E. Isla
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Arnold J. Stromberg
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - William Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN
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12
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Pectol RW, Kavolus MW, Sneed CR, Albano AY, Landy DC, Aneja A. Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study. J Orthop Trauma 2022; 36:628-633. [PMID: 35916777 DOI: 10.1097/bot.0000000000002468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications. DESIGN Retrospective chart review. SETTING Eleven Level I trauma centers. PATIENTS From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included. INTERVENTION Reamed IMN. MAIN OUTCOME MEASURES Incidence of postoperative thromboembolic and respiratory complications. RESULTS Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days. CONCLUSION In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries. LEVELS OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Richard W Pectol
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
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13
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Aneja A, Sneed CR, Pectol RW, Kavolus MW, Foster JA, Kinchelow DL. An Off-Label Use of a Tensioned Proximal Humerus Plate for Tibiotalar Fusion: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00033. [PMID: 36862106 DOI: 10.2106/jbjs.cc.22.00576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/27/2022] [Indexed: 03/03/2023]
Abstract
CASE A 70-year-old man presented with a left pilon fracture after a 10-foot fall from a ladder. The severe amount of comminution, joint destruction, and impaction from this injury eventually resulted in a tibiotalar fusion. Owing to multiple tibiotalar fusion plates not being long enough to span the extent of the fracture, a tensioned proximal humerus plate was used as an alternative. CONCLUSION We do not endorse the off-label use of a tensioned proximal humerus plate for all tibiotalar fusions; however, we do believe that this is a useful technique in certain situations with large zones of distal tibial comminution.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, Kentucky
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14
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Zacharias A, Nazal M, Dawson A, Aneja A, Srinath A. Avascular Necrosis of the Talus Following Subchondroplasty: A Case Report and Review of Literature. Foot Ankle Spec 2022:19386400221108730. [PMID: 35815428 DOI: 10.1177/19386400221108730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CASE Avascular necrosis (AVN) of the talus in a 45-year-old female following subchondroplasty with calcium phosphate bone filler for treatment of anterolateral and posteromedial talar dome bone marrow lesions (BMLs). The patient subsequently presented as consultation, 18 months postoperatively, with AVN of the talus. After failing conservative management, the patient underwent a total ankle arthroplasty at 46 months after subchondroplasty with resolution of pain. CONCLUSION There are few studies that have reported on the safety of subchondroplasty of the talus. Given the tenuous blood supply to the talar body and poor patient outcomes associated with AVN, caution should be taken before extrapolating the generally positive results of subchondroplasty in the knee. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Anthony Zacharias
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Mark Nazal
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Ashley Dawson
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arun Aneja
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arjun Srinath
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
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15
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Aneja A, Landy DC, Mittwede PN, Albano AY, Teasdall RJ, Isla A, Kavolus M. Inflammatory cytokines associated with outcomes in orthopedic trauma patients independent of New Injury Severity score: A pilot prospective cohort study. J Orthop Res 2022; 40:1555-1562. [PMID: 34729810 DOI: 10.1002/jor.25183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/30/2021] [Accepted: 09/30/2021] [Indexed: 02/04/2023]
Abstract
Traumatic injury is the leading cause of mortality in patients under 50. It is associated with a complex inflammatory response involving hormonal, immunologic, and metabolic mediators. The marked elevation of cytokines and inflammatory mediators subsequently correlates with the development of posttraumatic complications. The aim was to determine whether elevated cytokine levels provide a predictive value for orthopedic trauma patients. A prospective cohort study of patients with New Injury Severity Score (NISS) > 5 was undertaken. IL-6, IL-8, IL-10, and migration inhibitory factor levels were measured within 24-h of presentation. Demographic covariates and clinical outcomes were obtained from the medical records. Fifty-eight patients (83% male, 40 years) were included. Addition of IL-6 to baseline models significantly improved prediction of pulmonary complication (LR = 6.21, p = 0.01), ICU (change in R2 = 0.31, p < 0.01), and hospital length of stay (change in R2 = 0.16, p < 0.01). The addition of IL-8 significantly improved the prediction of acute kidney injury (LR = 9.15, p < 0.01). The addition of postinjury IL-6 level to baseline New Injury Severity Score model is better able to predict the occurrence of pulmonary complications as well as prolonged ICU and hospital length of stay.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - David C Landy
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Peter N Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashley Y Albano
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Robert J Teasdall
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Alexander Isla
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Matthew Kavolus
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
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16
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Aneja A, Marquez-Lara A, Luo TD, Teasdall RJ, Isla A, Albano A, Halvorson JJ, Carroll EA. Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study. HSS J 2022; 18:284-289. [PMID: 35645644 PMCID: PMC9097000 DOI: 10.1177/15563316211008176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023]
Abstract
Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA,Arun Aneja, MD, PhD, Assistant Professor,
Department of Orthopaedic Surgery, University of Kentucky College of Medicine, 740 S.
Limestone, Suite K401, Lexington, KY 40536-0284, USA.
| | - Alejandro Marquez-Lara
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - T. David Luo
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Robert J. Teasdall
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA
| | - Alexander Isla
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA
| | - Ashley Albano
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA
| | - Jason J. Halvorson
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Eben A. Carroll
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
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McKinley TO, Gaski GE, Billiar TR, Vodovotz Y, Brown KM, Elster EA, Constantine GM, Schobel SA, Robertson HT, Meagher AD, Firoozabadi R, Gary JL, O'Toole RV, Aneja A, Trochez KM, Kempton LB, Steenburg SD, Collins SC, Frey KP, Castillo RC. Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY). J Orthop Trauma 2022; 36:S14-S20. [PMID: 34924514 DOI: 10.1097/bot.0000000000002289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.
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Affiliation(s)
- Todd O McKinley
- Department of Orthopedic Surgery, Indiana University Health Methodist Hospital, Indianapolis, IN
| | - Greg E Gaski
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Krista M Brown
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Greg M Constantine
- Department of Mathematics and Statistics, University of Pittsburgh, Pittsburgh, PA
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Surgical Critical Care Initiative, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Henry T Robertson
- Department of Surgery, Uniformed Services University of the Health Sciences, Surgical Critical Care Initiative, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX (now at Keck School of Medicine of University of Southern California, Los Angeles, CA)
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Karen M Trochez
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Scott D Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine and Indiana University Health Methodist Hospital, Indianapolis, IN; and
| | - Susan C Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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18
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Hautala GS, Comadoll SM, Raffetto ML, Ducas GW, Jacobs CA, Aneja A, Matuszewski PE. Most orthopaedic trauma patients are using the internet, but do you know where they're going? Injury 2021; 52:3299-3303. [PMID: 33653619 DOI: 10.1016/j.injury.2021.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/13/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The Internet is a resource that patients can use to learn about their injuries, treatment options, and surgeon. Previously, it was demonstrated that orthopaedic trauma patients are unlikely to use a reliable, provided source. It is unknown however, if patients are seeking information from elsewhere. The purpose of this study was to determine if orthopaedic trauma patients utilize the Internet and what websites are utilized. Our hypothesis was that the majority of patients use the Internet and when they do, are unlikely to use a reliable source. METHODS Orthopaedic trauma patients were surveyed in clinic at a Level I trauma center in the United States. The survey queried demographics, injury information, Internet access, and eHealth Literacy Scale (eHEALS). Data were analyzed using t-tests, Chi-squared tests, and a multivariate logistic regression, as appropriate. RESULTS 138 patients with a mean age of 47.1 years (95% confidence interval: 44.0-50.3; 51.1% female) were included in the analysis. Despite 94.1% reporting access, only 55.8% of trauma patients used the Internet for information about their injury. Of those, 64.5% used at least one unreliable source. WebMD (54.8%) was the highest utilized website. Age, sex, employment, and greater eHEALS score were associated with increased Internet use (p<0.001). CONCLUSION The Internet has potential to be a useful, low cost, and readily available informational source for orthopaedic trauma patients. This study illustrates that a majority of patients seek information from the Internet after their injury, including unreliable websites like Wikipedia and Facebook. Our study emphasizes the need for active referral to trusted websites and initiation of organizational partnerships (e.g. OTA/AAOS) with common content providers (e.g. WebMD) to provide patients with accurate information about their injury and treatment. LEVEL OF EVIDENCE Prognostic, Level II.
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Affiliation(s)
- Gavin S Hautala
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, United States
| | - Shea M Comadoll
- University of Minnesota, Department of Orthopedic Surgery, United States
| | - Michael L Raffetto
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, United States
| | - G Wells Ducas
- University of Kentucky, College of Medicine, United States
| | - Cale A Jacobs
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, United States
| | - Arun Aneja
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, United States
| | - Paul E Matuszewski
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, United States.
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19
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Romano D, Boyle M, Isla AE, Teasdall RJ, Srinath A, Aneja A. Hypercoagulable Disorders in Orthopaedics: Etiology, Considerations, and Management. JBJS Rev 2021; 9:01874474-202110000-00003. [PMID: 34637409 DOI: 10.2106/jbjs.rvw.21.00079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Hypercoagulable disorders (HCDs) can be inherited or acquired. An HCD of either etiology increases the chance of venous thromboembolic events (VTEs). » Patients with an HCD often have the condition discovered only after surgical complications. » We recommend that patients with a concern for or a known HCD be referred to the appropriate hematological specialist for workup and treatment. » Tourniquet use in the orthopaedic patient with an HCD is understudied and controversial. We recommend that tourniquets be avoided in the surgical management of patients with an HCD, if possible. When tourniquets are applied to patients with unknown HCD status, close follow-up and vigilant postoperative examinations should be undertaken.
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Affiliation(s)
- David Romano
- Riverside Regional Medical Center, Newport News, Virginia
| | - Maxwell Boyle
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Alexander E Isla
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Robert J Teasdall
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arjun Srinath
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arun Aneja
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
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20
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Liporace FA, Aneja A, Carroll EA, Yoon RS. Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How? J Orthop Trauma 2021; 35:S38-S40. [PMID: 34533501 DOI: 10.1097/bot.0000000000002235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Distal femur fractures in the elderly have been historically treated with locked plating or retrograde intramedullary nailing with good, reliable results. However, in certain more complex fracture patterns (native or periprosthetic), increased density of fixation via dual-plate or nail plate combination can help achieve immediate weight-bearing. It can also potentially increase rates of union by shifting and maintaining the neutral axis, distributing forces more evenly across the fracture site. Here, we discuss the indications, pros and cons of both dual-plate and nail plate combination techniques in a concise case-based format.
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Affiliation(s)
- Frank A Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center/Saint Barnabas Medical Center-RWJBarnabas Health, Jersey City, NJ
| | - Arun Aneja
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Kentucky Medical Center, Lexington, KY; and
| | - Eben A Carroll
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Wake Forest University Medical Center, Winston-Salem, NC
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center/Saint Barnabas Medical Center-RWJBarnabas Health, Jersey City, NJ
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21
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Murphy M, Teasdall RJ, Comadoll S, Aneja A. Dorsal Thompson: Approach to the Proximal Radial Shaft. J Orthop Trauma 2021; 35:S16-S17. [PMID: 34227594 DOI: 10.1097/bot.0000000000002162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
Treatment principles in the management of radial shaft fractures, congruent with all fracture care, are to restore anatomy and function of the limb. Radial shaft fractures are unique in that preserving the anatomic bow of the radius, which allows for its rotation around the ulna during pronation and supination, is essential for proper function. The 2 main approaches for exposure of the proximal or middle third radial diaphyseal fractures are the volar "Henry" and the dorsal "Thompson." This article highlights the benefits of the dorsal Thompson approach, describes the key points of the operative technique, which allow for protection of the posterior interosseous nerve, and provides an overview of the measurable outcomes when using this approach. In the accompanying video, the steps of operative exposure to the proximal radial shaft with careful avoidance of the posterior interosseous nerve are demonstrated.
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Affiliation(s)
- Meredith Murphy
- Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Robert J Teasdall
- Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Shea Comadoll
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | - Arun Aneja
- Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
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22
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Soltero-Mariscal E, Vasireddi S, Chava R, Yousaf A, Kondapaneni M, Aneja A. Association Of Postoperative Myocardial Injury And Coronary Calcification. J Cardiovasc Comput Tomogr 2021. [DOI: 10.1016/j.jcct.2021.06.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Womble TN, Comadoll SM, Dugan AJ, Davenport DL, Ali SZ, Srinath A, Matuszewski PE, Aneja A. Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting? Foot Ankle Surg 2021; 27:581-587. [PMID: 32917527 DOI: 10.1016/j.fas.2020.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/14/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off. METHODS Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA). RESULTS 9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007). CONCLUSIONS Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanner N Womble
- School of Medicine, University of Kentucky, Lexington, KY, USA
| | - Shea M Comadoll
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Adam J Dugan
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Syed Z Ali
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arjun Srinath
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA.
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24
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Phillips SA, Comadoll SM, Hautala GS, Polich JG, Danelson KA, Carroll EA, Aneja A, Wright RD, Moghadamian ES, Matuszewski PE. Newer generation of proximal tibia locking plates demonstrate large variability in their ability to capture the posteromedial fragment in bicondylar tibial plateau fractures. Injury 2021; 52:1534-1538. [PMID: 33097198 DOI: 10.1016/j.injury.2020.10.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology -which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures. MATERIALS & METHODS Axial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates-in seven total configurations-were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment. RESULTS On average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p<0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p<0.0001) when compared to fixed angle constructs. CONCLUSION Newer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.
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Affiliation(s)
- Seth A Phillips
- Department of Orthopaedic Surgery, Mercy Health St. Vincent Medical Center, Toledo, OH, USA
| | - Shea M Comadoll
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Gavin S Hautala
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Julia-Grace Polich
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Kerry A Danelson
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Eben A Carroll
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Raymond D Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA.
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25
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Militky J, Novak O, Kremenakova D, Wiener J, Venkataraman M, Zhu G, Yao J, Aneja A. A Review of Impact of Textile Research on Protective Face Masks. Materials (Basel) 2021; 14:1937. [PMID: 33924470 PMCID: PMC8070024 DOI: 10.3390/ma14081937] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/25/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022]
Abstract
COVID-19, classified as SARS-CoV-2, is causing an ongoing global pandemic. The pandemic has resulted in the loss of lives and has caused economic hardships. Most of the devices used to protect against the transmission of the novel COVID-19 disease are related to textile structures. Hence, the challenge for textile professionals is to design and develop suitable textile structures with multiple functionalities for capturing viruses, passivating them, and, at the same time, having no adverse effects on humans during the complete period of use. In addition to manufacturing efficient, biocompatible, and cost-effective protective face masks, it is also necessary to inform the public about the benefits and risks of protective face mask materials. The purpose of this article is to address the concerns of efficiency and efficacy of face masks by primarily reviewing the literature of research conducted at the Technical University of Liberec. The main focus is on the presentation of problems related to the specification of aims of face mask applications, mechanisms of capture, durability, and modes of sterilization. The recommendations, instead of conclusions, are addressed to the whole textile society because they should be leading players in the design, creation, and proper treatment of face masks due to their familiarity with the complex behavior of textile structures and targeted changes of structural hierarchy starting from polymeric chains (nano-level) and ending in planar textile structures (millimeter level) due to action by mechanical, physical and chemical fields. This becomes extremely critical to saving hundreds of thousands of lives from COVID-19.
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Affiliation(s)
- Jiri Militky
- Department of Material Engineering, Faculty of Textile, Technical University of Liberec, 46117 Liberec, Czech Republic; (D.K.); (J.W.)
| | - Ondrej Novak
- Department of Nonwovens and nanomaterials, Faculty of Textile, Technical University of Liberec, 46117 Liberec, Czech Republic;
| | - Dana Kremenakova
- Department of Material Engineering, Faculty of Textile, Technical University of Liberec, 46117 Liberec, Czech Republic; (D.K.); (J.W.)
| | - Jakub Wiener
- Department of Material Engineering, Faculty of Textile, Technical University of Liberec, 46117 Liberec, Czech Republic; (D.K.); (J.W.)
| | - Mohanapriya Venkataraman
- Department of Material Engineering, Faculty of Textile, Technical University of Liberec, 46117 Liberec, Czech Republic; (D.K.); (J.W.)
| | - Guocheng Zhu
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou 310018, China; (G.Z.); (J.Y.)
| | - Juming Yao
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou 310018, China; (G.Z.); (J.Y.)
| | - Arun Aneja
- Department of Engineering, East Carolina University, Greenville, NC 27858, USA;
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26
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Arriola A, Aneja A, Rong Y, Taraif S, jhala N. Leveraging Existing Institutional Resources to Maintain Quality Assurance Practices in Anatomic Pathology in the Era of Social Distancing. Am J Clin Pathol 2020. [PMCID: PMC7665286 DOI: 10.1093/ajcp/aqaa161.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction/Objective Due to the COVID-19 pandemic, hospitals had to adapt practices to incorporate social distancing while maintaining quality assurance (QA) in anatomic pathology (AP). Prior to this, our general surgical pathology (SP) and cytopathology (CP) services held daily consensus conferences (CC) at a multi-headed microscope. Implementing social distancing meant only a few faculty were present onsite and avoidance of interactions at the multi-headed scope. In an effort to preserve QA through CC, faculty exploited the use of web conferencing through our HIPAA-compliant Zoom. We describe the utility of this new practice. Methods From 3/25-4/30/20, all SP and CP cases selected for CC were presented by respective pathologists (n=8) in their own offices by using individual microscopes with cameras, image acquisition software, and screen-sharing through Zoom. One pathologist was responsible for sending out a new CC Zoom link daily and recording the consensus diagnosis. All onsite pathologists and those at home participated. Results We presented 95 SP and 31 CP cases through Zoom compared to 300 SP and 60 CP cases presented at a similar timeframe prior to social distancing. This 68% and 48% decline could be attributed to elective procedure cancellation. We assigned a consensus diagnosis to all cases, with 77% overall being malignant diagnoses, and breast being the most common SP specimen type (22%). Additionally, all participating pathologists felt comfortable with the new format irrespective of being onsite or at home. Apart from minor audio issues, we did not notice significant lag time or visual disturbances that interfered with diagnostic abilities. Importantly, the transition did not involve investing in new technology. Conclusion The new virtual CC allowed our department to maintain QA practices in AP without sacrificing quality and serves as a starting point to investigating the use of this technology to other applications in AP, such as overnight frozen sections.
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Affiliation(s)
- A Arriola
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
| | - A Aneja
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
| | - Y Rong
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
| | - S Taraif
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
| | - N jhala
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
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27
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Aneja A, Arriola A, Jhala A. Pulmonary Granuloma Associated with Pneumocystis Jirovecii in a Patient with Peripheral T-Cell Lymphoma: Presentation of a Rare Case with Review of the Literature. Am J Clin Pathol 2020. [DOI: 10.1093/ajcp/aqaa161.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Casestudy: Although Pneumocystis jirovecii (PJ) is a known opportunistic pulmonary infection among immunocompromised patients, it is a rare (<5%) cause of pneumonia in this cohort. Majority of cases are observed in patients with HIV or solid organ transplant recipients. Granuloma formation in patients infected with PJ is even rarer. We present a case of multiple pulmonary granulomas associated with PJ in a non-HIV patient. A 49-year-old female with a history of asthma presented with worsening dyspnea. Initial imaging revealed multifocal bilateral areas of consolidation and a diagnostic bronchoalveolar lavage (BAL) demonstrated PJ organisms. Additional investigation was pursued to determine the etiology of this infection in a seemingly immunocompetent patient. New findings noted during hospitalization included a new maculopapular skin rash, significant weight loss, and lymphopenia. A bone marrow biopsy revealed a clonal proliferation of plasma cells. Subsequent imaging revealed mediastinal adenopathy. There was no improvement in symptoms despite treatment for pneumonia and a month later, a lung wedge biopsy revealed organizing acute lung injury and multiple non-caseating granulomas without lymphoid rimming, asteroid, or Schaumann bodies. Silver stain highlighted numerous PJ organisms within and outside of the granulomas. An inguinal lymph node and skin biopsies eventually revealed involvement by peripheral T-cell lymphoma (PTCL). Repeat BAL revealed clearance of organisms after additional therapy; however, the PTCL was refractory to chemotherapy and palliative care was pursued. To date, we could only find <30 cases of pulmonary PJ granulomas in patients with hematologic malignancies. Most are in patients with B cell lymphomas and just 1 report in a patient with adult T-cell leukemia/lymphoma. In summary, this case highlights that PJ associated pulmonary granulomas are uncommon, can be a harbinger of an underlying immunocompromised state, such as a lymphoma, and are even rarer to be associated with PTCL.
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Affiliation(s)
- A Aneja
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
| | - A Arriola
- Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, UNITED STATES
| | - A Jhala
- Harrison High School, Bryn Mawr, Pennsylvania, UNITED STATES
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28
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Venkatesh V, Rana SS, Kumar A, Aneja A, Lal SB. Hepatobiliary and Pancreatic: EUS-guided drainage of a ruptured amoebic liver abscess in a child. J Gastroenterol Hepatol 2020; 35:921. [PMID: 32144816 DOI: 10.1111/jgh.15014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/07/2020] [Accepted: 02/15/2020] [Indexed: 12/09/2022]
Affiliation(s)
- V Venkatesh
- Division Of Paediatric Gastroenterology, Post Graduate Institute Of Medical Education and Research, Chandigarh, India
| | - S S Rana
- Department of Gastroenterology, Post Graduate Institute Of Medical Education and Research, Chandigarh, India
| | - A Kumar
- Division Of Paediatric Gastroenterology, Post Graduate Institute Of Medical Education and Research, Chandigarh, India
| | - A Aneja
- Division Of Paediatric Gastroenterology, Post Graduate Institute Of Medical Education and Research, Chandigarh, India
| | - S B Lal
- Division Of Paediatric Gastroenterology, Post Graduate Institute Of Medical Education and Research, Chandigarh, India
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29
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Comadoll SM, Liu B, Abbenhaus E, King JD, Jacobs CA, Aneja A, Hsu JR, Matuszewski PE. The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population. Injury 2020; 51:919-923. [PMID: 32115210 DOI: 10.1016/j.injury.2020.02.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications. DESIGN Retrospective case control study. SETTING Academic level-1 trauma center. PATIENTS/PARTICIPANTS Patients with long bone, lower extremity fractures requiring operative fixation. INTERVENTION N/A. MAIN OUTCOME MEASURES Postoperative hospital admissions, emergency room (ER) visits, and reoperations. RESULTS 399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003). CONCLUSIONS Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.
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Affiliation(s)
- Shea M Comadoll
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States
| | - Boshen Liu
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States
| | - Eric Abbenhaus
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States
| | - John D King
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States
| | - Cale A Jacobs
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States
| | - Arun Aneja
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States
| | - Joseph R Hsu
- Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC, United States
| | - Paul E Matuszewski
- University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States.
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30
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Hautala G, Liu B, Hamilton D, Aneja A, Moghadamian E. Below-Knee Amputation Resulting from an Arterial Thrombosis from Tourniquet Use in a Patient with Undiagnosed Factor V Leiden: A Case Report. JBJS Case Connect 2020; 10:e0457. [PMID: 32224658 DOI: 10.2106/jbjs.cc.19.00457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE A 38-year-old woman presented with previously undiagnosed factor V Leiden (FVL), who suffered a complete superficial femoral arterial thrombosis after tourniquet use during the surgical repair of one of her bilateral tibial plafond fractures. This patient's injury eventually resulted in a below-knee amputation. CONCLUSION We recommend expanding hypercoagulable screening on patients with risk factors based on a detailed history and physical examination. We also recommend limiting or negating tourniquet use in patients with FVL or other hypercoagulable disorders.
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Affiliation(s)
- Gavin Hautala
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - Boshen Liu
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - David Hamilton
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
| | - Eric Moghadamian
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
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31
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Aneja A, Luo TD, Liu B, Domingo M, Danelson K, Halvorson JJ, Carroll EA. Anterolateral distal tibia locking plate osteosynthesis and their ability to capture OTAC3 pilon fragments. Injury 2018; 49:409-413. [PMID: 29305233 DOI: 10.1016/j.injury.2017.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/10/2017] [Accepted: 12/13/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures. METHODS From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures. RESULTS The Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively). CONCLUSIONS This study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments. LEVEL OF EVIDENCE Three.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40536, USA.
| | - T David Luo
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Boshen Liu
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40536, USA.
| | - Molina Domingo
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40536, USA.
| | - Kerry Danelson
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Jason J Halvorson
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Eben A Carroll
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA.
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Aneja A, Luo TD, Lerche EB, Halvorson JJ, Carroll EA. Coronal Plane Deformity Correction in Distal Radius Fracture Fixation With the Volar Locking Plate. J Surg Orthop Adv 2018; 27:160-163. [PMID: 30084826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The goal of treatment for distal radius fractures is anatomic articular reduction and restoration of coronal and sagittal plane alignment, rotation, and angulation of the metadiaphyseal component of these fractures. This article presents a reproducible technique for restoring coronal plane alignment of the metadiaphyseal component of the fracture using an indirect reduction maneuver leveraging the volar locking plate as an indirect reduction aid. After applying an appropriately sized volar locking plate, the first screw is placed in the center of the shaft of the plate. Next, the distal row of subarticular locking screws is placed to neutralize a reduced articular surface. The shaft screw is subsequently loosened, and two Freer elevators are used to rotate the plate, indirectly translating the distal articular block and achieving improved coronal plane alignment. Last, the remaining diaphyseal screws are applied to appropriately neutralize the fracture. (Journal of Surgical Orthopaedic Advances 27(2):160-163, 2018).
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina e-mail:
| | - T David Luo
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Eric B Lerche
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jason J Halvorson
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Eben A Carroll
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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Senehi R, Luo TD, Marquez-Lara A, Aneja A, Beard HR, Carroll EA. Use of Volar Plate for Indirect Coronal Plane Reduction in an Intraarticular Distal Radius Fracture. J Orthop Trauma 2017; 31 Suppl 3:S39-S41. [PMID: 28697086 DOI: 10.1097/bot.0000000000000904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Management of intraarticular distal radius fractures requires precise reconstruction of the articular surface to optimize outcomes. Treatment goals also include restoration of alignment, rotation, and angulation in both the coronal and sagittal planes of the metaphyseal component of these fractures. Surgical management with open reduction and internal fixation with a volar plate is often the preferred method of open treatment. However, a variety of different techniques have been described, and the preferred technique may be determined on an individual basis by the fracture characteristics, patient-dependent factors, or surgeon experience.
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Affiliation(s)
- Rebecca Senehi
- *Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC; and †Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
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Luo TD, Eady JM, Aneja A, Miller AN. Classifications in Brief: Rüedi-Allgöwer Classification of Tibial Plafond Fractures. Clin Orthop Relat Res 2017; 475:1923-1928. [PMID: 28054323 PMCID: PMC5449320 DOI: 10.1007/s11999-016-5219-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/19/2016] [Indexed: 01/31/2023]
Affiliation(s)
- T. David Luo
- 0000 0004 0459 1231grid.412860.9Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157 USA
| | - J. Matthew Eady
- 0000 0004 0459 1231grid.412860.9Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157 USA
| | - Arun Aneja
- 0000 0004 1936 8438grid.266539.dDepartment of Orthopaedic Surgery, University of Kentucky, Lexington, KY USA
| | - Anna N. Miller
- 0000 0001 2355 7002grid.4367.6Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO USA
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Aneja A, Jiang JJ, Cohen-Rosenblum A, Luu HL, Peabody TD, Attar S, Luo TD, Haydon RC. Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation. J Bone Joint Surg Am 2017; 99:315-323. [PMID: 28196033 DOI: 10.2106/jbjs.16.00023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture. METHODS We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups. RESULTS Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all). CONCLUSIONS Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arun Aneja
- 1Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina 2Department of Orthopaedic Surgery, University of Chicago Medicine, Chicago, Illinois 3Department of Orthopaedic Surgery, Northwestern University, Galter-Pavilion-Northwestern Memorial Hospital, Chicago, Illinois
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Abstract
Obstructive sleep apnea (OSA) is a common but underdiagnosed sleep disorder, which is associated with systemic consequences such as hypertension, stroke, metabolic syndrome, and ischemic heart disease. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness including electroencephalography (EEG), electrooculography (EOG), surface electromyography (EMG), airflow measurement using thermistor and nasal pressure transducer, pulse oximetry and respiratory effort (thoracic and abdominal). Multiple alternative and simpler methods that record respiratory parameters alone for diagnosing OSA have been developed in the past two decades. These devices are called portable monitors (PMs) and enable performing sleep studies at a lower cost with shorter waiting times. It has been observed and reported that comprehensive sleep evaluation coupled with the use of PMs can fulfill the unmet need for diagnostic testing in various out-of-hospital settings in patients with suspected OSA. This article reviews the available medical literature on PMs in order to justify the utility of PMs in the diagnosis of OSA, especially in resource-poor, high-disease burden settings. The published practice parameters for the use of these devices have also been reviewed with respect to their relevance in the Indian setting.
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Affiliation(s)
| | - A Aneja
- Department of Respiratory Medicine, MS Ramaiah Medical College, Bangalore, Karnataka, India
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Abstract
Abstract
The paper discusses the impact of drawing poly(ethylene terephthalate) (PET) fibers in the presence of solvents, which consist of the first five homologues of aliphatic primary alcohols, namely methanol to amyl alcohol. The solvent induced deformation under tensile load leads to surface fissures characterized by four stages: fissure formation (birth), incipient draw (neck formation), partial draw, and full draw. This process results in internal void formation in the presence of a propagating neck. A design of experiment (DOE) was performed to screen out the process parameters critical for understanding surface fissure formation. Four process parameters were investigated: initial material properties (orientation); environment of draw (i.e. type of alcohols used as solvent); rate of extension; and amount of extension. The response of solvent induced deformation were characterized by the natural draw force reduction; number of fissures formed at time of birth, fissure width at time of formation, and neck angle. Of all the four process parameters involved, the analysis indicates that the material properties and amount of extension were the best predictors of solvent induced fissure formation. Organic solvents reduce the tension required for draw and create internal voids, a porous network, with possibly the penetrant being “sucked” into the interior of PET fibers drawn in the presence of alcohols.
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Affiliation(s)
- M. Ramisetty
- Department of Chemistry, East Carolina University, Greenville, NC, USA
| | - A. Rodriguez
- Department of Chemistry, East Carolina University, Greenville, NC, USA
| | - A. Aneja
- DuPont Company, Kinston, NC, USA
| | - Y. Wang
- School of Materials Science and Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Benghuzzi H, Mohamed A, Aneja A, Cameron JA, Tucci M. The effects of sustained delivery of alendronate on the kidney in ovariectomized female rats. Biomed Sci Instrum 2012; 48:35-42. [PMID: 22846262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Bisphosphonates are indicated for the treatment and prevention of osteoporosis in adults; the treatment and prevention of glucocorticoid-induced osteoporosis; the treatment of Pagets disease; and the treatment of multiple myeloma in patients with documented bone metastases. Two long-term trials in cancer patients demonstrated an increase in serum creatinine (SCr) when 8 mg of bisphosphonate was administered, prompting a recommendation to reduce the dose to 4 mg. The risk for renal toxicity remains a possibility following chronic administration of bisphosphonate treatment for osteoporosis. The goal of the study was to evaluate the kidney of osteoporotic female rats following chronic administration of alendronate using a drug delivery device for 4 weeks and compare the finding with control non-ovariectomized animals, ovariectomized control animals (OVX), and ovariectomized animals with an empty drug delivery system. The results of the study showed significant increases in body weights in the ovariectomized animals compared with non-ovariectomized animals. The organ wet-weights were not statistically different between the control and treatment groups or the ovariectomized and non-ovariectomized animals. Histological and histomorphometric analysis of the kidney revealed significant changes in the glomerular area on alendronate treated animals at 4 weeks when compared with ovx, ovx-sham and control non-ovariectomized animals. The results indicate chronic use of alendronate for osteoporosis may impair renal function or increase renal related problems in patients with existing kidney disease.
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Affiliation(s)
- Anton Marcinčin
- a Faculty of Chemical and Food Technology, Department of Fibres and Textile Chemistry , Slovak University of Technology in Bratislava , Bratislava, SK
| | - Marcela Hricová
- a Faculty of Chemical and Food Technology, Department of Fibres and Textile Chemistry , Slovak University of Technology in Bratislava , Bratislava, SK
| | - Arun Aneja
- b College of Technology and Computer Science , East Carolina University , Greenville, NC, USA
| | - Alexandra Andrejková
- a Faculty of Chemical and Food Technology, Department of Fibres and Textile Chemistry , Slovak University of Technology in Bratislava , Bratislava, SK
| | - Eva Körmendyová
- a Faculty of Chemical and Food Technology, Department of Fibres and Textile Chemistry , Slovak University of Technology in Bratislava , Bratislava, SK
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Xiang L, Lu S, Fuller W, Aneja A, Russell GV, Jones LB, Hester R. Impaired blood pressure recovery to hemorrhage in obese Zucker rats with orthopedic trauma. Am J Physiol Heart Circ Physiol 2011; 302:H340-8. [PMID: 22003055 DOI: 10.1152/ajpheart.00439.2011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have shown that obese Zucker rats with orthopedic trauma (OZT) exhibit a loss of arteriolar tone in skeletal muscle. We hypothesize that the loss of arteriolar tone in OZT blunts vasoconstrictor responses to hemorrhage, resulting in an impaired blood pressure recovery. Orthopedic trauma was induced with soft tissue injury and local injection of bone components in both hindlimbs in lean (LZT) and OZT (11-13 wk). One day after the orthopedic trauma, blood pressure responses following hemorrhage were measured in conscious control lean, control obese, LZT, and OZT. In another set of experiments, the spinotrapezius muscle of control and trauma animals was prepared for microcirculatory observation. Arteriolar responses to phenylephrine (PE) or hemorrhage were determined. Hemorrhage resulted in similar blood pressure responses in control animals and LZT, but the blood pressure recovery following hemorrhage was blunted in the OZT. In the spinotrapezius, OZT exhibited decreased arteriolar tone and blunted vasoconstrictor responses to PE and hemorrhage. Treatment with glibenclamide improved the blood pressure recovery in the conscious OZT and improved the arteriolar tone, and PE induced vasoconstriction in the spinotrapezius of the OZT. Thus, ATP-dependent K(+) channel-mediated loss of arteriolar tone in OZT blunts the arteriolar constriction to hemorrhage, resulting in impaired blood pressure recovery.
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Affiliation(s)
- Lusha Xiang
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, 39216-4505, USA.
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Aneja A, Farkouh ME. Non-steroidal anti-inflammatory drugs and the heart. Heart 2011; 97:517-8. [DOI: 10.1136/hrt.2010.209536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Xiang L, Hester RL, Fuller WL, Sebai ME, Mittwede PN, Jones EK, Aneja A, Russell GV. Orthopedic trauma-induced pulmonary injury in the obese Zucker rat. Microcirculation 2011; 17:650-9. [PMID: 21044219 DOI: 10.1111/j.1549-8719.2010.00061.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Obese subjects with orthopedic trauma exhibit increased inflammation and an increased risk of pulmonary edema. Prostaglandin E(2) (PGE(2) ) production is elevated during inflammation and associated with increased vascular permeability. We hypothesize that pulmonary edema in obesity following orthopedic trauma is due to elevated PGE(2) and resultant increases in pulmonary permeability. METHODS Orthopedic trauma was induced in both hindlimbs in lean (LZ) and obese Zucker rats (OZ). On the following day, plasma interleukin-6 (IL-6) and PGE(2) levels, pulmonary edema, and pulmonary gas exchange capability were compared between groups: LZ, OZ, LZ with trauma (LZT), and OZ with trauma (OZT). Vascular permeability in isolated lungs was measured in LZ and OZ before and after application of PGE(2) . RESULTS As compared with the other groups, the OZT exhibited elevated plasma IL-6 and PGE(2) levels, increased lung wet/dry weight ratio and bronchoalveolar protein concentration, and an impaired pulmonary gas exchange. Indomethacin treatment normalized plasma PGE(2) levels and pulmonary edema. Basal pulmonary permeability in isolated lungs was higher in OZ than LZ, with a further increase in permeability following treatment with PGE(2) . CONCLUSIONS These results suggest that pulmonary edema in OZ following orthopedic trauma is due to an elevated PGE(2) and resultant increases in pulmonary permeability.
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Affiliation(s)
- Lusha Xiang
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA.
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Aneja A, Kroft J, Tyrwhitt J, Ternamian A. Laparoscopic Peritoneal Entry Preferences: A Multidisciplined National Survey. J Minim Invasive Gynecol 2009. [DOI: 10.1016/j.jmig.2009.08.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Aneja A, Krantz C, Tucci M, Benghuzzi HA. Use of demineralized bone matrix protein in osteoporotic rats: a histological evaluation - biomed 2009. Biomed Sci Instrum 2009; 45:36-41. [PMID: 19369736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Osteoporosis is a disease characterized by structural deterioration of bone tissue, leading to fragile bone with an increased risk for fractures. Bone morphogenetic proteins (BMPs) are supplemental bone graft materials that have osteoconductive properties of serving as a scaffold for bone to grow on and osteoinductive capability of stimulating the patient's own stem cells and growth factors to grow new bone. Osteoblast cells in osteoporotic bone have the ability to produce BMPs and other factors needed for adequate bone formation when activated, demonstrating that there are factors that can serve as stimulus for fracture repair in osteoporosis. The objective of this study was to deliver a cascade of growth factors from demineralized bone (DBM), a rich composite of BMP-2, BMP-4, and BMP-7, to the fracture defect site in an effort to enhance osteoporotic fracture healing. 72 female ovariectomized (OVX) rats were divided into six treatment groups: intact control, OVX control, intact + drill defect (sham), OVX + drill defect (sham), intact + drill defect + DBM, and OVX + drill defect + DBM. Ovariectomy induced osteoporosis. DBM was delivered in a sustained manner via a novel local drug delivery device, tricalcium phosphate combined with lysine (TCPL). At 2 and 4 weeks post implantation, animals in each group were sacrificed, the femurs were retrieved and underwent histological analysis. Other surrounding and vital organs were also harvested and analyzed to study the systemic effects of DBM. The results suggest that DBM was effective in increasing osteocyte number en route to restoring periosteal and endosteal area in both intact and OVX animal populations.
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Affiliation(s)
- Arun Aneja
- University of Mississippi Medical Center, Jackson, MS
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Aneja A, Woodall J, Wingerter S, Tucci M, Benghuzzi H. Analysis of tobramycin release from beta tricalcium phosphate drug delivery system. Biomed Sci Instrum 2008; 44:88-93. [PMID: 19141898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The purpose of this pilot study was to determine the in-vitro release properties of tobramycin by tricalcium phosphate (TCP) delivery capsules. In addition, two different forms of TCP capsules, matrix and reservoir, were characterized. Three types of TCP ceramic capsules were constructed: six sham matrix capsules (Group A), six tobramycin loaded matrix capsules (Group B), and four hollow tobramycin loaded reservoir capsules (Group C). The capsules were submerged in PBS and 1 mL of elutant was collected, centrifuged, and analyzed via spectrometry for 14 days. In addition, elutant from selected capsules was bleached onto bacterial discs and placed on confluent Staphylococcus aureus agar plates to evaluate zones of inhibition. Their was a statistically significant difference in the concentration of tobramycin released between Group A versus Group B and Group C capsules and a statistically significant difference in the concentration of tobramycin released between Group B and Group C capsules over a 14 day period. Bacterial discs containing Group A elutant did not have a visible zone of inhibition, while both Groups B and C elutant discs had an appreciable zone of inhibition for the duration of the study. Group A sham capsules eluted no antibiotics implying that TCP by itself lacks antibacterial properties. Group B matrix and Group C reservoir capsules eluted sustained tobramycin concentrations that were bactericidal for the duration of the study. The data from this study demonstrates that the sustained release property of tobramycin loaded TCP matrix and reservoir capsules make them a suitable mode for local antibiotic delivery.
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Affiliation(s)
- Arun Aneja
- Department of Orthopedic Surgery and Rehabilitation, School of Health Related Professions, University of Mississippi Medical Center, Jackson, MS, 39216, USA.
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Aneja A, Karas SG, Weinhold PS, Afshari HM, Dahners LE. Suture plication, thermal shrinkage, and sclerosing agents: effects on rat patellar tendon length and biomechanical strength. Am J Sports Med 2005; 33:1729-34. [PMID: 16093538 DOI: 10.1177/0363546505275492] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Shortening or tightening of dense, collagenous tissues is often desirable in the treatment of laxity. PURPOSE To compare the effect of stress-protection suture, radiofrequency thermal shrinkage combined with stress-protection suture, and a 5% sodium morrhuate sclerosing injection on the length and biomechanical strength of the rat patellar tendon. HYPOTHESIS Sclerosing agents will increase tendon mechanical strength. Thermal shrinkage combined with stress-protection suture and stress-protection suture only will cause a short-term decrease in tendon strength. All 3 methods will produce equivalent shortening of the tendon. STUDY DESIGN Controlled laboratory study. METHODS Forty-six female retired breeder rats were split into 4 groups, each receiving 1 of the 3 aforementioned treatments plus a control group that received a saline injection. After 4 weeks' survival, the length and biomechanical properties of the patellar tendons were measured and compared to the contralateral untreated tendon. RESULTS Rats treated with stress-protection suture had shorter tendons. Radiofrequency thermal shrinkage combined with stress-protection suture yielded tendons that were both shorter and stronger than were the untreated contralateral tendons. The sodium morrhuate-injected tendons were stronger whereas the saline-treated tendons were weaker than were their respective untreated contralateral tendons. CONCLUSION Surgical stress-protection suture without radiofrequency shrinkage is most effective at shortening the length of the rat patellar tendon, whereas radiofrequency thermal shrinkage combined with stress-protection suture as well as sodium morrhuate are effective at increasing the strength of rat patellar tendons. CLINICAL RELEVANCE Judicious use of thermal shrinkage in combination with stress protection may improve ligament strength and decrease laxity.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina 27599, USA
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Dwivedi S, Singh S, Agarwal MP, Rajpal S, Aneja A. Migration stress and premature coronary artery disease: an illustrative pedigree. J Assoc Physicians India 2004; 52:340-2. [PMID: 15636349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Megna J, Iqbal M, Aneja A. Pharmacology and Therapeutics of Gabapentin in the Treatment of Psychiatric Disorders; Present and Future Perspectives. Curr Neuropharmacol 2003. [DOI: 10.2174/1570159033477125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Rightor EG, Urquhart SG, Hitchcock AP, Ade H, Smith AP, Mitchell GE, Priester RD, Aneja A, Appel G, Wilkes G, Lidy WE. Identification and Quantitation of Urea Precipitates in Flexible Polyurethane Foam Formulations by X-ray Spectromicroscopy. Macromolecules 2002. [DOI: 10.1021/ma0122627] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- E. G. Rightor
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - S. G. Urquhart
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - A. P. Hitchcock
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - H. Ade
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - A. P. Smith
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - G. E. Mitchell
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - R. D. Priester
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - A. Aneja
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - G. Appel
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - G. Wilkes
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| | - W. E. Lidy
- Analytical Sciences, The Dow Chemical Company, 1897 Building, Midland, Michigan 48667; Department of Physics, North Carolina State University, Raleigh, North Carolina 27695; Brockhouse Institute for Materials Research, McMaster University, Hamilton, ON L8S 4M1 Canada; Polyurethanes, Dow Chemical, Building B-1608, 2301 N. Brazosport Blvd., Freeport, Texas 77541; and Department of Chemical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
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