Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

Management of Ulnar Styloid Nonunions

Ulnar styloid fractures commonly occur in the setting of distal radius fractures and often progress to asymptomatic nonunion. Displaced basilar ulnar styloid fractures involving the deep radioulnar ligament attachments may cause distal radioulnar joint (DRUJ) instability. A careful clinical history, physical examination, review of imaging studies, and selected diagnostic interventions are important for confirming the relationship of the ulnar styloid nonunion with ulnar-sided wrist symptoms and/or DRUJ instability. Improved functional and symptomatic outcomes can be achieved with nonunion repair or fragment excision with or without triangular fibrocartilage complex repair, depending on the location and size of the ulnar styloid fracture.

Metacarpal Neck Osteochondroma: An Atypical Cause of "Trigger Finger"

"Locking" of the digits is a relatively common patient complaint in hand surgery. Typically, this phenomenon arises from either triggering of tendons at the A1 pulley or subluxation of tendons around the metacarpal head. Although trigger digit and sagittal band injury comprise most diagnoses, clinicians must be aware of rarer entities that alter the underlying osseous anatomy and predispose the digits to "locking." Here, we present a case of metacarpal neck osteochondroma causing subluxation of the index metacarpophalangeal joint radial collateral ligament.

Pronator Quadratus Repair Does Not Affect Reoperation Rates Following Volar Locking Plate Fixation of Distal Radius Fractures

BACKGROUND

The purpose of this study was to evaluate the impact of pronator quadratus (PQ) repair on reoperation rates after distal radius open reduction internal fixation (ORIF) using a volar locking plate.

METHODS

A retrospective study of all patients undergoing distal radius ORIF with a volar locking plate between January 2012 and December 2016 at 2 urban, academic level I trauma centers was performed. Patient demographics, fracture and procedure characteristics, surgeon subspecialty, PQ repair, and reoperations were recorded. Descriptive statistics were used to determine whether patient-related or injury-related characteristics were associated with PQ repair. Bivariate and multivariable regression analyses were used to assess the effect of PQ repair on subsequent reoperations.

RESULTS

In total, 509 patients were included, including 31 patients with bilateral injuries. The average follow-up time was 3.7 ± 2.8 years. Patients undergoing PQ repair were younger (57 ± 17 years vs 61 ± 17 years) and were more likely to have a lower Soong grade (53% vs 44% with Soong grade 0) than patients without PQ repair. Pronator quadratus repair was not found to have a significant impact on hardware removal, reoperations for flexor tendon pathology, or overall reoperations.

CONCLUSIONS

Pronator quadratus repair was more commonly performed in younger patients and in patients with a lower Soong grade. Hand-subspecialized surgeons are more likely to pursue PQ repair than trauma-subspecialized surgeons. This study did not detect statistically significant differences in hardware removal, flexor tendon pathology, or overall reoperations between groups.

Influence of psychiatric co-morbidity on health-related quality of life among major trauma patients

PURPOSE

The purpose of this study was to compare 1-year post-discharge health-related quality of life (HRQL) between trauma patients with and without psychiatric co-comorbidity.

METHODS

A retrospective single-center cohort study identified all severely injured adult trauma patients admitted to a Level 1 trauma center between 2018 and 2019. Bivariate analysis compared patients with and without psychiatric co-morbidity, which was defined as prior diagnosis by a healthcare provider or acute psychiatric consultation for new or chronic mental illness. HRQL metrics included the EuroQol-5D-5L (EQ-5D) questionnaire, visual analogue scale (EQ-VAS), and overall index score. A multiple linear regression model was utilized to identify predictors of EQ-5D index scores.

RESULTS

Analysis of baseline characteristics revealed significantly greater rates of substance abuse, severe extremity injuries, inpatient morbidity, and hospital length-of-stay among patients with psychiatric illness. At 1-year follow-up, patients with psychiatric co-morbidity had lower median EQ-5D index scores compared to the control group (0.71, interquartile range [IQR] 0.32 vs. 0.79, IQR 0.22, p = 0.03). There were no differences between groups in individual EQ-5D dimensions, nor in EQ-VAS scores. Presence of psychiatric co-morbidity was not found to independently predict EQ-5D index scores in the linear regression model. Instead, Injury Severity Score (standardized regression coefficient [SRC] - 0.15, 95% confidence interval [CI] - 0.010 to - 0.001) and American Society of Anesthesiologists Physical Status score (SRC - 0.13, 95% CI - 0.08 to - 0.004) predicted poor HRQL 1-year after injury.

CONCLUSIONS

Psychiatric co-morbidity does not independently predict low HRQL 1 year after injury. Instead, lower HRQL scores among patients with psychiatric co-morbidity appear to be mediated by baseline health status and injury severity.

The Impact of the Soong Index on Hardware Removal and Overall Reoperation Rates After Volar Locking Plate Fixation of Distal Radius Fractures

PURPOSE

This study sought to determine the impact of volar plate prominence on reoperation rates after open reduction and internal fixation of distal radius fractures with volar locking plates and to identify other factors associated with removal of hardware (ROH) or a reoperation.

METHODS

A retrospective study of patients who underwent distal radius open reduction and internal fixation between 2012 and 2016 at 2 level I trauma centers was conducted. Plate prominence was evaluated using the Soong index at the first postoperative visit. The details of patient demographics, fracture and plate characteristics, complications, and reoperations were recorded. Bivariate and multivariable regression analyses were used to identify factors associated with increased rates of ROH and overall reoperation.

RESULTS

A total of 732 (70.2%) of 1,042 patients completed follow-up at an average of 38.2 months, including 34 patients with bilateral operations, yielding 766 distal radius fractures. One hundred sixteen (15.1%) patients underwent reoperation at an average of 12.1 ± 13.6 months after the index surgery. Removal of hardware was the most commonly performed reoperation (77 patients, 10%). The multivariable regression analysis revealed significantly higher rates of ROH in Soong grade 1 or 2 patients (odds ratio 16, 95% CI 5.8-47; odds ratio 44, 95% CI 14-140, respectively) than in Soong grade 0 patients. Plate type, younger age, bilateral injuries, and concomitant procedures at the time of the index operation were all associated with increased risk of ROH. There were significant differences between individual surgeons the in rates of ROH (range 2.1%-22%) and overall reoperation (range 5.2%-36%). Compared with other hand surgeons, fellowship-trained hand surgeons had lower rates of ROH (8% vs 14%, respectively) and overall reoperation (12% vs 22%, respectively).

CONCLUSIONS

The rates of ROH and overall reoperation increase with increasing Soong grade. Plate type is independently predictive of future ROH. Older patients and those undergoing open reduction and internal fixation experience lower rates of subsequent reoperation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery

PURPOSE

The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice.

METHODS

A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present.

RESULTS

A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts.

CONCLUSIONS

Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs.

CLINICAL RELEVANCE

Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.

Clavicle Fractures With Associated Acute Neurovascular Injury

Descriptions of acute neurovascular injury after clavicle fracture are limited to case reports. The objectives of this study were to assess both the prevalence of acute neurovascular injury after midshaft clavicle fracture and the outcomes of early fracture stabilization. A retrospective chart review was conducted of all adult patients with midshaft clavicle fracture who were treated surgically at 2 tertiary care referral centers from January 2010 to March 2019. The records of patients who were identified as having clinical or radiographic evidence of neurovascular compromise were reviewed to assess for deficits on physical examination on presentation, relevant radiographic and electro-diagnostic findings, timing and type of fixation, and time until resolution of symptoms and radiographic union postoperatively. Of the 443 adult patients undergoing surgical treatment for displaced midshaft clavicle fracture, 3 (1%) experienced acute neurovascular compromise and underwent early fixation. In all cases, fracture displacement caused compression of adjacent neurovascular structures in the costoclavicular space. No lacerations of underlying neurovascular structures were encountered intraoperatively, suggesting a pattern of nerve contusion or vascular compression from the initial injury and fracture displacement. Postoperatively, 2 patients had full recovery of preoperative neurologic deficits and 1 patient experienced partial recovery of motor deficits with persistent neuropathic pain. There were no instances of symptomatic vascular insufficiency at final follow-up. Acute neurovascular injury as a result of compression of underlying structures in the costoclavicular space is a rare complication of displaced midshaft clavicle fracture. Early surgical decompression of compressed neurovascular structures and rigid clavicle osteosynthesis can lead to significant postoperative functional improvement. [Orthopedics. 2021;44(3):e390-e394.].

Non-operative Treatment of Carpal Tunnel Syndrome

PURPOSE OF REVIEW

To determine the current evidence for various non-operative therapies in the treatment of carpal tunnel syndrome RECENT FINDINGS: Multiple non-operative treatment modalities exist in the treatment of mild to moderate carpal tunnel syndrome. While certain modalities such as splinting and corticosteroid injections have moderate- to high-quality evidence to support use, other less commonly used treatments have fewer therapeutic indications in the current literature. Healthcare providers should be able to initiate the appropriate diagnostic evaluation and assess the utility of non-operative therapies in the treatment of carpal tunnel syndrome. Moreover, healthcare providers should also be able to understand the evidence behind each treatment and the indications for surgical intervention.

Effect of Vertical or Beveled Chondral Defect Creation on Rim Deformation and Contact

OBJECTIVE

To determine biomechanical effects of knee cartilage defect perimeter morphology based on cartilage strain and opposing subchondral bone contact.

DESIGN

Articular cartilage defects were created in 5 bovine femoral condyles: group 1, 45° inner bevel with 8-mm rim; group 2, vertical with 8-mm rim; and group 3, 45° outer bevel with 8-mm base. Samples were placed into a custom-machined micro-computed tomography tube and subjected to 800 N of axial loading. DICOM data were used to calculate cartilage thickness 4 and 6 mm from the center, distance between tibial cartilage surface and femoral subchondral bone, and contact width between tibial cartilage and subchondral bone. Strain 4 mm from the center and both absolute and change in distance (mm) to subchondral bone were compared between groups 1 and 2 using paired t tests. Strain at 6 mm and distance changed, loaded distance, and contact width (mm) were compared between groups using the Friedman test with post hoc analysis using Wilcoxon signed rank test.

RESULTS

No significant differences in rim strain were noted between groups 1 and 2 at 4 mm ( P = 0.10) and between groups 1, 2, and 3 at 6 mm ( P = 0.247) from the defect center. The loaded distance was significantly different between groups 1 and 3 ( P = 0.013). No significant change in distance to the subchondral bone was found between groups ( P = 0.156). The difference in subchondral bone contact area approached but did not reach significance ( P = 0.074).

CONCLUSION

When debriding focal articular cartilage defects, establishment of an inner bevel decreases tissue deformation and contact with opposing subchondral bone.

The Effect of Surgical Insertion and Proinflammatory Cytokines on Osteochondral Allograft Survival and Metabolism

Objective To investigate the responses of refrigerated osteochondral allograft cartilage (OCA) and fresh cartilage (FC), including cell survival and metabolism, to surgical impaction and proinflammatory cytokines. Design Osteochondral plugs (8 mm diameter) were harvested from prolonged-refrigerated (14-28 days) and fresh (≤24 hours postmortem) human femoral hemicondyles and subjected to a 0.2 N s pneumatic impaction impulse. Cartilage explants were removed from subchondral bone and randomized to 1 of 6 treatment groups: (1) Unimpacted control (UIC), (2) Impacted control (IC), (3) Impacted + interleukin (IL)-1β (0.1 ng/mL), (4) Impacted + IL-1β (0.1 ng/mL) + IL-6, (5) Impacted + IL-1β (10 ng/mL), and (6) Impacted + IL-1β (10 ng/mL) + IL-6. Samples were measured for cell viability, histology, and proteoglycan (PG) content at days 0, 2, 7, and 14 of culture. Results In UIC, cell viability was indistinguishable between OCA and FC and remained constant. Impaction alone decreased cell viability by 30% ( P < 0.01) in the OCA superficial layer and by 26% ( P < 0.01) in the entire tissue, but did not affect viability in FC. Cytokine addition did not further influence cell viability. Impaction alone did not affect PG synthesis. Addition of cytokines to impacted tissue decreased PG synthesis by ~3-fold in both tissue types in comparison with corresponding impacted controls ( P < 0.01). Throughout 2-week culture, PG release remained stable in all FC groups, but peaked at day 14 in OCA cartilage subjected to cytokines. Conclusions Mechanical impaction, mimicking surgical insertion, has a more profound effect on cell viability in OCA than in FC. Addition of proinflammatory cytokines further decreases OCA tissue metabolism and integrity.

Evaluation of angle trunk rotation measurements to improve quality and safety in the management of adolescent idiopathic scoliosis

Purpose

The evaluation, management and follow-up of adolescent idiopathic scoliosis (AIS) occur frequently within a pediatric orthopedic surgery practice. Curve status can be assessed with Scoliometer measurements of angle trunk rotation (ATR), which are reliable and reproducible to within 3°. This study assessed the longitudinal efficacy, safety and cost savings of integrating ATR measurements to monitor curve status and progression in AIS, and suggests a quality-based management strategy.

Methods

A retrospective review of medical records between 2004 and 2014 included patients with AIS between 10-17 years, excluding those with Cobb angle >52° at presentation. Two cohorts were analyzed based on presentation prior to menarche (PRE) or after menarche (POST). The PRE groups was further classified based on whether the curve was Stable or Unstable. The cost of a single PA thoracolumbar radiograph was defined based on the 2015 CMS fee schedule ($36.27). Safety was defined based on the effective radiation dose avoided (0.14 millisieverts/radiograph).

Results

A total of 59 children were included with 45 in PRE and 14 in the POST cohort. The use of ATR measurements provided a cost benefit in both the PRE Stable and Unstable cohorts, by avoiding radiographs with an average savings of $161.76 and $147.50 respectively. Similarly in POST, there was an average cost savings of $105.18 per patient. The safety benefit of using ATR measurements included avoiding an average of 0.62, 0.56 and 0.4 millisieverts of radiation in the PRE Stable, PRE Unstable and POST groups respectively.

Conclusions

An evaluation strategy with ATR measurements provides for a reliable, cost-effective and safety advantage in the monitoring of curve progression in both skeletally mature and immature patients with AIS. These findings suggest that stable ATR measurements are a safe and cost effective alternative to serial radiographs in the clinical monitoring of AIS. Recent evidence from 25 years of scoliosis treatment in Denmark noted a cancer rate 17 times that of an age-matched population. Thus, reducing radiation exposure during scoliosis monitoring using ATR measurements has important clinical significance for cancer risk reduction.

Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up

BACKGROUND

Microfracture is an effective surgical treatment for full-thickness cartilage defects of the knee; however, little is known regarding long-term outcomes after microfracture in the shoulder.

PURPOSE

To present long-term clinical outcomes of patients undergoing microfracture of full-thickness articular cartilage defects of the glenohumeral joint.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixteen consecutive patients (17 shoulders) were retrospectively reviewed who underwent arthroscopic microfracture of the humeral head and/or glenoid surface, with or without additional procedures between 2001 and 2008 and with a minimum follow-up of 8.5 years. All patients completed pre- and postoperative surveys containing the visual analog scale, American Shoulder and Elbow Surgeons form, and Simple Shoulder Test. Complications and reoperations were analyzed. Failure was defined by biological resurfacing or conversion to arthroplasty.

RESULTS

Of the original 16 patients (17 shoulders), 13 patients (14 shoulders) were available for mean follow-up at 10.2 ± 1.8 years after microfracture (range, 8.5-15.8 years), for an overall clinical follow-up rate of 82%. The patients (6 men, 7 women) were 36.1 ± 12.9 years old at time of microfracture. The average size of humeral head defects was 5.20 cm² (range, 4.0-7.84 cm²), and the average size of glenoid defects was 1.53 cm² (range, 1.0-3.75 cm²). Four patients (4 shoulders) underwent at least 1 reoperation, and 3 were considered to have structural failures. The average time to failure was 3.7 years after microfracture (range, 0.2-9.6 years). The overall survival rate was 76.6% at 9.6 years. For these patients, there were statistically significant improvements in visual analog scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores as compared with preoperative values at long-term follow-up ( P < .05 for all), without any significant change from short-term (mean, 2.3 years) to long-term (mean, 10.2 years) follow-up. There was no significant difference in Single Assessment Numeric Evaluation or Short Form-12 Physical or Mental scores between short- and long-term follow-up. When compared with short-term follow-up, in which 2 patients had already failed, 1 additional patient progressed to failure at 9.6 years after the original microfracture. Two patients (2 shoulders) were considered to have clinical failure. Owing to the overall number of failures (3 structural failure and 2 clinical failure), the total long-term success rate of glenohumeral microfracture is 66.7% in the current study.

CONCLUSION

Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients. However, in this case series, 21.4% of patients required conversion to arthroplasty <10 years after the index microfracture procedure, and 33% to 42% of patients were considered to have potential clinical failure. Additional studies with larger patient cohorts are needed.

The Influence of Full-Thickness Chondral Defects on Outcomes Following Meniscal Allograft Transplantation: A Comparative Study

PURPOSE

To compare a series of patients who underwent meniscus allograft transplantation (MAT) with full-thickness chondral defects (FTD) with those with no chondral defect (ND) with regard to the following: change in patient-reported outcomes (PROs) from baseline to 2-year follow-up and baseline to the final follow-up (including comparisons to minimal clinically important differences), complications and complication rates, reoperations and reoperation rates/timing, and failures and time to failure (revision MAT or conversion to total knee arthroplasty).

METHODS

Patients who underwent isolated medial or lateral MAT between September 1997 and March 2013 with a minimum of 2 years of follow-up were retrospectively identified and split into 2 groups based on the presence or absence of FTD (femoral condyle or tibial plateau) identified intraoperatively after debridement to allow for a better understanding of the lesion characteristics (when applicable): ND (Outerbridge grade 0/I) or FTD (Outerbridge grade IV). Patients with osteochondritis dissecans were eligible for inclusion, as were those with isolated single lesions, multiple lesions, or bipolar lesions. Those with a moderate Outerbridge grade (II and III)-whether treated or neglected-were excluded given the poorer reliability of grading intermediate lesions. Indications for MAT included those patients with subjective complaints (persistent joint-line pain) and objective findings (previous meniscectomy or nonviable meniscus state with pain localized to the affected compartment) of functional meniscal deficiency. All lateral MAT patients used a bridge-in-slot surgical technique, as did most medial MAT patients (few patients with earlier surgical dates received a keyhole technique). All FTD were treated concurrently at the time of index MAT with cartilage restoration procedures (microfracture, autologous chondrocyte implantation, DeNovo particulate cartilage grafting, or osteochondral auto/allografting). Reoperations, failures (revision MAT or conversion to arthroplasty), and PRO deltas were reported comparing baseline to 2-year follow-up and baseline to the final follow-up. Intergroup comparisons were made using Bonferroni-adjusted independent sample t-tests for continuous variables and χ-square for categorical variables.

RESULTS

A total of 91 patients (22 ND and 69 FTD) were identified and followed for a mean 4.48 ± 2.63 and 3.84 ± 2.47 years, respectively. There were no significant between-group differences in age, body mass index, or number of prior surgeries. The mean chondral lesion size in the FTD group was 4.43 ± 2.5 cm². Concomitant anterior cruciate ligament reconstruction was performed significantly more in ND-group patients than FTD-group patients (8 [38.1%] vs 8 [11.8%], P = .004). There were no differences between ND-group and FTD-group patients in concomitant realignment procedures performed (2 [9.1%] vs 7 [10.1%], P = .986), or prior ligament reconstruction (9 [40.9%] vs 18 [26.1%], P = .111) or realignment procedure (0 [0%] vs 0 [0%]). FTD-group patients underwent concomitant osteochondral allograft (69.6%), autologous chondrocyte implantation (18.8%), microfracture (13.0%), osteochondral autograft (4.3%), or DeNovo juvenile particulate cartilage implantation (1.4%). A comparison of the patient groups found no statistically significant differences in PROs preoperatively (P > .003 for all). Intergroup comparisons of both the 2-year and final follow-up delta PRO scores showed no statistically (P > .003 for all) or clinically (number of PROs meeting minimal clinically important differences) significant differences. One complication occurred (fractured hardware) in the FTD-group patients (1.3%). There were no differences in the number of subsequent surgeries (revision MAT: ND, 2 (10.0%) vs FTD, 8 (12.9%); P = .845) or failures (conversion to total knee arthroplasty: ND, 1 (5.0%) vs FTD, 2 (3.3%); P = .646).

CONCLUSIONS

When comparing a patient series with FTD who underwent MAT with a patient series with ND, there were no differences in the change in individual PROs from preoperative to the final follow-up. Similarly, there were no differences in complications or failure between those with ND or FTD diagnosed intraoperatively. The results of the current study suggest that chondral damage identified and treated by cartilage restoration means at the time of MAT may not affect the clinical outcomes of MAT.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Effectiveness of Lavage Techniques in Removing Immunogenic Elements from Osteochondral Allografts

Objective This study aimed to compare standard saline lavage to combination saline and high-pressure carbon dioxide (CO₂) lavage in removing marrow elements from osteochondral allografts. Design Six fresh hemicondyles were obtained. Three osteochondral allograft plugs (15-mm diameter, 6-mm depth) were harvested from each hemicondyle and randomized to 1 of 3 treatment arms: A, no lavage; B, 1 L standard saline lavage; C, simultaneous saline (1 L) and 1-minute high-pressure CO₂ lavage. After hematoxylin and eosin staining, a "percentage fill" of remaining marrow elements was calculated for each overall sample and then repeated in 3 distinct compartments for each sample based on depth from surface: 1, deepest third; 2, middle third; and 3, most superficial third. Trial arms B and C were compared with 1-tailed Student t tests. Results Group A had an overall percentage fill of 51.2% ± 8.8%. While both lavage techniques decreased overall remaining marrow elements, group B yielded significantly higher percentages of remaining marrow elements than group C (28.6% ± 16.5%, 14.6% ± 8.7%, P = 0.045). On depth analysis, group A exhibited homogenous filling of trabecular space (63.0% ± 15.5%, 67.6% ± 13.7%, and 55.2% ± 10.1% in zones 1, 2, and 3, respectively). Both lavage arms equally removed marrow elements from superficial zone 3 (B, 17.4% ± 9.2%; C, 15.6% ± 12.4%, P = 0.41) and middle zone 2 (B, 30.2% ± 17.7%; C, 21.4% ± 15.5%, P = 0.18). However, group C lavage removed significantly more marrow elements in deep zone 1 than group B (29.7% ± 10.9%, 58.5% ± 25.2%, P = 0.01). Conclusion Combination saline and high-pressure CO₂ lavage more effectively clears marrow elements from osteochondral allografts than saline alone.

The Therapeutic Effect of Intra-articular Normal Saline Injections for Knee Osteoarthritis: A Meta-analysis of Evidence Level 1 Studies

BACKGROUND

Intra-articular normal saline (IA-NS) injections have been utilized as a placebo in a number of randomized controlled trials pertaining to the management of knee osteoarthritis (OA); however, it is believed that these "placebo" injections may have a therapeutic effect that has not been quantified in the literature.

PURPOSE

To (1) quantify the effect of IA-NS injections on patient-reported outcomes (PROs) and (2) compare postinjection PROs to established minimal clinically important difference (MCID) criteria to demonstrate a potential therapeutic effect.

STUDY DESIGN

Meta-analysis.

METHODS

A review was conducted to identify all randomized, placebo-controlled trials on injection therapy for knee OA between 2006 and 2016. Patient demographics and PROs before the injection and at 3 and 6 months after the injection were collected for patients in the IA-NS injection group in each study. A random-effects model was used to compare preinjection scores and scores at each postinjection time point in a pairwise fashion.

RESULTS

In total, there were 14 placebo cohorts in 13 studies that were analyzed after meeting inclusion criteria for this meta-analysis. This included 1076 patients (Kellgren-Lawrence grade 1-4), with a weighted mean age of 62.53 years and mean body mass index of 28.67 kg/m². There was only sufficient information to perform analyses of visual analog scale (VAS) pain and Western Ontario and McMaster Universities Arthritis Index (WOMAC) total scores. At 3 months after the IA-NS placebo injection, there was a significant improvement in VAS pain scores (mean difference [MD], 12.10 [95% CI, 3.27 to 20.93]; P = .007), whereas improvement in the WOMAC total scores approached but did not reach statistical significance (MD, 19.75 [95% CI, -0.50 to 40.09]; P = .06). At 6 months, both VAS pain scores (MD, 16.62 [95% CI, 12.13-21.10]; P < .00001) and WOMAC total scores (MD, 11.34 [95% CI, 7.03-15.65]; P < .00001) were significantly improved in comparison to preinjection values. Furthermore, improvements in both the VAS pain and WOMAC total scores at 6 months were clinically significant (MCID, 1.37 and 9, respectively).

CONCLUSION

The administration of an IA-NS placebo injection yields a statistically and clinically meaningful improvement in PROs up to 6 months after the injection in patients with knee OA. This observation supports the notion that the so-called placebo effect for IA-NS injections achieves a clinically meaningful response in patients with OA when provided during comparison studies to an active treatment group (ie, hyaluronic acid).

Flexion Posteroanterior Radiographs Affect Both Enrollment for and Outcomes After Injection Therapy for Knee Osteoarthritis

BACKGROUND

Knee injection therapy is less effective for severe osteoarthritis (OA), specifically Kellgren-Lawrence (KL) grade 4. Patient selection for knee injection trials has historically been based on extension anteroposterior (AP) radiographic evaluation; however, emerging evidence suggests that KL grading using a flexion posteroanterior (PA) radiograph more accurately and reproducibly predicts disease severity. The impact of radiographic view on patient selection and outcome after knee injection therapy remains unknown.

HYPOTHESIS

A 45° flexion PA radiograph will reveal more advanced knee OA in certain patients. These patients will report worse pre- and postinjection outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Four raters independently graded extension AP and flexion PA radiographs from 91 patients previously enrolled in a knee injection trial. Patients determined to have KL grade 4 OA by any rater on extension AP radiographs were excluded. Among included patients, those upgraded to KL grade 4 on flexion PA radiographs by at least 2 raters constituted group 2, while all remaining patients constituted group 1. Demographic data and patient-reported outcome scores before injection and at 6 weeks, 3 months, 6 months, and 12 months postinjection were compared between groups.

RESULTS

Overall, 64 patients met the inclusion criteria, of which 19 patients (30%) constituted group 2. Compared with group 1, patients in group 2 were older (58.7 vs 52.3 years, P = .02), had worse visual analog scale pain scores before (6.6 vs 5.3, P = .03) and 6 months after injection (5.3 vs 3.5, P = .01), had less improvement in both Lysholm (8.5 vs 20.5, P = .02) and Short Form-12 physical component (-2.2 vs 1.7, P = .03) scores from preinjection to 6 months postinjection, and had less improvement in both Lysholm (1.6 vs 13.1, P = .03) and Knee injury and Osteoarthritis Outcome Score sport subscale (-2.1 vs 16, P = .01) scores from preinjection to 12 months postinjection.

CONCLUSION

One in 3 patients considered to have mild to moderate knee OA on extension AP radiography is upgraded to severe knee OA (KL grade 4) on flexion PA radiography. These patients report worse preinjection outcomes, worse pain scores at short-term follow-up, and decreased improvement in knee function scores between 6 months and 1 year postinjection.

Prospective Clinical and Radiographic Outcomes After Concomitant Anterior Cruciate Ligament Reconstruction and Meniscal Allograft Transplantation at a Mean 5-Year Follow-up

BACKGROUND

Concomitant anterior cruciate ligament reconstruction and meniscal allograft transplantation (ACLR/MAT) has demonstrated short-term success in small, retrospective cohort studies. Patient- and disease-specific predictors of success after ACLR/MAT are largely unknown.

PURPOSE

To (1) prospectively evaluate the subjective and objective clinical and radiographic outcomes after ACLR/MAT and (2) conduct a subgroup analysis to identify patient- or disease-related factors that correlate with failure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patient-reported outcomes (PROs) were prospectively collected on 40 patients undergoing concomitant ACLR/MAT. Nineteen athletes responded to return-to-sport data. Clinical data (physical examination including Lachman and pivot-shift testing and KT-1000 arthrometer testing) were obtained on 28 patients who returned for an evaluation, while 24 of those patients additionally had radiographic data (progression of Kellgren-Lawrence [KL] grade and joint-space narrowing) evaluated. Reoperations and failures were documented for all patients at their final follow-up.

RESULTS

The overall cohort of 40 patients had a mean age of 30.3 ± 9.6 years (range, 16.0-54.0 years) and a mean body mass index of 27.7 ± 4.2 kg/m². The mean follow-up time was 5.7 ± 3.2 years (range, 1.7-16.5 years). There were 33 (83%) medial meniscal transplants performed compared with 7 (17%) lateral meniscal transplants. Patients underwent a mean of 2.9 ± 1.9 prior surgical procedures. Nineteen patients underwent concomitant procedures, including, most commonly, 9 hardware removals and 9 osteochondral allografts. There were significant improvements in 11 of 14 PRO measures as well as a 50% return-to-sport rate. Knee stability significantly improved in 28 patients who returned for a physical examination, and KT-1000 arthrometer testing indicated no differences between the affected and unaffected sides at final follow-up (mean, 0.9 ± 1.5 mm [range, -2 to 4 mm] in comparison to contralateral knee at 30 lb of testing; mean, 0.9 ± 1.9 mm [range, -4 to 4 mm] in comparison to contralateral knee at maximum manual strength). Significant improvements were seen in patients with Lachman grade ≥2A at final follow-up (18% vs 97%, respectively; P < .01) and with pivot shift ≥1+ at final follow-up (36% vs 94%, respectively; P < .01) compared with preoperatively. For the 24 patients with radiographic data, no significant joint-space decrease was recorded in the medial compartment for medial MAT-treated patients or the lateral compartment for lateral MAT-treated patients. The mean KL grade increased from 0.7 ± 0.8 to 1.6 ± 0.9 at final follow-up ( P < .01). There were no major (0%) and 2 minor (5%) complications, which constituted early postoperative drainage treated successfully with oral antibiotics. While 35% of patients underwent reoperations, the majority of these were simple arthroscopic debridements and occurred after nearly 4 years from the index surgery. The overall survival rate at final follow-up was 80%. Failures occurred at a mean of 7.3 years, and those who converted to arthroplasty did so at a mean of 8.3 years from the time of index ACLR/MAT. Patients with failed grafts were more frequently associated with workers' compensation claims (38% vs 13%, respectively) and less frequently self-identified as athletes (13% vs 56%, respectively) compared with patients with intact grafts.

CONCLUSION

Concomitant ACLR/MAT can provide significant improvements in clinical outcomes and enhancement in objective knee stability and was associated with an insignificant degree of radiographic joint-space narrowing changes with a 5-year survivorship of more than 80% for those with data available. Athlete status may be a preoperative predictor of midterm survival.

Outcomes After Shoulder and Elbow Injury in Baseball Players: Are We Reporting What Matters?

BACKGROUND

Return to play, as well as time to return to play, are the most important metrics considered by athletes when attempting to make treatment decisions after injury. However, the consistency of reporting of these metrics in the scientific literature is unknown.

PURPOSE

To investigate patterns of outcomes reporting in the medical literature of shoulder and elbow injuries in active baseball players.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of literature published within the past 10 years was performed to identify all recent clinical studies focusing on shoulder and elbow injuries in baseball players across all levels. Review articles, case reports, and laboratory/biomechanical studies were all excluded.

RESULTS

A total of 49 studies were included for review. The majority of studies were either level 3 or level 4 evidence (96%). In total, 71% of studies reported on rates of return to preinjury level of play, whereas 31% of studies reported on time to return to preinjury level of play. Only 47% of studies reported on both rate and time of return to preinjury level of play. A minority of studies (8%) reported patient satisfaction rates. Finally, 27 different subjective and patient-reported outcomes were reported, and none of these appeared in more than 14% of all studies.

CONCLUSION

Time to return to preinjury level of play is inadequately reported in studies of shoulder and elbow injury in baseball players. Similarly, satisfaction rates and scores are underreported. Finally, the significant variability of subjective and patient-reported outcomes utilized may undermine the ability of clinicians to accurately compare results from different studies.

Deciding How Best to Treat Cartilage Defects

The decision-making regarding and treatment of cartilage abnormalities requires a systematic approach. This article reviews the concepts and principles that guide the management of this complex problem. The precise incidence, demographics, and progression of cartilage lesions have not been clearly delineated. Pursuing a patient-centered approach that considers the available nonsurgical and surgical options remains the cornerstone of patient care. The importance of determining concomitant knee pathologies, the proper interpretation and implications of imaging findings, and an accurate determination of the intra-articular and subchondral findings represent the primary elements of the decision analysis. Treatment options vary depending on patient goals, the disposition of the lesion, and a variety of other factors. The authors recommend proper patient education and consideration of how nonsurgical treatment or less invasive options such as arthroscopic debridement might be effective. If these strategies should fail, appropriate matching of a surgical procedure to the patient's pathology, goals, and expectations is warranted. Surgical options include debridement, marrow stimulation techniques, surface allograft treatments, autologous chondrocyte implantation, and osteochondral grafting (autograft and allograft) in addition to some emerging technologies. This article focuses on the decision-making process. [Orthopedics. 2016; 39(6):343-350.].

Comprehensiveness of Outcome Reporting in Studies of Articular Cartilage Defects of the Knee

PURPOSE

To assess the comprehensiveness of outcome reporting after treatment of focal articular cartilage defects in the knee.

METHODS

A systematic review of literature published over the past 5 years (October 2010 to October 2015) in 5 high-impact orthopaedic journals was completed to identify all recent clinical studies tracking outcomes after surgery for focal articular cartilage defects in the knee. A metric reporting score was calculated for each study, according to reporting of 6 cardinal domains: pain, satisfaction, osteoarthritis progression, subjective knee function, objective knee function, and patient-reported outcomes.

RESULTS

Of the 122 studies included for review, 117 (96%) tracked patient-reported outcomes during follow-up. Nearly two-thirds of studies (63%) monitored progression of osteoarthritis at follow-up. Fewer than half of studies (39%) specifically monitored pain outcomes in patients. One-third of studies (30%) tracked patient satisfaction. Only 21% of studies monitored subjective knee function using proxies such as return to play, and only 17% of studies reported on objective knee function during return visits to the clinic. The average metric reporting score of all studies was 2.6, and nearly half of studies (48%) reported on only 1 or 2 domains of interest.

CONCLUSIONS

There is substantial variability in outcome reporting after cartilage surgery in high-impact orthopaedic journals. Furthermore, most studies do not comprehensively track outcomes across domains. Both factors hinder comparison of results across studies. Future outcome metrics should focus on patient-centered factors to improve both accuracy of results reporting and standardization across studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

In vitro transactivation of Bacillus subtilis RNase P RNA

Deletion of the 'signature' PL5.1 stem-loop structure of a Type II RNase P RNA diminished its catalytic activity. Addition of PL5.1 in trans increased catalytic efficiency (kcat/KM) rather than kcat. Transactivation was due to the binding of a single PL5.1 species per ribozyme with an apparent Kd near 600 nM. The results are consistent with the role of PL5.1 being to position the substrate near the active site of the ribozyme, and with the hypothesis that ribozymes can evolve by accretion of preformed smaller structures.

From Siberia to Mars

Because Mars is so similar to Earth, planetary scientists looking for answers to questions like these often use analogous environments on Earth to help them design future Mars missions. Such terrestrial sites, however remote, are still much more accessible than Mars. Field studies in such places give us a chance to test and refine instruments and procedures, develop overall concepts and collect baseline data to compare with actual results from Mars. Perhaps the best terrestrial analogue to the martian permafrost lies in northeastern Siberia. Freezing conditions have persisted here for over 3 million years. Although young by martian standards, these are among the oldest continuously frozen localities on Earth. They also hold something remarkable: not only organic residues, but also large numbers of viable bacteria (up to 100 million per gram of frozen soil), preserved for 3 million years in ice.

Biologically relevant physical measurements in the ice-free valleys of southern Victoria Land: soil temperature profiles and ultraviolet radiation

As part of the ongoing comprehensive study of the cryptoendolithic microbial community in the ice-free valleys of southern Victoria Land, thermal properties of the soil and the ultraviolet radiation regime were measured. Although soil temperature profiles have been measured in the ice-free valleys (e.g., Cameron et al. 1970; Cameron 1972), these are the first such data from higher elevations. This is apparently the first time the ultraviolet radiation regime has been measured in the Antarctic.

Antarctic cryptoendolithic microbial ecosystem research, 1986-1987

The apparent lifelessness of the Ross Desert is in marked contrast to the diversity of cryptoendolithic microorganisms inhabiting the interstices of sandstone rocks. The endolithic habitat provides a protective niche for lichens, bacteria, algae, and fungi, enabling them to exist in an extremely dry and cold climate. Composed solely of microorganisms living under the surface of rocks and totally lacking animals and protozoa, this ecosystem is controlled by measurable physical variables and well suited for ecosystem study and modeling. The work of the antarctic cryptoendolithic microbial ecosystem research group has involved physical measurements of nanoclimate (microbial environment inside rocks) (Friedmann, McKay, and Nienow 1987), taxonomy (Darling, Friedmann, and Broady 1987; Hale 1987), microdistribution, organism-substrate interactions including the ongoing process of fossilization (Friedmann and Weed 1987), physiological ecology, and quantification of the nitrogen economy.

School-based health centers as a locus for community health improvement

School-based health centers are critical resources for providing and coordinating health and medical services for children and adolescents. As such, they are an increasingly important component in a strategy to meet the comprehensive health, social, and educational needs of students and families. We show how educators and health professionals, using the language, methods and principles of continuous improvement, can collaborate effectively in addressing the specific concerns of school attendance and teen smoking.

Palatal myoclonus secondary to vertebral artery compression of the inferior olive

A 47-year-old male with a 5-year history of palatal myoclonus was found on magnetic resonance imaging (MRI) examination to have an ectatic dominant left vertebral artery that compressed the left inferior olive. Microvascular decompression effectively eliminated his symptoms. This case and a similar case presented here with an ectatic vertebral-basilar system illustrate the value of standard MRI in conjunction with magnetic resonance angiography (MRA) in evaluating palatal myoclonus, and they suggest a potential role for decompressive surgery when persistent, highly symptomatic inferior olivary ischemia or compression occurs.

Temporal lobe epilepsy presenting as panic attacks: detection of interictal hypometabolism with positron emission tomography

Cerebral glucose metabolism was studied using positron emission tomography (PET) in a 13-year-old girl with a history of panic attacks that were thought to be of psychiatric origin. Positron emission tomography imaging revealed marked right temporal lobe hypometabolism and magnetic resonance imaging (MRI) detected T2 changes consistent with right mesial temporal sclerosis. Electroencephalogram (EEG) studies 3 years later confirmed a primary diagnosis of right temporal lobe epilepsy. As shown by this case and one other, PET and MRI imaging of patients with panic disorder who are thought to have epilepsy may be helpful in leading to definitive electrographic studies that confirm temporal lobe epilepsy as the primary diagnosis.

Reduced F-18 fluorodeoxyglucose uptake within marrow after external beam radiation

PURPOSE

The authors examined the delayed effects of external beam radiation on the metabolism of intravertebral marrow cavities.

MATERIALS AND METHODS

Two neurologically normal persons who had completed a full course of external beam radiotherapy for squamous cell carcinoma of the head and neck had positron emission tomography (PET) scans with F-18 fluorodeoxyglucose (FDG) to identify residual neoplasm.

RESULTS

Abnormally low uptake of F-18 FDG was noted within the central marrow cavities of the cervical vertebral bodies in both cases.

CONCLUSIONS

Diminished metabolic activity within irradiated marrow can be revealed by F-18 FDG PET imaging techniques. Further correlative MRI PET studies are needed to determine if this postradiation phenomenon is related to fatty infiltration of the marrow cavity.

Gross and microscopic visceral anatomy of the male Cape fur seal, Arctocephalus pusillus pusillus (Pinnipedia: Otariidae), with reference to organ size and growth

The gross and microscopic anatomy of the Cape fur seal heart, lung, liver, spleen, stomach, intestine and kidneys (n = 31 seals) is described. Absolute and relative size of organs from 30 male seals are presented, with histological examination conducted on 7 animals. The relationship between log body weight, log organ weight and age was investigated using linear regression. Twenty five animals were of known age, while 6 were aged from counts of incremental lines observed in the dentine of tooth sections. For the range of ages represented in this study, body weight changes were accurately described by the exponential growth equation, weight = w(o)r(t), with body weight increasing by 23 % per annum until at least 9-10 y of age. Organ weight increased at a rate of between 25 % and 33 % per annum until at least 9-10 y of age, with the exception of the intestines, where exponential increase appeared to have ceased by about 7 y. The relationship between body weight and organ weight was investigated using logarithmic transformations of the allometric equation, y = ax(b), where the exponent b is 1 if organ weight is proportional to body weight. Most organs increased in proportion to the body. However, the heart, liver and spleen had exponents b > 1, suggesting that these organs increased at a faster rate than the body. The basic anatomical features of the viscera were similar to those of other pinnipeds, with some exceptions, including the arrangement of the multilobed lung and liver. Apart from the large liver and kidneys, relative size of the organs did not differ greatly from similar sized terrestrial carnivores. The histological features of the organs were generally consistent with those previously described for this species and other otariids. The heart, as in other pinnipeds, was unlike that of cetacea in not having unusually thick endocardium or prominent Purkinje cells. Notable histological features of the lungs included prominent fibrous septa, prominent smooth muscle bundles, cartilage extending to the level of the alveolar sacs and ample lymphoid tissue. The spleen had a thick capsule, well developed trabeculae and plentiful plasma cells. Abundant parietal cells were present in the fundic glands and lymphoid follicles were present in the gastric lamina propria, particularly in the pyloric region. Small intestinal villi were very long but this could have resulted from underlying chronic inflammation. Lymphoid follicles were prominent in the colon. The kidney reniculi each had a complete cortex, medulla and calyx, but a sportaperi medullaris musculosa was not identified.

Transient blindness associated with reversible occipital white matter abnormalities: two patients studied by MR, CT, and 18F-FDG PET imaging

Reversible, multifocal hyperintense T2 signal abnormalities were noted within the occipital and posterior parietal subcortical white matter in a previously healthy 59-year-old right-handed woman with acute onset of cortical blindness and seizures. Repeat brain magnetic resonance imaging and a positron emission tomographic scan of 18F-fluorodeoxyglucose brain uptake performed 2 months after the ictal event failed to reveal any abnormality. This patient is similar to a 57-year-old female who developed severe headache and magnetic resonance signal abnormalities in the subcortical white matter of both occipital lobes, which later normalized, as judged by correlative, sequential computed tomographic examinations. This study emphasizes that an increasingly more frequent phenomenon of reversible MRI signal abnormalities can occur within the occipital subcortical white matter in acutely ill individuals, and not be associated with any lasting abnormalities on clinical examination or on radiological imaging studies such as computed tomography, magnetic resonance imaging, or positron emission tomography.

Positron emission tomography in diagnosis of occult adenocarcinoma of the breast

Occult adenocarcinoma with clinically apparent axillary lymphadenopathy represents a challenging surgical problem. Mammography is frequently unable to identify a primary breast carcinoma, and extramammary sources are common and equally difficult to identify. This may leave the clinician and patient with a conundrum of whether to proceed with "blind" mastectomy. A 35-year-old white female presented with axillary adenopathy and a normal breast physical exam. Mammography was unable to demonstrate a specific tumor. Excisional biopsy of the axillary lymph node demonstrated metastatic adenocarcinoma. Positron emission tomography showed increased uptake in the breast and the axilla, consistent with breast carcinoma and axillary metastases. The patient underwent modified radical mastectomy and pathologic review of the specimen proved infiltrating ductal carcinoma in the breast with metastatic nodes. Positron emission tomography may be helpful in localizing occult carcinoma of the breast that presents with metastatic lymph nodes and in excluding other potential primaries.

Delayed-onset expulsive choroidal hemorrhage following traumatic globe rupture

The authors describe a 59-year-old woman who had a traumatic wound rupture 6 months following penetrating keratoplasty. While she was in the pre-operative holding area awaiting surgical repair, hemorrhagic choroidal detachments developed. Digital pressure was initiated on diagnosis of imminent expulsion of intraocular contents and maintained until repair of the wound rupture could be performed. Four months postoperatively, the patient's vision was 20/80 and her central pachymetry was 585 microns. This case demonstrates that a delayed-onset expulsive choroidal hemorrhage may be successfully managed with simple and rapid intervention based on knowledge of the disease process.

The effect of phacoemulsification on aqueous outflow facility

OBJECTIVE

Although control of intraocular pressure (IOP) after cataract extraction may be of critical importance, little is known regarding changes in facility of outflow in the early postoperative period. The effect of phacoemulsification and conjunctival peritomy size on the coefficient of aqueous outflow facility (C) and IOP was studied.

DESIGN

Participants were assigned randomly to one of two treatment groups.

PARTICIPANTS

Seventy-four patients with cataract and without evidence of glaucoma were studied.

INTERVENTION

Patients were randomized to receive either single- or two-quadrant conjunctival peritomy and phacoemulsification.

MAIN OUTCOME MEASURES

Tonometry and tonography were assessed before surgery and at 1 day, 1 week, 6 weeks, and 1 year after surgery by a masked observer.

RESULTS

Fifty patients with a mean of 11.4 months' (range, 10-13 months) follow-up were analyzed. Patients with reduced preoperative facility of outflow (as defined by C < or = 0.28 microliter/min/mmHg) showed a significant improvement from a mean preoperative value of 0.24 +/- 0.04 microliter/min/mmHg to 0.41 +/- 0.22 microliter/min/mmHg at 1 year (P = 0.002, N = 19). Among all patients, there was no significant change between mean preoperative C and last follow-up (0.39 +/- 0.23 vs. 0.46 +/- 0.38 microliter/min/mmHg, not significant [ns], N = 50). Furthermore, there was no significant change between mean preoperative and final IOP (23.7 +/- 4.1 vs. 23.3 +/- 3.9 mmHg, ns, N = 50). There was a significant elevation of mean IOP on postoperative day 1 to 27 +/- 6.2 mmHg (P = 0.001, N = 50). Patients with IOP elevations greater than 8 mmHg on postoperative day 1 had significantly elevated IOP at 1 year compared to preoperative values (P = 0.02, N = 12). There were no significant differences detected regarding C or IOP between single- or two-quadrant peritomy groups.

CONCLUSIONS

Outflow facility improves after phacoemulsification in patients with a reduced preoperative coefficient of aqueous outflow. Postoperative day 1 IOP is significantly elevated after phacoemulsification. Conjunctival peritomy size does not appear to play a role in aqueous outflow facility or IOP after surgery.

Bilateral peripheral ulcerative keratitis associated with pyoderma gangrenosum

PURPOSE

A 37-year-old Hispanic man with a history of chronic myelogenous leukemia was first seen with fever and preseptal cellulitis of this right orbit after a tooth extraction.

METHODS

The patient subsequently developed bilateral, severe peripheral ulcerative keratitis. He was treated with systemic antibiotics for a presumed underlying infectious cause. Several painful, necrotizing skin lesions developed over his face, trunk, and extremities.

RESULTS

Repeated skin biopsies of the necrotizing lesions were consistent with pyoderma gangrenosum. Both the skin lesions and peripheral ulcerative keratitis responded dramatically to systemic prednisone.

CONCLUSIONS

Pyoderma gangrenosum should be included in the differential diagnosis of peripheral ulcerative keratitis.

Decreased multi-band posterior interhemispheric coherence with a lipoma on the corpus callosum: a case report of a possible association

The corpus callosum plays a role in mediating interhemisphere communication. Coherence may be a quantitative EEG-based measure of this communication. The present report is of a female schizophrenic patient with a marked coherence deficit in the temporal-parietal-occipital region involving multiple frequency bands. An MRI scan of her brain revealed a lipoma involving the splenium of the corpus callosum. It is speculated that this lipoma may have caused a physical impingment on or developmental aberration of adjacent callosal fibers, resulting in the observed coherence deficit. Further studies of coherence measures in patients with collosal lipomas are proposed.

Streptococcal toxic shock syndrome complicating preseptal cellulitis

PURPOSE

Although substantial morbidity is uncommon in preseptal cellulitis, the incidence of severe infection resulting from group A streptococcal infection is increasing.

METHODS

A 62-year-old man was initially examined for preseptal cellulitis sustained after minor trauma to his brow. The patient rapidly experienced shock and multisystem organ failure. Intensive medical therapy prevented circulatory collapse and death.

RESULTS

A diagnosis of streptococcal toxic shock syndrome secondary to group A beta hemolytic streptococcal infection was made based on culture results and clinical course.

CONCLUSIONS

The ophthalmologist plays an essential role in diagnosing this condition. Aggressive and timely treatment are essential to preventing death.

Combined phacoemulsification and trabeculectomy with mitomycin-C

PURPOSE

To examine the safety and efficacy of primary combined phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy with mitomycin-C (0.4 mg/ml) in patients with open-angle glaucoma and visually significant cataract.

SETTING

University-hospital-based glaucoma referral practice.

METHODS

In this study, data of 43 patients of a single surgeon were retrospectively analyzed. These consecutive patients had combined phacoemulsification, posterior chamber IOL implantation, and trabeculectomy with mitomycin-C.

RESULTS

Thirty-eight patients (88%) had open-angle glaucoma and 5 (12%) pseudoexfoliative glaucoma. Thirty-eight patients (88%) had 12 months of follow-up; all had at least 6 months follow-up. Mean preoperative intraocular pressure (IOP) was 21.6 mm Hg +/- 6.8 (SD) (range 12.0 to 41.0 mm Hg) with 2.5 +/- 1.0 glaucoma medications. At last follow-up, mean IOP had decreased to 14.2 +/- 6.2 mm Hg (range 3.0 to 40.0 mm Hg) with 0.5 +/- 0.5 glaucoma medications. Twenty-one patients (55%) had an IOP of 15 mm Hg or less at 12 months. Best corrected visual acuity was 20/40 or better in 31 of 43 patients (72%) at last follow-up. A filtration bleb was noted in 33 of 40 patients (83%) at their last visit. Postoperative IOP spikes occurred in 17 patients (40%), transient hyphema in 12 (28%), transient wound leaks in 11 (26%), and superficial punctate keratopathy in 11 (26%). Three cases of persistent hypotony (IOP less than 5 mm Hg) and 1 case of epithelial downgrowth were also noted.

CONCLUSION

Phacoemulsification with IOL implantation and combined trabeculectomy with mitomycin-C produced good visual acuity and excellent IOP control but resulted in some complications. The use of mitomycin-C in combined procedures does not appear to confer a significant benefit.

Evaluating brain death with positron emission tomography: case report on dynamic imaging of 18F-fluorodeoxyglucose activity after intravenous bolus injection

A dynamic positron emission tomography (PET) study of the head was performed over 1 hour after the intravenous bolus administration of 18F-fluorodeoxyglucose (18F-FDG) to a 18-year-old patient with the clinical diagnosis of brain death. This dynamic PET study was performed on the seventh day after a severe posttraumatic closed-head injury. No intracerebral uptake or retention of tracer was noted, consistent with a diffuse absence of brain metabolism. A small amount of tracer was noted to slowly rise over time within the sagittal sinus, indicating that visualization of sagittal sinuses on technetium 99m-diethylene-triaminepentaacetic acid planar images could provide a falsely negative scintigraphic evaluation for the presence of brain death. It is concluded that PET FDG imaging may be a useful technique in evaluating patients for brain death.

A consensus approach to planetary protection requirements: recommendations for Mars lander missions

Over the last several years, the nature of the surface conditions on the planet Mars, our knowledge of the growth capabilities of Earth organisms under extreme conditions, and future opportunities for Mars exploration have been under extensive review in the United States and elsewhere. As part of these examinations, in 1992 the US Space Studies Board made a series of recommendations to NASA on the requirements that should be implemented on future missions that will explore Mars. In particular, significant changes were recommended in the requirements for Mars landers, changes that significantly alleviated the burden of planetary protection implementation for these missions. In this paper we propose a resolution implementing this new set of recommendations, for adoption by COSPAR at its 30th meeting in Hamburg. We also discuss future directions and study areas for planetary protection, in light of changing plans for Mars exploration.

Reversible Tc-99m diphosphonate uptake in gastric tissue associated with malignancy related hypercalcemia. A comparative study using PET FDG whole body imaging

A 52-year-old man with metastatic poorly differentiated bronchogenic carcinoma and serum calcium levels as high as 14.6 had intense Tc-99m MDP uptake found throughout the stomach wall on SPECT imaging. FDG uptake assessed by PET imaging was not elevated in the stomach, whereas multiple hyper-metabolic tumor foci could be found throughout the body. Three months later, when calcium levels normalized, no Tc-99m MDP uptake was found in the stomach despite persistence of neoplastic lesions elsewhere. This case study indicates that gastric MDP uptake in patients with malignancy related hypercalcemia can be reversible and not necessarily indicative of neoplastic infiltration.