Assessment of hypothermia with a new “tympanic” thermometer

Objective. Rapid and accurate core temperature measurement is vitally important in trauma patients, especially in those with accidental hypothermia. We tested a new aural thermometer to measure “tympanic” temperatures and assessed its accuracy during normothermic and hypothermic cardiopulmonary bypass.Methods. Tympanic, esophageal, and blood temperatures were compared in 10 patients undergoing open-heart surgery. In addition, the stability and reaction time of the tympanic thermometer was evaluated in 5 volunteers in a cold room, with and without facial fanning.Results. We observed a good linear correlation between tympanic and esophageal (r = 0.96) and blood (r = 0.81) temperature measurements during normothermia and hypothermia. There was no evidence of iatrogenic ear lesions in any of the patients. In the cold-room tests, stability was excellent and the time for adjustment of tympanic temperature measurement was about 2 min (with and without facial fanning).Conclusion. The new tympanic thermoprobe is a simple, fast, and reliable device for measuring core temperature. The device was designed particularly for, and may be useful for, patients suffering from accidental hypothermia.     

An analysis of the effect of venous resistance on the performance of gravity-fed intravenous infusion systems

Objective. Our objective was to assess the effect of venous resistance in a clinically relevant range on flow rates through intravenous (IV) cannulae.Methods. Since resistances in series are additive, the sum of the resistance of the IV cannula and the vein equates to the total resistance to flow. Using resistance data from earlier work, the total resistance for various combinations of cannula and vein size was calculated, allowing a prediction to be made of the comparative flow rates between these combinations for a given driving pressure. Next, the clinical situation was simulated by measuring flow rates through IV cannulae connected in series to a variety of infusion devices with resistances known to be within the range of clinically relevant venous resistance.Results. The effect of venous resistance was greatest on largebore cannulae, with significant reductions in flow occurring when even low levels of venous resistance were added. Throughout much of the range of venous resistances encountered clinically, total flows through two small-gauge cannulae exceeded that through a single large-gauge cannula.Conclusion. To achieve maximum benefit from a large-bore cannula, a suitably large vein must be chosen. Further, where venous access is difficult and high flow potential from an infusion system is required, two separate infusions through small cannulae may be a preferable option to a single large bore.     

Prevention and Surgical Management of Postburn Contractures of the Hand

In addition to burn surgeons, skilled nurses, and therapists, hand surgeons are a key part of the multidisciplinary team caring for patients following thermal injury to the hand. Despite appropriate initial treatment and compressive therapy, contractures are common after deep burn. The most common and functionally limiting are web space and hand contractures. Web space contractures can be managed with excision followed by local soft tissue rearrangement or skin grafting. The classic burn claw hand deformity includes extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstay of management of these postburn contractures includes complete surgical release of scar tissue and replacement by full-thickness skin graft. In cases in which scar contracture release results in major exposure of the tendons or joints, distant tissue transfer is required. This review focuses on prevention and management of late sequelae of thermal injury to the hand focusing on contractures of the webspaces and hand.     

The effect of midazolam on median nerve somatosensory evoked potentials

Objective. To quantify the effect of an induction dose of midazolam on median nerve somatosensory evoked potentials.Methods. We studied 10 patients undergoing lumbar spine surgery. After an induction dose of intravenous midazolam was given, MNEPs were collected for ten minutes. After ten minutes the patients were intubated and their anesthetic was supplemented with 0.5% isoflurane, narcotic, and N₂O.Results. We found a clinically significant decrease in amplitude and an insignificant delay in latency.Conclusion. When midazolam is used as an anesthetic induction agent, a decrease in amplitude can be expected.     

Training der Tiefenmuskulatur im Rahmen der multimodalen Schmerztherapie

Background

Low back pain has a point prevalence of 30-40 % in the German population and is mostly accompanied by substantial costs for the economy. Chronification is not uncommon. Patients with chronic low back pain have proven functional and structural deficits. In magnetic resonance imaging (MRI) it could be shown that contractile elements are replaced by fat.

Methods

After prior assessment interdisciplinary multimodal pain therapy (IMS) belongs to the appropriate treatment of patients with chronic low back pain and positive yellow flags. In IMS patients learn in educative and activating units how the deep lying musculature can be selectively targeted.

Result

The concept of deep stabilization can be successfully employed in the treatment of patients with chronic low back pain in IMS.     

Embryology,diagnosis, and evaluation of congenital hand anomalies

Although congenital hand anomalies are rare, musculoskeletal clinicians should have a basic understanding of their clinical manifestations and the possibility of concurrent anomalies and syndromes. In this review, we provide a brief overview of the embryology of limb development and the molecular pathways involved. We also summarize the clinical manifestations, diagnostic evaluation, and principles of surgical treatment for radial longitudinal deficiency, thumb hypoplasia, ulnar longitudinal deficiency, central deficiency, syndactyly, polydactyly, and amniotic constriction band. Although one of the main goals of treatment is to provide a functional upper extremity, musculoskeletal clinicians should be aware of the clinical findings that should trigger referral to evaluate for life-threatening syndromes.     

Venous Thromboembolism (VTE) Prophylaxis for Hip and Knee Arthroplasty: Changing Trends

Venous thromboembolism (VTE) has been identified as an immediate threat to patients undergoing major orthopedic procedures such as total hip arthroplasty (THA) and total knee arthroplasty (TKA). Given the known dangers of VTE, arthroplasty surgeons are sensitive to the need for VTE thromboprophylaxis. However, the modalities of thromboprophylaxis used to minimize the risks to patients have been variable. Clinical practice guidelines have been published by several professional organizations, while some hospitals have established their own protocols. The 2 most popular guidelines are those published by the Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP), both from North America. Prior to 2012, these recommendations varied depending on underlying definitions, methodology, and goals of the 2 groups. For the first time, both groups have similar recommendations that focus on minimizing symptomatic VTE and bleeding complications. The key to determining the appropriate chemoprophylaxis for patients is to balance efficacy of a prophylactic agent, while being safe in regards to bleeding complications. However, a multimodal approach that focuses on early postoperative mobilization and the use of mechanical prophylaxis, in addition to chemoprophylaxis, is essential.     

Mechanical,Anatomical, and Kinematic Axis in TKA: Concepts and Practical Applications

Successful total knee arthroplasty (TKA) has often been based on the restoration of the knee to neutral alignment postoperatively. Numerous reports have linked malaligned TKA components to increased wear, poor functional outcomes, and failure. There have been many different alignment philosophies and surgical techniques that have been established to attain the goal of proper alignment, which includes such techniques as computerized navigation, and custom cutting guides. In addition, these methods could potentially have the added benefit of leading to improved functional outcomes following total knee arthroplasty. In this report, we have reviewed and analyzed recent reports concerning mechanical, anatomic, and kinematic axis/alignment schemes used in total knee arthroplasty.     

Early response to pulse oximetry alarms with telemetry

Twenty ICU patients were monitored for an average of 45 hr each, with both bedside and nursing station monitors, which were set to alarm audibly if the patient’s oxygen saturation dropped below 90%. Bedside alarms alerted caregivers to 51 of the 74 hypoxemic events; central alarms alerted personnel to the other 23 events. The alarms led to a change in treatment in 35 of the 48 (73%) true desaturation episodes. We conclude that central oximetric monitoring may help with detection of arterial desaturation events even in a well-staffed ICU.     

The patella in total knee arthroplasty: to resurface or not is the question

The decision to resurface the patella during total knee arthroplasty remains controversial. Even though some surgeons routinely resurface the patella to avoid the increased rates of postoperative anterior knee pain and reoperation for secondary resurfacing, others selectively resurface based on the presence of anterior knee pain, notably damaged articular cartilage, inflammatory arthritis, isolated patellofemoral arthritis, and patellar subluxation and maltracking. The anatomy and biomechanics of the patellofemoral joint, combined with advances in surgical technique and prostheses must be taken into account when making a decision to resurface the patella. Accurate component implantation is imperative for a successful outcome if the patella is resurfaced.     

Prognostic Value of Stress Myocardial Perfusion Imaging in Asymptomatic Diabetic Patients

Although there has been a marked decline in mortality due to coronary artery disease (CAD) in the overall population in the past three decades, reducing CAD mortality in patients with diabetes has proven exceptionally difficult. Several epidemiological studies have shown that diabetes is associated with a marked increase in the risk of CAD. The symptoms are not a reliable means of identifying patients at higher risk considering that angina is threefold less common in diabetics than in nondiabetics. The increasing prevalence of diabetes and the associated high cardiac risk raised the question as to the need to develop approaches to identify the diabetic patients at the highest risk of CAD. Stress myocardial perfusion single-photon emission computed tomography has taken a central role in the diagnosis, evaluation, and management of CAD in diabetic patients. This review focuses on the prognostic value of cardiac radionuclide imaging in asymptomatic diabetic patients.     

Hand reanimation

Brachial plexus disruption, major traumatic amputations, and Volkmann’s contracture are all devastating injuries that present difficult reconstructive challenges. Advances in our understanding of nerve injury, regeneration, and refinement of microsurgical techniques have given rise to a number of therapeutic avenues over the last 4 decades. Hand reanimation aims to provide strength, stability, and mobility to a sensate hand. How this is achieved depends on a thorough understanding of the underlying pathophysiology, which in turn dictates what surgical modalities are suitable. Common to all reanimation procedures is the need to ensure full passive range of motion of the target joints prior to definitive surgery. Hand therapy is essential to prevent deleterious sequelae of injury, and to maximize rehabilitation following surgical reconstruction. Options for reanimation include nerve repair, nerve grafting, nerve transfer, tendon transfer, and free functioning muscle transfer.     

Agreement Between Large And Small Cuffs In Sphygmomanometry: A Quantitative Assessment

Objective. The objective of this study is to quantify agreement and differences between blood pressure (BP) measurements by large cuffs (15 X 33 cm) and small cuffs (12 X 23 cm) in a representative sample of the U.S. population with varying arm circumferences. Methods. The arm circumference and blood pressure (12 readings of each) of 85 subjects were measured, the latter with a mercury column sphygmo-manometer. Data were classified according to arm circumference (small arm circumference, ≤ 29 cm; large arm circumference, > 29 cm). Results were submitted to ANOVA, linear regression, difference between means (aggregate agreement), upper and lower limits of agreement at 95% confidence intervals, and intraclass correlation (individual-subject agreement/ quantification of agreement). Results. Small cuffs overestimated BP obtained from the large cuffs for the sample population as a whole, regardless of arm circumference. Limits of agreement at the lower end of 95% confidence interval were not clinically acceptable (SBP -1.56 to 11.05 mm Hg; DBP-2.06 to 8.63 mm Hg). However, measurements by both cuffs agreed among subjects with small arm circumferences (≤ 29 cm). Conclusion. Arm circumference plays an important role in determining proper cuff size for BP measurement. The small cuff overestimates BP in patients with large arm circumferences (> 29 cm), which represents more than 75% of the U.S. adult population. However, measurements of BP with the large cuff are not significantly different from those of small cuff measurements in subjects with small arm circumferences (≤ 29 cm). Therefore, we propose that the large cuff be used for routine BP measurement of the adults in the United States.     

Arthroplasty in young adults: options,techniques, trends,and results

Total knee arthroplasty (TKA) has been established as a very successful and commonly performed procedure for primary and secondary osteoarthritis, and also for inflammatory arthropathies of the knee in all age groups and both genders. It has predominantly been used as a procedure in the age group of patients 65 years and above. Consequently, the literature is replete with data relevant to various issues associated with TKA in the above 65 years age group population. Although there is reasonable clarity and consensus on the broad parameters of the use of TKA in the above 65 years age group (older), this cannot be said for the same issue as relevant to the below 65 years age group (young adults). Over the last 2 decades there has been an increasing tendency toward the use of TKA in young adults, with some countries reporting a 5-fold increase in the last 10 years [1]. The present article is designed to review the most recent literature specific to this subject and assess it vis-à-vis various issues as listed in the subsequent text, with the aim of highlighting evolving thoughts and trends, which could be useful for decision making by clinicians practicing in the community.     

Microsurgery in the urgent and emergent management of the hand

Appropriate use of microsurgical techniques in the emergency management of injured hands increases the salvage rate of complex upper limb injuries. Over time, the indications for replantation, both major and minor, have expanded and techniques refined to get better functional outcomes. The wide choice of free flaps available has made primary reconstruction possible to obtain a good functional and aesthetic outcome. The benefits microsurgery offers in the emergent management of the injured hand are now firmly established. The challenge is to create and maintain centers which can provide around-the-clock, high quality microsurgery services. The issues of adequate training opportunities, obtaining adequate work load to maintain high skill levels, attracting talent into the field are the challenges faced in maintaining high levels of service. In the developing countries, in addition to these issues, increasing the awareness of the potential of microsurgical services among the medical personal and the public has to be addressed.     

Techniques to evaluate glenoid bone loss

Assessing glenoid morphology as well as quantifying bone loss is critical when treating patients with recurrent anterior glenohumeral instability because this greatly affects surgeons surgical planning. Although many surgeons agree that 3-dimensionally reconstructed computed tomography (3DCT) images with humeral head digitally subtracted has been considered to be a gold standard when assessing glenoid morphology, there are some surgeons who are making an attempt to replace computed tomography with magnetic resonance imaging to reduce cost for imaging studies and avoid possible radiation exposure, and demonstrated that MRI was equally valuable as 3DCT to quantify glenoid bone loss. However, the role of preoperative imaging study is not only quantifying glenoid bone loss but to assess the glenoid shape and morphology to facilitate surgeons stabilizing the shoulder. In this view, 3DCT is the most recommended preoperative imaging study for bony tissue which provides critical and substantial information of the glenoid.     

Langwierige Sprunggelenksverletzungen und Beckendysfunktionen

Background and aim

Ankle injuries are the most commonly occurring injuries of the musculoskeletal system. Apart from causing pain, swelling and functional limitations, an association between ankle injuries and alterations in the pelvic region and especially the sacroiliac joint (SIJ) are suspected. This study was designed to test whether there is any correlation between ankle injuries and alterations to the pelvis and SIJ.

Material and methods

In this non-blinded cross-sectional study the pelvis and SIJ were examined in a test group of 18 patients with acute ankle injuries and a control group of 22 persons without ankle injuries. The functional state of the ankle was measured using the German version of the foot and ankle ability measure (FAAM). The evaluation of the pelvic posture was carried out by photometry so that the anterior superior iliac spine (ASIS) and posterior superior iliac spine PSIS) were directly compared. To evaluate alterations of the SIJ predefined pain provocation tests were conducted. The collected data of both groups were compared statistically.

Results

The functional situation of the ankle was significantly different between the control group and the test group. The differences in photometry according to pelvic symmetry were not statistically significant (ASIS p?=?0.426 and PSIS p?=?0.779). No significant differences were found with respect to the painfulness of the SIJ (p?=?0.477).

Conclusion

No positional alterations to the pelvis due to ankle trauma were observed and also no association between ankle injuries and the position of the pelvis or SIJ could be found.     

Upper extremity transplantation: current concepts and challenges in an emerging field

Loss of an isolated upper limb is an emotionally and physically devastating event that results in significant impairment. Patients who lose both upper extremities experience profound disability that affects nearly every aspect of their lives. While prosthetics and surgery can eventually provide the single limb amputee with a suitable assisting hand, limited utility, minimal haptic feedback, weight, and discomfort are persistent problems with these techniques that contribute to high rates of prosthetic rejection. Moreover, despite ongoing advances in prosthetic technology, bilateral amputees continue to experience high levels of dependency, disability, and distress. Hand and upper extremity transplantation holds several advantages over prosthetic rehabilitation. The missing limb is replaced with one of similar skin color and size. Sensibility, voluntary motor control, and proprioception are restored to a greater degree, and afford better dexterity and function than prosthetics. The main shortcomings of transplantation include the hazards of immunosuppression, the complications of rejection and its treatment, and high cost. Hand and upper limb transplantation represents the most commonly performed surgery in the growing field of Vascularized Composite Allotransplantation (VCA). As upper limb transplantation and VCA have become more widespread, several important challenges and controversies have emerged. These include: refining indications for transplantation, optimizing immunosuppression, establishing reliable criteria for monitoring, diagnosing, and treating rejection, and standardizing outcome measures. This article will summarize the historical background of hand transplantation and review the current literature and concepts surrounding it.     

Reconstruction of glenoid bone defects in shoulder instability with autologous bone

Bone defects, both at glenoid and at the humeral side are a frequent sequel of anterior shoulder instability. Although the transfer of the coracoid process (Latarjet, Bristow procedures) has gained popularity in treating the glenoid defect, equal results can be achieved with the use of a bone graft, for which mainly a graft of the iliac crest is used. Recently, arthroscopic procedures have been developed, leaving the subscapularis muscle largely intact.     

What makes a great resident? The programme director perspective

A career in orthopedic surgery in the United Kingdom is highly competitive. Great residents are trainees who understand that ultimately, they are responsible for their own training. They need to work with their Training Program Director to plan their career, to develop as surgeons, to reflect on their performance and any feedback they receive, be flexible, and plan ahead. There is competition but it is fair for everyone and the great resident will excel within this environment and will be successful in the long term.