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Previous studies have demonstrated that sterile equipment is frequently contaminated intraoperatively, yet the incidence of miniature c-arm (MCA) contamination in hand and upper extremity surgery is unclear. To examine this incidence, a prospective study of MCA sterility in hand and upper extremity cases was performed in a hospital main operating room (MOR) (n = 13) or an ambulatory surgery center operating room (AOR) (n = 16) at a single tertiary care center. Case length, MCA usage parameters, and sterility of the MCA through the case were examined. We found that MOR surgical times trended toward significance (p = 0.055) and that MOR MCAs had significantly more contamination prior to draping than AOR MCAs (p < 0.001). In MORs and AORs, 46.2 and 37.5% of MCAs respectively were contaminated intraoperatively. In MORs and AORs, 85.7 and 80% of noncontaminated cases, respectively, used the above hand- table technique, while 50 and 83.3% of contaminated MOR and AOR cases, respectively, used a below hand-table technique. Similar CPT codes were noted in both settings. Thus, a high-rate of MCA intraoperative contamination occurs in both settings. MCA placement below the hand-table may impact intraoperative contamination, even to distant MCA areas. Regular sterilization of equipment and awareness of these possible risk factors could lower bacterial burden.

Indications for radial head arthroplasty include significantly comminuted radial head fractures, radial head fractures with concomitant ligamentous injury, and radial head or neck malunions and nonunions. Contemporary prostheses allow for the restoration of elbow motion while preserving joint stability. Studies have demonstrated favorable clinical outcomes and decreased costs of care following radial head arthroplasty when compared to ORIF. However, complications such as aseptic loosening, stiffness, implant failure, arthritis, and infection have all been reported. This chapter will explore the indications, outcomes, complications of radial head arthroplasty, as well as the techniques and indications for revision radial head arthroplasty.

Objective: The impact of rotator cuff (RC) tear pattern on intramuscular fatty infiltration (FI) is not well understood. The purpose of our study is to determine if differing RC tear patterns are associated with discordant presentations of intramuscular FI. Methods: Fifty-one adults with full-thickness tear of the posterosuperior RC on shoulder magnetic resonance imaging (MRI) were identified retrospectively. The study subjects were stratified by RC tear pattern: (1) L-shaped tear cohort, (2) crescent-/U-shaped tear cohort, and (3) complete tear cohort. Clinical information pertaining to age, sex, tear size, trauma history, and length of clinical symptoms was recorded from the institution’s picture archiving and communication system. Goutallier grade was assessed on oblique sagittal T1-weighted MRI by two orthopedic surgeons and one orthopedic resident. A musculoskeletal radiologist recorded the shape and size of full-thickness RC tears. Descriptive, correlation, and reliability analyses were performed. Results: The L-shaped, crescent-/U-shaped, and compete tear cohorts demonstrated significant differences pertaining to tear size (P < 0.001) and infraspinatus Goutallier grade (P = 0.024), but not supraspinatus Goutallier grade (P = 0.370). Age had strong correlation to supraspinatus Goutallier grade (rs = 0.712, P = 0.031) and infraspinatus Goutallier grade (rs = 0.712, P = 0.029) in the crescent-/U-shaped tear cohort. Tear size had strong correlation to supraspinatus Goutallier grade (rs = 0.796, P = 0.001) and infraspinatus Goutallier grade (rs = 0.793, P = 0.001) in the complete tear cohort. Moderate interobserver agreement was present for supraspinatus (kappa, 0.484) and infraspinatus (kappa, 0.427) Goutallier grade. Conclusion: RC tear pattern is associated with different presentations of intramuscular FI at the posterosuperior RC. Full-thickness tears involving the crescent region of the RC cuff are associated with age. Intramuscular FI is associated with RC tear size.

Fingertip injuries are common and can be difficult to manage because of unique anatomical considerations. Optimal treatment minimizes residual pain while preserving the function, length, and sensation of the affected digit. Several types of fingertip injury, including sharp or crush injuries, partial or complete amputations, and those involving the nail plate or nail bed, can occur. Depending on the type of injury, location within the fingertip, degree of soft-tissue loss, and involvement of perionychium, the most effective management may be one of several options. Knowledge of local and regional anatomy is paramount in selecting and performing the procedure that provides the best outcome. To address the array of possible fingertip injuries, we demonstrate several treatment options including (1) local flap reconstruction, (2) regional flap reconstruction, (3) revision or completion amputation, (4) nail bed repair, (5) acellular dermal regeneration templating, and (6) replantation. Outcomes are generally favorable but can be affected by injury and patient characteristics. The most common complications include nail deformity, cold intolerance, and painful neuroma formation.

Objective: Stringent selection criteria pose challenges to recruiting patients into clinical trials testing potential novel therapies for stroke. We conducted a pilot study, Safety of Intravenous Mononuclear Cells for Acute Stroke (SIMVAS) trial involving autologous bone marrow cell administration in patients with middle cerebral artery (MCA) territory stroke within 72 hours of symptom onset. Given the stringent selection criteria for initial cell therapy clinical trials in stroke, we analyzed reasons for patient ineligibility into the SIVMAS trial to assess feasibility of recruitment. Methods: We retrospectively collected ischemic stroke patients from our stroke registry admitted from March 2009 to June 2010, the recruitment period of SIVMAS, and identified which of the selection criteria the patients did not meet. Results: Of a total of 534 MCA territory stroke patients, 25 met all the selection criteria. Ten patients were enrolled as planned over the 15 month period, 3 declined enrollment, 2 were excluded due to pending DSMB review on previously enrolled patients, and the rest did not have an adequate time window between bone marrow aspiration and dosing. A total of 1,943 exclusions were recorded; major reasons were NIHSS (15.3%) and infarct sizes above or below the selection criteria (12.4%). The table summarizes the patient exclusion frequency based on selection criteria. Among ineligible patients (n=509), 47 (9.2%) had a single exclusion, 81 (15.9%) had two exclusions and 108 (21.2%) had three exclusions. The figure presents a CONSORT flow diagram of the entire recruitment. Conclusion: This is the first study to assess recruitment of patients with acute ischemic stroke into a pilot cell therapy clinical trial. Among eligible patients, there was a low refusal rate. Among excluded patients, stroke severity and infarct size were major reasons for exclusion from SIVMAS. It is hoped that the data from this study may help facilitate the design of future clinical trials testing new cell-based therapies for ischemic stroke. We encourage investigators to choose selection criteria that will provide scientifically meaningful data but are not overly rigid in selecting potential research candidates.