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Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Surgical site infections are one of the more common major complications of elbow fracture surgery and can contribute to other adverse outcomes, prolonged hospital stays, and increased healthcare costs. We asked: (1) What are the factors associated with a surgical site infection after elbow fracture surgery? (2) When taking the subset of closed elbow fractures only, what are the factors associated with a surgical site infection? (3) What are the common organisms isolated from an elbow infection after open treatment? One thousand three hundred twenty adult patients underwent surgery for an elbow fracture between January 2002 and July 2014 and were included in our study. Forty-eight of 1320 patients (4%) had a surgical site infection develop. Thirty-four of 1113 patients with a closed fracture (3%) had a surgical site infection develop. For all elbow fractures, use of plate and screw fixation (adjusted odds ratio [OR]= 2.2; 95% CI, 1.0–4.5; p = 0.041) and use of external fixation before surgery (adjusted OR = 4.7; 95% CI, 1.1–21; p = 0.035) were associated with higher infection rates. When subset analysis was performed for closed fractures, only smoking (adjusted OR = 2.2; 95% CI, 1.1–4.5; p = 0.023) was associated with higher infection rates. Staphylococcus aureus was the most common bacteria cultured (59%). The only modifiable risk factor for a surgical site infection after open reduction and internal fixation was cigarette smoking. Plate fixation and temporary external fixation are likely surrogates for more complex injuries, therefore no recommendations should be inferred from this association. Surgeons should counsel patients who smoke. Level IV, prognostic study.

Allogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after administration of allogeneic blood transfusions.Our primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused.This is a retrospective cohort study from a tertiary care spine referral center.A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine.Postoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included.Multivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery.The adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval [CI]: 1.7-3.9, p.001); 2.2 for urinary tract infections (95% CI: 1.3-3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96-5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3-5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis.Conscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures.

Background Orthopaedic surgical site infections (SSIs) can delay recovery, add impairments, and decrease quality of life, particularly in patients undergoing spine surgery, in whom SSIs may also be more common. Efforts to prevent and treat SSIs of the spine rely on the identification and registration of these adverse events in large databases. The effective use of these databases to answer clinical questions depends on how the conditions in question, such as infection, are defined in the databases queried, but the degree to which different definitions of infection might cause different risk factors to be identified by those databases has not been evaluated.

Radiographs and medical record of all adult patients with a mallet fracture in three hospitals between 2004 and 2014 were reviewed. International Classification of Diseases, Ninth Revision (ICD-9) codes and text search in radiographic reports were used to identify all acute patients with potential mallet fractures in our institutional database. Manually checking, 392 true mallet fractures were identified among them, 78 had subluxation at the time of diagnosis and 19 had subluxation at a later time point during treatment. Fragment size, fragment displacement, and interval between injury and treatment were associated with initial and late subluxation. Subluxation was not observed when the fracture size was less than 39% of the total articular surface. For each 1% increase in total articular surface involvement in fractures with more than 39% involvement, the risk of subluxation increased by 4% and for each 1% of displacement, the risk of subluxation increased by 4%.Level of Evidence: IV

Background: Variation in pain intensity and magnitude of disability among patients with musculoskeletal illness is largely accounted for by variations in symptoms of depression, catastrophic thinking, and heightened illness concern. It is possible that patients with greater stress, distress, and less effective coping strategies might be more likely to seek the use of Complementary Health Approaches (CHA). This study addressed the primary null hypothesis that there are no demographic, illness-related, or psychological factors associated with CHA use among patients with upper extremity illness. Methods: A cohort of 170 patients completed a web-based Complementary and Alternative Medicine (CAM) questionnaire the Patient Reported Outcomes Measurement Information System (PROMIS) Depression and Pain Interference questionnaires. We evaluated differences between patients who sought CAM treatment regarding the PROMIS Pain Interference and PROMIS Depression scores. Ninety-four patients (56%) use or plan to use CAM treatment. A CAM provider was consulted by 61 patients (37%): most commonly a massage therapist (30/61), chiropractor (26/61), or acupuncturist (14/61). Results: In bivariate analysis patients who sought CAM reported greater average PROMIS Pain Interference than those who did not. In multivariable logistic regression, CAM use was associated with a higher Pain Interference Score and the specific surgeon. Conclusion: In conclusion, CHA use is prevalent amongst orthopaedic patients and associated with less effective coping strategies. Orthopaedic surgeons might consider asking patients about CHA use and determining whether those patients are interested in cognitive behavioral therapy.

Little is known about factors related to patient satisfaction with treatment for trigger digits. This study tested the null hypothesis that there are no factors associated with treatment satisfaction 2 months after completion of treatment (absence of triggering) or 4 months after the last visit for patients with a trigger thumb or finger. Secondary null hypotheses were: 1) There are no factors associated with a change in patients' preferred treatment before and after consultation with a hand surgeon; and 2) Initial treatment provided is not different from final received treatment. In an observational study, 63 English-speaking adult patients were enrolled after being diagnosed with one or more new idiopathic trigger digits by one of two hand surgeons, but before the hand surgeon discussed treatment options. Patients were asked to fill out questionnaires at enrollment. Final evaluation was by phone. Satisfaction with treatment was not related to the initial treatment or other patient or disease factors. Twenty-three patients (37 %) had a different preference for treatment after talking with a hand surgeon. Involvement of the long and ring fingers were the only factors associated with staying with pre-visit treatment preferences. There was a significant difference in proportions of the various treatments provided at enrollment and final treatment recorded at the final phone evaluation, 14 patients (22 %) had a subsequent alternative form of treatment. Patients' preferences for trigger finger treatment often change after consulting with a hand surgeon and during treatment, but these choices do not affect treatment satisfaction.

Prospective cohort study.Some third-party payers require hand therapists to rate patient's functional disability based on patient self-rating using patient-reported outcome measures (PROMs), objective measurements of impairment, and observation of functional tasks-hand therapist-rated function (HTRF).To test the correlation between HTRF and PROMs (upper limb functional index [ULFI] and Patient-Reported Outcomes Measurement Information System upper extremity [PROMIS UE]) and its association with psychological factors.In 2014, 100 new patients with upper extremity illness presenting to hand therapists were asked to participate in an observational cross-sectional study. Demographic-, condition-related, and psychological factors were obtained in addition to PROMs and HTRF.HTRF correlated moderately with PROMIS UE (r = -0.49, P.001) and ULFI (r = -0.56, P.001). Correlation between PROMIS UE and ULFI was strong (r = 0.78, P.001). Psychological factors explained most of the variations in both HTRF and PROMs.Hand therapists' ratings of patient function correlate less strongly with PROMs than PROMs correlate with one other. The discrepancy between HTRF and PROMs may offer an opportunity to address stress, distress, or ineffective coping strategies that can interfere with recovery-an opportunity for therapists and patients to collaborate and develop goals and for future research to develop effective and feasible strategies for hand therapists.Level II, diagnostic study.

Surgical resection is the only curative treatment for pancreatic neuroendocrine tumors (PNETs), but pancreatic operations carry a significant morbidity. We investigated whether the resection of small, asymptomatic nonfunctioning PNETs is beneficial. Clinicopathologic factors were retrospectively reviewed for all PNET cases from 1998 to 2014.Kaplan-Meier survival and multivariable regression analyses were performed. A total of 249 patients had nonfunctioning PNETs with adequate follow-up, of whom 193 were resected and 56 were observed. Median age was 56 years, and 48 % of the patients were female.Overall, the resected patients had a significantly longer survival (OS) (p = 0.001). However, for the patients with PNETs ≤2.5 cm in size and without metastasis at presentation, tumor size significantly modified the effect of resection on overall survival (p 0.05). The protective effect of resection increased as tumor size increased. An operation became a significant predictor of overall survival for tumors1.5 cm (p = 0.050 or less for larger tumors) but was not significant for tumors1.5 cm (p = 0.317 or more for smaller tumors), controlling for age-adjusted Charlson comorbidity index.Resection of nonfunctioning PNETs over 1.5 cm is independently and significantly associated with a longer survival. However, the benefit of resection for tumors under 1.5 cm is unclear.

Surgery for fixation of olecranon fractures is associated with reoperation, mostly for implant removal. A study of a large cohort of patients treated by many different surgeons allows us to determine if specific techniques or implants are associated with a higher rate of reoperation. After open reduction and internal fixation of isolated olecranon fractures, what factors are associated with (1) reoperation and (2) implant removal? Three hundred ninety-two adult patients who had operative treatment of a displaced olecranon fracture not associated with other fractures, dislocation, or subluxation at two area hospitals between January 2002 and May 2014 were analyzed to determine factors associated with reoperation. One hundred thirty-eight (35%) patients had plate and screw fixation and 254 (65%) tension band wiring. Nearly 100% of patients with displaced olecranon fractures are currently treated operatively at our hospitals. All patients were followed for at least four months. Two hundred three of the 392 (52%) patients were followed for one year or more. Ninety-nine patients (25%) had a second operation, 92 (93%) at least in part for implant removal (12 for wire migration [3% of all fractures, 12% of reoperations]). We considered patient-related, fracture-related, and implant-related endpoints as possible factors associated with reoperation. With a total sample size of 99 reoperations, an α of 0.05, and an effect size of 0.3, we had 87% power. Reoperation was less common in men (36 [36%], women: 63 [64%]; adjusted odds ratio, 0.32; 95% confidence interval, 0.18–0.56; p < 0.001) and older patients (adjusted odds ratio, 0.75; 95% confidence interval, 0.65–0.87; p < 0.001). Similarly, request for implant removal was less in men (33 [36%], women: 59 [64%], adjusted odds ratio, 0.31; 95% confidence interval, 0.18–0.56; p < 0.001) and older patients (adjusted odds ratio, 0.75; 95% confidence interval, 0.65–0.87; p < 0.001). Patients who have operative fixation of a fracture of the olecranon can be counseled that most patients keep their implants, that only 3% experience implant migration, and that technical factors such as the type or configuration of an implant seem less important than personal factors in determining who requests a second surgery for implant removal. Level III, prognostic study.

Purpose To identify factors associated with reoperation for early loosening or breakage of implants or nonunion after operative treatment of AO type C distal humerus fractures. Methods We retrospectively analyzed 129 adult patients who had operative treatment of an isolated AO type C distal humerus fracture at 1 of 5 hospitals to determine factors associated with reoperation for early loosening or breakage of implants or nonunion. Results Within 6 months of original fixation, 16 of 129 fractures (12%) required reoperation for loosening or breakage of implants (n = 8) or nonunion (n = 8). In bivariate analyses, the Charlson comorbidity index, smoking, a coded diagnosis of obesity, diabetes mellitus, and radiographic osteoarthritis were significantly associated with reoperation for early loosening or breakage of implants or nonunion. Conclusions With the numbers available, patient factors rather than technical factors were associated with reoperation for loosening or breakage of implants and nonunion. Because of the relative infrequency of fixation problems and nonunion, a much larger study is needed to address technical deficiencies. Type of study/level of evidence Therapeutic IV.

Introduction. Chondrosarcomas are malignant bone tumors that are characterized by the production of chondroid tissue. Since radiation therapy and chemotherapy have limited effect on chondrosarcoma, treatment of most patients depends on surgical resection. We conducted this study to identify independent predictive factors and survival characteristics for conventional central chondrosarcoma and dedifferentiated central chondrosarcoma.Methods. A systematic literature review was performed in September 2014 using the Pubmed, Embase, and Cochrane databases. Subsequent to a beforehand-composed selection procedure we included 13 studies, comprising a total of 1114 patients.Results. The prognosis of central chondrosarcoma is generally good for the histologically low-grade tumors. Prognosis for the high-grade chondrosarcoma and the dedifferentiated chondrosarcoma is poor with lower survival rates. Poor prognostic factors in conventional chondrosarcoma for overall survival are high-grade tumors and axial/pelvic tumor location. In dedifferentiated chondrosarcoma the percentage of dedifferentiated component has significant influence on disease-free survival.Conclusion. Despite the fact that there are multiple prognostic factors identified, as shown in this study, there is a need for prospective and comparative studies. The resulting knowledge about prognostic factors and survival can give direction in the development of better therapies. This could eventually lead to an evidence-based foundation for treating chondrosarcoma patients.

Telomerase activity (TA) has been shown to correlate with poor clinical outcome in various tumour entities, indicating that tumours expressing this enzyme may be more aggressive and that TA may be a useful prognostic marker. For breast cancer, however, TA is a controversial prognostic marker; whereas some studies suggest an association between TA and disease outcome, others do not find this association. This study used tissue microarrays (breast carcinoma prognosis arrays) containing 611 samples (each 0.6 mm in diameter) from the tumour centre of paraffin-embedded breast carcinomas to analyse the catalytic subunit of telomerase, human telomerase reverse-transcriptase (hTERT), and the internal RNA component (hTR), which are the core components of the telomerase holoenzyme complex. hTERT protein expression was obtained by immunohistochemistry (human anti-telomerase antibody Ab-2, Calbiochem), and hTR RNA was measured by radioactive in situ hybridization. hTERT and hTR expression were determined semi-quantitatively and graded (scores 1-4). Clinical data, such as histological subtype, pT stage, tumour diameter, pN stage, BRE grade, tumour-specific survival (in months), patient's age and others, were available for statistical analysis. A statistically significant correlation was found between tumour-specific survival (overall survival) and hTERT expression (p < 0.0001) or hTR expression (p = 0.00110). Tumours with higher scores (scores 3, 4) for hTR and/or hTERT were associated with a worse prognosis. In multivariate analysis, hTERT expression was an independent prognostic factor. Previous studies, focusing on analysis of TA in smaller numbers of fresh-frozen breast carcinomas by the TRAP assay, gave controversial results with respect to TA as a prognostic marker. Using tissue microarrays from 611 breast carcinomas, this study has demonstrated that increased expression levels of the telomerase core components, hTERT and hTR, are associated with lower overall survival. These findings suggest that TA should be included in future validation studies as a prognostic marker in breast cancer.

Previous studies have shown that perioperative blood transfusion increases cancer recurrence and decreases patient survival after resection of primary malignancies. The question arises whether this association also exists in patients with already disseminated disease undergoing surgery for metastatic long-bone fractures.We sought to determine whether perioperative allogeneic blood transfusion is associated with decreased survival after operative treatment of long-bone metastatic fractures after accounting for clinical, laboratory, and treatment factors. Secondarily, we aimed to identify potential factors that are associated with decreased survival.We included 789 patients in our retrospective study who underwent surgery at two institutions for a pathologic or impending metastatic long-bone fracture. We used multivariable Cox proportional hazards regression model analysis to assess the relationship of perioperative allogeneic blood transfusion with survival, and accounted for patient age, sex, comorbidities, BMI, tumor type, fracture type and location, presence of other bone and visceral metastases, previous radiotherapy and systemic therapy, preoperative embolization, preoperative hemoglobin level, treatment type, anesthesia time, blood loss, duration of hospital admission, year of surgery, and hospital.Considering transfusion as an "exposure," and comparing patients who received transfusions with those who did not, we found that blood transfusion was not associated with decreased survival after accounting for all explanatory variables (hazard ratio [HR] 1.06; 95% CI, 0.87-1.30; p = 0.57). Evaluating transfusion in terms of dose-response, we found that patients who received more transfusions had lower survival compared with those who had fewer transfusions after accounting for all explanatory variables (HR per unit of blood transfused, 1.07; 95% CI, 1.02-1.12; p = 0.005). We found that age (HR, 1.02; 95% CI, 1.01-1.02; p 0.001), comorbidity status (HR, 1.06; 95% CI, 1.01-1.10; p = 0.014), duration of hospital stay (HR, 1.02; 95% CI 1.00-1.03; p = 0.021), tumor type (HR, 1.71; 95% CI, 1.44-2.03; p 0.001), and visceral metastases (HR, 1.59; 95% CI, 1.34-1.88; p 0.001) were independently associated with survival.We found that exposure to perioperative allogeneic blood transfusion does not decrease survival, with the numbers available. However, our sample size might have been insufficient to reveal a small but potentially relevant effect. Our results do suggest a dose-response relationship; patients who received more transfusions had lower survival compared with those with fewer transfusions. Risk of death increased by 7% per unit of blood transfused.Level III, prognostic study.

In Ewing's sarcoma family of tumours (ESFT), the clinically most adverse prognostic parameters are the presence of tumour metastasis at time of diagnosis and poor response to neoadjuvant chemotherapy. To identify genes differentially regulated between metastatic and localised tumours, we analysed 27 ESFT specimens using Affymetrix microarrays. Functional annotation of differentially regulated genes revealed 29 over-represented pathways including PDGF, TP53, NOTCH, and WNT1-signalling. Regression of primary tumours (n = 20) induced by polychemotherapy was found to be correlated with the expression of genes involved in angiogenesis, apoptosis, ubiquitin proteasome pathway, and PI3 kinase and p53 pathways. These findings could be confirmed by in vitro cytotoxicity assays. A set of 46 marker genes correctly classifies these 20 tumours as responding versus non-responding. We conclude that expression signatures of initial tumour biopsies can help to identify ESFT patients at high risk to develop tumour metastasis or to suffer from a therapy refractory cancer., This work was supported by grants from the ‘Forschungskommission der Medizinischen Fakultaet Duesseldorf’, and the ‘Madeleine Schickedanz-KinderKrebs-Stiftung’. The Departments of Pathology (Heinrich-Heine-University, Duesseldorf, Germany) and the Laboratory of Molecular Pathology (Universidad de Salamanca-CSIC, Spain) are partners of the EuroBoNeT consortium, a European Commission granted Network of Excellence for studying the pathology and genetics of bone tumours.

Despite tremendous effort and progress in the diagnostics of pancreatic cancer with respect to imaging techniques and molecular genetics, only very few patients can be cured by surgery leading to a 5-year survival rate of only 3%. Especially the lack of chemotherapeutical options in this entity requires a better understanding of the molecular mechanisms leading to pancreatic carcinoma growth and progression in order to develop novel treatment regimens. To identify signaling pathways that are critical for this tumor entity, we compared six well-established pancreatic cancer cell lines (Capan-1, Capan-2, HUP-T3, HUP-T4, KCL-MOH, PaTu-8903) with colon cancer cell lines and tumor cell lines of non-epithelial origin by expression profiling. For this purpose we employed Human Genome Focus Arrays representing about 8500 well annotated human genes. We identified 353 genes with significantly high expression in the group of pancreatic carcinomas. Based on Gene Ontology annotations these genes are especially involved in Rho protein signal transduction, proteasome activator activity, cell motility, apoptotic program, and cell-cell adhesion processes indicating these pathways to be interesting candidates for the design of targeted therapies. Most pancreatic carcinomas are characterized by mutations in the TP53 and the KRAS genes and the absence of microsatellite instability, which could also be confirmed for our panel of pancreatic carcinoma cell lines. Looking for individual differences within this group that may be responsible for more or less aggressive behavior, we identified genomic amplifications at the 8q22.1 and the 8q24.22 loci to be associated with enhanced gene transcription. Because we have previously shown that gains of genomic material from the long arm of chromosome 8 have an adverse effect on the outcome of pancreatic carcinoma patients, we conclude that functional analysis of amplified genes at 8q22 and/or 8q24 may lead to an improved understanding of pancreatic carcinoma progression.

The effect of ionizing irradiation on telomerase activity and further associated biological factors was evaluated in a human Ewing tumor xenograft model on nude mice.The human Ewing tumor cell line STA-ET-1 was established in a nude mouse model. Initially, the dose-response relationship for the tumor model was established. For the radiation experiments two dose levels were chosen: 5 Gy and 30 Gy. After 5 Gy, there was no significant growth delay whereas after 30 Gy there was a marked growth delay without the induction of a complete remission. Tumors were examined 6, 12, 24, 48, 72, and 96 hours post irradiation. After irradiation with 30 Gy further time points were 6, 9, 12 and 15 days. For each dose and time group, three tumors were evaluated.There was a reduction of telomerase activity after 5 Gy to 50% (not statistically significant) after 3 days; however, after 30 Gy there was a reduction of telomerase activity to 23% of the initial value after 6 days (p = 0.001). Telomerase activity correlated with the expression of human telomerase reverse transcriptase (hTERT), but not with the expression of telomerase-associated protein (TP1) and human telomerase RNA (hTR). The maximal amounts of necrosis or apoptosis after 30 Gy were 19% and 6.9%, respectively.Ionizing radiation reduces telomerase activity and the expression of hTERT which cannot be explained by the induction of necrosis or apoptosis alone. The reduction of telomerase activity may contribute to delayed cell death after radiotherapy. The combined use of radiation and specific telomerase inhibitors may be a potentially synergistic treatment strategy.