Triceps Rupture After Olecranon Fixation with Proximal Ulna Plate and Suture Augmentation: A Case Report.

CASE: Olecranon fractures treated with proximal ulna plate fixation and repairing the triceps with suture augmentation to the plate decrease the risk of "olecranon escape," but may lead to failure through triceps rupture. In this case report, a rare complication of triceps rupture occurred, and the patient underwent triceps repair. CONCLUSION: When fixing olecranon fractures, surgeons should minimize triceps dissection for hardware placement. If subjected to significant force, a surgical insult to the tendon footprint for a better plate contact on the bone and the presence of suture augmentation may change the construct failure mechanism and result in triceps rupture as opposed to fracture redisplacement.

Return to Play After Thumb Ulnar Collateral Ligament Injuries Managed Surgically in Athletes-A Systematic Review.

Purpose: The purpose of this systematic review was to summarize the available data on how surgical management of injuries to the thumb ulnar collateral ligament (UCL) complex affects athletes and their return-to-play (RTP) and postinjury performance metrics in addition to evaluating rehabilitation guidelines. Methods: A systematic search was performed on PubMed and Embase databases for articles on outcomes of surgical treatment of thumb UCL injuries in athletes. Articles with expert recommendations on postoperative management and RTP guidelines were also included separately. Study characteristics were recorded, including sport, RTP rates, and data on performance. Recommendations were summarized by sport. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess methodological quality. The authors also present their recommended return-to-sport algorithm. Results: Twenty-three articles were included, including 11 with reports on patients and 12 expert opinions on guiding RTP. The mean MINORS score for the applicable studies was 9.4. In the 311 patients included, RTP was 98.1% in aggregate. No performance detriments were noted in athletes after surgery. Thirty-two (10.3%) patients had postoperative complications. The recommendations on timing to RTP vary by sport and author, but all recommended initial thumb protection when returning to sport. Newer techniques, such as suture tape augmentation, suggest the permission for earlier motion. Conclusions: Return-to-play rates after surgical treatment of thumb UCL injuries are high, with reassuring return to preinjury level of play with few complications. Recommendations for surgical technique have trended toward suture anchors and, now, suture tape augmentation with earlier motion protocols, although rehabilitation guidelines vary by sport and author. Current information on thumb UCL surgery in athletes is limited by the low quality of evidence and expert recommendations. Type of study/level of evidence: Prognostic IV.

Trends in the Management of Pediatric Trigger Thumb in the United States.

BACKGROUND: Recent literature suggests that initial observation of pediatric trigger thumb without early surgical interventions can lead to spontaneous resolution. We sought to analyze current trends in the management of pediatric trigger thumb and compare real-world data with what the literature supports. METHODS: We conducted a retrospective study of data collected using the PearlDiver database between 2015 and 2018. Patients who were aged younger than 10 years with a diagnosis of trigger thumb were identified using International Classification of Diseases codes. Current Procedural Terminology codes were used to identify patients who had an operation for trigger thumb. Patient demographics, comorbidities, utilization of hand therapy, and treatment cost were also collected. RESULT: Of the 997 patients included in the study, 69% were diagnosed with trigger thumb between the age of 2 and 5 years. In all, 492 patients (49%) had surgery for trigger thumb: 65% of patients had surgery within 1 year of diagnosis, and 76% patients had surgery before the age of 5 years. This treatment pattern was similar across multiple regions of the United States, and there were no significant predictors for surgery. The average cost of treating patients without surgery was $593/patient, whereas that for patients with surgery was $1363/patient. CONCLUSIONS: Nationwide data show that pediatric trigger thumb may be managed surgically at higher frequencies and in patients at younger ages than supported by the existing literature. Possible overtreatment is not only detrimental to patients but also burdens the health care system with unnecessary cost.

Percutaneous Release of Trigger Finger With and Without Steroid Injection A Systematic Review and Meta-Analysis.

PURPOSE: This study sought to determine if concomitant steroid administration with percutaneous release (PRS) of trigger finger leads to better functional outcomes, less postoperative pain, lower rates of trigger recurrence, and lower rates of subsequent open release versus percutaneous release (PR) alone. METHODS: Articles related to trigger finger disorder, percutaneous release of trigger finger, and steroid admin- istration were assessed by two independent reviewers ac- cording to PRISMA guidelines. Data related to satisfaction, pain, disability, recurrence, and need for open release was abstracted from relevant studies. A meta-analysis using random effects models was performed to calculate pooled effect size estimates controlling for heterogeneity between studies. Sensitivity analyses were performed to identify pos- sible sources of heterogeneity between studies. RESULTS: Forty-five studies with a total of 4,188 digits were included in the PR group and seven studies with a total of 700 digits were included in the PRS group. Our meta-analysis showed no significant difference between treatment options with regard to overall satisfaction, postoperative pain, recur- rence rates, or subsequent need for open release. A small difference between groups was observed in postoperative disability, with lower levels of disability following PRS versus PR. CONCLUSIONS: Based on current literature, both PR and PRS are safe and effective treatments for trigger finger. Steroid administration with percutaneous release may lead to lower rates of postoperative disability, but due to the small difference observed and the modest sample size of studies that examined this outcome, further studies are needed to elucidate if the difference seen in disability is clinically relevant.

Patient outcomes and costs after isolated flexor tendon repairs of the hand.

BACKGROUND: Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries. PURPOSE: We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care. STUDY DESIGN: A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued. METHODS: A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs. RESULTS: The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation. CONCLUSION: Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

Virtual reality may reduce anxiety and enhance surgical experience during wide-awake local anaesthesia no tourniquet surgery: A report of two cases.

Virtual reality is an immersive experience that has been gaining acceptance in the field of medicine as a tool for reducing patient anxiety. We recently observed the effectiveness of this technology in wide-awake local anaesthesia no tourniquet (WALANT) surgeries. Here we report two cases of patients who used a virtual reality device during hand surgery using the WALANT technique. Both patients reported that the use of VR technology reduced their anxiety and improved their overall experience during surgery. This case report highlights the novel use of virtual reality during hand surgeries where the patients were awake. Based on these two cases, virtual reality may have the potential to reduce anxiety during the perioperative period and enhance a patient's overall experience in WALANT surgeries.

Scaphoid fracture displacement is not correlated with the fracture angle.

Classifications of scaphoid fractures associate the angle of the fracture with its stability. To examine this assumption, we measured acute scaphoid fracture angles and inclinations in relation to different scaphoid axes, using fracture displacement as an indicator of instability. We examined the effect of using different axes on the measurements of angles. CT scans of 133 scaphoid fractures were classified according to the location of the fractures. Using a three-dimensional computer model, we computed four scaphoid axes. For each fracture, we then measured the fracture angle and the direction of the fracture inclination in relation to each one of the axes. We found a correlation between displacement and the angles of proximal fractures using one of these axes (the surface principal component analysis axis). No such correlations were found for waist fractures, which were the majority of fractures. There were significant differences between the measurements made with different axes. The findings indicate that the angle of the fracture and the direction of the fracture inclination are minor factors in the displacement of most scaphoid fractures.Level of evidence: III.

Opioid Use following Open versus Endoscopic Carpal Tunnel Release: A Population Study.

Open (OCTR) and endoscopic carpal tunnel release (ECTR) are both effective treatments for carpal tunnel syndrome, with similar outcomes and complication rates. Given the opioid epidemic, it is important to consider how surgical modality impacts narcotic use. We compared narcotic use after OCTR and ECTR to identify trends and risk factors for prolonged postoperative use. METHODS: We utilized the PearlDiver database to identify patients who underwent OCTR and ECTR between 2008 and 2015. Patients with opioid use were analyzed for trends. Early refills, prolonged postoperative opioid use, and new persistent opioid use were defined by time periods relating to the date of surgery. Age, gender, Charlson comorbidity index (CCI), and surgery type (open versus endoscopic) were analyzed as predictors for opioid use. RESULTS: A total of 29,583 patients were included: 4125 (14%) ECTR and 25,458 (86%) OCTR. Significantly more OCTR patients filled perioperative prescriptions (62% versus 60%), and the OCTR group filled higher quantities of perioperative opioids (411 OME versus 379 OME). Patients in the OCTR group were also significantly more likely to obtain early refills and to have prolonged postoperative use. There was no difference in the rate of new persistent use. CONCLUSIONS: Compared with ECTR, patients who underwent OCTR filled higher quantities of opioids in the perioperative period, were more likely to obtain early refills, and were more likely to have prolonged postoperative use. These findings suggest either a lower opioid requirement after ECTR or a lower perceived requirement reflected in the difference in prescribing habits between techniques.

Management of Metadiaphyseal Proximal Radius Fractures.

Metadiaphyseal proximal radius fractures blur the distinction between the radial neck and radial shaft fractures. Operative management presents unique technical challenges both in terms of surgical approach and fixation method. We discuss relevant anatomy, safe surgical approach, and options and techniques for fracture fixation. We describe 6 patients who achieved satisfactory functional outcomes, even in cases of severe bone loss secondary to ballistic trauma. An extensile dorsal approach with exposure of the posterior interosseous nerve is recommended when normal soft tissue intervals have not already been extensively disrupted. Robust fixation can be achieved by contouring and repurposing a variety of plates such as a variety of mini fragment plates (2.4 mm T or Y-plates), flexible nails, or even distal radius plates.

Flexor Tendon Rupture After Distal Radius Malunion Associated With Electromyographic Abnormalities: A Case Report.

CASE: A 63-year-old woman with a history of a malunited distal radius fracture presented with left hand pain and inability to flex her thumb, index, and middle fingers. Anterior interosseous neuropathy was suggested because of abnormal electromyography findings. However, magnetic resonance imaging later revealed flexor tendon ruptures. A distal radius corrective osteotomy with autograft and volar fixation was performed with tendon transfers and carpal tunnel release. CONCLUSIONS: Attritional flexor tendon rupture after a nonoperatively managed distal radius fracture is rare but remains an important differential diagnosis in patients with signs and symptoms of anterior interosseous nerve paralysis.

Wide-Awake Local Anesthesia for Minor Hand Surgery Associated With Lower Opioid Prescriptions, Morbidity, and Costs: A Nationwide Database Study.

Purpose: We sought to investigate the perioperative opioid prescription patterns, complication rates, and costs associated with wide-awake local anesthesia (WALA) techniques using a nationwide insurance claims-based database. Methods: We used the PearlDiver Humana administrative claims database to identify opioid-naive adult patients who underwent a carpal tunnel release, trigger finger release, or de Quervain release between 2007 and 2015. Patients were divided into WALA and standard anesthesia groups by the presence or absence of anesthesia Current Procedural Terminology codes. We evaluated for differences in perioperative opioid prescribing patterns, rates of opioid refills, and insurance reimbursement. The incidence of surgical complications and medical complications within 30 days of surgery were determined by International Classification of Diseases, Ninth Revision codes. Adjusted odds ratios were calculated with multivariable logistic regression models to identify factors associated with filling or refilling opioid prescriptions and complication rates. Results: There were 6,285 patients in the WALA group and 28,657 in the standard anesthesia group. The WALA patients were prescribed significantly lower quantities of opioids than were standard anesthesia patients across all 3 procedures. After controlling for type of surgery, gender, and comorbidities in a multivariate model, WALA patients were less likely to fill an initial opioid prescription during the perioperative period but were equally likely to obtain a refill. The WALA patients had lower odds of developing both surgical and medical complications compared with standard anesthesia patients. Moreover, WALA was associated with significantly lower costs for all procedures. Conclusions: Wide-awake local anesthesia technique is an increasingly common and viable option for minor hand surgery. It is a cost-effective and safe technique for simple hand surgical procedures and can be a strategy to minimize postoperative opioid use. Type of study/level of evidence: Prognostic II.

Incidence of Corrective Procedures After Nonoperatively Managed Distal Radius Fractures in the Elderly.

Although the majority distal radius fractures in the elderly are initially managed nonoperatively, the true incidence of subsequent corrective surgery is unknown. The purpose of this study was to determine the incidence and predictors of corrective surgery after conservative management. METHODS: ICD-9 and Current Procedural Terminology codes were queried from the Medicare 5% sample to select patients aged 65 years and older undergoing nonsurgical treatment of distal radius fractures with a minimum 5-year follow-up. Rates of subsequent ipsilateral wrist surgery were correlated against patient age, sex, geographic region, and initial closed reduction. RESULTS: Five thousand eighty patients with a mean age of 78.3 years were included. Fifty-five patients (1.1%) had undergone subsequent wrist surgery at a median time of 182 days after injury. The youngest cohort (65 to 69 years) had a significantly higher operation rate (1.9%, P = 0.007) than the oldest cohort (80+ years) (0.5%, P = 0.004). There was no notable difference in corrective procedures between sex, geographic region, and initial closed reduction. DISCUSSION: Once surgical intervention is deemed unnecessary per standard guidelines, the data support successful nonsurgical management in a large majority of patients but highlight a small subset of younger patients who remain at increased risk of requiring additional surgery.

A Biomechanical Study of Posteromedial Tibial Plateau Fracture Stability: Do They All Require Fixation?

OBJECTIVES: Although the posteromedial fragment in tibial plateau fractures is often considered unstable, biomechanical evidence supporting this view is lacking. We aimed to evaluate the stability of the fragment in a cadaver model. Our hypothesis was that under the expected small axial force during rehabilitation and the combined effects of this force with shear force, internal rotation torque, and varus moment, the most common posteromedial tibial fragment morphology could maintain stability in early flexion. METHODS: Axial compression force alone or combined with posterior shear, internal rotation torque, or varus moment was applied to the femurs of 5 fresh cadaveric knees. A Tekscan pressure mapping system was used to measure pressure and contact area between the femoral condyles, meniscus, and tibial plateau. A Microscribe 3D digitizer was used to define the 3-dimensional positions of the femur and tibia. A 10-mm and then a 20-mm osteotomy was created with a saw at an angle of 30 degrees in the axial plane with respect to the tangent of the posterior tibial plateau and 75 degrees in the sagittal plane, representing a typical posteromedial fracture fragment. At each flexion angle (15, 30, 60, 90, and 120 degrees) and loading condition (axial compression only, compression with shear force, torque, and varus moment), distal displacement of the medial femoral condyle and the tibial fracture fragments was determined. RESULTS: For the 10-mm fragment, medial femoral condyle displacement was little affected up to approximately 30-degree flexion, after which it increased. For the 20-mm fragment, there was progressive medial femoral condyle displacement with increasing flexion from baseline. However, for the 10- and 20-mm fragments themselves, displacements were noted at every flexion angle, starting at 1.7 mm inferior displacement with 15 degrees of flexion and internal rotation torque and up to 10.2 mm displacement with 90 degrees of flexion and varus bending moment. CONCLUSIONS: In this cadaveric model of a posteromedial tibial plateau fracture, both fracture fragments studied displaced with knee flexion, even at low flexion angles. Although such fragments may initially seem nondisplaced after injury, posteromedial fragments similar to these tested are likely to displace during knee range of motion exercises in non-weight-bearing conditions.

Lower extremity nerve trauma.

Peripheral nerve injuries of the lower extremity (LE) are frequently encountered in orthopaedic practice. They can be traumatic or iatrogenic. Proper and timely diagnosis and treatment are the keys to optimizing outcomes. This paper reviews and discusses the basic anatomy and physiology of nerve injury and the current literature on the incidence, pathogenesis, diagnosis, management and outcomes of sciatic, femoral, peroneal, and tibial nerve injuries. The purpose of this review is to suggest a protocol for evaluation and management of LE nerve injuries.

Use of emergency department services for hand, wrist, and forearm fractures in the United States in 2008.

The objective of this study was to determine demographic characteristics and epidemiology of hand, wrist, and forearm fracture patients treated in the emergency departments (EDs) to identify the at-risk populations. The Nationwide Emergency Department Sample database collected by the Agency for Healthcare Research and Quality was used to estimate ED visits for hand, wrist, and forearm fractures during 2008. The overall rate of ED visits for these injuries was 54 per 10,000 population. Children aged 6 to 15 had the highest rate of ED visits at 124 per 10,000. A secondary increase in ED visits occurred at age 50 and rose with age. Metacarpals were the most common fracture location in adults aged 16 to 25, while radius and ulna were the most common fracture location in all other age groups. Demographic analysis identified children, adult males aged 16 to 25, and the elderly as target populations for preventive interventions.

Ulnar variance as a predictor of persistent instability following Galeazzi fracture-dislocations.

BACKGROUND: We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture. MATERIALS AND METHODS: Fifty consecutive patients, ages 20-79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment. RESULTS: Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2-12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0-11 mm, SD = 3.5) in patients without. Only 4/20 patients (20%) with DRUJ instability had normal ulnar variance (-2 to +2 mm) versus 15/30 (50%) patients without (p = 0.041). CONCLUSION: In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.

Total knee arthroplasty in patients with a previous patellectomy.

Post-patellectomy patients represent a specific subgroup of patients that may develop arthritis and persistent knee pain and potentially require treatment with total knee arthroplasty. This article reviews the treatment and functional outcomes following total knee arthroplasty in patients with prior patellectomy. A case report is presented as an example of the clinical management of a post-patellectomy patient with significant knee pain and disability treated with total knee arthroplasty. Emphasis will be placed in decision- making, specifically with the use of a posterior stabilized implant. In addition, postoperative strengthening of the quadriceps is essential to compensate for the lack of the patella and increase the success of total knee arthroplasty in this subgroup of patients.