Determining the Optimal Intramedullary Screw Canal Fill Ratio in Length Unstable Metacarpal Fractures: A Biomechanical Investigation.

PURPOSE: Intramedullary (IM) screw fixation is gaining popularity in the treatment of metacarpal fractures. Despite its rapid adoption, there is a paucity of evidence regarding parameters to optimize effectiveness. This study aimed to quantify the relationship between stability, IM screw size, and canal fill using a cadaveric model. METHODS: Thirty cadaveric metacarpals (14 index, 13 middle, and three ring fingers; mean age: 58.3 years, range: 48-70) were selected to allow for canal fill ratios of 0.7-1.1 for screws sized 3.0, 3.5, and 4.5 mm. Metacarpals underwent a 45° volar-dorsal osteotomy at the midpoint before fixation with an IM screw. Specimens were subjected to 100 cycles of loading at 10 N, 20 N, and 30 N before load-to-failure testing. Correlation coefficients for angular displacement on the final cycle at each load, peak load to failure, and average stiffness were assessed. RESULTS: Correlation coefficients for the angular displacement on the 100th cycle were as follows: 10 N, R = 0.62, 20 N, R = 0.57, and 30N, R = 0.58. Correlation values for peak load to failure as a function of canal fit were as follows: 3.0 mm, R = 0.5, 3.5 mm, R = 0.17, and 4.5 mm, R = 0.44. The canal fill ratio that intersected the line-of-best fit at an angular deformity of 10° was 0.74. Average peak forces for 3.0-, 3.5-, and 4.5-mm screws were 79.5, 136.5, and 179.6 N, respectively. Average stiffness for each caliber was 14.8, 33.4, and 52.3 N/mm. CONCLUSIONS: Increasing screw diameter and IM fill resulted in more stable fixation, but marginal gains were seen in ratios >0.9. A minimum fill ratio of 0.74 was sufficient to withstand forces of early active motion with angular deformity <10°. CLINICAL RELEVANCE: An understanding of the relationship of IM fill ratio of metacarpal screws to fracture stability may provide a framework for clinicians to optimally size these implants.

Evolution of Surgical Management of Sagittal Synostosis.

ABSTRACT: Numerous methods for surgical correction of sagittal synostosis have been described in the literature, yielding similar outcomes. At the authors' institution, surgical approaches to correct this condition have evolved over the past few decades, including Π, H-type craniectomies (Renier), endoscopic suturectomy, and our current technique, the FLAG procedure. Our aim is to review the evolution of these surgical techniques at our institution and compare patient outcomes. A retrospective review was performed on consecutive patients undergoing correction for craniosynostosis from 2008 to 2018. All patients with a diagnosis of nonsyndromic isolated sagittal craniosynostosis were included and classified into one of 4 groups by the type of surgical correction performed (H-type, FLAG, endoscopic, other). The authors identified 166 consecutive patients with a mean age at time of surgery of 6.7 ± 4.0 months. 91 (54.8%) carried a diagnosis of nonsyndromic sagittal synostosis. 63 patients underwent H-type procedures, 9 underwent FLAG procedures, 5 underwent endoscopic procedures, and 14 were classified as other (distraction or other implant). Perioperatively, the FLAG group had the shortest ICU stay (1.3 days, P < 0.05), postoperative transfusion requirement (42cc pRBC, P < 0.001), and complication rate (0.0%). The endoscopic group had the shortest surgical time at 2.00 hours (p < 0.001). No statistically significant difference in cranial index or revision procedures between the four groups was identified. Overall, the mean length of follow-up was 25.3 months. All procedures had similar results for cranial index with decreased surgical time, transfusion volume, and hospital stay seen in FLAG and endoscopic groups.

Granulocytic Sarcoma: A Rare Cause of Wrist Pain.

Septic, inflammatory, or crystal-induced arthritis are common etiologies of wrist pain without antecedent trauma associated with pain, loss of motion, swelling, redness, and warmth. In this report, we detail the case of granulocytic sarcoma of the wrist that presented as acute wrist pain, swelling, and limitation in motion. Granulocytic sarcoma is an exceedingly rare extramedullary tumor associated with acute myeloblastic leukemia. It may be found in any part of the body; however, upper extremity involvement is uncommon. To our knowledge, this is the first description of granulocytic sarcoma occurring in the wrist joint.

Early Functional Outcomes After Prepectoral Breast Reconstruction: A Case-Matched Cohort Study.

INTRODUCTION: Staged, tissue expander-based implant reconstruction continues to be the most common mode of breast reconstruction after mastectomy and has evolved significantly for the past 60 years. Prepectoral acellular dermal matrix (ADM)-assisted breast reconstruction is gaining popularity with complication rates similar to total submuscular and ADM-assisted partially submuscular reconstruction. Ours is among the first reports comparing postoperative pain and early functional outcomes between 2-stage ADM-assisted prepectoral and partial submuscular breast reconstruction. METHODS: Patients reconstructed with a 2-stage, ADM-assisted prepectoral approach were case matched with patients who had undergone ADM-assisted, partial submuscular reconstruction. Demographics and complication rates were compared. Primary outcomes included postoperative pain, number of days until full active shoulder range of motion was achieved, and postoperative days until drain removal. RESULTS: Forty-five breasts among 24 patients were reconstructed with ADM-assisted prepectoral tissue expanders after mastectomy and 90 breasts among 48 patients were reconstructed with ADM-assisted partial submuscular placement. There was a similarly acceptable complication profile between the 2 groups. The prepectoral group had significantly lower inpatient pain scores, required significantly less intravenous opioids and less oral opioids as outpatients. The prepectoral group saw a return to full active range of shoulder motion in half the number days of the partial submuscular group. Drain duration was similar between groups. CONCLUSIONS: Prepectoral ADM-assisted breast reconstruction can be performed safely and with significantly less pain and earlier return to function than partial submuscular expander placement. Expander placement exclusively in the prepectoral pocket did not result in increased drain duration while affording patients the benefits of avoiding surgical elevation of the pectoralis muscle.

Radial Artery Reconstruction After Iatrogenic Cannulation-Related Occlusion: A Case Report.

A 59-year-old male, with a history of angiogram via the left radial artery during the workup for multi-trauma, presented to the hand clinic with a 14-day history of progressive critical ischemia in the left thumb and index finger, along with dry gangrene of the distal index fingertip. Radial artery occlusion was confirmed on imaging. The patient underwent radial artery thrombectomy, arterial reconstruction with vein graft, and amputation of the index fingertip. Postoperatively, perfusion to the thumb and index finger was restored, resulting in the resolution of associated pain and hypersensitivity. This case demonstrates the delayed presentation of ischemia following radial artery cannulation, which was successfully managed with radial artery thrombectomy and a saphenous vein graft.

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report.

CASE: A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA. CONCLUSION: At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

"The Feasibility of Targeted Muscle Reinnervation for the Management of Morton's Neuroma".

BACKGROUND: Despite multiple surgical modalities available for the management of Morton's neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be explored as an option for the prevention of recurrence of Morton's neuroma. The purpose of the present investigation was to determine the consistency of the relevant foot neurovascular and muscle anatomy and to demonstrate the feasibility of TMR as an option for Morton's neuroma. METHODS: The anatomy of 5 fresh-tissue donor cadaver feet was studied, including the course and location of the medial and lateral plantar nerves (MPNs and LPNs), motor branches to abductor hallucis (AH) and flexor digitorum brevis (FDB), as well as the course of sensory plantar digital nerves. Measurements for the locations of the muscular and sensory branches were taken relative to landmarks including the navicular tuberosity (NT), AH, FDB, and the third metatarsophalangeal joint (third MTPJ). RESULTS: The mean number of nerve branches to FDB identified was 2. These branch points occurred at an average of 8.6 cm down the MPN or LPN, 9.0 cm from the third MTPJ, 3.0 cm distal to AH distal edge, and 4.8 cm from the NT. The mean number of nerves to AH was 2.2. These branch points occurred at an average of 6.3 cm down the MPN, 11.9 cm from the third MTPJ, 0.8 cm from the AH distal edge, and 3.8 cm from the NT. CONCLUSIONS: Recurrent interdigital neuroma, painful scar, and neuropathic pain are common complications of operative management for Morton's neuroma. Targeted muscle reinnervation is a technique that has demonstrated efficacy for the prevention and treatment of neuroma, neuropathic pain, and phantom limb pain in amputees. Herein, we have described the neuromuscular anatomy for the application of TMR for the management of Morton's neuroma. Target muscles, including the AH and FDB, have consistent innervation patterns in the foot, and consequently, TMR represents a viable option to consider for the management of recalcitrant Morton's neuroma. LEVELS OF EVIDENCE: V.

Quality Improvement: Effect of Standardized Plastic Surgery Consultation Note Templates on Charge Capture.

BACKGROUND: Effective medical record documentation is imperative for both patient care and reimbursement for care provided. The purpose of this study was to compare coding/billing patterns for plastic surgery consultations before and after implementation of a standardized documentation protocol. METHODS: Standardized hand, facial trauma, and general plastic surgery consult note templates were created. Following institutional approval, records were reviewed for all plastic surgery consultations from January to October 2019. Template notes were universally implemented in July 2019. Medical coding was performed by a certified professional coder using the 1995 Evaluation and Management Review Worksheet. Coding/billing patterns between groups were compared with and without standardized documentation using univariate analysis. RESULTS: Seventy-five consecutive preimplementation consult notes and 75 consecutive postimplementation consult notes were selected for review. Each group included 25 hand, 25 facial trauma, and 25 general plastic surgery consultation notes. The history and physical examination components of the visit code were more frequently coded as "comprehensive"postimplementation (P = 0.000). There was no significant difference in coding for medical decision making between the two groups (P = 0.340). The final visit code was significantly higher in the postimplementation group (45.3% 99254/99284 versus 2.7%, P = 0.000), and the charges were significantly higher post implementation-average charge per consult $250 versus $203 (P = 0.000) with a 22.8% increase in total charges generated. CONCLUSION: Utilization of standardized consultation note templates increases the accuracy of coding and associated billing of inpatient and emergency department plastic surgery consultations through documentation and reflection of level of service provided.

Outcomes and Complications of Tendon Transfers to Address Pinch and Grasp Weakness: A Systematic Review of the Operative Management of Ulnar Nerve Paralysis.

BACKGROUND: Patients with ulnar nerve paralysis note difficulties performing activities of daily living because of weakness of pinch and altered grasp mechanism. This review investigates outcomes of tendon transfers for ulnar nerve paralysis to assist in shared decision-making with patients during preoperative counseling and to inform operative choices. METHODS: A systematic review was conducted to identify studies reporting outcomes following tendon transfer for ulnar nerve palsy. Studies were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and inclusion and exclusion criteria were applied. Primary outcome measures included postoperative pinch strength and mechanism of grasp. RESULTS: A total of 26 studies (687 patients) met criteria for inclusion. After pooled analysis, the flexor digitorum superficialis lasso procedure yielded the highest rate of complete correction of claw deformity (60.6 percent), followed by flexor digitorum superficialis four-tail operation (31.4 percent). The extensor carpi radialis longus four-tail operation yielded the greatest improvement in grip strength (3.8 kg). The extensor carpi radialis brevis four-tail operation resulted in the best open hand assessment and mechanism of closing scores; however, these studies did not objectively evaluate grip strength. The greatest increase in pinch strength was following tendon transfer to adductor pollicis alone. CONCLUSIONS: Despite the heterogeneous data, if the primary goal is improvement in the appearance of claw deformity, the evidence supports flexor digitorum superficialis lasso transfer. However, if the primary concern is grip strength, the data favor extensor carpi radialis longus four-tail transfer. When pinch strength is functionally limiting, adductorplasty alone is most effective. These data will assist providers in appropriately informing patients of common risks and complications and setting realistic expectations following tendon transfer procedures.