Diagnosis and Arthroscopic Management of Dorsal Wrist Capsular Impingement.

PURPOSE: Dorsal wrist capsular impingement (DWCI) is characterized by pain attributable to impingement of dorsal capsular tissue during wrist extension. The diagnostic criteria and management algorithm for this condition have not been well established. The aims of our study were (1) to retrospectively review the clinical presentation and arthroscopic findings of patients treated surgically for DWCI and (2) to evaluate the outcomes of arthroscopic debridement for this condition. METHODS: A total of 19 patients were treated with arthroscopic debridement for isolated DWCI from 2006 to 2015 by two surgeons (M.J.R. and D.S.R.) at a single institution. A chart review was performed to gather information on clinical presentation, radiological findings, operative details, and outcomes including numeric pain scale rating, range of motion, Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand score. Patients were contacted at the time of the study for final telephone follow-up. RESULTS: Symptoms were present for a median of 12.5 months (range, 3.5-124.4 mo) prior to surgical intervention, and all patients had pain localized to the dorsal and central wrist with passive terminal wrist extension (100%; 19 of 19). We obtained magnetic resonance imaging in 66% of patients (12 of 19). Diagnostic arthroscopy yielded evidence of infolded, redundant dorsal capsular tissue in all cases (19 of 19), and there was no evidence of concomitant wrist pathology. Compared with preoperative values, postoperative improvements were seen in average numeric pain scale rating (6.0-1.9), Quick Disabilities of the Arm, Shoulder, and Hand score (45.8-4.8), and Mayo wrist score (50.0-87.8). These improvements were sustained at 41.6 months after surgery (range, 11.9-73.8 months). One complication of superficial cellulitis occurred. CONCLUSIONS: Dorsal wrist capsular impingement is a clinical diagnosis; magnetic resonance imaging may be helpful in evaluating for other pathologies. Diagnostic arthroscopy yields evidence of redundant dorsal capsular tissue, and arthroscopic debridement of this tissue offers a safe and effective treatment to improve pain and functional scores. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Perioperative Glucocorticoid Administration Improves Elbow Motion in Terrible Triad Injuries.

PURPOSE: Among patients who undergo surgical treatment of terrible triad elbow injuries (TTEI), we hypothesized that those who received perioperative glucocorticoid (GC) therapy would have improved postoperative pain and range of motion (ROM) and a similar complication rate compared with patients who did not receive GC therapy. METHODS: We retrospectively identified 26 patients who underwent surgical treatment of TTEI from 2009 to 2015. Thirteen patients received a single intraoperative dose of 10 mg intravenous dexamethasone followed with a 6-day oral methylprednisolone taper course (GC group), and 13 did not (control group). After surgery, patients were placed in an orthosis at 90° flexion with the forearm in pronation for 2 weeks, after which ROM was initiated. Patients were seen in clinic at 2, 6, 12, and 24 weeks after surgery, at which time numeric pain scale scores and ROM data were collected and any complications were noted. RESULTS: Compared with the control group, the GC group had a greater flexion-extension arc of motion at 24 weeks (132.5° vs 105.5°); significant differences were not found at earlier time points. Supination measurements were significantly greater for the GC group at every time point with a difference at final follow-up of 23.2° (61.0° vs. 84.2°). There were 5 complications in the control group (35.8%), 3 of which required additional surgery, and 3 complications in the GC group (23.1%), 1 of which required another surgery. No postoperative infections were found in either group. CONCLUSIONS: Perioperative glucocorticoid administration is associated with improved ROM after surgical treatment of TTEI. Flexion-extension, pronosupination arc of motion, and overall supination were significantly improved. Postoperative pain scores and complication rates were similar between GC and control groups. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A review of modern management of lateral epicondylitis.

Lateral epicondylitis, or tennis elbow, is the most common cause of elbow pain. This degenerative condition can manifest as an acute process lasting < 3 months or a chronic process often refractory to treatment. Symptom resolution occurs in 70% to 80% of patients within the first year. A "watch-and-wait" approach can be an appropriate treatment option, although physical therapy has been shown to be an effective first-line therapy. Corticosteroids, while providing relief of pain in the acute setting, may be detrimental to recovery in the long term. Platelet-rich plasma injections, although recently well publicized, have not been proven by well-controlled clinical trials to be effective therapy. For patients with symptoms refractory to conservative management, surgical intervention has shown to be a successful treatment modality.

Predictors of Insurance Claim Rejection in Hand and Upper Extremity Surgery.

INTRODUCTION: Insurance claim rejections represent a challenge for healthcare providers because of the potential for lost revenue and administrative costs of reworking claims. METHODS: The billing records of five hand and upper extremity surgeons at a tertiary academic center were queried for all patient billing activity over a 1-year period yielding a total of 14,421 unique patient encounters. RESULTS: A total of 11,839 unique patient encounters were included, and the overall claim rejection rate was 19.3%. Claim rejection rate varied significantly by payer (P < 0.0001) and was lowest in private insurance (14.0%) and highest in Medicare (31.2%). The use of multiple Current Procedure Terminology codes for an encounter was independently associated with an increased risk of claim rejection for both office (25.6%, relative risk [RR] 1.27, 95% confidence interval [CI] 1.03 to 1.49, P = 0.0032) and surgical (25.6%, RR 1.67, 95% CI 1.28 to 2.18, P = 0.0002) settings. After multivariate regression adjustment, modifier 25 was associated with a decreased risk of claim rejection (23.3%, RR 0.72, 95% CI 0.61 to 0.85, P < 0.0001). DISCUSSION: Insurance claim rejection occurs frequently (19.3%) in hand/upper extremity surgery and varies by insurance type, with the highest rejection rate occurring in Medicare (31.2%). For a given encounter, the use of multiple Current Procedure Terminology codes and specific modifiers are predictive of rejection risk. LEVEL OF EVIDENCE: Level III, prognostic.

Determination of the Optimal Location for Bone Graft Harvest in the Distal Radius.

Background: The distal radius is commonly used as a bone graft donor site for surgery in the hand and wrist. The aim of this study was to evaluate the volume and relative density of cancellous bone in the distal radius. Methods: Thirty-four consecutive computed tomographic scans of the wrist in 33 patients without distal radius pathology were included. For each subject, 6 spherical regions of interest (ROIs) were identified within the distal radius. In each ROI, volumetric measurements and mean Hounsfield unit (HFU) values were recorded by 2 observers using a 3-dimensional imaging reconstruction software. Results: Compared with proximal bone, distal bone had larger volume (0.82 vs 0.27 cm3) and greater relative density (178 vs 152 HFU) on average. Among the 6 ROIs, the distal-central region had the largest average volume (1.20 cm3) and the distal-ulnar ROI had the greatest average relative density (193 HFU). Conclusion: Based on these results, we recommend performing cancellous autograft harvest relatively distal and ulnar within the distal radius.

The effect of obesity on fatty infiltration of the rotator cuff musculature in patients without rotator cuff tears.

BACKGROUND: The modified Goutallier classification system describes the fatty infiltration of rotator cuff musculature (RCM) seen on magnetic resonance imaging (MRI) to assist with surgical decision-making for patients with rotator cuff tears (RCT). We describe the relationship between body mass index (BMI) and fatty infiltration in patients without RCT. METHODS: Twenty-five patients from each of four different BMI ranges (< 25 kg/m2; 25 kg/m2 to 30 kg/m2; 30 kg/m2 to 35 kg/m2; > 35 kg/m2) were randomly selected from 1088 consecutive shoulder MRI scans (T1 parasagittal series). Four physician-readers evaluated MRI scans and assigned modified Goutallier grades (0 to 4) in each of the four rotator cuff muscles, as well as two adjacent muscles. RESULTS: Grade distributions varied significantly based on BMI category for infraspinatus (p = 0.001), teres minor (p < 0.001), subscapularis (p = 0.025), teres major (p < 0.001) and deltoid (p < 0.001). Higher grades were evident with a diagnosis of diabetes mellitus in three of six muscles (p < 0.05), hyperlipidaemia in one muscle (p = 0.021) and greater patient age in three muscles (p < 0.05). CONCLUSIONS: Obese and severely obese patients without RCT have more fatty infiltration seen on MRI. Patient factors (older age and diagnosis of diabetes mellitus) can be predictive of fatty infiltration in RCM. Fatty infiltration of RCM is not solely attributable to the presence of a RCT.

Neural Perforasomes of the Upper Extremity.

BACKGROUND: In the setting of the rapid advancement of integumentary vascular knowledge, the authors hypothesized that the extrinsic blood supply to the major peripheral nerves of the upper extremity could be categorized into discrete neural "perforasomes." METHODS: Total limb perfusion of the arterial system was performed with gelatin-red lead oxide in cadaveric upper limbs. The perforating vessels to the radial, median, and ulnar nerves were identified, confirmed with fluoroscopy, and dissected. Distances to major anatomical landmarks of the upper extremity were measured. Additional cadaveric limbs' nerves were dissected and source arteries were selectively cannulated and injected to assess specific contribution to extrinsic nerve perfusion. The perfusion of each nerve was then calculated among all specimens. RESULTS: The radial, median, and ulnar nerve perforators were mapped. The corresponding neural perforasomes were mapped. The distal portions of the superficial radial nerve and the posterior interosseous nerve demonstrated a lack of staining. Similarly, at the carpal tunnel and at the proximal 25 percent of the median nerve (corresponding to the pronator teres), the nerve lacked vascular staining. At the Guyon canal and the flexor carpi ulnaris, the ulnar nerve demonstrated a lack of vascular staining. CONCLUSIONS: Peripheral nerves can be divided into neural perforasomes with limited overlap. The extrinsic perfusion of peripheral nerves is highly segmental. Absent stains within the nerves correspond to common sites of compression: carpal tunnel and pronator teres for the median nerve, supinator for the posterior interosseous nerve, and the Guyon canal and the flexor carpi ulnaris for the ulnar nerve.

Surgical Management of Proximal Tibiofibular Joint Instability Using an Adjustable Loop, Cortical Fixation Device.

A technique for proximal tibiofibular joint stabilization using an adjustable loop, cortical fixation device is presented. A standard diagnostic arthroscopy is performed to exclude intra-articular pathology. After arthroscopy, a 5-cm posterior-based curvilinear incision is made over the fibular head with dissection of the fascia and decompression of the common peroneal nerve ensuring adequate exposure of the fibular head. A guidewire is placed across 4 cortices using fluoroscopic guidance from the fibular head to the anteromedial tibia. A cannulated drill bit is guided through the 4 cortices. A shuttle wire carrying the adjustable loop, cortical fixation device is fed from lateral to medial and through the skin until the medial cortical button is deployed. The device is tightened until the lateral circular cortical button is secured on the fibula. Fluoroscopy is performed to confirm the button position. The device is secured after tensioning by tying the sutures. To confirm joint stabilization, a shuck test can be performed. If a second fixation device is necessary, this procedure can be repeated distally to the first.

Influence of Trainee Experience on Choice of Orthopaedic Subspecialty Fellowship.

INTRODUCTION: Most orthopaedic surgery residents elect to pursue additional subspecialty training; however, factors influencing the choice of subspecialty and the ways that these factors change during training are not well understood. The aim of this investigation was to determine, on the basis of a trainee's postgraduate year (PGY), whether variability exists in factors valued when choosing a specific subspecialty. METHODS: We emailed an online survey (intended for distribution to current trainees) to a list of orthopaedic surgery residency program coordinators in the United States. The survey queried demographic information, PGY level, and the importance of 14 discrete factors in the selection of fellowship specialty according to a Likert scale rating from 1 to 4. RESULTS: There were 359 respondents representing an even distribution of PGY levels. Junior trainees assigned greater relative value to geographic location, on-call responsibilities, financial compensation, and the tradition of the residency program, whereas senior trainees assigned greater relative value to variety of cases and intellectual stimulation (all P < 0.05). DISCUSSION: The differences seen in factors valued based on trainee experience may highlight the relative importance of greater exposure to the breadth of orthopaedic surgical practice during training and increasing awareness of clinical competencies and responsibilities. CONCLUSIONS: When deciding on orthopaedic subspecialty choice, junior trainees value lifestyle factors relatively more than do senior trainees, whereas senior trainees value case variety and stimulation relatively more than junior trainees do.

Simultaneous Intraoperative Measurement of Cadaver Ankle and Subtalar Joint Compression During Arthrodesis With Intramedullary Nail, Screws, and Tibiotalocalcaneal Plate.

BACKGROUND: Suboptimal tibiotalocalcaneal arthrodesis (TTCA) fusion rates may result from inadequate compression that increases motion and interferes with bony bridging. The aim of this study was to evaluate compressive forces at the ankle and subtalar joints with 3 contemporary TTCA constructs. METHODS: Thirty fresh-frozen cadaveric lower extremity specimens were divided into 3 groups of 10 each: 3 partially threaded cannulated screws, hindfoot nail, and lateral plate. Specimens were mounted to a testing apparatus, and compression was independently measured at the tibiotalar and talocalcaneal interfaces. Statistical analysis included paired Student t tests, analysis of variance, and Tukey post hoc tests. RESULTS: Mean forces at the ankle joint for the screws, nail, and plate constructs were 331 ± 86, 479 ± 137, and 548 ± 199 N, respectively, with plates providing significantly more compression than screws ( P < .01). Similarly, subtalar compressive forces demonstrated 319 ± 105 N in the screws group, 466 ± 125 N, in the nail group, and 513 ± 181 N in the plate group, with plate compression greater than that achieved with screws ( P < .01). No differences were identified in compression between ankle and subtalar joints within specimens in any group. CONCLUSIONS: Lateral TTCA plates provided increased compressive forces at the ankle and subtalar joint compared with screws-only constructs. Hindfoot nails did not demonstrate significant differences in either of these parameters compared with plates or screws in this study. CLINICAL RELEVANCE: Hindfoot nail and lateral plate options should be strongly considered when aiming to maximize compression in patients undergoing TTCA.

Application of a Modified Pedicled Adipofascial Lateral Arm Flap in the Prevention and Treatment of Radial Nerve Injuries.

The fasciocutaneous lateral arm flap is a workhorse flap in upper extremity reconstruction. However, its adipofascial variant is not widely used. The technique can be used in various clinical scenarios. The adipofascial flap can be transposed to circumferentially wrap the radial nerve with a pliable, vascularized fat and fascial envelope, mimicking the natural fatty environment of peripheral nerves. This technique has the advantage of providing a scar tissue barrier, a barrier to hardware irritation and a milieu for vascular regeneration of the nerve. Suggested applications include nerve coverage in the setting of posterior humerus plating to prevent adhesions; anticipation of bone grafting in the setting of an open fractures with bone loss, infection, or with the use of the Masquelet technique; in revision total elbow arthroplasty or endoprosthetic humerus replacement; and in the setting of neurolysis, repair or nerve grafting. The technique is straightforward and does not require microvascular expertise.

Comparison of Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Fixation for Medial Malleolus Fractures.

INTRODUCTION: Surgical treatment of medial malleolus (MM) fractures can be performed through open or percutaneous approaches, although comparisons between these two approaches have not been undertaken. In this study, we compared patients with MM fractures treated with closed reduction and percutaneous fixation (CRPF) with patients treated with traditional open reduction and internal fixation (ORIF). METHODS: A group of 165 consecutive patients underwent surgical fixation of a closed MM fracture from 2011 to 2015 at a single institution. Thirty-one underwent CRPF and 134 underwent ORIF. Patient demographics, injury characteristics, treatment methods, and outcome variables were recorded through review of patient charts, radiographs, and surgical reports. RESULTS: The rate of MM fracture comminution was higher in the ORIF group compared with the CRPF group (9.7% vs 27.6%; P = 0.04). All other patient and injury variables were similar between the two groups. There was no statistically significant difference observed between the CRPF and ORIF groups regarding outcomes, including nonunion, malunion, time to union, rate of hardware removal, and wound complications. DISCUSSION: Both CRPF and ORIF resulted in acceptable radiographic outcomes and low complication rates for the treatment of MM fractures.

Predictors of Time to Union After Operative Fixation of Closed Ankle Fractures.

BACKGROUND: Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union. METHODS: A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student's T-test, and multivariate linear regression modeling. RESULTS: Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05). CONCLUSION: Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing. LEVELS OF EVIDENCE: Prognostic, Level IV: Case series.

Factors Influencing Orthopedic Surgery Residents' Choice of Subspecialty Fellowship.

In the setting of increasing student debt, a rapidly changing health care system, and growing transparency in the age of outcome reporting, residents have many factors to consider when determining which fellowship to pursue. An institutional review board-approved link to an online survey was emailed to orthopedic surgery trainees across the United States. Demographics were collected, and 14 fellowship influences were assessed using a Likert scale. A total of 360 responses were received. Of the respondents, 85.5% (n=308) were male and 14.5% (n=52) were female. Responses were received from every region of the United States and from every postgraduate year. Respondents represented the gamut of relationship status and indebtedness. Respondents were interested in all of the current major subspecialties. Pursuit of an intellectually stimulating subspecialty had the highest average Likert score (3.38), followed by variety of cases (3.26). The lowest scores were for residency program with a strong tradition of placing into a particular subspecialty (2.08) and potential to conduct research in that subspecialty (2.09). Marital status, number of children, and level of debt did not significantly affect the importance of factors in selecting a fellowship. Choice of subspecialty did influence the level of importance of various factors. Intellectual stimulation and a strong mentor were the most influential factors in the decision to pursue a given fellowship. Because fellowship is now the norm, it is important to understand the motives behind young orthopedic surgeons' career aspirations. [Orthopedics. 2017; 40(5):e820-e824.].

Percutaneous Treatment of Unstable Scaphoid Waist Fractures.

BACKGROUND: Percutaneous techniques have been described for the treatment of nondisplaced scaphoid fractures, although less information has been reported about outcomes for unstable, displaced fractures. The aim of this study was to evaluate the union and complication rates following manual closed reduction and percutaneous screw placement for a consecutive series of unstable, displaced scaphoid fractures. METHODS: A total of 28 patients (average age, 27 years; 22 male/6 female) were treated for isolated unstable displaced scaphoid waist fractures. Closed reduction and percutaneous headless, compression screw fixation was successfully performed in 14 patients (average age, 32 years; 10 male/4 female), and the remaining 14 patients required open reduction. Patients who underwent percutaneous treatment were followed for radiographic fracture union and clinical outcomes. RESULTS: Thirteen of 14 fractures (93%) had clinical and radiographic evidence of bone union at an average of 2.8 months postoperatively. Average visual analog pain score at the time of union was 0.9. The average Quick Disability of the Arm, Shoulder, and Hand score at 2.5 years follow-up (range, 1.5-8.3 years) was 9.6 (range, 0.0-27.3). Complications included 1 case of nonunion and 1 case of intraoperative Kirschner wire breakage. CONCLUSIONS: Manual closed reduction followed by percutaneous headless, compression screw fixation was possible in 50% of patients who presented with acute unstable, displaced scaphoid fractures. This technique appears to be a safe and effective method when a manual reduction is possible, and it may offer a less invasive option when compared with a standard open technique.

Determining the Cost-Savings Threshold and Alignment Accuracy of Patient-Specific Instrumentation in Total Ankle Replacements.

BACKGROUND: Traditional intraoperative referencing for total ankle replacements (TARs) involves multiple steps and fluoroscopic guidance to determine mechanical alignment. Recent adoption of patient-specific instrumentation (PSI) allows for referencing to be determined preoperatively, resulting in less steps and potentially decreased operative time. We hypothesized that usage of PSI would result in decreased operating room time that would offset the additional cost of PSI compared with standard referencing (SR). In addition, we aimed to compare postoperative radiographic alignment between PSI and SR. METHODS: Between August 2014 and September 2015, 87 patients undergoing TAR were enrolled in a prospectively collected TAR database. Patients were divided into cohorts based on PSI vs SR, and operative times were reviewed. Radiographic alignment parameters were retrospectively measured at 6 weeks postoperatively. Time-driven activity-based costing (TDABC) was used to derive direct costs. Cost vs operative time-savings were examined via 2-way sensitivity analysis to determine cost-saving thresholds for PSI applicable to a range of institution types. Cost-saving thresholds defined the price of PSI below which PSI would be cost-saving. A total of 35 PSI and 52 SR cases were evaluated with no significant differences identified in patient characteristics. RESULTS: Operative time from incision to completion of casting in cases without adjunct procedures was 127 minutes with PSI and 161 minutes with SR ( P < .05). PSI demonstrated similar postoperative accuracy to SR in coronal tibial-plafond alignment (1.1 vs 0.3 degrees varus, P = .06), tibial-plafond alignment (0.3 ± 2.1 vs 1.1 ± 2.1 degrees varus, P = .06), and tibial component sagittal alignment (0.7 vs 0.9 degrees plantarflexion, P = .14). The TDABC method estimated a PSI cost-savings threshold range at our institution of $863 below which PSI pricing would provide net cost-savings. Two-way sensitivity analysis generated a globally applicable cost-savings threshold model based on institution-specific costs and surgeon-specific time-savings. CONCLUSIONS: This study demonstrated equivalent postoperative TAR alignment with PSI and SR referencing systems but with a significant decrease in operative time with PSI. Based on TDABC and associated sensitivity analysis, a cost-savings threshold of $863 was identified for PSI pricing at our institution below which PSI was less costly than SR. Similar internal cost accounting may benefit health care systems for identifying cost drivers and obtaining leverage during price negotiations. LEVEL OF EVIDENCE: Level III, therapeutic study.

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon Surgery Wound Complications.

INTRODUCTION: Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here, we describe coverage of a series of posterior heel and Achilles wounds via simple, local tissue transfer, called a bipedicle fasciocutaneous flap. This flap can be performed by an orthopaedic foot and ankle surgeon, without resources of tertiary/specialized care or microvascular support. METHODS: Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 2 was a heel venous stasis ulcer with calcaneal exposure in a diabetic patient with vasculopathy. Case 3 was a patient with wound breakdown following midsubstance Achilles tendon repair. All three cases were treated with a single-stage bipedicle local tissue transfer for posterior ankle and heel wound complications. RESULTS: All 3 patients demonstrated complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site after surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. CONCLUSIONS: The bipedicled fasciocutaneous flap described here offers a predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap can be performed with short operative times and can be customized to facilitate defect coverage. The flap is durable to withstand local tissue stresses required for early ambulation. Despite its reliability, patients require careful follow-up to manage underlying comorbid conditions that may complicate wound healing. LEVELS OF EVIDENCE: Level IV: Case series.

Obese Patients Have Fewer Wound Complications Following Fixation of Ankle Fractures.

Outcomes following ankle fracture surgery have been well studied; however, factors associated with surgical wound healing specifically are less clear. We aimed to study the relationship between wound healing and body mass index, as well as other variables following surgical treatment of ankle fractures. There were 127 consecutive, isolated, closed, malleolar ankle fractures treated with open reduction and internal fixation at a level-1 trauma center from 2008 to 2012. Patient, injury, and treatment variables were recorded and clinical records were reviewed to identify wound complications. There were 6 major and 18 minor wound complications. The overall rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared with 25.4% (17/67, P < .05) in nonobese patients. When controlling for other variables obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087-0.822), as was low energy mechanism (OR 0.246, 95% CI 0.067-0.906). No other covariates tested were associated with an increased risk of a wound infection. Ankle anatomy may present a unique situation whereby obesity may be protective against wound complications. Further studies are needed to confirm this clinical observation, and to demonstrate the mechanism through which this may occur. LEVELS OF EVIDENCE: Therapeutic, Level IV: Retrospective.

Management of the Essex-Lopresti Injury.

Essex-Lopresti injuries (ELIs) are characterized by fracture of the radial head, disruption of the forearm interosseous membrane, and dislocation of the distal radioulnar joint. This injury pattern results in axial and longitudinal instability of the forearm. Initial radiographs may fail to reveal the full extent of the injury, and therefore diagnosis in the acute setting requires a high index of suspicion. Early recognition and treatment are preferred as failure to fully treat the problem may result in chronic wrist pain from ulnar abutment or chronic elbow pain from radiocapitellar arthrosis. In this article the presentation, relevant anatomy, and management options for ELIs are overviewed, and a summary of outcomes reported in the literature is provided. Additionally, the preferred surgical technique of the senior author is presented, which involves reconstruction of the interosseous membrane with a local pronator rerouting autograft.

Technique Tip: The Use of Cannulated Drill as a Tamp to Remove Loose Cannulated Screws.

UNLABELLED: Subtalar arthrodesis is considered to be the gold standard surgical solution for end-stage subtalar joint arthrosis. Although subtalar joint fusion rates are high, nonunion has been reported to range from 0% to 43%. Revision subtalar arthrodesis regardless of etiology often requires removal of loose hardware in soft bone. The inability of screw threads to engage bone may result in longer operative time, frustration for the surgeon, and potential negative outcome for the patient. We describe a novel technique in which a cannulated drill bit is used as a tamp to remove subtalar arthrodesis screws. We have found this method to be efficient and safe and transferable to any extremity. LEVELS OF EVIDENCE: Therapeutic, Level V: Expert opinion.