Ultrasound versus MRI in the evaluation of the thumb metacarpophalangeal joint.

An intricate and unique combination of ligamentous, fibrocartilaginous, and osseous structures stabilize the thumb metacarpophalangeal joint. Both ultrasound and high-resolution magnetic resonance imaging are extremely useful in evaluating these critical structures. This article reviews common injuries of the thumb metacarpophalangeal joint, while highlighting the merits, limitations, and pitfalls of the two imaging modalities. A clear appreciation of each method, paired with anatomic knowledge, will lend greater confidence and accuracy to diagnosing impactful injuries and guiding intervention.

The Role of Surgery in the Management of Radiation-Induced Brachial Plexopathy.

Radiation-induced brachial plexopathy (RIBP) is a rare long-term complication of radiation therapy often causing pain, motor deficit, and overall quality of life reduction for affected patients. While a standard treatment for RIBP is yet to be established, management consists mostly of symptom management through the use of medications and physical therapy. There is a lack of evidence regarding the efficacy of surgical treatment. Omentoplasties and other vascularized flaps are commonly discussed options for eliminating neuropathic pain associated with RIBP. However, these approaches show no meaningful improvement in motor function. While limited, current literature suggests that nerve transfers may be an option for relief of neuropathic pain as well as restoration of motor function. This review of literature explores the options available to those affected by RIBP with a focus on the role of surgery.

Excision of recurrent penile schwannoma with neurovascular bundle sparing: A novel surgical approach.

Penile schwannomas are rare, often painless lesions usually growing on the dorsum of the penis. A young and otherwise healthy male with recurrent painful penile schwannomas and decreased libido was successfully treated with surgical excision. Through fine dissection of the nerve fascicles leading to the primary schwannoma, the lesion was successfully removed without compromising erectile or ejaculatory function. This novel approach allowed for significant symptomatic relief and improved quality of life.

Preinjury Social Determinants of Health Disparities Predict Postinjury Psychosocial Conditions in Adult Traumatic Brachial Plexus Injuries.

BACKGROUND: Adult traumatic brachial plexus injuries (TBPIs) are life-altering events that can have detrimental effects on a patient's quality of life. OBJECTIVE: To examine how social determinants of health (SDOH) disparities influence the risk of developing new psychosocial conditions after TBPIs in previously psychiatric-naïve patients. METHODS: Between January 2010 and June 2019, a retrospective analysis was performed using PearlDiver's Mariner, an all-payer claims database, to create 3 cohorts: TBPI disparity cohort: patients with TBPI and presence of at least 1 SDOH disparity before injury, TBPI without disparity cohort: patients with TBPI and the absence of any SDOH disparity, and control cohort: patients without TBPIs. RESULTS: The matched population analyzed in this study consisted of 1176 patients who were equally represented in the TBPI disparity cohort (n = 392, 33.33%), TBPI without disparity cohort (n = 392, 33.33%), and control cohort (n = 392, 33.33%). A total of 301 patients developed any psychosocial condition with 4 years of their injury. Patients in the TBPI disparity cohort had significantly higher rates of developing any psychosocial condition (31.12%, P < .0005), depression (22.70%, P = .0032), anxiety (18.62%, P = .0203), drug abuse (7.91%, P = .0060), and alcohol abuse (4.85%, P = .03499) when compared with the other cohorts. Furthermore, the disparity cohort carried a significantly increased risk of developing any psychosocial condition (hazard ratio 1.42, 95% CI 1.09-1.86). The rates of suicide attempt, post-traumatic stress disorder, and divorce did not significantly differ between groups. CONCLUSION: TBPI patients with SDOH disparities are at increased risk of developing new-onset psychosocial conditions, such as depression, anxiety, drug abuse, and alcohol abuse. Level of Evidence: Prognostic Level III.

Surgical Trigger Finger Release Is Associated With New-Onset Dupuytren Contracture in the Short-Term Postoperative Period: A Matched Analysis.

BACKGROUND: This article compares the rates and time-to-development of new-onset Dupuytren disease in patients with trigger finger treated by steroid injection, surgical release, or both. METHODS: PearlDiver's Mariner 30 database was queried to identify patients with trigger finger between January 2010 and June 2019. One-to-one exact matching based on baseline patient demographics allowed us to create 4 identical groups defined by the type of trigger finger intervention received. RESULTS: The matched population analyzed in this study consisted of 85 944 patients who were equally represented in the steroid injection cohort (n = 21 486, 25.00%), surgical release cohort (n = 21 486, 25.00%), steroids prior to surgery cohort (n = 21 486, 25.00%), and no intervention (control) cohort (n = 21 486, 25.00%). A new Dupuytren diagnosis after trigger finger treatment occurred in 1 in 128 patients overall, 1 in 156 patients treated with steroid injection, and 1 in 126 patients treated with surgical release. Trigger fingers treated by steroid injection only had the lowest rates of Dupuytren disease overall (n = 137, 0.64%, P = .0424) and treatment with fasciectomy (n = 14, 0.07%, P < .0005). In all, 171 patients in the surgery cohort developed Dupuytren disease 1 year after undergoing surgical trigger finger release. Furthermore, this cohort had the highest rates of fasciectomy (n = 55, 0.26%, P < .0005) and the lowest rates of no intervention (n = 103, 0.48%, P = .0471). Trigger fingers managed by surgical release developed Dupuytren disease (mean, 56.11 days; SD, 80.93 days, log-rank P = .02) and underwent fasciectomy (mean, 49.74 days; SD, 62.27 days; log-rank P < .0005) more quickly than all other cohorts. CONCLUSIONS: Patients solely undergoing surgical release of their trigger finger had significantly higher odds and expedited rate of developing new-onset Dupuytren disease overall and undergoing subsequent treatment by fasciectomy compared with trigger fingers managed by other interventions.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy.

BACKGROUND: Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies. METHODS: A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher. CONCLUSION: Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Effect of Anticoagulation on the Treatment of Dupuytren Contracture with Collagenase.

BACKGROUND: There have been no formal studies of the use of collagenase clostridium histolyticum (Xiaflex; Endo Pharmaceuticals, Malvern, Pa.) in the anticoagulated patient. Previous study on its use excluded patients receiving anticoagulation therapy. This study reviewed the effects of anticoagulation use in patients undergoing collagenase clostridium histolyticum injection and cord rupture to determine safety and efficacy. METHODS: The authors retrospectively reviewed patients receiving collagenase clostridium histolyticum injections for Dupuytren contracture between 2010 and 2017. Outcomes included type of anticoagulation, skin tear, tendon rupture, lymphadenopathy, sensory abnormality, hematoma, and bleeding. RESULTS: A total of 388 injections were performed in 197 patients. The average clinical follow-up was 311 days. Fifty-two percent of patients (n = 201) were anticoagulated. The vast majority were taking aspirin (acetylsalicylic acid) (n = 182), followed by warfarin (n = 27), clopidogrel (n = 9), apixaban (n = 8), rivaroxaban (n = 4), and dabigatran (n = 2). There were 42 skin tears, 21 in the anticoagulated group. One tendon rupture occurred in the anticoagulated group (acetylsalicylic acid) and none occurred in the nonanticoagulated group (p = 0.34). No patients experienced sensory abnormalities, a hematoma requiring intervention, or uncontrollable bleeding. CONCLUSIONS: Anticoagulation is commonly encountered by hand surgeons treating Dupuytren contracture. There is no significant difference in complications in the anticoagulated patient versus the nonanticoagulated patient. It is safe to perform collagenase clostridium histolyticum injections for Dupuytren contracture in the anticoagulated patient, regardless of the type of anticoagulation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Orthopedics and US Politics: Trends in Political Donations by Orthopedic Surgeons.

The political climate surrounding health care policy in the United States has become increasingly controversial over the past two decades. Policies influencing the provision and administration of health care have provoked more political activism among physician stakeholders. Herein we describe the trends in political donations made by US orthopedic surgeons from 2003 to 2020. Political donation data from 2003 to 2020 were obtained from the Federal Election Commission website. Contributions were filtered by occupation matching either "orthopedic surgeon" or "orthopaedic surgeon." Individual contributions were assigned to a beneficiary committee associated with a political party and used to classify donations as Independent, Republican, or Democratic. A total of 71,492 donations amounting to $30,930,242 were made by orthopedic surgeons between 2003 and 2020. The number of donations increased from 1368 in 2003 to 14,961 in 2020, with Independent committees averaging 68.4% of donations over the 18-year period. From 2003 to 2020, monies donated to Independent committees decreased from 71% to 34%, Republican donations increased from 23% to 55%, and Democratic donations increased from 6% to 11%. When stratified by state, orthopedic surgeon contributions favored Independent committees. There has been an increase in political involvement among US orthopedic surgeons in the past 18 years. Contributions to Independent committees were the most common; however, most donations were allocated to the American Academy of Orthopaedic Surgeons Independent political action committee, which has traditionally supported Republican candidates. Contributions became partisan in 2020 in favor of Republican committees. [Orthopedics. 2022;45(3):134-138.].

Trends in Peripheral Nerve Surgery: Workforce, Reimbursement, and Procedural Rates.

BACKGROUND: Peripheral nerve surgery is one of the smallest neurosurgical subspecialties. It is hypothesized that the number of neurosurgeons performing these procedures has declined over the last decade due to many factors, including limited training opportunities and lower compensation relative to other subspecialties. METHODS: Data for physicians who performed peripheral nerve surgical procedures (PNSPs) were obtained from the Medicare Provider Utilization Database and used to calculate the total number of procedures performed by physicians of each specialty for each year. The Physician Fee Schedule Look-Up Tool was used to determine reimbursement rates for the top 5 PNSPs for neurosurgeons, which were then adjusted for inflation using the U.S. Bureau of Labor's Consumer Price Index Inflation Calculator. RESULTS: From 2012 to 2019, the top 3 contributing specialties were orthopedic surgery, urology, and hand surgery. Both the percentage of PNSPs performed by neurosurgeons and the number of neurosurgeons performing PNSPs decreased. Between 2000 and 2020, the average reimbursement for the commonly identified codes 64721, 64718, 64722, and 64718 decreased, whereas the reimbursement for 64555 (implantation of peripheral nerve neurostimulator electrodes) increased. CONCLUSIONS: Despite an overall increase in number of PNSPs, the percentage of PNSPs performed by neurosurgeons decreased from 2012 to 2019. There was overall workforce exit among neurosurgical peripheral nerve specialists over time. From 2000 to 2020, the average reimbursement for most PNSPs has decreased. Further investigation is needed to establish factors contributing to these trends and how they may be mitigated.

Addition of an Oblique Interfragmentary Screw to T-plate Fixation Decreases Nonunion Rate in Trapeziometacarpal Arthrodesis.

Background: T-plate fixation is a popular method for trapeziometacarpal arthrodesis in patients with osteoarthritis. Previous studies report an 8% to 18% rate of symptomatic nonunion and a 26% rate of radiographic nonunion. In this study, we present our surgical technique of trapeziometacarpal arthrodesis using the addition of an oblique interfragmentary screw to T-plate fixation on the rate of symptomatic and radiographic nonunion. Methods: A retrospective review of all trapeziometacarpal arthrodeses for osteoarthritis was completed by a single surgeon between 2010 and 2018. Preoperative demographics, pain, and Eaton classification were included. The technique was identical in all surgical cases, using a T-plate and oblique interfragmentary screw across the arthrodesis site from the metacarpal to the trapezium. Postoperative nonunion rate and time to clinical healing (absence of pain) and radiographic union were reviewed. Results: A total of 22 trapeziometacarpal arthrodeses were performed on 17 patients using the above technique. The average age was 53 years, 71% were women, and 53% involved the dominant hand. Mean preoperative Eaton classification was 2.74 (±0.73). Mean time to clinical healing was 34 days (±12 days), and mean time to radiographic union was 55 days (±23 days). Mean follow-up was 9 months, and no patients were found to have symptomatic or radiographic nonunion. Hardware removal was required bilaterally in 1 patient after complete healing. Conclusions: The addition of an oblique interfragmentary screw to T-plate fixation is a novel technique in trapeziometacarpal arthrodesis, resulting in no symptomatic or radiographic nonunion.

The Effects of Obesity and Bariatric Surgery on Rates of Upper Extremity Compression Neuropathies.

Objectives: To estimate the effects of obesity on all types of upper extremity compression neuropathies (UECN) (carpal tunnel syndrome and other median nerve, radial nerve, and ulnar nerve compression neuropathies) and to assess whether bariatric surgery modifies these effects. Background: UECN are increasingly prevalent and decrease the quality of life of affected individuals. Studies suggest obesity as a risk factor for carpal tunnel syndrome, the most common type of UECN. Methods: A retrospective cohort study was conducted using the PearlDiver Mariner Database, an all-payor claims database containing claims for over 53 million patients from 2010 to 2019 in all 50 US states. Rates and odds of all types of UECN were compared between 1:1:1 exact matched cohorts of obese patients who were medically managed, obese patients who underwent bariatric surgery, and nonobese patients (111,967 patients in each cohort). Results: Compared with nonobese patients, patients with obesity were significantly more likely to develop any UECN (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.09-1.18), carpal tunnel syndrome (OR, 1.15; 95% CI, 1.10-1.30), and 2 or more UECN (OR, 1.34; 95% CI, 1.20-1.48). Compared with obese patients who were managed medically, obese patients who underwent bariatric surgery were significantly less likely to develop any UECN (OR, 0.87; 95% CI, 0.84-0.91) and carpal tunnel syndrome (OR, 0.85; 95% CI, 0.81-0.89). Conclusions: Obese patients have higher odds of both single and concomitant UECN, specifically carpal tunnel syndrome, compared with nonobese patients. Bariatric surgery decreases the odds of developing UECN compared with obese patients not undergoing surgical intervention.

Right radial nerve decompression for refractory radial tunnel syndrome.

BACKGROUND: Radial tunnel syndrome arises due to compression of the radial nerve through the radial tunnel.[1,5] The radial nerve divides into superficial and deep branches in the forearm. The deep branch travels posteriorly through the heads of the supinator where compression commonly occurs.[3,9,7] This syndrome results in pain in the hand and forearm with no motor weakness.[8] This condition can be treated conservatively with splinting and anti-inflammatory medication.[2,4,6] For cases of refractory radial tunnel syndrome, surgical management can be considered. Herein, we have presented a step-by-step video guide on how to perform a radial nerve decompression with a review of the relevant anatomy and surgical considerations. CASE DESCRIPTION: A 68-year-old right-handed woman presented to the Mayo Clinic (Scottsdale, AZ) with the right elbow pain which radiated to the forearm causing significant difficulties with daily tasks. She had been dealing with worsening symptoms for 4 months. The patient's history of gardening and clinical presentation allowed for diagnosis of radial tunnel syndrome. After conservative measures failed and other differential diagnoses were excluded, surgical decompression was recommended to treat her symptoms. The patient's right arm was marked preoperatively between the brachioradialis and extensor carpi radialis longus (ECRL) muscles. The posterior cutaneous nerve of the forearm was identified which allowed for the determination of the interval between the brachioradialis and ECRL. Separation of the two muscles allowed for the identification of the radial sensory nerve. A nerve stimulator was used to confirm the sensory nature of this nerve. The nerve to the extensor carpi radialis brevis (ECRB) was identified and retracted with a vessel loop. Dorsal to the nerve to the ECRB is the posterior interosseous nerve (PIN), which was identified and retracted with a vessel loop. The fascia of the ECRB was divided both longitudinally and transversely and the supinator below was identified. The supinator muscle was carefully divided to further decompress the PIN. Informed consent for publication of this material was obtained from the patient. CONCLUSION: The patient tolerated the procedure well and reported significantly reduced pain at 7-month follow-up. To the best of our knowledge, video tutorials on this procedure have not been published. This video can serve as an educational guide for peripheral nerve specialists dealing with similar lesions.