Intramedullary Screw Fixation of Olecranon Fractures Reduces the Risk of Early Unplanned Reoperation: A Retrospective Review of 556 Patients.

OBJECTIVES: To determine the effect of intramedullary screw-based fixation on early postoperative complications after olecranon fractures. We hypothesized that intramedullary screw-based fixation results in decreased need for reoperation compared with plate and screw-based and tension band-based fixation. DESIGN: Retrospective cohort. SETTING: Two academic Level-1 trauma centers. PATIENTS/PARTICIPANTS: Five hundred fifty-six patients treated with a tension band-based, plate and screw-based, or intramedullary screw-based construct for an olecranon fracture over a 10-year period. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENT: Unplanned reoperation. Demographic, injury type and severity, supplemental fixation, and length of follow-up data were viewed as potential confounders and analyzed as such. RESULTS: We identified 556 relevant patients. One hundred ninety-nine patients were treated with an intramedullary screw-based construct, 229 with a plate and screw-based construct, and 128 with a tension band-based construct. We observed significant differences in the age, fracture type, percentage of open fractures, use of supplemental fixation, and treating institution between the treatment groups. Ninety-five patients (17.1%) had an unplanned reoperation. When we adjusted for confounders, intramedullary screw-based fixation reduced the odds of an unplanned reoperation by 54% compared with plate and screw-based treatment. In the adjusted analysis, we did not observe a difference between plate and screw-based treatment and tension band-based fixation. CONCLUSIONS: Intramedullary screw-based fixation of olecranon fractures results in decreased need for early reoperation compared with more common olecranon fixation strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Four Ways Plastic Surgeons Can Fight Climate Change.

The climate crisis demands that surgeons reduce their environmental impact. Operating rooms are resource-intensive and are often wasteful. This makes them fitting targets for climate-conscious decision making. METHODS: We searched for peer-reviewed literature describing how plastic surgeons might positively affect the environment through action in the operating room. RESULTS: Several evidence-based, pro-climate practices may be undertaken by plastic surgeons. These strategies may be grouped into 4 types: material, energy, technique, and dissemination. Each strategy is a way to reduce, reuse, recycle, research, or rethink. CONCLUSIONS: Administrative obstacles to greener operating rooms are predictable and surmountable, especially because environmentally minded decisions are likely to save money. We anticipate a surge of environmental consciousness in healthcare. Plastic surgeons, as thought leaders, are well positioned to champion this cause.

The Effect of Malnutrition on Postoperative Complications Following Surgery for Distal Radius Fractures.

PURPOSE: Malnutrition is known to negatively affect outcomes after arthroplasty, hip fracture, and spine surgery. Although distal radius fracture surgery may be considered in a similar patient cohort, the effect of malnutrition in this scenario is unknown. We hypothesized that admission serum albumin level, as a marker for malnutrition, would correlate with the rate of postoperative complications following surgery for distal radius fracture. METHODS: We performed a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement database. Patients undergoing open reduction and internal fixation of a distal radius fracture were identified using Current Procedural Terminology codes. We excluded patients who were septic at presentation, were multiply injured, or had open fractures. We collected patient demographics, length of stay, 30-day complications, reoperation, and readmission rates. We performed multivariable linear regression analysis controlling for age, sex, body mass index, operative time, discharge destination, and modified Frailty Index score. RESULTS: We identified 1,989 patients (mean age, 56 years; range, 18-90 years) with available albumin levels, and 14.7% had hypoalbuminemia (albumin, < 3.5 g/dL). Multivariable regression revealed that malnourished patients had higher rates of postoperative complications (6.5% vs 1.3%; odds ratio [OR] 4.88; 95% confidence interval [95% CI], 2.47-9.66). Specifically, these patients had increased rates of Clavien-Dindo IV (life-threatening) complications (2.4% vs 0%), readmission (7.2% vs 2%; OR, 3.37; 95% CI, 1.88-6.03), and mortality (1.7% vs 0.1%; OR, 9.23; 95% CI, 1.55-54.87). Malnourished patients had significantly longer length of stay (3.55 vs 0.73 days). Albumin concentration was inversely associated with risk of death (OR, 0.12; 95% CI, 0.03-0.52). CONCLUSIONS: Malnutrition, indicated by albumin less than 3.5 g/dL, is a powerful predictor of uncommon, but important, postoperative complications, including mortality, following surgery for distal radius fracture. Evaluation of preoperative albumin level may, therefore, help surgeons provide individualized counseling and more accurately stratify the risk of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Repaired Flexor Tendon Excursion with Half a Fist of True Active Movement Versus Full Fist Place and Hold in the Awake Patient.

Supplemental Digital Content is available in the text.

The Multidisciplinary Approach to the Diagnosis and Management of Nonobstetric Traumatic Brachial Plexus Injuries.

OBJECTIVE: Nonobstetric traumatic brachial plexus injuries can result in significant morbidity and chronic disability if not managed in a timely manner. Functional arm recovery is possible, but it requires a multidisciplinary approach toward the diagnosis and management of such injuries. CONCLUSION: This article provides an overview of the clinical, electrophysiology, and diagnostic imaging knowledge needed for accurate imaging interpretation and to participate in multidisciplinary discussions aimed at expediting optimal patient management.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures.

PURPOSE: Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures. METHODS: We retrospectively reviewed the American College of Surgeons-National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed. RESULTS: We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS. CONCLUSIONS: A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Ten Tips to Simplify the Spaghetti Wrist.

Hand surgeons refer to deep lacerations of the volar distal forearm as "spaghetti wrists." Given that multiple tendons, vessels, and nerves often require repair, this injury may be intimidating. We review management of spaghetti wrists and summarize with 10 simplifying tips.

Ulnar Artery Aneurysm in a 6-Month-Old: A Case Report.

BACKGROUND: Pediatric ulnar aneurysms are rare and, unlike their adult counterparts, cannot be explained by repetitive trauma to the palm. A small number of case reports describe diagnostic difficulty with these lesions and different treatments. METHODS: We present the case of a 6-month-old with an ulnar artery aneurysm of unknown cause. The diagnosis was supported with magnetic resonance imaging, and the lesion was resected. RESULTS: Because the hand remained well perfused, the ulnar artery was not reconstructed. CONCLUSIONS: Although the early result was good, the long-term outcome of this approach is unknown.

Suture-Button Reconstruction of the Interosseous Membrane.

BACKGROUND: Reconstruction of the interosseous membrane (IOM) may play a role in the treatment of acute and chronic longitudinal forearm instability. Several reconstruction techniques have been proposed. Suture-button reconstruction is attractive because it obviates donor site morbidity and is relatively easy to perform. How this method compares to its alternatives, however, is unknown. MATERIALS AND METHODS: We review literature describing reconstruction of the forearm axis. We describe how we perform suture-button reconstruction of the IOM, summarize our previously published biomechanical data on the subject, and offer a case report. DESCRIPTION OF TECHNIQUE: A suture-button is implanted so as to approximate the course of the interosseous ligament. This may be accomplished percutaneously, or when grafting is desired, through an open approach. RESULTS: Data informing the choice of one reconstruction technique over another consist mostly of biomechanical studies and a small number of case reports. CONCLUSIONS: Suture-button reconstruction of the IOM may encourage anatomic healing of acute forearm axis injuries especially as an adjunct to radial head replacement or repair. Chronic injuries may benefit from a combination suture-button graft construct and ulnar shortening osteotomy.

Identifying the Risk of Swallowing-Related Pulmonary Complications in Older Patients With Hip Fracture.

To identify and potentially modify the risk of pulmonary complications in a group of older patients with hip fracture, the authors obtained speech and language pathology consultations for these patients. Then they performed a retrospective chart review of all patients 65 years and older who were admitted to their institution between June 2011 and July 2013 with acute hip fracture, were treated surgically, and had a speech and language pathology evaluation in the immediate perioperative period. The authors identified 52 patients who met the study criteria. According to the American Society of Anesthesiologists (ASA) classification system, at the time of surgery, 1 patient (2%) was classified as ASA I, 12 patients (23%) were ASA II, 26 (50%) were ASA III, and 12 (23%) were ASA IV. Based on a speech and language pathology evaluation, 22 patients (42%) were diagnosed with dysphagia. Statistical analysis showed that ASA III status and ASA IV status were meaningful predictors of dysphagia and that dysphagia itself was a strong risk factor for pulmonary aspiration, pneumonia, and aspiration pneumonitis. Evaluation by a speech and language pathologist, particularly of patients classified as ASA III or ASA IV, may be an efficient means of averting pulmonary morbidity that is common in older patients with hip fracture.

The hand surgery fellowship application process: expectations, logistics, and costs.

PURPOSE: To investigate expectations, logistics, and costs relevant to the hand surgery fellowship application process. We sought to discover (1) what both applicants and program directors are seeking, (2) what both parties have to offer, (3) how both parties collect information about each other, and (4) the costs incurred in arranging each match. METHODS: We conducted on-line surveys of hand surgery fellowship applicants for appointment in 2015 and of current fellowship program directors. RESULTS: Sixty-two applicants and 41 program directors completed the survey. Results revealed applicants' demographic characteristics, qualifications, method of ranking hand fellowship programs, costs incurred (both monetary and opportunity) during the application process, ultimate match status, and suggestions for change. Results also revealed program directors' program demographics, rationale for offering interviews and favorably ranking applicants, application-related logistical details, costs incurred (both monetary and opportunity) during the application process, and suggestions for change. CONCLUSIONS: Applicants for hand surgery fellowship training are primarily interested in a potential program's academic reputation, emphasis on orthopedic surgery, and location. The typical, successfully matched applicant was a 30-year-old male orthopedic resident with 3 publications to his credit. Applicants rely on peers and Web sites for information about fellowships. Fellowship directors are primarily seeking applicants recommended by other experienced surgeons and with positive personality traits. The typical fellowship director offers a single year of orthopedic-based fellowship training to 2 fellows per year and relies on a common application and in-person interviews to collect information about applicants. Applicants appear to be more concerned than directors about the current state of the match process. Applicants and directors alike incur heavy costs, in both dollars and opportunity, to arrange each match. A nuanced understanding of the match process suggests specific changes and may help reduce these costs. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis V.

The biomechanical stability of salvage procedures for distal radioulnar joint arthritis.

PURPOSE: To test distal forearm stability after 3 surgical procedures for distal radioulnar joint (DRUJ) arthritis. METHODS: We tested 11 cadaver limbs with the DRUJ intact, after distal ulna-matched hemiresection, after Darrach distal ulna resection, and after unlinked total DRUJ arthroplasty. We evaluated distal forearm stability in neutral rotation, full pronation, and full supination in unweighted and 1-kg-weighted conditions. We measured dorsal/palmar translation and convergence/divergence of the distal radius relative to the ulna. RESULTS: Under neutral rotation, whether weighted or unweighted, matched hemiresection and Darrach specimens demonstrated significant radioulnar convergence relative to intact specimens. Weighted and unweighted, DRUJ arthroplasty demonstrated similar radioulnar convergence to intact. Weighted and unweighted, only Darrach specimens showed significant radius-palmar translation compared with intact, hemiresected, and DRUJ arthroplasty. In pronation, no testing scenario, either weighted or unweighted, demonstrated statistically significant radioulnar convergence relative to intact state. In unweighted pronation, palmar translation of the radius was significantly different from the intact state for all surgical scenarios and the Darrach was significantly worse than the other procedures. In weighted pronation, palmar translation of the radius was significantly different from the intact state for all surgical scenarios and the matched hemiresection was significantly better than the other procedures. In supination, weighted and unweighted, Darrach specimens had significant radioulnar convergence relative to intact. Either weighted or unweighted, the hemiresection and arthroplasty groups demonstrated similar radioulnar convergence relative to intact. Unweighted, all scenarios demonstrated similar dorsal translation of the radius. Weighted, the Darrach group showed significant radius-dorsal translation relative to intact specimens. CONCLUSIONS: For tested procedures, DRUJ arthroplasty overall was biomechanically superior to the other conditions except that we found greater stability in the hemiresected group in weighted pronation. CLINICAL RELEVANCE: Knowledge of baseline biomechanical characteristics of DRUJ arthritis procedures will aid surgical decision-making and patient counseling.

Deep vein thrombosis and pulmonary embolism after spine surgery: incidence and patient risk factors.

Anticoagulation after spine surgery confers the unique risk of epidural hematoma. We sought to determine the incidence of and patient risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) after spine surgery. We retrospectively reviewed the charts of 1485 patients who had spine surgery at a single tertiary-care center between 2002 and 2009. DVT and PE incidence were recorded along with pertinent patient history information. Univariate and multivariate analyses were performed on the data. VTE incidence was 1.1% (DVTs, 0.7%; PEs, 0.4%). Univariate analysis demonstrated that VTEs had 9 positive risk factors: active malignancy, prior DVT or PE, estrogen replacement therapy, discharge to a rehabilitation facility, hypertension, major depressive disorder, renal disease, congestive heart failure, and benign prostatic hyperplasia (P<.05). Multivariate analysis demonstrated 4 independent risk factors: prior DVT or PE, estrogen replacement therapy, discharge to a rehabilitation facility, and major depressive disorder (P>.05). Surgeons with an improved understanding of VTE after spine surgery can balance the risks and benefits of postoperative anticoagulation.

Hand fractures: a review of current treatment strategies.

Fractures of the tubular bones of the hand are common and potentially debilitating. The majority of these injuries may be treated without an operation. Surgery, however, offers distinct advantages in properly selected cases. We present a review of hand fracture management, with special attention paid to advances since 2008. The history and mechanisms of these fractures are discussed, as are treatment options and common complications. Early mobilization of the fractured hand is emphasized because soft tissue recovery may be more problematic than that of bone.

Instrumented reduction of a fixed C1-2 subluxation using occipital and C2/C3 fixation: A case report.

BACKGROUND: Different strategies exist for reduction of the cervical spine. Placement of C1 lateral mass screws is a powerful technique but may be impossible in a degenerative or revision setting. We report the open, posterior-only, and instrumented reduction of a fixed C1-2 subluxation using occipital and C2/C3 fixation. The patient had rheumatoid arthritis and had undergone previous surgery of the cervical spine. METHODS: We performed a retrospective chart review and focused appraisal of the literature. RESULTS: Satisfactory reduction was achieved with this infrequently reported technique. CONCLUSIONS/LEVEL OF EVIDENCE: Spine surgeons may consider the described procedure a viable treatment alternative in problematic subluxations of the cervical spine. Level V.

Diagnostic accuracy of maxillofacial trauma two-dimensional and three-dimensional computed tomographic scans: comparison of oral surgeons, head and neck surgeons, plastic surgeons, and neuroradiologists.

BACKGROUND: The authors' objectives were to study differences in diagnostic accuracy between two- and three-dimensional computed tomographic scans and among the specialties of plastic surgery, head and neck surgery, oral surgery, and neuroradiology, since this had not previously been done. METHODS: Four groups of subspecialists completed time-proctored tests of 20 maxillofacial trauma scans with zygomatic arch, zygomatic complex, orbital, Le Fort I, II, III, mandibular and panfacial fractures from five institutions (n = 40). Accuracy of diagnosis and indication for surgery, efficiency, and preference were assessed. Comparison between two- and three-dimensional scans, between expert (experienced attending) versus novice (resident/fellow), and among the four subspecialties was performed. RESULTS: For two- and three-dimensional scans, two-dimensional was more accurate for orbital floor/medial wall (40 percent and 34 percent) and frontal sinus (26 percent for diagnostic) fractures. Two-dimensional examinations took 2.3 times longer but were preferred (85 percent). Experts and novices had similar accuracy with three-dimensional scanning, but experts were more accurate with the two-dimensional scanning. Experts were 3.3 times faster with two-dimensional scanning but not with three-dimensional scanning. Accuracy of diagnosis among subspecialists was similar, except that oral surgery was less accurate with orbitozygomatic fractures (79 percent versus 90 to 92 percent); neuroradiology was less accurate with indications for surgery (65 percent versus 87 to 93 percent). CONCLUSIONS: Differences in diagnostic accuracy exist between two- and three-dimensional maxillofacial scans and between expert and novice readers but not between subspecialties. Combined modalities are preferred.