Failure of humeral shaft fixation: construct characteristics.

PURPOSE: Fixation failure following open reduction and internal fixation (ORIF) of humeral shaft fractures can be a challenging complication. We aimed to identify the modes of failure and characteristics of failed fixation constructs. METHODS: We queried our institutional database for patients > 18 years old with fixation failure after ORIF with single plate and screw constructs of humeral shaft fractures from 2006 to 2017. Demographics, fracture characteristics, fixation construct design and mode of failure were recorded. RESULTS: Twenty-three failures were identified. Mean age was 55.9 years (SD 19.2 years) with 15 (65%) women. Twelve patients (52%) had midshaft fractures; the remainder had distal-third shaft (8 pts, 35%) or proximal-third shaft (3 pts, 13%) fractures. Midshaft fractures were most commonly fixed through an anterolateral approach with plates and all non-locking screws (83%), while distal-third shaft fractures were fixed with a combination of locking and non-locking screws from a posterior approach. Distal-third shaft fractures failed by plate breakage (63%) or screw pullout (38%) and all midshaft failures occurred by screw pullout proximal (92%) or distal (8%) to the fracture. Resultant varus deformity occurred in 20 (87%) fractures. CONCLUSION: Screw pullout in midshaft fractures suggests that fixation to bone was insufficient or biomechanically disadvantageous. Varus moments contribute significantly to the failure of humeral shaft fracture ORIF. Plate breakage in distal fractures suggests high concentrations of stress over a narrow working length of constructs with inadequate plate strength. Recognizing how these constructs fail can aid proper implant selection and application for humeral shaft fracture. LEVEL OF EVIDENCE: Treatment level IV.

Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate.

PURPOSE: Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing. METHODS: Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement. RESULTS: No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group. CONCLUSION: There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group. CLINICAL SIGNIFICANCE: When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement.

Radial Sided Triangular Fibrocartilage Complex Tears: A Comprehensive Review.

When evaluating the available literature on the diagnosis and management of triangular fibrocartilage complex tears (TFCC), ulnar tears comprise the major focus of TFCC literature. Radial-sided (Class 1D) tears are seldom researched or discussed. The purpose of this study was to review the methods for identifying and treating radial-sided TFCC lesions, by examining the anatomy of the TFCC, the pathology of its radial portion, diagnostic techniques, and both surgical and nonoperative treatments. The avascular nature of the radial TFCC may influence its healing potential. Magnetic resonance arthrogram is the gold standard for non-invasively diagnosing a radial-sided tear. Non-operative management should be exhausted prior to surgical intervention, which commonly involves an inside-out repair involving radial trans-osseous sutures. Still, the literature is limited by patient sample size and therefore requires a greater population of class 1-D tears to confirm optimal diagnostic and treatment methods.

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases.

BACKGROUND: Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF. METHODS: Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant. RESULTS: Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988). CONCLUSIONS: There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Cost Drivers in Carpal Tunnel Release Surgery: An Analysis of 8,717 Patients in New York State.

PURPOSE: The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems. METHODS: Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes. RESULTS: During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges. CONCLUSIONS: This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analyses II.

Weight-Bearing Restrictions With Distal Radius Wrist-Spanning Dorsal Bridge Plates.

PURPOSE: The fixation of comminuted distal radius fractures using wrist-spanning dorsal bridge plates has been shown to have good postoperative results. We hypothesized that using a stiffer bridge plate construct results in less fracture deformation with loads required for immediate crutch weight bearing. METHODS: We created a comminuted, extra-articular fracture in 7 cadaveric radii, which were fixed using dorsal bridge plates. The specimens were positioned to simulate crutch/walker weight bearing and axially loaded to failure. The axial load and mode of failure were measured using 2- and 5-mm osteotomy deformations as cutoffs. Bearing 50% and 22% of the body weight was representative of the force transmitted through crutch and walker weight bearing, respectively. RESULTS: The load to failure at 2-mm deformation was greater than 22% body weight for 2 of 7 specimens and greater than 50% for 1 of 7 specimens. The load to failure at 5-mm deformation was greater than 22% body weight for 6 of 7 specimens and greater than 50% for 4 of 7 specimens. The mean load to failure at 2-mm gap deformation was significantly lower than 50% body weight (110.4 N vs 339.2 N). The mean load to failure at 5-mm deformation was significantly greater than 22% body weight (351.8 N vs 149.2 N). All constructs ultimately failed through plate bending. CONCLUSIONS: All constructs failed by plate bending at forces not significantly greater than the 50% body weight force required for full crutch weight bearing. The bridge plates supported forces significantly greater than the 22% body weight required for walker weight bearing 6 of 7 times when 5 mm of deformation was used as the failure cutoff. CLINICAL RELEVANCE: Elderly, walker-dependent patients may be able to use their walker as tolerated immediately after dorsal bridge plate fixation for extra-articular fractures. However, patients should not be allowed to bear full weight using crutches immediately after bridge plating.

Rates of and Risk Factors for Trigger Finger after Open Carpal Tunnel Release.

Background We have anecdotally noticed a higher rate of trigger fingers (TFs) developing in patients who have undergone carpal tunnel release (CTR). Questions/Objective Is the rate of TFs after CTR greater compared to the nonoperative hand? Is the thumb more commonly involved postoperatively compared with spontaneous TFs? Do particular associated comorbidities increase this risk? Patients and Methods We queried our institutional database for patients who had undergone open CTR during a 2-year period and recorded the development of an ipsilateral TF after a CTR or a contralateral TF in the nonoperative hand. Patient demographics, comorbidities, concurrent initial procedures, time to diagnosis, and finger involvement were recorded. Results A total of 435 patients underwent 556 CTRs during this period. Furthermore, 46 ipsilateral TFs developed in 38 of 556 cases (6.83%) at an average of 228.1 ± 195.7 days after surgery. The thumb was most commonly involved (37.0%) followed by the ring finger (28.3%). The incidence rate of TF in the nonoperative hand during this period was 2.7%, with the ring finger and middle finger most commonly involved (33.3 and 28.6%, respectively). Only history of prior TF in either hand was found to be a significantly associated on Chi-square analysis and multivariable regression ( p < 0.001). Conclusion In patients with carpal tunnel syndrome, ipsilateral TFs occurred after 6.83% of CTRs, compared with a rate of 2.7% in the nonoperative hand, making it an important possible outcome to discuss with patients. The thumb was more commonly involved in triggering in the surgical hand compared with the nonoperative hand. Patients with a history of prior TFs in either hand were more likely to develop an ipsilateral TF after CTR. Level of Evidence This is a Level III, retrospective study.

Modifying the RAPT Score to Reflect Discharge Destination in Current Practice.

BACKGROUND: The Risk Assessment Prediction Tool (RAPT) is a validated 6-question survey designed to predict primary total joint arthroplasty (TJA) patients' discharge disposition. It is scored from 1 to 12 with patients stratified into high-, intermediate-, and low-risk groups. Given recent advancements in rapid-discharge protocols and increasing utilization of home services, the RAPT score may require modified scoring cutoffs. METHODS: A retrospective chart review of all patients undergoing primary TJA at a single academic center over 14 months was performed. The RAPT score was implemented during the sixth month. Patients undergoing revision TJA, complex TJA, and TJA after resection of malignancy were excluded. Outcomes before and after RAPT implementation were analyzed with additional subanalysis investigating of post-RAPT data. RESULTS: A total of 1264 patients (624 Pre-RAPT and 640 Post-RAPT) were evaluated. The post-RAPT group (245 total hip arthroplasty and 395 total knee arthroplasty) experienced significant decreases in mean hospital length of stay (2.22 days pre-RAPT to 1.82 days post-RAPT, P < .001) and the proportion of patients discharged to facility (21.8% pre-RAPT to 15.2% post-RAPT, P = .002). The modified system demonstrated the highest overall predictive accuracy at 92% and was found to be predictive of hospital length of stay. CONCLUSION: Owing to the recent trends favoring in-home services over rehab facility after discharge, previously published RAPT scoring cutoffs are inaccurate for modern practice. Using mRAPT cutoffs maximizes the number of patients for whom a discharge prediction can be made, while maintaining excellent predictive accuracy.

Management of Post-Amputation Pain.

INTRODUCTION: The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an estimated 95% of people with amputations experiencing one or both. Medical Management: The majority of chronic PAP is due to phantom limb pain, which is neurogenic in nature. Common medications used include tricyclic antidepressants, gabapentin, and opioids. Newer studies are evaluating alternative drugs such as ketamine and local anesthetics. Rehabilitation Management: Mirror visual feedback and cognitive behavioral therapy are often effective adjunct therapies and have minimal adverse effects. Surgical Management: Neuromodulatory treatment and surgery for neuromas have been found to help select patients with PAP. CONCLUSION: PAP is a complex condition with mechanisms that can be located at the residual limb, spinal cord, and brain - or a combination. This complex pain can be difficult to treat. The mainstays of treatment are largely medical, but several surgical options are also being studied.

Shoulder and elbow injuries in NCAA football players, 2009-2010 through 2013-2014.

Background: Although football is one of the most popular collegiate sports, the epidemiology of and risk factors for shoulder and elbow injuries in this population not been recently described. We aimed to characterize this incidence in National Collegiate Athletic Association (NCAA) football players, determine risk factors, and establish outcomes after injury. Methods: All shoulder and elbow injuries in men's football occurring during the 2009-2010 through 2013-2014 academic years were retrospectively identified in the NCAA Injury Surveillance Program database. The injury incidence per 10,000 athletic exposures (AEs) was calculated overall, and by different risk factors. In addition to descriptive statistics, risk factors were compared using injury risk-ratios, and outcomes were compared using injury proportion ratios. Results: NCAA football players sustained 1,187 shoulder and elbow injuries in 899,225 AEs (incidence: 13.20/10,000 AE), most commonly acromioclavicular separation (29.9%), anterior shoulder subluxation (9.0%), shoulder contusion (9.0%), and rotator cuff tear/sprain (8.0%). Together, shoulder instability comprised 28.1% of injuries. Injuries were split evenly between offense (43.5%) and defense (45.9%), and a tackling mechanism caused 37.7%, with 30.3% coming from blocking. The incidence was eight times higher in competition than practice (62.9/10,000 vs 7.9/10,000AE, p < 0.001). Surgery was performed for 9.9% of injuries, and most commonly for all types of shoulder instability (56.8% of surgeries). Injuries were season-ending in 5.2% of players. The likelihood of an injury being season-ending was 2.9 times greater for recurrent injuries than a new injury (p < 0.001); 86.1% of all injuries were new. Conclusions: Shoulder and elbow injuries to NCAA football players can be severe. Competition had an eight times higher incidence than did practice. Tackling and blocking were the most common mechanisms, while AC separation and shoulder instability were the most common injuries. This epidemiology may help players, coaches, trainers, and governing bodies target injury-prevention programs and assess improvement over time.

Incidence, Timing, and Risk Factors for Secondary Revision After Primary Revision of Traumatic Digit Amputations.

PURPOSE: Primary revision amputation is the most common treatment method for traumatic digit amputations in the United States. Few studies have reported secondary revision rates after primary revision amputation. The primary aim of our study was to identify risk factors for secondary revision within 1 year of the index procedure. Secondarily, we describe the incidence and timing of complications requiring secondary revision. METHODS: Our institution's emergency department (ED) database was reviewed for traumatic digit amputations over a 6-year period. Patients were reviewed for demographic characteristics, comorbidities, site of treatment (ED versus operating room), and complications requiring secondary revision. Conditional Cox Proportional Hazard regression was used to model hazard of revision within 1 year of index procedure relative to site of initial management, mechanism of injury, injury characteristics, and patient demographics. RESULTS: Five hundred and thirty-seven patients with 677 digits were managed with primary revision amputation. Five hundred and eighty-six digits (86.6%) were revised in the ED, and 91 (13.4%) in the operating room. Ninety-one digits required secondary revision, including 83 within 1 year. No increased risk of secondary revision amputation within 1 year of the index procedure was observed for patients treated in the ED compared with the operating room. Relative to crush injuries, bite and sharp laceration amputations had 4.8 times and 2.6 times increased risk of secondary revision, respectively. The index finger had a 5.3-fold increased risk of revision with the thumb as the reference digit. Work-related injuries had a 1.9-fold increased risk of secondary revision compared with non-work-related injuries. CONCLUSIONS: No evidence was found indicating that traumatic digit amputations primarily revised in the ED had an increased risk of secondary revision. Patients may be counseled on the risk of secondary procedures based on the mechanism of injury, injury characteristics and demographics, as well as the timing of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Ulnar Collateral Ligament Injuries of the Elbow in the Throwing Athlete.

UPDATE: This article was updated on February 26, 2018, because of a previous error. On pages 1 and 7, in the author byline section, the authors' names that had read "Andrew Harris" and "Brett Owens" now reads "Andrew P. Harris" and "Brett D. Owens."