Key Considerations for Nerve Transfer Rehabilitation After Surgical Reconstruction for Brachial Plexus and Peripheral Nerve Injuries.

Nerve transfer surgery is commonly used to treat patients with brachial plexus injuries. However, guidelines on postoperative rehabilitation are not clearly established. Nerve transfers require the patient to relearn how to recruit newly innervated muscle(s), which may not occur naturally or intuitively. Supervised therapy is a valuable resource to guide patients through their lengthy recovery (often >12 months) because target muscle strength is both obtained and functionally used in daily life. This article highlights 10 key principles that provide the foundation for rehabilitation following nerve transfer surgery after a brachial plexus injury. Due to the shortcomings of the current evidence base for nerve transfer rehabilitation, we have included our anecdotal experience to augment the existing literature. It is important to have a collaborative surgeon-therapist relationship to communicate regarding operative details, expected timelines for reinnervation, patient needs, and realistic expectations. We provide examples of how to tailor the exercise program to synergistically recruit both the donor and target muscle action, including how to appropriately advance exercises based on the current level of nerve return. We also discuss the role that fatigue plays in denervated muscle and how fatigue may affect the exercise demands placed on the target muscle during specific stages of recovery.

Appropriateness and Reliability of an Online Artificial Intelligence Platform's Responses to Common Questions Regarding Distal Radius Fractures.

PURPOSE: Chat Generative Pre-Trained Transformer (ChatGPT) is a novel artificial intelligence chatbot that is changing the way humans gather information online. The purpose of this study was to investigate ChatGPT's ability to appropriately and reliably answer common questions regarding distal radius fractures. METHODS: Thirty common questions regarding distal radius fractures were presented in an identical manner to the online ChatGPT-3.5 interface three separate times, yielding 90 unique responses because ChatGPT produces an original answer with each query. All responses were graded as "appropriate," "appropriate but incomplete," or "inappropriate" by a consensus discussion among three hand surgeon reviewers. The questions were additionally subcategorized into one of four domains based on Bloom's cognitive learning taxonomy, and descriptive statistics were reported. RESULTS: Seventy of the 90 total responses (78%) produced by ChatGPT were "appropriate," and 29 of the 30 questions (97%) had at least one response considered appropriate (of the three possible). However, only 17 of the 30 questions (57%) were answered appropriately on all three iterations. The test-retest reliability of ChatGPT was poor with an intraclass correlation coefficient of 0.12. Finally, ChatGPT performed best answering questions requiring lower-order thinking skills (Bloom's levels 1-3) and less well on level 4 questions. CONCLUSIONS: This study found that although ChatGPT has the capability to answer common questions regarding distal radius fractures, caution should be taken before implementing its use, given ChatGPT's inconsistency in providing a complete and accurate response to the same question every time. CLINICAL RELEVANCE: As the popularity and technology of ChatGPT continue to grow, it is important to understand the potential and limitations of this platform to determine how it may be best implemented to improve patient care.

A Prospective Randomized Pilot Study: One-Year Outcomes of Ligament Reconstruction Tendon Interposition Versus Suture Tape Suspensionplasty for Thumb Carpometacarpal Joint Arthritis.

PURPOSE: We performed a randomized controlled trial assessing patient-reported outcome measures following trapeziectomy with ligament reconstruction and tendon interposition (LRTI) or suture tape suspensionplasty (STS) for treatment of thumb carpometacarpal joint osteoarthritis. METHODS: Patients undergoing surgery for thumb carpometacarpal joint osteoarthritis were prospectively randomized to LRTI or STS. Outcome measures were collected at 2 weeks, 4 weeks, 3 months, and 1 year and included visual analog scale pain, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity, return to work/activity, range of motion, grip/pinch strength, and complications. RESULTS: Thirty-one patients (32 thumbs) were randomized from 51 patients offered participation over two years. One-year follow-up was 97%. Both groups had a decrease in visual analog scale pain scores at all postoperative time points. The trajectory of postoperative Patient-Reported Outcomes Measurement Information System Upper Extremity scores was similar, and both groups achieved the meaningful clinically important difference for improvement in PROMIS Upper Extremity by three months. Grip strength was substantially increased in both groups at one year. Return to work/activity and surgical complications favored the LRTI group. CONCLUSIONS: Our study did not suggest any clinically relevant differences in the postoperative patient-reported outcome measures or objective clinical measurements between LRTI and STS, although LRTI patients had a faster return to work/activity and lower complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Prospective randomized clinical trial, level IIB clinical.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis.

BACKGROUND: Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care. METHODS: This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention. RESULTS: Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care. CONCLUSIONS: Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients. TRIAL REGISTRATION: Not applicable.

What Are Orthopaedic Patients' and Clinical Team Members' Perspectives Regarding Whether and How to Address Mental Health in the Orthopaedic Care Setting? A Qualitative Investigation of Patients With Neck or Back Pain.

BACKGROUND: Across virtually all orthopaedic subspecialties, symptoms of depression, anxiety, and unhelpful thinking are associated with worse patient-reported satisfaction with orthopaedic treatment and increased postoperative complications. In the orthopaedic community, there is growing interest in patients' mental health in the orthopaedic care setting, but addressing mental health is still not a focus of orthopaedic clinical training. There is a persistent awareness gap about how to address mental health in orthopaedic care in a manner that is simultaneously feasible in a busy orthopaedic practice and acceptable to patients who are presenting for treatment of a musculoskeletal condition. QUESTIONS/PURPOSES: (1) What are orthopaedic patients' and clinical team members' current perceptions and motivators regarding addressing mental health as part of orthopaedic care? (2) What barriers do patients and clinicians face regarding addressing mental health as part of orthopaedic care? (3) What are facilitators for patients and clinicians related to addressing mental health as part of orthopaedic care? (4) What are practical, acceptable implementation strategies to facilitate addressing mental health as part of orthopaedic care? METHODS: This was a single-center, qualitative study conducted from January through May 2022 in the orthopaedic department of a large, urban, tertiary care academic medical center. Semistructured interviews were conducted with members of two stakeholder groups: orthopaedic patients and orthopaedic clinical team members. We interviewed 30 adult patients (of 85 patients who were eligible and approached) who had presented to our orthopaedic department for management of neck or back pain lasting for 3 or more months. By prescreening clinic schedules, patients were purposively sampled to include representatives from varied sociodemographic backgrounds and with a range of severity of self-reported symptoms of depression and anxiety (from none to severe on the Patient-Reported Outcomes Measurement Information System Depression and Anxiety measures) (mean age 59 ± 14 years, 70% [21 of 30] women, 60% [18 of 30] White, median pain duration 3.3 [IQR 1.8 to 10] years). We also interviewed 22 orthopaedic clinicians and clinical support staff members (of 106 team members who were eligible and 25 who were approached). Team members were purposively sampled to include representatives from the full range of adult orthopaedic subspecialties and early-, mid-, and late-career physicians (11 of 22 were women, 16 of 22 were White, and 13 of 22 were orthopaedic surgeons). Interviews were conducted in person or via secure video conferencing by trained qualitative researchers. The interview guides were developed using the Capability, Opportunity, Motivation, Behavior model of behavior change. Two study team members used the interview transcripts for coding and thematic analysis, and interviews with additional participants from each stakeholder group continued until two study team members independently determined that thematic saturation of the components of the Capability, Opportunity, Motivation, Behavior model had been reached. Each participant statement was coded as a perception, motivator, barrier, facilitator, or implementation strategy, and inductive coding was used to identify themes in each category. RESULTS: In contrast to the perceptions of some orthopaedic clinicians, most patients with orthopaedic conditions expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopaedic care plan. Motivation to address mental health was expressed the most strongly among orthopaedic clinical team members who were aware of high-quality evidence that demonstrated a negative impact of symptoms of depression and anxiety on metrics for which they are publicly monitored or those who perceived that addressing patients' mental health would improve their own quality of life. Barriers described by patients with orthopaedic conditions that were related to addressing mental health in the context of orthopaedic care included clinical team members' use of select stigmatizing words and perceived lack of integration between responses to mental health screening measures and the rest of the orthopaedic care encounter. Orthopaedic clinical team members commonly cited the following barriers: lack of available mental health resources they can refer patients to, uncertainty regarding the appropriateness for them to discuss mental health, and time pressure and lack of expertise or comfort in discussing mental health. Facilitators identified by orthopaedic clinical teams and patients to address mental health in the context of orthopaedic care included the development of efficient, adaptable processes to deliver mental health interventions that preferably avoid wasted paper resources; initiation of mental health-related discussion by an orthopaedic clinical team member in a compassionate, relevant context after rapport with the patient has been established; and the availability of a variety of affordable, accessible mental health interventions to meet patients' varied needs and preferences. Practical implementation strategies identified as suitable in the orthopaedic setting to increase appropriate attention to patients' mental health included training orthopaedic clinical teams, establishing a department or institution "mental health champion," and integrating an automated screening question into clinical workflow to assess patients' interest in receiving mental health-related information. CONCLUSION: Orthopaedic patients want their mental health to be acknowledged as part of a holistic orthopaedic care plan. Although organization-wide initiatives can address mental health systematically, a key facilitator to success is for orthopaedic clinicians to initiate compassionate, even if brief, conversations with their patients regarding the interconnectedness of mental health and musculoskeletal health. Given the unique challenges to addressing mental health in the orthopaedic care setting, additional research should consider use of a hybrid effectiveness-implementation design to identify effective methods of addressing mental health that are feasible and appropriate for this clinical setting. CLINICAL RELEVANCE: Orthopaedic clinicians who have had negative experiences attempting to address mental health with their patients should be encouraged to keep trying. Our results suggest they should feel empowered that most patients want to address mental health in the orthopaedic care setting, and even brief conversations using nonstigmatizing language can be a valuable component of an orthopaedic treatment plan.

Catastrophic Health Expenditures Associated With Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: Distal radius fracture is one of the most common upper-extremity traumatic injuries. These injuries result in time off work and potential financial consequences for patients. Therefore, we aimed to understand the risk of catastrophic health expenditures (CHEs) after open reduction and internal fixation of distal radius fractures and examine the association between patient characteristics and the risk of CHE. METHODS: We used data from patients undergoing open reduction and internal fixation of a distal radius fracture from a large, urban, level I trauma center (2018-2020). The risk of CHE was defined as out-of-pocket expenses of ≥40% of postsubsistence income. We used multivariable logistic regression to assess the impact of age, sex, race, and insurance status on the risk of CHE. RESULTS: In our cohort of 394 patients, 121 patients (30.7%) were at risk of CHE after their distal radius fracture. After controlling for patient characteristics and insurance status, patients aged 26-34 years were 5.7 times more likely to be at risk of CHE (odds ratio, 5.73; 95% CI, 1.81-18.13) than patients aged ≥65 years. Patients who were uninsured were six times more likely to be at risk of CHE than patients with employer-sponsored health insurance (odds ratio, 6.02; 95% CI, 1.94-18.66). Lastly, non-White patients were at a higher risk of CHE (odds ratio, 3.63; 95% CI, 1.70-7.79) than White patients. CONCLUSIONS: Distal radius fractures are unexpected and place patients at risk of financial harm, with one in three patients at risk of CHEs. Policies aimed at minimizing cost-sharing after traumatic injury may help alleviate the financial consequences of health care delivery and reduce disparities. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

Factors Influencing Patient Experience After Cubital Tunnel Syndrome Surgery.

PURPOSE: The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care. METHODS: Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved. RESULTS: Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution. CONCLUSIONS: Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery. CLINICAL RELEVANCE: Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care.

Catastrophic Health Care Expenditure Following Brachial Plexus Injury.

PURPOSE: Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery. METHODS: Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis. RESULTS: Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE. CONCLUSIONS: Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery. CLINICAL RELEVANCE: Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury.

PURPOSE: Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery. METHODS: We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race. RESULTS: Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. CONCLUSIONS: Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased. LEVEL OF EVIDENCE: Prognostic II.

'Being a patient the rest of my life'- The influence of patient participation during recovery after brachial plexus injury.

BACKGROUND: Given the modest functional outcomes seen after surgical reconstruction and subsequent therapy, increasing attention is being directed to patient satisfaction and psychological aspects of recovery after brachial plexus injury (BPI). PURPOSE: To better understand the recovery course after surgical reconstruction for BPI, we used qualitative interviews and focused on common points of frustration for patients. STUDY DESIGN: Qualitative, interpretive description study METHODS: We conducted semi-structured interviews with BPI patients who were 6+ months post-surgical reconstruction. The interview focused on the patients' experience with BPI, focusing on emotional aspects of recovery. Interviews were transcribed and independently coded by 2 researchers. We used inductive and deductive analysis to organize codes into themes. Once thematic saturation was reached, no additional interviews were conducted. RESULTS: We interviewed 15 BPI patients at median 13 months after surgery (range: 6-43 months). Our analysis revealed: (1) BPI patients expressed variable degrees of participation during recovery, with the indeterminate state of function making it difficult to adjust to life after BPI. (2) The uncertainty while waiting for improved function is frustrating to BPI patients, with many patients expressing concern for activities and moments they are missing due to injury. (3) While many BPI patients feel left out of decision-making, those who felt engaged in the process expressed less frustration and more acceptance of their status. CONCLUSION: Traumatic BPI patients those who felt engaged in decision-making were more receptive to adjustment to their new state of function. When coordinating multidisciplinary care, measures to encourage patients to feel agency over their outcome and to develop self-management skills have the potential to improve patient satisfaction.

Optimizing the Virtual Interview Experience for Hand Surgery Fellowships.

Similar to many other medical training programs, fellowship interviews for hand surgery will be conducted virtually for a second consecutive year. We provide strategies for applicants to ideally portray themselves and to learn about fellowship programs. We include approaches for fellowship programs to identify candidates that match their values as a program, as well as ways to provide useful information to applicants about the program's culture. Given that components of virtual interviewing and recruitment will likely be an ongoing part of fellowship applications, we hope this article provides a framework to guide both applicants and program faculty for the 2021 to 2022 cycle and beyond.

Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery.

PURPOSE: Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients' thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options. METHODS: Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain's tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets. RESULTS: Eight participants reported that patients have a general bias against being "knocked out," 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type. CONCLUSIONS: Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery. CLINICAL RELEVANCE: This study provides insights into patients' thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.

Development and Testing of a Novel Locking Pin Cap to Create a Fixed-Angle K-Wire Plate Construct.

PURPOSE: To test the effectiveness of a novel locking pin cap to attach a K-wire rigidly to a volar locking plate and resist fracture displacement compared with commercially available alternatives. METHODS: Two different methods of fracture fixation were tested on a total of 12 Sawbones models with volar shear distal radius fracture (6/group). The fragments were fixed with either 2 commercially available pin plates (industry standard) or a volar plate with 2 locking screws fixing the scaphoid facet and 2 pins locked to the plate with a novel locking pin cap in the lunate facet. Axial load conditioning was performed followed by sinusoidal loading to 250 N at 50 mm/s. A motion capture system was used to assess the relative movement of the fracture fragments relative to the intact shaft. The strength of the fixation construct was quantified by (1) the force required to achieve a 2-mm gap between the shaft and fracture fragments and (2) ultimate load to failure. RESULTS: One industry standard pin plate demonstrated disassociation of the pin from the plate after fatigue conditioning. This did not occur in the locking pin cap group. The locking pin cap construct group was able to sustain a significantly higher load compared with the industry standard when the construct was displaced to the 2-mm gap. The locking pin cap also significantly increased the ultimate load to failure compared with the industry standard. CONCLUSIONS: The novel locking pin cap creates a fixed-angle attachment of a K-wire to an existing locking screw hole in a plate. This fixed-angle K-wire is significantly stronger in preventing gap formation and resisting ultimate failure than commercially available plates that use bent K-wires. CLINICAL RELEVANCE: The development of novel techniques to secure small articular fragments may ultimately improve clinical outcomes.

Management of Adult Brachial Plexus Injuries.

Adult brachial plexus injuries result in profound functional deficits, debilitating pain, substantial mental health implications, and extensive economic impacts. Their initial evaluation includes a detailed physical examination, electrodiagnostic studies, advanced imaging, and patient counseling. A team-based approach, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain-management specialists, is used to provide optimal longitudinal care during the lengthy recovery process. The options for the surgical management of brachial plexus injuries include exploration, neurolysis, nerve grafting, nerve transfer, free functional muscle transfer, tendon transfer, arthrodesis, and amputation. When treated within 6 months, the outcomes are favorable for the restoration of essential shoulder and elbow function. Free functional muscle transfer is a powerful tool to address elbow flexion and rudimentary grasp in both primary and delayed settings. The restoration of hand function remains a challenge for patients with complete brachial plexus injury. The purpose of this review is to summarize foundational concepts in diagnosis and management, discuss current trends and controversial topics, and address areas for future investigation.

Evolving Techniques in Peripheral Nerve Regeneration.

Reliable and robust peripheral nerve regeneration after a nerve injury and repair remains an elusive goal. A variety of strategies have been proposed to mitigate the effects of Wallerian degeneration (through molecular therapies), enhance axonal regeneration across the repair site (through electrical stimulation and gene therapy), and explore alternatives to suture coaptation (through the fusion of transected ends). Although most of these techniques are in their infancy, animal data and some clinical trials have demonstrated promise for improving the restoration of function after these devastating injuries.

Histologic and Functional Outcomes of Conduit Wrapping for Peripheral Nerve Repair: Early Results in a Rat Model.

BACKGROUND: The concept of utilizing a nerve conduit for augmentation of a primary nerve repair has been advocated as a method to prevent neural scarring and decrease adhesions. Despite clinical use, little is known about the effects of a nerve conduit wrapped around a primary repair. To better understand this, we investigated the histologic and functional effects of use of a nerve conduit wrapped around a rat sciatic nerve repair without tension. METHODS: Twenty Lewis' rats were divided into two groups of 10 rats each. In each group, unilateral sciatic nerve transection and repair were performed, with the opposite limb utilized as a matched control. In the first group, direct repair alone was performed; in the second group, this repair was augmented with a porcine submucosa conduit wrapped around the repair site. Sciatic functional index (SFI) was measured at 6 weeks with walking track analysis in both groups. Nonsurvival surgeries were then performed in all animals to harvest both the experimental and control nerves to measure histomorphometric parameters of recovery. Histomorphometric parameters assessed included total number of neurons, nerve fiber density, nerve fiber width, G-ratio, and percentage of debris. Unpaired t-test was used to compare outcomes between the two groups. RESULTS: All nerves healed uneventfully but compared with direct repair; conduit usage was associated with greater histologic debris, decreased axonal density, worse G-ratio, and worse SFI. No significant differences were found in total axon count or gastrocnemius weight. CONCLUSION: In the absence of segmental defects, conduit wrapping primary nerve repairs seem to be associated with worse functional and mixed histologic outcomes at 6 weeks, possibly due to debris from conduit resorption. While clinical implications are unclear, more basic science and clinical studies should be performed prior to widespread adoption of this practice.

Absence of the Pronator Quadratus Muscle Precluding Distal Nerve Transfer.

The branch of the anterior interosseous nerve to the pronator quadratus (PQ) is increasingly used as a donor nerve for end-to-end and reverse end-to-side nerve transfers. The anatomy of the PQ (and its nerve branch) is generally considered reliable in the absence of prior trauma. In this report, we describe a patient with an absent PQ despite intact clinical examination of other muscles supplied by the anterior interosseous nerve. The absence of the PQ precluded the use of its nerve as a donor nerve for transfer.

Frequency and Risk Factors for Prolonged Opioid Prescriptions After Surgery for Brachial Plexus Injury.

PURPOSE: We hypothesized that patients with preoperative opioid prescriptions and diagnoses of depression and anxiety would be at increased risk for prolonged opioid prescriptions after surgery for brachial plexus injury (BPI). METHODS: Using an administrative database of privately insured patients, we assembled a cohort of BPI surgery patients and a control group of non-BPI patients, matching for age, sex, and year. Pharmacy claims for prescriptions filled for opioids and neuropathic pain medications were examined 12 months before surgery to 180 days after surgery. The primary outcome was prolonged opioid prescription, defined as receiving a prescription 90 to 180 days after the index (BPI surgery or randomly selected date of service for controls). Multivariable regression was used to examine risk factors for postoperative opioid use, including diagnoses of depression, anxiety, drug abuse, tobacco use, and preoperative use of opioids and neuropathic pain medications. A subgroup analysis was performed for opioid-naive BPI patients between 30 days to 1 year before surgery. RESULTS: Among BPI surgery patients (n = 1,936), 27.7% had prolonged opioid prescriptions. Among opioid-naive BPI patients (n = 911), 10.8% had prolonged opioid prescriptions. In controls (n = 19,360), frequency of prolonged opioid prescriptions was 0.11%. Among all BPI patients, after adjustment for age and sex, predictors of prolonged postoperative opioid prescriptions in BPI patients were preoperative opioids, preoperative neuropathic pain medication use, histories of drug abuse, tobacco use, and anxiety. CONCLUSIONS: Prolonged postoperative opioids prescriptions after BPI reconstruction are higher than previous estimates among other surgical patients. In addition to establishing normative data among this population, our findings serve to increase awareness of risk factors for prolonged opioids after BPI reconstruction and encourage coordinated multidisciplinary care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion.

BACKGROUND: Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid). METHODS: Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014). RESULTS: The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012). CONCLUSION: Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.