Medial malleolus screws: out in one view and out.

Cartilage damage or mechanical blocking from screw penetration into intra-articular cartilage can reduce the chances of successful outcomes during medial malleolus fixation. There have been diverging opinions among surgeons concerning the reliability of radiographic assessment of fracture fixation and malleolus screw positioning. Therefore, this radiographic study examines the location of medial malleolus lag screws relative to the ankle mortise articular surface. In three Sawbones models, Kirschner wires were overdrilled with a 4.0-mm cannulated cortical screw simulating screws that would be intra- and extra-articular when performing open reduction and internal fixation of a medial malleolar fracture. Under fluoroscopy, images were evaluated to determine whether known intra-articular screws appeared extra-articular in any radiographic view. No image from models with known intra-articular penetration appeared extra-articular in any view or under "live" fluoroscopy. At 20° internal rotation, a screw with a known extra-articular position appeared to be within the cartilage. Intra-operative fluoroscopy is necessary to ensure proper extra-articular placement of screws. If a screw is pictured extra-articular in any radiograph, then it can be assumed that the screw is indeed out of the joint.

International knee documentation committee knee survey use after anterior cruciate ligament reconstruction: a 2005-2012 systematic review and world region comparison.

PURPOSE: The purpose of this review was to evaluate International Knee Documentation Committee (IKDC) survey use after anterior cruciate ligament reconstruction compared with other surveys and determine evidence levels and methodologic study quality by world region. METHODS: The Medline database was searched from January 2005 through December 2012. RESULTS: We identified 421 studies and 33 surveys. Europe and Australia had more objective and subjective IKDC form use (χ(2) = 9.6, P = .047). Europe and Asia had more objective IKDC form use (χ(2) = 19.4, P = .001). Asia had more Lysholm knee scale use (χ(2) = 29.9, P < .0001). Europe had more Tegner Activity Level scale (χ(2) = 31.7, P < .0001) and Knee Injury and Osteoarthritis Outcome Score (χ(2) = 20.5, P < .0001) use. North America and Australia had more Cincinnati or Noyes knee rating scale use (χ(2) = 21, P < .0001). Asia and Australia had more studies with greater than 60 subjects (χ(2) = 24.4, P = .018). Europe had more studies with greater than 24 months' follow-up (χ(2) = 18.4, P = .018). Asia had more studies with adequate surgical descriptions (χ(2) = 33.2, P < .0001). North America had more studies with well-described rehabilitation (χ(2) = 18.2, P = .02). Europe had more studies with confirmed recruitment (χ(2) = 12.9, P = .012). Australia and North America had more studies with confirmed independent investigators (χ(2) = 11.1, P = .026). Europe had more studies with greater than 80% recruitment (χ(2) = 16.0, P = .04). Methodologically stronger studies used the objective IKDC survey (P < .0001), the objective and subjective IKDC survey (P = .002), or the Cincinnati or Noyes scale (P = .002). This group also made greater use of the Tegner scale (P = .013). CONCLUSIONS: Objective and subjective IKDC form use is comparable with Lysholm and Tegner scale use. Objective and subjective IKDC form use in combination with the Tegner Activity Level scale is recommended. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Diabetes Increases Median Nerve Cross-Sectional Area but Not Disease Severity in Patients with Carpal Tunnel Syndrome.

Background: Ultrasonography (US) is a useful diagnostic modality for diagnosis of carpal tunnel syndrome (CTS). Diabetes mellitus is increasingly prevalent and is a risk factor for CTS. Given the increasing use of US in the diagnosis of CTS, our goal was to evaluate the influence of diabetes on CTS severity and the cross-sectional area (CSA) of the median nerve in patients with CTS. Methods: Patients with clinically diagnosed CTS were seen in the outpatient setting from October 2014 to February 2021. Median nerve CSA and patient reported severity measures were obtained: Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) and CTS-6. For patients with diabetes, additional parameters were collected including most recent A1c, insulin pharmacotherapy, and polypharmacy. Results: Ninety-nine patients (122 nerves) without diabetes and 55 patients (82 nerves) with diabetes were recruited for the study. Patients in the diabetes group were more obese and older and had a significantly increased median nerve CSA compared with patients without diabetes. Obesity was associated with higher median nerve CSA in all patients but not in patients with diabetes. There was no difference in disease severity in patients with and without diabetes as reported by BCTSQ or CTS-6 scores. In patients with diabetes, there was significantly decreased median nerve CSA with A1c of 6.5 or higher and a trend to decreased CSA with polypharmacy. There was no influence of insulin therapy on median nerve CSA. Conclusion: Diabetes is associated with higher median nerve CSA in patients with CTS of similar disease severity. The increased median nerve CSA in patients with diabetes may be reflective of diabetes-related microvascular changes. Interestingly, the trend to decreased median nerve CSA in patients with suboptimal diabetic control (A1c ≥ 6.5) may suggest eventual degenerative changes to the median nerve. In summary, clinicians should be cautious with interpreting a larger median nerve CSA as more severe CTS in patients with diabetes. Level of Evidence: Level 3 Diagnostic.

Repeat Irrigation and Debridement of Upper Extremity Infections: Do Repeat Cultures Change Antibiotic Treatment Regimens?

BACKGROUND: Organism identification and their antibiotic sensitivity profile are critical for the successful treatment of upper extremity infections. Although many infections resolve with antibiotics alone, some require 1 or more surgical procedures in which culture data are obtained. The purpose of this study was to determine whether repeat cultures taken at subsequent irrigation and debridement of upper extremity infections changed antibiotic treatment. METHODS: A retrospective review was performed using International Classification of Diseases, Ninth Revision codes to identify all adult patients with an upper extremity infection treated with 2 irrigation and debridement procedures with 2 separate culture data sets over a period of 5 years. Culture organisms and antibiotic sensitivity profiles were compared from each procedure, and changes in antibiotic treatment based on repeat culture information were identified. RESULTS: In all, 183 patients who underwent 2 irrigation and debridement procedures with repeat culture data were identified. Organisms identified with repeat culture were the same or there was no growth in 153 patients and were different in 30 patients. The antibiotic treatment did not require a change in 170 (92.9%) of 183 patients. Of the 30 patients with different repeat cultures, antibiotic treatment changed in only 13 patients (43.3%). Patients who had a change in antibiotic treatment were more likely to have hepatitis C (P = .005). CONCLUSIONS: Repeat culture data changed antibiotic treatment in only 7.1% of patients from our cohort. Patients with hepatitis C were more likely to require a change in antibiotic management after obtaining repeat cultures.

Ultrasound Cross-Sectional Area of the Median Nerve Is Not a Predictor of Patient Reported Outcomes After Carpal Tunnel Release.

BACKGROUND: The purpose of this study was to evaluate the relationship between cross sectional area (CSA) of the median nerve on ultrasound (US) with pre- and postoperative Boston Carpal Tunnel Questionnaire (BCTQ) scores. We hypothesize that there is a positive correlation between CSA and the ΔBCTQ after carpal tunnel release (CTR). METHODS: This was a single center study. During a 6-year period (2014-2020), CSA of the median nerve on US and BCTQ scores were collected prospectively for patients presenting with the chief complaint of numbness and tingling in the upper extremity. Patients who underwent CTR and presented for their 6-week follow-up had repeat measurements of the CSA and BCTQ. These patients were included in this study. Patients were then divided into ultrasound positive (CSA ≥ 10) and ultrasound negative (CSA < 10) groups. These groups were compared on the basis of demographics, preoperative BCTQ scores, postoperative BCTQ scores, and 6-week ΔBCTQ score. RESULTS: US-positive and-negative groups did not differ significantly in their preoperative BCTQ, postoperative BCTQ, or ΔBCTQ scores. Both groups did, however, experience significant improvement when comparing preoperative to postoperative BCTQ scores within their respective US group. CONCLUSION: Regardless of the preoperative CSA of the median nerve, patients who underwent CTR experienced a significant improvement in their BCTQ results. US-positive patients experienced no greater improvement than US-negative patients. These results would suggest that US is not a good predictor of subjective surgical outcome measures such as the BCTQ.

Patients Prefer Ultrasound to Nerve Conduction Studies for the Diagnosis of Carpal Tunnel Syndrome.

Background: The net promoter score (NPS) allows analysis of patient satisfaction and preference between treatment and/or diagnostic testing. Electrodiagnostic testing (EDX) and ultrasound (US) are commonly used diagnostic tests for carpal tunnel syndrome. Although EDX is reliable for diagnosing carpal tunnel syndrome (CTS), it can be uncomfortable and inconvenient for patients. We aimed to determine whether patients preferred US or EDX studies for the diagnosis of CTS, using the NPS. Methods: Seventy-five patients presenting to the clinic for evaluation of CTS complaints who had EDX were prospectively studied. US evaluation of the median nerve was then completed at time of evaluation. Patient satisfaction was determined by asking, "how likely are you to recommend this procedure to a friend or relative?" for both EDX and US. Patient demographics, comorbidities, CTS-6 questionnaire (CTS-6), and functionality assessed through patient-reported qDASH were also recorded. Results: Sixty-five patients were included in the study. Most patients did not have any comorbidities and were nonsmokers. The gender composition was similar, and the average age of the enrolled patients was 58. The NPS for US was significantly higher than EDX (P < 0.0001). Patients with diabetes mellitus rated their EDX experience significantly lower than those without diabetes mellitus. Conclusions: Patients are more likely to recommend US instead of EDX in the evaluation of CTS complaints. This allows for shared decision-making between the patient and provider if ordering diagnostic testing for CTS.

Patient Satisfaction in the Preoperative Period: Preparing for Hand Surgery.

Background: The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling and medical clearance encounters. Methods: Questionnaires investigating satisfaction with the preoperative process were collected for 200 patients presenting for elective hand surgery. The number of telephone, surgeon, and medical clearance encounters were recorded, and satisfaction was determined for each type based on a 4-category Likert scale. All patients 18 years or older were included, while only patients providing incomplete questionnaires were excluded. Outcome data were assessed for associations between different encounter totals or types and satisfaction rates. Results: Among 200 patients, 197 completed the questionnaire and were included. Overall satisfaction with the preoperative process was 92.9%, with only 3% of patients dissatisfied. There was a significant association between satisfaction and the number of telephone and total encounters. Satisfaction fell below 90% after 4 or more telephone calls (66.6%, P = 0.005) and 5 or more total encounters (80%, P = 0.008). When considered individually, there was no significant association between satisfaction and the number of surgeon (P = 0.267) or medical office encounters (P = 0.087), or a patient's perceived health status (P = 0.14). Conclusions: Greater than 3 telephone or 4 total encounters significantly decreases patient satisfaction, while surgeon and medical office visits are not associated with satisfaction rates when considered individually. This suggests the number, not the type, of preoperative encounters impact satisfaction and highlight the importance of efficient communication between patients and providers.