Revision of Failed Radial Head Arthroplasty.

BACKGROUND: Revision of radial head arthroplasty (RHA) may be indicated in cases of prosthesis loosening and malposition. Inherent difficulties in revision surgery include poor bone stock and disrupted soft tissue envelope. Although cases of RHA used for revision of failed RHA are rare, there is reasonable expectation for increasing frequency of these cases due to the increasing incidence of primary RHA. Furthermore, there is an increasing demand for postoperative recovery of function; thus, surgeons may consider revising a failed RHA to a new RHA. We report on series of failed RHA which were revised to a new radial head prosthesis. METHODS: A retrospective review was performed at multiple institutions for a single radial head prosthesis used for revision of a failed radial head prosthesis. Clinical and radiographic outcomes were collected with a minimum of 1 year of follow-up. RESULTS: Across 11 patients at a mean follow-up of 45.1 months, the mean Mayo Elbow Performance Score was 81.7; mean Disabilities of the Arm, Shoulder, and Hand scores were 24.4; and mean Visual Analog Scale for pain was 0.6. Radiographic analysis yielded no evidence of capitellar wear or stem loosening. CONCLUSION: A radial head prosthesis can produce satisfactory results when used for revision of a failed prosthesis. Inherent difficulties in revision surgery include the potential for reduced bone stock and a disrupted soft tissue envelope. Elements of prosthesis design which may contribute to effectively managing revision surgery include a long stem with in-growth surface and prosthetic head alignment to the axis of forearm rotation.

Analysis of the Quality of Prospective Randomized Controlled Trials for Treatment of Boxer's Fractures.

BACKGROUND: This study aimed to review level I and II therapeutic studies on boxer's fractures to measure variation in quality among the highest level study designs. METHODS: We used quantitative measures of study quality to evaluate prospective randomized controlled trials (RCTs) of treatments of boxer's fractures. A search of PubMed, using terms "boxer's fracture" and "fifth metacarpal neck fracture" identified 164 articles from 1961 to 2019. From this list, we identified 6 RCTs. Two observers classified each trial according to 3 systems: the Oxford Levels of Evidence, the modified Coleman Methodology Score, and the revised Consolidated Standards of Reporting Trials (CONSORT) score. RESULTS: The 2 reviewers were consistent in their use of the Oxford Levels of Evidence (100% agreement). The differences between the average modified Coleman Methodology scores and the average CONSORT scores assigned by the 2 observers were not significant (46.2 vs 45.3 points, κ = 0) and (13.7 vs 14.3 points, κ = 0.33), respectively. Both observers rated all the studies as level I and as unsatisfactory according to the Coleman Methodology Score (100% and 100%), and less than half as unsatisfactory according to the CONSORT score (50% and 17%). Areas of deficiency included randomization, blinding, group comparability, clinical effect measurements, and allocation into treatment arms. CONCLUSION: Classifying orthopedic scientific reports according to the levels of evidence implies a degree of respect for level I and II studies that may not always be merited. Our data suggest that the quality of higher level studies, namely those involving boxer's fractures, varies and may often be unsatisfactory when critically evaluated.

Negative pressure wound therapy on complex extremity wounds requiring coverage with a meshed bilayer wound matrix: a retrospective analysis.

OBJECTIVE: The treatment of complex extremity wounds is technically challenging. In this 5-year retrospective review, we compared the use of Integra Meshed Bilayer Wound Matrix (IMBWM; Integra LifeSciences, US) followed by a split-thickness skin graft (STSG) combined with negative pressure wound therapy (NPWT) versus IMBWM followed by STSG alone for the management of these wounds. METHOD: Data from patients undergoing management using IMBWM for a complex extremity wound coverage were collected. RESULTS: Among the 109 patients studied, the wounds of 62 patients were managed using IMBWM and NPWT, and 47 were managed using IMBWM alone. The most common aetiology of these injuries was trauma. Wound size and location were similar for each group, ranging in size from 2-30cm2 and being primarily on the forearm, followed by the leg and arm. There was a significantly greater take of the IMBWM+STSG with NPWT (96.8%) compared to without NPWT (85.1%, p=0.03). There were significantly fewer reapplications of the dermal matrix required in the NPWT group (3.2%) versus the non-NPWT group (14.9%, p=0.03). There were significantly fewer postoperative complications, prior to STSG, in the NPWT group (3.2%) versus the non-NPWT group (14.9%, p=0.03). CONCLUSION: The combination of IMBWM with NPWT leads to a higher success rate, and can reduce the number of dermal matrix reapplications and postoperative complications, in the setting of complex extremity wounds. The use of IMBWM in combination with NPWT has the potential to improve both surgical procedures and patient outcomes in this setting.

Predictors of Success following Microvascular Replantation Surgery of the Upper Extremity in Adult Patients.

The purpose of this study is to ascertain which factors are associated with successful replantation in the upper extremity. Secondarily, the purpose was to determine patient factors that differentiate those patients who undergo initial replantation versus initial amputation. Methods: Data gathered for this retrospective study were obtained from a custom subset of the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. Data were sorted using Current Procedural Terminology codes and International Classification of Disease, Ninth and Tenth Revision, diagnosis codes. Results: Increasing age was significantly associated with undergoing initial amputation compared with replantation (P < 0.001; 95% CI, 47.146-50.654). Among comorbid conditions, patients with diabetes mellitus type II (2.4% versus 24.3%; P < 0.001), hypertension (11.9% versus 28.0%; P = 0.03), end-stage renal disease (0% versus 10.5%; P = 0.03), and hypertensive chronic kidney disease (0% versus 8.7%; P = 0.04) more commonly underwent an initial amputation procedure. When evaluating the need for secondary procedure after replantation, there was no statistical significance between groups when comparing age, gender, insurance type, general comorbidities, connective tissue disorders, mental health disorders, or geographic location. Conclusions: In conclusion, this study demonstrates that age and the presence of comorbidities are important factors in the differentiation of which patients undergo initial reimplantation versus initial amputation. Additionally, no specific factors were identified that were associated with secondary procedures after replantation.

Validity of Using the Scratch Collapse Test in the Lower Extremities.

BACKGROUND: The scratch collapse test is a provocative test that has been successfully used for peripheral neuropathies. The elbow is the main testing site, but there may be times when use of the upper extremities is contraindicated. This study sought to determine the sensitivity of using the scratch collapse test on the lower extremity for upper extremity neuropathies. METHODS: One hundred patients with an electromyographically confirmed diagnosis of carpal tunnel or cubital tunnel syndrome were prospectively enrolled. As a control, the scratch collapse test was conducted normally using the elbow as a testing site. After a baseline was established, the test was repeated using eversion of the foot and ankle against an inversion force. RESULTS: Of the 100 study patients, 89 had a positive scratch collapse test on the upper extremity and 84 had a positive test on the lower extremity. In the 51 patients with carpal tunnel syndrome, 45 had a positive test on the upper extremity (sensitivity, 88.2 percent; 95 percent CI, 76.13 to 95.56 percent), and 42 had a positive test of the lower extremity (sensitivity, 82.35 percent; 95 percent CI, 69.13 to 91.60 percent). In the 49 patients with cubital tunnel syndrome, 44 had a positive test on the upper extremity (sensitivity, 89.8 percent; 95 percent CI, 77.77 to 96.6 percent), and 42 had a positive test on the lower extremity (sensitivity, 85.7 percent; 95 percent CI, 72.76 to 94.06 percent). CONCLUSION: There were no statistically significant differences in the sensitivities of the scratch collapse test on the upper or lower extremities, suggesting that the lower extremity could serve as an alternative site for the scratch collapse test. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Supercharge End-to-Side Nerve Transfer: Systematic Review.

Background: To decrease the time to reinnervation of the intrinsic motor end plates after high ulnar nerve injuries, a supercharged end-to-side (SETS) anterior interosseous to ulnar motor nerve transfer has been proposed. The purpose of this study was to compile and review the indications, outcomes, and complications of SETS anterior interosseous to ulnar motor nerve transfer. Methods: A literature search was performed, identifying 73 papers; 4 of which met inclusion and exclusion criteria, including 78 patients. Papers included were those that contained the results of SETS between the years 2000 and 2018. Data were pooled and analyzed focusing on the primary outcomes: intrinsic muscle recovery and complications. Results: Four studies with 78 patients met inclusion and exclusion criteria. Most patients (33.3%) underwent SETS for an ulnar nerve lesion in continuity, the average age was 46.5 years, and the average follow-up was 10 months. The average duration of symptoms before surgery was 99 weeks, all patients had weakness and numbness, nearly all (96%) had atrophy, and half (53%) had pain. Grip and key pinch strength improved 202% and 179%, respectively, from the preoperative assessment. The vast majority (91.9%) recovered intrinsic function at an average of 3.7 months. Other than 8% of patients who did not recover intrinsic strength, no other complications were reported in any of the 78 patients. Conclusions: The SETS is a successful procedure with low morbidity, which may restore intrinsic function in patients with proximal nerve injuries.

Radial to Axillary Nerve Transfer Outcomes in Shoulder Abduction: A Systematic Review.

BACKGROUND: Brachial plexus and axillary nerve injuries often result in paralysis of the deltoid muscle. This can be functionally debilitating for patients and have a negative impact on their activities of daily living. In these settings, transferring the branch of the radial nerve innervating the triceps to the axillary nerve is a viable treatment option. Additional nerve transfers may be warranted. This study sought to determine the efficacy of nerve transfer procedures in the setting of brachial plexus and axillary nerve injuries and factors affecting clinical outcomes. METHODS: The U.S. National Library of Medicine's website "PubMed" was queried for "radial to axillary nerve transfer" and "brachial plexus nerve transfer." An initial review by two authors was performed to identify relevant articles followed by a third author validation utilizing inclusion and exclusion criteria. Individual patient outcomes were recorded and pooled for final analysis. RESULTS: Of the 80 patients, 66 (82.5%) had clinical improvement after surgical nerve transfer procedures. Significant difference in clinical improvement following nerve transfer procedures was correlated with patient age, mechanism of injury, brachial plexus vs isolated axillary nerve injuries, multiple nerve transfers vs single nerve transfers, and surgery within the first 7 months of injury. The branch of the radial nerve supplying the triceps long head showed improved clinical results compared with the branch of the radial nerve supplying the triceps medial head and anconeus. CONCLUSION: Nerve transfers have been shown to be effective in restoring shoulder abduction in both isolated axillary nerve injuries and brachial plexus injuries.

The Educational Impact of a Fellowship-trained Orthopaedic Oncologist.

INTRODUCTION: Musculoskeletal oncology is a subspecialty of orthopaedics with few fellowship-training locations. Although orthopaedic oncologists comprise a minority within the field of orthopaedic surgery, most work at academic centers and serve in leadership roles with notable impact on patients and the training of residents. This article investigates the objective impact orthopaedic oncologists have regarding resident operative case volume and performance on in-training examinations. METHODS: The William Beaumont Army Medical Center and Texas Tech University Health Sciences Center of El Paso combined orthopaedic residency program's case logs and Orthopaedic In-Training Examination (OITE) scores between 2013 and 2018 were reviewed. This provided 3 academic years of data before and after an orthopaedic oncology faculty member arrived in 2016. The case volume and OITE examination performance before and after the addition of the orthopaedic oncology faculty member were compared. RESULTS: After the addition of an orthopaedic oncology faculty member, a significant increase was observed in the program's OITE overall correctly answered questions (171.30 versus 181.03, P = 0.004) and oncology subsection percentile (56th to the 66th percentile, P = 0.038). An increase was also observed in resident oncology case volume from 29 oncology cases per year to 138 cases on average (P = 0.022). DISCUSSION: The addition of a fellowship-trained orthopaedic oncologist results in increased exposure to orthopaedic oncology cases and improved resident performance on the OITE. This may correlate to improved American Board of Orthopaedic Surgeons Part I pass rates and improved overall resident satisfaction.

Outcomes and Return to Work Following Complex Nerve Lacerations in the Volar Forearm in an Underserved Spanish-Speaking Population.

Purpose: Lacerations to the ulnar and median nerve in the volar forearm have demonstrated considerable long-term clinical and socioeconomic impacts on patients. The purpose of this study was to evaluate the outcomes of complex volar forearm lacerations involving one or more major peripheral nerves in an economically disadvantaged patient population. Methods: In this study, a retrospective analysis of 61 patients who sustained lacerations to the median nerve, ulnar nerve, or both with volar wrist lacerations was performed. Each patient's preinjury and postinjury occupation, dominant extremity, and demographic variables were evaluated. Sensation recovery, motor recovery, Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale scores, cold intolerance, and return to work were evaluated at 3, 6, and 12 months after the injury. Results: Patients with isolated median nerve injuries demonstrated improved motor recovery compared with patients with isolated ulnar nerve injuries. Patients with combined nerve injuries had worse sensation recovery and motor recovery, and lower rates of return to work than either group of patients with isolated nerve injuries. Manual laborers had worse motor recovery and lower rates of return to work than did patients who were office workers. Conclusions: Patients with combined median and ulnar nerve injuries have worse functional recovery and lower rates of return to work than do patients with isolated median or isolated ulnar nerve injuries at 1 year. Manual laborers demonstrated worse functional recovery and lower rates of return to work compared with office workers at 1 year. Type of study/level of evidence: Therapeutic III.