Outcomes Following Surgical Fixation of Distal Radius Fractures in Patients With Chronic Kidney Disease.

Purpose: Moderate-to-severe chronic kidney disease (CKD, stages III-IV) and end-stage renal disease (ESRD or CKD stage V) are known to be independent risk factors for fragility fracture. Altered bone and mineral metabolism contributes to greater complications and mortality rates in the setting of fractures, although most existing literature is limited to hip fractures. We hypothesized that patients with moderate-to-severe CKD or ESRD would have greater complication rates after surgical treatment of distal radius fractures compared with those without CKD. Methods: We retrospectively identified all patients at a level 1 trauma center between 2008 and 2018 who had a diagnosis of stage III-IV CKD or ESRD at the time of operative fixation of a distal radius fracture. We recorded demographic data, comorbidities, and surgical complications. Data for readmissions within 90 days and 1-year mortality were collected. A 2:1 sex-matched control group without CKD who underwent distal radius fixation was selected for comparison, with age-adjusted analysis. Results: A total of 32 patients with CKD (78.1% CKD stage III/IV, 21.9% ESRD) and 62 without CKD were identified. The mean age was 67 ± 12 years in the CKD group and 55 ± 15 years in the control group. The CKD group had a higher Charlson Comorbidity Index (5.7 vs 2.0). Surgical complication rate in the CKD group was 12.5% (12.0% CKD III/IV; 14.3% ESRD). Neither early nor late surgical complication rates were statistically different from those in patients without CKD. Reoperation rate as well as 30- and 90-day readmission rates were similar between groups. Overall, 1-year mortality was greater in the CKD group (9.4% vs 0%). Conclusions: Surgical complications and readmission rates are similar in patients with and without CKD after distal radius fracture fixation. However, 1-year mortality rate is significantly higher after distal radius fixation in patients with moderate-to-severe CKD or ESRD. Type of study/level of evidence: Prognostic IIIa.

Outcomes Following Surgical Fixation of Upper Extremity Fractures in Patients with Chronic Kidney Disease.

Purpose: Moderate to severe (stage III-IV) chronic kidney disease (CKD) and end stage renal disease (ESRD) have been shown to be independent risk factors for sustaining a fragility fracture. High rates of complications and mortality are associated with fracture fixation in patients with CKD, but existing literature is limited. It is unknown how CKD stage III-IV or ESRD affects outcomes in upper-extremity fractures. We hypothesize that patients with CKD stage III-IV or ESRD will have high complication rates after surgical fixation of upper extremity fractures. Methods: We identified all patients between 2008 and 2018 who underwent operative fixation of an upper extremity fracture proximal to the distal radius with a diagnosis of CKD stage III-IV or ESRD at the time of injury. Those with an acute kidney injury at the time of injury or a history of a kidney transplant were excluded. Demographics, medical complications, and surgical complications were collected retrospectively. Data on readmissions within 90 days and mortality within 1 year were also collected. Results: Thirty-five patients were identified. Three patients had ESRD. Fractures included two clavicle, twelve proximal humerus, one humeral shaft, ten distal humerus, five olecranon, two ulnar shaft, one radial shaft, and two both-bone forearm fractures. In total, 91.4% of fractures were closed injuries. Surgical complications occurred in 40% of patients. The reoperation rate was 11.4%, and all cases of reoperation involved hardware removal. The all-cause 90-day readmission rate was 34.3%. The 1-year mortality rate was 8.6%. Conclusions: Surgical complications occurred in 40% of patients with CKD stage III-IV or ESRD who underwent fixation for an upper extremity fracture. It is important to counsel these patients regarding their high risk for complications. Further research is needed to investigate and identify how to mitigate risk. Type of study/level of evidence: Prognostic IV.

A Comparison of Patient Characteristics and Outcomes Between Patients Receiving Flexor Digitorum Superficialis Slip Excision or Isolated A1 Pulley Release for Trigger Finger.

PURPOSE: Resection of the radial or ulnar slip of the flexor digitorum superficialis (FDS) tendon is a known treatment option for persistent trigger finger. Risk factors for undergoing FDS slip excision are unclear. We hypothesized that patients who underwent A1 pulley release with FDS slip excision secondary to persistent triggering would have a higher comorbidity burden compared to those receiving A1 pulley release alone. METHODS: We identified all adult patients who underwent A1 pulley release with FDS slip excision because of persistent triggering either intraoperatively or postoperatively from 2018 to 2023. We selected a 3:1 age- and sex-matched control group who underwent isolated A1 pulley release. Charts were retrospectively reviewed for demographics, selected comorbidities, trigger finger history, and postoperative course. We performed multivariable logistic regression to assess the probability of FDS slip excision after adjusting for several variables that were significant in bivariate comparisons. RESULTS: We identified 48 patients who underwent A1 pulley release with FDS slip excision and 144 controls. Our multivariable model showed that patients with additional trigger fingers and a preoperative proximal interphalangeal (PIP) joint contracture were significantly more likely to undergo FDS slip excision. CONCLUSIONS: Patients who underwent A1 pulley release with FDS slip excision were significantly more likely to have multiple trigger fingers or a preoperative PIP joint contracture. Clinicians should counsel patients with these risk factors regarding the potential for FDS slip excision in addition to A1 pulley release to alleviate triggering of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Techniques and Fixation of Olecranon Osteotomy: A Systematic Review.

Purpose: We aimed to characterize the incidence of complications regarding olecranon osteotomy, looking more specifically at the type of osteotomy and the fixation construct used to repair the osteotomy. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search was performed. A study was included if it was an adult clinical study, a transverse or chevron olecranon osteotomy was performed, and the study explicitly states the fixation construct used to repair the osteotomy. A quality assessment was performed in each study prior to data extraction. Results: We included 39 studies with a total of 1,445 patients. Most studies included patients who were being treated primarily for a distal humerus fracture. The overall incidence of delayed union was 27/643 (4.2%), with a higher rate in transverse osteotomy than in chevron osteotomy (5/49 (10.2%) vs 22/595 (3.7%)). Nonunion occurred in 43/811 (5.4%) of patients, with a higher rate in transverse osteotomy (6/73 (8.2%) vs. 37/712 (5.2%)). Implant failure or loss of reduction occurred in 44/746 (5.9%) of patients, with a higher rate in transverse osteotomy (11/49 (22.4%) vs 33/688 (4.8%)). The removal of implants occurred in 236/1078 (21.9%) of all patients, with the highest rate in those studies that used plate fixation 44/99 (44.4%). Conclusions: Compared with chevron osteotomy, patients who underwent transverse osteotomy had a higher incidence of delayed union, nonunion, and implant failure or loss of reduction requiring revision surgery. The incidence of implant removal indicates that patients should be informed that nearly half of the osteotomy fixed with a plate was removed after implantation. Type of study/level of evidence: Therapeutic III.

Current Outcomes and Treatments of Complex Phalangeal and Metacarpal Fractures.

Phalangeal and metacarpal fractures that require operative treatment have documented complications in around 50% of patients. The most common of these complications are stiffness and malunion. These can be highly challenging problems for the hand surgeon. In this article, we discuss complications after phalangeal and metacarpal fractures and treatment strategies for these complications.

Routine Postoperative Radiographs Do Not Affect Decision Making Following Carpometacarpal Arthroplasty.

Purpose: Arthritis of the first carpometacarpal (CMC) joint affects up to 15% of the population aged over 30 years and 40% of the population aged over 50 years. Arthroplasty of the first CMC joint is a widely accepted treatment option for these patients, with most patients doing well long term despite radiographic evidence of subsidence. Postoperative treatment protocols vary with no defined gold standard, and the need for routine postoperative radiographs has not been defined. The purpose of this study was to evaluate the use of routine postoperative radiographs following CMC arthroplasty. Methods: A retrospective review of patients who underwent CMC arthroplasty from 2014 to 2019 at our institution was performed. Patients receiving a concomitant trapezoid resection or metacarpophalangeal capsulodesis/arthrodesis were excluded. Demographic data, as well as the frequency and timing of postoperative radiographs, were collected. Radiographs were included if taken up to 6 months from the date of surgery. The primary outcome was a repeated operative intervention. Descriptive statistics were used for the analysis. Results: A total of 155 CMC joints from 129 patients were included in the study. Sixty-one (39.4%) patients had no postoperative radiographs, 76 (49.0%) patients had one postoperative radiographic series, 18 (11.6%) had two, 8 (5.2%) had three, and 1 (0.6%) patient had four postoperative series of radiographs. A radiographic series is defined as multiple views taken at a single time point. Four of 155 (2.6%) patients underwent additional operative intervention. There were no patients who underwent revision CMC arthroplasty. Two had wound infections that underwent irrigation and debridement. Two developed metacarpophalangeal arthritis and underwent arthrodesis. There were no cases where repeat operative intervention was driven by postoperative radiographic findings. Conclusions: Routine postoperative radiographs following CMC arthroplasty do not lead to changes in patient management, specifically further surgery. These data may support forgoing routine radiographs in the postoperative period following CMC arthroplasty. Type of study/level of evidence: Therapeutic IV.

2-Octyl Cyanoacrylate (Dermabond®) Inhibits Bridging Bone Formation of Articular Fractures in a Rat Model.

One technique often used for small intraarticular fracture fixation involves the use of 2-octyl-cyanoacrylate (2-OCTA) (Dermabond®, Ethicon, Inc., Raritan, USA). The purpose of this study was to determine if 2-OCTA impedes bony healing. Osteochondral plugs in 38 retired Sprague-Dawley rats were created in both hind legs. Each rat had one plug dipped in 2-OCTA before fixation and one control plug. H&E staining was used to quantify bone bridging. The 2-OCTA group had a mean bridging bone circumference of 22.80%, significantly less than 67.75% in the control group (p<0.05). Our data suggests that 2-OCTA blocks bridging bone formation, making it a poor choice for fracture fixation.

Design Parameters of Hand Surgery Screws: Measurement Discrepancies and Clinical Implications.

Purpose: The use of self-tapping cortical screws is indicated in patients with metacarpal and phalangeal fractures requiring formal stabilization. The aim of this study was to systematically compare and evaluate the design parameters of 4 commercially available self-tapping screw systems. Methods: We measured various design parameters of self-tapping cortical screws of different lengths from several manufactures using scanning electron microscopy. Screws were obtained in 8, 12, 16, and 20 mm lengths. The measured parameters included screw length, head height, pitch, outer diameter, inner diameter, terminal thread diameter, terminal thread-to-tip distance, thread-to-tip distance of 1 full revolution, and crest width. Data were assessed statistically using 1- and 2-way analysis of variance (ANOVA) tests, and the significance level was set at a P value < .05. Results: There was variability in advertised screw lengths compared with measured screw lengths with 2 manufacturers. There was a statistically significant difference between the thread-to-tip distance and head height between screws while controlling for diameter. Conclusions: Screw sizes and dimensions are critical in order to avoid complications such as prominent hardware and postoperative stiffness. Knowledge of the design parameters presented for each of the different manufacturers may prove useful to hand surgeons when selecting screws for fixation of metacarpal and phalangeal fractures. Clinical relevance: Specific design characteristics of commonly used screws in hand surgery vary slightly by manufacturer and may have clinically relevant implications in fixation of metacarpal and phalangeal fractures.

Intra-arterial Foreign Body following Radial Artery Cannulation Requiring Microsurgical Removal: Case Report and Review of the Literature.

We report the case of a pediatric patient who underwent intra-arterial exploration and removal of foreign body after an arterial catheter cannula inadvertently fractured during removal and a fragment remained within the radial artery. The fragment was visualized using fluoroscopy intraoperatively and was successfully removed from the common digital artery to the index finger where it had migrated. We present the case as a rare complication of an exceedingly common procedure with a timely response to avoid further complication.

The Effect of Intraoperative Glove Choice on Carpal Tunnel Pressure.

Introduction The aim of this study was to quantify the effect of surgical gown and glove wear on carpal tunnel pressure. The authors hypothesized that gowning and gloving is associated with an increase in carpal tunnel pressure in cadaveric specimens wearing appropriately sized gloves. Furthermore, they hypothesized that increased glove thickness, double gloving, and smaller-than-appropriately sized gloves would all serve to increase carpal tunnel pressure. Materials and Methods Baseline carpal tunnel pressure measurements were obtained in 11 cadaveric specimens. Each specimen was subsequently gowned and gloved. Carpal tunnel pressures were obtained for each specimen fitted with four different types of gloves in four scenarios: (1) appropriately sized gloves, (2) one full-size smaller, (3) one full-size larger, and (4) double gloved. Results Mean carpal tunnel baseline value was 3.5 mm Hg. Appropriately sized single-glove wear more than doubled baseline carpal tunnel pressure. Double gloving and smaller-than-appropriately sized glove wear more than tripled baseline values. Among the single-glove subgroup, the thickest gloves (ortho) were associated with the highest increase in pressure from baseline values. Conclusion Glove selection can have repercussions related to carpal tunnel pressure. Susceptible surgeons should consider these factors when making decisions regarding intraoperative glove wear.

A Biomechanical Comparison of Modified Radioscapholunate Fusion Constructs for Radiocarpal Arthritis.

PURPOSE: This biomechanical study compared fixation constructs used in radioscapholunate (RSL) arthrodesis. We hypothesized that plates and screws, pin plate, and headless screws would all provide similarly stable fixation constructs. METHODS: We chose 27 fresh-frozen cadaveric extremities, 14 of which were matched pairs and randomized them into 3 groups to match age, body mass index, and sex. An RSL arthrodesis was simulated with plates and screws, pin plates, or headless compression screws via a standard dorsal approach to the wrist. Specimens were mounted into a custom jig and cycled through an arc of 120° for 5,000 cycles to simulate 6 weeks range of motion (ROM). A 9-mm stroke differential variable reluctance transducer recorded continuous displacement, and gross hardware failure in the form of screw or pin cutout was investigated after the simulation. RESULTS: Greater distraction across the RSL articulation was observed in the headless screws compared with the plate-and-screws and pin-plate constructs, with no difference between the plates and screws and pin plates. Greater average displacement was observed in the headless screws compared with the plate-and-screws and pin-plate constructs, with no difference between the pin plates and plates and screws. Gross hardware failure was observed least in plates and screws followed by pin plates. CONCLUSIONS: Plate-and-screw and pin-plate constructs are biomechanically superior in resisting RSL distraction compared with headless compression screws for RSL arthrodesis over 6 weeks of simulated ROM in the absence of healing. CLINICAL RELEVANCE: The results of this study demonstrated negligible arthrodesis site distraction in the plate-and-screws and pin-plate constructs when 6 weeks of ROM was simulated. When translated to a clinical scenario, these findings may allow earlier discontinuation of external immobilization after surgery.

Evaluation of zoledronate, cytochalasin-D, and desferrioxamine on osseointegration in an intra-medullary femoral implant model.

OBJECTIVE: The rise in primary and revision surgeries utilizing joint replacement implants suggest the need for more reliable means of promoting implant fixation. Zoledronate-(Zol), cytochalasin-D-(cytoD), and desferrioxamine-(DFO) have been shown to enhance mesenchymal stem cell (MSC) differentiation into osteoblasts promoting bone formation. The objective was to determine whether Zol, cytoD, and DFO can improve fixation strength and enhance peri-implant bone volume about intra-medullary femoral implants. METHODS: 48 Sprague-Dawley female rats were randomized into four treatments, saline-control or experimental: Zol-(0.8 µg/µL), cytoD-(0.05 µg/µL), DFO-(0.4 µg/µL). Implants were placed bilaterally in the femoral canals following injection of treatment solution and followed for 28 days. Mechanical push-out testing and micro-CT were our primary evaluations, measuring load to failure and bone volume. Qualitative evaluation included histological assessment. Data was analyzed with a one-way ANOVA with Holm-Sidak mean comparison testing. RESULTS: Significant results included pushout tests showing an increase in maximum energy for Zol (124%) and cytoD (82%); Zol showed an increase in maximum load by 48%; Zol micro-CT showed increase in BV/TV by 35%. CONCLUSIONS: Our findings suggest that locally applied Zol and cytoD enhance implant mechanical stability. Bisphosphonates and actin regulators, like cytoD, might be further investigated as a new strategy for improving osseointegration.

Minocycline microspheres did not significantly improve outcomes after collagenase injection of tendon.

BACKGROUND: Tetracycline antibiotics inhibit matrix metalloproteinases and pro-inflammatory cytokines implicated in the pathogenesis of tendinopathy, while microsphere formulations allow sustained release of drug contents. The purpose of this study was to evaluate the ability of a local minocycline microsphere injection to restore normal tendon properties in a rat model of collagenase-induced patellar tendinopathy. METHODS: A total of 22 rats were randomly assigned to the control (n = 11) or minocycline (n = 11) group and received bilateral patellar tendon injections of collagenase. After 7 days, the minocycline group received the minocycline microsphere treatment and the control group received phosphate buffered solution. Pain was assessed via activity monitors and Von Frey filament testing. At 4 weeks post-collagenase injections, animals were euthanized. RESULTS: Cage crossings significantly decreased among all rats 2-3 days following each injection period, however, tactile allodynia measures did not reflect this injury response. Biomechanical properties, interleukin-1 beta levels, and glycosaminoglycan content did not differ between groups. While not statistically significant, levels of leukotriene B4 were lower in the minocycline group compared to controls (p = 0.061), suggesting a trend. CONCLUSIONS: Our study further characterizes the collagenase model of tendinopathy by demonstrating no evidence of central sensitization with collagenase-induced injury. We found no adverse effect of intratendinous injections of minocycline-loaded poly-lactic-co-glycolic acid microspheres, although no therapeutic effect was observed. Future studies involving a more substantial tendon injury with a greater inflammatory component may be necessary to more thoroughly evaluate the effects of minocycline on tendon pathology.

Gender Preferences of Patients When Selecting Orthopaedic Providers.

Background: Orthopaedic surgery is a male-dominated specialty associated with many stereotypes, despite the increased representation of females compared to 30 years ago. Numerous studies have examined medical student and resident perceptions regarding females in orthopaedic surgery to explain the disparity, but there are few studies that analyze whether patients have a gender preference in their orthopaedic surgeon. Our study sought to determine whether patients have a preference for the gender of their orthopaedic surgeon, and what traits in orthopaedic surgeons are important to their patients. Methods: A total of 191 new patients seen in the emergency department and orthopaedic urgent care clinic were administered a 22-question survey regarding preferences in their orthopaedic provider. Patients were asked questions regarding preferred gender of their provider, as well as preferences in characteristics exhibited. Results: The majority of patients did not have a preference for the gender of their orthopaedist (83.9%); however, 14.5% of patients preferred a female surgeon and 1.6% of patients preferred a male surgeon. Female patients had a preference for the same gender compared to male patients and preferred females (p=0.04). Of the patients that had a preference, 90% preferred a female provider. There were trends towards preference for gender that varied depending on subspecialty. There was a statistically insignificant trend towards preference for male providers in total joint replacements and spine surgery, and conversely a preference for female providers in hand surgery and pediatric orthopaedics. 48.6% of patients cited the single most important trait to be board certification, followed by years in practice (27.1%), then reputation or prestige (16.7%). Over one-third of patients found physical appearance, gender, racial background and age to be important traits. Conclusions: The majority of patients did not have a preference for the gender of their orthopaedic surgeon. 16.1% of patients had a preference, and the majority of these patients preferred female surgeons. Preferences for a specific gender were seen that varied based on the subspecialty. Efforts at increasing gender diversity in orthopaedics should continue to be a major goal.Level of Evidence: III.

Effect of Nerve-Cutting Technique on Nerve Microstructure and Neuroma Formation.

Background Peripheral neuroma formation results from partial or complete nerve division. Elucidating measures to prevent the development of peripheral neuromas is of clinical importance. The aim of this study was to determine the effect of various surgical nerve-cutting techniques on nerve microstructure and resultant neuroma formation. Methods Twenty Sprague-Dawley rats were randomly assigned to one of the following nerve-cutting techniques: No. 15 scalpel blade with tongue depressor, micro-serrated scissors, nerve-cutting guide forceps with straight razor, and bipolar cauterization. The right sciatic nerve was transected using the assigned nerve-cutting technique. Neuromas were harvested 6 weeks postoperatively, and samples were obtained for histologic analysis. The contralateral sciatic nerve was transected at euthanasia and analyzed with histology and with scanning electron microscopy in a subset of the rats. Results Fifteen of the 20 rats survived the 6-week experiment. Scanning electron microscopy of the No. 15 scalpel blade group showed the most visual damage and disorganization whereas the nerve-cutting guide forceps and micro-serrated scissors groups resulted in a smooth transected surface. Bipolar cauterization appeared to enclose the fascicular architecture within a sealed epineurium. Each neuroma was significantly larger than contralateral controls. There were no significant differences in neuroma caliber between nerve transection groups. No substantial differences in microstructure were evident between transection groups. Conclusion Despite disparate microscopic appearances of the cut surfaces of nerves using various nerve-cutting techniques, we found no significant differences in the caliber or incidence of neuroma formation based on nerve-cutting technique. Nerve-cutting technique used when transecting peripheral nerves may have little bearing on the formation or size of resultant neuroma formation.

Deferoxamine-Soaked Suture Improves Angiogenesis and Repair Potential After Acute Injury of the Chicken Achilles Tendon.

BACKGROUND: A major obstacle to the treatment of soft tissue injuries is the hypovascular nature of the tissues. Deferoxamine (DFO) has been shown to stimulate angiogenesis by limiting the degradation of intracellular hypoxia-inducible factor 1-alpha. HYPOTHESIS: DFO-saturated suture would induce angiogenesis and improve the markers of early healing in an Achilles tendon repair model. STUDY DESIGN: Controlled laboratory study. METHODS: Broiler hens were randomly assigned to the control (CTL) group or DFO group (n = 9 per group). The right Achilles tendon was partially transected at its middle third. The defect was surgically repaired using 3-0 Vicryl suture soaked in either sterile water (CTL group) or 324 mM DFO solution (DFO group). All animals were euthanized 2 weeks after the injury, and the tendon was harvested. Half of the tendon was used to evaluate angiogenesis via hemoglobin content and tissue repair via DNA content and proteoglycan (PG) content. The other half of the tendon was sectioned and stained with hematoxylin and eosin, safranin O, and lectin to evaluate vessel density. RESULTS: Hemoglobin content (percentage of wet tissue weight) was significantly increased in the DFO group compared with the CTL group (0.081 ± 0.012 vs 0.063 ± 0.016, respectively; P = .046). DNA content (percentage of wet tissue weight) was also significantly increased in the DFO group compared with the CTL group (0.31 ± 0.05 vs 0.23 ± 0.03, respectively; P = .024). PG content (percentage of wet tissue weight) was significantly decreased in the DFO group compared with the CTL group (0.26 ± 0.02 vs 0.33 ± 0.08, respectively; P = .035). Total chondroid area (number of vessels per mm2 of tissue area evaluated) was significantly decreased in the DFO group compared with the CTL group (17.2 ± 6.6 vs 24.6 ± 5.1, respectively; P = .038). Articular zone vessel density (vessels/mm2) was significantly increased in the DFO group compared with the CTL group (7.1 ± 2.5 vs 2.1 ± 0.9, respectively; P = .026). CONCLUSION: The significant increase in hemoglobin content as well as articular zone vessel density in the DFO group compared with the CTL group is evidence of increased angiogenesis in the fibrocartilaginous region of the tendon exposed to DFO. The DFO group also displayed a significantly greater level of DNA and significantly lower level of PG, suggesting enhanced early healing by fibrous tissue formation. CLINICAL RELEVANCE: Stimulating angiogenesis by DFO-saturated suture may be clinically useful to improve healing of poorly vascularized tissues.

Accuracy in Screw Selection in a Cadaveric, Small-Bone Fracture Model.

PURPOSE: Using a cadaveric model simulating clinical situations experienced during open reduction and internal fixation of proximal phalangeal fractures, the aim of this study was to evaluate the relationship between level of training and the rates of short, long, and ideal screw length selection based on depth gauge use without fluoroscopy assistance. METHODS: A dorsal approach to the proximal phalanx was performed on the index, middle, and ring fingers of 4 cadaveric specimens, and 3 drill holes were placed in each phalanx. Volunteers at different levels of training then measured the drill holes with a depth gauge and selected appropriate screw sizes. The rates of short, long, and ideal screw selection were compared between groups based on level of training. Ideal screws were defined as a screw that reached the volar cortex but did not protrude more than 1 mm beyond it. RESULTS: Eighteen participants including 3 hand fellowship-trained attending physicians participated for a total of 648 selected screws. The overall rate of ideal screw selection was lower than expected at 49.2%. There was not a statistically significant relationship between rate of ideal screw selection and higher levels of training. Attending surgeons were less likely to place short screws and screws protruding 2 mm or more beyond the volar cortex CONCLUSIONS: Overall, the rate of ideal screw selection was lower than expected. The most experienced surgeons were less likely to place short and excessively long screws. CLINICAL RELEVANCE: Based on the low rate of ideal screws, the authors recommend against overreliance on depth gauging alone when placing screws during surgery. The low-rate ideal screw length selection highlights the potential for future research and development of more accurate technologies to be used in screw selection.

Submuscular Versus Subcutaneous Ulnar Nerve Transposition: A Cadaveric Model Evaluating Their Role in Primary Ulnar Nerve Repair at the Elbow.

PURPOSE: To investigate the length gained from subcutaneous and submuscular transposition of the ulnar nerve at the elbow. Specifically, the study aimed to define an expected nerve gap able to be overcome, and to determine if a difference between transposition techniques exists. METHODS: Eleven cadaveric specimens from the scapula to fingertip were procured. In situ decompression and mobilization of the ulnar nerve at the elbow followed by simulated laceration of the nerve was performed. Nerves were marked 5 mm from the laceration site to facilitate overlap measurement and to simulate nerve end preparation to viable fascicles before primary coaptation. Nerve ends were attached to spring gauges set at 100 g of tension (strain ≤ 10%). Measurements of nerve overlap were obtained in varying degrees of wrist (0°, 30°, 60°) and elbow (0°, 15°, 30°, 45°, 60°, 90°) flexion. Measurements were performed after in situ decompression and mobilization, and then repeated after both subcutaneous and submuscular transposition. RESULTS: Ulnar nerve transposition was found to increase nerve overlap at an elbow flexion of 30° or greater. No difference was seen between subcutaneous and submuscular transpositions at all wrist and elbow positions. In situ decompression and mobilization alone provided an average of 3.5 cm of length gain with the elbow extended. Transposition in conjunction with clinically feasible wrist and elbow flexion (30° and 60°, respectively) provided 5.2 cm of length gain. Controlling for mobilization, a statistically significant increase in overlap of approximately 2 cm was gained from transposition. CONCLUSIONS: Although mobilization combined with wrist and elbow flexion may afford substantial gap reduction and should be used initially when approaching proximal ulnar nerve lacerations, transposition should be considered when faced with a large nerve gap greater than 3 cm at the elbow. No difference was seen between submuscular and subcutaneous transposition techniques. CLINICAL RELEVANCE: This study defines the extent an ulnar nerve gap at the elbow can be overcome by in situ mobilization, joint positioning, and transposition. It additionally compares the efficacy of submuscular and subcutaneous transposition techniques in closing this gap.

Volar Anatomy of the Proximal Phalanx: Implications for Screw Length Selection for Fixation of Shaft Fractures.

PURPOSE: To investigate the anatomy of the volar surface of the proximal phalanx of the hand, specifically the longitudinal groove running along the volar phalangeal shaft. METHODS: We measured skeletonized proximal phalanges from 10 embalmed human cadaver hands at 5 equidistant points along the shaft. The difference between the maximum dorsal-palmar thickness of the shaft and thickness measured from the center of the volar groove to the most dorsal aspect of the phalanx indicated the depth of the groove at each point. These specimens underwent microtomography to characterize their osseous morphology further. Screws placed dorsal to palmar into the specimens and viewed fluoroscopically simulated the appearance of screw protrusion into the volar groove under intraoperative imaging. Similarly, screws placed into a fresh-frozen cadaveric hand illustrated possible screw impingement on soft tissue in vivo. RESULTS: The volar groove was most pronounced at the proximal and distal ends of the phalangeal shaft, becoming shallower along the midportion of the bone. The average difference between total bone thickness and thickness measured from the depth of the groove was significant at each of the 5 points of measurement along the phalangeal shaft for each of the 5 digits of the hand, including the thumb. Average groove depths ranged from 4% to 14% of total bone thickness, with a maximum individual measurement of 22%. Average depth of the groove at each of these positions ranged from 0.19 to 1.64 mm, reaching a maximum of 2.31 mm. CONCLUSIONS: We demonstrated that there is a longitudinal groove running the length of the phalangeal shaft. CLINICAL RELEVANCE: Viewed laterally, the cupped edges of the groove obscure its depth. Dorsally placed bicortical screws could protrude into the groove, remaining unnoticed on intraoperative imaging. The resulting impingement on the flexor tendon could lead to postsurgical stiffness or flexor tendon attritional rupture.

Neurogenic Edema from Complex Regional Pain Syndrome Resulting in Fulminant Infection Necessitating Below Elbow Amputation.

We report a case of severe upper extremity complex regional pain syndrome type 1 (CRPS-1) and neurogenic edema that ultimately led to a medically necessary below-elbow amputation. The patient presented with a history of remote bilateral carpal tunnel release complicated by debilitating and recalcitrant bilateral CRPS-1. Following years of severe neurogenic edema of the left upper extremity, the patient had full-thickness skin sloughing on the dorsum of her hand due to massive edema. This subsequently led to maggot infestation of the soft tissues of the left hand ultimately necessitating amputation. We present the case as an illustration of an extreme case of neurogenic edema, a potential physical manifestation of CRPS-1. The case presented discusses upper extremity amputation as an end treatment option for CRPS-1, though in this case amputation was primarily indicated secondary to medical necessity.