Ulnar Nerve Palsy as COVID-19 Sequelae in 3 Patients.

The pathophysiology and treatment of COVID-19 have been at the forefront of medical research this past year. While great strides have been made in our knowledge of the disease, there is still much that is unknown. More than one-third of patients with COVID-19 present with symptoms involving the nervous system. The reason for this is unclear, although several theories have been postulated. In this case study, we present 3 patients with severe ulnar nerve dysfunction following treatment for COVID-19 in the intensive care unit. We discuss reasons why this may have occurred, the etiology of which is likely multifactorial. We are reporting these cases to inform and alert physicians to the possibility of ulnar nerve involvement in the presentation of patients with COVID-19.

The Cutting Edge: Surface Texture Analysis following Resection of Nerve Stumps Using Various Instruments.

BACKGROUND: Preparation of nerve ends is an essential part of nerve repair surgery. Multiple instruments have been described for this purpose; however, no consensus exists regarding which is the least traumatic for tissue handling. We believe that various instruments used for nerve-end excision will lead to different surface roughness. METHODS: Median and ulnar nerves from fresh frozen cadavers were dissected, and 1-2 cm lengths were excised using a No. 11 blade, a razor blade, or a pair of scissors. Using electron microscopy, 3-dimensional surface analysis of roughness (Sa) for each specimen was performed using ZeeScan optical hardware and GetPhase software (PhaseView, Buisson, France). An ANOVA or Kruskal-Wallis test compared roughness measures among cutting techniques. RESULTS: Forty nerves were included. Of these, 13 (32.5%) were cut using scissors, 15 (37.5%) using a razor blade, and 12 (30%) using a No. 11 blade. An ANOVA test showed statistical differences in Sa among the cutting techniques (P = 0.002), with the lowest mean Sa noted in the scissors group (7.2 µM, 95% CI: 5.34-9.06), followed by No. 11 blade (7.29 µM, 95% CI: 5.22-9.35), and razor blade (11.03 µM, 95% CI: 9.43-12.62). Median Ra (surface profile roughness) was 4.58 (IQR: 2.62-5.46). A Kruskal-Wallis test demonstrated statistical difference in Ra among techniques (P = 0.003), with the lowest by No. 11 blade (3 µM, IQR: 1.87-4.38), followed by scissors (3.29 µM, IQR: 1.56-4.96), and razor (5.41 µM, IQR: 4.95-6.21). CONCLUSION: This novel technique of 3-dimensional surface analysis found razor blade use demonstrated poor roughness, whereas a No. 11 blade or nerve-specific scissors led to equivocally smooth nerve ends.

Selective versus nonselective embolization versus no embolization in pelvic trauma: A multicenter retrospective cohort study.

BACKGROUND: Traumatic hemorrhage from pelvic fractures is a significant challenge, and angioembolization has become standard. Optimal treatment is undefined in two clinical scenarios. The first is in the presence of a negative angiogram. Can arterial embolization treat venous bleeding by decreasing the arterial pressure head? If the angiogram is positive, is nonselective embolization (NSE) or selective embolization (SE) better? The purpose of this study is to determine if embolization after a negative angiogram aids in hemorrhage control and when the angiogram is positive, which level of embolization is superior? METHODS: A multicenter retrospective review was conducted including blunt trauma patients with pelvic fractures who underwent angiography. Demographic and clinical data were compiled on all subjects. NSE refers to an intervention at the level of the internal iliac artery and SE is defined as any distal intervention. Theoretical complications of pelvic embolization are those thought to arise from decreased pelvic blood flow and will be referred to as embolization-related complications. Thromboembolic complications included deep vein thrombosis or pulmonary embolism. RESULTS: One hundred ninety-four patients met inclusion criteria. Of the 67 patients with a negative angiogram, 26 (38.8%) were embolized. In those patients requiring transfusion, the units given in the first 24 hours were decreased in the embolization group (7.5 vs. 4.0, p = 0.054). Embolization-related complications occurred more frequently in those not embolized (11.4% vs. 6.0%, p = 0.414).One hundred forty-five patients were embolized, 99 (68.3%) NSE and 46 (31.7%) SE. There were no significant differences in mortality or transfusion requirements. There was no difference in the rate of embolization-related complications (4.1% vs. 2.1%, p = 0.352). There was a significantly increased rate of thromboembolic complications in the NSE group (12.1% vs. 0, p = 0.010). CONCLUSION: Embolization in the face of a negative angiogram may aid in hemorrhage control for those patients being actively transfused. If embolized, then selective occlusion of more distal vessels rather than of the main internal iliac artery should be performed. LEVEL OF EVIDENCE: Therapeutic, level IV.

Percutaneous freezing of sensory nerves prior to total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a common procedure resulting in significant post-operative pain. Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve could relieve post-operative knee pain by temporarily blocking sensory nerve conduction. METHODS: A retrospective chart review of 100 patients who underwent TKA was conducted to assess the value of adding perioperative cryoneurolysis to a multimodal pain management program. The treatment group consisted of the first 50 patients consecutively treated after the practice introduced perioperative (five days prior to surgery) cryoneurolysis as part of its standard pain management protocol. The control group consisted of the 50 patients treated before cryoneurolysis was introduced. Outcomes included hospital length of stay (LOS), post-operative opioid requirements, and patient-reported outcomes of pain and function. RESULTS: A significantly lower proportion of patients in the treatment group had a LOS of ≥2days compared with the control group (6% vs. 67%, p<0.0001) and required 45% less opioids during the first 12weeks after surgery. The treatment group reported a statistically significant reduction in symptoms at the six- and 12-week follow-up compared with the control group and within-group significant reductions in pain intensity and pain interference at two- and six-week follow-up, respectively. CONCLUSIONS: Perioperative cryoneurolysis in combination with multimodal pain management may significantly improve outcomes in patients undergoing TKA. Promising results from this preliminary retrospective study warrant further investigation of this novel treatment in prospective, randomized trials. LEVEL OF EVIDENCE: III.

Does Insurance Status Affect the Management of Acute Clavicle Fractures?

OBJECTIVES: To evaluate whether insurance is an unrecognized factor that plays a role in determining whether a patient receives surgery. METHODS: A retrospective cross-sectional analysis was performed using the Healthcare Cost and Utilization Project data for Florida in the year 2010. Discharge level data from emergency departments and ambulatory surgery settings were used to identify clavicle fractures by International Classification of Diseases 9 codes 81,000, 81,002, and 81,003. Internal fixation was identified using the Current Procedural Terminology code 23,515. Clavicle fractures that did not result in a Current Procedural Terminology code of 23,515 were assumed to have been managed nonoperatively. Multivariate logistic regression, allowing for intragroup correlation among surgeons, was used to determine the influence of payer source on treatment modality adjusting for race, age, number of chronic conditions, and sex. RESULTS: In total, there were 7858 clavicle fractures that met criteria for inclusion. Observations were removed from the analysis if there was missing personal demographic data or if the ability to track patients from the emergency department to follow-up care was not possible. Therefore, the final sample consisted of 5185 clavicle fractures of which 233 received internal fixation (4.5%). The odds of a patient with private insurance receiving internal fixation was 7.58 times [95% confidence interval (CI) = (4.04 to -14.21), P < 0.001] greater than a self-pay patient, all else being held constant. Patients defined by "other" sources of coverage, a group that includes worker's compensation, CHAMPUS (military), CHAMPVA (veterans), or other government insurance other than Medicare and Medicaid were also associated with an increased likelihood of receiving internal fixation by a factor of 6.80 (95% CI = 3.15, 14.64, P < 0.001) relative to self-pay patients, all else being held constant. The likelihood of patients with Medicare or Medicaid receiving internal fixation did not differ statistically from self-pay patients. CONCLUSIONS: Patients with any form of insurance, when compared with the self-pay, Medicare, and Medicaid populations, had a higher likelihood of operative intervention in Florida in 2010. This may represent an unintended trend in treatment. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Influence of prosthetic design on squeaking after ceramic-on-ceramic total hip arthroplasty.

Squeaky ceramic-on-ceramic (COC) total hips have received much recent publicity, and implant design may be implicated. We reviewed 270 consecutive COC total hip arthroplasties in 233 patients comparing 4 implant combinations representing 4 manufacturers. A cohort (n = 45) of Stryker Trident acetabular cups paired with Stryker Accolade femoral stems showed a dramatically higher incidence of "problem squeaking"--defined as always audible to others and occurring at least once per week--with a 35.6% incidence of squeaking and 11.1% incidence of problem squeaking. The 3 non-Stryker designs (n = 225) revealed 3.6% squeaking (P < .0001) and 0.44% problem squeaking (P = .006). The Stryker system has a unique design and metallurgy. Our results suggest that although the genesis of squeaking in COC total hips is multifactorial, prosthetic design plays a key role.