Comparing Plastic Surgeon Versus Orthopedic Surgeon Outcomes Following Distal Upper Extremity Amputations: A Study of the National Surgical Quality Improvement Program (NSQIP) Database.

BACKGROUND: Both plastic and orthopedic surgeons manage care for urgent/emergent hand conditions. It is unclear if surgeon specialty affects patient outcomes of these cases. The purpose of this study was to evaluate differences in 30-day perioperative outcomes between plastic and orthopedic surgeons following distal upper extremity amputations. METHODS: Patients who underwent distal upper extremity amputations between 2005 and 2016 were identified within the National Surgical Quality Improvement Program (NSQIP) database using Current Procedural Terminology (CPT) codes. Differences in operative procedures, patient demographics, patient comorbidities, and 30-day perioperative complications were compared between orthopedic and plastic surgeons by univariate analysis. A Bonferroni correction was applied to account for multiple comparisons of complications. RESULTS: A total of 1583 cases met inclusion criteria. Orthopedic surgeons performed 981 cases (62.0%) and plastic surgeons performed 602 cases (38.0%). Finger amputations comprised the majority of procedures for both orthopedic and plastic surgeons (95.5% and 94.4%, respectively). Orthopedic surgeons had a lower operative time (41.7 ± 36.2 minutes vs 47.1 ± 40.9 minutes, P = .008). There were no differences in proportion of emergency surgery, inpatients, or wound class. There were no differences in age, gender, or body mass index. The most common indications for amputation were trauma, gangrene, and osteomyelitis. There were no differences between surgical specialties in 18 30-day perioperative complications assessed, including death, reoperation, surgical site infection, or wound dehiscence. CONCLUSIONS: Plastic and orthopedic surgeons achieved equivalent outcomes comparing 30-day perioperative complications following upper extremity amputations. These results support that both orthopedic and plastic surgeons provide similar quality distal upper extremity amputation care.

HISTORIQUE: Tant les plasticiens que les chirurgiens orthopédiques prennent en charge les cas d'affections urgentes ou d'extrême urgence touchant les mains. On ne sait pas si la spécialité chirurgicale a une incidence sur le pronostic des patients atteints de ces problèmes. La présente étude visait à évaluer les différences entre les résultats périopératoires des plasticiens et des chirurgiens orthopédiques 30 jours après des amputations distales des extrémités supérieures. MÉTHODOLOGIE: Les patients qui ont subi une amputation distale des extrémités supérieures entre 2005 et 2016 ont été extraits de la base de données du Programme national d'amélioration de la qualité des soins chirurgicaux (NSQIP) à l'aide des codes du Catalogue des actes médicaux (CPT). Au moyen d'une analyse univariée, les chercheurs ont comparé les différences entre les interventions opératoires effectuées par les chirurgiens orthopédiques et les plasticiens, les caractéristiques démographiques des patients, leurs autres affections et leurs complications périopératoires au bout de 30 jours. Ils ont utilisé une correction de Bonferroni pour tenir compte de multiples comparaisons entre les complications. RÉSULTATS: Au total, 1 583 cas respectaient les critères d'inclusion. Les chirurgiens orthopédiques ont opéré 981 cas (62,0 %) et les plasticiens, 602 cas (38,0 %). Les amputations des doigts représentaient la majorité des interventions effectuées par les chirurgiens orthopédiques et les plasticiens (95,5 % et 94,4 % respectivement). Les opérations pratiquées par les chirurgiens orthopédiques étaient plus courtes (41,7 ± 36,2 minutes par rapport à 47,1 ± 40,9 minutes, p = 0,008). Il n'y avait pas de différence quant à la proportion d'opérations d'urgence, de patients hospitalisés ou de catégories de plaies ni pour ce qui est de l'âge, du genre et de l'indice de masse corporelle. Les principales indications d'amputation étaient des traumatismes, la gangrène et l'ostéomyélite. Il n'y avait pas de différence entre les spécialités chirurgicales lors de l'évaluation des complications périopératoires au bout de 18 et 30 jours, y compris les décès, les réopérations, l'infection au foyer des infections et la déhiscence des plaies. CONCLUSIONS: Les plasticiens et les chirurgiens orthopédiques ont obtenu des résultats équivalents si l'on comparait les complications périopératoires après des amputations des extrémités supérieures au bout de 30 jours. Selon ces résultats, à la fois les chirurgiens orthopédiques et les plasticiens fournissent des soins de qualité semblables lors d'amputations distales des membres supérieurs.

Emergency Department Utilization After Outpatient Hand Surgery.

BACKGROUND: The purpose of this study was to identify the utilization rate and most common reasons for presentation to the emergency department (ED) after elective outpatient hand surgery and to determine preoperative risk factors for these ED visits. METHODS: Patients who underwent elective hand surgery at an ambulatory surgery center between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization. RESULTS: From 2014 to 2015, 212,506 procedures were identified; the 7- and 30-day ED visit rates were 1.8% and 4.4%, respectively. Postoperative pain was the most common cause of an ED visit after outpatient hand surgery at 7 days (25.4%) and 30 days (16.1%) postoperatively. Overall, 98% of patients presenting to the ED for postoperative pain were subsequently discharged home. After controlling for confounding, comorbid congestive heart failure, chronic lung disease, diabetes, renal failure, schizophrenia, and depression were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare insurance were 94% more likely to present to the ED within 30 days than those with private health insurance, whereas those with Medicaid were more than three times as likely to present to the ED as those with private insurance. DISCUSSION: ED utilization after outpatient hand surgery is low, with postoperative pain being the most common cause of an ED visit at all time points. Nearly 98% of patients presenting to the ED for postoperative pain are subsequently discharged home. LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

Scaphoid Fracture Repair Does Not Significantly Diminish Short-Term Participation in the National Football League.

BACKGROUND: Fixation of scaphoid fractures is recommended in elite athletes to hasten healing and return-to-sport times. Complications such as nonunion negatively affect athletic performance. QUESTIONS/PURPOSES: The purpose of this study was to examine the prevalence and impact of scaphoid repair on National Football League (NFL) participation during athletes' first season in the NFL, while identifying significant predictors for development of carpal arthritis and scaphoid nonunion. METHODS: A total of 1311 football athletes invited to the NFL Scouting Combine from 2012 to 2015 were evaluated for history of scaphoid fracture repair. Athlete demographics, surgical history, and imaging and physical examination findings were recorded. Future NFL participation based on draft status, games played, and games started during athletes' first season were gathered using publicly available databases. RESULTS: Nineteen (1.4%) athletes underwent 24 operations for scaphoid repair. Limitations in wrist range of motion or strength were present in 47.4% of athletes with a history of repair. Arthritic changes were present in 32% of wrists, while radiographic nonunion was present in two athletes following scaphoid fracture. Defensive backs were observed to have a higher incidence for arthritic changes following repair compared to other positions. No significant difference in prospective NFL participation was found in athletes with a history of scaphoid repair than in those without. CONCLUSIONS: Athletes with a history of scaphoid repair are not at significant risk for diminished participation during their first season in the NFL.

Anatomic Investigation of Commonly Used Landmarks for Evaluating Rotation During Forearm Fracture Reduction.

BACKGROUND: Evaluating rotation during open reduction and internal fixation of a forearm fracture is of paramount importance. In challenging cases, surgeons may utilize radiographic relationships between proximal and distal radial and ulnar landmarks to assess rotational position. However, to our knowledge, limited anatomic data are available to confirm these relationships. METHODS: Six hundred cadaveric radii and ulnae were obtained. Digital representations of the bicipital tuberosity, the radial styloid, the coronoid process, and the ulnar styloid were acquired, and the rotational profiles between respective landmarks were calculated. In order to validate the results and investigate the ability to differentiate rotated osseous positions, each bone was imaged in increments of 10° of rotation and the profile of each landmark was measured. RESULTS: The radial styloid was at a mean of 158° ± 14° of supination relative to the bicipital tuberosity. The ulnar styloid was at a mean of 185° ± 14° of supination relative to the coronoid process. Imaging of the bones in increments of 10° of rotation supported the relationships above. It was also found that a 1-mm difference in profile size corresponded to up to 60° of rotation for the average ulna, compared with 10° for the average radius. CONCLUSIONS: Our findings suggest that using the bicipital tuberosity and the radial styloid to assess intraoperative rotation of the radius on anteroposterior radiographs may be of limited value; the landmarks were not generally 180° apart. Although the rotational positions of the coronoid process and the ulnar styloid were, on average, closer to 180°, surgeons should be aware of the wide range of normal anatomy as well as the inability to judge rotation by as much as 60°, even for an "ideal" ulna. CLINICAL RELEVANCE: This study, to our knowledge, represents the first anatomic investigation of the rotational profiles between the osseous landmarks used to assess forearm rotation after fracture. We recommend that surgeons first image the bicipital tuberosity at its largest profile, supinate the arm 20°, and confirm that the radial styloid is at its largest profile. The ulna can then be assessed to support the lack of rotational deformity in the forearm.

Management of complications with hand fractures.

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.

Zone 2 flexor digitorum profundus and superficialis rupture treated with single-stage tendon reconstruction using an Active Hunter Rod Implant.

To our knowledge, no report has been published of a flexor tendon rupture as a result of a closed phalangeal fracture.A 58-year-old woman with multiple medical comorbidities presented with a closed, apex volar fracture of her long finger proximal phalynx with clinically intact flexor digitorum profundus and superficialis tendons in zone 2 of the flexor tendon sheath. After 5 weeks of nonoperative treatment, the patient reported hearing a pop in her finger, and clinical findings suggested rupture of the flexor digitorum profundus and superficialis tendons. Intraoperatively, the nonreparable attritional rupture was underneath the A2 pulley. A bony prominence in the tendon sheath floor from the healed phalynx fracture made rerupture a concern with a tendon graft. A Hunter Active Tendon Implant (Wright Medical Technology, Inc, Arlington, Tennessee) was used to reconstruct the flexor digitorum profundus tendon to avoid a second procedure. The patient progressed well and had regained a functional arc of active finger range of motion by 2 months postoperatively.The Hunter Active Tendon Implant provided a suitable alternative to a 2-staged procedure, with the added benefit that a good tendon bed was developed in the event that a second procedure was needed.

Ulnar collateral ligament reconstruction in posttraumatic elbow release.

The purpose of this retrospective cohort comparison study was to determine the effect of ulnar collateral ligament reconstruction on postoperative range of motion (ROM) in patients undergoing posttraumatic elbow contracture release. Twenty-four consecutive patients underwent elbow arthrolysis. Six patients also underwent simultaneous collateral ligament excision and reconstruction, and 18 did not require ligament excision. All patients followed the same postoperative rehabilitation program. Minimum follow-up was 12 months. Final flexion/extension ROMs were similar in both groups. No subjective reports of postoperative elbow instability occurred in either group. Ligament reconstruction and early postoperative motion can be safely performed in the setting of posttraumatic elbow capsulectomy without sacrificing ROM gain or compromising stability provided by the ligament reconstruction.

The effect of intra-articular epinephrine lavage on blood loss following total knee arthroplasty.

The purpose of this study was to examine the effects of intra-articular epinephrine lavage on blood loss following total knee arthroplasty (TKA). Our retrospective study involved 189 patients who had primary cemented TKA by 1 of 2 surgeons. Surgeon 1 performed 41 procedures without and 53 with the epinephrine lavage. Surgeon 2 performed 41 procedures without and 54 with the epinephrine lavage. We compared calculated blood loss (CBL) for the patients in all 4 groups. We found no significant differences in CBL among the patients in the 4 patient groups. Our results show that an intra-articular epinephrine lavage does not affect blood loss after TKA.

Microvascular supply of the lateral epicondyle and common extensor origin.

Lateral epicondylitis is a common condition affecting 1% to 3% of the population. Although the exact cause is still unknown, numerous theories have been put forth. One theory suggests a hypovascular zone at the origin of the common extensor mass. This study examines the microvascular supply of the lateral epicondyle and the common extensor mass, with the use of India ink injection and the Spalteholz tissue-clearing technique. Six fresh-frozen cadaveric arms underwent serial sectioning (coronal plane in five and axial plane in one) after vascular injection with India ink. Sections were cleared via a modified Spalteholz technique. Photographs were taken before and after the clearing procedure, and the microvascular pattern of the common extensor mass and lateral epicondyle was described. Two hypovascular zones were identified in the region of the lateral epicondyle. The first was noted at the proximal lateral epicondyle just distal to the supracondylar ridge and the second 2 to 3 cm distal to the lateral epicondyle on the deep surface of the common extensor tendon. Two regions of hypovascularity were noted at the lateral epicondyle and within the common extensor origin. These hypovascular regions may preclude the normal inflammatory cascade and healing response to microtearing in this region. Thus, these zones may play a role in the etiology of lateral epicondylitis.

Surgical correction of dorsally angulated distal radius malunions with fixed angle volar plating: a case series.

PURPOSE: To report our experience using a fixed-angle volar plate in conjunction with a corrective osteotomy and cancellous bone graft for the treatment of distal radius malunions with dorsal angulation in 4 patients. METHODS: Four consecutive patients had a volarly based opening wedge osteotomy with a fixed angle volar plate and cancellous bone grafting for the treatment of a dorsally angulated distal radius malunion. Data collected retrospectively included a visual analog pain scale, grip strength, range of motion, radiographic parameters, and each patient's subjective functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire. Motion, strength, and radiographic values were compared with the contralateral arm for each patient. RESULTS: The average time from initial fracture to corrective osteotomy was 346 days. The average length of follow-up evaluation was 13.5 months. The flexion-extension arc of motion increased an average of 21 degrees to a value of 84% of the contralateral side; the pronation-supination arc of motion increased an average of 20 degrees to a value of 98% of the contralateral side. The average tilt of the radius improved from 26 degrees extension to 2 degrees extension; the average radial inclination improved from 22 degrees to 24 degrees; the average ulnar variance excluding the 1 patient who had a distal ulna resection improved from 5 mm to 1 mm. The average retrospective Disabilities of the Arm, Shoulder, and Hand score improved from 30 to 7; the average retrospective visual analog pain scale score improved from 4.5 to 1. The average grip strength increased from 20 to 29 kg, which corresponded to 73% of the contralateral extremity. CONCLUSIONS: The rigid characteristics of fixed angle volar plates can provide an alternative to the traditional techniques of distal radius osteotomy including structural bone grafting and dorsal plate fixation or external fixation. In addition these plates are strong enough to allow for early postoperative motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.