Demystifying the Radial Nerve The Management of Radial Nerve Palsy in the Setting of Humeral Shaft Fracture.

The association of radial nerve palsy and humeral shaft fracture is well known. Primary exploration and fracture fixation is recommended for open fractures and vascular injury while expectant management remains the standard of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5 months following injury. When direct repair or nerve grafting is unlikely to achieve a suitable outcome, nerve and tendon transfers are potential options for the restoration of wrist and finger extension.

Bone Health Evaluations and Secondary Fragility Fractures in Hip Fracture Patients.

Purpose: This study sought to examine the utilization of bone health evaluations in geriatric hip fracture patients and identify risk factors for the development of future fragility fractures. Materials and Methods: A consecutive series of patients ≥55 years who underwent surgical management of a hip fracture between September 2015 and July 2019 were identified. Chart review was performed to evaluate post-injury follow-up, performance of a bone health evaluation, and use of osteoporosis-related diagnostic and pharmacologic treatment. Results: A total of 832 patients were included. The mean age of the patients was 81.2±9.9 years. Approximately 21% of patients underwent a comprehensive bone health evaluation. Of this cohort, 64.7% were started on pharmacologic therapy, and 73 patients underwent bone mineral density testing. Following discharge from the hospital, 70.3% of the patients followed-up on an outpatient basis with 95.7% seeing orthopedic surgery for post-fracture care. Overall, 102 patients (12.3%) sustained additional fragility fractures within two years, and 31 of these patients (3.7%) sustained a second hip fracture. There was no difference in the rate of second hip fractures or other additional fragility fractures based on the use of osteoporosis medications. Conclusion: Management of osteoporosis in geriatric hip fracture patients could be improved. Outpatient follow-up post-hip fracture is almost 70%, yet a minority of patients were started on osteoporosis medications and many sustained additional fragility fractures. The findings of this study indicate that orthopedic surgeons have an opportunity to lead the charge in treatment of osteoporosis in the post-fracture setting.

Proximal Hamate Reconstruction of Proximal Pole Scaphoid Nonunion: A Case Series and Analysis of Clinical Outcomes.

BACKGROUND: Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction. METHODS: A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature. RESULTS: Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified. CONCLUSIONS: Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

Assessing the Adequacy and Readability of Surgical Consents in Orthopedic Surgery.

BACKGROUND: Handwritten consent forms for medical treatment are commonly used despite the associated risk of documentation errors. We performed an internal audit of handwritten surgical consent forms to assess the quality of consenting practices within the department of hand surgery at our orthopedic specialty hospital. METHODS: A sample of 1,800 charts was selected. Con- sents were assessed for procedure type, physician details, abbreviations, consistency, and legibility. RESULTS: A total of 1,309 charts met the inclusion crite- ria. Two hundred and eight consents contained at least one illegible word. The name of the consenting physician was not listed or illegible on 114 forms. Medical abbreviations were found on 1.8% of all included forms, and 19 consent forms contained a crossed-out word or correction. CONCLUSIONS: Although the majority of the handwrit- ten consent forms were complete, accurate, and legible, there were notable errors in the consenting process at our institution. Documentation errors have medical and ethical ramifications. Further research into consenting practices is necessary to improve the quality of consent forms and the process of informed consent.

Predicting the Subsequent Contralateral Hip Fracture: Is FRAX the Answer?

OBJECTIVES: To (1) determine the ability of the Fracture Risk Assessment Tool (FRAX) to identify the probability of contralateral hip fractures within 2 years of index fracture and (2) identify independent risk factors for a subsequent hip fracture. DESIGN: Retrospective. SETTING: Urban, academic medical center. PATIENTS: This study included a consecutive series of patients treated for unilateral hip fractures between September 2015 and July 2019. RESULTS: Eight hundred thirty-two consecutive patients were included in the analysis with a mean age of 81.2 ± 9.9 years. Thirty-one (3.7%) patients sustained a contralateral hip fracture within 2 years with these patients sustaining the second fracture at a mean 294.1 days ± 197.7 days. The average FRAX score for the entire cohort was 11.9 ± 7.4, and the area under receiving operating characteristic curve (AUROC) for FRAX score was 0.682 (95% CI, 0.596-0.767). Patients in the high-risk FRAX group had a >7% risk of contralateral hip fracture within 2 years. Independent risk factors for contralateral hip fracture risk included patient age 80 years or older and decreasing BMI. CONCLUSIONS: This study demonstrates the strong ability of the FRAX score to triage patients at risk of subsequent contralateral hip fracture within 2 years. In this high-risk FRAX group, patients age older than 80 years and who have decreasing BMI after their index fracture have a 12.5% increased risk of fracture within 2 years which is 4× higher than the current World Health Organization 10-year 3% hip fracture risk standard used to initiate pharmacologic treatment. Therefore, high-risk patients identified using this methodology should be targeted more aggressively with preventative measures including social, medical, and potentially surgical interventions. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The impact of preoperative neurological symptom severity on postoperative outcomes in cervical spondylotic myelopathy.

Study Design: The study design is a retrospective cohort study. Objective: To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM). Summary of Background Data: Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements. Materials and Methods: A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was classified according to the modified Japanese Orthopaedic Association (mJOA) scale as either mild (≥15) or moderate-to-severe (<15). Other outcomes included neck disability index (NDI), 12-item short-form survey (SF-12), and visual analog scale (VAS) for arm and neck pain. Differences in outcomes were tested by linear mixed-effects models followed by pairwise comparisons using least square means. Multiple linear regression determined whether any baseline outcomes or demographics predicted postoperative mJOA. Results: There were 67 patients with mild and 50 patients with moderate-to-severe myelopathy. Preoperatively, patients with moderate-to-severe myelopathy reported significantly worse outcomes compared to the mild group for NDI, Physical Component Score (PCS-12), and VAS arm (P = 0.031). While both groups experienced improvements in NDI, PCS-12, VAS Arm and Neck after surgery, only the moderate-to-severe patients achieved improved mJOA (+3.1 points, P < 0.001). However, mJOA was significantly worse in the moderate-to-severe when compared to the mild group postoperatively (-1.2 points, P = 0.017). Both younger age (P = 0.017, ß-coefficient = -0.05) and higher preoperative mJOA (P < 0.001, ß-coefficient = 0.37) predicted higher postoperative mJOA. Conclusions: Although patients with moderate-to-severe myelopathy improved for all outcomes, they did not achieve normal absolute neurological function, indicating potential irreversible spinal cord changes. Early surgical intervention should be considered in patients with mild myelopathy if they seek to prevent progressive neurological decline over time.

Opioid Prescribing Patterns Among Orthopedic Hand Surgeons After Implementation of a Divisional Protocol.

INTRODUCTION: Overprescribing contributes to the misuse and overuse of narcotics. We hypothesized that implementation of postoperative prescribing guidelines would consistently reduce the amount of opioids prescribed after ambulatory hand surgery. METHODS: A divisional protocol was instituted in November 2018. A retrospective cohort study was designed to examine the policy's effects on postoperative prescribing. Postoperative opioid prescriptions for patients undergoing ambulatory hand surgery were evaluated 1 year before and 1 year after policy initiation. All prescriptions were converted into the total oral morphine equivalent (OME) prescribed. RESULTS: A total of 1,672 surgeries were included. Six hundred sixty-one cases were in preimplementation group, and 1,011 cases were in the postimplementation group. The median of total OME decreased significantly after distribution of prescribing guidelines from 75 in the preimplementation group to 45 in the postimplementation group (p < .001) with significant reductions seen for carpal tunnel release (p < .001), trigger finger release (p < .001), distal radius open reduction internal fixation (p < .001), and finger closed reduction and pinning (p < .001). When categorized by procedure type, the median of total OME decreased from 75 to 30 for soft tissue procedures (p < .001) and from 120 to 100 for bony procedures (p < .001). CONCLUSION: Divisional prescribing guidelines lead to consistent short-term to mid-term reductions in the amount of opioid medication prescribed postoperatively.

Modified Oxford Bone Scores Are Reduced in Patients With Slipped Capital Femoral Epiphysis Compared With Healthy Controls.

BACKGROUND: The etiology and pathogenesis of slipped capital femoral epiphysis (SCFE) are attributable to abnormalities of the proximal femoral epiphysis. This study aimed to examine if there is a difference in the bone age of patients diagnosed with SCFE compared with patients without hip pathology. METHODS: We identified a consecutive series of patients treated for SCFE between December 2012 and December 2019 from a departmental database. Retrospective chart review was performed to collect demographic information and patient medical history. We then obtained a control group of statistically similar patients based on age and sex. These patients did not have hip pathology or medical comorbidities that could alter their bone age. The modified Oxford bone score (mOBS) was calculated for both groups by 3 blinded reviewers. We excluded patients with unstable slips, endocrine disorders, and inadequate imaging. RESULTS: We identified 60 patients with stable idiopathic SCFE during the study period; 45 met inclusion criteria and were included in the final analysis. There were 27 males and 18 females. The average age of patients with SCFE was higher in males than females (12.6 vs. 11.1, P<0.01). Patients in the comparison cohort did not differ significantly from the SCFE cohort in terms of age (11.6 vs. 12.0, P=0.06) or sex (P=0.52). The comparison group's median mOBS was significantly higher than the SCFE group (22.5 vs. 20.5, P<0.01). The difference in the mOBS between male and female patients in the SCFE group approached significance (20.0 vs. 21.0, P=0.05). The weighted κ coefficient was 0.93. CONCLUSIONS: Patients with SCFE have a decreased bone age compared with patients without hip pathology. Male patients with SCFE were more likely to be older compared with female patients. LEVEL OF EVIDENCE: Level IV-retrospective study.

Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures: A Nationwide Survey Comparing Attending Surgeons and Trainees.

BACKGROUND: Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees. METHODS: Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure. RESULTS: A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons. CONCLUSIONS: Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability.

BACKGROUND: The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. METHODS: We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. RESULTS: Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. CONCLUSION: IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.