Outcomes of Volar Plating Distal Radius Fractures Based on Surgical Timing.

BACKGROUND: While complexity of distal radius fractures varies, volar plating is the most prevalent surgical option in adult injuries. The time between date of injury and surgical intervention varies according to several factors, including the timing of presentation and the surgeon's availability. This study aims to understand the impact of a delay in surgical intervention on operative time, patient-reported outcomes, and reoperation rates. METHODS: A retrospective review was performed on patients treated with volar plating of distal radius fractures from 2017 to 2020 at a single institution by multiple surgeons. Perioperative medical records were reviewed. Patients were divided into 2 groups using a cut-off date of surgery performed 12 days after injury. Descriptive analyses were used to compare demographics, fracture characteristics, operative information, and outcome data including postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores and reoperation rates between groups. RESULTS: A total of 257 patients were included. There was no difference in age, gender, smoking status, fracture type, or postoperative QuickDASH scores between groups. Patients fixed at 12 days or more after injury had a higher rate of reoperation, higher American Society of Anesthesiologists scores, and more surgeon experience. CONCLUSIONS: Volar distal radius fixation at 12 or more days after injury had no discernible differences with fracture type, operative time, or tourniquet time; however, a higher rate of reoperation was found in this group compared to earlier intervention. These data may provide important prognostic information that can be used to educate patients who present in a delayed fashion.

Treatment of Fingertip Injuries.

The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.

Surgical Treatment of Wrist Arthritis in Young Patients.

Surgical treatment of wrist arthritis in the younger patient population remains a challenging issue, and various surgical options need to be carefully considered for each patient. Proximal row carpectomy and 4-corner arthrodesis have proven to be reliable options for reducing pain and restoring adequate function in most young high-demand patients if the lunate facet is spared. Selective neurectomy has proven to be a promising stand-alone or complementary procedure for the treatment of pain that is associated with wrist arthritis in patients of all ages, with spared motion and the opportunity to perform additional procedures if pain continues. Alternative procedures, including capitolunate arthrodesis, total wrist arthrodesis, radial styloidectomy, total wrist arthroplasty, and wrist hemiarthroplasty, have considerable strengths and weaknesses and need to be studied further in younger patients.

Observed patterns of cervical radiculopathy: how often do they differ from a standard, "Netter diagram" distribution?

BACKGROUND CONTEXT: Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a "Netter diagram." To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF. PURPOSE: The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns. STUDY DESIGN/SETTING: A retrospective study. PATIENT SAMPLE: Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included. OUTCOME MEASURES: Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams. METHODS: We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern. RESULTS: Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p<.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern. CONCLUSIONS: Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III level of evidence.

Laminoplasty Does not Lead to Worsening Axial Neck Pain in the Properly Selected Patient With Cervical Myelopathy: A Comparison With Laminectomy and Fusion.

STUDY DESIGN: Retrospective cohort study of prospectively collected data. OBJECTIVE: To determine if laminoplasty (LP) is associated with worsening axial neck pain in patients with multilevel cervical myelopathy, and to compare neck pain, clinical outcomes, and radiographic measures in a group undergoing laminectomy and fusion (LF). SUMMARY OF BACKGROUND DATA: Postoperative new or worsening axial neck pain is commonly cited as a major disadvantage of laminoplasty. However, there remains a paucity of corroborative data from large series. METHODS: Following institutional review board approval, we reviewed the medical records, radiographs, and prospective clinical outcomes database of 85 patients undergoing LP and 52 patients undergoing LF for cervical myelopathy with minimum 1-year radiographic follow-up and average clinical follow-up of 18.5 months. LP was performed in those with neutral to lordotic C2-7 alignment and who did not complain of diffuse axial pain. Otherwise, LF was performed. Clinical outcomes included visual analogue score (VAS)-neck pain, VAS-total pain, neck disability index (NDI), short form 36, modified Japanese Orthopaedic Association (mJOA), and several radiographic parameters. RESULTS: VAS-neck did not worsen in LP (-0.2, P = 0.54) and did improve in LF (-2.0, P = 0.0013). VAS-total improved significantly in both groups (LF -1.04 ±â€Š0.52, P = 0.05; LP -1.4 ±â€Š0.51, P = 0.008). NDI improved in both groups, but was significant in only LP (LP decreased 6.79 ±â€Š2.25, P = 0.0032; LF decreased 4.01 ±â€Š3.05, P = 0.19). mJOA scores improved significantly in both groups (LP improved 2.89 ±â€Š0.27, P < 0.0001; LF improved 2.45 ±â€Š0.33, P < 0.0001). There was a small loss of cervical lordosis in both groups that was significant in LP (LP 2.92° loss, P = 0.0181; LF 1.25° loss, P = 0.53). CONCLUSION: In a carefully selected group of myelopathic patients without significant diffuse axial pain preoperatively and appropriate sagittal alignment, laminoplasty did not lead to worsening axial neck pain, and it was associated with significant improvements in other clinical and myelopathy outcomes. Although laminoplasty is not indicated in every myelopathic patient, this study exemplifies its efficacy as a non-fusion operation in the appropriately selected patient and assuages concerns regarding worsening axial neck pain in such patients following surgery. LEVEL OF EVIDENCE: 3.

Indocyanine Green Angiography: A Helpful Tool for Intraoperative Assessment of Upper Extremity Perfusion.

Assessment of tissue perfusion can be a challenge for the hand surgeon. Indocyanine green (ICG) angiography has been shown to be a valuable adjunct to physical examination and clinical judgment when there is a concern for tissue perfusion. The use of this technology has risen sharply in recent years in reconstructive surgery. Applications of ICG angiography have been developed throughout the field of surgery, including breast surgery, free tissue transfer, bowel surgery, neurosurgery, and lymphatic reconstruction. In this study, we discuss the novel applications of ICG angiography within the field of upper extremity surgery, and provide specific case examples of its successful use.

Where should a laminoplasty start? The effect of the proximal level on post-laminoplasty loss of lordosis.

BACKGROUND CONTEXT: Open-door laminoplasty is a useful operation in the surgical management of cervical myelopathy with favorable outcomes and relatively low complications. One potential undesirable outcome is a decrease in cervical lordosis postoperatively. It is unknown whether the most proximal level undergoing laminoplasty affects the magnitude of loss of lordosis. PURPOSE: This study aimed to compare the loss of cervical lordosis postoperatively in patients for whom the most proximal level undergoing laminoplasty is C3 versus C4. STUDY DESIGN/SETTING: A retrospective radiographic review at an academic center was carried out. PATIENT SAMPLE: A total of 65 patients at a single institution who underwent plated open door laminoplasty for cervical myelopathy by multiple surgeons over a 5-year period were included. OUTCOME MEASURES: The primary outcome was change in cervical lordosis, which was the difference in C2-T1 Cobb angle between the postoperative and preoperative films. METHODS: Patients were divided into two groups based on the most proximal vertebral level undergoing laminoplasty. There were 49 patients who underwent laminoplasty beginning at C3, whereas 16 patients underwent laminoplasty beginning at C4. The C2-T1 Cobb angle was measured on the preoperative film and on the final postoperative follow-up film. The difference between these values was calculated for each patient, and the mean of the differences for the C3 group was compared with that of the C4 group. RESULTS: When C3 was the proximal plated laminoplasty level, loss of lordosis averaged 9°. In contrast, when C4 was the proximal plated level, loss of lordosis was significantly less and averaged only 3° (p=.047). In the group as a whole, mean preoperative lordosis was 18° compared with 11° postoperatively, for an overall 7° loss of lordosis. CONCLUSIONS: Starting the laminoplasty at C4 led to significantly less loss of lordosis than starting at C3. When the pattern of spinal cord compression does not require laminoplasty at C3, consideration should be given to making C4 the most cephalad laminoplasty level rather than C3 to better preserve lordosis.

Optimal approach to circumferential decompression and reconstruction for thoracic spine metastatic disease.

BACKGROUND: Circumferential decompression has been demonstrated to be the first-line therapy for patients with metastatic tumors in the thoracic spine requiring surgical intervention. However, there is significant debate regarding whether these tumors are best accessed anteriorly utilizing a thoracotomy or posteriorly. We used decision analysis to determine which approach yields greater health-related quality of life (QOL). METHODS: We searched Medline, Embase, and the Cochrane Library for relevant articles published between 1990 and 2011 on anterior and posterior approaches to metastatic disease in the thoracic spine. QOL values for major treatment outcomes were determined using the existing literature. Separate models were created for ambulatory and nonambulatory patients. A Monte Carlo simulation and sensitivity analyses were used to determine which treatment strategy resulted in the highest QOL. RESULTS: For ambulatory patients, an anterior approach resulted in a slightly higher QOL, and for nonambulatory patients, a posterior approach was favored, but these differences were not statistically significant. CONCLUSIONS: Using a decision-analytic model, we found no significant difference in QOL resulting from anterior versus posterior approaches to metastatic lesions in the thoracic spine. Decisions should instead be based on surgeon comfort, tumor characteristics, anatomy of the lesion, patient-related factors, and goals of the operation.