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.

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.

Glenohumeral Hydrodistension for Postoperative Stiffness After Arthroscopic Primary Rotator Cuff Repair.

Background: Postoperative stiffness is a known complication after rotator cuff repair (RCR). Glenohumeral hydrodistension (GH) has been a treatment modality for shoulder pathology but has not been used to treat postoperative stiffness after RCR. Purpose/Hypothesis: The purpose of this study was to identify the risk factors for postoperative stiffness after RCR and review outcomes after treatment with GH. Our hypotheses were that stiffness would be associated with diabetes and hyperlipidemia and correlated with the tendons involved and that patients with stiffness who underwent GH would have significant improvement in range of motion (ROM). Study Design: Case series; Level of evidence, 4. Methods: Included were 388 shoulders of patients who underwent primary RCR by a single surgeon between 2015 and 2019. Shoulders with revision RCRs were excluded. Patient characteristics, medical comorbidities, and perioperative details were collected. A total of 40 shoulders with postoperative stiffness (10.3%) received GH injectate of a 21-mL mixture (15 mL of sterile water, 5 mL of 0.5% ropivacaine, and 1 mL of triamcinolone [10 mg/mL]). The primary outcome measure was ROM in forward flexion, internal rotation, external rotation, and abduction. Statistical tests were performed using analysis of variance. Results: Patients with diabetes had significantly decreased internal rotation at final follow-up after RCR as compared with patients without diabetes. GH to treat stiffness was performed most commonly between 1 and 4 months after RCR (60%), and patients who received GH saw statistically significant improvements in forward flexion, external rotation, and abduction after the procedure. Patients with hyperlipidemia had the most benefit after GH. Among those undergoing concomitant procedures, significantly more patients who had open subpectoral biceps tenodesis underwent GH. Patients who underwent subscapularis repair or concomitant subacromial decompression had significant improvement in ROM after GH. Only 1 patient who received GH underwent secondary surgery for resistant postoperative stiffness. Conclusion: Patients with diabetes had increased stiffness. Patients with a history of hyperlipidemia or concomitant open subpectoral biceps tenodesis were more likely to undergo GH for postoperative stiffness. Patients who underwent subscapularis repair demonstrated the most improvement in ROM after GH. After primary RCR, GH can increase ROM and is a useful adjunct for patients with stiffness to limit secondary surgery.

Legislation Limiting Postoperative Opioid Prescribing Does Not Impact Patients' Perception of Pain Management After Total Joint Arthroplasty.

BACKGROUND: In an effort to combat the opioid epidemic, state legislation was passed to limit postoperative narcotic prescribing. The purpose of this study was to assess if the legislation had an impact on patients' perception of pain management after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that patients would not perceive their pain management experience to be impacted. METHODS: A prospective survey study was performed on all consenting patients undergoing primary THA or TKA at a large academic center from July 2019 to February 2020. Patients taking opioids preoperatively were excluded. Surveys given preoperatively and at 2 weeks postoperatively assessed patients' concerns surrounding postoperative pain control and their perception of the impact of a newly implemented legislation. Descriptive analysis and Spearman's rho correlation coefficients were performed. RESULTS: Ninety-three patients met inclusion criteria and consented. Seventy-nine (29 THA and 50 TKA) completed both surveys. Preoperatively, 9.2% of patients were concerned that the legislation would impact their pain management, despite 43.0% having pain concerns. Postoperatively, 87.0% of patients felt that the legislation had no or mild effect on pain control. Although 36.7% of patients reported moderate to severe postoperative pain, 15.2% of patients reported being dissatisfied with pain control. There was no statistical correlation between preoperative pain concern and feelings that the legislation impacted pain. CONCLUSIONS: After primary THA and TKA, our data suggest that patients' perception of their pain management was not impacted by the legislation. Prescribers should be reassured that the decreased allowable opioids does not hinder the patients' perception of their pain management experience.

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.

Analysis of Risks and Consequences of Postcatheter Urinary Retention After Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Postoperative urinary retention (POUR) in total joint arthroplasty (TJA) is common. However, risk factors for POUR and its consequences, specifically on postoperative renal function, have not been well defined. METHODS: We performed a review of prospectively collected data on consecutive adult patients undergoing primary total joint arthroplasty from August 2014 to December 2015. Catheters were placed preoperatively and removed on the first or second postoperative day. The exclusion criterion was traumatic catheter insertion or the presence of fracture or neoplasm. Univariate and multiple logistic regression identified associations with POUR and its invasive therapies. Subgroup analysis of renal function by incidence of preoperative bladder outlet obstruction (BOO) and POUR was performed with nonparametric testing. RESULTS: A total of 591 operations met inclusion criteria. The incidence of POUR was 6.4% and was directly related to a positive history of BOO (odds ratio [OR]: 4.15) and increased the duration of urinary catheterization (OR: 1.04). These factors, in addition to preoperative incontinence (OR: 8.36, 28.69) and lengthier hospitalizations (OR: 1.37, 1.30), were significantly associated with intermittent straight catheterization and reinsertion of an indwelling catheter to treat POUR. Serum creatinine increased with combined preoperative BOO and POUR (+0.22 mg/dL) but was preserved in others (+0.02-0.04 mg/dL) (P < 0.01). CONCLUSIONS: Preoperative BOO and longer catheterization increased the risk of POUR and were associated with the use of invasive modalities to treat POUR. POUR was associated with a longer hospitalization and impaired renal function in those with preoperative BOO; therefore, renal function should be monitored closely and nephrotoxic medications used cautiously when using urinary catheters in this patient population. LEVEL OF EVIDENCE: Retrospective Analysis, Level IV.

Analysis of Transitional and Turbulent Flow Through the FDA Benchmark Nozzle Model Using Laser Doppler Velocimetry.

Transitional and turbulent flow through a simplified medical device model is analyzed as part of the FDA's Critical Path Initiative, designed to improve the process of bringing medical products to market. Computational predictions are often used in the development of devices and reliable in vitro data is needed to validate computational results, particularly estimations of the Reynolds stresses that could play a role in damaging blood elements. The high spatial resolution of laser Doppler velocimetry (LDV) is used to collect two component velocity data within the FDA benchmark nozzle model. Two flow conditions are used to produce flow encompassing laminar, transitional, and turbulent regimes, and viscous stresses, principal Reynolds stresses, and turbulence intensities are calculated from the measured LDV velocities. Axial velocities and viscous stresses are compared to data from a prior inter-laboratory study conducted with particle image velocimetry. Large velocity gradients are observed near the wall in the nozzle throat and in the jet shear layer located in the expansion downstream of the throat, with axial velocity changing as much as 4.5 m/s over 200 µm. Additionally, maximum Reynolds shear stresses of 1000-2000 Pa are calculated in the high shear regions, which are an order of magnitude higher than the peak viscous shear stresses (<100 Pa). It is important to consider the effects of both viscous and turbulent stresses when simulating flow through medical devices. Reynolds stresses above commonly accepted hemolysis thresholds are measured in the nozzle model, indicating that hemolysis may occur under certain flow conditions. As such, the presented turbulence quantities from LDV, which are also available for download at https://fdacfd.nci.nih.gov/ , provide an ideal validation test for computational simulations that seek to characterize the flow field and to predict hemolysis within the FDA nozzle geometry.