The Influence of Mental Health Diagnoses on Patient Experiences and Outcomes in Patients Undergoing WALANT Hand Surgery.

Purpose: The purpose of this study was to gauge whether patients with preexisting mental health conditions have desirable outcomes when undergoing wide-awake local anesthesia with no tourniquet (WALANT) hand surgery. Methods: A retrospective review of 133 patients who underwent WALANT surgery by 2 senior authors from August 2019 to October 2020 was performed. Patients were administered a 10-question postoperative survey detailing perioperative pain, experience, and satisfaction concerning their procedure. Analysis was performed for patient responses to the questionnaire, demographics, comorbidities, and patient-reported outcomes using the Single Assessment Numeric Evaluation (SANE). Results: There were 61 patients identified as having a preexisting psychiatric diagnosis compared to 70 patients without who underwent WALANT surgery. Comparing psychiatric diagnosis and nonpsychiatric diagnosis cohorts, there was no significant difference in preoperative anxiety (3.75 vs 3.30), pain during procedure (0.67 vs 0.56), or pain after surgery (4.89 vs 4.26). There was a significantly higher pain score with preoperative injection in the psychiatric diagnosis cohort (4.07 vs 2.93). When asked if they would have a WALANT procedure again, 95.1% of patients in the psychiatric diagnosis cohort and 98.6% of patients in the nonpsychiatric diagnosis group said they would. There was no significant difference in average preoperative SANE scores (59.67 [no psych diagnosis] vs 61.70 [psych diagnosis]) or postoperative SANE scores (82.82 [no psych diagnosis] vs 81.06 [psych diagnosis]) between the two cohorts. Conclusions: WALANT surgery was nearly as well tolerated in patients with a preexisting mental health diagnosis when compared to those without a preexisting diagnosis. Clinical Relevance: Surgeons who are currently or potentially performing WALANT surgery should not rule out patients as eligible candidates because of a prior diagnosis of a mental health condition.

Wide Awake Local Anesthesia No Tourniquet Technique in Hand Surgery: The Patient Experience.

BACKGROUND: We attempted to evaluate patient satisfaction and overall experience during wide awake, local anesthesia, with no tourniquet (WALANT) hand surgery and quantify surgery-related outcomes. METHODS: We conducted a retrospective analysis of patient demographics, comorbidities, and patient reported outcomes via Single Assessment Numeric Evaluation (SANE) scores collected pre- and postoperatively of patients undergoing WALANT surgery by the 2 participating senior authors. A solution of 1% lidocaine with 1:100,000 epinephrine was used by 1 surgeon, while the other used a 1:1 ratio of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine for local anesthetic injection. Patients were administered a postoperative survey to assess patient experience, including anxiety and pain levels, and overall satisfaction in the perioperative period. RESULTS: Overall, 97.7% of patients indicated that they would undergo a WALANT-style surgery if indicated in the future, 70.5% ate the day of surgery, and a total of 39.1% of patients reported driving to and from surgery. Postoperative SANE scores increased as compared with preoperative scores across all patients. The use of combination 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine was associated with lower intraoperative and postoperative visual analog scale pain scores. CONCLUSIONS: WALANT hand surgery was generally well tolerated with excellent surgical outcomes. Patients reported ease of preparation for surgery, faster recovery, and lack of anesthetic side effects as the main benefits of wide-awake surgery. Combination use of lidocaine and bupivacaine may be better than lidocaine alone with respect to pain control in the initial recovery period.

Augmentation of Distal Biceps Tendon Ruptures With the Lacertus Fibrosus: A Biomechanical Study in a Tendon-Deficient Model.

BACKGROUND: Chronic distal biceps tendon ruptures may require tendon graft augmentation secondary to tendon attrition or retraction. The lacertus fibrosus is a local, cost-effective graft that can be used to supplement reconstruction. PURPOSE: To compare the biomechanical strength of distal biceps tendon repairs with and without lacertus fibrosus augmentation in a tendon-deficient cadaveric model. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen fresh-frozen matched cadaveric pairs of elbows were randomized into 2 groups: (1) standard distal biceps tendon repair and (2) tendon-deficient (50% step cut) repair with lacertus fibrosus augmentation. All repairs were completed using an oval bone trough and 2 double-loaded No. 2 braided nonabsorbable sutures in a locked Krackow fashion tied over a lateral bone bridge. For the lacertus augmentation group, the lacertus was wrapped circumferentially in a tubular fashion around the tendon to restore the native size and incorporated into the Krackow suture. All specimens underwent cyclic loading and then were loaded to failure. Displacement, stiffness, load to failure, and mode of failure were recorded. RESULTS: The standard repair and lacertus augmentation groups had similar displacements on cyclic loading (1.66 ± 0.62 vs 1.62 ± 0.58 mm, respectively; P = .894). The stiffness was significantly greater for the standard repair group (21.3 ± 2.5 vs 18.5 ± 3.5 N/mm; P = .044). Both groups provided excellent mean peak load to failure strengths, despite the standard repair group having significantly greater strength (462.4 ± 140.5 vs 377.3 ± 101.1 N; P = .022). The primary mode of failure in the standard repair group was fracture at the bone bridge (n = 5/8) compared with suture pullout (n = 4/8) in the lacertus augmentation group. CONCLUSION: Lacertus fibrosus augmentation of a tendon-deficient biceps repair was less stiff and had lower mean load to failure compared with repair of the native tendon in this cadaveric model, but these values remained biomechanically acceptable above critical thresholds. Consequently, lacertus fibrosus augmentation is a viable option for chronic distal biceps tendon ruptures with tendon attrition. CLINICAL RELEVANCE: Chronic distal biceps tendon ruptures may require autograft or allograft reconstruction secondary to tendon scarring, shortening, attrition, and degeneration. The lacertus fibrosus is a cost-effective and low-morbidity local autograft that can be used to augment repairs.

Three-Dimensional Footprint Mapping of the Deltoid and Trapezius: Anatomic Pearls for Acromioclavicular Joint Reconstruction.

PURPOSE: To perform a quantitative anatomic evaluation of the deltoid and trapezius footprints in relation to the lateral clavicle and acromioclavicular (AC) joint capsule to assist in surgical technique of AC joint reconstructions. METHODS: Fourteen fresh-frozen human cadaveric shoulders from 9 donors were analyzed. Meticulous dissection of the deltoid origin and trapezius insertions to the clavicle and AC joint was performed. Footprints were reconstructed using a MicroScribe digitizer. The inferior extension of the deltoid origin beneath the lateral clavicle and the footprints of the deltoid and trapezius onto the acromioclavicular ligamentous complex (ACLC) were quantified. Reproducibility was assessed by redigitizing 5 shoulders in a blinded and random fashion. RESULTS: The anterior deltoid fibers extended on average 4.0 ± 1.6 mm inferiorly with respect to the anteroinferior clavicular ridge and attached to 90.9 ± 7.3% of the anterior ACLC. The trapezius inserted onto the posterior and superior ACLC, covering 15.3 ± 3.4% of the anterior-posterior width of the superior capsule. The deltopectoral interval was 6 cm, or 37% the length of the clavicle from the distal end of the clavicle. CONCLUSIONS: The deltoid has superior, anterior, and not as well described, inferior attachments to the lateral clavicle. Furthermore, the deltoid and trapezius muscles have intimate attachments to the AC joint capsule, particularly the trapezius to the posterior and posterosuperior capsule. Lastly, the deltoid origin attaches to the lateral 6 cm of the clavicle. CLINICAL RELEVANCE: Subperiosteal elevation of the deltoid off the lateral clavicle starting superiorly, anteriorly, and lastly inferiorly will reduce deltoid muscle injury and improve visibility of the coracoid process during reconstruction. Furthermore, knowledge of the attachments of the deltoid and trapezius to the ACLC may help limit iatrogenic injury to these dynamic stabilizers.

Is the Caprini Score Predictive of Venothromboembolism Events in Orthopaedic Fracture Patients?

OBJECTIVE: Explore the validity of the Caprini Score in orthopaedic patients with lower-extremity fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma academic medical center. PATIENTS/PARTICIPANTS: Eight hundred forty-eight patients with lower-extremity fractures from 2002 to 2015 with exclusion criteria: minors, follow-up less than 30 days. INTERVENTION: Stratify patients into 2 groups: high-risk (pelvic and acetabular fractures) and low-risk groups (isolated foot and ankle fractures). MAIN OUTCOME: Caprini Score, fracture classification, length of follow-up, deep vein thrombosis (DVT) chemoprophylaxis, and venothromboembolism (VTE) events [DVT and/or pulmonary embolism (PE)] diagnosed with objective testing. RESULTS: Eight hundred forty-eight patients (499 M; 349 F) 18-93 years of age (average 43.7) with average body mass index of 29. Three hundred high-risk and 548 low-risk patients with no differences in demographics with average follow-up of 288 days. There were 33 (3.9%) VTE events, which were more common in the high-risk group (8%: 9 DVT, 15 PE) than the low-risk group (1.6%: 8 DVT, 1 PE) (P < 0.0001). The cutoff that best-predicted VTE events based on receiver-operating curves was 12 (c = 0.74) in the high-risk group, 11 (c = 0.79) in the low-risk group, and 12 (c = 0.83) overall. CONCLUSION: There was a significant lower VTE rate found in the low-risk group, but the Caprini prediction model was not significantly different between the 2 groups. This displays that patient factors play a large role in the development of VTE events independent of injury type. The Caprini score may help identify patients who may require increased protection. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Three Concurrent Periprosthetic Joint Infections: A Case Report and Literature Review.

Periprosthetic joint infections are a major cause of morbidity and mortality following total joint arthroplasty. Two-stage arthroplasty, with the use of an antibiotic cement spacer, is an effective means of managing periperiprosthetic joint infections. There is a lack of data relating to the management, prognosis, and clinical outcomes associated with multiple peri-prosthetic joint infections. Here, we present a case report of a patient successfully treated for three synchronic peri-prosthetic joint infections of both knees and a single hip.

Facial emotion recognition impairments are associated with brain volume abnormalities in individuals with HIV.

Impaired facial emotion recognition abilities in HIV+ patients are well documented, but little is known about the neural etiology of these difficulties. We examined the relation of facial emotion recognition abilities to regional brain volumes in 44 HIV-positive (HIV+) and 44 HIV-negative control (HC) adults. Volumes of structures implicated in HIV-associated neuropathology and emotion recognition were measured on MRI using an automated segmentation tool. Relative to HC, HIV+ patients demonstrated emotion recognition impairments for fearful expressions, reduced anterior cingulate cortex (ACC) volumes, and increased amygdala volumes. In the HIV+ group, fear recognition impairments correlated significantly with ACC, but not amygdala volumes. ACC reductions were also associated with lower nadir CD4 levels (i.e., greater HIV-disease severity). These findings extend our understanding of the neurobiological substrates underlying an essential social function, facial emotion recognition, in HIV+ individuals and implicate HIV-related ACC atrophy in the impairment of these abilities.