Fibrin Glue Acutely Blocks Distal Muscle Contraction after Confirmed Polyethylene Glycol Nerve Fusion: An Animal Study.

Background: Polyethylene glycol (PEG) is a synthetic, biodegradable, and hyperosmotic material promising in the treatment of acute peripheral nerve injuries. Our team set out to investigate the impact of fibrin glue upon PEG fusion in a rat model. Methods: Eighteen rats underwent sciatic nerve transection and PEG fusion. Electrophysiologic testing was performed to measure nerve function and distal muscle twitch. Fibrin glue was applied and testing repeated. Due to preliminary findings, fibrin glue was applied to an uncut nerve in five rodents and testing was conducted before and after glue application. Mann-Whitney U tests were used to compare median values between outcome measures. A Shapiro-Wilk test was used to determine normality of data for each comparison, significance set at a P value less than 0.05. Results: PEG fusion was confirmed in 13 nerves with no significant change in amplitude (P = 0.054), latency (P = 0.114), or conduction velocity (P = 0.114). Stimulation of nerves following PEG fusion produced distal muscle contraction in 100% of nerves. Following application of fibrin glue, there was a significant reduction in latency (P = 0.023), amplitude (P < 0.001), and conduction velocity (P = 0.023). Stimulation of the nerve after application of fibrin glue did not produce distal muscle twitch. Five uncut nerves with fibrin glue application blocked distal muscle contraction following stimulation. Conclusions: Our data suggest that fibrin glue alters the nerve's function. The immediate confirmation of PEG fusion via distal muscle twitch is blocked with application fibrin glue in this experimental model. Survival and functional outcome studies are necessary to understand if this has implications on the long-term functional outcomes.

Medicare Reimbursement in Hand and Upper Extremity Procedures: A 20-Year Analysis.

PURPOSE: Concern exists that Medicare physician fees for procedures have decreased over the past 20 years. The Centers for Medicare & Medicaid Services (CMS) is set to re-evaluate these physician fees in the near future for concern that these procedures are overvalued. Our study sought to analyze trends in Medicare reimbursement rates from 2000 to 2019 for the top 20 most billed hand and upper extremity surgical procedures at our institution. METHODS: The financial database of a single academic tertiary care center was queried to identify the Current Procedural Terminology codes most frequently utilized in orthopedic hand and upper extremity procedures in 2019. The Physician Fee Schedule Look-Up Tool from the CMS was queried for annual physician fee data. Monetary data were adjusted for inflation using the consumer price index of Urban Research Series (CPI-U-RS) and expressed in 2019 constant US dollars (USD). The average annual and total percent change in reimbursement were calculated via linear regression for all procedures (P < .05). RESULTS: Accounting for inflation, the total average physician reimbursement decreased by 20.9% from 2000 to 2019, with 12 of 20 codes decreasing by more than 20%. The greatest decrease pertained to arthrodesis of the wrist at 33.9%. Upon linear regression, all procedures were found to decrease annually, with arthrodesis of the wrist decreasing by an average of 2.3% annually over this period. CONCLUSIONS: Over the past 2 decades, physician reimbursement for hand and upper extremity procedures has significantly decreased.

Incidence, Risk Factors, Prevention, and Management of Peripheral Nerve Injuries Following Shoulder Arthroplasty.

In this article, the authors review the incidence and causes of iatrogenic peripheral nerve injuries following shoulder arthroplasty and provide preventative measures to decrease nerve injury rate and management options. They describe common direct and indirect causes of injury such as laceration and retractor use versus arm positioning and lengthening, respectively. Preventative measures include an understanding of anatomy and high-risk locations in the shoulder, minimizing extreme ranges of arm motion and utilization of intraoperative nerve monitoring. Lastly, the authors review diagnosis and management of neurologic symptoms including how and when to use electrodiagnostic studies, nerve grafts, transfers, or muscle/tendon transfers.

Hybrid Fixation of Open Distal Humerus Fracture With Acute Loss of Lateral Articular Condyle.

Acute, major articular bone loss associated with an open fracture is an uncommon injury. These injuries typically occur after high-energy trauma and are challenging to treat. Various approaches to treatment include allografts, prosthetic composite structures, custom implants, and total joint arthroplasty. These treatment options provide a wide array of variability in outcomes, costs, and challenges, especially in young and active patients. Two patients presented to our institution with open elbow injuries that included structural bone loss of the lateral column including the entire capitellar articular surface and a portion of the lateral trochlea. With the limited portions of bone available, the surgical principles for distal humerus fracture of articular repair followed by medial and lateral column restoration were followed. Each patient was treated with repair of the residual remnant of the articular surface. Then, repair of the columns of the distal humerus was performed by using a combination of internal fixation and hinged external fixation. In both cases, a plate was inserted to repair the medial column and a hinged external fixation was applied laterally to protect the lateral column. Immediate motion was allowed and progressed within each patient's tolerance. The lateral, hinged external fixator was removed at 8 weeks after injury and converted to a lateral column plate fixed distally into the lateral portion of the residual trochlea. At follow-up, both patients had radiographic evidence of reconstitution of the lateral column of the distal humerus and were able to return to heavy manual labor. [Orthopedics. 2022;45(3):e162-e167.].

Diagnosis and treatment of a closed and inverted metacarpal head fracture.

This case report documents a rare inversion of a closed metacarpal head fracture in the setting of polytrauma. Although rare, hemispherical articular bones can fracture and rotate 180°. Because of the symmetry of the bone and the rarity of an inverted, metacarpal head fracture, a delay in diagnosis and subsequent treatment can occur, which can lead to a poor outcome. This is particularly true in the setting of polytrauma. A 38-year-old male, polytrauma patient presented to the emergency department (ED) after falling off a bridge and being struck by an oncoming vehicle. He presented with multiple surgical fractures of the upper and lower extremities as well as his pelvis. Three days after he was brought to the ED, x-rays were performed of his painful left hand, which revealed an extra-articular third metacarpal head fracture, for which he underwent open reduction of the closed fracture. Both collateral ligaments were intact and the head fragment had inverted within the constraints of these ligaments. Some of the ligament and capsular tissue remained attached to the head fragment along the radial and ulnar margins but was otherwise entirely covered with cartilage. The reduction maneuver was difficult but after the reduction was achieved, the fracture appeared stable and no internal fixation was used. Post reduction, the injury was splinted for 2 weeks and then early motion was allowed. The fracture has since healed, and the patient has attained near-full function of the finger and joint.

Recurrent Adolescent Giant-Cell Tumor of the Scaphoid: Scaphoid Excision with Intracarpal Fusion after Failed Curettage and Bone Grafting.

We present a case of the giant-cell tumor of bone in the scaphoid of a 17-year-old female. Imaging revealed an expansile lytic lesion of her scaphoid, and the diagnosis was confirmed with open biopsy. She was treated with curettage and iliac crest bone graft, in an effort to spare reconstruction of her wrist. After one year, she developed increasing tightness and pain. Local recurrence was apparent on radiographs, and CT revealed increased lucency with bony destruction in the area of prior excision. She was successfully treated, without recurrence to date, with complete scaphoid excision and a four-corner wrist fusion. Local recurrence of the giant-cell tumor of bone is high, especially in carpal bones. When treating patients with advanced lesions, more aggressive initial options should be considered.

Matching into an Orthopedic Residency: Which Application Components Correlate with Final Rank List Order?

OBJECTIVE: To determine if any of the unique elements of the applications of medical students who were granted interviews to an orthopedic residency program correlate to the program's final rank order list of candidate residents. DESIGN: Eight domains of the standard residency application were considered as independent variables for 36 applicants. Personal, identifying information was removed from the application material within each domain, thus blinding the application domains for 5 core faculty members from the program to review and rank independently. These 8 domain rank lists were then compared to the program's final rank list order to determine the correlation of each domain with the final rank list order. SETTING: Academic medical center. PARTICIPANTS: Applicants to a university-based orthopedic surgery residency program who were granted interviews in the 2016 academic year. RESULTS: Two domains of the application correlated with the final rank list order: interview and personal statement. None of the other domains had a significant correlation with the final rank list order. Interobserver variability among the faculty members was high for the rankings of the different domains. CONCLUSIONS: Interview and personal statement were the only domains within the application that had correlation with the final rank list for an orthopedic residency program. A better understanding of how these 2 components affect the rank list may provide opportunity for process improvements.

Shoulder Arthrodesis.

PURPOSE: The purpose of this video is to demonstrate the surgical technique of a shoulder arthrodesis for a patient with multidirectional instability and multiple failed previous surgeries. METHODS: A 25-year-old woman with a long history of left shoulder multidirectional instability in the setting of Ehlers-Danlos syndrome is shown undergoing a shoulder arthrodesis. The video demonstrates intraoperative patient positioning, approach, shoulder osseous and articular preparation, implant placement (narrow 4.5 dynamic compression plate), and wound closure. The video includes a brief case history with preoperative radiographic imaging, indications, and patient outcome with postoperative radiographic imaging. RESULTS: The video is 11 minutes, 34 seconds in time. CONCLUSION: This video demonstrates a left shoulder arthrodesis with successful glenohumeral positioning of 30 degrees/30 degrees/30 degrees flexion, abduction, and internal rotation, respectively, and functional ability to reach the mouth and top of the head.

Comparison of Hand Drills for the Insertion of Skeletal Traction Pins.

Skeletal traction pins are inserted as part of emergent stabilization of lower extremity fractures. The purpose of this study is to compare two drill options: a reusable store-bought drill and a single-use, sterilely packaged drill. The reusable drill and disposable drill were compared by having volunteers insert traction pins within a foam bone, fully encased, knee joint model using both systems. The two drill types were evaluated on three measures: user satisfaction, time required for insertion of the pins, and cost. The disposable drill received a statistically significant higher user satisfaction score and a statistically significant faster time to pin insertion. The per-use cost of the disposable system was found to be higher. For skeletal traction pin insertion, the disposable, single-use drill was found to be superior to the reusable drill in user satisfaction and time required for traction pin insertion. Institutional cost analysis favors the disposable system because of the more predicable charge capture, while the per-use cost of the disposable system remains higher. (Journal of Surgical Orthopaedic Advances 27(4):274-276, 2018).

Extensile Fasciotomy for Compartment Syndrome of the Forearm and Hand.

PURPOSE: The purpose of this video is to demonstrate the technique of an extensile fasciotomy of the forearm and hand. METHODS: A patient presented to our hospital with a rapidly progressing infection of the right upper extremity and clinical signs and symptoms of compartment syndrome. The patient was immediately taken to the operating room for decompressive fasciotomy, debridement, drainage, and irrigation of what cultures subsequently revealed to be a virulent streptococcal infection. Important anatomical structures are identified in the video as the compartments of the forearm and hand are decompressed through volar and dorsal incisions. In the conclusion of the video, the skin is loosely approximated over the elbow and wrist flexion creases, and a bulky gauze dressing is applied including a plaster splint. RESULTS: The video is 6 minutes, 20-second duration in time, and 558,180,000 bytes in size. CONCLUSIONS: This video successfully demonstrates the anatomical approach and technique of an extensile forearm and hand fasciotomy for compartment syndrome related to a rapidly progressing infection.

Open Reduction, Internal Fixation Distal Intraarticular Distal Humerus Fracture.

PURPOSE: The purpose of this video is to demonstrate the surgical repair of an intraarticular distal humerus fracture. METHODS: A polytrauma patient with an intraarticular distal humerus fracture is shown. The patient is positioned laterally, with a posterior skin incision and olecranon osteotomy for exposure. An anatomic reduction is achieved, and internal fixation with perpendicular plating of the distal humerus is performed. RESULTS: The video is 18 minutes, 34 seconds duration in time and 2,048,752,000 bytes in size. CONCLUSIONS: Open reduction with internal fixation of a distal humerus fracture is demonstrated in this video.

Olecranon Osteotomy With Tension Band Wire Repair.

PURPOSE: The purpose of this video is to demonstrate the surgical technique of olecranon osteotomy with tension band wire repair. METHODS: A patient with a comminuted, intra-articular distal humerus fracture requiring ORIF is presented in this video demonstration of the surgical technique of an olecranon osteotomy. The olecranon osteotomy is an established technique for approaching the distal humerus for surgical repair of fracture. In the video, the patient is positioned laterally allowing a dorsal incision. The ulnar nerve is identified and protected. A chevron osteotomy, apex distally based, is created in the proximal ulna using osteotomes, centering the osteotomy within the sulcus of the proximal ulna. Once the osteotomy has been completed, the proximal ulna is reflected proximally to allow access to the distal humerus. The osteotomy is repaired using a tension band wire technique. The 2 longitudinal K-wires (0.062 inches) engage the volar cortex of the ulna and the tips of the pins are buried beneath the triceps tendon. A figure 8, 18-gauge cerclage wire is twisted to compress the osteotomy site at the end of the procedure to promote stability and healing. RESULTS: The video is 10 minutes, 30 seconds duration in time and 2,048,409,000 bytes in size. CONCLUSIONS: Various techniques of olecranon osteotomy have been described. The principles of a well-centered osteotomy and a stable repair are essential to this technique. This is demonstrated in the video of an olecranon osteotomy using osteotomes and a tension band repair.

Split Thickness Skin Graft to Lower Leg.

PURPOSE: The purpose of this video is to demonstrate the steps of harvesting, meshing, and applying a split thickness skin graft (STSG) to a lower leg to cover a lateral fasciotomy wound. METHODS: A patient with a gunshot wound to his tibia has already undergone intramedullary rodding of the fracture and has had and medial and lateral fasciotomies for compartment syndrome. In the video, the lateral leg wound is covered with an STSG from the ipsilateral, lateral thigh. The graft is harvested with a dermatome, then meshed, and then inset for full coverage of the wound. A sterile, negative pressure dressing is applied at the conclusion of the case. RESULTS: The video is 5 minutes, 46 seconds duration in time and 1,922,884,000 bytes in size. CONCLUSION: Various techniques of STSG have been described. This video demonstrates a successful strategy for coverage of a lateral leg wound with an STSG and negative pressure dressing.

Heterotopic ossification of the shoulder in patients with traumatic brain injury.

BACKGROUND: We retrospectively reviewed 10 consecutive patients (11 shoulders) with traumatic brain injury who underwent surgical resection of heterotopic ossification (HO) of the shoulder. Our primary research goal was to determine the change in range of motion (ROM) at the shoulder after resection of heterotopic ossification in patients with traumatic brain injury. Secondary research goals were to determine simple functional outcome gains related to activities of daily living and to determine complications in this patient cohort. METHODS AND MATERIALS: Data were collected retrospectively and included measured ROM of the shoulder and observed ability to perform daily activities. The average age of the patients was 33 years (range, 20 -45). RESULTS: Sagittal plane motion (flexion/extension) increased by 85.0°, coronal plane motion (adduction/abduction) increased by 59.1°, and axial plane motion (internal/external rotation) increased by 66.8° (P < .001). Nine patients increased independence with improved functional status (7 patients able to perform all 3 activities of feeding, grooming, and toiletry) (P < .001). CONCLUSION: Surgical resection of heterotopic ossification of the shoulder is an effective procedure to increase joint mobility and improve function.

Foot salvage after loss of the first and second metatarsal rays with a free fibular osteocutaneous flap.

Severely comminuted fractures of the metatarsal bones with significant bone and soft-tissue loss have commonly subjected patients to proximal amputation procedures. We describe two patients who experienced high-energy traumatic injuries to their limbs that resulted in significant destruction of their first and second metatarsal bones with overlying soft-tissue trauma not amenable to local coverage. In both cases, a vascularized free fibular osteocutaneous flap was used to reconstruct the metatarsal bone defect and traumatized soft tissues so that a proximal amputation was avoided. At an average of 14 months of follow-up, both patients had recovered well and regained independent ambulation, with one patient being able to play soccer. We show that the free fibular osteoseptocutaneous flap is useful in reconstructing significant metatarsal bone defects and in avoiding amputations in this patient population. The skin component of the flap may be used to fill soft-tissue losses, and the fibula bone may be osteotomized so that more than one ray may be reconstructed.

Glans penis coronaplasty with palmaris longus tendon following total penile reconstruction.

Total penile reconstruction has been performed successfully with the use of vascularized flaps, to the point of obtaining a functioning penis where the patient can urinate voluntarily, have sexual relations, and obtain an acceptable reconstruction. Less attention has been paid to the cosmetic appearance, however, perhaps due to an already complex reconstructive effort. In particular, the anatomic distinction between the penile shaft and the glans penis in the reconstruction is commonly flat with absence of the corona. We present a 39-year-old male who underwent complete penile reconstruction following total penectomy for malignancy with a radial forearm osteocutaneous flap and had loss of the corona postoperatively. A palmaris longus graft was used for glans penis coronaplasty. The tendon graft provides autologous tissue, which is easy to harvest, has minimal donor morbidity, and structurally can be manipulated to provide tissue bulk for the reconstruction.

Excision of heterotopic ossification from the knee: a functional outcome study.

UNLABELLED: We retrospectively reviewed 17 consecutive patients with neurologic injuries (22 knees) who had excision of heterotopic ossification (22 knees, five bilateral) of the knees. Our primary research goal was to determine the change in range of motion at the knee after resection of heterotopic ossification in patients with neurologic injuries. Our secondary research goal was to determine the mobility gains measured regarding ambulatory and sitting functions for these patients. Diagnoses included traumatic brain injury (15 patients), anoxia (one patient), and spinal cord injury (one patient). The average age of the patients was 33 years (range, 19-51 years). Data were collected by an independent observer and included range of motion of the knee, ambulatory ability according to a five-level scale, and sitting ability according to a three-level scale. The average followup was 32 months. Range of motion improved by 65 degrees postoperatively. Extension improved from a preoperative mean of 16 degrees to a postoperative mean of 2 degrees . Flexion improved from a preoperative mean of 57 degrees to a postoperative mean of 107 degrees . Ambulatory and sitting function improved as a result of treatment. Surgical excision of heterotopic ossification of the knee is an effective procedure to increase joint mobility and function. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series-no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

The influence of dynamic polyelectromyography in formulating a surgical plan in treatment of spastic elbow flexion deformity.

OBJECTIVE: To determine the influence of motor-control analysis with dynamic electromyography on surgical planning in patients with spastic elbow flexion deformity. DESIGN: Prospective observational design. SETTING: A Traumatic Brain Injury Model Systems-affiliated specialty referral center for the evaluation and treatment of mobility problems associated with neurologic injury and disease. PARTICIPANTS: Twenty-one patients with spastic elbow flexion deformity. INTERVENTIONS: Two surgeons each formulated a detailed surgical plan for each individual muscle-tendon unit. Patients then underwent motor-control analysis in which kinetic and polyelectromyographic data were collected by using a standard protocol. Each surgeon formulated another surgical plan after independently reviewing the laboratory study. MAIN OUTCOME MEASURES: The frequency of change and degree of agreement in the surgical plans after review of the laboratory data were used as measures of the effect of the laboratory studies. RESULTS: Fifty-seven percent of the surgical plans were changed after the motor-control study. The frequency of change did not differ by clinical experience. There was a trend toward higher agreement between surgeons after the study than before. CONCLUSIONS: Detailed electromyographic motor-control analysis alters surgical planning for patients with spastic elbow flexion deformity. Clinical assessment alone does not accurately identify the muscles responsible for the deformity or dysfunction. More clinical experience does not result in greater accuracy. Motor-control analysis produces higher agreement between surgeons in planning surgery.