Neuroma Treatment With the Acellular Nerve Allograft Reconstruction Technique.

Treatment of a painful neuroma is a challenging problem for both the patient and the providers. Current surgical treatment options typically include excision of the neuroma and stump relation. However, with both treatment options, patients have high rates of persistent pain and rates of neuroma recurrence. We describe two patients with neuromas treated with our acellular nerve allograft reconstruction technique. This technique involves the excision of the neuroma and bridging the proximal nerve end to the surrounding tissue with an acellular nerve allograft. Both patients had immediate resolution of their neuropathic pain that was maintained at their final follow-up. Acellular nerve allograft reconstruction is a promising treatment option for the treatment of painful neuromas.

Shoulder Surgery Google Search Trends during the COVID-19 Pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic has strained many healthcare systems. Google Trends is a tool that provides information on online interest in selected keywords and topics over time. The purpose of this study is to describe the effect of the COVID-19 pandemic on online interest in elective shoulder pathology. Online search pattern data were obtained via Google Trends from November 2019 to November 2020 using the search terms 'orthopedic surgery' and 'shoulder pathology' search terms. Relative search volume index (SVI) graphs were generated from this data and the 7-day average of new COVID-19 cases in the United States. Orthopaedic surgery and shoulder pathology search trends decreased during March 2020 with a sudden rise in the 7-day average of new COVID-19 cases. After March 2020, orthopaedic surgery and shoulder pathology search terms approached pre-COVID-19 pandemic values despite continued increases in the 7-day average of new COVID-19 cases. (Journal of Surgical Orthopaedic Advances 32(1):014-016, 2023).

A simple surgical mask modification to pass N95 respirator-equivalent fit testing standards during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has infected hundreds of millions of people resulting in millions of deaths worldwide. While N95 respirators remain the gold standard as personal protective equipment, they are resource-intensive to produce and obtain. Surgical masks, easier to produce and obtain, filter ≥95% submicron particles but are less protective due to a lack of seal around a user's face. This study tested the ability of a simple surgical mask modification using rubber bands to create a seal against particle exposure that would pass N95 standards. METHODS AND FINDINGS: Forty healthcare workers underwent TSI PortaCount mask fit testing using an ASTM Level 1 surgical mask modified with rubber bands. Fit Factor was determined after testing four standard OSHA N95 fit testing scenarios. Performance of the properly-modified surgical mask was compared to that of a poorly-modified surgical mask, an unmodified standard surgical mask, and an N95 respirator. Thirty-one of forty (78%) healthcare workers passed Fit Factor testing using a properly-modified mask. The Fit Factor success rate significantly improved by subsequent test date (p = 0.043), but was not associated with any other participant characteristics. The average Fit Factor score for the properly-modified mask was 151 (SD 65.2), a significantly better fit than the unmodified mask score of 3.8 (SD 3.1, p<0.001) and the poorly-modified mask score of 24.6 (SD 48.4, p<0.001) but significantly lower than a properly fitted N95 score of 199 (SD 4.5, p<0.001).do. CONCLUSIONS: Rubber bands, a low-cost and easily-accessible modification, can improve the seal and protective ability of a standard surgical mask to the level of an N95 respirator. This could mitigate N95 respirator shortages worldwide and provide individuals in under-resourced regions a practical means for increased personal respiratory protection.

Utilizing Google Trends to Track Online Interest in Elective Hand Surgery During the COVID-19 Pandemic.

Introduction Elective hand surgery encompasses a large volume of orthopaedic cases annually. Carpal tunnel syndrome, ganglion cysts, and trigger digits are some of the most common pathologies treated by hand surgeons. In the midst of the COVID-19 pandemic, patient's interest in elective hand surgery for these conditions is uncertain. The objective of this study is to use Google Trends to track online interest in elective hand surgery in the United States during the COVID-19 pandemic. Methods Online search trends regarding elective orthopaedic hand surgery were obtained via Google Trends from November 2019 to November 2020. Three common hand pathologies in lay terms ("carpal tunnel," "'ganglion cyst' + 'wrist cyst,'" and "trigger finger") and three hand surgery-specific keywords ("hand surgery," "carpal tunnel surgery," and "trigger finger surgery") were used as search terms. The search volume index (SVI) graphs for the United States for both sets of search terms were then generated from the Google Trends data and compared to the seven-day average of new COVID-19 cases per day as reported by the CDC. A separate SVI graph was then created for the search term "coronavirus" and was compared against both sets of search terms as above. Results Search trends for all elective hand pathologies and surgery-specific keywords remained constant from November 2019 to the beginning of March 2020 and then decreased significantly within a one-month period following the peak in COVID-19 cases the week of March 15, 2020. Search trends for these keywords increased to baseline levels over the next few months. The search trend for "coronavirus" demonstrated a small search volume index peak of 13 during January 2020 followed by the maximum peak of 100 during the week of March 15, 2020, corresponding to the decrease in search trends of elective hand surgery at that time. Conclusions Online interest in elective hand surgery remained constant prior to the COVID-19 pandemic; however, there was a marked decrease in search trends of elective hand surgery with the rise in daily reported COVID-19 cases, suggesting that patient's interest in elective hand surgery decreased with the onset of the pandemic.

Flexor Pollicis Longus Tendon Wear Associated With Volar Plating: A Cadaveric Study.

PURPOSE: This study examined the effect of low-profile volar rim plates (VR), proximally placed standard variable-angle locking plates (pVA-LCP), and distally placed standard variable-angle locking plates (dVA-LCP) on the flexor pollicis longus (FPL) tendon in a cadaver model. We hypothesized that tendons from the VR and pVA-LCP groups would exhibit similar contact pressures, wear patterns, and post-fatigue testing mechanical properties, whereas dVA-LCP tendons would exhibit higher contact pressures, increased tendon wear patterns, and decreased mechanical properties. METHODS: Nine matched pairs of cadaveric specimens were used in this study. Thin-film pressure sensors were used to measure the initial contact loads between plates and FPL tendons. Specimens were cyclically loaded for 10,000 cycles by actuating the FPL tendon. Cycled tendons were harvested, photographed with a stereomicroscope, and graded for wear on a Likert scale by 5 observers who were blinded to the study protocol. Uniaxial tensile testing measured mechanical properties of the tendon: ultimate failure load, ultimate stress, percent stress relaxation, elastic modulus, and stiffness. RESULTS: With regard to the cadaveric FPL tendon, VR and dVA-LCP had increased contact pressure and tendon wear compared with pVA-LCP. There were no significant differences in contact pressure or tendon wear between dVA-LCP and VR. There was no major difference in the tested mechanical properties of the FPL tendon among any of the groups. CONCLUSIONS: Plates placed directly on or beyond the volar rim demonstrate increased contact pressures and increased tendon wear in a cadaveric model. CLINICAL RELEVANCE: Although low-profile plates allow for fixation of smaller volar fragments in the distal radius, they cause substantial contact with the FPL tendon, which may rupture if the plate is not removed.

Loss of Elbow Flexion in Congenital Arthrogryposis Treated with a Bipolar Latissimus Transfer: A Case Report.

CASE: A 20-year-old man with congenital arthrogryposis presented for evaluation of biceps dysfunction. Although his left elbow was supple with 0° to 110° passive range of motion (ROM), he had no active ROM and was unable to perform basic activities of daily living such as bringing his hand to his mouth to feed himself. A bipolar latissimus transfer was performed to achieve functional active ROM. CONCLUSION: Bipolar latissimus transfer is a challenging, robust flap able to restore active elbow flexion in select groups of patients with biceps dysfunction, supple elbow, and functional latissimus dorsi.

The Saline Load Test is Effective at Diagnosing Traumatic Arthrotomies of the Shoulder.

The purpose of this study is to evaluate the fluid volume required for a saline load test to detect intra-articular involvement of the glenohumeral joint after penetrating trauma. A human cadaver study was conducted with 22 thawed, fresh-frozen forequarter amputations. A standard posterior shoulder portal was made with an 11-blade scalpel. A 19-gauge needle was inserted into the anterior portal site, and intra-articular position of both the blade and needle was confirmed with fluoroscopy. The blade was removed and normal saline was injected through the needle until extravasation of fluid was observed through the posterior portal. Injection volume required for extravasation was recorded. A logarithmic distribution of the volumes was then calculated in order to obtain estimated sensitivity ranges. Using a logarithmic distribution, 90%, 95% and 99% of simulated glenohumeral arthrotomies could be detected using injections of: 62 ml [41-96], 81 ml [50-133] and 136 ml [72-252], respectively. (Journal of Surgical Orthopaedic Advances 28(4):268-271, 2019).

Preoperative Risk Factor Score Predicts Malnutrition in Total Joint Arthroplasty Patients.

Malnutrition is a modifiable risk factor for poor outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study is to highlight risk factors for hypoalbuminemia and develop a predictive model that identifies patients at risk for this condition before THA or TKA. The study retrospectively reviewed the National Surgical Quality Improvement Program database to analyze preoperative independent risk factors for a diagnosis of hypoalbuminemia in adult patients who underwent THA or TKA. These factors were used to create a preoperative risk model to predict hypoalbuminemia. Individuals with three or more risk factors in the seven-point model are predicted to have hypoalbuminemia in 20.4% of THA or 10.5% of TKA cases. Accurate identification of hypoalbuminemic patients may allow preoperative nutrition interventions to improve postoperative outcomes. (Journal of Surgical Orthopaedic Advances 28(2):97-103, 2019).

A Decade of Progress Toward Establishing Regional Hand Trauma Centers in the United States.

Although upper extremity amputations have become less common in the workplace because of improvements in safety and equipment, the American health system's ability to provide emergent microvascular care for these injuries remains highly fragmented, inconsistent, overburdened, and at times unavailable. Over the past decade, hand surgeons have worked to improve this disparity within health systems. This article discusses the need for emergent microsurgical treatment, barriers encountered in improving access to care, and a description of current and future efforts of developing a sustainable network of highly specialized regional hand trauma centers.

Enteroarticular Fistula Following Antibiotic Spacer Placement for a Periprosthetic Joint Infection in a Patient with Chronic Pelvic Discontinuity: A Case Report.

CASE: A 50-year-old man with a history of chronic refractory periprosthetic joint infection following total hip arthroplasty, which had been treated with multiple antibiotic spacers, developed an enteroarticular fistula. He was able to avoid hip disarticulation after undergoing a laparoscopic colectomy with a diverting colostomy and a functional hip resection arthroplasty. At the 1-year follow-up, he was walking independently with crutches and had minimal pain. CONCLUSION: An enteroarticular fistula following total hip arthroplasty is a rare and serious complication. To our knowledge, this is the first reported case that occurred in the setting of an antibiotic spacer. A multidisciplinary team approach is essential for achieving clinical success.

The Saline Load Test is Effective at Diagnosing Traumatic Arthrotomies of the Wrist.

BACKGROUND: The saline load test has previously been shown to be an effective tool to diagnose traumatic arthrotomies, but no studies have assessed the test's efficacy in the wrist. The purpose of this study was to investigate the amount of fluid required during a saline load test to detect intra-articular wrist involvement of traumatic wounds with high sensitivity. METHODS: A cadaveric study was conducted using 7 thawed, fresh-frozen forequarter amputations from 7 different donors (3 male, 4 female). Specimen age (mean: 67.7 y, range: 52 to 80 y), laterality (1 right, 6 left), body weight (mean: 164.3 lbs, range: 100 to 223 lbs), and wrist range of motion (ROM) was assessed before testing. The wrist capsule was punctured with an 11-blade scalpel through the 6R radiocarpal portal site under fluoroscopic guidance to ensure the injury was intra-articular. A 19-G needle was then placed through the 3,4 radiocarpal portal site and confirmed with fluoroscopy to ensure intra-articular placement. Normal saline was then injected at a steady rate into the 3,4 radiocarpal portal site until extravasation of the saline was observed from the 6R radiocarpal arthrotomy site. The volume of saline required for extravasation from the 6R radiocarpal arthrotomy was recorded as the volume required to detect the arthrotomy. A plot of saline volumes (by percentile) was created, and a logarithmic distribution was calculated. A Wilcoxon rank-sum test was used to compare injection volumes between male and female specimens, and Pearson Coefficients were used to determine any correlations between injection volume and ROM. RESULTS: The average amount of saline that resulted in extravasation was 4 mL (range: 2 to 7 mL). In order to identify 75%, 90%, 95%, and 99% of the simulated wrist arthrotomies, 5 (95% confidence interval: 3-7), 6 (4-9), 7 (4-10), and 9 (5-14) mL were required, respectively. Pretest ROM did not correlate with saline volume. CONCLUSIONS: This study demonstrates the efficacy of the saline load test in detecting traumatic arthrotomies of the wrist joint with 95% sensitivity after loading 7 mL of saline. Prompt and accurate diagnosis of traumatic arthrotomies is paramount to guide management and optimize postinjury outcomes.

Nicotine impairs intra-substance tendon healing after full thickness injury in a rat model.

Nicotine is harmful to many bodily systems; however, the effects of nicotine on intra-substance tendon healing remain largely unexplored. The purpose of this study was to examine the functional, structural, and biomechanical effects of nicotine on the healing of Achilles tendons in rats after an acute full-thickness injury. Sixty Sprague-Dawley rats were enrolled in this study. Half were exposed to 0.9% saline and half to 61 ng/mL of nicotine for 3 months via subcutaneous osmotic pumps. At 3 months, all rats underwent blunt full thickness transection of the left Achilles tendon and were immobilized for one week in plantarflexion. In-vivo assays were conducted prior to injury, at 21 days, and at 42 days post-injury and included the following: Functional limb assessment, passive joint mechanics, and vascular evaluation. Rats were sacrificed at 21 and 42 days for biomechanical testing and histologic evaluation. Rats exposed to nicotine demonstrated decreased vascularity, greater alteration in gait mechanics, and increased passive ROM of the ankle joint. Biomechanically, the nicotine tendons failed at lower maximum loads, were less stiff, had smaller cross-sectional areas and had altered viscoelastic properties. Histologically, nicotine tendons demonstrated decreased vessel density at the injury site. This study demonstrates that nicotine leads to worse functional outcomes and biomechanical properties in tendons. The decreased vascularity in the nicotine group may suggest an underlying mechanism for inferior tendon healing. Patients should be counseled that using nicotine products increase their risk of poor tendon healing and may predispose them to tendon re-rupture. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Variable-Angle Locking Compression Plate Fixation of Distal Radius Volar Rim Fractures.

Background: To compare functional and radiographic outcomes of radius fractures distal to the watershed line treated with variable-angle volar rim locking compression plates (VA-LCP) with traditional fixed-angle volar rim locking compression plates (FA-LCP). Methods: A retrospective review of patients who underwent open reduction and internal fixation (ORIF) using either VA-LCP (19 wrists) or traditional fixation with FA-LCP (28 wrists). The average follow-up period was 14.5 months (range 11-16 months) for the VA-LCP group and 15.8 months (range 12-18 months) for the FA-LCP group. Clinical outcomes were evaluated using the Modified Mayo wrist score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, wrist range of motion (ROM) and grip strength relative to the uninjured side, and signs of flexor tendon irritation. Radiographic evaluation included radial height, radial inclination, volar tilt, and volar tear drop angle. All outcomes were assessed at 3, 6, and 12 months postoperatively. Results: MMWS and DASH scores improved with time postoperatively in both groups. Relative ROM was improved in VA-LCP compared to the FA-LCP at 12 months. VA-LCP was associated with a decreased incidence of flexor tendon irritation compared to FA-LCP. VA-LCP also better held the volar tilt reduction compared the FA-LCP. Conclusion: VA-LCP shows improved clinical and radiographic outcomes throughout the follow up period when compared to traditional fixation. VA-LCP may be an effective alternative to traditional fixation methods to treat radius fractures distal to the watershed line.

Chronic Nicotine Exposure Alters Uninjured Tendon Vascularity and Viscoelasticity.

BACKGROUND: Although nicotine and tobacco use are well established to have adverse health effects, the effects on tendons are less well understood. The purpose of this study was to investigate the effect of chronic nicotine exposure on Achilles tendon (AT) and supraspinatus tendon (SS) physiologic and mechanical properties in a rodent model. METHODS: Sprague-Dawley rats (n = 20) were exposed to either 0.9% saline or 36 mg/mL nicotine through an implantable osmotic pump for 12 weeks. At 12 weeks, the AT was imaged in vivo with contrast-enhanced ultrasound (CE-US) to assess vascularity. Bilateral AT and SS were then harvested for ex vivo biomechanical analysis. Statistical analysis was performed using Student t test and Mann Whitney U test. RESULTS: AT CE-US demonstrated a significantly increased wash-in rate in the nicotine group compared to the saline group, indicating an increase in tissue perfusion rate in the nicotine group. AT percent stress relaxation, a measure of tendon viscoelasticity, was significantly increased in the nicotine group compared to the saline group. Similarly, there was a trend toward increased SS percent stress relaxation in the nicotine group compared to the saline group. No differences in other mechanical properties were observed. CONCLUSION: AT perfusion rate increased and both AT and SS viscoelasticity were altered with chronic nicotine exposure at a clinically relevant dose that models the average smoker in the United States (14 cigarettes per day). Further studies are necessary to link these properties with tendon degeneration and injury. CLINICAL RELEVANCE: Chronic nicotine exposure affects tendon health. Patients should be counseled as such.

Preparation is the Only Shortcut You Need in Surgery: A Guide to Surgical Rehearsals for Hand and Upper Extremity Transplantation.

As upper extremity transplantation is becoming more accepted worldwide, the demand for a fresh tissue cadaveric training model for this procedure is increasing and necessary to assure surgical success. Surgical rehearsals can decrease operative time, improve technique, and reduce errors made on the actual day of surgery. The purpose of this article is to describe a method for surgical rehearsal of upper extremity transplantation using cadaveric specimens based on the clinical experience of an academic institution with an active transplantation program. The logistics of rehearsal setup, equipment, and modified version of procedural checklists are described.

Biceps Detachment Preserves Joint Function in a Chronic Massive Rotator Cuff Tear Rat Model.

BACKGROUND: Lesions of the long head of the biceps tendon are often associated with massive rotator cuff tears (MRCTs), and biceps tenotomy is frequently performed for pain relief and functional reservation. However, the efficacy and safety of biceps tenotomy regarding the effects on the surrounding tissues in chronic MRCT are unclear. HYPOTHESIS: Biceps tenotomy would result in improved mechanical and histological properties of the intact subscapularis tendon and improved in vivo shoulder function while not compromising glenoid cartilage properties. STUDY DESIGN: Controlled laboratory study. METHODS: Right supraspinatus and infraspinatus tendons were detached in 25 male Sprague-Dawley rats, followed by 4 weeks of cage activity to create a chronic MRCT condition. Animals were randomly divided into 2 groups and received either biceps tenotomy (n = 11) or sham surgery (n = 14) and were sacrificed 4 weeks thereafter. Forelimb gait and ground-reaction forces were recorded 1 day before the tendon detachment (baseline), 1 day before the surgical intervention (biceps tenotomy or sham), and 3, 7, 10, 14, 21, and 28 days after the intervention to assess in vivo shoulder joint function. The subscapularis tendon and glenoid cartilage were randomly allocated for mechanical testing or histologic assessment after the sacrifice. RESULTS: Compared with sham surgery, biceps tenotomy partially restored the in vivo shoulder joint function, with several gait and ground-reaction force parameters returning closer to preinjury baseline values at 4 weeks. With biceps tenotomy, mechanical properties of the subscapularis tendons were improved, while mechanical properties and histological Mankin scores of the glenoid cartilage were not diminished when compared with the sham group. CONCLUSION: Biceps tenotomy in the presence of chronic MRCT partially preserves overall shoulder function and potentially restores subscapularis tendon health without causing detrimental effects to joint cartilage. This laboratory study adds to the growing literature regarding the protective effects of biceps tenotomy on the shoulder joint in a chronic MRCT model. CLINICAL RELEVANCE: This study provides important basic science evidence supporting the use of biceps tenotomy in patients with massive rotator cuff tears.

Total Hip Arthroplasty for Crowe Type IV Developmental Dysplasia of the Hip Using a Titanium Mesh Cup and Subtrochanteric Femoral Osteotomy.

Background: Treatment of Crowe IV developmental dysplasia of the hip (DDH) with total hip arthroplasty (THA) reconstructs the true acetabulum, which improves hip biomechanics and function. However, restoration of the native acetabulum may lead to limb lengthening and traction neuropraxia. The purpose of this study is to describe the short term results of a retrospectively reviewed series of patients with Crowe IV DDH treated with THA using a titanium mesh cup, cemented liner, and subtrochanteric femoral shortening osteotomy. Methods: Eighteen patients (21 hips) with an average age of 47 years (age range: 28-61 years) with Crowe IV DDH underwent reconstructive THA and subtrochanteric femoral shortening osteotomy between September 2005 and February 2014. Follow up was assessed at 1, 3, 6, 9, and 12 months post operatively and then annually after the first year. The average follow up was 3.5 years (range 0.5-9 years). At each follow up visit, radiographs were used to assess for osteolysis and subsidence. Preoperative and postoperative patient reported outcomes including Harris Hip Score and Modified Merle d'Aubigne Hip Score were compared. Results: At the minimum 6 month follow up, all radiographic assessments showed no signs of osteolysis or subsidence of the implants. Both the Harris Hip Score and Modified Merle d'Aubigne Hip Score improved from preoperative assessments (p<0.05). Three patients developed symptoms of sciatic nerve neuropraxia that subsequently resolved. Conclusion: THA of Crowe IV DDH by reconstructing the acetabulum with bone graft, a titanium mesh cup, cemented liner, and subtrochanteric femoral shortening osteotomy demonstrated no osteolysis or subsidence and improved function with a low incidence of sciatic nerve palsy at short term follow up.Level of evidence: IV.

Can an arthroplasty risk score predict bundled care events after total joint arthroplasty?

BACKGROUND: The validated Arthroplasty Risk Score (ARS) predicts the need for postoperative triage to an intensive care setting. We hypothesized that the ARS may also predict hospital length of stay (LOS), discharge disposition, and episode-of-care cost (EOCC). METHODS: We retrospectively reviewed a series of 704 patients undergoing primary total hip and knee arthroplasty over 17 months. Patient characteristics, 90-day EOCC, LOS, and readmission rates were compared before and after ARS implementation. RESULTS: ARS implementation was associated with fewer patients going to a skilled nursing or rehabilitation facility after discharge (63% vs 74%, P = .002). There was no difference in LOS, EOCC, readmission rates, or complications. While the adoption of the ARS did not change the mean EOCC, ARS >3 was predictive of high EOCC outlier (odds ratio 2.65, 95% confidence interval 1.40-5.01, P = .003). Increased ARS correlated with increased EOCC (P = .003). CONCLUSIONS: Implementation of the ARS was associated with increased disposition to home. It was predictive of high EOCC and should be considered in risk adjustment variables in alternative payment models.

Acute Radial Nerve Repair with Humeral Shaft Shortening and Fixation Following a Closed Humeral Shaft Fracture: A Case Report.

CASE: A 65-year-old woman sustained a closed segmental humeral shaft fracture with a complete radial nerve palsy. Radial nerve neurotmesis was found during acute surgical exploration and fixation. Treatment included a 2-cm shortening osteotomy of the humeral shaft and osteosynthesis in order to obtain a tension-free primary end-to-end repair of the radial nerve. CONCLUSION: Tension-free primary nerve repair can be technically challenging with humeral shaft fractures. A shortening osteotomy of the humeral shaft and osteosynthesis are feasible to achieve tension-free neurorrhaphy without nerve-grafting.