Not All Patients Undergoing Stabilization of Impending Pathologic Fractures for Renal Cell Carcinoma Metastases to the Femur Need Preoperative Embolization.

BACKGROUND: Preoperative transarterial embolization has been utilized in the surgical treatment of metastatic renal cell carcinoma of the femur to decrease perioperative blood loss. However, few studies have documented its efficacy in decreasing the proportion of patients receiving transfusions in the setting of prophylactic treatment of impending pathologic femur fractures. QUESTIONS/PURPOSES: In a population of patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation, the purpose of this study was to quantify and compare the proportion of patients who received at least one transfused unit of blood between a group treated with preoperative embolization and a group without preoperative embolization. METHODS: A retrospective study was performed using a Medicare claims-based database. International Classification of Diseases, 9 Revision and Current Procedural Terminology codes were used to identify 1285 patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation. The proportion of patients who received one or more blood transfusions was compared between 135 patients who underwent preoperative embolization and a group of 1150 concurrent control patients who did not undergo preoperative embolization. The control group was older than the embolization group, with 44% of these patients > 75 years old and 33% of the embolization group > 75 years. There was no difference in the female:male ratio between groups. Statistical comparisons of outcomes related to transfusion percentages were performed using Pearson chi square analysis with p < 0.05 considered significant. With the numbers available, we had 80% power to detect a difference in the percentage of patients transfused of 11% between the study groups at α = 0.05. RESULTS: No difference in transfusion percentage was observed between preoperative transarterial embolization (41 of 135 [30%]) and the control group (359 of 1150 [31%]; relative risk, 0.973; 95% confidence interval, 0.743-1.274; p = 0.84). The percentage of all patients who received a transfusion was 31% (400 of 1285). CONCLUSIONS: Preoperative embolization may not be mandatory in the prophylactic treatment of metastatic renal cell carcinoma of the femur, as demonstrated by the 69% of patients who received zero units of blood despite not receiving embolization. However, assessment of the efficacy of embolization in decreasing blood loss in the current study is limited as a result of biases associated with the database design of the study; the decision of whether to send a patient for embolization should be made on a case-by-case basis. The current study does not identify specific risk factors that should factor into this decision and underscores the need for further research in this regard. A plausible future research design to account for the low numbers and selection bias that limited the current study as well as the existing studies might be a multicenter, retrospective case-control study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Accuracy in Screw Selection in a Cadaveric, Small-Bone Fracture Model.

PURPOSE: Using a cadaveric model simulating clinical situations experienced during open reduction and internal fixation of proximal phalangeal fractures, the aim of this study was to evaluate the relationship between level of training and the rates of short, long, and ideal screw length selection based on depth gauge use without fluoroscopy assistance. METHODS: A dorsal approach to the proximal phalanx was performed on the index, middle, and ring fingers of 4 cadaveric specimens, and 3 drill holes were placed in each phalanx. Volunteers at different levels of training then measured the drill holes with a depth gauge and selected appropriate screw sizes. The rates of short, long, and ideal screw selection were compared between groups based on level of training. Ideal screws were defined as a screw that reached the volar cortex but did not protrude more than 1 mm beyond it. RESULTS: Eighteen participants including 3 hand fellowship-trained attending physicians participated for a total of 648 selected screws. The overall rate of ideal screw selection was lower than expected at 49.2%. There was not a statistically significant relationship between rate of ideal screw selection and higher levels of training. Attending surgeons were less likely to place short screws and screws protruding 2 mm or more beyond the volar cortex CONCLUSIONS: Overall, the rate of ideal screw selection was lower than expected. The most experienced surgeons were less likely to place short and excessively long screws. CLINICAL RELEVANCE: Based on the low rate of ideal screws, the authors recommend against overreliance on depth gauging alone when placing screws during surgery. The low-rate ideal screw length selection highlights the potential for future research and development of more accurate technologies to be used in screw selection.

Pediatric Scaphoid Proximal Pole Nonunion With Avascular Necrosis.

A 13-year-old, right hand-dominant, otherwise healthy boy presented with left wrist pain 19 months after a nonmotorized scooter injury. Radiographs and magnetic resonance imaging at presentation demonstrated proximal pole scaphoid nonunion with avascular necrosis of the proximal fragment. Operative and nonsurgical treatment options were discussed and the family elected for an attempt at nonsurgical management. The patient was placed in a short-arm thumb spica cast, with a window for a bone stimulator, for 14 weeks. At the conclusion of the treatment, the pain had resolved and x-ray and computed tomography scan demonstrated bony union. The authors recommend considering an initial trial of nonsurgical management for treatment of all pediatric scaphoid nonunions.

Submuscular Versus Subcutaneous Ulnar Nerve Transposition: A Cadaveric Model Evaluating Their Role in Primary Ulnar Nerve Repair at the Elbow.

PURPOSE: To investigate the length gained from subcutaneous and submuscular transposition of the ulnar nerve at the elbow. Specifically, the study aimed to define an expected nerve gap able to be overcome, and to determine if a difference between transposition techniques exists. METHODS: Eleven cadaveric specimens from the scapula to fingertip were procured. In situ decompression and mobilization of the ulnar nerve at the elbow followed by simulated laceration of the nerve was performed. Nerves were marked 5 mm from the laceration site to facilitate overlap measurement and to simulate nerve end preparation to viable fascicles before primary coaptation. Nerve ends were attached to spring gauges set at 100 g of tension (strain ≤ 10%). Measurements of nerve overlap were obtained in varying degrees of wrist (0°, 30°, 60°) and elbow (0°, 15°, 30°, 45°, 60°, 90°) flexion. Measurements were performed after in situ decompression and mobilization, and then repeated after both subcutaneous and submuscular transposition. RESULTS: Ulnar nerve transposition was found to increase nerve overlap at an elbow flexion of 30° or greater. No difference was seen between subcutaneous and submuscular transpositions at all wrist and elbow positions. In situ decompression and mobilization alone provided an average of 3.5 cm of length gain with the elbow extended. Transposition in conjunction with clinically feasible wrist and elbow flexion (30° and 60°, respectively) provided 5.2 cm of length gain. Controlling for mobilization, a statistically significant increase in overlap of approximately 2 cm was gained from transposition. CONCLUSIONS: Although mobilization combined with wrist and elbow flexion may afford substantial gap reduction and should be used initially when approaching proximal ulnar nerve lacerations, transposition should be considered when faced with a large nerve gap greater than 3 cm at the elbow. No difference was seen between submuscular and subcutaneous transposition techniques. CLINICAL RELEVANCE: This study defines the extent an ulnar nerve gap at the elbow can be overcome by in situ mobilization, joint positioning, and transposition. It additionally compares the efficacy of submuscular and subcutaneous transposition techniques in closing this gap.

Volar Anatomy of the Proximal Phalanx: Implications for Screw Length Selection for Fixation of Shaft Fractures.

PURPOSE: To investigate the anatomy of the volar surface of the proximal phalanx of the hand, specifically the longitudinal groove running along the volar phalangeal shaft. METHODS: We measured skeletonized proximal phalanges from 10 embalmed human cadaver hands at 5 equidistant points along the shaft. The difference between the maximum dorsal-palmar thickness of the shaft and thickness measured from the center of the volar groove to the most dorsal aspect of the phalanx indicated the depth of the groove at each point. These specimens underwent microtomography to characterize their osseous morphology further. Screws placed dorsal to palmar into the specimens and viewed fluoroscopically simulated the appearance of screw protrusion into the volar groove under intraoperative imaging. Similarly, screws placed into a fresh-frozen cadaveric hand illustrated possible screw impingement on soft tissue in vivo. RESULTS: The volar groove was most pronounced at the proximal and distal ends of the phalangeal shaft, becoming shallower along the midportion of the bone. The average difference between total bone thickness and thickness measured from the depth of the groove was significant at each of the 5 points of measurement along the phalangeal shaft for each of the 5 digits of the hand, including the thumb. Average groove depths ranged from 4% to 14% of total bone thickness, with a maximum individual measurement of 22%. Average depth of the groove at each of these positions ranged from 0.19 to 1.64 mm, reaching a maximum of 2.31 mm. CONCLUSIONS: We demonstrated that there is a longitudinal groove running the length of the phalangeal shaft. CLINICAL RELEVANCE: Viewed laterally, the cupped edges of the groove obscure its depth. Dorsally placed bicortical screws could protrude into the groove, remaining unnoticed on intraoperative imaging. The resulting impingement on the flexor tendon could lead to postsurgical stiffness or flexor tendon attritional rupture.

The Effect of Intraoperative Glove Choice on Carpal Tunnel Pressure.

Introduction The aim of this study was to quantify the effect of surgical gown and glove wear on carpal tunnel pressure. The authors hypothesized that gowning and gloving is associated with an increase in carpal tunnel pressure in cadaveric specimens wearing appropriately sized gloves. Furthermore, they hypothesized that increased glove thickness, double gloving, and smaller-than-appropriately sized gloves would all serve to increase carpal tunnel pressure. Materials and Methods Baseline carpal tunnel pressure measurements were obtained in 11 cadaveric specimens. Each specimen was subsequently gowned and gloved. Carpal tunnel pressures were obtained for each specimen fitted with four different types of gloves in four scenarios: (1) appropriately sized gloves, (2) one full-size smaller, (3) one full-size larger, and (4) double gloved. Results Mean carpal tunnel baseline value was 3.5 mm Hg. Appropriately sized single-glove wear more than doubled baseline carpal tunnel pressure. Double gloving and smaller-than-appropriately sized glove wear more than tripled baseline values. Among the single-glove subgroup, the thickest gloves (ortho) were associated with the highest increase in pressure from baseline values. Conclusion Glove selection can have repercussions related to carpal tunnel pressure. Susceptible surgeons should consider these factors when making decisions regarding intraoperative glove wear.

Managing the Athlete with a Scaphoid Fracture.

Most minimally displaced scaphoid fractures and all displaced scaphoid fractures in elite athletes are treated with early fixation to maximally expedite the return to full function. Computed tomographic (CT) scans are recommended in all scaphoid fractures to facilitate a complete understanding of fracture anatomy and to allow for optimal screw placement. Screw placement is important to maximize healing capacity of the fracture and allow for return to sport. Postoperative CT scans can be helpful to evaluate the extent of healing and may allow patients to return to play sooner.

Effect of Nerve-Cutting Technique on Nerve Microstructure and Neuroma Formation.

Background Peripheral neuroma formation results from partial or complete nerve division. Elucidating measures to prevent the development of peripheral neuromas is of clinical importance. The aim of this study was to determine the effect of various surgical nerve-cutting techniques on nerve microstructure and resultant neuroma formation. Methods Twenty Sprague-Dawley rats were randomly assigned to one of the following nerve-cutting techniques: No. 15 scalpel blade with tongue depressor, micro-serrated scissors, nerve-cutting guide forceps with straight razor, and bipolar cauterization. The right sciatic nerve was transected using the assigned nerve-cutting technique. Neuromas were harvested 6 weeks postoperatively, and samples were obtained for histologic analysis. The contralateral sciatic nerve was transected at euthanasia and analyzed with histology and with scanning electron microscopy in a subset of the rats. Results Fifteen of the 20 rats survived the 6-week experiment. Scanning electron microscopy of the No. 15 scalpel blade group showed the most visual damage and disorganization whereas the nerve-cutting guide forceps and micro-serrated scissors groups resulted in a smooth transected surface. Bipolar cauterization appeared to enclose the fascicular architecture within a sealed epineurium. Each neuroma was significantly larger than contralateral controls. There were no significant differences in neuroma caliber between nerve transection groups. No substantial differences in microstructure were evident between transection groups. Conclusion Despite disparate microscopic appearances of the cut surfaces of nerves using various nerve-cutting techniques, we found no significant differences in the caliber or incidence of neuroma formation based on nerve-cutting technique. Nerve-cutting technique used when transecting peripheral nerves may have little bearing on the formation or size of resultant neuroma formation.

Trends in Surgical Management and Costs for Operative Treatment of Proximal Humerus Fractures in the Elderly.

Proximal humerus fractures in the elderly are increasing in frequency as the population ages. The purpose of this study was to investigate surgical and cost trends in the Medicare population. The PearlDiver database was queried using diagnosis codes to identify Medicare recipients with proximal humerus fractures from 2005 to 2012. Surgical trends, demographics, and charge/reimbursement data were analyzed. There were 750,426 proximal humerus fractures in Medicare recipients during the 8-year period. Eighty-five percent of the fractures were treated nonoperatively; however, the percentage of operative vs nonoperative management increased significantly over time for all fractures, isolated fractures, and fracture dislocations. Open reduction and internal fixation (ORIF) was the most common surgical treatment and remained constant. Reverse total shoulder arthroplasty (RTSA) increased by 406% and hemiarthroplasty (HEMI) decreased by 47%. Compared with younger patients, older patients were more likely to undergo HEMI or RTSA than to undergo ORIF for isolated fractures and fracture dislocations. Charges and reimbursements from Medicare increased over time. The charge to reimbursement gap increased from 87% in 2005 to 104% in 2012. Charges were higher for RTSA than for ORIF or HEMI. Nonoperative management was the treatment of choice for 85% of proximal humerus fractures in the elderly; however, there was a trend toward higher rates of surgery. The RTSA rate increased and the HEMI rate decreased, while ORIF remained constant. There was an increasing charge to reimbursement ratio for all procedure types. [Orthopedics. 2017; 40(4):e641-e647.].

Soft tissue masses for the general orthopedic surgeon.

Soft tissue sarcomas are a rare, heterogeneous group of malignancies that should be included in the differential diagnosis for any patient presenting with a soft tissue mass. This article reviews strategies for differentiating between benign and malignant soft tissue masses. Epidemiology, appropriate workup, and treatment of soft tissue sarcomas are reviewed.