Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Obesity Increases Complexity of Distal Radius Fracture in Fall From Standing Height.

OBJECTIVES: To investigate the relationship between obesity and distal radius fracture severity after low-energy trauma and to identify patient-specific risk factors predictive of increasing fracture severity. DESIGN: Retrospective review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Four hundred twenty-three adult subjects with a history of fracture of the distal radius resulting from a fall from standing height. INTERVENTION: Demographic data and injury characteristics were obtained. Preoperative wrist radiographs were reviewed and classified by the OTA classification system. Distal radius fractures were categorized as simple [closed and extra-articular (OTA 23-A)] and complex [intra-articular (OTA 23-B or 23-C) or open fracture or concomitant ipsilateral upper extremity fracture]. Multivariate logistic regression was completed to model the probability of incurring a complex fracture. MAIN OUTCOME MEASUREMENTS: Simple versus complex fracture pattern. RESULTS: Average age at the time of injury was 53.8 years (range, 18.9-98.4). Seventy-nine percent of subjects were female. The average body-mass index was 28.1 (range, 13.6-59.5). Two hundred forty-four patients (58%) suffered complex distal radius fractures per study criteria. Obese patients (body-mass index > 30) demonstrated increased fracture severity as per the OTA classification (P = 0.039) and were more likely to suffer a complex injury (P = 0.032). Multivariate regression identified male gender, obesity, and age ≥50 as independent risk factors for sustaining a complex fracture pattern. CONCLUSIONS: Obesity is associated with more complex fractures of the distal radius after low-energy trauma, particularly in elderly patients. This relationship may have important epidemiologic implications predictive of future societal fracture burden and severity in an obese, aging population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

3D model analysis of existing CT syndesmosis measurements.

INTRODUCTION: Use of Computed Tomography (CT) to evaluate syndesmotic reduction following injury has significantly increased in recent years. The aim of this study was to compare existing clinical measurements of syndesmotic reduction to gold standard measurements of fibular motion obtained from a full 3D model. METHODS: Three common clinical measures for assessing syndesmotic congruity on axial CT slices were identified in the literature. Each measure was manually performed on 170 cadaveric ankle CT scans obtained with variable degrees of simulated syndesmotic displacement. Clinical measures were assessed for intraobserver and interobserver reliability and compared to objective measures of true medial/lateral and anterior/posterior translation and fibular rotation that were obtained from a 3D model. Pearson correlation coefficients (PCC) were computed to determine which clinical measurements were most accurate for describing syndesmotic motion obtained from the 3D model. RESULTS: All three clinical measurement techniques demonstrated good to excellent interobserver and intraobserver reliability. Medial/lateral displacement of the fibula was best correlated with the difference between the anterior and posterior tibiofibular joint space measurements described by Elgafy et al (PCC = 0.29 small correlation). Anterior/posterior displacement of the fibula was well correlated with the anterior/posterior measurement described by Phisitkul et al (PCC = 0.69 large correlation). Fibular rotation was best correlated with the average of the Elgafy anterior and posterior tibiofibular joint space measurements (PCC = 0.33, moderate correlation). Proximal/ distal displacement of the lateral malleolus was best correlated with the Elgafy posterior tibiofibular joint space measurement (PCC = 0.49, moderate correlation). DISCUSSION: While the clinical measurements were adequately reproducible, they showed only moderate to small correlations with the 3D measurements of movement of the fibula in the longitudinal, medial/lateral or rotational directions. The only fibular translation measured by the 3D model that was well described by the three clinical measures was fibular movement in the anterior/ posterior direction. This work demonstrates a need for improved clinical measurements of syndesmotic congruity on axial CT scans to serve as surrogates for the true movement of the fibula.

Southwick-Fulkerson Osteotomy with intraoperative femoral nerve guidance.

BACKGROUND: Patellofemoral instability is a complex problem with most previous treatment plans addressing static alignment and static stabilizers. Although the quadriceps muscles are known to affect the tracking of the patella, they are rarely taken into account during a surgical procedure. PURPOSE: The purpose of this study is to determine the two year minimum results of 37 knees which received a Southwick-Fulkerson Osteotomy and MPFL repair or reconstruction both under the guidance of femoral nerve stimulation. METHODS: Patients underwent a Southwick-Fulkerson Osteotomy and either medial patellofemoral ligament (MPFL) repair or reconstruction using femoral nerve stimulation as a means of dynamic intraoperative evaluation of patello-femoral congruity in terminal extension. Two year minimum outcomes of 26 patients, 31 knees (84% return rate) were evaluated using KOOS and IKDC scores, and physical exam features of apprehension and assessment of dynamic tracking in the last 30 degrees of knee extension. Variables were evaluated with t-tests and ANOVA. RESULTS: 29/31 knees reported they were happy with the procedure and reported they would do it again. One knee (3%) reportedly "redislocated", but did not return for verification by exam. 30/31 had non-pathologic tracking. One knee displayed a small but residual J sign. 4/16 knees with MPFL repair only and 0/15 with MPFL repair and reconstruction exhibited a positive apprehension sign. Increased age and apprehension were correlated with lower outcome scores. CONCLUSIONS: Intraoperative femoral nerve stimulation is an effective way of evaluating patellar tracking intraoperatively that leads to 97% stable patellae with near congruent patello-femoral tracking. MPFL reconstruction is superior to MPFL repair in eliminating the persistence of the apprehension sign.

Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study.

BACKGROUND: Recent studies have shown that it is difficult to accurately reduce and assess the reduction of the syndesmosis after ankle injury. The syndesmosis is most commonly reduced with use of reduction clamps to compress across the tibia and fibula. However, intraoperative techniques to optimize forceps reductions to restore syndesmotic relationships accurately have not been systematically studied. The purpose of the present study was to evaluate the accuracy of syndesmosis reduction with different rotational vectors of clamp placement. METHODS: Ten through-the-knee cadaveric specimens were used. Markers were placed on the tibia and fibula to produce consistent clamp placement and radiographic evaluation. A computed tomographic scan of the ankle was made to serve as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture, and large posterior malleolus fracture. Following each step in the destabilization, clamps were applied to compress the syndesmosis at varying angles and computed tomography was performed to measure the alignment of the syndesmosis as compared with that on the control scan. RESULTS: In all degrees of induced instability, and for all vectors of clamp placement, a small but consistent amount of overcompression of the syndesmosis was observed. The average overcompression (and standard deviation) for all samples was 0.93 ± 0.70 mm. Both obliquely oriented clamp arrangements consistently caused fibular malreductions in the sagittal plane. Placing the clamp in the neutral anatomical axis reduced the syndesmosis most accurately, with an average displacement of 0.1 ± 0.77 mm compared with control through all degrees of instability. CONCLUSIONS: Clamp placement in the neutral anatomical axis reduced the syndesmosis most accurately in our cadaveric model, although slight overcompression was frequently observed. Placing the clamp obliquely malreduced the unstable syndesmosis.

Modifications of the Fulkerson osteotomy: a pilot study assessment of a novel technique of dynamic intraoperative determination of the adequacy of tubercle transfer.

Medial transfer of the tibial tubercle is commonly implemented to correct patellar alignment in patients with patellar instability. However, the extent of transfer needed is difficult to determine. This article reports a pilot-study experience with a novel technique employing intraoperative femoral nerve stimulation to better determine the distance of tubercle transfer required for proper patellar tracking. This pilot study is a case series involving seven knees, all with a clinical history of dislocation, evidence of maltracking, and excessive medial patellofemoral ligament (MPFL) laxity to the point of producing a positive apprehension sign. All seven knees received femoral nerve stimulation for patellar tracking assessment as part of a modified Fulkerson osteotomy. All knees received clinical follow-up for a minimum of 24 months. Six of the seven cases in this series remained stable during two years of follow-up. Through these findings we conclude that the use of femoral nerve stimulation for patellar tracking assessment may be associated with a sufficiently high rate of success to warrant more extensive investigation.