Capitate Fracture Subsequent to Capitolunate Staple Fusion: A Case Report.

We report a case of a 71-year-old man who underwent capitolunate fusion for scapholunate advanced collapse. At the patient's 4-month follow-up, there was evidence of a fracture at the distal staple tine. He subsequently underwent removal of staple hardware with revision open reduction internal fixation using headless compression screw fixation and bone grafting. The literature review aimed to identify possible mechanisms and analyze similar cases of this complication. We presume that the fracture resulted from increased stress on the bone from both drill holes and the orientation of the staples. Placing the tines in different planes may decrease the risk of this complication.

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients.

BACKGROUND: Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. METHODS: We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. RESULTS: There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). CONCLUSION: Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Cubital Tunnel Syndrome: Current Concepts.

PURPOSE OF REVIEW: Compressive neuropathy of the ulnar nerve across the elbow is a common diagnosis encountered frequently within a hand and upper extremity clinical practice. Appropriate and timely evaluation, diagnosis, objective testing, and evidence-based decisions regarding treatment options are paramount in the optimal care of the patient with this pathology. An understanding of current literature is critical in determining and understanding best practices. RECENT FINDINGS: A thorough review of the recent literature regarding physical examination, diagnostic testing, and nonoperative versus operative results was performed. Regarding physical examination, the glenohumeral internal rotation test and scratch collapse test are more effective and sensitive than traditional maneuvers such as Tinel's testing and the elbow flexion test. Electrodiagnostic testing, magnetic resonance imaging, and ultrasound evaluation have all been shown to be effective in diagnosing cubital tunnel syndrome. However, no single test has proven itself to be superior. Nonoperative treatment can be successful for mild cases of cubital tunnel syndrome. Surgical release techniques comparing open with endoscopic release are equivocal, and in situ release versus transposition techniques show that transposition should not be performed routinely. The diagnosis and treatment of cubital tunnel syndrome do not have a well-defined algorithm based on current literature. The treating physician must therefore utilize the available information to determine a diagnostic and treatment plan individualized to the patient. More rigorous scientific studies are needed to determine the most effective surgical approaches for cubital tunnel syndrome.

Medial Femoral Condyle Periosteal Free Flap for the Treatment of Talus Avascular Necrosis.

BACKGROUND: In patients with avascular necrosis (AVN) of the talus in the precollapse stage unresponsive to conservative measures, joint preservation should be considered. Good results have previously been reported for vascularized bone grafting. The medial femoral condyle (MFC) free flap has recently been introduced, which consists of corticoperiosteal bone. We present a novel surgical technique using a periosteal-only MFC (pMFC) free flap in the treatment of talus AVN. METHODS: We retrospectively reviewed all pMFC free flaps performed from 2016 to 2018 in the precollapse stage of talus AVN. Surgical management included an ankle arthroscopy, talus core decompression, and ipsilateral pMFC free flap to the talus. Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and visual analog scale (VAS) pain scores were evaluated, and pre- and postoperative imaging studies were assessed by a musculoskeletal-trained radiologist for all patients. Six pMFC free flaps in 5 patients were included in this case series. AVN etiology included idiopathic, posttraumatic, and sepsis-related treatment. All patients were female with an average age of 44.2 (range, 37-67) years. Average postoperative follow-up was 16.9 (range, 6-28) months. RESULTS: Pre- to postoperative FAAM-ADL, ADL single assessment numeric evaluation, and VAS scores showed statistically significant improvement (P < .039). No reoperations or flap complications were observed. There was 1 minor complication, which included postoperative paresthesias at the pMFC harvest site. Postoperative x-rays showed no subsequent collapse, and magnetic resonance imaging (MRI) illustrated progressive improvement of bone marrow edema, decreased surrounding areas of AVN, and decreased joint effusion when compared to preoperative MRI. CONCLUSION: The pMFC free flap is a novel modification of a previously described technique, which appears to have similar results compared to the traditional MFC free flap. It was safe and effective in the short term with excellent clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Incidence of metacarpal fractures in the US population.

BACKGROUND: There are scarce data regarding the epidemiology of metacarpal fractures within the US population. The purpose of this study is to report the epidemiology of metacarpal fractures in the USA using the National Electronic Injury Surveillance System Database (NEISS). METHODS: The NEISS database represents a national probability sample of approximately 100 hospitals in the USA and its territories. The database was queried for metacarpal fractures during the time period 2002-2006. US census data were used to calculate incidence rate (IR) for various demographic criteria. RESULTS: A total of 4,718 metacarpal fractures were identified, representing approximately 160,790 metacarpal fractures. The calculated IR was 13.6 (95 % CI, 13.6-13.67) per 100,000 person-years. The highest IR occurred in the 10-19 age group (IR 38.8; 95 % CI, 38.6-38.9) followed by those 20-29 years of age (IR 28.4; 95 % CI, 28.3-28.5). Metacarpal fractures were found more commonly in males (IR 23; 95 % CI, 22.9-23.1) than females (IR 4.5; 95 % CI, 4.5-4.5), with an incidence rate ratio of 5.08. The most common mechanisms of injury were contact with a wall or door, and falls. The most common setting was in the home, followed by recreational locations. CONCLUSIONS: The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years. Males in the second and third decades of life sustain this injury most commonly. Metacarpal fractures occur frequently in the home or recreational setting, with contact force as the primary mechanism of injury.