Usability of Nerve Tape: A Novel Sutureless Nerve Coaptation Device.

PURPOSE: Microsuture neurorrhaphy is technically challenging and has inherent drawbacks. This study evaluated the potential of a novel, sutureless nerve coaptation device to improve efficiency and precision. METHODS: Twelve surgeons participated in this study-six attending hand/microsurgeons and six trainees (orthopedic and plastic surgery residents or hand surgery fellows). Twenty-four cadaver arm specimens were used, and nerve repairs were performed at six sites in each specimen-the median and ulnar nerves in the proximal forearm, the median and ulnar nerves in the distal forearm, and the common digital nerves to the second and third web spaces. Each study participant performed nerve repairs at all six injury locations in two different cadaver arms (n = 12 total repairs for each participating surgeon). The nerve repairs were timed, tested for tensile strength, and graded for alignment and technical repair quality. RESULTS: A substantial reduction in time was required to perform repairs with the novel coaptation device (1.6 ± 0.8 minutes) compared with microsuture (7.2 ± 3.6 minutes). Device repairs were judged clinically acceptable (scoring "Excellent" or "Good" by most of the expert panel) in 97% of the repairs; the percentage of suture repairs receiving Excellent/Good scores by most of the expert panel was 69.4% for attending surgeons and 36.1% for trainees. The device repairs exhibited a higher average peak tensile force (7.0 ± 3.6 N) compared with suture repairs (2.6 ± 1.6 N). CONCLUSIONS: Nerve repairs performed with a novel repair device were performed faster and with higher technical precision than those performed using microsutures. Device repairs had substantially greater tensile strength than microsuture repairs. CLINICAL RELEVANCE: The evaluated novel nerve repair device may improve surgical efficiency and nerve repair quality.

Cost-effectiveness analysis of Avance® allograft for the treatment of peripheral nerve injuries in the USA.

Aim: Peripheral nerve injury (PNI) is a debilitating condition with significant associated morbidity, and which places a substantial socioeconomic burden on healthcare systems worldwide. Recently, allograft has emerged as a viable surgical alternative to autograft for the treatment of PNI. This study evaluated the cost effectiveness of allograft (Avance® Nerve Graft) compared with autograft for the peripheral nerve repair, from a US payer perspective. Methods: A Markov cohort model was developed to consider the treatment pathways followed by a patient population undergoing a single transected nerve repair with either allograft, or autograft. The marginal difference in meaningful recovery (MR) (effectiveness), and costs, between the two groups were estimated over a lifetime horizon. Deterministic and probabilistic sensitivity analyses (PSA) were performed to consider the uncertainty surrounding the base-case input parameter values and their effect on the overall incremental cost-effectiveness ratio (ICER). Results: The base-case analysis indicates that there is a small difference in the average probability of MR between the two groups (75.15% vs 70.46%; +4.69% with allograft). Allograft also results in cost savings ($12,677 vs $14,023; -$-1346 with allograft) compared with autograft. Deterministic sensitivity analysis shows that the costs of the initial surgical procedures are the main drivers of incremental cost, but that the intervention is likely to be cost saving compared with autograft regardless of the parameter variations made. Conclusion: The use of allograft with the Avance Nerve Graft has the potential to be a cost-effective alternative to autograft for the surgical treatment of PNI in the USA.

Eponyms of Upper Extremity Surgical Approaches: A Historical Perspective.

Numerous eponymous surgical approaches are used in the treatment of upper extremity pathology, especially in the trauma setting. Knowledge of anatomy and planes is critical to maximize visualization, achieve anatomic reduction, and avoid iatrogenic injury to critical neurovascular structures. Understanding the history of these commonly used eponymous upper extremity approaches (Kaplan, Kocher, Boyd, Thompson, and Henry) provides a humanistic perspective of each of these surgeons' narratives, which shaped their description of anatomic approaches that have forever changed the course of hand and upper extremity surgeries, providing greater means and possibilities to treat our patients.

Procedure Costs of Peripheral Nerve Graft Reconstruction.

Peripheral nerve injuries not repaired in an effective and timely manner may lead to permanent functional loss and/or pain. For gaps greater than 5 mm, autograft has been the gold standard. Allograft has recently emerged as an attractive alternative, delivering comparable functional recovery without risk of second surgical site morbidities. Cost is an important factor when considering surgical options, and with a paucity of nerve repair cost data, this study aimed to compare allograft and autograft procedure costs. Methods: A retrospective cross-sectional observational study using the US all-payer PINC AI Healthcare Database examined facility procedure costs and cost drivers in patients undergoing allograft or autograft repair of an isolated single peripheral nerve injury between January 2018 and August 2020. Inpatient repairs were limited to nerve-specific DRGs. Multivariable regression evaluated risk-adjusted procedure cost differences. Results: Peripheral nerve graft repairs (n = 1363) were more frequent in the outpatient setting, and more than half involved the use of allograft nerve. Procedure costs for allograft and autograft repair were not significantly different in the outpatient (P = 0.43) or inpatient (P = 0.71) setting even after controlling for other risk factors. Operating room cost was significantly higher for autograft in outpatient (P < 0.0001) but not inpatient (P = 0.46), whereas allograft implant cost was significantly higher in both settings (P < 0.0001). Conclusions: No significant differences in procedure costs for autograft and allograft repair in inpatient and outpatient settings were found using real-world data. Future research should explore longer-term costs.

A Systematic Review and Meta-Analysis of Nerve Gap Repair: Comparative Effectiveness of Allografts, Autografts, and Conduits.

BACKGROUND: Ideal nerve repair involves tensionless direct repair, which may not be possible after resection. Bridging materials include nerve autograft, allograft, or conduit. This study aimed to perform a systematic literature review and meta-analysis to compare the meaningful recovery (MR) rates and postoperative complications following autograft, allograft, and conduit repairs in nerve gaps greater than 5 mm and less than 70 mm. A secondary aim was to perform a comparison of procedure costs. METHODS: The search was conducted in MEDLINE from January of 1980 to March of 2020, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included whether they reported nerve injury type, repair type, gap length, and outcomes for MR rates. Thirty-five studies with 1559 nerve repairs were identified. RESULTS: Overall MR for sensory and motor function was not significantly different between autograft ( n = 670) and allograft ( n = 711) across both short and long gaps. However, MR rates for autograft (81.6%) and allograft (87.1%) repairs were significantly higher compared with conduits (62.2%) ( P < 0.05) in sensory short gap repairs. Complication rates were comparable for autograft and allograft but higher for conduit with regard to pain. Analysis of costs showed that total costs for allograft repair were less than autograft in the inpatient setting and were comparable in the outpatient setting. CONCLUSIONS: Literature showed comparable rates of MR between autograft and allograft, regardless of gap length or nerve type. Furthermore, the rates of MR were lower in conduit repairs. In addition, the economic analysis performed demonstrates that allograft does not represent an increased economic burden compared with autograft.

Validation of a Novel Smartphone-Based Electronic Data Capture System Following Surgical Fixation of Distal Radial Fractures.

BACKGROUND: Large prospective institutional data provide the opportunity to conduct level II and III studies using robust methodologies and adequately powered sample-sizes, while circumventing limitations of retrospective databases. We aimed to validate a prospective data collection tool, the Orthopaedic Minimal Data Set Episode of Care (OME), implemented at a tertiary North American health care system for distal radial fracture (DRF) open reduction and internal fixation (ORIF). METHODS: The first 100 DRF ORIFs performed after OME inception (February 2015) were selected for this validation study. A blinded review of the operative notes and charts was performed, and extracted data of 75 perioperative DRF ORIF procedure variables were compared with OME collected data for agreement. Outcomes included completion rates and agreement measures in OME versus electronic medical record (EMR)-based control datasets. Data counts were evaluated using raw percentages and McNemar tests. Cohen (κ) and concordance correlation coefficient analyzed categorical and numerical variable agreement, respectively. RESULTS: Overall, OME demonstrated superior completion and agreement parameters versus EMR-based retrospective review. Nine data points (12.0%) demonstrated significantly higher completion rates within the OME dataset (P < .05, each), and 88% (66/75) of captured variables demonstrated similar completion rates. Up to 80.0% (60/75) of variables either demonstrated an agreement proportion of ≥0.90 or were solely reported in the OME. Of 33 variables eligible for agreement analyses, 36.4% (12/33) demonstrated almost perfect agreement (κ > 0.80), and 63.6% (21/33) exhibited almost perfect or substantial agreement (κ > 0.60). CONCLUSIONS: The OME is a valid and accurate prospective data collection tool for DRF ORIF that is reliably able to match or supersede traditional retrospective chart review. Future investigations could use this tool for large-scale analyses investigating peri/intraoperative DRF ORIF variables.

The "Fight Bite" Saline Joint Loading Test: Effectiveness in Detecting Simulated Traumatic Metacarpophalangeal Arthrotomies.

Background: The saline load test is routinely used to recognize other joints' traumatic arthrotomies; however, there are currently no studies evaluating the novelty of this test for metacarpophalangeal joints (MCPJs). This study aimed to investigate the effectiveness and sensitivity of saline load testing in identifying the traumatic arthrotomies of the MCPJs using human cadavers. Methods: This was a cadaveric study of 16 hands (79 MCPJs). Traumatic arthrotomies were created using 11-blade stab-incisions, followed by blunt probing into the joint on the radial or ulnar side of the flexed MCPJs. A 3-mL syringe was used to inject intra-articular methylene-blue-dyed saline from the contralateral side. The volume at saline extravasation was recorded. Test sensitivity and factors influencing extravasation volume were assessed. Results: The mean (range) volume injected to identify arthrotomy of all MCPJs was 0.18 mL (0.1-0.4 mL). The mean volume to identify MCPJ arthrotomy of the thumb, index, long, ring, and small fingers was 0.16 mL (0.1-0.3 mL), 0.19 mL (0.1-0.3 mL), 0.21 mL (0.1-0.4 mL), 0.17 mL (0.1-0.3 mL), and 0.16 mL (0.1-0.3 mL), respectively. Cadaver age, laterality, and joint range of motion were not significantly associated with the injected volume at extravasation(P > .05, each). Injection volumes of 0.3 and 0.32 mL were required to detect arthrotomies at 95% and 99% sensitivities across all MCPJs. None of the MCPJs required > 0.4 mL to detect arthrotomy. Conclusions: Saline joint loading volumes to detect traumatic arthrotomy were similar for all MCPJs. Injection volumes of 0.32 mL is suggested for 99% sensitivity. Our findings provide the first report, to our knowledge, on intra-articular injection volumes expected to detect an arthrotomy of MCPJ. This is critical for further validation using in vivo clinical studies.

Wrist Arthrotomy Saline Load Test.

BACKGROUND: Failure to recognize a potential wrist arthrotomy may lead to missed septic arthritis and devastating sequelae. The saline load test is routinely used to recognize traumatic arthrotomies of other joints; however, there are limited data optimizing this test for the wrist. The purpose of this study was to investigate and perform saline load testing to identify traumatic arthrotomies of the wrist. METHODS: This was a cadaveric study of 15 wrists. Traumatic arthrotomies were created using a blunt trocar through the 3-4 portal. A 3-mL syringe with 0.1 mL markings was used to inject methylene blue dyed saline into the wrist through the 1-2 portal. Once extravasation was visible from the atherectomized site, the volume was recorded. RESULTS: The mean (range) volume injected to identify the arthrotomy of all wrists was 1.22 mL (range, 0.1-3.1 mL). Multivariate regression demonstrated that cadaver age, laterality, and extension range of motion were not significantly associated with the injected saline volume at extravasation (P > .05, each). Greater joint range of motion was independently associated with higher saline volume load for extravasation (odds ratio: 1.049; 95% confidence interval: 1.024-1.075; P = .003). CONCLUSIONS: We found that 2.68 and 3.02 mL of methylene blue dyed saline offered 95% and 99% sensitivity, respectively, for diagnosing traumatic wrist arthrotomy. The maximum volume of saline needed to recognize an arthrotomy was 3.1 mL. We recommend this be the minimum volume used to evaluate a traumatic wrist arthrotomy.

Validation of a Smartphone-Based Institutional Electronic Data Capture System for Thumb Carpometacarpal Joint Arthroplasty.

BACKGROUND: The Orthopaedic Minimal Data Set (OrthoMiDaS) Episode of care (OME) is a prospectively collected database enabling capture of patient and surgeon-reported data in a more efficient, comprehensive, and dependable manner than electronic medical record (EMR) review. We aimed to assess and validate the OME as a data capture tool for carpometacarpal (CMC) arthroplasty compared to traditional EMR-based review. Specifically, we aimed to: (1) compare the completeness of the OME versus EMR data; and (2) evaluate the extent of agreement between the OME and EMR data-based datasets for carpometacarpal (CMC) arthroplasty. METHODS: The first 100 thumb CMC arthroplasties after OME inception (Febuary, 2015) were included. Blinded EMR-based review of the same cases was performedfor 48 perioperative variables and compared to their OME-sourced counterparts. Outcomes included completion rates and agreement measures in OME versus EMR-based control datasets. RESULTS: The OME demonstrated superior completion rates compared to EMR-based retrospective review. There was high agreement between both datasets where 75.6% (34/45) had an agreement proportion of >0.90% and 82.2% (37/45) had an agreement proportion of >0.80. Over 40% of the variables had almost perfect to substantial agreement (κ > 0.60). Among the 6 variables demonstrating poor agreement, the surgeon-inputted OME values were more accurate than the EMR-based review control. CONCLUSIONS: This study validates the use of the OME for CMC arthroplasty by illustrating that it is reliably able to match or supersede traditional chart review for data collection; thereby offering a high-quality tool for future CMC arthroplasty studies.

Prolonged Operative Time Associated with Increased Healthcare Utilization after Open Reduction and Internal Fixation of Intra-Articular and Extra-Articular Distal Radial Fractures: An Analysis of 17,482 Cases.

Background The current literature does not contain a quantitative description of the associations between operative time and adverse outcomes after open reduction and internal fixation (ORIF) of distal radial fractures (DRF). Questions/Purpose We aimed to quantify associations between DRF ORIF operative time and 1) 30-day postoperative health care utilization and 2) the incidence of local wound complications. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DRF ORIF cases (January 2012-December 2018). A total of 17,482 cases were identified. Primary outcomes included health care utilization (length of stay [LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative-time category. Secondary outcome was incidence of wound complications per operative-time category. Multivariate regression was conducted to determine operative-time categories associated with increased risk while adjusting for demographics, comorbidities, and fracture type. Spline regression models were constructed to visualize associations. Results The 121 to 140-minute category was associated with significantly higher risk of a LOS > 2 days (odds ration [OR]: 1.64; 95% confidence interval [CI]:1.1-2.45; p = 0.014) and nonhome discharge (OR: 1.72; 95% CI:1.09-2.72; p = 0.02) versus 41 to 60-minute category. The ≥ 180-minute category exhibited highest odds of LOS > 2 days (OR: 2.08; 95%CI: 1.33-3.26; p = 0.001), nonhome discharge disposition (OR: 1.87; 95% CI: 1.05-3.33; p = 0.035), and 30-day reoperation occurrence (OR: 3.52; 95% CI: 1.59-7.79; p = 0.002). There was no association between operative time and 30-day readmission ( p > 0.05 each). Higher odds of any-wound complication was first detected at 81 to 100-minute category (OR: 3.02; 95% CI: 1.08-8.4; p = 0.035) and peaked ≥ 181 minutes (OR: 9.62; 95% CI: 2.57-36.0; p = 0.001). Spline regression demonstrated no increase in risk of adverse outcomes if operative times were 50 minutes or less. Conclusion Our findings demonstrate that prolonged operative time is correlated with increased odds of health care utilization and wound complications after DRF ORIF. Operative times greater than 60 minutes seem to carry higher odds of postoperative complications.

Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study.

BACKGROUND: There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures. METHODS: We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared. RESULTS: A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7). CONCLUSIONS: The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.

Malpractice Litigation in Hand Surgery: A Comprehensive Nationwide Analysis.

BACKGROUND: The circumstances surrounding claims against hand surgeons have not been elucidated in the literature. The purpose of this study was to analyze trends in malpractice litigation regarding hand surgery through a nationwide legal database. METHODS: The Westlaw legal research database was queried for verdicts and settlements between 1985 and 2017 for hand surgery-related malpractice cases. Cases were included if the hand surgeon was sued for malpractice. Procedure type and complications and/or adverse events that resulted in litigation were recorded. Patient characteristics, state, date of case, case outcomes, and indemnity payment were also noted. All dollar amounts were adjusted to 2017 values using the Consumer Price Index. RESULTS: In all, 171 cases (35 states) were included. The most frequently litigated surgeries were carpal tunnel releases followed by fracture treatment. Nerve injury was the predominant cause of litigation. The median nerve was predominantly injured, followed by the ulnar and radial nerves. In fracture surgery, malunion was the predominant cause, followed by weakness, nerve injury, and infection. In total, 72.5% of cases yielded verdicts in favor of the defense, 21.6% favored the plaintiff, and 5.9% were settled. Indemnity varied between $7800 and $8.99 million, averaging $570,397 for cases when the jury ruled in favor of the plaintiffs. Settled cases averaged $1,140,527. CONCLUSIONS: Malpractice litigation has substantial financial implications on surgeons and the health care system. Litigation arises most commonly from routine procedures (carpal tunnel release and fracture fixation) rather than complex surgical cases, potentially due to the high variability in operating surgeon subspecialization, with discrepant training.

Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft.

BACKGROUND: Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA. METHODS: Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale. RESULTS: Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs. CONCLUSION: Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.

Scapulothoracic fusion using nonabsorbable suture fixation: surgical technique and review of the literature.

Background: Historically, scapulothoracic fusion (STF) is performed using steel wire and plate construct fixation. The purpose of this study is to report a recent fusion achieved through ultra-high-molecular-weight polyethylene-reinforced suture fixation as well as to perform a systematic literature review of techniques, fusion rates, complications, and reoperation. Methods: Patient data were gathered from chart review and clinical encounters. For the review, MEDLINE, Embase, and Ovid databases were queried for STF cases. Thirty articles reporting on 386 fusion procedures were included. Results: Including this patient, 5 of 387 (1.3%) STFs have been attempted with fiber suture. Fusion rates of metal-only constructs is 90.8% (346 of 381) with 11.3% (43 of 381) requiring wire removal or trimming because of symptomatic hardware and 7% (27 of 381) causing a postoperative pneumothorax. Although a small sample size, all fiber-suture constructs have achieved union without implant removal and without pneumothorax development. In this patient, fusion was determined radiographically at 6 months with substantial improvement in pain level and function. Conclusion: Scapulothoracic fusion has benefit to patients to have failed other management options for winged scapula, most commonly those with neurologic trauma or facioscapulohumeral muscular dystrophy. With advancements in surgical options, fiber-suture offers an alternative to steel wire to achieve fusion. Further cases with longer term follow-up are needed to determine if significant differences in outcomes exist between constructs.

Pediatric Hand Infections.

Infections are an important source of morbidity in pediatric hands that come from frequent exposure to mouths and other dangers while exploring the world. Although Staphylococcus aureus is still the most common organism in pediatric hand infections, it is less common than in adults because pediatric patients are more likely to develop mixed aerobic/anaerobic infections or group A Streptococcus pyogenes infection. Pediatric patients with open physes potentially may sustain Seymour fractures of the distal phalanges that may become infected and sources for osteomyelitis if not recognized early.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

The effect of tendon rotation on distal biceps repair.

BACKGROUND: The distal biceps tendon externally rotates from proximal to distal before inserting onto the radius. Our hypothesis is that an externally rotated (anatomic) repair would re-create native supination moment arm and flexion force, whereas an internally rotated (nonanatomic) repair would result in reduced force transmission. METHODS: The mechanical tests performed in this study measured isometric moment arms and elbow flexion force using a validated elbow simulator as previously published. Mechanical testing was performed on 8 native cadaveric elbows (61 ± 15 years). The distal biceps tendons in all specimens were then incised from their footprint and repaired with anatomic and nonanatomic tendon rotations. After each repair, the specimens were retested. The repair sequence was randomly assigned. RESULTS: Gross observation showed repair site bunching with the nonanatomic repairs. There was no statistical difference in the moment arms between the native, anatomic, and nonanatomic rotations for the 3 forearm angles (P ≥ .352). Analysis showed no statistical difference in flexion force ratio for the elbow at 90° (P ≥ .283). DISCUSSION: The study showed that biceps tendon rotation does not play a role in supination moment arm or flexion force. Twisting the distal biceps tendon around the tendon axis does not change the direction of its applied force on the tuberosity. Tendon bunching in nonanatomic reattachments increases repair site width, which may lead to tendon-ulnar impingement during forearm rotation.

Adult Primary Bone Sarcoma and Time to Treatment Initiation: An Analysis of the National Cancer Database.

OBJECTIVE: The time to treatment interval (TTI), defined as the period from diagnosis to first definitive treatment, has very limited descriptions toward understanding delays in primary bone sarcoma (PBS) care. Our primary goal was to determine the national standard for time to treatment initiation (TTI) in PBS in adults and to identify characteristics associated with TTI variability. METHODS: An analysis of the National Cancer Database identified 15,083 adult patients with PBS diagnosed from 2004 to 2013. Kruskal-Wallis analysis identified differences between covariates regarding TTI and regression modeling identified covariates that independently influenced TTI. RESULTS: The median TTI was 22 days. Approximately 60% of patients were definitively treated in the same center where the index diagnosis was made. Increased TTI was correlated with a transition in care institution (incidence rate ratio (IRR) = 1.89; P < 0.001), being uninsured (IRR = 1.36; P < 0.001), primary tumor site in the pelvis (IRR = 1.26; P < 0.001), Medicaid insurance status (IRR = 1.22; P < 0.001), care at an academic center (IRR = 1.14; P < 0.001), non-white race (IRR = 1.12; P=0.002), and Medicare insurance status (IRR = 1.08; P=0.017). Decreased TTI was correlated with a diagnosis of chondrosarcoma (IRR = 0.85; P < 0.001), having surgery as the index treatment (IRR = 0.88; P < 0.001), a primary tumor site of the lower (IRR = 0.91; P=0.001) or upper extremity (IRR = 0.92; P=0.023), and stage II or stage III disease (IRR = 0.91; P=0.010). CONCLUSIONS: TTI is associated with tumor, treatment, and socioeconomic and healthcare system characteristics. Transitions in care between institutions are responsible for the greatest increase in TTI. As TTI is more commonly used as a quality metric, physicians need to be aware of the causes for prolonged TTI, as we work to improve national delays in diagnosis and treatment initiation.

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty.

Revision total knee arthroplasty (rTKA) is a challenging problem in the setting of soft tissue defects. The purpose of this study was to evaluate patients who underwent rTKA requiring flap coverage and determine patient factors that predisposed them to failure. Forty-three consecutive patients (mean follow-up, 46.5 months) who underwent rTKA requiring flap coverage were retrospectively reviewed between January 1, 2000 and December 31, 2010. Sixteen of 43 patients experienced failure requiring either flap revision (n = 2) or above the knee amputation (n = 14). Patients with heart failure (p = 0.008), cancer (p = 0.049), or infection with Klebsiella pneumoniae (p = 0.002) had greater rates of failure. Smoking (p = 0.287), diabetes (p = 0.631), and flap type (p = 0.634, p = 0.801) were not associated with increased failure. Mean survival was 46.4 months. Survival of patients with a history of cancer (34.3 months) was less (p = 0.033) than those without (49.2 months). Flap coverage in rTKA is a viable limb salvage option for patients with soft tissue defects; however, failure rates are much higher than in patients not requiring flap coverage.

Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers.

BACKGROUND: A medial ulnar collateral ligament (UCL) injury of the elbow is an increasingly common injury in professional baseball pitchers. Predictors of success and failure are not well defined for the nonoperative management of these injuries. PURPOSE: To evaluate the efficacy of objective measures to predict failure of the nonoperative management of UCL injuries. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Thirty-two professional pitchers (82%) met inclusion criteria and underwent an initial trial of nonoperative treatment for UCL tears based on clinical and radiological findings. Age, preseason physical examination results, magnetic resonance imaging (MRI) characteristics, and performance metrics were analyzed for these pitchers. Successful nonoperative management was defined as a return to the same level of play or higher for >1 year. Failure was defined as recurrent pain or weakness requiring a surgical intervention after a minimum of 3 months' rest when attempting a return to a throwing rehabilitation program. RESULTS: Thirty-two pitchers (mean age, 22.3 years) who underwent initial nonoperative treatment of UCL injuries were evaluated. Thirty-four percent (11/32) failed and required subsequent ligament reconstruction. Sixty-six percent (21/32) successfully returned to the same level of play for 1 year without a surgical intervention. There was no significant difference seen in physical examination findings or performance metrics between these patients. When comparing MRI findings between the groups, 82% (9/11) ( P < .001) who failed nonoperative management had distal tears, and 81% (17/21) who did not fail had proximal tears ( P < .001). When adjusting for age, location, and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.40 times greater ( P = .020) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88% (7/8) failed nonoperative management. CONCLUSION: In professional pitchers, distal UCL tears showed significantly higher odds of failure with nonoperative management compared with proximal tears. Thus, tear location should be considered when deciding between operative and nonoperative management.