Intraoperative Nerve Conduction Studies During Open Carpal Tunnel Release: A Pilot Study.

Background: Operative management of carpal tunnel syndrome (CTS) involves release of the transverse carpal ligament (TCL) and often the volar antebrachial fascia (VAF). Evidence of a difference between TCL and TCL+VAF release is limited. We conducted a pilot study to measure changes of intraoperative nerve conduction velocity (NCV) after CTS surgery and compared outcomes of variable degrees of decompression. Methods: Patients aged 18 to 65 years diagnosed with idiopathic CTS that failed to respond to conservative management were included in this study. Patients were excluded if they had prior surgical release, diabetes, acute CTS, trauma, or cervical spine radiculopathy. Outcomes included motor and sensory amplitude and latency. Electrodes were placed on the skin intraoperatively along the abductor pollicis brevis, index finger, and forearm. Outcome data were recorded at baseline, after TCL release, and after TCL+VAF release. Data were compared using a single-tail t test. Results: A total of 10 patients were included in this study. There were no significant changes in mean motor or sensory amplitude and latency from baseline to TCL release, TCL to VAF release, or from baseline to TCL+VAF release measured intraoperatively. Conclusions: This pilot study shows there is no immediate detectable difference in NCV following release of TCL or TCL+VAF. This suggests that NCV may not be useful for assessing intraoperative improvement. We highlight the need for future research in the form of case-control studies to determine the utility of intraoperative NCV. These studies should be conducted with larger numbers of patients and involve multiple hand specialists.

Anatomic reconstruction of acromioclavicular joint dislocations using allograft and synthetic ligament.

BACKGROUND: Acromioclavicular (AC) separations are commonly seen shoulder injuries. Numerous surgical reconstruction techniques have been described. In this study, we present a series of patients who underwent an anatomic reconstruction using a synthetic ligament and allograft construct. METHODS: We performed a retrospective review of patients with type IV or V AC separations who underwent primary or revision AC reconstruction with a luggage-tag synthetic ligament and a semitendinosus allograft placed through the anatomic insertion sites of the coracoclavicular ligaments. Patient-reported outcomes, as well as complication rates, were recorded at a minimum 2-year follow-up. RESULTS: Ten patients with a mean age of 44.2 ± 14.9 years were included in the study. The mean Disabilities of the Arm, Shoulder and Hand score was 15.5 ± 15.4; mean Single Assessment Numeric Evaluation score, 81.8 ± 12.1; mean Simple Shoulder Test score, 11.4 ± 1.1; mean American Shoulder and Elbow Surgeons score, 84.6 ± 15.7; mean Constant score, 82.5 ± 11.6; and mean visual analog scale score, 2 ± 2.6. CONCLUSION: The technique using a luggage-tag synthetic ligament along with an anatomic allograft coracoclavicular ligament reconstruction is a safe, effective alternative to other techniques described in the literature.

Evaluation of the Content and Accessibility of Web Sites for Accredited Orthopaedic Trauma Surgery Fellowships.

BACKGROUND: Orthopaedic trauma fellowship applicants use online-based resources when researching information on potential U.S. fellowship programs. The 2 primary sources for identifying programs are the Orthopaedic Trauma Association (OTA) database and the San Francisco Match (SF Match) database. Previous studies in other orthopaedic subspecialty areas have demonstrated considerable discrepancies among fellowship programs. The purpose of this study was to analyze content and availability of information on orthopaedic trauma surgery fellowship web sites. METHODS: The online databases of the OTA and SF Match were reviewed to determine the availability of embedded program links or external links for the included programs. Thereafter, a Google search was performed for each program individually by typing the program's name, followed by the term "orthopaedic trauma fellowship." All identified fellowship web sites were analyzed for accessibility and content. Web sites were evaluated for comprehensiveness in mentioning key components of the orthopaedic trauma surgery curriculum. By consensus, we refined the final list of variables utilizing the methodology of previous studies on the topic. RESULTS: We identified 54 OTA-accredited fellowship programs, offering 87 positions. The majority (94%) of programs had web sites accessible through a Google search. Of the 51 web sites found, all (100%) described their program. Most commonly, hospital affiliation (88%), operative experiences (76%), and rotation overview (65%) were listed, and, least commonly, interview dates (6%), selection criteria (16%), on-call requirements (20%), and fellow evaluation criteria (20%) were listed. Programs with ≥2 fellows provided more information with regard to education content (p = 0.0001) and recruitment content (p = 0.013). Programs with Accreditation Council for Graduate Medical Education (ACGME) accreditation status also provided greater information with regard to education content (odds ratio, 4.0; p = 0.0001). Otherwise, no differences were seen by region, residency affiliation, medical school affiliation, or hospital affiliation. CONCLUSIONS: The SF Match and OTA databases provide few direct links to fellowship web sites. Individual program web sites do not effectively and completely convey information about the programs. The Internet is an underused resource for fellow recruitment. The lack of information on these sites allows for future opportunity to optimize this resource.

The Role of Orthobiologics in Fracture Healing and Arthrodesis.

Nonunion after tibial shaft fracture and hindfoot arthrodesis remains a major problem. Known risk factors include advanced age, immunosuppression, smoking, and diabetes. Several factors must be considered in the fracture healing process. This review evaluates the efficacy of orthobiologics in improving union rates after fracture or arthrodesis. Use of compounds have shown increased cellular proliferation experimentally. Percutaneous autologous bone marrow has shown increased cellular proliferation. Matrix supplementation has shown significant improvements in bone healing. Several studies have highlighted the importance of adequate graft fill over graft type. Patients at increased risk for nonunion would benefit most from these adjuvant therapies.

Rehabilitation Charges Associated With Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Pre- and postoperative rehabilitation are important to the management of patients with anterior cruciate ligament (ACL) reconstruction, but little attention has been given to the costs. This study evaluated the pre- and postoperative rehabilitation charges in patients with ACL reconstruction in the United States. HYPOTHESIS: Patients receive preoperative rehabilitation less commonly than postoperative rehabilitation. STUDY DESIGN: Retrospective database study. LEVEL OF EVIDENCE: Level 4. METHODS: Using the PearlDiver database, we identified patients undergoing ACL reconstruction from 2007 through 2011 using Current Procedural Terminology codes. The associated rehabilitation charges billed to insurance providers for 90 days preoperatively and 6 months postoperatively were categorized as physical therapy or as durable medical equipment (DME). The charges were examined by year and geographic region and represented as per-patient average charges (PPACs). RESULTS: A total of 92,179 patients were identified in the study period. The PPAC for rehabilitation was $241 during the 90-day preoperative period and $1876 for the 6-month postoperative period. Patients averaged 2 preoperative sessions for physical therapy, with 44% of patients receiving preoperative rehabilitation in contrast with an average of 17 postoperative sessions per patient in 93% of patients. Rehabilitation charges were greater postoperatively than preoperatively (P < 0.05). Preoperatively, 24% of patients received a DME, while 35% received a DME postoperatively. Preoperative rehabilitation PPACs were highest in the Northeast, followed by Midwest, South, and West (P < 0.05). There were no significant differences in postoperative rehabilitation PPACs for geographic region (P = 0.43). CONCLUSION: Preoperative rehabilitation charges were lower than postoperative charges. A patient undergoing ACL reconstruction typically received 9 times more sessions of postoperative physical therapy than preoperative. CLINICAL RELEVANCE: This study found that preoperative supervised rehabilitation for patients with ACL reconstruction was infrequent across the United States.

Demographic trends in arthroscopic and open biceps tenodesis across the United States.

BACKGROUND: The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis. METHODS: A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient's age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics. RESULTS: There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P = .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions (P = .009; P = .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders. CONCLUSION: Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes.

Use of inertial sensors to predict pivot-shift grade and diagnose an ACL injury during preoperative testing.

BACKGROUND: The pivot-shift (PS) examination is used to demonstrate knee instability and detect anterior cruciate ligament (ACL) injury. Prior studies using inertial sensors identified the ACL-deficient knee with reasonable accuracy, but none addressed the more difficult problem of using these sensors to determine whether a subject has an ACL deficiency and to correctly assign a PS grade to a patient's knee. HYPOTHESIS: Inertial sensor data recorded during a PS examination can accurately predict ACL deficiency and the PS score assigned by the examining physician. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 32 patients with unilateral ACL deficiency and 29 with intact ACLs in both knees had inertial sensor modules strapped to the tibia and femur of each limb for preoperative PS testing under anesthesia. Support vector machine (SVM) methods assessed PS grades on the basis of these data, with the examiner's clinical grading shift used as ground truth. A fusion of regression and SVM classification techniques diagnosed ACL deficiency. RESULTS: The clinically determined PS grades of all 122 knees were as follows: 0 (n = 69), +1 (n = 23), +2 (n = 27), and +3 (n = 3). The SVM classification analysis was 77% accurate in correctly classifying these grades, with 98% of computed PS grades falling within ±1 grade of the clinically determined value. The system fusion algorithm diagnosed ACL deficiency in an individual with an overall accuracy of 97%. This method yielded 6% false negatives and 0% false positives. CONCLUSION: This study used inertial sensor technology with SVM algorithms to accurately determine clinically assigned PS grades in ACL-intact and ACL-deficient knees. By extending the assessment to a separate group of patients without ACL injury, the inertial sensor data demonstrated highly accurate diagnosis of ACL deficiency.

In vivo evaluation of electrospun polycaprolactone graft for anterior cruciate ligament engineering.

The anterior cruciate ligament (ACL) is critical for the structural stability of the knee and its injury often requires surgical intervention. Because current reconstruction methods using autograft or allograft tissue suffer from donor-site morbidity and limited supply, there has been emerging interest in the use of bioengineered materials as a platform for ligament reconstruction. Here, we report the use of electrospun polycaprolactone (PCL) scaffolds as a candidate platform for ACL reconstruction in an in vivo rodent model. Electrospun PCL was fabricated and laser cut to facilitate induction of cells and collagen deposition and used to reconstruct the rat ACL. Histological analysis at 2, 6, and 12 weeks postimplantation revealed biological integration, minimal immune response, and the gradual infiltration of collagen in both the bone tunnel and intra-articular regions of the scaffold. Biomechanical testing demonstrated that the PCL graft failure load and stiffness at 12 weeks postimplantation (13.27±4.20N, 15.98±5.03 N/mm) increased compared to time zero testing (3.95±0.33N, 1.95±0.35 N/mm). Taken together, these results suggest that electrospun PCL serves as a biocompatible graft for ACL reconstruction with the capacity to facilitate collagen deposition.

What is the frequency of vascular injury after knee dislocation?

BACKGROUND: Vascular injury secondary to an acute knee dislocation is a known complication. However, there exist wide discrepancies in the reported rate of vascular injury in this setting. QUESTIONS/PURPOSES: Using a large private insurance database, we determined the frequency of vascular injury in knee dislocations across year of diagnosis, age, sex, and US geographic region and the proportion of these injuries requiring surgical repair. METHODS: The PearlDiver database, which contains records from 11 million orthopaedic patients, was searched using ICD-9 diagnostic codes for all knee dislocation events from 2004 to 2009. Within this subset, we identified which knee dislocations had an associated vascular injury ICD-9 code. Patients were stratified by year of diagnosis, age, sex, and US geographic region, and Current Procedural Terminology codes were used to identify the subset of patients with vascular injury requiring surgical repair. Differences in frequency across demographic groups and over time were analyzed with Poisson regression analysis. RESULTS: Among the 8050 limbs with knee dislocation identified over the study period, 267 had a concomitant vascular injury for an overall frequency of 3.3%. Males were found to have an increased risk of vascular injury compared to females (odds ratio = 2.59, p < 0.001). Additionally, patients aged 20 to 39 years had a higher risk of vascular injury when compared to those aged 0 to 19 years (odds ratio = 1.93, p = 0.001), 40 to 59 years (odds ratio = 1.57, p = 0.014), and 60 years or older (odds ratio = 2.81, p = 0.036). There were no differences in vascular injury frequency across US geographic regions or diagnosis year. Thirty-four of the 267 cases of vascular injury (13%) underwent surgical treatment. CONCLUSIONS: This is the largest study, to our knowledge, that analyzes the proportion of knee dislocations that result in vascular injury. Our data suggest that there is a lower frequency of vascular injury associated with knee dislocation and a lower proportion of vascular injuries undergoing surgical treatment than previously reported. These findings may support a more selective angiography protocol to screen for vascular injury, rather than performing this invasive diagnostic test on all knee dislocations, as has been done historically. Future large-scale and prospective studies should analyze factors that may predispose to vascular injuries after knee dislocation and determine which patients should be screened for vascular injury after knee dislocation. LEVEL OF EVIDENCE: Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Vascular and nerve injury after knee dislocation: a systematic review.

BACKGROUND: Vascular injury is a devastating complication of acute knee dislocation. However, there are wide discrepancies in the reported frequency of vascular injury after knee dislocations, as well as important differences among approaches for diagnosis of this potentially limb-threatening problem. QUESTIONS/PURPOSES: We determined (1) the frequency of vascular and neurologic injury after knee dislocation and whether it varied by the type of knee dislocation, (2) the frequency with which surgical intervention was performed for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury. METHODS: We searched the MEDLINE(®) literature database for studies in English that examined the clinical sequelae and diagnostic evaluation after knee dislocation. Vascular and nerve injury incidence after knee dislocation, surgical repair rate within vascular injury, and amputation rate after vascular injury were used to perform a meta-analysis. Other measures such as diagnostic modality used and the vessel injured after knee dislocation were also evaluated. RESULTS: We identified 862 patients with knee dislocations, of whom 171 sustained vascular injury, yielding a weighted frequency of 18%. The frequency of nerve injuries after knee dislocation was 25% (75 of 272). We found that 80% (134 of 160) of vascular injuries underwent repair, and 12% (22 of 134) of vascular injuries resulted in amputation. The Schenck and Kennedy knee dislocation classifications with the highest vascular injury prevalence were observed in knees that involved the ACL, PCL, and medial collateral liagment (KDIIIL) (32%) and posterior dislocation (25%), respectively. Selective angiography was the most frequently used diagnostic modality (61%, 14 of 23), followed by nonselective angiography and duplex ultrasonography (22%, five of 23), ankle-brachial index (17%, four of 23), and MR angiography (9%, two of 23). CONCLUSIONS: This review enhances our understanding of the frequency of vascular injury and repair, amputation, and nerve injuries after knee dislocation. It also illustrates the lack of consensus among practitioners regarding the diagnostic and treatment algorithm for vascular injury. After pooling existing data on this topic, no outcomes-driven conclusions could be drawn regarding the ideal diagnostic modality or indications for surgical repair. In light of these findings and the morbidity associated with a missed diagnosis, clinicians should err on the side of caution in ruling out arterial injury.

The changing demographics of knee dislocation: a retrospective database review.

BACKGROUND: Knee dislocations are uncommon but devastating orthopaedic injuries. Little is known about their frequency and the types of patients who are affected. QUESTIONS/PURPOSES: Using a large national insurance database, we determined (1) the incidence of knee dislocation in patients with orthopaedic injuries and examined the incidence as a function of (2) year of diagnosis, (3) dislocation type (open versus closed, direction), and (4) patient demographic factors (sex, age). METHODS: We searched the PearlDiver database, a national database of private insurance records consisting of 11 million patients with orthopaedic diagnoses, using diagnosis (ICD-9-CM) codes for knee dislocation between the years 2004 and 2009. The PearlDiver database does not include Medicare, Medicaid, or uninsured patients. Patients were stratified by age, sex, and year of diagnosis. Incidence was defined as the number of dislocation events per 100 patient-years. RESULTS: We identified 8050 dislocations, representing an incidence of 0.072 events per 100 patient-years between 2004 and 2009. Annual dislocation incidence did not increase during the 6-year study period. Of the 8050 dislocations, 1333 (17%) were open and 6717 (83%) were closed, representing an incidence of 0.060 per 100 for closed dislocations and 0.012 per 100 for open dislocations. The most common direction of dislocation was unspecified or other (65%), followed by anterior (13%), lateral (11%), posterior (6%), and medial (5%). Of the patients sustaining dislocations, 4172 (52%) were female and 3878 (48%) were male. Males displayed an increased risk of knee dislocation compared to females (odds ratio = 1.09). The mean patient age was 35 years, and patient age was inversely correlated to the incidence of knee dislocation (10-year odds ratio = 0.77). CONCLUSIONS: Our data suggest that knee dislocation might represent a significantly larger burden among orthopaedic injuries than previously thought. The finding that males and females have a nearly equal risk of knee dislocation enhances the diagnosing physician's clinical suspicion of this injury. Future large prospective studies analyzing the various causes of knee dislocation could provide insight into the changing demographics of this injury. LEVEL OF EVIDENCE: Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery.

BACKGROUND: An acute infection after arthroscopic shoulder surgery is a rare but serious complication. Previous studies estimating the incidence of infections after arthroscopic surgery have been conducted, but the majority of these had either relatively small study groups or were not specific to shoulder arthroscopic surgery. PURPOSE: To investigate the incidence of acute infections after arthroscopic shoulder surgery and compare infection rates by age group, sex, geographic region, and specific procedures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of a large insurance company database was performed for all shoulder arthroscopic surgeries performed in the United States between 2004 and 2009 that required additional surgery for infections within 30 days. The data were stratified by sex, age group, and region. Data were also stratified for specific procedures (capsulorrhaphy, treatment for superior labrum anterior-posterior tears, claviculectomy, decompression, and rotator cuff repair) and used to assess the variation in the incidence of infections across different arthroscopic shoulder procedures. Linear regression was used to determine the significance of differences in the data from year to year. χ(2) analysis was used to assess the statistical significance of variations among all groups. Poisson regression analysis with exposure was used to determine significant differences in a pairwise comparison between 2 groups. RESULTS: The total number of arthroscopic shoulder surgeries performed was 165,820, and the number of infections requiring additional surgery was 450, resulting in an overall infection rate of 0.27%. The incidence of infections varied significantly across age groups (P < .001); the infection rate was highest in the ≥60-year age group (0.36%) and lowest in the 10- to 39-year age group (0.18%). The incidence of infections also varied by region (P < .001); the incidence was highest in the South (0.37%) and lowest in the Midwest (0.11%). The incidence of infection treatments was also significantly different between different arthroscopic procedures (P < .01) and was highest for rotator cuff repair (0.29%) and lowest for capsulorrhaphy (0.16%). The incidence did not significantly vary by year or sex. CONCLUSION: The overall infection rate for all arthroscopic shoulder procedures was 0.27%. The incidence was highest in elderly patients, in the South, and for rotator cuff repair. The incidence was lowest in young patients, in the Midwest, and for capsulorrhaphy. In general, shoulder arthroscopic surgery in this study population had a low rate of reoperation in the acute period.

The costs associated with the evaluation of rotator cuff tears before surgical repair.

BACKGROUND: Patients undergoing rotator cuff repair typically have a diagnostic evaluation and trial of nonoperative therapy before surgery. Recent studies have evaluated the cost-effectiveness of surgery, but none have attempted to estimate the costs associated with the preoperative evaluation. This study used available data to examine major expenditures during the preoperative period. MATERIALS AND METHODS: We conducted a search using an insurance company database to identify patients undergoing rotator cuff repair from 2004 to 2009. Patients were identified by the common Current Procedural Terminology codes for rotator cuff repair. The associated charge codes for the 90-day period before surgery were categorized as outpatient physician visits, diagnostic imaging studies, injections, physical therapy, laboratory and other preoperative studies, prior surgeries, and miscellaneous. The frequency of each code and the associated charges were noted. RESULTS: In total, 92,688 patients were identified in the study period. A total of $161,993,100 was charged during the preoperative period, for an average of $1,748 per patient. Diagnostic imaging charges totaled $104,510,646 (65%); injections, $5,145,227 (3%); outpatient visits, $29,723,751 (18%); physical therapy, $13,844,270 (8.5%); preoperative studies, $6,792,245 (4.2%); and miscellaneous, $1,164,688 (<1%). CONCLUSIONS: The costs for preoperative evaluation of rotator cuff tears are substantial, and the majority of the costs are associated with magnetic resonance imaging. To help reduce costs, future studies should attempt to identify the factors that predict which patients might not respond to nonoperative management and might benefit from early surgical intervention. In addition, magnetic resonance imaging should perhaps be reserved for patients in whom the diagnosis cannot be achieved by other modalities.

Incidence of postoperative infections requiring reoperation after arthroscopic knee surgery.

PURPOSE: The purposes of this study were to determine the incidence of infection requiring reoperation after arthroscopic knee surgery during a 6-year period and to compare infection rates across different age groups, genders, geographic regions of the United States, and Current Procedural Terminology (CPT) codes through a retrospective review of a large insurance company database. METHODS: A retrospective review of an insurance company database was performed for all knee arthroscopies performed in the United States from 2004 to 2009. The database was first queried for all knee arthroscopies, and the number of those cases requiring additional surgery for infection within 30 days was determined to calculate the incidence of infection. The incidence was stratified by gender, age group, region within the United States, and CPT code. A separate analysis for procedures using allografts was also performed. RESULTS: A total of 432,038 arthroscopic surgeries were performed, and the number of infections requiring drainage was 638, for an overall incidence of infection from 2004 to 2009 of 0.15%. Among adults, men were affected almost twice as often as women (P < .001), and among children, boys were affected almost 3 times as often as girls (P < .001). A decreasing incidence was noted in patients 60 years or older between 2004 and 2009 (P = .01). Overall, the incidence did not significantly vary by age, region, or CPT codes that specified the implantation of allograft tissue. Compared with diagnostic arthroscopy, the relative risk of infection was higher for CPT-29889 (posterior cruciate ligament reconstruction). CONCLUSIONS: The incidence of infection requiring reoperation after knee arthroscopy from 2004 to 2009 was 0.15%. The incidence was higher among male patients in both the adult and pediatric populations. The incidence of infection decreased from 2004 to 2009 in patients 60 years or older. Among adult patients, the incidence did not vary by age, by region, or by CPT codes that involved implantation of allografts. LEVEL OF EVIDENCE: Level IV, cross-sectional study.