Distal Radius Fracture Management: Surgeon Factors Markedly Influence Decision Making.

INTRODUCTION: It is our hypothesis that physician-specific variables affect the management of distal radius (DR) fractures in addition to patient-specific factors. METHODS: A prospective cohort study was conducted evaluating treatment differences between Certificate of Additional Qualification hand surgeons (CAQh) and board-certified orthopaedic surgeons who treat patients at level 1 or level 2 trauma centers (non-CAQh). After institutional review board approval, 30 DR fractures were selected and classified (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. The patient-specific demographics and surgeon's information regarding the volume of DR fractures treated per year, practice setting, and years posttraining were obtained. Statistical analysis was done using chi-square analysis with a postanalysis regression model. RESULTS: A notable difference was observed between CAQh and non-CAQh surgeons. Surgeons in practice longer than 10 years or who treat >100 DR fractures/year were more likely to choose surgical intervention and obtain a preoperative CT scan. The two most influential factors in decision making were the patients' age and medical comorbidities, with physician-specific factors being the third most influential in medical decision making. DISCUSSION: Physician-specific variables have a notable effect on decision making and are critical for the development of consistent treatment algorithms for DR fractures.

A Simplified Modification of the Henderson Extensor Carpi Ulnaris Opposition Transfer.

PURPOSE: There are several potential donor muscle-tendon units for a thumb opposition transfer. The extensor carpi ulnaris (ECU) is useful when the more usual donor units are not available. The technique and results of a simplified ECU opposition transfer elongated with a free tendon graft are described. METHODS: Ten ECU opposition transfers were performed using this modification of Henderson technique in 5 adults after complex trauma, 3 adults with median and ulnar nerve palsies, and 2 children with congenital hand differences. RESULTS: Seven patients achieved a Kapandji opposition score of 6 to the distal phalanx of the small finger, and 3 patients achieved a Kapandji score of 5 to the distal phalanx of the ring finger. None of the patients required a secondary tenolysis or developed a radial deviation imbalance of their wrist. CONCLUSIONS: This modification of the Henderson technique using ECU elongated with a free tendon graft and inserted directly and only into the abductor pollicis brevis tendon is an effective method of restoring opposition to the thumb, especially when other conventional donor muscle-tendon units are not available. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Impact of Sickle Cell Anemia on Inpatient Morbidity After Spinal Fusion.

STUDY DESIGN: A retrospective study. OBJECTIVE: To determine the impact of sickle cell anemia on perioperative outcomes and resource utilization in elective spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Sickle cell anemia has been identified as an important surgical risk factor in otolaryngology, cardiothoracic surgery, general surgery, and total joint arthroplasty. However, the impact of sickle cell anemia on elective spine surgery is unknown. METHODS: Hospitalizations for elective spinal fusion surgery between the years of 2001-2014 from the US National Inpatient Sample were identified using ICD-9-CM codes and patients were grouped into those with and without sickle cell anemia. The main outcome measures were in-hospital neurological, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, and wound-related complications and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing elective spinal fusion with or without sickle cell anemia. RESULTS: From a total of 4,542,719 patients undergoing elective spinal fusions from 2001 to 2014, 456 sickle cell disease patients were identified. Sickle cell anemia is a significant independent predictor for pulmonary embolism [odds ratio (OR)=7.37; confidence interval (CI), 4.27-12.71; P<0.001], respiratory complications (OR=2.36; CI, 1.63-3.42; P<0.001), wound complications (OR=3.84; CI, 2.72-5.44; P<0.001), and overall inpatient complications (OR=2.58; CI, 2.05-3.25; P<0.001). Sickle cell anemia patients also have significantly longer length of stay (7.0 vs. 3.8 d; P<0.001) and higher inpatient costs ($20,794 vs. $17,608 P<0.05). CONCLUSIONS: Sickle cell anemia is associated with increased risk of perioperative complications and greater health care resource utilization. Sickle cell anemia patients undergoing spinal fusion surgeries should be counseled on these increased risks. Moreover, current strategies for perioperative management of sickle cell anemia patients undergoing spinal fusion surgery need to be improved.

Additional Dorsal Fibrocartilage Repair in a Combined Radial Collateral Ligament and Dorsal Fibrocartilage Injury of the Thumb Metacarpophalangeal Joint.

The purpose of this study was to evaluate the necessity of an additional dorsal fibrocartilage (DFC) repair in combined radial collateral ligament (RCL) and DFC injuries of the thumb metacarpophalangeal joint (MPJ). Eight cadaveric thumbs were used. Ulnar/radial deviation, prosupination, and volar/dorsal laxity were measured. Serial sectioning was performed of the RCL and the DFC. The RCL followed by the DFC were then reattached sequentially. Measurements were performed for intact, RCL cut, RCL+DFC cut, RCL repair alone, and RCL+DFC repair. The neutral position shifted ulnarly, pronated, and subluxed volarly after RCL+DFC cut. Volar subluxation was reduced with RCL+DFC repair compared with RCL repair alone. With external loading, ulnar deviation, pronation, and volar laxity increased significantly after RCL+DFC cut. Ulnar deviation reduced significantly with RCL+DFC repair (12.4°, 10.8°, and 10.9°) compared with RCL repair alone (14.4°, 14.3°, and 18.9°) at 0°, 30°, and 60°, respectively. Pronation reduced significantly with RCL+DFC repair (7.1° and 9.4°) compared with RCL repair alone (10.2° and 12.6°) at 0° and 30°, respectively. Volar subluxation reduced significantly with RCL+DFC repair (0.9 mm and 1.2 mm) compared with RCL repair alone (2.1 mm and 1.8 mm) at 30°and 60°, respectively. Radial collateral ligament repair alone does not restore anatomic dorsoradial stability of the thumb MPJ in a combined RCL and DFC injury. Combined repair of the RCL and the DFC is recommended to reduce the MPJ to its native position and minimize postoperative laxity. [Orthopedics. 2019; 42(2):e268-e272.].

Dorsoradial Instability of the Thumb Metacarpophalangeal Joint: A Biomechanical Investigation.

PURPOSE: To define the role of the dorsal capsule and associated dorsal fibrocartilage (DFC) and their interactions with the radial collateral ligament (RCL) as a thumb metacarpophalangeal (MCP) joint stabilizer. METHODS: Eight cadaveric thumbs were mounted onto a custom jig with 20 N of muscle load applied. The thumb position in space was digitized to measure ulnar-radial, pronation-supination, and volar-dorsal laxity at 0°, 30°, and 60° MCP joint flexion. Serial sectioning was performed and measurements were repeated for the intact state, proper RCL insufficiency, proper and accessory (complete) RCL insufficiency, complete RCL with 50% DFC (radial) insufficiency, and complete RCL with complete DFC insufficiency. RESULTS: Ulnar-radial deviation, pronation-supination, and volar-dorsal translation significantly changed at 30° and 60° MCP joint flexion when comparing complete RCL insufficiency with complete RCL with 50% DFC insufficiency. At 30° flexion, significant increases were found in ulnar deviation, pronation, and volar translation, and there was a decrease in supination. At 60° flexion, ulnar deviation, pronation, and volar translation increased and radial deviation decreased significantly. At 30° flexion, the resting position significantly pronated and translated volarly. At 60° flexion, the resting position significantly shifted ulnarly, pronated, and translated volarly. CONCLUSIONS: The DFC acts as a secondary stabilizer of the thumb MCP joint, working in tandem with the RCL. It acts by stabilizing the MCP joint dorsoradially when external forces are applied across the joint. This cadaveric study shows that RCL insufficiency with a concomitant DFC injury is less likely to be stable than RCL injuries alone, and that this effect is more pronounced with MCP joint flexion. CLINICAL RELEVANCE: Increasing incompetence of the secondary stabilizers of the RCL, such as the DFC, will likely result in increased clinical instability upon physical examination. The results of this study also suggest the need to consider repair of the DFC at the time of RCL repair.

Evolving paradigm in treatment of Merkel cell carcinoma of the digit from ray resection to wide local excision and flap coverage.

BACKGROUND: Merkel cell carcinoma is a rare cutaneous neuroendocrine neoplasm that typically presents on the head and neck. Merkel cell carcinoma (MCC) of the digits is rare, and thus limited treatment options have been presented. METHODS: In contrast to the current treatment recommendation of ray resection of the affected digit, two patients were treated by sentinel node biopsy, wide local excision, and flap coverage of the defect. RESULTS: No local recurrences or metastases have been seen 24 months postoperatively. CONCLUSION: We suggest that the paradigm of ray amputation of a digit affected by MCC should evolve to initial treatment with a sentinel lymph node biopsy (SLNB) with subsequent local excision with wide margins and local flap coverage.