Effect of Proximal Row Carpectomy and Wrist Arthrodesis on the Resting Length of Extrinsic Digit Flexor Tendons: A Cadaveric Study.

Background Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Methods Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Results Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00-3.00 cm). A weak direct relationship ( R = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated ( p = 0.811). Conclusion This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

Opioid-Sparing Multimodal Analgesia Efficacy in Hispanic Patients Undergoing Total Knee Arthroplasty.

Adequate pain control after total knee arthroplasty (TKA) has been associated with improved patient mobility and satisfaction, and is a task that has historically relied on opioids. Multimodal analgesic regimens can be considered a therapeutic alternative for postoperative pain control to avoid opioid consumption and its adverse side effects. This study aimed to evaluate the use of a multimodal analgesia protocol based on nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as an alternative to reduce opioid consumption in Hispanic patients undergoing primary TKA. Methods: An institutional review board-approved, randomized controlled trial evaluated postoperative pain control after TKA in a Hispanic population. The experimental opioid-sparing group received 30-mg ketorolac intravenously every 6 hours and 1-g acetaminophen orally every 6 hours as the patient requested. The experimental group had the option to use morphine and oxycodone combined with acetaminophen as a rescue therapy. The control group received opioids in the form of 0.1-mg/kg morphine intravenously every 6 hours and/or oxycodone combined with acetaminophen (2.5 and 325 mg), 2 tablets orally every 6 hours, as the patient requested. Sociodemographic, operative, and immediate postoperative data and pain intensity measurements according to the numerical rating scale (NRS) were compared between groups. Analgesic efficacy was assessed according to the NRS scores at 12, 24, and 48 hours postoperatively. Results: Eighty-one Hispanic patients met inclusion criteria: 42 patients in the experimental group and 39 patients in the control group. None of the patients in the experimental group requested oxycodone combined with acetaminophen as a rescue therapy. Only 2 patients in the experimental group used a mean of 3.0 ± 1.4 mg of rescue morphine; in comparison, the control group consumed a mean of 28.0 ± 7.9 mg of morphine and 64.8 ± 26.0 mg of oxycodone per patient. A pain intensity decrease was observed in the experimental and control groups, with no postoperative evaluation differences at 12 hours (6.7 ± 2.9 compared with 5.9 ± 2.8; p = 0.209), 24 hours (6.2 ± 2.0 compared with 6.1 ± 2.2; p = 0.813), and 48 hours (4.7 ± 2.1 compared with 4.6 ± 1.7; p = 0.835). Conclusions: The use of a multimodal analgesic regimen based on intravenous ketorolac and oral acetaminophen was adequate in reducing postoperative pain and opioid consumption in Hispanic patients undergoing TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Level of Supervision and Radiation Exposure of Senior Orthopedic Residents During Surgical Treatment of Proximal Femur Fracture.

The sustained use of intraoperative fluoroscopy has led to increased use of minimally invasive surgical techniques, enhanced surgeon proficiency, improved anatomic corrections, reduced patient morbidity, earlier functional recovery, and decreased length of hospital stay. As a result, orthopedic attending surgeons and residents are exposed to more radiation, increasing the risk of cancer and radiation-induced cataracts compared with the general population and those who work in other surgical specialties. The magnitude of radiation exposure depends on the susceptibility of the tissues affected, medical specialty, the position of the C-arm, distance from the radiation beam, level of difficulty of the surgical procedure, surgeon experience, level of resident training, and level of supervision by the attending surgeon. However, little information is available on the effect of supervision level on radiation exposure for orthopedic senior residents. The goal of this study was to investigate whether level of supervision by the attending surgeon affects the radiation exposure of orthopedic senior residents during surgical treatment of proximal femur fracture with cephalomedullary nail fixation. This retrospective cohort study was performed from January 2019 to March 2019. No significant relationship between supervision level and radiation exposure of senior residents was observed. Supervision level does not significantly affect radiation exposure for senior residents; therefore, the implementation of standardized training in radiation safety may be a more essential measure to decrease radiation exposure. [Orthopedics. 2021;44(3):e402-e406.].

Hypomagnesemia following posterior spinal fusion in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) usually require surveillance in the pediatric ICU (PICU). Some reports have documented evidence of hypomagnesemia following PSF at PICU. Little has been studied about relationship between AIS and postoperative serum magnesium (Mg+2) levels. The aim of this study is to determine the prevalence and risk factors of hypomagnesemia in AIS patients admitted to PICU after PSF. IRB approved the cross-sectional study of AIS patients admitted to PICU after PSF from January 2016 to May 2017. Serum electrolyte levels of phosphorous, calcium, sodium, potassium and hemoglobin were taken preoperative and 24 h postoperative and compared with postoperative magnesium levels. Blood volume reinfused from cell saver return (CSR), estimated blood loss (EBL), volume of fluids intraoperative and average of vertebra levels operated were charted and compared with postoperative magnesium levels. A total of 46 AIS patients undergoing PSF met inclusion criteria, with an average age of 15 years (78% female). Postoperatively, hypomagnesemia was reported in 24/46 patients (53%). No association was found between hypomagnesemia and serum electrolyte (phosphorous, calcium, sodium and potassium) or hemoglobin levels. In addition, no statistical association was found with age, operative time, vertebrae level fused, CSR, EBL and volume of fluids intraoperatively. Fifty-three percent of pediatric patients developed hypomagnesemia after surgical correction for AIS. Further investigation of this electrolyte disturbance will likely result in a useful clinical tool for physician in the management of AIS.

Practice Variation Among Hispanic American Orthopedic Surgeons in the Management of Geriatric Distal Radius Fracture.

INTRODUCTION: There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience. MATERIAL & METHODS: A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed. RESULTS: A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons <15 years (P = 0.01). A general consensus trend toward operative fixation was noted among geriatric and young adult patients with the same fracture type in all clinical scenarios. DISCUSSION AND CONCLUSIONS: This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Musculoskeletal Manifestations of Child Abuse: Analysis at a Level 2 Trauma Center in Puerto Rico.

OBJECTIVE: To describe the epidemiological manifestations and assess major risk factors in children under the age of three years presenting with non-accidental injury (NAI) fractures in a level two trauma center in Puerto Rico. METHODS: An IRB approved retrospective descriptive study was performed by reviewing case records of 75 patients who presented with a NAI fracture at the Pediatric University Hospital of the Puerto Rico Medical Center. The study time period was from October 1996 to October 2014. The inclusion criteria for our population consisted of: (1) patients between the ages of zero to three years, (2) suffered a long bone fracture, and (3) had a history of suspected child abuse at our academic institution. The exclusion criteria were: (1) patients older than three years, (2) no history of NAI, or (3) had a congenital bone disorder. RESULTS: A total of 117 long bone fractures were observed in our population. Similar distribution was seen between sex,, with 52% being male and 48% being female. The mean age was 10.8 months. The group with the highest frequency of NAI fractures were children under the age of one year (57.3 %). The most commonly involved fractured bone for all age groups was the femur (48.0 %). No statistical significance was observed when comparing sex, age, associated injuries or multiple fractures. CONCLUSION: Children younger than one year of age who present with long bone fracture, multiple fractures, low household income and parental unemployment are associated with an increased risk of NAI fractures.

Bilateral Posterior-Stabilized Total Knee Arthroplasty in a Patient With Osteopetrosis and Literature Review.

We present a case report of a patient with osteopetrosis and refractory bilateral knees osteoarthritis who underwent bilateral total knee arthroplasties (TKAs). After conservative management has failed, surgical treatment with arthroplasty is an excellent alternative with satisfactory outcomes. TKA in patients with osteopetrosis has only been described in 6 other case studies, none of which underwent bilateral TKA. To perform this procedure, additional attention should be directed toward the presurgical planning because of the amplified difficulty of the procedure and the altered bone biology that increases the risks of intraoperative fractures and markedly extends the time of surgery. This report describes a case of osteopetrosis with refractory osteoarthritis managed with bilateral TKA, the surgical technique and special considerations, complications, and future recommendations.

The Effect of Total Hip Arthroplasty on the Sciatic Nerve: an Electrodiagnostic Evidence Study.

OBJECTIVE: Objectively evaluate the incidence of sciatic nerve injury after a total hip arthroplasty (THA) performed through a posterolateral approach. METHODS: Patients scheduled to undergo THA were evaluated preoperatively and postoperatively with electrophysiologic studies, the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) questionnaire and other methods described in the study. Patients older than 21 years with any of the following preoperative diagnoses: primary or secondary osteoarthritis, aseptic avascular necrosis, rheumatoid arthritis, and posttraumatic arthritis were included. Variables used for analysis were sex, age, and body mass index (BMI). The Mann-Whitney U and Wilcoxon tests and, Pearson and Spearman correlation statistics were used for analysis of categorical and continuous data respectively. RESULTS: Electrodiagnostic data showed alterations in 17 patients (70.8%). No signs of sciatic nerve injury. The mean preoperative and postoperative WOMAC scores were 40 and 74, respectively (p = 0.0001). Statistical differences were noted in sural sensory amplitude (SSA) and distal amplitude of the tibialis motor nerve in the female group (p=0.007; p=0.036, respectively). The SSA also demonstrated differences in the obese group (p=0.008). In terms of age, both the SSA (Pearson p=0.010 and Spearman p=0.024) and the proximal latency of the peroneal motor nerve (Pearson p=0.026 and Spearman p=0.046) demonstrated a decrease in amplitude and an increase in latency that was inversely related with age. CONCLUSION: According to our subclinical electrophysiological findings, surgeons that use the posterolateral approach in THA procedures must be conscious of the sciatic nerve's vulnerability to reduce possible clinical complications.

Anterior tibialis artery pseudoaneurysm after minimally invasive plate osteosynthesis in the proximal tibia: a case report.

Tibial plateau fractures are common fractures associated with high-energy trauma. The treatment of these fractures remains a challenge today. Recent management of fractures has moved from open surgery toward minimally invasive surgery to reduce complications and improve functional outcomes. Nevertheless, such a minimalistic approach makes visualization of neurovascular structures difficult, placing them at risk. We report the case of a 39-year-old male who developed a pseudoaneurysm of the anterior tibial artery following minimally invasive plate osteosynthesis of the right proximal tibia. Diagnosis was made through noninvasive duplex ultrasound and was referred to endovascular service. Understanding of the anatomy of the surgical site is vital to minimize complications. In addition, proper postsurgical patient evaluation is important to monitor the insurgence of such complications.

Functional and Disability Assessment Among Hispanics With Zone 2 Flexor Tendon Injuries: Comparative Study Between Flexor Digitorum Superficialis Repair and Flexor Digitorum Superficialis Excision.

INTRODUCTION: Flexor tendon lacerations in zone II have been reported to be the most complicated of all tendon injuries. Currently, there is no consensus on treatment in surgical management for patients with flexor tendon laceration of flexor digitorum profundus and flexor digitorum superficialis (FDS). The aim of this study was to evaluate whether the repair of FDS tendons provided superior functional outcomes compared with FDS excision in Hispanic patients. METHODS: Total active motion, original Strickland criteria, and the disability of arm shoulder and hand questionnaire were provided postoperatively at 3 and 6 months to all consecutive Hispanic patients who underwent zone II flexor tendon repair. The cohort was divided into two groups, those who underwent FDS repair and those underwent FDS excision. RESULTS: Functional and disability outcome analysis showed a notable improvement with FDS repair using total active motion, Strickland criteria, and disability of arm shoulder and hand score at the 3 months postoperative interval. No statistical differences were identified regarding functional and disability outcomes at the 6-month evaluation between both groups. CONCLUSIONS: Among Hispanics, the FDS-repaired group had similar functional and disability outcomes at their 6 months postoperative evaluation compared with the FDS-excised group. Increased awareness for tendon rerupture during the initial 3 months of index surgery is recommended for FDS-excised patients.

Socioeconomic Factors Influencing Self-reported Outcomes After Posterior Wall Fractures of the Acetabulum: Lessons Learned From a Hispanic Population.

INTRODUCTION: Demographic and socioeconomic factors are important determinants that may affect patient self-reported outcomes after acetabular fracture surgery. Hispanics, as a minority group, have an increased tendency to suffer demographic and socioeconomic disparities. At the present time, there is scant information regarding their role among Hispanic patients with acetabular fractures. The aim of this study was to investigate whether demographic or socioeconomic factors would affect satisfaction and self-reported functional outcomes in Hispanic patients who endured open reduction and internal fixation (ORIF) of posterior wall fractures of the acetabulum. METHODS: A cross-sectional study of 78 patients with posterior wall fracture of the acetabulum treated with ORIF from 2011 to 2017 was performed. Data from demographics (age, sex, and body mass index [BMI]) and socioeconomic factors (household income, highest educational level achieved, employment status, type of medical insurance, workers' compensation involvement, and injury-related litigation process) were obtained and compared with the Short Musculoskeletal Form Assessment-46 (SMFA-46) questionnaire using a multivariable logistic regression analysis. RESULTS: Unemployment was the most significant variable associated with dissatisfaction among 15 of the 46 responses of the SMFA-46 (P < 0.048). Patients who had an overweight or obese BMI and had an age of 41 years or older exhibited significantly worse outcomes in 7 of the 46 questions (P < 0.049). Finally, women were less likely to be satisfied in 1 of the 46 questions (P = 0.028). No notable difference was observed in any of the SMFA-46 responses regarding insurance plan, educational level, workers' compensation involvement, and injury-related litigation process. DISCUSSION: A strong association exists between dissatisfaction after ORIF of posterior wall fractures of the acetabulum and employment status, BMI, and age among the Hispanic population. Addressing socioeconomic factors can be critical to overcome dissatisfaction and improve functional status among Hispanic patients with acetabular fractures.

Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures.

Purpose: Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation. Methods: We performed an institutional review board-approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale-Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated. Results: Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale-Revised Survey results. No hematoma block-associated complications were reported. Conclusions: The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF. Type of study/level of evidence: Therapeutic II.