Alidad Ghiassi

The Variation in the Absence of the Palmaris Longus in a Multiethnic Population of the United States: An Epidemiological Study

The absence of the palmaris longus (PL) has been shown to vary based on body side, gender, and ethnicity. In prior studies, homogenous ethnic populations have been shown to have differences in rates of absence. However, no study thus far has analyzed the differences in palmaris longus prevalence in a multiethnic population. We prospectively collected data on 516 patients visiting the outpatient hand clinics at LAC+USC Medical Center and Keck Medical Center. Analysis of the data was then performed for variables including ethnicity, laterality, and gender. There were no differences in the absence of the PL based on laterality or gender. Ethnically, there was no difference between white (non-Hispanic) and white (Hispanic) patients, with prevalence of 14.9% and 13.1%, respectively. However, African American (4.5%) and Asian (2.9%) patients had significantly fewer absences of the PL than the Caucasian, Hispanic reference group (P = 0.005 and P = 0.008, resp.). African Americans and Asians have a decreased prevalence of an absent PL. The Caucasian population has a relatively greater prevalence of an absence of the PL. This epidemiological study demonstrates the anatomic variation in this tendon and may be taken into account when planning an operation using tendon grafts.

Distal Radius Fractures: Approaches, Indications, and Techniques

Distal radius fractures remain among the most common fractures of the upper extremity. The indications for operative management continue to evolve based on outcomes from the most recent clinical studies. Advancements over the past decade have expanded the variety of fixation options available; however, the clinical superiority of a particular treatment modality remains without consensus. Each approach requires the use of unique surgical techniques, and the choice of a particular implant system should be based on the surgeons familiarity with the implant design and its limitations. As our understanding of the management of distal radius fractures improves, so will our indications for each specific treatment modality.

Risk of Tendon Entrapment Under a Dorsal Bridge Plate in a Distal Radius Fracture Model

PURPOSE To determine the risk of iatrogenic damage to the extensor tendons and sensory nerves under a bridge plate along the second versus third metacarpal. METHODS Using 6 paired (left-right) cadaver forearms-wrists and via a volar approach, we created a distal radius fracture with metaphyseal comminution. We then applied a dorsal distraction plate to either the second or third metacarpal. We next performed dorsal dissection of the hand and wrist over the zone of injury to determine the position of the plate relative to the extensor tendons and sensory nerves. RESULTS The bridge plate on the third metacarpal entrapped tendons of the first and third compartment in all 6 specimens. When the plate was applied to the second metacarpal there were no cases of tendon entrapment. There were no instances of nerve entrapment in plating to either the second or third metacarpal. CONCLUSIONS Distraction plating has been proposed for use in the second and third metacarpals for unstable comminuted distal radius fractures. We recommend formal exposure of the extensor tendons over the zone of injury when applying a distraction bridge plate to the third metacarpal. CLINICAL RELEVANCE Plating to the second metacarpal decreases the risk of entrapment of extensor tendons compared with plating to the third metacarpal.

Pronator-Sparing Technique for Volar Plating of Distal Radius Fractures

Acute distal radius fractures are commonly treated by volar locking plate fixation and typically involve reflection of the pronator quadratus for adequate exposure of the fracture. Recently, attention has been centered on the role and repair of the pronator quadratus. This article presents an alternative approach to fixation of distal radius fractures with a pronator-sparing technique that offers similar short-term radiographic outcomes to the conventional volar plating approach.

Volar Percutaneous Screw Fixation of the Scaphoid: A Cadaveric Study

PURPOSE To test the efficacy of a previously described technique of angiocatheter-assisted instrument positioning in achieving a central screw position in a cadaveric model for volar percutaneous screw fixation (PSF) of the scaphoid and to quantify the damage to surrounding soft tissue and articular cartilage associated with the procedure. METHODS We performed fluoroscopically guided volar PSF of the scaphoid on 10 fresh cadaveric wrists. We then dissected the specimens, analyzed screw position in cross sections of the scaphoid, and described injury to nearby soft tissue structures as well as articular cartilage of the scaphotrapezial joint. RESULTS All 10 screws were positioned within the central third of the scaphoid on at least 2 of 3 cross sections, and 8 of 10 screws were positioned within the central third of the proximal pole. Two wrists required a transtrapezial trajectory for satisfactory screw positioning. None of the specimens sustained visible neurovascular damage, and 2 wrists revealed minor tendon damage. Trajectories involving the scaphotrapezial joint violated, on average, 7% of the scaphoid articular cartilage. With a transtrapezial trajectory, 11% of the trapezial cartilage was violated CONCLUSIONS Central positioning of the screw is biomechanically superior, and screw position within the central one third of the proximal pole has been associated with faster time to union. Volar PSF achieved satisfactory screw position in the scaphoid. The majority of wrists were amenable to PSF via the scaphotrapezial joint, though a transtrapezial approach was a viable alternative for wrists with restrictive anatomy. Both approaches minimally disrupted the scaphotrapezial joint and surrounding soft tissues. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Evaluation of Percutaneous First Annular Pulley Release: Efficacy and Complications in a Perfused Cadaveric Study.

PURPOSE Trigger finger is the most common entrapment tendinopathy, with a lifetime risk of 2% to 3%. Open surgical release of the flexor tendon sheath is a commonly performed procedure associated with a high rate of success. Despite reported success rates of over 94%, percutaneous trigger finger release (PFTR) remains a controversial procedure because of the risk of iatrogenic digital neurovascular injury. This study aimed to evaluate the safety and efficacy of traditional percutaneous and ultrasound (US)-guided first annular (A1) pulley releases performed on a perfused cadaveric model. METHODS First annular pulley releases were performed percutaneously using an 18-gauge needle in 155 digits (124 fingers and 31 thumbs) of un-embalmed cadavers with restored perfusion. A total of 45 digits were completed with US guidance and 110 digits were completed without it. Each digit was dissected and assessed regarding the amount of release as well as neurovascular, flexor tendon, and A2 pulley injury. RESULTS Overall, 114 A1 pulleys were completely released (74%). There were 38 partial releases (24%) and 3 complete misses (2%). No significant flexor tendon injury was seen. Longitudinal scoring of the flexor tendon was found in 35 fingers (23%). There were no lacerations to digital nerves and one ulnar digital artery was partially lacerated (1%) in a middle finger with a partial flexion contracture that prevented appropriate hyperextension. The ultrasound-assisted and blind PTFR techniques had similar complete pulley release and injury rates. CONCLUSIONS Both traditional and US-assisted percutaneous release of the A1 pulley can be performed for all fingers. Perfusion of cadaver digits enhances surgical simulation and evaluation of PTFR beyond those of previous cadaveric studies. The addition of vascular flow to the digits during percutaneous release allows for Doppler flow assessment of the neurovascular bundle and evaluation of vascular injury. CLINICAL RELEVANCE Our cadaveric data align with those of published clinical investigations for percutaneous A1 pulley release.

Surgical Approach and Anesthetic Modality for Carpal Tunnel Release A Nationwide Database Study With Health Care Cost Implications

Background: Carpal tunnel release (CTR) is commonly performed for carpal tunnel syndrome once conservative treatment has failed. Operative technique and anesthetic modality vary by surgeon preference and patient factors. However, CTR practices and anesthetic trends have, to date, not been described on a nationwide scale in the United States. Methods: The PearlDiver Patient Records Database was used to search Current Procedural Terminology codes for elective CTR from 2007 to 2011. Anesthetic modality (eg, general and regional anesthesia vs local anesthesia) and surgical approach (eg, endoscopic vs open) were recorded for this patient population. Cost analysis, patient demographics, regional variation, and annual changes in CTR surgery were evaluated. Results: We identified 86 687 patients who underwent carpal tunnel surgery during this 5-year time period. In this patient sample, 80.5% of CTR procedures were performed using general or regional anesthesia, compared with 19.5% of procedures performed using local anesthesia; 83.9% of all CTR were performed in an open fashion, and 16.1% were performed using an endoscopic technique. Endoscopic surgery was on average

Utility of Postoperative Imaging in Radial Shaft Fractures.

794 more expensive than open surgery, and general or regional anesthesia was

Predictive Factors of Neurovascular and Tendon Injuries Following Dog Bites to the Upper Extremity

654 more costly than local anesthesia. Conclusions: In the United States, open CTR under local anesthesia is the most cost-effective way to perform a CTR. However, only a small fraction of elective CTR procedures are performed with this technique, representing a potential area for significant health care cost savings. In addition, regional and age variations exist in procedure and anesthetic type utilized.

A Biomechanical Comparison of Distal Fixation for Bridge Plating in a Distal Radius Fracture Model

Background: Postoperatively, radial shaft fractures are often followed clinically with serial radiographs to assess for fracture healing. Currently, there is no standard of care regarding postoperative imaging for these injuries. The purpose of this study is to determine whether imaging influences management decisions. Methods: Patients who presented to a level I trauma center between 2009 and 2014 with an operatively treated radial shaft fracture were retrospectively screened for inclusion in our study. Patients with ipsilateral ulna or radius fractures, or with inadequate imaging or inadequate follow-up, were excluded. Four blinded, board-certified, orthopedic surgeons reviewed the postoperative films twice for each patient and stated whether the imaging would influence management decisions. Images were separated into 3 groups based on time from surgery: 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks. The number of times imaging influenced these hypothetical management decisions was recorded. Interobserver and intraobserver agreements were calculated using Fleiss’s and Cohen’s kappa coefficients, respectively. Results: One hundred eighteen patients underwent operative fixation for an isolated radial shaft fracture, of whom 38 met inclusion criteria. Imaging from 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks postoperatively resulted in a change of management in 0%, 32%, and 16% of patients, respectively. After 4 weeks, changes were primarily for immobilization and activity-level modification. Intraobserver and interobserver agreement kappa coefficients were 0.761 and 0.563, respectively. Conclusions: Films obtained within 4 weeks of surgery for radial shaft fractures are unlikely to change postoperative management and may not be warranted during routine postoperative follow-up.