Daniel A. Osei

The Effect of Suture Caliber and Number of Core Suture Strands on Zone II Flexor Tendon Repair: A Study in Human Cadavers

PURPOSE To compare the tensile properties of a 3-0, 4-strand flexor tendon repair with a 4-0, 4-strand repair and a 4-0, 8-strand repair. METHODS Following evaluation of the intrinsic material properties of the 2 core suture calibers most commonly used in tendon repair (3-0 and 4-0), we tested the mechanical properties of 40 cadaver flexor digitorum profundus tendons after zone II repair with 1 of 3 techniques: a 3-0, 4-strand core repair, a 4-0, 8-strand repair, or a 4-0, 4-strand repair. We compared results across suture caliber for the 2 sutures and across tendon repair methods. RESULTS Maximum load to failure of 3-0 polyfilament caprolactam suture was 49% greater than that of 4-0 polyfilament caprolactam suture. The cross-sectional area of 3-0 polyfilament caprolactam was 42% greater than that of 4-0 polyfilament caprolactam. The 4-0, 8-strand repair produced greater maximum load to failure when compared with the 2 4-strand techniques. Load at 2-mm gap, stiffness, and work to yield were significantly greater in the 4-0, 8-strand repair than in the 3-0, 4-strand repair. CONCLUSIONS In an ex vivo model, an 8-strand repair using 4-0 suture was 43% stronger than a 4-strand repair using 3-0 suture, despite the finding that 3-0 polyfilament caprolactam was 49% stronger than 4-0 polyfilament caprolactam. These results suggest that, although larger-caliber suture has superior tensile properties, the number of core suture strands across a repair site has an important effect on time zero, ex vivo flexor tendon repair strength. CLINICAL RELEVANCE Surgeons should consider using techniques that prioritize multistrand core suture repair over an increase in suture caliber.

Predictors of surgical revision after in situ decompression of the ulnar nerve

BACKGROUND This study was performed to identify factors associated with the need for revision surgery after in situ decompression of the ulnar nerve for cubital tunnel syndrome. METHODS This case-control investigation examined all patients treated at one institution with open in situ decompression for cubital tunnel syndrome between 2006 and 2011. The case patients were 44 failed decompressions that required revision, and the controls were 79 randomly selected patients treated with a single operation. Demographic data and disease-specific data were extracted from the medical records. The rate of revision surgery after in situ decompression was determined from our 5-year experience. A multivariate logistic regression model was used based on univariate testing to determine predictors of revision cubital tunnel surgery. RESULTS Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period. Predictors of revision surgery included a history of elbow fracture or dislocation (odds ratio [OR], 7.1) and McGowan stage I disease (OR, 3.2). Concurrent surgery with in situ decompression was protective against revision surgery (OR, 0.19). DISCUSSION The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery.

Factors associated with failure of nonoperative treatment in lateral epicondylitis.

Background: Lateral epicondylitis is a common cause of elbow pain that is treated with a variety of nonoperative measures and often improves with time. Minimal research is available on patients in whom these nonoperative treatments fail. Purpose: To identify baseline patient and disease factors associated with the failure of nonoperative treatment of lateral epicondylitis, defined as surgery after a period of nonoperative treatment. Study Design: Case control study; Level of evidence, 3. Methods: A total of 580 patients treated for lateral epicondylitis at a tertiary center between 2007 and 2012 were analyzed. Disease-specific and patient demographic characteristics were compared between patient groups (nonoperative vs surgical treatment). A multivariable logistic regression model was created based on preliminary univariate testing to determine which characteristics were associated with failure of nonoperative treatment. Results: Of the 580 patients, 92 (16%) underwent surgical treatment at a mean of 6 months (range, 0-31 months) from their initial visit. Univariate analysis demonstrated a potential association (P < .10) between operative management and the following factors at initial diagnosis: increased age, body mass index, duration of symptoms, presence of radial tunnel syndrome, prior injection, physical therapy, splinting, smoking, workers’ compensation, a labor occupation, use of narcotics, use of antidepressant medications, and previous orthopaedic surgery. In the final multivariable model, a workers’ compensation claim (odds ratio [OR], 8.1), prior injection (OR, 5.6), the presence of radial tunnel syndrome (OR, 3.1), previous orthopaedic surgery (OR, 3.2), and duration of symptoms >12 months (OR, 2.5) remained significant independent predictors of surgical treatment. Conclusion: This study identifies risk factors for surgical treatment for lateral epicondylitis. While these findings do not provide information regarding causal factors associated with surgery, these patient and disease-specific considerations may be helpful when counseling patients regarding treatment options and the likelihood of the success of continued nonoperative treatment.

The effect of core and epitendinous suture modifications on repair of intrasynovial flexor tendons in an in-vivo canine model

PURPOSE To determine in vivo effects of modifications to core and epitendinous suture techniques in a canine intrasynovial flexor tendon repair model using clinically relevant rehabilitation. Our null hypothesis was that gap formation and rupture rates would remain consistent across repair techniques. METHODS We evaluated gap formation and rupture in 75 adult mongrel dogs that underwent repair of intrasynovial flexor tendon lacerations followed by standardized postoperative therapy. The current suture technique was a 4-0, 8-strand core suture with a purchase of 1.2 cm and a 5-0, epitendinous suture repair with a 2-mm purchase length and depth. We compared gap and failure by chi-square analysis to a historical group of in vivo repairs (n = 76) from the same canine model using 8-strand core suture repair with purchase of 0.75 cm and 6-0 epitendinous suture with a 1-mm purchase length and depth. RESULTS A total of 93% of tendons (n = 70) demonstrated gapping of less than 3 mm using the current suture technique. Five percent of tendons (n = 4) had a gap of 3 mm or greater, and there was 1 repair site failure. This was significantly improved over the comparison group of historical 8-strand core repair technique, which resulted in 82% (n = 62) of repairs with a gap of less than 3 mm and 7 failures (9%). CONCLUSIONS In an in vivo model, current modifications to suture techniques for intrasynovial flexor tendon repair demonstrated significant improvements in gap formation and rupture compared with a similar technique using shorter purchase lengths and shallower purchase depth. CLINICAL RELEVANCE Suggested repair modifications for the treatment of zone II flexor tendon transections demonstrate improvements in gap formation and tendon rupture in vivo.

The Impact of Patient Activity Level on Wrist Disability after Distal Radius Malunion in Older Adults

Objective: To determine if high-activity older adults are adversely affected by distal radius malunion. Design: Cross-sectional study. Setting: Hand clinics at a tertiary institution. Participants: Ninety-six patients 60 years or older at the time of fracture were evaluated at least 1 year after distal radius fracture. Intervention: Physical Activity Scale of the Elderly scores stratified participants into high- and low-activity groups. Malunions were defined radiographically by change of ≥20 degrees of lateral tilt, ≥15 degrees radial inclination, ≥4 mm of ulnar variance, or ≥4 mm intra-articular gap or step-off, compared with the uninjured wrist. Main Outcome Measure: Patient-rated disability of the upper extremity was measured by the QuickDASH and visual analog scales (VAS) for pain/function. Strength and motion measurements objectively quantified wrist function. Results: High-activity participants with a distal radius malunion were compared with high-activity participants with well-aligned fractures. There was no significant difference in QuickDASH scores, VAS function, strength, and wrist motion despite statistically, but not clinically, relevant increases in VAS pain scores (difference 0.5, P = 0.04) between the groups. Neither physical Activity Scale of the Elderly score (&bgr; = 0.001, 95% confidence interval: −0.002 to 0.004) nor malunion (&bgr; = 0.133, 95% confidence interval: −0.26 to 0.52) predicted QuickDASH scores in regression modeling after accounting for age, sex, and treatment. Operative management failed to improve outcomes and resulted in decreased grip strength (P = 0.05) and more frequent complications (26% vs. 7%, P = 0.01) when compared with nonoperative management. Conclusions: Even among highly active older adults, distal radius malunion does not affect functional outcomes. Judicious use of operative management is warranted provided heightened complication rates. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes following modified oblique medial epicondylectomy for treatment of cubital tunnel syndrome.

PURPOSE To quantify and define objective and patient-rated outcomes after our modification of medial epicondylectomy for the treatment of cubital tunnel syndrome. Although medial epicondylectomy has been previously studied, data are lacking regarding elbow-specific outcomes after our technique that aims to minimize complications historically associated with medical epicondylectomy. METHODS A total of 27 subjects with clinical and electrodiagnostic evidence of cubital tunnel syndrome underwent a modified oblique medial epicondylectomy that was designed to minimize bony resection and preserve the origin of the ulnar collateral ligament of the elbow. Average age was 57 years, mean duration of symptoms was 24 months, and mean postoperative follow-up was 29 months. Eight patients had McGowan stage I disease, 14 had stage II, and 5 had stage III. Preoperatively, we measured intrinsic hand strength, 2-point discrimination, and residual medial elbow pain, and assessed for continuing signs and symptoms of nerve compression. Postoperatively, we added to the clinical examination elbow stability testing, elbow range of motion, and assessment of medial antebrachial cutaneous nerve injury. We collected patient-reported outcomes, including Quick Disabilities of the Shoulder, Arm, and Hand; Levine-Katz Severity Score; and Patient-Rated Elbow Evaluation. RESULTS We noted improvement of at least 1 McGowan grade in 20 of 27 patients (74%). Three of the 7 patients who had no change in McGowan grade still reported excellent patient-rated outcomes. Good to excellent results were achieved in 25 of 27 patients (93%). One patient had long-term severe medial elbow pain. Three patients had postoperative medial elbow pain that resolved with a single corticosteroid injection. One patient had a 30° flexion contracture; preoperative motion was not available for comparison. No patients had signs of elbow instability or numbness in the medial antebrachial cutaneous nerve distribution. CONCLUSIONS Modified oblique medial epicondylectomy was effective in improving symptoms in cubital tunnel syndrome. This medial collateral ligament sparing technique minimized complications previously associated with the original technique. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Simultaneous Bilateral or Unilateral Carpal Tunnel Release? A Prospective Cohort Study of Early Outcomes and Limitations.

BACKGROUND Over 60% of patients with carpal tunnel syndrome present with symptoms and findings of nerve compression in both hands. Our goal was to compare patient-rated difficulties in performing activities of daily living in the early postoperative period between those undergoing bilateral carpal tunnel release and those undergoing unilateral carpal tunnel release. METHODS This prospective cohort study enrolled consecutive patients with bilateral carpal tunnel syndrome undergoing bilateral carpal tunnel release (n = 47) or unilateral carpal tunnel release (n = 41). Patient function and disease severity were measured by an abbreviated form of the Disabilities of the Arm, Shoulder and Hand questionnaire, QuickDASH, and the Boston Carpal Tunnel Questionnaire at baseline, at postoperative visit 1 at a mean time (and standard deviation) of 10 ± 3 days, and at postoperative visit 2 at a mean time (and standard deviation) of 30 ± 6 days. Patients rated their difficulty in completing fifteen activities of daily living each day for the first postoperative week. Patients reported the factors that influenced their choice of surgery. RESULTS There was no difference in baseline function or disease severity between the two groups with regard to QuickDASH and the Boston Carpal Tunnel Questionnaire. Patients in both groups improved after carpal tunnel release with no difference between groups either at postoperative visit 1 for QuickDASH (p = 0.97) and the Boston Carpal Tunnel Questionnaire (p = 0.86) or at postoperative visit 2 for QuickDASH (p = 0.43) and the Boston Carpal Tunnel Questionnaire (p = 0.34). Patients undergoing bilateral carpal tunnel release had more difficulty only during postoperative days 1 to 2 in opening jars (p = 0.03), cooking (p = 0.008), and doing household chores (p = 0.02). Patients in the two groups did not differ (p > 0.05) in their abilities to perform activities of daily living necessary for personal hygiene or independence on any day during the first seven days following surgery with regard to using the bathroom, bathing, dressing, or eating. Although the most common reason why patients chose bilateral carpal tunnel release was to avoid two surgical procedures (42%), the most common reason why patients chose unilateral carpal tunnel release was concern for self-care (36%). CONCLUSIONS Patients with bilateral carpal tunnel syndrome can anticipate more severe functional impairment during the first few postoperative days with bilateral carpal tunnel release compared with unilateral carpal tunnel release, but limitations beyond postoperative day 2 or 3 are similar for bilateral and unilateral carpal tunnel release. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Evaluation and treatment of osetoporotic distal radius fracture in the elderly patient.

Distal radius fractures are an increasingly prevalent upper extremity injury, especially among elderly patients. While treatment guidelines for the acute bony injury have been well documented, treatment of the underlying metabolic bone disease has been less commonly discussed in the orthopedic literature. Distal radius fractures in the elderly patient should be considered a sentinel event for injuries associated with greater morbidity and mortality, such as hip fracture. Management of fracture-related factors, such as osteoporosis and increased fall risk following a distal radius fracture, may prevent the mortality and morbidity of future injuries. This review highlights both the fracture-specific and medical goals of treatment in the elderly patient with a distal radius fracture.

Trapeziometacarpal Arthritis: A Prospective Clinical Evaluation of the Thumb Adduction and Extension Provocative Tests.

PURPOSE To determine the diagnostic performance (ie, sensitivity, specificity, interrater reliability) of the thumb metacarpal adduction and extension tests against traditional examination maneuvers for trapeziometacarpal (TMC) arthritis. METHODS This cross-sectional study recruited 129 patients from 2 outpatient offices at a tertiary institution. All patients had radiographic wrist examinations and completed a standardized physical examination consisting of the thumb adduction and extension tests as well as standard examination maneuvers for radial wrist and thumb pain. The physical examinations were performed by 1 of 2 attending physicians and an independent examiner. Patients were recruited for 3 diagnostic groups: TMC arthritis, radial wrist or hand pain, and nonradial wrist pain controls. Statistical analysis calculated the sensitivity, specificity, and interrater reliability of each physical examination maneuver for detecting TMC arthritis. RESULTS The thumb adduction maneuver was found to have a sensitivity of 0.94 (confidence interval [CI], 0.82-0.98) and a specificity of 0.93 (CI, 0.86-0.97). The thumb extension maneuver had a sensitivity of 0.94 (CI, 0.82-0.98) and a specificity of 0.95 (CI, 0.87-0.98). The interrater reliability was excellent for both the adduction (κ = 0.79) and the extension tests (κ = 0.84). The grind test had a sensitivity of 0.44 (CI, 0.30-0.59), a specificity of 0.92 (CI, 0.84-0.97), and poor interrater reliability (0.31). Point tenderness at the TMC joint had a sensitivity of 0.94 (CI, 0.82-0.98), a specificity of 0.81 (CI, 0.71-0.88) and fair interrater reliability (κ = 0.63). CONCLUSIONS The adduction and extension tests each proved to be more sensitive than the grind test for the detection of TMC arthritis. Further, these provocative tests were more specific for basal joint arthrosis than was the elicitation of point tenderness at the joint. The metacarpal adduction and extension maneuvers demonstrated excellent utility as screening tests for the identification of TMC arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.

Soft-tissue Defects After Total Knee Arthroplasty: Management and Reconstruction

Wound healing complications associated with total knee arthroplasty present a considerable challenge to the orthopaedic surgeon. To ensure preservation of a functional joint, the management of periprosthetic soft-tissue defects around the knee requires rapid assessment, early and aggressive débridement, and durable, contoured coverage. Several reconstructive options are available to tailor soft-tissue coverage to the location, size, and depth of the wound. Special consideration should be given to the timing of the intervention, management of infection, and prosthesis salvage. The merits of each reconstructive option, including perforator, fasciocutaneous, muscular, and free microvascular flaps, should be weighed to select the most appropriate option. The proposed approach can guide surgeons in treating patients with these complex soft-tissue defects.