J. Megan M. Patterson

The Influence of Patient Insurance Status on Access to Outpatient Orthopedic Care for Flexor Tendon Lacerations

PURPOSEnTo determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations.nnnMETHODSnThe research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded.nnnRESULTSnOf the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials).nnnCONCLUSIONSnFor patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnPrognostic II.

Late Deformities Following the Transfer of the Flexor Carpi Ulnaris to the Extensor Carpi Radialis Brevis in Children With Cerebral Palsy

PURPOSEnThe transfer of flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) (the Green transfer) in children with cerebral palsy (CP) is a surgical option frequently used to address the typical wrist flexion deformity that is often present in these patients. We hypothesize that late deformities may occur when these transfers are performed in patients before skeletal maturity. The purpose of this investigation was to determine the frequency of these deformities and the factors that influence their development.nnnMETHODSnWe performed 41 FCU to ECRB tendon transfers in children with CP at our institution between 1987 and 2005 and retrospectively reviewed them. A total of 24 patients with 25 transfers had a minimum 2-year follow-up and were included in the study population. We identified patients who developed a late deformity after tendon transfer. We analyzed medical records of these patients to identify factors associated with the development of a deformity.nnnRESULTSnOf the 25 transfers, 12 developed a late deformity between 10 and 105 months postoperatively. The deformities that developed were extension deformities (8), supination deformities (one), and recurrent flexion deformities (3). Of the 12 patients with deformity, 9 required revision surgeries. Of these 12 patients, 9 who were less than 13 years of age at the time of transfer developed a late deformity, compared with 3 who were older than 13 years of age.nnnCONCLUSIONSnThe FCU to ECRB tendon transfer remains a viable option to address the wrist flexion deformity seen in patients with CP. Care should be taken when performing this tendon transfer in patients less than 13 years of age because they may develop a postoperative deformity, commonly an extension deformity. We believe that these deformities develop when the patient enters a growth spurt and the transferred muscle-tendon unit does not lengthen at the same rate as the involved upper extremity.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Effects of Hand Fellowship Training on Rates of Endoscopic and Open Carpal Tunnel Release

PURPOSEnTo investigate rates, trends, and complications for carpal tunnel release (CTR) related to fellowship training using the American Board of Orthopaedic Surgery Part II Database.nnnMETHODSnWe searched the American Board of Orthopaedic Surgery database for patients with carpal tunnel syndrome who underwent either open carpal tunnel release (OCTR) or endoscopic (ECTR) from 2003 to 2013. Cases with multiple treatment codes were excluded. Data were gathered on geographic location, fellowship, and surgical outcomes. Data were then divided into 2 cohorts: hand fellowship trained versus non-hand fellowship trained. We performed analysis with chi-square tests of independence and for trend.nnnRESULTSnOverall, 12.4% of all CTRs were done endoscopically. Hand fellowship-trained orthopedists performed about 4.5 times the number of ECTR than did non-hand fellowship-trained surgeons. An increasing trend over time of ECTR was seen only among the hand fellowship cohort. The northwest region of the United States had the highest incidence (23.1%) of ECTR, and the Southwest the lowest incidence (5.9%). The complication incidence associated with CTR overall was 3.6%, without a significant difference between ECTR and OCTR. Within the hand fellowship cohort the complication incidence for ECTR was significantly less than for OCTR. There was no difference in overall complication rates with ECTR and OCTR between the 2 cohorts. Wound complications were higher with OCTR (1.2% vs 0.25%) and nerve palsy with ECTR (0.66% vs 0.27%); with postoperative pain equivalent between techniques independent of fellowship training.nnnCONCLUSIONSnWithin the United States from 2003 to 2013, the rate of ECTR increased, as did complications. However, complication rates remained low in the first 2 years of practice. Hand fellowship-trained surgeons performed more ECTR than did non-hand fellowship-trained orthopedic surgeons, and both groups had similar complication rates.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Bicolumnar Intercarpal Arthrodesis: Minimum 2-Year Follow-Up

PURPOSEnTo determine greater than 2-year outcomes for combined lunate-capitate and triquetrum-hamate arthrodeses.nnnMETHODSnWe identified 16 patients who underwent scaphoid excision and combined arthrodeses of the lunate-capitate and triquetrum-hamate joints (bicolumnar arthrodesis) from 2007 to 2010.xa0Eleven patients returned for follow-up evaluation, which included measurement of operative and contralateral control wrist flexion, extension, and grip strength, and completion of a patient-reported outcomes questionnaire, visual analog scale pain assessment, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Radiographs of each patient were reviewed for evidence of union. Complications including nonunion and hardware migration were recorded.nnnRESULTSnWrist flexion-extension in the operative wrist was 68% of the contralateral control wrist. Grip strength of the operative wrist was 97% of the contralateral wrist. All 11 patients had radiographic bicolumnar union; 8 patients had spontaneous radiographic fusion of the capitohamate joint. One patient required capitolunate screw removal for migration despite having evidence of union.nnnCONCLUSIONSnResults from scaphoid excision and bicolumnar intercarpal arthrodesis are comparable to those reported for traditional scaphoid excision and 4-corner arthrodesis, with a similar loss of wrist range of motion and with possible preservation of better grip strength in the operative wrist. Advantages of this modification include preservation of the normal lunate-triquetrum and capitate-hamate anatomic relationships and simplification of operative technique.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Accuracy in Screw Selection in a Cadaveric, Small-Bone Fracture Model

PURPOSEnUsing a cadaveric model simulating clinical situations experienced during open reduction and internal fixation of proximal phalangeal fractures, the aim of this study was to evaluate the relationship between level of training and the rates of short, long, and ideal screw length selection based on depth gauge use without fluoroscopy assistance.nnnMETHODSnA dorsal approach to the proximal phalanx was performed on the index, middle, and ring fingers of 4 cadaveric specimens, and 3 drill holes were placed in each phalanx. Volunteers at different levels of training then measured the drill holes with a depth gauge and selected appropriate screw sizes. The rates of short, long, and ideal screw selection were compared between groups based on level of training. Ideal screws were defined as a screw that reached the volar cortex but did not protrude more than 1 mm beyond it.nnnRESULTSnEighteen participants including 3 hand fellowship-trained attending physicians participated for a total of 648 selected screws. The overall rate of ideal screw selection was lower than expected at 49.2%. There was not a statistically significant relationship between rate of ideal screw selection and higher levels of training. Attending surgeons were less likely to place short screws and screws protruding 2 mm or more beyond the volar cortex CONCLUSIONS: Overall, the rate of ideal screw selection was lower than expected. The most experienced surgeons were less likely to place short and excessively long screws.nnnCLINICAL RELEVANCEnBased on the low rate of ideal screws, the authors recommend against overreliance on depth gauging alone when placing screws during surgery. The low-rate ideal screw length selection highlights the potential for future research and development of more accurate technologies to be used in screw selection.

Neuroma in Continuity

Carpal tunnel release is one of the most common procedures performed in the upper extremity and while outcomes are usually very good, complications do occur. Iatrogenic injury to the median nerve is a devastating complication which can be minimized by careful surgical technique. Those patients who sustain an intraoperative nerve injury require careful assessment and meticulous surgical reconstruction in order to maximize their recovery.

Simplified Cable Nerve Grafting with Nerve-Cutting Guides and Fibrin Glue

Cable nerve grafting is the recommended surgical treatment for large peripheral nerve defects. Traditionally, this is performed by bridging a gap in the nerve with multiple autologous nerve cables, repairing the epineurium of each cable to the perineurium of a fascicle of the injured nerve that is similar in size to the graft. The authors present a new technique in which they used nerve-cutting guides to aid in the placement of fibrin glue to secure the sides of the cabled nerve graft together to facilitate handling of the cabled nerve graft and to expedite repair. Freshening the graft nerve ends after the application of fibrin glue using appropriately sized nerve-cutting guides allows for donor-recipient size match and epineurium-to-epineurium repair of the cabled graft to injured nerve. Though further follow-up is needed to determine long-term outcomes following this technique, early results are promising with clinical improvement seen in a similar timeframe to traditional grafting.

Submuscular Versus Subcutaneous Ulnar Nerve Transposition: A Cadaveric Model Evaluating Their Role in Primary Ulnar Nerve Repair at the Elbow

PURPOSEnTo investigate the length gained from subcutaneous and submuscular transposition of the ulnar nerve at the elbow. Specifically, the study aimed to define an expected nerve gap able to be overcome, and to determine if a difference between transposition techniques exists.nnnMETHODSnEleven cadaveric specimens from the scapula to fingertip were procured. In situ decompression and mobilization of the ulnar nerve at the elbow followed by simulated laceration of the nerve was performed. Nerves were marked 5 mm from the laceration site to facilitate overlap measurement and to simulate nerve end preparation to viable fascicles before primary coaptation. Nerve ends were attached to spring gauges set at 100 g of tension (strain ≤ 10%). Measurements of nerve overlap were obtained in varying degrees of wrist (0°, 30°, 60°) and elbow (0°, 15°, 30°, 45°, 60°, 90°) flexion. Measurements were performed after in situ decompression and mobilization, and then repeated after both subcutaneous and submuscular transposition.nnnRESULTSnUlnar nerve transposition was found to increase nerve overlap at an elbow flexion of 30° or greater. No difference was seen between subcutaneous and submuscular transpositions at all wrist and elbow positions. In situ decompression and mobilization alone provided an average of 3.5 cm of length gain with the elbow extended. Transposition in conjunction with clinically feasible wrist and elbow flexion (30° and 60°, respectively) provided 5.2 cm of length gain. Controlling for mobilization, a statistically significant increase in overlap of approximately 2 cm was gained from transposition.nnnCONCLUSIONSnAlthough mobilization combined with wrist and elbow flexion may afford substantial gap reduction and should be used initially when approaching proximal ulnar nerve lacerations, transposition should be considered when faced with a large nerve gap greater than 3 cm at the elbow. No difference was seen between submuscular and subcutaneous transposition techniques.nnnCLINICAL RELEVANCEnThis study defines the extent an ulnar nerve gap at the elbow can be overcome by in situ mobilization, joint positioning, and transposition. It additionally compares thexa0efficacy of submuscular and subcutaneous transposition techniques in closing this gap.

Pediatric Scaphoid Proximal Pole Nonunion With Avascular Necrosis

A 13-year-old, right hand-dominant, otherwise healthy boy presented with left wrist pain 19 months after a nonmotorized scooter injury. Radiographs and magnetic resonance imaging at presentation demonstrated proximal pole scaphoid nonunion with avascular necrosis of the proximal fragment. Operative and nonsurgical treatment options were discussed and the family elected for an attempt at nonsurgical management. The patient was placed in a short-arm thumb spica cast, with a window for a bone stimulator, for 14 weeks. At the conclusion of the treatment, the pain had resolved and x-ray and computed tomography scan demonstrated bony union. The authors recommend considering an initial trial of nonsurgical management for treatment of all pediatric scaphoid nonunions.