Jeffrey G. Stepan

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.

Defending Puts the Anterior Cruciate Ligament at Risk During Soccer A Gender-Based Analysis

Background: Soccer athletes are at risk for anterior cruciate ligament (ACL) injury. To date, there are limited studies on the mechanisms of ACL injuries in soccer athletes and no video-based analysis or sex-based comparison of these mechanisms. Hypothesis: There is no difference in ACL injury mechanisms among soccer athletes by sex. Study design: Case series. Level of evidence: Level 4. Methods: Fifty-five videos of ACL injuries in 32 male and 23 female soccer players were reviewed. Most athletes were professionals (22 males, 4 females) or collegiate players (8 males, 14 females). Visual analysis of each case was performed to describe the injury mechanisms in detail (game situation, player behavior, and lower extremity alignment). Results: The majority of ACL injuries occurred when the opposing team had the ball and the injured athlete was defending (73%). Females were more likely to be defending when they injured their ACLs (87% vs 63% for males, P = 0.045). The most common playing action was tackling (51%), followed by cutting (15%). Most injuries occurred due to a contact mechanism (56%) with no significant difference for sex. Females were more likely to suffer a noncontact injury in their left knee (54%) than males (33%) (P = 0.05). Conclusion: Soccer players are at greatest risk for ACL injury when defending, especially when tackling the opponent in an attempt to win possession of the ball. Females are more likely to injure their ACLs when defending and are at greater risk for noncontact injuries in their left lower extremity. Clinical Relevance: Soccer ACL injury prevention programs should include proper defending and tackling techniques, particularly for female athletes.

Accuracy of patient recall of hand and elbow disability on the QuickDASH questionnaire over a two-year period

BACKGROUND Patient self-reporting questionnaires such as the QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, are critical to current orthopaedic outcomes research. The use of these questionnaires could introduce recall bias in retrospective, case-control, and cross-sectional studies if no preoperative data has been collected prior to study inception. The purpose of this study was to quantify recall accuracy on the QuickDASH questionnaire as a function of the duration of the recall interval. METHODS This cross-sectional study enrolled 140 patients with nontraumatic hand and elbow diseases. Patients were stratified into groups of thirty-five based on the time since their initial office visit (three months, six months, twelve months, or twenty-four months). All patients had completed the QuickDASH as part of a standard intake form at the time of the initial office visit (actual baseline score). Patients were contacted by phone and asked to recall their upper extremity disability from the time of the initial office visit with use of the QuickDASH questionnaire. Patients also completed the QuickDASH to rate their current disability. Actual and recalled QuickDASH scores for each group were statistically compared. Kruskal-Wallis analysis was used to determine any differences in recall accuracy between the groups. Pearson correlation coefficients quantified relations between recall accuracy and patient age and current function (absolute QuickDASH scores). RESULTS Mean differences between recalled QuickDASH scores and actual scores were all less than the QuickDASH minimal clinically important difference (MCID) of 13 points at different time points: three months (-7.1, p < 0.01), six months (0.8, p = 0.79), twelve months (-2.3, p = 0.43), and twenty-four months (-2.8, p = 0.26). There were no significant differences in recall accuracy across the four groups (p = 0.77). Recalled QuickDASH scores were highly correlated with actual baseline values (rp ≥ 0.74). Recall accuracy was neither correlated with patient age nor current QuickDASH scores (rp ≤ 0.04). CONCLUSIONS Patients with a nontraumatic hand or elbow diagnosis are able to recall prior level of function accurately for up to two years with the QuickDASH questionnaire. Although data collected prospectively remain optimal, our data suggest that research conducted with use of recalled QuickDASH scores produces reliable assessment of disability from common upper extremity diagnoses with acceptable recall bias.

Determining the Michigan Hand Outcomes Questionnaire minimal clinically important difference by means of three methods.

Background: To interpret patient-rated outcome measures, clinicians rely on the minimal clinically important difference. The authors studied the range of minimal clinically important difference scores for the overall Michigan Hand Outcomes Questionnaire score its and subscales in a population with various diagnoses and treatments. Methods: Patients with a single, unilateral, atraumatic hand/forearm diagnosis completed the Michigan Hand Outcomes Questionnaire before treatment and at 4 ± 1 weeks and 12 ± 2 weeks after treatment. Three methods were used to calculate the minimal clinically important difference: two anchor question methods based on satisfaction (mean change and receiver operating characteristic) and a statistical distribution method. Results: One hundred eighty-six patients were enrolled, with a baseline median overall questionnaire score of 60.7. Using the mean change method, a minimal clinically important difference of 13 was calculated for the overall questionnaire score. Using a receiver operating characteristic curve (0.8 effect size), the minimal clinically important difference was 9, with an area under the curve of 0.92. When receiver operating characteristic analysis was based on dichotomization of reported satisfaction, the minimal clinically important difference was 12, with an area under the curve of 0.85. Calculating the difference by statistical distribution gave a value of 8. For the subscales, by all methods, triangulated minimal clinically important difference estimates ranged from 10.9 to 14.4. Conclusions: The minimal clinically important difference for the overall Michigan Hand Outcomes Questionnaire score in atraumatic hand/forearm conditions falls between 8 and 13. Multiple analytic methods produce nonidentical but similar minimal clinically important differences. The authors recommend using difference estimates in these ranges when planning a clinical trial to investigate hand/forearm function across a range of diagnoses and treatments.

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.

The Impact of Obesity on Complications of Elbow, Forearm, and Hand Surgeries

PURPOSE To compare the rates of postoperative complications in obese and nonobese patients following elbow, forearm, and hand surgeries. METHODS This case-control study examined 436 patients whose body mass index (BMI) was over 35 and who underwent hand, wrist, forearm, or elbow surgery between 2009 and 2013. Controls were patients (n = 433) with a BMI less than 30 who had similar surgeries over the same period, and who were frequency-matched by type of surgery (ie, bony, soft tissue, or nerve), age, and sex. Postoperative complications were defined as infection requiring antibiotic or reoperation, delayed incision healing, nerve dysfunction, wound dehiscence, hematoma, and other reoperation. Medical comorbidities (e.g., hypertension, diabetes, stroke, vascular disease, kidney disease, and liver disease) were recorded. Chi-square analyses were performed to explore the association between obesity and postoperative complications. Similar analyses were performed stratified by surgery type and BMI classification. Logisticregression modeling was performed to identify predictors of postoperative complications accounting for surgery type, BMI, the presence of comorbidities, patient age, and patient sex. This same model was also run separately for case and control patients. RESULTS The overall complication rate was 8.7% with similar rates between obese and nonobese patients (8.5% vs. 9.0%). Bony procedures resulted in the greatest risk of complication in both groups (15% each group). Multivariate analysis confirmed surgery type as the only significant predictor of complications for nonobese patients. However, among obese patients, both bony surgery and increasing BMI were associated with greater complication rates. CONCLUSIONS Not all obese patients appear to be at any higher risk for complications after elbow, forearm, and hand surgery compared with nonobese patients. However, there appears to be a dose-dependent effect of BMI among obese patients such that increasing obesity heightens the risk of complications, especially for those with a BMI greater than 45. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

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.

Pediatric proximal phalanx fractures: outcomes and complications after the surgical treatment of displaced fractures.

Background: The outcomes literature on proximal phalanx fractures in children is sparse. The purpose of this study is to report the complications and outcomes of displaced proximal phalanx fractures after treatment with closed reduction and percutaneous pinning (CRPP). Methods: A retrospective chart review identified 105 patients treated with CRPP of displaced proximal phalanx fractures. Specific complications were recorded for all patients. Thirty-one of these patients returned >1 year after surgery for assessment including visual analogue scales (VAS) of pain level, functional ability, and esthetics. Objective measurements included range of motion, grip and pinch strength, and finger deformity. Radiographs were taken to assess deformity. Results: Five of the 105 patients (4.8%) had a complication including infection, pin site complication, or malunion. Of the entire group, 36 had stiffness and 31 ultimately underwent hand therapy to regain motion. Subcondylar fractures were associated with a greater likelihood of stiffness. In the 31 patients returning for assessment, the median VAS score was 0 for pain (none), function (full), and esthetics (perfect). Range of motion, grip, and pinch strength were equivalent to the contralateral side. Seven of the 31 patients (22.6%) had a measureable coronal plane deviation averaging 5 degrees (range, 3 to 13 degrees) on radiographs. Deviation was associated with subcondylar fractures and a worse esthetic VAS. Deviation was not associated with worse outcomes overall. Conclusions: Pediatric patients with a displaced proximal phalanx fracture treated with CRPP have an initial notable complication rate related to stiffness; subcondylar proximal phalanx fractures are more commonly affected. At >1-year follow-up, patients had full motion, no pain, and were happy with both function and appearance despite minor deformity in some. These complication data may help better inform patients and families before surgical intervention. Level of Evidence: Level IV—therapeutic.

Epidemiology and Severity of Sports and Recreation Injuries Presenting to a Tertiary Adult Emergency Department

ABSTRACT Objective: This study aims to evaluate all sports and recreation injuries that present to an emergency department, identify the activity and injury patterns associated with hospital admission, and determine injuries that could be better treated in alternative care settings. Methods: This is a retrospective review of all sports injuries that presented to the emergency department of a high volume, urban, tertiary referral center from 1/1/2010 to 12/31/2011. These were identified by a sports term search algorithm applied to all emergency department records. The main outcome measured was hospital admission status after sports injury. Univariate and multivariate regression analysis was performed to identify risk factors for hospital admission in the sports injury population. Results: 1,101 of the 191,259 encounters (0.6%) had 1,210 sports injuries. 84 were admitted (7.6%). Basketball injuries were most prevalent (31.6%). All-terrain vehicle (ATV) related injuries was most often admitted (46.4%). Logistic regression identified ATV riding (95% CI 6.15–23.37, p < 0.001) and age over 50 years-old (4.09–17.40, p < 0.001) as independent risk factors for admission while basketball (0.101–0.985, p = 0.047) and black race (0.17–0.77, p = 0.008) were independently protective. Isolated sprains/strains and soft tissue injuries (4/649, 0.6%) rarely required admission. Conclusions: The 7.6% admission rate is higher than previously reported, likely because the study institution is a tertiary referral center. ATV riding is associated with higher severity injuries that are more likely to require hospital admission. Most sports injuries that present to an emergency department, specifically isolated soft tissue injuries of the extremities, may be more efficiently treated in a non-emergent setting.

Extra-Articular Lipoma Arborescens of the Dorsal Aspect of the Wrist with Invasion of the Extensor Tendons

Lipoma arborescens is a rare, benign proliferative condition affecting synovial-lined anatomic spaces. It is characterized by proliferation of subsynovial fat, responsible for its characteristic imaging findings: fronds of fat-containing villi projecting into a synovial space1-3. It is unclear whether this condition is postinflammatory, neoplastic, or metaplastic4-6. Since it is typically limited to the synovium without invasion of other structures, treatment is simple debridement with synovectomy. Lipoma arborescens commonly affects the knee and to a lesser extent the ankle and hip4-8. It is usually monoarticular, but there are reports of multiple sites involved synchronously and metachronously9-11. Lipoma arborescens rarely affects the upper extremity; a review of the published literature revealed only one previous case reporting the condition as an extra-articular lesion affecting the extrinsic tendons of the hand and wrist11-15. To the best of our knowledge, aggressive growth and invasion of structures outside of the synovium have been reported only twice. Both reports noted osseous erosion of the tumor: one in the shoulder joint and the other in the knee13,16. Disease has also been reported in the subacromial-subdeltoid bursa with an associated rotator cuff tear12. We present a case of extra-articular lipoma arborescens with direct invasion of the extensor tendons in a young patient with a chronic mass on the dorsal aspect of the wrist. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A twenty-four-year-old right-hand dominant woman presented to our office with a mass that was localized to the dorsum of the right wrist and hand. The mass had been present but asymptomatic for eight years. A month prior to presentation, the mass had …