Ram K. Alluri

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.

Preoperative risk factors for discharge to a postacute care facility after shoulder arthroplasty

BACKGROUND Shoulder arthroplasty procedures are becoming increasingly prevalent in the United States due to expanding indications and an aging population. Most patients are discharged home, but a subset of patients is discharged to a postacute care (PAC) facility. The purpose of this study was to identify the risk factors for discharge to a PAC facility after shoulder arthroplasty. METHODS The Nationwide Inpatient Sample discharge records from 2011 to 2012 were analyzed for patients who underwent a total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). Patient and hospital characteristics were identified. Univariate and multivariate analysis were used to determine the statistically significant risk factors for discharge to a PAC facility while controlling for covariates. RESULTS In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 TSAs and 44,893 RTSAs were identified. RTSA patients were 1.3 times as likely to be discharged to a PAC facility as TSA patients (P = .001). Medicare patients were 2 times as likely to be discharged to a PAC facility than those with private insurance (P < .001). In addition, women and patients presenting with a fracture, older age, or an increasing number of medical comorbidities were more likely to be discharged to a PAC facility (P < .001). CONCLUSION The risk factors identified in our study can be used to stratify patients at high risk for postoperative discharge to PAC, allowing for greater improvement in overall care and the facilitation of postoperative discharge planning.

Effect of Insurance on Rates of Total Ankle Arthroplasty Versus Arthrodesis for Tibiotalar Osteoarthritis

Background: Several studies have examined the effect of insurance on the management of various orthopedic conditions. The purpose of our study was to assess the effect of insurance and other demographic factors on the operative management of tibiotalar osteoarthritis. Methods: The National Inpatient Sample (NIS) database was used to identify patients who underwent a total ankle arthroplasty (TAA) or tibiotalar arthrodesis (TTA) for tibiotalar osteoarthritis. Insurance status was identified for each patient, and the proportions of each insurance type were computed for each operative modality. A multivariate analysis was performed to account for confounding variables to isolate the effect of insurance type on operative treatment. Results: From 2007 to 2012, a total of 10 010 patients (35.6%) were identified who underwent a total ankle replacement (TAR) procedure and 18 094 patients (64.4%%) who underwent TTA for tibiotalar osteoarthritis. Patients receiving a TAR were older (65.8 vs 64.2, P < .001), more likely to be female (54% vs 51%, P < .001), and had fewer comorbidities (4.2 vs 4.5, P < .001) than patients who underwent a TTA. After controlling for baseline differences, patients with Medicare (odds ratio [OR] 3.00, P < .001), and private insurance (OR 3.19, P < .001) were approximately 3 times more likely to undergo TAR than patients with Medicaid. Conclusions: Patients with tibiotalar osteoarthritis were more likely to receive a TAR procedure if they had Medicare or private insurance compared with patients who had Medicaid. Further research should be done to better understand the drivers of this phenomenon if equitable care is to be achieved. Level of Evidence: Level II, prognostic study.

Utility of Postoperative Imaging in Radial Shaft Fractures.

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.

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

Background: Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. Currently, there are no clear guidelines dictating which patients may benefit from early operative exploration. The purpose of this study was to identify clinical variables that were predictive of abnormal intraoperative findings in patients who sustained an upper extremity dog bite injury. Methods: All patients who presented to a level I trauma center between 2007 and 2015 with an upper extremity dog bite injury who underwent subsequent surgical exploration were retrospectively screened for inclusion in our study. Patients with inadequate documentation or preexisting neurovascular or motor deficits were excluded. Abnormalities on physical exam and injuries encountered during surgical exploration were recorded for each patient. Contingency tables were constructed comparing normal and abnormal nerve, tendon, and vascular physical exam findings with intact or disrupted neurovascular and musculotendinous structures identified during surgical exploration. Results: Between 2007 and 2014, 117 patients sustained a dog bite injury to the upper extremity, of which 39 underwent subsequent surgical exploration and were included in our analysis. Sixty-nine percent of patients with neuropraxia on exam had intraoperative nerve damage. Seventy-seven percent of patients with an abnormal tendon exam had intraoperative musculotendinous damage. One hundred percent of patients with an abnormal vascular physical exam had intraoperative arterial injury. Conclusions: To date, there are no clear guidelines on what clinical criteria indicate the need for operative exploration and possible repair of neurovascular structures in upper extremity dog bite injuries. In our study, nerve, tendon, and vascular abnormalities noted on physical exam were strongly predictive of discovering neurovascular and musculotendinous damage during surgical exploration.

Gene Therapy to Enhance Bone and Cartilage Repair in Orthopaedic Surgery

Musculoskeletal conditions are a major public health problem. Approximately 66 million individuals seek medical attention for a musculoskeletal injury in the United States, with current medical costs being estimated at

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

873 billion annually. Despite advances in pharmaceuticals, implant materials and surgical techniques, there remains an unmet clinical need for successful treatment of challenging musculoskeletal injuries and pathologic conditions, particularly in the setting of compromised biological environments. Tissue engineering via gene therapy attempts to provide an alternative treatment strategy to address the deficits associated with conventional approaches. The transfer of specific target genes coding for proteins with therapeutic or regenerative properties to target cells and tissues in the disease environment allows for their sustained production and release specifically at the site of interest. The increasing reports of success with gene therapy-based treatments in the clinical management of a variety of diseases provide genuine optimism that similar methods can be adapted for mainstream clinical application in musculoskeletal disorders. In preclinical studies, gene therapy has been successfully used to treat cartilaginous, bone, skeletal muscle, tendon, ligament and intervertebral disk injuries. In addition, gene therapy is being assessed in clinical trials for its safety and therapeutic potential in osteoarthritis. This review will specifically address the clinical potential, preclinical data and future hurdles for gene therapy to be a viable clinical entity for the treatment of fracture nonunion and difficult bone repair scenarios, articular cartilage repair and osteoarthritis.

Acute Isolated Flexor Tendon Laceration Associated With a Distal Radius Fracture

PURPOSE To compare the biomechanical properties of second versus third metacarpal distal fixation when using a radiocarpal spanning distraction plate in an unstable distal radius fracture model. METHODS Biomechanical evaluation of the radiocarpal spanning distraction plate comparing second versus third metacarpal distal fixation was performed using a standardized model of an unstable wrist fracture in 10 matched-pair cadaveric specimens. Each fixation construct underwent a controlled cyclic loading protocol in flexion and extension. The resultant displacement and stiffness were calculated at the fracture site. After cyclic loading, each specimen was loaded to failure. The stiffness, maximum displacement, and load to failure were compared between the 2 groups. RESULTS Cyclic loading in flexion demonstrated that distal fixation to the third metacarpal resulted in greater stiffness compared with the second metacarpal. There was no significant difference between the 2 groups with regards to maximum displacement at the fracture site in flexion. Cyclic loading in extension demonstrated no significant difference in stiffness or maximum displacement between the 2 groups. The average load to failure was similar for both groups. CONCLUSIONS Fixation to the third metacarpal resulted in greater stiffness in flexion. All other biomechanical parameters were similar when comparing distal fixation to the second or third metacarpal in distal radius fractures stabilized with a spanning internal distraction plate. CLINICAL RELEVANCE The treating surgeon should choose distal metacarpal fixation primarily based on fracture pattern, alignment, and soft tissue integrity. If a stiffer construct is desired, placement of the radiocarpal spanning plate at the third metacarpal is preferred.

Database studies: an increasing trend in the United States orthopaedic literature

Background: Subacute rupture of the flexor tendons secondary to distal radius fractures is well documented. Recently, accounts of flexor tendon rupture following open reduction internal fixation have been associated with volar plate fixation. However, discovery of an occult traumatic flexor tendon laceration during fixation of an acute distal radius fracture is not well described. This case indicates the importance of careful preoperative and intraoperative examination of the flexor tendons in the setting of comminuted distal radius fractures. Methods: A forty-seven-year-old male sustained a comminuted, dorsally displaced distal radius fracture. Initial and post-reduction examinations revealed no gross functional abnormalities. Upon operative fixation of the fracture, laceration of the flexor digitorum profundus (FDP) tendon to the index finger was incidentally noted at the level of the fracture site. Results: Due to extensive dorsal comminution, shortening, and the presence of a lunate facet fragment, we performed volar fragment-specific and dorsal spanning bridge plate fixation. The proximal and distal ends of the FDP tendon were marked, but repair was deferred until implant removal. This allowed for proper informed consent and avoided potential compromise of the repair given the presence of a volar implant. Conclusions: Acute flexor tendon rupture secondary to closed distal radius fractures may go unnoticed if a high index of suspicion is not maintained. Delayed diagnosis of these ruptures convolutes the mechanism of injury and disrupts the recovery process. Hand surgeons should be vigilant in examining flexor tendon function during the preoperative evaluation, especially in the setting of acute high-energy injury.

Volar, Intramedullary, and Percutaneous Fixation of Distal Radius Fractures.

Background:There has been a recent increase in the number of orthopaedic publications using large-scale databases. The purpose of this study was to examine current database publication trends in the United States orthopaedic literature. In addition, we briefly discuss the strengths and limitations of the most utilized databases. Methods:PubMed was queried, and all abstracts and text were screened by two authors to insure that they reported on an orthopaedic topic using database findings. Studies from international databases, single-center databases, specialty-specific registries, and review articles were excluded. Annual and subspecialty trends were analyzed using Spearman correlation. Significance was set at P<0.05. Results:Our initial search yielded 1080 articles, of which 306 met inclusion criteria. There was a significant increase in the number of database studies published from 2004 to 2014, and an almost two-fold increase in the number of published studies from 2013 to 2014. The Journal of Bone and Joint Surgery, Spine (Phila Pa 1976), and Clinical Orthopaedics and Related Research had the most database publications over the period examined. Spine, joints, and sports subspecialties published the most database studies. Conclusions:There has been a large increase in the number of database studies published in United States orthopaedic literature, with the most dramatic increase observed between 2013 and 2014. Understanding the general strengths and limitations of these databases, as well as the differences between the various types of databases, is essential to fully understand this medium of orthopaedic research.