Samir K. Trehan

Nerve Repair and Nerve Grafting

Direct repair and nerve autografting are primary options in the treatment of upper extremity peripheral nerve injuries. Deciding between these surgical options depends on the mechanism of injury, time since injury, and length of repair defect. Principles of direct repair and nerve autografting are reviewed. Finally, a literature-based review of the outcomes of upper extremity peripheral nerve repair and autografting is provided. Taken together, this article provides relevant and recent data for surgeons regarding patient selection, technique selection, surgical technique, surgical outcomes, and prognostic factors that will aid surgeons treating patients with upper extremity peripheral nerve injuries.

Online Patient Ratings of Hand Surgeons

PURPOSE To evaluate factors associated with positive online patient ratings and written comments regarding hand surgeons. METHODS We randomly selected 250 hand surgeons from the American Society for Surgery of the Hand member directory. Surgeon demographic and rating data were collected from 3 physician review Web sites (www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com). Written comments were categorized as being related to professional competence, communication, cost, overall recommendation, staff, and office practice. Online presence was defined by 5 criteria: professional Web site, Facebook page, Twitter page, and personal profiles on www.Healthgrades.com and/or www.Vitals.com. RESULTS A total of 245 hand surgeons (98%) had at least one rating among the 3 Web sites. Mean number of ratings for each surgeon was 13.4, 8.3, and 1.9, respectively, and mean overall ratings were 4.0 out of 5, 3.3 out of 4, and 3.8 out of 5 stars on www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, respectively. Positive overall ratings were associated with a higher number of ratings, Castle Connolly status, and increased online presence. No consistent correlations were observed among online ratings and surgeon age, sex, years in practice, practice type (ie, private practice vs academics), and/or geographic region. Finally, positive written comments were more often related to factors dependent on perceived surgeon competence, whereas negative comments were related to factors independent of perceived competence. CONCLUSIONS Physician review Web sites featured prominently on Google, and 98% of hand surgeons were rated online. This study characterized hand surgeon online patient ratings as well as identified factors associated with positive ratings and comments. In addition, these findings highlight how patients assess care quality. CLINICAL RELEVANCE Understanding hand surgeon online ratings and identifying factors associated with positive ratings are important for both patients and surgeons because of the recent growth in physician-rating Web sites.

Online Patient Ratings: Why They Matter and What They Mean

The increasing focus on patient satisfaction and consumer-driven health care, combined with the recent rise in online social media, have resulted in the growing trend of patients rating physicians on publicly accessible Web sites. The number and use of such Web sites continue to grow despite potential concerns about the validity of these ratings and negative physician perception. These Web sites can influence patient decision making regarding physician selection. In this article, we review the literature regarding the use of such Web sites by patients, the validity of these ratings, potential implications for hand surgical practice, and methods to minimize or challenge inaccurate reviews.

Rating a Sports Medicine Surgeon’s “Quality” in the Modern Era: an Analysis of Popular Physician Online Rating Websites

BackgroundConsumer-driven healthcare and an increasing emphasis on quality metrics have encouraged patient engagement in the rating of healthcare. As such, online physician rating websites have become mainstream and may play a potential role in future healthcare policy.Questions/PurposesThe purpose of this study was to evaluate online patient ratings for US sports medicine surgeons, determine predictors of positive ratings and analyze for inter-website scoring correlation.MethodsThe American Orthopedic Society for Sports Medicine (AOSSM) member directory was sampled. Surgeon demographic and rating data were searched on three online physicians rating websites: HealthGrades.com (HG), RateMDs.com (RM) and Vitals.com (V). Written rating comments were categorized as relating to the following: surgeon competence, surgeon affability and process of care. Bivariate linear regression, Pearson correlation and multivariable analyses were used to determine factors associated with positive ratings.ResultsTwo hundred seventy-five sports medicine surgeons were included. Two hundred seventy-one (99%) had ratings on at least one of the three websites. Sports surgeons were rated highly across all three websites (mean >4.0/5); however, there was only a low to moderate degree of correlation among websites. On HG, female surgeons and surgeons in academia were more likely to receive higher overall ratings. Across all three websites, increased number of years in practice inversely correlated with ratings; this relationship neared significance for HG and was significant for RM. A surgeon’s online presence or geographic location was not associated with higher ratings. In multivariable regression analysis for ratings on HG, female sex was the only significant predictor of higher ratings. Two thousand three hundred forty-one written comments were analyzed: perceived surgeon competence and communication influenced the direction of ratings for the top and bottom tier surgeons.ConclusionThere was a low degree of correlation among online websites for surgeon ratings. Female surgeons and those with fewer years in practice appear to have higher ratings on these websites; comment content analysis suggests that high and low ratings are influenced by perceived surgeon competence and affability.

The effect of simulated elbow contracture on temporal and distance gait parameters

BACKGROUND Elbow contractures can be functionally debilitating. Extensive research has been published on treatments to restore elbow motion, but few have discussed clinical implications beyond the affected extremity. Reciprocal arm swing in normal gait has been shown to increase stability and reduce energy expenditure. The importance of arm swing has been clinically demonstrated in patients with cerebral palsy, stroke and Parkinsons disease. We hypothesized that elbow contractures would result in an abnormal spatio-temporal gait parameters. METHODS Forty volunteer subjects walked on the Gaitmat II which provided real-time analysis of temporal and distance gait parameters. Five conditions were tested: no brace (control 1), elbow brace unlocked (control 2) and brace locked in 30°, 90° or 120° flexion (simulating fixed elbow contractures). Condition order was randomized for each subject. Each condition consisted of five walking trials. RESULTS All three fixed elbow conditions (120°, 90° and 30°) demonstrated significantly decreased gait velocity (1.37, 1.39 and 1.39m/s) and stride length (1.45, 1.46 and 1.46m) compared to the control condition (1.42m/s and 1.48m, respectively). Single limb stance and double support times were decreased and increased, respectively, compared to control. There was no significant difference in cadence or limb asymmetry in the three fixed elbow conditions. CONCLUSIONS Despite well-established functional limitations in elbow contracture patients and importance of arm swing in normal gait, the impact of elbow contractures on gait is unknown. This study demonstrates that simulated elbow contracture results in significant differences in spatio-temporal gait parameters suggesting that elbow contractures have a broader functional impact beyond the affected extremity. LEVEL OF EVIDENCE II.

Characteristics of Glomus Tumors in the Hand Not Diagnosed on Magnetic Resonance Imaging

PURPOSE To determine whether the diagnosis of hand glomus tumors by magnetic resonance imaging (MRI) is associated with tumor size, tumor pathology, tumor location, and/or clinical suspicion. METHODS We reviewed our pathology database for patients with hand glomus tumors diagnosed between 2006 and 2013 and included those patients who had preoperative MRI at our institution. We excluded patients with recurrent and persistent tumors. Magnetic resonance imaging reports were reviewed for clinical history, tumor location, and associated bone erosion. Pathology reports were reviewed for diagnosis and tumor size. We classified MRI studies as positive (glomus tumor diagnosis), negative (no mention of glomus tumor as possible diagnosis), or indeterminate (glomus tumor mentioned as possible differential diagnosis). Fisher exact test was used to compare positive studies and those that were nondiagnostic (ie, either negative or indeterminate). RESULTS Of the 46 patients who had pathologically confirmed hand glomus tumors, 38 had preoperative MRI studies. A total of 24 MRI studies were positive, 5 were indeterminate, and 7 were negative. Five patients had atypical pathology, 1 had a multifocal tumor, and 2 had extra-digital hand glomus tumors. Failure to diagnose glomus tumors on MRI was associated with atypical pathology, atypical location (ie, not located in the subungual region), absence of bone erosion, and lack of clinical suspicion. Tumor size was not associated with MRI diagnosis. CONCLUSIONS In this series of 36 hand glomus tumors, one-third of MRI studies were nondiagnostic. Occurrence of nondiagnostic MRIs was more likely when glomus tumors were pathologically and/or anatomically atypical, without bone erosion, and with no or unrelated clinical history provided. These findings highlight the continued importance of clinical suspicion in glomus tumor diagnosis. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.

Coronal Shift of Distal Radius Fractures: Influence of the Distal Interosseous Membrane on Distal Radioulnar Joint Instability

ISTAL RADIUS FRACTURES ARE frequently associated with distal radioulnar joint (DRUJ) injury and a substantial proportion of patients develop symptomatic instability after fracture union. Distal radioulnar joint instability can lead to ulnarsided wrist pain, painful or limited forearm rotation, grip strength weakness, and/or degenerative arthritis. Distal radioulnar joint stability depends on the triangular fibrocartilage complex (TFCC), bony articulation between the ulnar head and sigmoid notch of the radius with its fibrocartilaginous rim, dorsal and palmar radioulnar ligaments, distal interosseous membrane (DIOM), and the musculotendinous units of the extensor carpi ulnaris and pronator quadratus. Cadaveric studies have demonstrated that the primary stabilizer of the DRUJ is the TFCC (specifically the radioulnar ligaments) and that the DIOM is an important secondary stabilizer of the DRUJ. 1,2 In the setting of a distal radius fracture, the usually intact DIOM has a central role in DRUJ stability because the TFCC is frequently injured. The DIOM is an isometric stabilizer of the forearm and its stabilizing effect has been attributed to its resting tension. 1 A recent anatomic study defined the DIOM as originating palmar and proximal on the ulna and inserting distal and dorsal on the radius, thus providing a structural basis for its function in resisting dorsal translation of the radius in supination. 3 In addition, approximately 40% of patients have a distinct ligamentous thickening of the DIOM known

Scapholunate Advanced Collapse: Nomenclature and Differential Diagnosis

S CAPHOLUNATE ADVANCED COLLAPSE (SLAC) was first described by Watson and Ballet upon identifying common radiographic patterns of arthritis in 210 wrists among 4000 radiographs. They described 3 stages of SLAC: arthritis that involves (1) the articulation between the radial styloid and scaphoid distal pole (Fig. 1), (2) the entire radioscaphoid articulation (Fig. 2), and (3) the capitolunate articulation (Fig. 3). Others have described a fourth stage of radiolunate involvement in 14% to 83% of patients. Despite the universal presence of lunate dorsal tilt (ie, dorsal intercalated segment instability [DISI]), Watson and Ballet observed that the radiolunate joint was always spared arthritic involvement because of its congruence in all rotational postures. Importantly, patients with inflammatory arthritis were excluded from the analysis. However, subsequent authors have suggested that the definition be expanded to include crystalline arthropathy or scaphotrapezium-trapezoidal (STT) arthritis in the SLAC staging paradigm. The classic presenting symptoms of SLAC include wrist pain with activity, loss of motion, swelling, and periscaphoid tenderness. This presentation should prompt a diagnostic evaluation in which other potential causes are ruled out. Wrist arthritis may develop secondary to crystalline arthropathy, inflammatory arthritis, STT arthritis, or scaphoid nonunion. Hand surgeons must distinguish between these diagnoses given their differing etiologies and natural histories, to provide appropriate treatment. History, physical examination, and radiographs are generally sufficient for

Baseball and Softball Injuries: Elbow, Wrist, and Hand

ASSH Disclaimer: The material presented in this CME activity is mad ASSH for educational purposes only. This material is not intended to methods or the best procedures appropriate for the medical situation rather it is intended to present an approach, view, statement, or opin that may be helpful, or of interest, to other practitioners. Examinees a in this medical education activity, sponsored by the ASSH, with fu awareness that they waive any claim they may have against the ASS any information presented. The approval of the US Food and Drug required for procedures and drugs that are considered experimenta systems discussed or reviewed during this educational activity may not

Glomus Tumors in the Foot Case Series

Glomus tumors are painful, benign neoplasms that frequently are associated with delayed diagnosis. Commonly in the hand, they rarely present in the foot. The purpose of this case series is to characterize the clinical presentation, radiology, pathology, and surgical outcomes associated with foot glomus tumors. We reviewed our pathology database for patients with foot glomus tumors diagnosed between 1995 and 2013. Medical records including physician notes, pathology, and radiology were reviewed. Eleven patients had foot glomus tumors excised at our institution during the study period. The mean age was 45.4 (range = 28-60) years. One patient was lost to follow-up. Mean follow-up for the remaining 10 patients was 44.7 (range = 3-142) months. Ten tumors were located in the subungual region, while 1 was located in the plantar pulp of the distal phalanx. All patients presented with pain. Point tenderness, cold hypersensitivity, and nail abnormalities were variably documented but frequently present. Four patients had had prior surgery for an ingrown toenail prior to presentation at our institution. Six patients had preoperative magnetic resonance imaging studies, which were diagnostic of glomus tumor in all cases except one. Radiographs failed to provide diagnosis in all 8 patients for whom they were obtained. Postoperatively, all patients had complete symptom relief with no recurrences.In conclusion, this case series demonstrates that foot glomus tumors frequently present with classic symptoms including pain, point tenderness, and cold hypersensitivity. When clinically suspected, magnetic resonance imaging should be obtained. Marginal excision results in symptom relief and cure. Level of Evidence: Therapeutic, Level IV: Case series