Steven Papp

Proper placement of the distal biceps tendon during repair improves supination strength—a biomechanical analysis

BACKGROUND Anatomic repair of the distal biceps tendon can be difficult to achieve. This study was designed to compare the effect of anatomic and nonanatomic repairs on forearm supination torque. A nonanatomic repair re-establishes the footprint radial and more anterior to the tuberosity apex, whereas an anatomic repair re-establishes the footprint ulnar and more posterior to the tuberosity apex. METHODS Eight fresh frozen cadaver arms were surgically prepared and mounted on an elbow simulator. Controlled loads were applied to the long head and short head in positions of pronation, neutral, and supination. This was done with intact tendons and then repeated with repaired tendons that were repaired either anatomically (ulnar position) or nonanatomically (radial position). RESULTS All anatomic repairs showed no difference compared with intact tendon measurements. In comparing anatomic and nonanatomic repairs, we found no differences in the supination torque when the forearm was in 45° of pronation. However, when the arm was in neutral rotation, we found that 15% less supination torque was generated by the nonanatomic repair. When the arm was tested in 45° of supination, we found that 40% less supination torque was generated in the nonanatomic repair (P = .01). CONCLUSION This study supports the idea that an anatomic repair of the biceps tendon onto the ulnar side of the radial tuberosity is important. If the tendon is repaired too radially, the biceps will lose the cam effect and may not be able to generate full supination torque when the forearm is in neutral rotation or in supination.

Physical Examination of the Wrist

Physical examination of the wrist requires knowledge of wrist anatomy and pathology to make a diagnosis or narrow the differential diagnosis. Symptoms are provoked by palpation and signs are produced by manipulation. Negative findings elsewhere in the wrist are important. Final diagnosis may require diagnostic imaging. By having all three methods of assessment agree one is assured of correct diagnosis. The physical examination of the wrist is not unlike that of other joints, in that a systematic approach includes observation, range of motion, palpation, and special tests.

Negative-Pressure Wound Therapy After Fasciotomy Reduces Muscle-Fiber Regeneration in a Pig Model

BACKGROUND Negative-pressure wound therapy (NPWT) can improve fasciotomy wound closure, but its effects on skeletal muscle are largely unknown. The purpose of this study was to evaluate NPWT effects on skeletal muscle after fasciotomy for compartment syndrome in an animal model and to assess regional variability in muscle fiber regeneration. METHODS Compartment syndrome was induced in the hindlimb of twenty-two adult female pigs with use of a continuous intracompartmental serum-infusion model. Fasciotomy was performed after six hours, and animals were randomized to receive either wet-to-dry gauze dressings (control group) or NPWT dressings (-125 mm Hg, continuous suction) for seven days. Delayed primary wound closure was attempted at seven days, and the peroneus tertius was harvested for analysis seven days or twenty-one days after fasciotomy. Muscles were weighed, and hematoxylin and eosin-stained samples from four regions of the muscle (superficial central, deep central, lateral, and proximal) were mapped for different cellular morphologies. RESULTS Muscle weight was greater in the affected limb at all time points with no difference between treatment groups. At seven days, only the deep central samples in the NPWT group had a significantly greater cross-sectional area containing normal fibers as compared with that found in the controls. By twenty-one days, the deep central, lateral, and proximal regions of the NPWT-treated muscles had a smaller cross-sectional area containing normal fiber morphology and a greater cross-sectional area containing only mononucleated cells as compared with the controls. CONCLUSIONS NPWT did not decrease muscle weight. At twenty-one days, the extent of muscle fiber regeneration after fasciotomy for compartment syndrome was reduced in muscles treated with NPWT for seven days compared with the values in the control group treated with wet-to-dry gauze dressings. CLINICAL RELEVANCE NPWT may be harmful to skeletal muscle after compartment syndrome requiring fasciotomy and local wound care.

A Multicenter Randomized Control Trial Comparing a Novel Intramedullary Device (InterTAN) Versus Conventional Treatment (Sliding Hip Screw) of Geriatric Hip Fractures.

Objectives: To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT). Design: Prospective, randomized, multicenter clinical trial. Setting: Five level 1 trauma centers. Patients: Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. Intervention: Computer generated randomization to either IT (n = 123) or SHS (n = 126). Main Outcome Measurements: The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality. Results: Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT. Conclusions: Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Going Paperless? Issues in Converting a Surgical Assessment Tool to an Electronic Version

Construct: The competence of a trainee to perform a surgical procedure was assessed using an electronic tool. Background: “Going paperless” in healthcare has received significant attention over the past decades given the numerous potential benefits of converting to electronic health records. Not surprisingly, medical educators have also considered the potential benefits of electronic assessments for their trainees. What literature exists on the transition from paper-based to electronic-based assessments suggests a positive outcome. In contrast, work done examining the transition to and implementation of electronic health records has noted that hospitals who have implemented these systems have not gone paperless despite the benefits of doing so. Approach: This study sought to transition a paper-based assessment tool, the Ottawa Surgical Competency Operating Room Evaluation (which has strong evidence for validity) to an electronic version, in three surgical specialties (Orthopedic Surgery, Urology, General Surgery). However, as the project progressed, it became necessary to change the focus of the study to explore the issues of transitioning to a paperless assessment tool as we identified an extremely low participation rate. Results: Over the first 3 months 440 assessment cases were logged. However, only a small portion of these cases were assessed using the electronic tool (Orthopedic Surgery = 16%, Urology = 5%, General Surgery = 0%). Participants identified several barriers in using the electronic assessment tool such as increased time compared to the paper version and technological issues related to the log-in procedure. Conclusions: Essentially, users want the tool to be as convenient as paper. This is consistent with research on electronic health records implementation but different from previous work in medical education. Thus, we believe our study highlights an important finding. Transitioning from a paper-based assessment tool to an electronic one is not necessarily a neutral process. Consideration of potential barriers and finding solutions to these barriers will be necessary in order to realize the many benefits of electronic assessments.

The Effect of Varying Tension of a Suture Button Construct in Fixation of the Tibiofibular Syndesmosis—evaluation Using Stress Computed Tomography

BACKGROUND/PURPOSE There have been no studies assessing the optimal biomechanical tension of suture button constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a stress computed tomography (CT) model. METHODS Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified ankle load frame that allowed for the application of sustained torsional axial or combined torsional/axial loads. The syndesmosis and the deep deltoid ligaments complex were sectioned and the limbs were randomized to receive a suture button construct tightened at 4, 8, or 12 kg. The specimens were loaded under the 3 loading scenarios with CT scans performed after each and at the conclusion of testing. Multiple measurements of translation and rotation were compared with baseline CT scan taken before sectioning. RESULTS Significant lateral (maximum 5.26 mm) and posterior translation (maximum 6.42 mm) and external rotation (maximum 11.71 degrees) was noted with the 4 kg repair. Significant translation was also seen with both the 8 and the 12 kg repairs; however, the incidence was less than with the 4 kg repair. Significant overcompression (ML = 1.69 mm, B = 2.69 mm) was noted with the 12 kg repair and also with the 8 kg repair (B = 2.01 mm). CONCLUSION Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. These constructs also demonstrate overcompression of the syndesmosis; however, the clinical effect of this remains to be determined.BACKGROUND/PURPOSE There have been no studies assessing the optimal biomechanical tension of suture button constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a stress computed tomography (CT) model. METHODS Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified ankle load frame that allowed for the application of sustained torsional axial, or combined torsional/axial loads. The syndesmosis and the deltoid ligament complex were sectioned and the limbs were randomized to receive a suture button construct tightened at 4kg, 8kg, or 12kg. The specimens were loaded under the 3 loading scenarios with CT scans performed after each as well as at the conclusion of testing. Multiple measurements of translation and rotation were compared to baseline CT scan taken prior to sectioning. RESULTS Significant lateral (maximum 5.26mm) and posterior translation (maximum 6.42mm) as well as external rotation (maximum 11.71°) was noted with the 4kg repair. Significant translation was also seen with the both the 8kg and 12 kg repairs however the incidence was less than with the 4kg repair.Significant overcompression (ML=1.69mm, B=2.69mm) was noted with the 12kg repair and also with the 8kg repair (B=2.01mm). CONCLUSION Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. These constructs also demonstrate overcompression of the syndesmosis however the clinical effect of this remains to be determined.

Lateral Elbow Exposures: The Extensor Digitorum Communis Split Compared with the Kocher Approach

Introduction In comparison with the frequently used modified Kocher approach, the extensor digitorum communis (EDC) splitting approach allows improved access to the anterior half of the radial head, which is most commonly fractured, while reducing the risk of iatrogenic injury to the lateral collateral ligament. Step 1 Make the Incision Modified Kocher Approach Make an oblique 7-cm lateral incision beginning at the proximal edge of the lateral epicondyle and extending distally over the center of the radial head toward the posterior ulnar border of the extensor carpi ulnaris muscle belly. Step 2 Develop the Interval Between the Anconeus and the Extensor Carpi Ulnaris Identify and develop the intermuscular interval between the anconeus and the extensor carpi ulnaris. Step 3 Perform the Lateral Elbow Capsulotomy Longitudinally incise the lateral elbow capsule and annular ligament anterior to the lateral ulnar collateral ligament. Step 4 The Extended Modified Kocher Approach Extend the exposure by elevating the common extensor origin (extensor carpi radialis brevis, EDC, and extensor carpi ulnaris) proximally off the lateral epicondyle and reflect it anteriorly. Step 5 Make the Incision EDC Splitting Approach Make a longitudinal oblique 5 to 6-cm lateral incision beginning at the proximal edge of the lateral epicondyle and extending distally over the radial head toward the Lister tubercle. Step 6 Identify and Split the EDC The EDC tendon is identified and bisected longitudinally starting proximally at its origin on the lateral epicondyle and extending 20 mm distally from the radiocapitellar joint. Step 7 Perform the Lateral Elbow Capsulotomy The annular ligament and joint capsule are then incised collinear with the EDC split anterior to the equator of the capitellum. Step 8 Extended EDC Splitting Approach Extend the exposure by detaching the anterior half of the EDC tendon and the extensor carpi radialis brevis tendon from the lateral epicondyle. Step 9 Layered Closure Perform an interrupted layered closure. Results In our recent cadaveric study, we quantitatively compared the modified Kocher and EDC splitting approaches in order to determine which provided the greatest exposure of the anterior aspect of the radial head, which is most commonly fractured.IndicationsContraindicationsPitfalls & Challenges.