Management of Recalcitrant Cubital Tunnel Syndrome

Lauder, Alexander MD; Chen, Christopher MD; Bolson, Rajshri M. MD; Leversedge, Fraser J. MD

doi : 10.5435/JAAOS-D-20-01381

August 1, 2021 - Volume 29 - Issue 15 - p 635-647

Cubital tunnel syndrome is a common upper extremity compressive neuropathy. Recalcitrant cubital tunnel syndrome poses diagnostic and treatment challenges. Potential etiologies of persistent or recurrent symptoms after surgical treatment include an inaccurate preoperative diagnosis, incomplete nerve decompression, iatrogenic injury, postsurgical perineural adhesions, irreversible nerve pathology, or conditions associated with secondary nerve compression. Confirmation of recalcitrant ulnar nerve pathology relies on a thorough history to consider symptoms and chronology, careful examination to quantify nerve function and to assess for focal nerve provocation, and objective testing to highlight a possible nerve lesion such as ultrasonography and electrodiagnostic testing. Conservative treatment may provide symptomatic relief; however, surgical management such as revision neuroplasty, neurolysis, nerve reconstruction, and/or anterior transposition may be indicated. Optimizing the biology of the local nerve environment is critical. No surgical treatment procedure has shown superiority over another; however, individualized treatment is emphasized to improve symptoms and maximize nerve recovery potential.

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Baseball Injuries of the Hand and Wrist

Gallant, Gregory G. MD, MBA; Tulipan, Jacob E. MD; Rivlin, Michael MD; Ilyas, Asif M. MD, MBA

doi : 10.5435/JAAOS-D-20-00101

August 1, 2021 - Volume 29 - Issue 15 - p 648-658

Injuries of the hand and wrist are common in baseball. Because of the unique motions and loads encountered in this sport, physicians treating baseball players may encounter hand and wrist injuries ranging from common to rare. An understanding of these baseball-related injuries must include their pathoanatomy, diagnosis, and treatment options. This knowledge is critical for the general orthopaedic surgeon treating baseball players to allow for timely and appropriate treatment. This article reviews the pathophysiology, diagnosis, and treatment of baseball-related hand and wrist injuries, with a target audience of general orthopeadic surgeons.

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Postoperative Digit and Hand Replantation Protocols: A Review of the Literature

Chen, Christopher MD; Scott, Frank MD; Ipaktchi, Kyros R. MD; Lauder, Alexander MD

doi : 10.5435/JAAOS-D-20-01176

August 1, 2021 - Volume 29 - Issue 15 - p e732-e742

Successful replantation and revascularization of the hand and digit require a skilled team with urgent access to an operating room with microsurgical capabilities. Although careful indications and surgical techniques contribute to success, postoperative management also plays a vital role in the survival of a replanted digit. Previous research has assessed surgical efficiency and techniques to conduct these procedures, but few studies evaluate postoperative protocols to care for patients undergoing these procedures. Because of the lack of high-level evidence specific to replantation, many common postoperative practices related to monitoring, anticoagulation, and diet have been inferred from elective microsurgical procedures, despite notable differences in operating conditions. The highest level of evidence pertaining to digital replantation was found with the use of peripheral nerve blockade, leeching/bleeding, and nicotine use. This review provides an in-depth evaluation of the literature and insight into the rationale and level of evidence that support each postoperative intervention. It highlights institutional variability and a paucity of high-level evidence pertaining to this topic while identifying the areas of future research.

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Megaprostheses in Nononcologic Hip and Knee Revision Arthroplasty

Melnic, Christopher M. MD; Lightsey, Harry M. IV MD; Lozano Calder?n, Santiago A. MD, PhD; Heng, Marilyn MD, MPH, FRCSC

doi : 10.5435/JAAOS-D-20-01052

August 1, 2021 - Volume 29 - Issue 15 - p e743-e759

Megaprostheses as a means of limb salvage originated in orthopaedic oncology, and implant evolution was initially driven by developments within this field. Improvements in imaging modalities and in chemotherapeutics prolonged patient survival and promoted a transformation in the surgeon's mentality from salvage operation to functional limb reconstruction. As primary arthroplasty operations became more popular, megaprostheses found new utility in hip and knee revision arthroplasty. In this capacity, these implants provided much needed alternatives to traditional arthroplasty revision options for addressing massive bone loss and complex periprosthetic fractures. The indications for megaprostheses continue to expand with advances in design, stability, and overall longevity. Thus, greater numbers of orthopaedic surgeons in arthroplasty and traumatology have to be familiar with this technology. Importantly, each anatomic location presents unique considerations for reconstruction; however, additional variables such as the quantity of bone loss, the quality of remaining bone stock, and fracture type also influence implant selection. Ultimately, there is still much to be optimized in the use of megaprostheses for hip and knee revision arthroplasty. High multifactorial complication and revision surgery rates compared with conventional prostheses make these implants for many a “last resort” option.

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American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Early Screening for Psychosocial Risk and Protective Factors

Piuzzi, Nicolas S. MD; Ring, David MD, PhD

doi : 10.5435/JAAOS-D-20-00810

August 1, 2021 - Volume 29 - Issue 15 - p e760-e765

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons (AAOS) have developed Appropriate Use Criteria for the Early Screening for Psychosocial Risk and Protective Factors. Evidence and clinical expertise were used to develop criteria for addressing mental and social health opportunities to help people recover from musculoskeletal injuries to the extremity, spine, and pelvis. The criteria were developed by identifying observable symptoms and results of screening that suggest mental and social health challenges among patients with lower extremity trauma in clinical practice. The 32 patient scenarios and three interventions (evaluate for psychological distress, evaluate for social health opportunities, and evaluate coping and resilience strategies) were developed by the writing panel of clinicians who are specialists in mental and social health in musculoskeletal illness. Next, a separate, multidisciplinary, voting panel made up of specialists and nonspecialists rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as “appropriate” (median rating, 7 to 9), “may be appropriate” (median rating, 4 to 6), or “rarely appropriate” (median rating, 1 to 3). Notably, with a high level of agreement, the voting panel determined that interventions to address mental and social health were appropriate in all scenarios as follows: 86% were rated appropriate, 14% were rated possibly appropriate, and none were rated rarely appropriate.

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American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Psychosocial Risk and Protective Factors

Ring, David MD, PhD; Miller, Melissa LMSW; Corral, Cynthia LCSW-S

doi : 10.5435/JAAOS-D-20-01377

August 1, 2021 - Volume 29 - Issue 15 - p e766-e768

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An Analysis of Formal Patient Complaints and Malpractice Events Involving Hand and Upper Extremity Surgeons

Grandizio, Louis C. DO; Barreto Rocha, Daniela F. MD; Piper, James Paul MD; Hayes, Daniel S. BS; Klena, Joel C. MD

doi : 10.5435/JAAOS-D-21-00073

August 1, 2021 - Volume 29 - Issue 15 - p 659-665

Our purpose was to define and categorize patient complaints within a hand surgery practice over a 10-year period. In addition, we aimed to define surgeon and patient factors associated with formal complaints.

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Immediate Weight Bearing of Plated Both-Bone Forearm Fractures Using Eight Cortices Proximal and Distal to the Fracture in the Polytrauma Patient Is Safe

Marchand, Lucas S. MD; Horton, Steven MD, MS; Mullike, Alexandra BS; Goel, Ritu MS OTR/L; Krum, Nicole DPT, NCS; Ochenjele, George MD; O'Hara, Nathan MPH; O'Toole, Robert V. MD; Eglseder, W. Andrew MD; Pensy, Raymond MD

doi : 10.5435/JAAOS-D-20-01252

August 1, 2021 - Volume 29 - Issue 15 - p 666-672

Rehabilitation of trauma patients is facilitated by surgical stabilization permitting weight bearing (WB) of the fractured extremity. Both-bone forearm fracture (BBFx) plate osteosynthesis is an accepted technique with high union and low complication rates; yet, postoperative WB protocols have not been adequately investigated. There exists concern for increased complications in plated BBFx fractures for patients prescribed immediate WB. We hypothesized that immediate WB of surgically treated BBFxs results in acceptable rates of complications.

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Should Insulin-dependent Diabetic Patients Be Screened for Malnutrition Before Total Joint Arthroplasty? A Cohort at Risk

Schneider, Andrew M. MD; Brown, Nicholas M. MD

doi : 10.5435/JAAOS-D-20-00729

August 1, 2021 - Volume 29 - Issue 15 - p 673-680

The association of malnutrition in the morbidly obese cohort has led to recommendations for preoperative screening before total joint arthroplasty (TJA). However, despite the connection between diabetes and poor nutrition, preoperative screening in the diabetic cohort has not been closely examined. This study compared malnutrition risk between diabetic patients and morbidly obese patients undergoing TJA and investigated the association of malnutrition on 30-day postoperative TJA outcomes in the diabetic cohort.

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Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty: A Matched Cohort Analysis

Tirumala, Venkatsaiakhil MS; Bounajem, Georges MD; Klemt, Christian PhD; Barghi, Ameen MD; Kwon, Young-Min MD, PhD

doi : 10.5435/JAAOS-D-20-00795

August 1, 2021 - Volume 29 - Issue 15 - p e769-e781

Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA.

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