Publications by Year: 2020

PURPOSE: To determine the rate of and risk factors for complications in solid organ transplant (SOT) patients who have had surgery of the upper extremity.

METHODS: All SOT recipients who had an upper extremity procedure performed by 1 of 6 surgeons at our institution were identified from 2006 to 2018. Demographic data, transplant date and type, upper extremity surgery procedure and date, antirejection medications, American Society of Anesthesiologists Physical Status Classification System (ASA) score, and complications were recorded. Complications were defined as any surgical complication within 1 year and any medical complication within the first 30 days after surgery. Complications were categorized according to the Clavien-Dindo classification system.

RESULTS: Fifty-one upper extremity procedures in 32 SOT patients were included. Of the 51 procedures, 21 were complicated, for an overall complication rate of 41%. Surgical complications occurred equally before and after 30 days with infection being the most common. Only 1 of the procedures resulting in surgical site infection had an implant (temporary K-wire fixation). The majority of complications were grade II, and there were no grade IV or V complications. Age, ASA score, type or number of SOT, and immunosuppressive regimens were similar between complicated and noncomplicated procedures. Procedures involving male patients were more likely to be complicated than those involving female patients.

CONCLUSIONS: Complications after upper extremity operations are common in SOT patients, and surgical complications often occur after 30 days. Surgeons should counsel this population that they carry a higher complication risk than the general population and may require longer-term monitoring after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

PURPOSE: The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale.

METHODS: We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008-2018). Preoperative and postoperative range of motion, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed.

RESULTS: We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry's translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen.

CONCLUSIONS: The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

BACKGROUND:  This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes.

METHODS:  All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs).

RESULTS:  Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15-2.87, p = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0-1.94, p = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22-2.12, p < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times.

CONCLUSION:  DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars.

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

Gunshot-related injuries remain a significant and important cause of global morbidity and cost. The foot and ankle has certain anatomic and functional considerations that make gunshot-related injuries challenging to manage. While the scientific literature regarding gunshot-related injuries is extensive, little of the existing literature focuses on the foot and ankle. While principles of management can be somewhat extrapolated from the current literature, an understanding of the body of work specific to the foot and ankle is valuable. Therefore, this review provides an overview of ballistic injuries to the foot and ankle as well as specific guidelines to aid surgeons in treating these difficult injuries. Level of Evidence: Level V, expert opinion.

INTRODUCTION: Recent studies in general surgery and internal medicine have shown that female physicians may have improved morbidity and mortality compared with their male counterparts. In the field of orthopaedic surgery, little is known about the influence of surgeon gender on patient complications. This study investigates patient complications after hip and knee arthroplasty based on the gender of the treating surgeon.

METHODS: Using a risk-adjusted outcomes database of 100% Medicare data from a third party, an analysis of outcomes after primary hip and knee arthroplasty based on surgeon gender was performed. This data set, which provided risk-adjusted complication rates for each surgeon performing at least 20 primary knee or hip arthroplasties from 2009 to 2013, was matched with publically available Medicare data sets to determine surgeon gender, year of graduation, area of practice, and surgical volume. Confounding variables were controlled for in multivariate analysis.

RESULTS: Of the 8,965 surgeons with identified gender, 187 (2.0%; 187 of 8,965) were identified as women and performed 21,216 arthroplasties (1.4%; 21,216 of 1,518,419). Overall, female surgeons averaged fewer arthroplasties (total knee arthroplasty: 87.0 versus 124.9 [P < 0.001]; total hip arthroplasty [THA]: 62.8 versus 78.8 [P = 0.02]) and were earlier in their practice (20.6 versus 25.0 years; P < 0.001) compared with their male counterparts. Male and female surgeons had similar adjusted complication rates for THA (2.78% versus 2.84%) and total knee arthroplasty (2.24% versus 2.26%). Multivariate analysis found that the predictors of increased complications were decreased surgeon volume, THA, increased surgeons' years in practice, and geographic region.

DISCUSSION: Overall, female orthopaedic surgeons performed fewer arthroplasties and were earlier in their career. This, however, did not a have a negative impact on their surgical outcomes. Rather, complication rates were dependent on surgeon volume, surgeon experience, and region.

LEVEL OF EVIDENCE: Level III-prognostic retrospective case-control study.

STUDY DESIGN: Narrative review.

OBJECTIVES: Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery.

METHODS: A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence.

RESULTS: SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy.

CONCLUSIONS: Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.

INTRODUCTION: Determining deltoid ligament incompetence in supination external rotation (SER) injuries commonly relies on stress radiography, given several studies demonstrating low predictive value of physical examination. Stress radiography can be difficult to obtain and may result in suboptimal radiographs with equivocal determination of stability. This study revisits the concept of medial ankle tenderness and its association with mortise instability.

METHODS: Patients who presented with an isolated lateral malleolus fracture underwent prospective data collection. VAS scores were recorded with palpation at the lateral malleolar fracture site, anterior deltoid ligament, and posterior deltoid ligament. Three non-weightbearing radiographs of the ankle and a gravity stress view were obtained. Statistical analysis was performed to determine a correlation between tenderness and instability defined as MCS widening > 4 mm on gravity stress x-ray.

RESULTS: 51 patients met inclusion criteria. Group I (stable) and Group II (unstable) demonstrated no difference in tenderness over the lateral malleolus (p = 0.94) or anterior deltoid (p = 0.12), but patients in Group II reported significantly more tenderness over the posterior deltoid (p = 0.03). Taking the higher pain score from either anterior or posterior deltoid palpation, patients with unstable ankle fractures reported significantly more tenderness with medial palpation (p = 0.02). The relative risk of having an unstable ankle fracture with any tenderness to palpation over either the anterior or posterior deltoid ligament was 1.77 (95% CI 1.03 - 3.06, P = 0.039). When comparing no pain versus the presence of any pain with palpation medially, the sensitivity for any medial tenderness to detect an unstable ankle fracture was 0.76 (specificity 0.59, PPV 0.79, NPV 0.56).

CONCLUSION: Patients with any medial tenderness were at significantly higher risk of having an unstable SER ankle fracture in this study, but strict reliance on the presence or absence of medial tenderness without stress radiographs would lead to an unacceptable number of both false positive and false negative determinations of instability. However, our findings suggest that medial tenderness is associated with instability. The 0.79 PPV of any medial tenderness for instability may be useful to cast doubt on equivocal stress radiography and prompt surgeons to repeat stress radiography or shorten the interval for radiographic follow up.

LEVEL OF EVIDENCE: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]).