Faculty Bibliography

PURPOSE/OBJECTIVE:We report 8 cases of acute or subacute unilateral nondissociative carpal instability (CIND) in the context of nondisplaced scaphoid fractures. METHODS:Eight patients from 3 centers developed abnormal volar intercalated segment instability (VISI) or dorsal intercalated segment instability (DISI) following the diagnosis of a nondisplaced scaphoid fracture. An operative inspection in each patient confirmed intact scapholunate and lunotriquetral interosseous ligaments. We outline the demographic characteristics of our patient cohort, radiologic and operative findings of CIND-DISI and CIND-VISI, and the outcomes of acute and delayed treatment. RESULTS:Two patients were diagnosed with CIND-DISI and 6 with CIND-VISI associated with ipsilateral nondisplaced scaphoid fractures. The average time from injury to diagnosis of CIND was 11 weeks, and the mean clinical and radiographic follow-up was 18 months. Rapid healing of the scaphoid fractures was achieved in all patients (4 open reduction internal fixation, 4 cast). All patients underwent surgery to improve proximal carpal row alignment: in 3 of the 4 patients who were diagnosed and treated surgically within 12 weeks of injury, the radiolunate angle (RLA) was successfully restored. A contracture release and ligament repair or reconstruction with tendon graft 12 or more weeks following injury was unsuccessful in restoring proximal row alignment in all 4 patients. Two patients in the delayed treatment group required secondary surgery for partial fusion. CONCLUSIONS:Based on the arthroscopic, imaging, and operative findings, we propose that the ligamentous restraints to CIND-VISI are dorsal at the radiocarpal joint and volar at the midcarpal joint. Conversely, the ligamentous restraints to CIND-DISI are dorsal at the midcarpal joint and volar at both the radiocarpal and midcarpal joints. In our series, a delayed diagnosis and late reconstructive surgery were associated with no improvement in RLA. We recommend early recognition of traumatic CIND and prompt treatment of injured ligaments prior to the development of a fixed deformity. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic V.

PURPOSE/OBJECTIVE:To use a CT-based approach with 3D modeling to determine novel radiographic views of the scaphotrapezial (STl) and scaphotrapezoid (STd) joints. MATERIALS AND METHODS/METHODS:Consecutive wrist CT scans excluding those with pathology of the distal radius, scaphoid, trapezium, or trapezoid of subjects between ages 18 and 60 years were retrospectively reviewed. Three-dimensional reconstructions of CT scans were created and best-fit planes of the STl and STd joints were generated. Angles of these planes relative to a distal radial coordinate system were calculated to determine tilt of the wrist and the X-ray beam for novel radiographic views of these joints. RESULTS:Fifty eligible wrist CT scans were identified. The mean age was 38 years (range, 18 to 59). For the novel STl PA view, the wrist is supinated 17° from the standard PA view and the X-ray beam is canted 6° caudad. In the STl lateral view, the wrist is pronated 17° from the standard lateral view, and the X-ray beam is canted 20° caudad. In the STd PA tilt view, the wrist is supinated 28° from the standard PA view, and the X-ray beam is canted 13° caudad. In the STd joint lateral tilt view, the wrist is pronated 28° from the standard lateral view, and the X-ray beam is canted 29° caudad. CONCLUSION/CONCLUSIONS:We describe novel radiographic views of the STl and STd joints based on 3D modeling of wrist CT scans. Further studies are required to assess the efficacy of these views in detecting joint pathology.

BACKGROUND:Although relatively uncommon, neurological deficits following hip and knee arthroplasty can have permanent and debilitating consequences. This study was conducted to quantify the effectiveness of an educational curriculum aimed at standardizing the identification of and acute response to postoperative neurological deficits in the inpatient setting, specifically with respect to improvements in clinician knowledge, confidence levels, and communication skills. METHODS:A multidisciplinary committee at a single, high-volume academic institution created an algorithm delineating the appropriate clinical actions and escalation procedures in the setting of a postoperative neurological deficit for each clinical practitioner involved in care for patients who undergo arthroplasty. An educational curriculum composed of online learning modules and an in-person "boot camp" featuring simulations with standardized patients was developed, along with assessments of clinician knowledge, confidence levels, and communication skills. Nurses, physical therapists, physician assistants, residents, fellows, and attending surgeons were encouraged to participate. The intervention spanned a 5-month period in 2015 with a mean time of 18.4 weeks between baseline assessments and the time of the latest follow-up. RESULTS:Online modules were completed by 322 individuals, boot camp was completed by 70 individuals, and latest assessments were completed by 38 individuals. The percentage correct on the knowledge assessment increased from 74.5% before the learning modules to 89.5% immediately after (p < 0.001) but degraded over time such that there was no significant difference between baseline and the latest follow-up scores (p = 0.11). Over the course of the boot camp, physician assistants and residents successfully performed approximately 91% of the indicated actions on the scoring rubric; physical therapists and nurses successfully performed 78%. Scores on the communication skills assessment showed a significant mean increase (p = 0.02) over the course of the intervention from 30.32 to 32.50, and the mean self-assessed confidence survey scores increased by 16.7%, from 7.2 to 8.4 (p < 0.001). CONCLUSIONS:A multimodality educational curriculum aimed at quality improvement can produce significant knowledge improvements, but these gains may not be maintained over time without further instruction. Gains in confidence and communication skills appear to be more long-lasting.

BACKGROUND:Lateral epicondylitis is a common condition encountered by orthopedic surgeons. Whereas the majority of patients improve with conservative management, a small percentage will require surgery. The purpose of this study was to compare the clinical outcomes of surgical débridement of the common extensor origin alone with débridement combined with rotation of an anconeus muscle flap in patients who failed to respond to conservative management of chronic lateral epicondylitis. METHODS:Fifty-seven patients who failed to respond to a minimum of 5 months of conservative treatment for lateral epicondylitis were retrospectively reviewed. Patients in group 1 were treated with open débridement of the common extensor origin. Patients in group 2 were treated with open débridement combined with rotation of an anconeus muscle flap. Outcome measures included elbow range of motion, grip strength, visual analog scale (VAS) for pain score, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Statistical analyses were performed by Student's t test with 95% confidence intervals. RESULTS:At final follow-up, average DASH scores were significantly lower in group 2. There were no significant differences between the groups with regard to elbow range of motion or grip strength. VAS pain scores were significantly reduced in both groups. Preoperative VAS pain scores were significantly greater in group 2; however, at final follow-up, there was no significant difference between groups. There were no apparent complications in either group. CONCLUSIONS:In addition to débridement of the common extensor origin, the rotation of an anconeus muscle flap may improve outcomes in cases of lateral epicondylitis that require operative intervention.