Faculty Bibliography

BACKGROUND:Corticosteroid injections are a first-line treatment of trigger finger and de Quervain's tenosynovitis. Little research has evaluated preinjection patient-reported outcomes as a predictive factor for treatment success following corticosteroid injection. We hypothesized that patients with less pretreatment impairment would demonstrate greater post-treatment improvement than patients whose function was more severely impaired. METHODS:We retrospectively reviewed prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) scores in patients undergoing corticosteroid injection for trigger finger or de Quervain's tenosynovitis from 2017 to 2023. Independent variables were patient baseline characteristics, comorbidities, and baseline PROMIS UE. The primary outcome was treatment success between 30 days and 12 weeks, defined as achieving the minimal clinically important difference for PROMIS UE without undergoing surgery. RESULTS:= .44). CONCLUSION/CONCLUSIONS:Corticosteroid injection provides meaningful improvement for a subset of trigger finger and de Quervain's tenosynovitis patients. Corticosteroid injection remains a first-line treatment for trigger finger and de Quervain's tenosynovitis patients, especially for those with more severe functional impairment.

Imaging plays an important role in evaluating peripheral nerves. In the preoperative setting, imaging helps overcome pitfalls of electrodiagnostic testing and provides key anatomical information to guide surgical management. In the postoperative setting, imaging also offers key information for treating physicians, although it comes with several challenges due to postsurgical changes and alteration of normal anatomy. This article reviews our approach to peripheral nerve imaging, including how we use imaging in the pre- and postoperative setting for several common indications.

BACKGROUND: While prior studies have recommended immediate flap coverage within 72 hours of injury for soft tissue reconstruction for traumatic extremity injuries, recent evidence in the setting of advanced wound care techniques de-emphasizes the need for immediate coverage. Negative-pressure wound therapy (NPWT) has been an essential tool for extending the time to definitive soft tissue coverage. This study sought to elucidate the impact of preoperative NPWT use on the success of microsurgical reconstruction. METHODS: A literature search was conducted using the following databases from their inception up to February 2023: PubMed, OVID databases (Embase and Cochrane Library), Web of Science, and Scopus. Of 801 identified articles, 648 were assessed and 24 were included. Cases were divided based on whether NPWT was used preoperatively or not. Timing to definitive coverage, injury details, and basic demographics were recorded. Rates of flap failure, infection, bone nonunion, reoperation, and complications were compared between groups. RESULTS: A total of 1,027 patients and 1,047 flaps were included, of which 894 (85.39%) received preflap NPWT. The average time to definitive coverage for the NPWT and non-NPWT groups was 16 and 18 days, respectively. The NPWT group experienced lower postoperative complication rates than the non-NPWT group in all reported complications except for deep infections. Compared with the non-NPWT group, the NPWT group experienced lower rates of any flap failure (3.69 vs. 9.80%) and partial flap failure (2.24 vs. 6.54%). CONCLUSION/CONCLUSIONS: Preoperative NPWT was associated with reduced postoperative complications, most importantly flap failure rates. This merits further investigation into the decision-making process for traumatic extremity reconstruction. Future prospective studies adopting standardized protocols with longer follow-up are required to better understand the potentially beneficial role of preoperative NPWT use in soft tissue reconstruction.

BACKGROUND/UNASSIGNED:The needle scope is a less invasive intervention to evaluate carpal pathology. We hypothesize that there is no difference in the evaluation and diagnostic capability of the needle scope versus the conventional wrist arthroscope. METHODS/UNASSIGNED:Twenty patients indicated for wrist arthroscopy were prospectively enrolled. Prior to insertion of the 2.7-mm arthroscope, the needle scope evaluated for synovitis; cartilage damage (location and modified Outerbridge classification); integrity of the volar, scapholunate (SL), and lunotriquetral ligaments; and the triangular fibrocartilage complex (TFCC). Following needle scope evaluation, the surgeon completed a survey regarding the visualization and diagnosis. The 2.7-mm arthroscope was then inserted, and the surgeon completed the second portion of the survey. Statistical analysis was then completed to determine statistical significance. RESULTS/UNASSIGNED:Twelve patients were female (60%), and the mean age was 39.8 years (±11.8 years). Eleven patients underwent arthroscopy for TFCC pathology, 4 patients for SL tearing, and 5 patients for extensive synovitis. There was no difference between the needle scope and wrist arthroscopy diagnosis. There was no difference between radiocarpal and midcarpal visualization. Surgeon-rated ease of use and diagnostic confidence were the same between two groups. The needle scope was better able to visualize the scapho-trapezium-trapezoid and carpometacarpal joints; however, the image was of marginally decreased quality. CONCLUSION/UNASSIGNED:In this study, there was no difference between radiocarpal or midcarpal visualization and surgeon-rated ease of use, while diagnostic confidence was the same between two groups. LEVEL OF EVIDENCE/UNASSIGNED:II (prospective cohort study)-Diagnostic.

BACKGROUND/UNASSIGNED:This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS/UNASSIGNED:Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS/UNASSIGNED:One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION/UNASSIGNED:Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE/UNASSIGNED:Level IV.

Open tibia fractures are the most common open long bone injury. Most of these injuries involve a high-energy mechanism. Many standards for management have been created to provide guidance and a baseline for quality. There are several factors that must be considered when determining the timing of coverage for an open fracture with soft tissue compromise. Understanding the available options for soft tissue coverage, including local/rotational flaps and free tissue transfer, will allow for a tailored approach based on the personality of the injury. The aim of this review was to characterize the critical window of treatment based on the current literature and to provide a review of the available soft tissue coverage options.

Background The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. Methods Approval from the Institutional Review Boards was granted at each site. A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between 01/01/2018 and 02/01/2021 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet-use during three operative segments: (1) flap elevation, (2) vessel harvest and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. Results A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was a traumatic event (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). 70% of procedures used a tourniquet for flap elevation. When these cases were compared to those that did not use a tourniquet for flap elevation, there was no difference in complication rates. 61% of procedures used a tourniquet for vessel harvest and 32% for anastomosis. Similarly, additional analyses identified no difference in complication rates when compared to procedures for which a tourniquet was not used for the intervention. Conclusions Based on these results, the authors encourage the use of tourniquets for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

BACKGROUND/UNASSIGNED:Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes. METHODS/UNASSIGNED:A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD. RESULTS/UNASSIGNED:Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%. CONCLUSION/UNASSIGNED:Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability. LEVEL OF EVIDENCE/UNASSIGNED:I, Systematic Review.

INTRODUCTION/BACKGROUND:The purpose of this study was to evaluate the role of body mass index (BMI) in predicting postoperative complications following myocutaneous free flap transfer. In addition, we sought to identify certain body composition variables that may be used to stratify patients into low- versus high-risk for gracilis myocutaneous free flap with skin paddle failure. METHODS:Using the National Surgical Quality Improvement Program database, we collected data for all patients who underwent myocutaneous free flap transfer from 2015 to 2021. Demographic data, medical history, surgical characteristics, and postoperative outcomes, including complications, reoperations, and readmissions, were collected. Body mass index was correlated with outcome measures to determine its role in predicting myocutaneous free flap reliability. Subsequently, we retrospectively obtained measurements of perigracilis anatomy in patients who underwent computed tomography angiography bilateral lower extremity scans with intravenous contrast at our institution. We compared body composition data with mathematical equations calculating the potential area along the skin of the thigh within which the gracilis perforator may be found. RESULTS:Across the United States, 1549 patients underwent myocutaneous free flap transfer over the 7-year study period. Being in obesity class III (BMI ≥40 kg/m2) was associated with a 4-times greater risk of flap complications necessitating a return to the operating room compared with being within the normal BMI range. In our computed tomography angiography analysis, average perigracilis adipose thickness was 18.3 ± 8.0 mm. Adipose thickness had a strong, positive exponential relationship with the area of skin within which the perforator may be found. CONCLUSIONS:In our study, higher BMI was associated with decreased myocutaneous free flap reliability. Specifically, inner thigh adipose thickness can be used to estimate the area along the skin within which the gracilis perforator may be found. This variable, along with BMI, can be used to identify patients who are considered high-risk for flap failure and who may benefit from additional postoperative monitoring, such as the use of a color flow Doppler probe and more frequent and prolonged skin paddle monitoring.