Faculty Bibliography

BACKGROUND:It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis. OBJECTIVE:To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy. METHODS:A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded. RESULTS:The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups. CONCLUSION/CONCLUSIONS:The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.

INTRODUCTION/UNASSIGNED:The purpose of this study was to describe the outcomes after operative repair of ballistic femoral neck fractures. To better highlight the devastating nature of these injuries, we compared a cohort of ballistic femoral neck fractures to a cohort of young, closed, blunt-injury femoral neck fractures treated with open reduction and internal fixation (ORIF). METHODS/UNASSIGNED:Retrospective chart review identified all patients presenting with ballistic femoral neck fractures treated at three academic trauma centers between January 2016 and December 2021, as well as patients aged ≤50 with closed, blunt-injury femoral neck fractures who received ORIF. The primary outcome was failure of ORIF, which includes the diagnosis of non-union, avascular necrosis, conversion to total hip arthroplasty, and conversion to Girdlestone procedure. Additional outcomes included deep infection, postoperative osteoarthritis, and ambulatory status at last follow-up. RESULTS/UNASSIGNED:Fourteen ballistic femoral neck fractures and 29 closed blunt injury fractures were identified. Of the ballistic fractures, 7 (50%) patients had a minimum of 1-year follow-up or met the failure criteria. Of the closed fractures, 16 (55%) patients had a minimum of 1-year follow-up or met the failure criteria. Median follow-up was 21 months. 58% of patients with ballistic fractures were active tobacco users. Five of 7 (71%) ballistic fractures failed, all of which involved non-union, whereas 8 of 16 (50%) closed fractures failed (p=0.340). No outcomes were significantly different between cohorts. CONCLUSION/UNASSIGNED:Our results demonstrate that ballistic femoral neck fractures are associated with high rates of non-union. Large-scale multicenter studies are necessary to better determine optimal treatment techniques for these fractures. LEVEL OF EVIDENCE/UNASSIGNED:Level III. Retrospective cohort study.

Pronator syndrome is a median nerve entrapment neuropathy that can be difficult to diagnose due to its variable presentation and objective findings. Neurolymphomatosis is an uncommon disease in which malignant lymphocytes infiltrate central or peripheral nerve endoneurium and is often missed for prolonged periods prior to diagnosis. We present a rare case of pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis that was occult on initial MRI in spite of the presence of a median nerve mass discovered intra-operatively during neurolysis. This case demonstrates the value of ultrasound for the examination of peripheral nerve pathology and illustrates its utility as an adjunct to MRI, in part due to the ability to screen a large region.

PURPOSE/OBJECTIVE:Operating room (OR) efficiency has an impact on surgeon productivity and patient experience. Accuracy of case duration estimation is important to optimize OR efficiency. The purpose of this study was to identify factors associated with inaccurate case time estimates in outpatient hand surgery. A better understanding of these findings may help to improve OR efficiency and scheduling. METHODS:All outpatient hand surgical cases from 2018 to 2019 were reviewed. Poorly-estimated cases (i.e., poor scheduling accuracy) were defined as those cases where the actual operative time differed from the predicted time by >50% (either quicker by >50% or slower by >50% than the predicted time). The percentages of poorly-estimated cases were analyzed, categorized, and compared by surgeon, procedure type, and scheduled case length. RESULTS:A total of 6,620 cases were identified. Of 1,107 (16.7%) cases with poorly estimated case durations, 75.2% were underestimated. There was no difference in the likelihood of poor estimation related to start time. Well-estimated cases tended to have longer scheduled case duration, but shorter realized case duration and surgical time. Our systems analysis identified specific surgeons and procedures as predictable outliers. Cases scheduled for 15-30 minutes frequently were inaccurate, whereas cases scheduled for 30-45 and 106-120 minutes had accurate estimates. CONCLUSIONS:The accuracy of case time estimations in a standard outpatient hand surgery practice is highly variable. Nearly one-fifth of outpatient hand surgery case durations are poorly estimated, and inaccurate case time estimation can be predicted based on surgeon, procedure type, and case time. CLINICAL RELEVANCE/CONCLUSIONS:Maximizing OR efficiency should be a priority for surgeons and hospital systems. With multiple surgeries done per day, the efficiency of the OR has an impact on surgeon productivity and patient experience.

PURPOSE/OBJECTIVE:Autologous bone grafts demonstrate osteoconductive, osteoinductive, and osteogenic properties. Hand surgeons commonly augment surgical fixation with autografts to promote fracture healing. This study compared the intrinsic stem cell-like properties of 2 commonly used autograft sources in hand surgery: the iliac crest and distal radius. METHODS:A total of 9 subjects who received an iliac crest bone graft and distal radius bone graft harvest as a part of the standard care of distal radius malunion or nonunion correction or scaphoid nonunion open reduction and internal fixation were enrolled in the study. Cells were isolated by serial collagenase digestion and subjected to fibroblast colony-forming units, osteogenesis, and adipogenesis assays. The expression levels of genes involved in osteogenesis and adipogenesis were confirmed using quantitative polymerase chain reaction. RESULTS:The cells isolated from the iliac crest bone graft compared with those isolated from the distal radius bone graft demonstrated significantly higher mean fibroblast colony-forming unit efficiency; increased osteogenesis, as measured using alizarin red quantification; increased adipogenesis, as measured using oil red O quantification; and higher expression levels of genes involved in osteogenesis and adipogenesis under the respective differentiation conditions. CONCLUSIONS:The cells isolated from the iliac crest bone graft demonstrated a higher fibroblast colony-forming unit capacity and an increased capability to undergo both osteogenesis and adipogenesis. CLINICAL RELEVANCE/CONCLUSIONS:Limited evidence exists comparing the intrinsic stem cell-like properties of the iliac crest and distal radius despite the widespread use of each source in hand and wrist surgery. The information from this investigation may assist hand and wrist surgeons with the selection of a source of autograft.

Introduction: Open fractures with degloving injuries are commonly managed by serial debridements prior to definitive flap coverage in the United States (US). Some international institutions minimize the number of debridements prior to coverage. The purpose of this study was to compare clinical outcomes in patients with open tibia fractures requiring free flap coverage from institutions with differing debridement philosophies. Methods: This was a multi-site retrospective cohort study of patients treated at two US tertiary care facilities (serial debridement cohort) and one in India (early total debridement cohort) with Type IIIB or IIIC open tibia fractures requiring free tissue transfer. The number of debridements prior to flap coverage were recorded and primary outcomes were rates of infection, non-union, and flap failure. Fischer's exact tests were used to compare outcomes between the cohorts. Results: 80 patients were included, 44 from India and 36 from the US. Patients in the serial debridement cohort underwent more debridements prior to flap coverage (mean 3.64 vs 1.84, p < 0.001) and had significantly higher rates of infection and non-union compared to patients in the early total debridement cohort (p < 0.05). There were no differences in rates of flap failure between the cohorts. Conclusions: Patients with open tibia fractures treated at institutions favoring serial debridements underwent more debridements and had higher rates of infection and non-union compared to patients treated at a center favoring early total debridement. Serial debridements may not be necessary prior to flap coverage for open tibia fractures and the current practice should be further investigated.

BACKGROUND/UNASSIGNED:The purpose of this study was to evaluate the association between timing of nerve repair and the ability to perform a primary nerve repair versus a bridge repair requiring the use of allograft, autograft, or a conduit in lacerated upper extremity peripheral nerve injuries. METHODS/UNASSIGNED:This is a retrospective case-control study of patients who underwent upper extremity nerve repair for lacerated peripheral nerves identified by Current Procedural Terminology codes. Timing of injury and surgery, as well as other information such as demographic information, mechanism of injury, site of injury, and type of nerve repair, was recorded. The odds of a patient requiring bridge repair based on the duration of time between injury and surgery was evaluated using logistic regression. RESULTS/UNASSIGNED:A total of 403 nerves in 335 patients (mean age 35.87 ± 15.33 years) were included. In all, 241 nerves were primarily repaired and 162 required bridge repair. Patients requiring bridge repair had a greater duration between injury and surgery compared with patients who underwent primary repair. Furthermore, the nerves requiring bridge repair were associated with a greater gap compared with the nerves repaired primarily. Based on logistic regression, each 1-day increase in duration between injury and surgery was associated with a 3% increase in the odds of requiring bridge repair. CONCLUSIONS/UNASSIGNED:There is no defined critical window to achieve a primary nerve repair following injury. This study demonstrated that nerve injuries requiring bridge repair were associated with a significantly greater delay to surgery.

BACKGROUND/UNASSIGNED:Corticosteroid injection is the mainstay of nonoperative treatment for trigger finger (stenosing tenosynovitis), but despite substantial experience with this treatment, there is minimal available evidence as to the optimal corticosteroid dosing. The purpose of this study is to compare the efficacy of 3 different injection dosages of triamcinolone acetonide for the treatment of trigger finger. METHODS/UNASSIGNED:Patients diagnosed with a trigger finger were prospectively enrolled and treated with an initial triamcinolone acetonide (Kenalog) injection of 5 mg, 10 mg, or 20 mg. Patients were followed longitudinally over a 6-month period. Patients were assessed for duration of clinical response, clinical failure, Visual Analog Scale (VAS) pain scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. RESULTS/UNASSIGNED:A total of 146 patients (163 trigger fingers) were enrolled over a 26-month period. At 6-month follow-up, injections were still effective (without recurrence, secondary injection, or surgery) in 52% of the 5-mg group, 62% of the 10-mg group, and 79% of the 20-mg group. Visual Analog Scale at final follow-up improved by 2.2 in the 5-mg group, 2.7 in the 10-mg group, and 4.5 in the 20-mg group. The QuickDASH scores at final follow-up improved by 11.8 in the 5-mg group, 21.5 in the 10-mg group, and 28.9 in the 20-mg group. CONCLUSIONS/UNASSIGNED:Minimal evidence exists to guide the optimal dosing of steroid injection in trigger digits. When compared with 5-mg and 10-mg doses, a 20-mg dose was found to have a significantly higher rate of clinical effectiveness at 6-month follow-up. The VAS and QuickDASH scores were not significantly different between the 3 groups.

OBJECTIVE:To correlate patient and surgeon specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Three Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS/METHODS:A consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS/METHODS:Primary outcomes include superficial and deep infection. Secondary outcomes include nonunion, loss of articular reduction, and implant removal. RESULTS:The following patient specific factors correlated with poor surgical outcomes: increased age with superficial infection rate (p<0.05), smoking with rate of nonunion (p<0.05), and Charlson Comorbidity Index with loss of articular reduction(p<0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with increased rate of implant removal, as did fibular plating. CONCLUSIONS:While many of the patient-specific factors that negatively impact surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined as these may be addressed. Pilon fracture fixation has evolved to increasingly utilize fragment specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection while additional fibular plate fixation, was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.