Advance care planning and health literacy in older dialysis patients: qualitative interview study

OBJECTIVES

Low health literacy among older adults is associated with limited engagement in end-of-life care planning, higher hospitalisation rates and increased mortality. Frequently, older dialysis patients derive no survival benefit from dialysis and their quality of life often deteriorates further on dialysis. Older dialysis patients' values and wishes are frequently unknown during key healthcare decision making and many endure medically intensive end-of-life scenarios. The objectives of this study were to explore older dialysis patients' understanding of haemodialysis, to explore their engagement in end-of-life care planning and to explore their satisfaction with life on haemodialysis.

METHODS

15 older dialysis patients participated in qualitative semistructured interviews in two haemodialysis units in Ireland. Thematic saturation was reached. Thematic analysis, applied inductively, was used to distill the data.

RESULTS

Themes identified included disempowerment among participants reflected limited health literacy, poor advance care planning compromised participant well-being, haemodialysis compromised participants' core values.

CONCLUSION

Health literacy levels among older dialysis patients are poor, patient empowerment is limited and their participation in shared decision making and advance care planning is suboptimal. Consequently, healthcare decision making, including haemodialysis, may jeopardise patients' core values. Improving health literacy through enhanced patient education and improved communication skills training for clinicians is necessary to promote patient participation in shared decision making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with patients' core values. This approach will optimise the circumstances for patient-centred care.

Advance care planning in older dialysis patients: health care literacy qualitative study

OBJECTIVES

Low health literacy among older adults is associated with limited engagement in end-of-life care plans, more hospitalisations and excess mortality. Frequently, older patients derive no survival benefit from dialysis and quality of life often deteriorates with dialysis. Older dialysis patients' values and wishes are often unknown during key healthcare decision-making and many endure medically intensive end-of-life interventions . The objectives of this study were to examine older dialysis patients' understanding of haemodialysis, their engagement in end-of-life care planning and their satisfaction with life on haemodialysis.

METHODS

15 older dialysis patients participated in qualitative semi-structured interviews in two haemodialysis units . Thematic saturation was reached. Thematic analysis, applied inductively, distilled the data.

RESULTS

Themes identified included disempowerment which reflected limited health literacy, poor advance care planning compromised well-being and haemodialysis compromised their core values.

CONCLUSION

Health literacy among older dialysis patients appeared poor, patient empowerment was limited and participation in shared decision-making and advance care planning suboptimal. Consequently, complex healthcare decision-making, including haemodialysis may jeopardise patients' core values. These findings have significant implications for the validity of the informed consent process prior to dialysis initiation. Improved health literacy through enhanced patient education and better communication skills for clinicians are necessary to promote patient participation in shared decision-making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with individual core values. This will optimise patient-centred care.

Cubital Tunnel Syndrome: Current Concepts

PURPOSE OF REVIEW

Compressive neuropathy of the ulnar nerve across the elbow is a common diagnosis encountered frequently within a hand and upper extremity clinical practice. Appropriate and timely evaluation, diagnosis, objective testing, and evidence-based decisions regarding treatment options are paramount in the optimal care of the patient with this pathology. An understanding of current literature is critical in determining and understanding best practices.

RECENT FINDINGS

A thorough review of the recent literature regarding physical examination, diagnostic testing, and nonoperative versus operative results was performed. Regarding physical examination, the glenohumeral internal rotation test and scratch collapse test are more effective and sensitive than traditional maneuvers such as Tinel's testing and the elbow flexion test. Electrodiagnostic testing, magnetic resonance imaging, and ultrasound evaluation have all been shown to be effective in diagnosing cubital tunnel syndrome. However, no single test has proven itself to be superior. Nonoperative treatment can be successful for mild cases of cubital tunnel syndrome. Surgical release techniques comparing open with endoscopic release are equivocal, and in situ release versus transposition techniques show that transposition should not be performed routinely. The diagnosis and treatment of cubital tunnel syndrome do not have a well-defined algorithm based on current literature. The treating physician must therefore utilize the available information to determine a diagnostic and treatment plan individualized to the patient. More rigorous scientific studies are needed to determine the most effective surgical approaches for cubital tunnel syndrome.

Dual Antegrade Intramedullary Headless Screw Fixation for Treatment of Unstable Proximal Phalanx Fractures

Background: Although intramedullary headless screw (IMHS) fixation is a promising minimally invasive surgical treatment option for unstable proximal phalanx fractures, a single IMHS may provide inadequate fixation for certain fracture patterns. The purpose of this study was to evaluate the short-term clinical outcomes in a pilot series of patients with proximal phalanx fractures treated with dual antegrade IMHS fixation. Methods: We performed a retrospective chart review of proximal phalanx fractures treated with dual antegrade IMHS fixation with a minimum 1 year of follow-up. Demographic information including patient age, sex, occupation, workers' compensation status, mechanism of injury, hand dominance, and injured digit were obtained. Postoperative outcomes measured included range of motion, grip strength, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome scores, return to full-duty work interval, and complications. Results: Ten fractures in 10 patients (4 male, 6 female) satisfied study inclusion. The mean age of patients was 39 years (range, 20-62), and average follow-up duration was 84 weeks (range, 61-106). Final postoperative total active motion was 258° (range, 245°-270°), mean grip strength was 97% (range, 84%-104%) of the uninjured side, and QuickDASH score was 3.9 (range, 0-13.6). No complications occurred, and no patients required additional intervention. Conclusions: Dual antegrade IMHS fixation of proximal phalanx fractures resulted in excellent postoperative motion, near-normal grip strength, positive self-reported patient outcomes, and no complications with follow-up of at least 1 year. Further study in a larger number of patients is warranted to determine if this promising technique is superior to other modes of fixation.

Advance care plan barriers in older patients with end-stage renal disease: a qualitative nephrologist interview study

OBJECTIVES

Older patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists' clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group.

METHODS

A qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results.

RESULTS

Three key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion.

CONCLUSIONS

Advance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.

Sleep disturbance and response to surgical decompression in patients with carpal tunnel syndrome: a prospective randomized pilot comparison of open versus endoscopic release

BACKGROUND

Sleep disturbance is a common complaint of patients with carpal tunnel syndrome (CTS). While carpal tunnel release (CTR) surgery has been shown to relieve subjective sleep-related complaints, data is lacking on the global effect on sleep using validated sleep measures. Additionally, it is not known if open (OCTR) or endoscopic release (ECTR) produce differing degrees of sleep-symptom relief.

METHODS

Sixty patients were randomly allocated to undergo either OCTR (n=30) or ECTR (n=30) surgery. Forty-three (71.7%) of the patients were female, and mean age of all patients was 49.4 years (range, 35-78). Prior to surgery, patients were administered three baseline self-reported outcome measures: the Pittsburgh Sleep Quality Index (PQSI), the Insomnia Severity Scale (ISI) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, which were subsequently administered at three postoperative time points: 1-2 weeks, 4-6 weeks and 6-12 months.

RESULTS

All 60 patients experienced significant improvements in the three outcome scores by their first postoperative visit compared to preoperatively. ECTR provided superior improvement to OCTR at the first postoperative visit for ISI (P=0.006) and PSQI (P=0.016), and at the second visit for PSQI (P=0.0038). There were no significant differences between the two groups for the QuickDASH at any time points, or for the ISI/PSQI at the final follow-up.

CONCLUSION

Endoscopic and open CTR both improve sleep symptoms postoperatively in the short-term which is sustained for 6-12 months, although endoscopic CTR does so more rapidly.

Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures: A Nationwide Survey Comparing Attending Surgeons and Trainees

BACKGROUND

Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees.

METHODS

Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure.

RESULTS

A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons.

CONCLUSIONS

Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.

Late Reconstruction of the Interosseous Membrane with Bone-Patellar Tendon-Bone Graft for Chronic Essex-Lopresti Injuries: Outcomes with a Mean Follow-up of Over 10 Years

BACKGROUND

The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries.

METHODS

We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores.

RESULTS

IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to -1.6 mm (95% CI, -2.3 to -0.9 mm) immediately postoperatively and -1.1 mm (95% CI, -1.8 to -0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively.

CONCLUSIONS

IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mid-term outcomes of routine proximal row carpectomy compared with proximal row carpectomy with dorsal capsular interposition arthroplasty for the treatment of late-stage arthropathy of the wrist

AIMS

The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone.

PATIENTS AND METHODS

A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups.

RESULTS

At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes.

CONCLUSION

PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197-204.

Platelet-Rich Plasma Injection With Percutaneous Needling for Recalcitrant Lateral Epicondylitis: Comparison of Tenotomy and Fenestration Techniques

Background

Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance.

Purpose

To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction.

Results

At a mean follow-up of 40 months, significant improvements in VAS-P (mean, -6.1; 95% CI, -6.8 to -5.5; P < .0001), QuickDASH (mean, -46; 95% CI, -52 to -40; P < .0001), and PRTEE (mean, -57; 95% CI, -64 to -50; P < .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P < .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group (P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course.

Conclusion

A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm.

Single- versus double-bundle suture button reconstruction of the forearm interosseous membrane for the chronic Essex-Lopresti lesion

PURPOSE

Reconstruction of the ruptured interosseous membrane (IOM) is critical to restore forearm stability for the chronic Essex-Lopresti injury. Positive outcomes have been reported following IOM reconstruction with a single-bundle suture button (Mini-Tightrope) construct, although recent work suggests that double-bundle Mini-TightRope^® IOM reconstruction is biomechanically superior. The purpose of this study was to determine whether double-bundle Mini-TightRope^® reconstruction of the forearm IOM results in superior clinical outcomes to the single-bundle technique.

METHODS

Five patients with chronic Essex-Lopresti injuries treated with double-bundle Mini-TightRope^® IOM reconstruction were matched to five patients treated with single-bundle Mini-TightRope^® reconstruction. Improvement in clinical examination measures and patient-reported outcomes was compared between the groups.

RESULTS

Results were good to excellent in all 10 patients. At final follow-up, forearm rotation was significantly better in the single-bundle group, while maintenance of ulnar variance was better in the double-bundle group. No significant differences were noted between the two groups for any other numerical outcomes, and no complications occurred.

CONCLUSION

These findings suggest that while IOM reconstruction with a double-bundle Mini-TightRope^® construct results in greater resistance to proximal migration of the radius in the intermediate term, there is a modest concomitant loss of forearm rotation when compared to single-bundle reconstruction.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Neurolysis with Amniotic Membrane Nerve Wrapping for Treatment of Secondary Wartenberg Syndrome: A Preliminary Report

Background: Entrapment of the superficial sensory branch of the radial nerve (SRN) commonly results in debilitating pain of the dorsoradial wrist. Symptom relief following SRN neurolysis is often incomplete or temporary due to recurrent perineural scarring.

Methods: We performed a retrospective review with prospective follow-up of all patients with SRN neuropathy who were treated with neurolysis and nerve wrapping using an amnion-based allograft adhesion barrier over a one-year interval. Measured outcomes included pain rated by Visual Analog Scale (VAS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) functional outcome scores.

Results: Three females satisfied inclusion. At mean follow-up of 28.9 months, all three patients exhibited improved pain (mean VAS change −4.7 ± 0.6), function (mean QuickDASH change −40 ± 5), and subjective satisfaction. No adverse events or reactions to the implanted tissue occurred.

Conclusions: SRN entrapment neuropathy was safely and effectively treated with neurolysis and amnion nerve wrapping in this small series. Use of this technique for perineural scar prevention warrants additional study in larger groups of patients and in other upper extremity entrapment neuropathies.

Prognostic Variables for Patient Return-to-Work Interval Following Carpal Tunnel Release in a Workers' Compensation Population

BACKGROUND

We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery.

METHODS

We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW.

RESULTS

Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval.

CONCLUSIONS

WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Dorsal versus lateral plate fixation of finger proximal phalangeal fractures: a retrospective study

INTRODUCTION

Unstable proximal phalanx fractures are relatively common injuries but consensus of standard treatment is lacking. Outcomes following plate fixation are highly variable, and it remains unclear which factors are predictive for poorer results. The purpose of this study was to compare dorsal and lateral plate fixation of finger proximal phalangeal fractures with regard to factors that influence the outcome.

MATERIALS AND METHODS

A retrospective chart review of proximal phalanx fractures treated with dorsal and lateral plating over a 6-year study interval was performed. Demographic data and injury-specific factors were obtained from review of clinic and therapy notes of 42 patients. Fractures were classified based on the OTA classification using preoperative radiographs. Outcomes investigated included final range of motion (ROM) and total active motion (TAM) of all finger joints. Complications and revision surgeries were also analyzed.

RESULTS

Fracture comminution, dorsal and a lateral plate position, occupational therapy, and demographic factors did not significantly influence the outcome, complication, and revision rate after plate fixation of finger proximal phalangeal fractures.

CONCLUSIONS

Based on the results of this study, no differences in the outcome of finger proximal phalangeal fractures treated by both dorsal and lateral plate fixation were observed.

LEVEL OF EVIDENCE

Therapeutic, retrospective comparative, level III.

Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion

PURPOSE

To report outcomes of patients with distal radius fracture malunions treated with corrective osteotomy and orthogonal volar and radial "90-90" plate fixation.

METHODS

We performed a retrospective review of all patients who underwent distal radius corrective osteotomy and 90-90 fixation from January 2008 through December 2014. Demographic data, injury history, prior treatments, and clinical examination values were recorded. Preoperative radiographic measurements were used to classify the type and severity of deformity. The outcomes were patient-reported pain levels, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) functional scores, and radiographic outcomes. Secondary outcomes, including complications and the need for additional surgeries, were also noted.

RESULTS

Thirty-nine cases (31 extra-articular, 8 combined intra- and extra-articular) were included. At mean postoperative follow-up interval of 4 years, significant improvements were observed clinically in wrist flexion-extension arc, grip strength, pain, and Quick Disabilities of the Arm, Shoulder, and Hand scores. Radiographically, significant postoperative improvements were noted in ulnar variance, radial inclination, intra-articular stepoff, and radial tilt, with volarly and dorsally angulated malunions corrected to 9° and 7° of volar tilt, respectively. Twelve patients (31%) underwent additional surgery, the most common being plate removal in 7 patients, 3 of which involved removal of the radial plate.

CONCLUSIONS

For patients with symptomatic malunion of the distal radius, corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intra-articular component.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.

Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping

BACKGROUND

Perineural scarring of the ulnar nerve is a predominant cause of symptom recurrence after surgical treatment for primary cubital tunnel syndrome (CuTS). We report our preliminary experience in revision ulnar nerve decompression and nerve wrapping with an amniotic membrane allograft adhesion barrier for treatment of recurrent CuTS.

METHODS

We performed a retrospective review with prospective follow-up of patients with recurrent CuTS who were treated with revision neurolysis with amniotic membrane nerve wrapping. Preoperative elbow motion, grip and pinch strengths, pain level on the visual analog scale level, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand functional outcome score were compared with postoperative values using paired t testing. Symptom characteristics, physical examination findings, complications, and level of satisfaction were also obtained.

RESULTS

Eight patients (mean age, 47.5 years) who had undergone at least 2 prior ulnar nerve operations satisfied study inclusion. At mean postoperative follow-up of 30 months, significant improvements were noted across all patients in visual analog scale pain levels (-3.5 vs. preoperatively; P < .0001), 11-item version of the Disabilities of the Arm, Shoulder and Hand scores (-30 vs. preoperatively; P < .0001), and grip strength (+25 pounds vs. preoperatively; P < .0001). Pinch strength and elbow motion were also significantly improved for those patients with comparative preoperative data available. All patients expressed subjective satisfaction with their results. No adverse reactions or complications occurred in any patients.

CONCLUSIONS

Ulnar nerve wrapping with amniotic membrane allograft, when combined with revision neurolysis, was a safe and subjectively effective treatment for patients with debilitating recurrent CuTS.

Evaluation and Management of Sleep Disorders in the Hand Surgery Patient

Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition.

Novel Treatment of a Scapholunate Ligament Injury with Proximal Pole Scaphoid Nonunion

BACKGROUND

Nonunion of scaphoid proximal pole fractures presents a challenging management dilemma to hand surgeons. This problem is further complicated in the uncommon concurrence of scapholunate (SL) ligament disruption.

CASE DESCRIPTION

A 39-year-old male patient presented with new-onset wrist pain following a remote history of a proximal pole scaphoid fracture sustained as a teenager, which was treated nonoperatively. Six months before presentation, the patient sustained a fall while snowboarding. The patient was found to have a chronic nonunion of his scaphoid proximal pole with an associated SL ligament disruption. As the proximal fragment was too small to be amenable to fixation, the patient was treated with an arthroscopic partial scaphoid excision and SL ligament reconstruction using a scapholunateintercarpal screw placed percutaneously. At 26 months, the patient exhibited no pain, near-normal strength, and wrist motion, and expressed a high-level of satisfaction from his surgery.

LITERATURE REVIEW

Although cases of SL ligament disruption with concomitant proximal scaphoid fractures have been reported, to our knowledge, this is the first report of SL ligament rupture occurring in the setting of a preexisting proximal pole scaphoid nonunion.

CLINICAL RELEVANCE

We report the use of SL ligament reconstruction augmented with intercarpal screw fixation, and excision of the proximal pole scaphoid nonunion. This minimallyinvasive approach may be a particularly useful option in young, active patients such as our own, where a motion-sacrificing salvage procedure would be less than ideal.

Geographic and Age-Based Variations in Medicare Reimbursement Among ASSH Members

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members' Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). "Hand-surgeons-per-capita" and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state's average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus number of hand surgeons per capita, and (3) total reimbursement from Medicare versus number of years in practice. Analysis of variance (ANOVA) was used to detect a difference in reimbursement based on categorical range of years as an ASSH member. Results: A total of 1667 ASSH members satisfied inclusion in this study. Although there was significant variation among states' average reimbursement, reimbursement was not significantly correlated with the state's hand surgeons per capita or total number of hand surgeons in that given state. Correlation between years as an ASSH member and average reimbursement was significant but non-linear; the highest reimbursements were seen in surgeons who had been ASSH members from 8 to 20 years. Conclusions: Peak reimbursement from Medicare for ASSH members appears to be related to the time of surgeons' peak operative volume, rather than any age-based bias for or against treating Medicare beneficiaries. In addition, though geographic variation in reimbursement does exist, this does not appear to correlate with density or availability of hand surgeons.

The Joint-Gut Axis Exploring the Orthopaedic and Rheumatologic Manifestations of Inflammatory Bowel Disease

Inflammatory bowel diseases (IBD) are chronic immunemediated inflammatory conditions involving the gastrointestinal system with potential to adversely affect the musculoskeletal system as well. The numerous overlapping immunogenic and pathophysiologic disease mechanisms of the gastrointestinal and musculoskeletal systems have led to the concept of the "Joint-Gut Axis," illustrating an intimate link between the two organ systems. A solid understanding of the Joint-Gut Axis is necessary for the rheumatologist as well as the orthopaedic surgeon, as concomitant musculoskeletal disease may impart a profoundly negative impact on the quality of life of patients with IBD. Furthermore, a significant subset of patients initially present with secondary musculoskeletal symptoms resulting from an underlying, undiagnosed IBD. Additional non-inflammatory musculoskeletal sequelae of IBD that are not typically attributed to the Joint-Gut Axis should also be recognized by rheumatologists and orthopaedic surgeons in order that the proper preventative and supportive interdisciplinary management may be employed, maximizing patient outcomes and quality of life.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability

BACKGROUND

The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability.

METHODS

We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded.

RESULTS

Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall.

CONCLUSION

IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

Pleomorphic Hyalinizing Angiectatic Tumor Arising in the Hand: A Case Report

Background: Background: Pleomorphic hyalinizing angiectatic tumors (PHATs) are extremely rare, non-metastasizing tumors of uncertain origin that are typically seen in the lower extremities. To date, it is estimated that less than 100 cases have been reported worldwide since first described in 1996. Methods: The case of a 35-year-old male with a several-year history of a dorsal hand mass is presented. Although the patient was initially asymptomatic, in the months prior to presentation, the patient complained of pain with power grasp and direct pressure over the mass. The patient underwent uncomplicated surgical excision, during which the mass was noted to be adherent to the underlying extensor tendons. Results: Immunopathology confirmed the mass to be PHAT. We believe this is the first documented case of this rare tumor occurring in the hand. Conclusions: History and epidemiology of PHAT are reviewed. Then, in the context of the presented case, pre-operative evaluation, surgical management, pathologic findings and post-operative follow-up are all discussed.

Single-Incision Carpal Tunnel Release and Distal Radius Open Reduction and Internal Fixation: A Cadaveric Study

BACKGROUND

The safety of surgical approaches for single- versus double-incision carpal tunnel release in association with distal radius open reduction and internal fixation remains controversial.

PURPOSE

The purpose of this study was to identify critical structures to determine if a single-incision extension of the standard flexor carpi radialis (FCR) approach can be performed safely.

METHODS

Nine cadaveric arms with were dissected under loupe magnification, utilizing a standard FCR approach. After the distal radius exposure was complete, the distal portion of the FCR incision was extended to allow release of the carpal tunnel. Dissection of critical structures was performed, including the recurrent thenar motor branch of the median nerve, the palmar cutaneous branch of the median nerve (PCBm), the palmar carpal and superficial palmar branches of the radial artery, and proximally the median nerve proper. The anatomic relationship of these structures relative to the surgical approach was recorded.

RESULTS

Extension of the standard FCR approach as described in this study did not damage any critical structure in the specimens dissected. The PCBm was noted to arise from the radial side of the median nerve an average of 6.01cm proximal to the proximal edge of the transverse carpal ligament. The PCBm became enveloped in the layers of the antebrachial fascia and the transverse carpal ligament at the incision site, protecting it from injury. The recurrent motor branch of the median nerve, branches of the radial artery and the median nerve proper were not at risk during extension of the FCR approach to release the carpal tunnel.

CONCLUSIONS

Extension of the standard FCR approach to include carpal tunnel release can be performed with minimal risk to the underlying structures. This exposure may offer benefits in both visualization and extent of carpal tunnel release.

The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II–IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included ‘patient-centred care’, ‘quality of life’ and ‘shared decision making’. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations.

The effects of partial carpal fusions on wrist range of motion

The objective of this investigation was to evaluate the effects of different partial wrist fusions on wrist motion. A total of 20 cadaveric wrists were tested in the intact state and after undergoing either a four-corner fusion or 2- and 3-bone fusion. The moment-rotation behaviour was measured in 24 directions of wrist motion about the forearm axis. The 2- and 3-bone fusion groups demonstrated increased radial deviation and pure flexion. Pure flexion was decreased in the four-corner fusion group. Radial extension and pure extension were decreased in all treatments compared with normal range of motion. Increasing the number of carpal bones within the fusion construct did not alter the functional axis of the wrist. Essentially equivalent motion is possible with 2-bone, 3-bone and four-corner fusions, with the exceptions of pure flexion and radial deviation. This data may influence surgeons when choosing between treatment methods.

LEVEL OF EVIDENCE

N/A.

Concomitant Total Wrist and Total Elbow Arthroplasty in a Rheumatoid Patient

Background Concomitant arthroplasty has been described to have several benefits over multistage procedures. Ipsilateral total elbow and total shoulder arthroplasty has been reported with good outcomes in upper extremity concomitant arthroplasty. Case Description A 65-year-old woman presented with ipsilateral left-sided wrist and elbow joint degeneration as a result of longstanding rheumatoid arthritis. Concomitant total wrist and total elbow arthroplasty was performed with satisfactory results at both joints. She tolerated the procedure well and had an uneventful clinical course postoperatively. Literature Review Currently, no literature exists that describes one-stage total wrist and total elbow arthroplasty. Individually, total wrist and total elbow arthroplasty have both been reported to result in good outcomes and patient satisfaction. Previous studies have reported the utility of concomitant ipsilateral upper extremity procedures with a one-stage total elbow and total shoulder arthroplasty having been identified as a cost-saving procedure with expedited return to functionality versus a two-stage procedure. Clinical Relevance Patients with ipsilateral degenerative changes in the wrist and elbow should be considered on an individual case basis for concomitant total wrist and total elbow arthroplasty.

Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome

BACKGROUND

Medial epicondylectomy (ME) is one of several accepted surgical options for the treatment of cubital tunnel syndrome (CuTS). Although reported outcomes after ME are generally favorable, few data exist regarding which patients are prone to poorer outcomes requiring revision surgery. The goal of this study was to identify risk factors predicting the need for revision surgery after ME for the treatment of CuTS.

METHODS

We conducted a retrospective chart review of all patients treated at our institution with ME for CuTS from 2006 through 2011. We identified patients who underwent additional operations for recurrent or persistent ulnar nerve symptoms as the revision cohort. We performed bivariate analysis to determine which variables had a significant influence on the need for revision surgery. We examined qualitative factors associated with revision, including the degree of bony resection performed during the index ME, and intraoperative findings at the time of revision surgery.

RESULTS

Revision surgery was required in 13.3% of cases (11 of 83). On bivariate analysis, younger age, associated workers' compensation claims, lesser disease severity, and preoperative opioid use were all significant predictors of the need for revision surgery. Perineural scarring and heterotopic bone formation about the elbow were the 2 most common findings at the time of revision.

CONCLUSIONS

For patients with CuTS, the risk of revision surgery after ME is higher in younger patients, patients with less severe disease, patients taking opioid medications preoperatively, and patients with associated workers' compensation claims.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Variables Prognostic for Delayed Union and Nonunion Following Ulnar Shortening Fixed With a Dedicated Osteotomy Plate

PURPOSE

To examine potential risk factors for the development of delayed or nonunion following elective ulnar shortening osteotomy using a dedicated osteotomy plating system.

METHODS

We performed a retrospective review of all patients who underwent elective ulnar shortening using the TriMed single osteotomy dynamic compression plating system by 1 of 2 fellowship-trained hand surgeons over a 5-year period. Demographic data and medical, surgical, and social histories were reviewed. Time to bony union was determined radiographically by a blinded reviewer. Bivariate statistical analysis was performed to examine the effect of explanatory variables on the time to union and the incidence of delayed or nonunion. Those variables associated with the development of delayed or nonunion were used in a multivariate logistic regression model. Complications, including the need for additional surgery, were also recorded.

RESULTS

Seventy-two ulnar shortening osteotomy procedures were performed in 69 patients. Delayed union, defined as ≥ 6 months to union, occurred in 8 of 72 cases (11%). Of 72 surgeries, 4 (6%) resulted in nonunions, all of which required additional surgery. Hardware removal was performed in 13 of 72 (18%) of the cases. Time to union was significantly increased in smokers (6 ± 3 months) versus nonsmokers (3 ± 1 months). On multivariable analysis, diabetics and active smokers demonstrated a significantly higher risk of developing delayed union or nonunion. Patient age, sex, body mass index, thyroid disease, worker's compensation status, alcohol use, and amount smoked daily did not have an effect on the time to union or the incidence of delayed or nonunion.

CONCLUSIONS

Despite the use of an osteotomy-specific plating system, smokers and diabetics were at significantly higher risk for both delayed union and nonunion following elective ulnar shortening osteotomy. Other known risk factors for suboptimal bony healing were not found to have a deleterious effect.

Complications Following Partial and Total Wrist Arthroplasty: A Single-Center Retrospective Review

PURPOSE

To describe our institution's experience with complications following partial and total wrist arthroplasty (TWA).

METHODS

We performed a retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with prosthetic replacement of the distal radius, the proximal carpus, or both at a single institution. Patient factors including age, sex, body mass index, handedness, underlying disease, and previous injury were recorded. Outcomes focused particularly on postoperative complications and need for revision surgery.

RESULTS

Forty-seven TWAs, 52 distal radius hemiarthroplasties, and 6 proximal carpal hemiarthroplasties were reviewed with a mean follow-up duration of 35 ± 28 months. Overall complication and revision rates were 51% (53 of 105) and 39% (41 of 105), respectively. Postoperative contracture accounted for the largest number of complications needing additional surgery (20%), followed by component failure (15%). Deep infections occurred in 2 TWAs and 1 distal radius hemiarthroplasty and required removal of hardware, antibiotic spacer placement, and a prolonged course of intravenous antibiotics prior to a definitive operation. Of those patients requiring additional surgery, 41% (n = 10) underwent at least 2 procedures, and 10% (n = 4) underwent at least 6 additional surgeries.

CONCLUSIONS

Although TWA and partial wrist arthroplasty are attractive treatment options for the painful arthritic wrist, there remains a noteworthy potential for complications requiring additional surgery. A detailed understanding of these risks is essential for surgeons so that patients may be counseled accordingly and that alternative treatment options may be considered.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The effects of distal interlocking screws on torsional stability in three-part intertrochanteric hip fractures

OBJECTIVE

Many surgeons currently use long cephomedullary nails for the treatment of intertrochanteric fractures. The optimal indications for deploying distal interlocks are still debatable. This study examined the torsional biomechanical properties of 3-part intertrochanteric femur fractures in a cadaveric bone model using two different distal fixation strategies, an unlocked long cephalomedullary nail versus a dynamically locked nail. Our hypothesis is that a long cephalomedullary nail does not require distal locking fixation when used for treatment of a 3-part intertrochanteric fracture.

METHODS

Five matched pairs of cadaveric femora were randomly assigned to one of two distal fixation treatment groups; a single distal interlock screw placed in the dynamic orientation or no distal fixation. A 3-part intertrochanteric fracture was produced. Specimens were potted and mounted in a double gimbal fixture facilitating unconstrained motion in the sagittal and coronal planes. Specimens were cyclically loaded dynamically in both internal and external rotation. Range of motion, internal and external rotation stiffness, torsion stiffness, torsion yield and ultimate torsion magnitude were calculated.

RESULTS

The samples instrumented with a distal locking screw reported statistically greater external rotational stiffness than the unlocked samples in nondestructive testing. The results of the destructive data demonstrated no statistical difference between the locked and unlocked group with regard to yield torque (p = 0.282), peak torque (p = 0.340), stiffness (p = 0.220), displacement at yield torque (p = 0.0605), and displacement at peak torque (p = 0.280).

CONCLUSION

Distal locking of a long cephalomedullary nail increases the stiffness of the nail-femur construct in a 3-part biomechanical fracture model. However, our testing illustrates that an unlocked construct will tolerate at least equal stress before catastrophic failure in a torsional loading model.

Hybrid Anterolateral Approach for Open Reduction and Internal Fixation of Femoral Neck Fractures

Displaced femoral neck fractures in physiologically young patients are best treated with anatomic reduction and stable fixation. Several surgical approaches to the femoral neck have previously been described, although they are fraught with disadvantages such as poor visualization, the need for 2 incisions, and risk of injury to the lateral femoral cutaneous nerve and branches of the medial femoral circumflex artery. The authors' hybrid anterolateral approach to the hip allows for excellent visualization of femoral neck fractures and for placement of plate and/or screw constructs through a single incision. This surgical technique additionally minimizes risk to neurovascular structures.

Management of complications of wrist arthroplasty and wrist fusion

The human wrist joint is unique from functional and anatomic standpoints. Numerous articulations exist within the wrist that allow for many options for partial wrist fusion and arthroplasty. In cases of pancarpal disease, fusion or arthroplasty of the entire wrist joint can be performed. Because of the high functional demand of the wrist, many of these surgical options can fail, leading to devastating complications. This article addresses the types of fusions and arthroplasties available for the wrist and discusses the potential complications associated with each. Methods to prevent these complications are presented and those to treat them once they have occurred are discussed.

Emergency department external fixation for provisional treatment of pilon and unstable ankle fractures

Unstable ankle fractures and impacted tibial pilon fractures often benefit from provisional external fixation as a temporizing measure prior to definitive fixation. Benefits of external fixation include improved articular alignment, decreased articular impaction, and soft tissue rest. Uniplanar external fixator placement in the Emergency Department (ED ex-fix) is a reliable and safe technique for achieving ankle reduction and stability while awaiting definitive fixation. This procedure involves placing transverse proximal tibial and calcaneal traction pins and connecting the pins with two external fixator rods. This technique is particularly useful in austere environments or when the operating room is not immediately available. Additionally, this bedside intervention prevents the patient from requiring general anesthesia and may be a cost-effective strategy for decreasing valuable operating time. The ED ex-fix is an especially valuable procedure in busy trauma centers and during mass casualty events, in which resources may be limited.

The effect of supination and pronation on wrist range of motion

Wrist range of motion (ROM) is a combination of complex osseous articulations and intricate soft tissue constraints. It has been proposed that forearm rotation contributes significantly to carpal kinematics. However, no studies have investigated whether supination or pronation influence this course of motion. The purpose of this study is to examine whether supination and pronation affect the mechanical axis of the wrist. After being screened for gross anatomic abnormalities, six upper extremity cadaver specimens (three matched pairs) were fixed to a custom-designed jig that allows 24 different directions of wrist motion. Each specimen was tested in three separate forearm positions: neutral, full supination, and full pronation. Moments of ± 2 Nm were applied, and the applied moment versus wrist rotation data were recorded. Forearm position did not significantly (p > 0.31) affect the ROM values of the wrist. In forearm neutral, supination, and pronation positions the envelope of wrist ROM values was ellipsoidal in shape, consistent with prior neutral forearm biomechanical testing. The major axis of the ellipse was oriented in a radial extension to ulnar flexion direction, with the largest ROM in ulnar flexion. We hypothesized that forearm position would influence wrist ROM. However, our biomechanical testing showed no statistically significant difference in the orientation of the mechanical axis nor the passive ROM of the wrist. The primary passive mechanical axis in all three forearm positions tested (neutral, supination, and pronation) was aligned with radial extension and ulnar flexion. Although it has been shown that forearm position affects various radioulnar, radiocarpal, and ulnocarpal ligamentous tensions and lengths, it appears that wrist ROM is independent of forearm position. Consequently we feel our biomechanical testing illustrates that wrist ROM is primarily dependent on the osseous articulations of the carpus. Additionally, given that no change is observed in wrist ROM relative to forearm position, the significance of the contribution of the distal radioulnar joint (DRUJ) to wrist kinematics is debatable.

Treatment of diaphyseal forearm fractures in children

Both bone forearm fractures are common orthopedic injuries. Optimal treatment is dictated not only by fracture characteristics but also patient age. In the pediatric population, acceptable alignment can tolerate greater fracture displacement due to the bone’s ability to remodel with remaining growth. Generally, these fractures can be successfully managed with closed reduction and casting, however operative fixation may also be required. The optimal method of fixation has not been clearly established. Currently, the most common operative interventions are open reduction with plate fixation versus closed or open reduction with intramedullary fixation. Plating has advantages of being more familiar to many surgeons, being theoretically superior in the ability to restore radial bow, and providing the possibility of hardware retention. Recently, intramedullary nailing has been gaining popularity due to decreased soft tissue dissection; however, a second operation is needed for hardware removal generally 6 months after the index procedure. Current literature has not established the superiority of one surgical method over the other. The goal of this manuscript is to review the current literature on the treatment of pediatric forearm fractures and provide clinical recommendations for optimal treatment, focusing specifically on children ages 3-10 years old.

Forearm diaphyseal fractures in the adolescent population: treatment and management

BACKGROUND

Pediatric both-bone diaphyseal forearm fractures are commonly treated in a variety of clinical settings. Most often, closed reduction followed by immobilization leads to satisfactory results. However, in the adolescent population (10-16 years of age), forearm fractures are more challenging due to less remodeling potential. The purpose of this review was to provide an overview of the anatomy, biomechanics, and treatment options relevant to adolescent patients.

METHODS

A systematic review of peer-reviewed publications and abstracts related to the treatment for pediatric both-bone diaphyseal forearm fractures in adolescents was carried out.

RESULTS

Forearm fractures in the pediatric population are most common following indirect blows to the forearm. When treating these fractures using closed reduction, it is important to recognize the muscular attachments of the forearm. In roughly 70-90% of cases, closed reduction leads to adequate alignment. In all cases, return to function is the primary goal; however, exact alignment parameters remain controversial. In the adolescent population, surgical treatment has risen substantially in the last few decades. Intramedullary nailing and open reduction using plate fixation are the two most common operative techniques. Unfortunately, recent results have shown that nonunion, malunion, and overall complication rates are higher in older pediatric patients. Moreover, no consensus exists regarding one technique over another.

CONCLUSIONS

Both-bone diaphyseal fractures in the adolescent population present unique challenges regarding optimal treatment, especially when considering surgical intervention. Further research is necessary to better understand indications for specific surgical treatment.

Effect of distal interlock fixation in stable intertrochanteric fractures

The objective of this study was to evaluate the torsion stiffness of locked and unlocked distal fixation of long cephalomedullary nail constructs, in both a fresh fracture and healed, stable intertrochanteric fracture model. Samples were tested in both internal and external rotation (0±3 Nm) for a duration of 10 cycles. Each femur was tested without instrumentation (intact femur), with instrumentation and no fracture (healed intertrochanteric fracture), and with instrumentation with an osteotomy creating a stable intertrochanteric fracture (fresh fracture). All specimens were instrumented with a long cephalomedullary nail. A distal interlock was placed in the dynamic position in 1 femur, and the other femur of the matched pair was left unlocked. Mean external (ER) and internal (IR) rotation stiffness for intact femurs without instrumentation (ER, 2.1±0.5 Nm/degree; IR, 2.2±0.5 Nm/degree) was statistically stiffer (P<.05 for all) compared with fresh fractured locked (ER, 1.1±0.2 Nm/degree; IR, 1.1±0.3 Nm/degree) and fresh fractured unlocked (ER, 0.9±0.3 Nm/degree; IR, 1.0±0.2 Nm/degree) samples. Similarly, healed locked (ER, 2.5±0.2 Nm/degree; IR, 2.8±0.1 Nm/degree) and healed unlocked (ER, 2.5±0.5 Nm/degree; IR, 2.4±0.3 Nm/degree) samples had statistically higher stiffness compared with fresh fractured treatments. These results suggest that the unlocked distal constructs provide similar torsional strength compared with locked fixation in these models.

Temporizing management of pediatric femur fractures using J-splints

This article describes a novel splinting technique for the temporizing management of pediatric femur fractures. The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and pitfalls of other described temporizing measures, such as skeletal traction, skin traction, traction splinting, and posterior splinting. This technique of J-splinting femur fractures has low morbidity and provides many advantages in the temporizing management of pediatric femur fractures.

Arabitol dehydrogenase as a selectable marker for rice

Arabitol dehydrogenase has been adapted for use as a plant selectable marker. Arabitol is a five-carbon sugar alcohol that can be used by E. coli strain C, but not by the laboratory K12 strains. The enzyme converts the non-plant-metabolizable sugar arabitol into xylulose, which is metabolized by plant cells. Rice was transformed with a plant-expression-optimized synthetic gene using Biolistic-mediated transformation. Selection on 2.75% arabitol and 0.25% sucrose yielded a transformation efficiency (9.3%) equal to that obtained with hygromycin (9.2%). Molecular analyses showed that the atlD gene was integrated into the rice genome of selected plants and was inherited in a Mendelian manner. This study indicates that arabitol could serve as an effective means of plant selection.

Cytosolic Ca2+ homeostasis is a constitutive function of the V-ATPase in Saccharomyces cerevisiae

The vacuole is the major site of intracellular Ca(2+) storage in yeast and functions to maintain cytosolic Ca(2+) levels within a narrow physiological range via a Ca(2+) pump (Pmc1p) and a H(+)/Ca(2+) antiporter (Vcx1p) driven by the vacuolar H(+)-ATPase (V-ATPase). We examined the function of the V-ATPase in cytosolic Ca(2+) homeostasis by comparing responses to a brief Ca(2+) challenge of a V-ATPase mutant (vma2Delta) and wild-type cells treated with the V-ATPase inhibitor concanamycin A. The kinetics of the Ca(2+) response were determined using transgenic aequorin as an in vivo cytosolic Ca(2+) reporter system. In wild-type cells, the V-ATPase-driven Vcx1p was chiefly responsible for restoring cytosolic Ca(2+) concentrations after a brief pulse. In cells lacking V-ATPase activity, brief exposure to elevated Ca(2+) compromised viability, even when there was little change in the final cytosolic Ca(2+) concentration. vma2Delta cells were more efficient at restoring cytosolic [Ca(2+)] after a pulse than concanamycin-treated wild-type cells, suggesting long term loss of V-ATPase triggers compensatory mechanisms. This compensation was dependent on calcineurin, and was mediated primarily by Pmc1p.

Mutational analysis of subunit G (Vma10p) of the yeast vacuolar H+-ATPase

The G subunit of V-ATPases is a soluble subunit that shows homology with the b subunit of F-ATPases and may be part of the "stator" stalk connecting the peripheral V(1) and membrane V(0) sectors. When the N-terminal half of the G subunit is modeled as an alpha helix, most of the conserved residues fall on one face of the helix (Hunt, I. E., and Bowman, B. J. (1997) J. Bioenerg. Biomembr. 29, 533-540). We probed the function of this region by site-directed mutagenesis of the yeast VMA10 gene. Stable G subunits were produced in the presence of Y46A and K55A mutations, but subunit E was destabilized, resulting in loss of the V-ATPase assembly. Mutations E14A and K50A allowed wild-type growth and assembly of V-ATPase complexes, but the complexes formed were unstable. Mutations R25A and R25L stabilized V-ATPase complexes relative to wild-type and partially inhibited disassembly of V(1) from V(0) in response to glucose deprivation even though the mutant enzymes were fully active. A 2-amino acid deletion in the middle of the predicted N-terminal helix (DeltaQ29D30) allowed assembly of a functional V-ATPase. The results indicate that, although the N-terminal half of the G subunit is essential for V-ATPase activity, either this region is not a rigid helix or the presence of a continuous, conserved face of the helix is not essential.

The H subunit (Vma13p) of the yeast V-ATPase inhibits the ATPase activity of cytosolic V1 complexes

V-ATPases are composed of a peripheral complex containing the ATP-binding sites, the V(1) sector, attached to a membrane complex containing the proton pore, the V(o) sector. In vivo, free, inactive V(1) and V(o) sectors exist in dynamic equilibrium with fully assembled, active V(1) V(o) complexes, and this equilibrium can be perturbed by changes in carbon source. Free V(1) complexes were isolated from the cytosol of wild-type yeast cells and mutant strains lacking V(o) subunit c (Vma3p) or V(1) subunit H (Vma13p). V(1) complexes from wild-type or vma3Delta mutant cells were very similar, and contained all previously identified yeast V(1) subunits except subunit C (Vma5p). These V(1) complexes hydrolyzed CaATP but not MgATP, and CaATP hydrolysis rapidly decelerated with time. V(1) complexes from vma13Delta cells contained all V(1) subunits except C and H, and had markedly different catalytic properties. The initial rate of CaATP hydrolysis was maintained for much longer. The complexes also hydrolyzed MgATP, but showed a rapid deceleration in hydrolysis. These results indicate that the H subunit plays an important role in silencing unproductive ATP hydrolysis by cytosolic V(1) complexes, but suggest that other mechanisms, such as product inhibition, may also play a role in silencing in vivo.

Regulation of V-ATPases by reversible disassembly

V-ATPases consist of a complex of peripheral subunits containing catalytic sites for ATP hydrolysis, the V(1) sector, attached to several membrane subunits containing a proton pore, the V(0) sector. ATP-driven proton transport requires structural and functional coupling of the two sectors, but in vivo, the interaction between the V(1) and V(0) sectors is dynamic and is regulated by extracellular conditions. Dynamic instability appears to be a general characteristic of V-ATPases and, in yeast cells, the assembly state of V-ATPases is governed by glucose availability. The structural and functional implications of reversible disassembly of V-ATPases are discussed.

Assembly and regulation of the yeast vacuolar H(+)-ATPase

The yeast vacuolar H(+)-ATPase (V-ATPase) consists of a complex of peripheral subunits containing the ATP binding sites, termed the V(1) sector, attached to a complex of membrane subunits containing the proton pore, termed the V(o) sector. Interaction between the V(1) and V(o) sectors is essential for ATP-driven proton transport, and this interaction is manipulated in vivo as a means of regulating V-ATPase activity. When yeast (Saccharomyces cerevisiae) cells are deprived of glucose for as little as 5 min, up to 75% of the assembled V-ATPase complexes are disassembled into cytoplasmic V(1) sectors and membrane-bound V(o) sectors. Remarkably, this disassembly is completely reversible. Restoration of glucose to the growth medium results in quantitative reassembly of the disassembled complexes in as little as 5 min, even in the absence of any new protein synthesis. Cells also appear to regulate the extent of V(1)V(o) assembly on a long-term basis. Yeast cells grown for extended periods in a poor carbon source contain a high proportion of free V(1) and V(o) sectors, and these sectors remain poised for reassembly when growth conditions improve. Parallel experiments on the Manduca sexta V-ATPase suggest that reversible disassembly may be a general regulatory mechanism for V-ATPases. These results imply that V-ATPases are surprisingly dynamic structures, and their unique ‘regulated instability’ raises a number of interesting physiological and structural questions. How are extracellular conditions such as carbon source communicated to V-ATPase complexes present on intracellular membranes? How are such major structural changes in the V-ATPase generated and how are V(1) sectors ‘silenced’ in vivo to prevent unproductive hydrolysis of cytoplasmic ATP by the dissociated enzyme? We are addressing these questions using a combination of genetic and biochemical approaches.

The presence of the alternatively spliced A2 cassette in the vacuolar H+-ATPase subunit A prevents assembly of the V1 catalytic domain

Vacuolar ATPases (V-ATPases) are multisubunit enzymes that couple the hydrolysis of ATP to the transport of H+ across membranes, and thus acidify several intracellular compartments and some extracellular spaces. Despite the high degree of genetic and pharmacological homogeneity of V-ATPases, cells differentially modulate the lumenal pH of organelles and, in some cells, V-ATPases are selectively targetted to the plasma membrane. Although the mechanisms underlying such differences are not known, the subunit isoform composition of V-ATPases could contribute to altered assembly, targeting or activity. We previously identified an alternatively spliced variant of the chicken A subunit in which a 30 amino acid cassette (A1) containing the Walker consensus sequence for ATP binding is replaced by a 24 amino acid cassette (A2) that lacks this feature. We have examined the ability of chimeric yeast/chicken A subunits containing either the A1 or the A2 cassette to restore the V-ATPase activity of yeast that lack the A subunit. The A1-containing chimeric subunit, but not the chimera that contains the A2 cassette, partially restores the ability of the mutated yeast to grow at neutral pH. Both chimeric proteins are expressed, although at lower levels than the similarly transfected yeast A subunit. The A2-containing subunit fails to associate with the vacuolar membrane or support the assembly of V-ATPase complexes. Thus, the substitution of the A1 sequence by A2 not only removes the Walker nucleotide binding sequence but also compromises the ability of the A subunit to assemble with other V-ATPase subunits.

Early steps in assembly of the yeast vacuolar H+-ATPase

Vacuolar proton-translocating ATPases are composed of a complex of integral membrane proteins, the Vo sector, attached to a complex of peripheral membrane proteins, the V1 sector. We have examined the early steps in biosynthesis of the yeast vacuolar ATPase by biosynthetically labeling wild-type and mutant cells for varied pulse and chase times and immunoprecipitating fully and partially assembled complexes under nondenaturing conditions. In wild-type cells, several V1 subunits and the 100-kDa Vo subunit associate within 3-5 min, followed by addition of other Vo subunits with time. Deletion mutants lacking single subunits of the enzyme show a variety of partial complexes, including both complexes that resemble intermediates in the assembly pathway of wild-type cells and independent V1 and Vo sectors that form without any apparent V1Vo subunit interaction. Two yeast sec mutants that show a temperature-conditional block in export from the endoplasmic reticulum accumulate a complex containing several V1 subunits and the 100-kDa Vo subunit during incubation at elevated temperature. This complex can assemble with the 17-kDa Vo subunit when the temperature block is reversed. We propose that assembly of the yeast V-ATPase can occur by two different pathways: a concerted assembly pathway involving early interactions between V1 and Vo subunits and an independent assembly pathway requiring full assembly of V1 and Vo sectors before combination of the two sectors. The data suggest that in wild-type cells, assembly occurs predominantly by the concerted assembly pathway, and V-ATPase complexes acquire the full complement of Vo subunits during or after exit from the endoplasmic reticulum.