Take-Home Points

• The ulnohumeral joint can tolerate substantial articular surface loss without compromising stability.
• Consider BP as an alternative to AS in unreconstructable olecranon fractures.
• Both BP and AS of olecranon fractures maintain elbow stability.
• BP has the advantage of maintaining elbow range of motion.

Olecranon fractures constitute about 10% of all forearm fractures.¹ Many are low-energy fractures in osteoporotic bone in the elderly.^1,2 Unstable fractures require operative fixation in which the goal is restoration of articular congruity and stability.³ Various fixation methods are used to treat unstable olecranon fractures, and outcomes are good overall.^3-21 However, severely comminuted olecranon fractures, especially in osteoporotic bone, pose a unique challenge, where reconstruction may not be feasible.9 Although the articular surface can be reconstructed in most cases, reconstruction is not feasible with severe comminution or low bone mineral density. When articular congruity is no longer possible, the primary goal of fixation becomes elbow stability. Postoperative stability is linked to favorable outcomes, as it allows patients to engage in early range-of-motion (ROM) exercises, which improves joint function.^5,21,22

When treating these severely comminuted olecranon fractures, surgeons have 2 options: bridge plating (BP) and acute shortening (AS). In BP, a plate is used to restore the length of the olecranon. The plate is spanned over the comminuted segment with fixation at proximal and distal pieces but without open reduction of the comminuted pieces.⁸ This process may be performed with or without bone grafting.²¹ Although any bony defect between the proximal and distal pieces may be filled, there is now a gap in articular congruity within the sigmoid notch. One concern with this fixation method is that joint stability is lost when this gap becomes too large. Surgeons therefore may decide to forgo BP and perform AS instead, as long as the coronoid is intact.²¹ In AS, often referred to as olecranon excision, comminuted fragments are removed and the triceps muscle advanced distally. AS constructs, often reserved for older, less active patients, yield acceptable results in this population.⁵ However, the long-term effects of AS in young, active patients are unclear, and biomechanical studies suggest reduced triceps muscle strength.²³

Surgeons have had no studies guiding them in deciding which construct to use, BP or AS, in severely comminuted olecranon fractures in which the articular surface cannot be reconstructed.

We conducted a biomechanical study to determine the percentage loss of articular surface at which a BP construct becomes significantly clinically unstable. We also compared BP stability and AS stability for each percentage loss of articular surface and compared initial elbow ROM with the 2 methods. We hypothesized that, at a certain percentage loss of articular congruity, the BP construct would become too unstable and would require conversion to the AS construct.

Materials and Methods

Specimen Preparation

Eight fresh-frozen paired cadaveric upper limbs (2 male, 2 female; mean age, 61.8 years; age range, 56-74 years) were obtained from donors with no history of elbow trauma or prior surgery. Specimens were stored at –20°C, thawed to room temperature before testing, and, using clinical and radiographic evaluation, screened for abnormalities.

Each specimen was positioned with the arm draped in the lateral decubitus position, as in typical olecranon fracture surgery. A standard posterior approach to the olecranon was made with a midline posterior longitudinal skin incision. Subcutaneous flaps were developed, and the subcutaneous border of the proximal olecranon was exposed, preserving the medial and lateral collateral ligaments as well as the extensor mechanism. Baseline maximum flexion and extension of the elbow as well as olecranon length were measured with fluoroscopy (BV Pulsera, Philips) and ImageJ software (National Institutes of Health). 

To ensure reproducible anatomical reduction during plating, a 3.5-mm 4-hole nonlocking periarticular anatomically contoured plate (Zimmer Biomet) was applied posteriorly to the intact olecranon through a longitudinal slit in the distal triceps tendon. The plate was predrilled to house 4 nonlocking screws, 2 proximal and 2 distal.

Fracture Generation and Testing of Fixation Constructs

Analysis

ImageJ software was used to analyze the C-arm radiographs. Measurements were divided into 4 groups of joint surface loss caused by the resections: 0% to 20%, 20% to 40%, 40% to 60%, and >60%. Differences in ROM between the BP and AS constructs were analyzed with a Wilcoxon signed rank test with statistical significance set at P < .05 (Prism 6; GraphPad Software).

Results

As many as 6 serial resections were made before the proximal fragment of the olecranon was judged too small to be secured to a plate with at least 2 screws. Only 7 specimens were large enough for the fifth cut, and only 4 were large enough for the sixth cut. After the final resection, mean loss of olecranon length was 77.3% (range, 63.7%-88%; median, 80.6%). All elbow specimens remained stable to manual valgus and varus testing in full extension, 30° of flexion, and full flexion in both supination and pronation. There was no medial or lateral opening of the ulnohumeral joint on fluoroscopy throughout testing, for either the BP or the AS constructs. There was no anterior or posterior subluxation throughout the entire ROM.

Discussion

Our goal in this study was to determine the maximum articular surface loss that can be tolerated before a BP construct becomes unstable. This finding applies to situations in which the degree of comminution makes reconstruction of the articular surface impossible. Contrary to our hypothesis, the ulnohumeral joint remained stable despite extensive loss of congruity within the sigmoid notch. In 1 specimen, the joint remained stable at 88% loss of olecranon. However, the 2 constructs had different ROM results: ROM was significantly lower at more resections with AS but remained unchanged from baseline with BP.

Dorsal plating has become standard treatment for comminuted olecranon fractures, and many studies, both clinical and biomechanical, have reported favorable results, good functional outcomes, and acceptable ROM.^{3,7,10,13,18-20,25} However, the multiple studies on the use of various plates in comminuted olecranon fractures did not address whether articular congruity was maintained during reductions or how much articular surface was reconstructed. Although we may reasonably assume larger studies included cases with some unmeasured loss of articular congruity, it is difficult to directly compare our findings with those of other studies. In addition, it is possible those studies did not include fractures that were deemed unfit for BP (because of very severe comminution) and underwent AS instead. Only 1 case series has focused on BP without complete articular reconstruction.8 The cases in that series had good outcomes with good stability—consistent with our finding of extreme comminution in a worst-case scenario. 

Complete elbow stability after AS is consistent with findings in the literature.^4,6,12,14,16 As AS is reserved for severely comminuted fractures and bone resections,^21,23,26 our findings can be compared with the earlier findings. In AS, either the proximal pieces or the intermediate pieces are removed to create a smaller but congruent articular surface, with less concern for nonunion.²¹ When the proximal piece is removed, the triceps muscle is advanced to the ulnar shaft, creating a slinglike structure for the trochlea.^4,11,16,23 When the intermediate piece is removed, the proximal piece is advanced to the shaft along with the triceps.^12,14,27 In either technique, the triceps muscle is advanced distally, potentially affecting its extensibility and moment arm.²³

Although small in numbers, case series and retrospective reviews have found that AS has good outcomes,^4,14,16 whereas our study found significantly decreased ROM. A few patients in these studies lost ROM or triceps strength,^12,14,16 but the cause, AS or fracture severity, is unclear. It is possible only 0% to 20% of the olecranon was resected in those cases, whereas our study found no significant change in ROM. It is also possible that cadaveric muscles do not stretch as well as muscles in vivo. Biomechanical studies have demonstrated changes in triceps stretch and strength,^23,26 but perhaps these changes are subclinical or overcome with therapy and time.^12,14 There are no data regarding whether patients who undergo AS (vs another fixation method) need more physical therapy. In extreme resection, some reduction in ROM is expected.¹³

The ulnohumeral joint is a primary static stabilizer of the elbow joint.28-30 Recent studies on the role of the ulnohumeral joint in elbow stability have focused mainly on the coronoid process in the setting of dislocation.^28,29,31,32 According to these studies, 50% of the coronoid must remain intact for the elbow to be stable when all other stabilizers are intact.³² In our study, resections preserved the coronoid and the ligamentous stabilizers of the elbow. It is therefore possible that the elbow joint remained stable despite the considerable articular surface loss. Although the term ulnohumeral joint refers to both the coronoid and the remaining articular surface, our findings support the coronoid as a primary stabilizer and the remaining articular surface as a secondary static stabilizer.

This study had several limitations. First, its fractures were simulated by serial resection of only the middle portion of the olecranon. In reality, comminution could extend farther proximally or distally and involve the surrounding tissues, which help stabilize the elbow. However, our focus was on loss of articular surface and stability, so keeping surrounding structures intact avoided confounding factors that could contribute to stability. A second possible limitation is that the implant used here may be different from the implant used in a clinical setting. However, our focus was not on fixation quality, and stability alone should not be affected by plate type. Third, stability was measured not quantitatively but instead subjectively under manual stress and fluoroscopy. We chose this method because it mimics what happens during surgery and is the clinical standard for stability assessment.²⁴ Fourth, soft-tissue properties of the cadaver models used in this biomechanical study may differ from soft-tissue properties in vivo. This study could not evaluate possible long-term complications, such as posttraumatic arthritis and heterotopic ossification.^5,10 There are no long-term studies comparing BP and other olecranon fixation methods in terms of postoperative elbow arthritis.

Conclusion

The ulnohumeral joint can tolerate substantial articular surface loss without compromising stability. As a result, in the management of highly comminuted olecranon fractures, BP may be considered before AS is performed. Quality and amount of intact proximal bone, rather than degree of comminution, may be more important factors in deciding which fixation method to use.

This biomechanical study is the first to focus on olecranon fracture BP without complete reconstruction of the articular surface. When treating a highly comminuted olecranon fracture that has an unreconstructible articular surface, surgeons may consider BP with or without bone graft, as well as AS. Our study findings suggest that, though both constructs maintain elbow stability, BP may have the advantage of maintaining ROM too. BP can avoid effects on triceps and elbow ROM, which may be more important in younger, more active patients. Clinical correlates are needed to validate these findings, as overall outcomes may be affected by concurrent fractures and injuries to surrounding structures.

Take-Home Points

• The ulnohumeral joint can tolerate substantial articular surface loss without compromising stability.
• Consider BP as an alternative to AS in unreconstructable olecranon fractures.
• Both BP and AS of olecranon fractures maintain elbow stability.
• BP has the advantage of maintaining elbow range of motion.

Olecranon fractures constitute about 10% of all forearm fractures.¹ Many are low-energy fractures in osteoporotic bone in the elderly.^1,2 Unstable fractures require operative fixation in which the goal is restoration of articular congruity and stability.³ Various fixation methods are used to treat unstable olecranon fractures, and outcomes are good overall.^3-21 However, severely comminuted olecranon fractures, especially in osteoporotic bone, pose a unique challenge, where reconstruction may not be feasible.9 Although the articular surface can be reconstructed in most cases, reconstruction is not feasible with severe comminution or low bone mineral density. When articular congruity is no longer possible, the primary goal of fixation becomes elbow stability. Postoperative stability is linked to favorable outcomes, as it allows patients to engage in early range-of-motion (ROM) exercises, which improves joint function.^5,21,22

When treating these severely comminuted olecranon fractures, surgeons have 2 options: bridge plating (BP) and acute shortening (AS). In BP, a plate is used to restore the length of the olecranon. The plate is spanned over the comminuted segment with fixation at proximal and distal pieces but without open reduction of the comminuted pieces.⁸ This process may be performed with or without bone grafting.²¹ Although any bony defect between the proximal and distal pieces may be filled, there is now a gap in articular congruity within the sigmoid notch. One concern with this fixation method is that joint stability is lost when this gap becomes too large. Surgeons therefore may decide to forgo BP and perform AS instead, as long as the coronoid is intact.²¹ In AS, often referred to as olecranon excision, comminuted fragments are removed and the triceps muscle advanced distally. AS constructs, often reserved for older, less active patients, yield acceptable results in this population.⁵ However, the long-term effects of AS in young, active patients are unclear, and biomechanical studies suggest reduced triceps muscle strength.²³

Surgeons have had no studies guiding them in deciding which construct to use, BP or AS, in severely comminuted olecranon fractures in which the articular surface cannot be reconstructed.

We conducted a biomechanical study to determine the percentage loss of articular surface at which a BP construct becomes significantly clinically unstable. We also compared BP stability and AS stability for each percentage loss of articular surface and compared initial elbow ROM with the 2 methods. We hypothesized that, at a certain percentage loss of articular congruity, the BP construct would become too unstable and would require conversion to the AS construct.

Materials and Methods

Specimen Preparation

Eight fresh-frozen paired cadaveric upper limbs (2 male, 2 female; mean age, 61.8 years; age range, 56-74 years) were obtained from donors with no history of elbow trauma or prior surgery. Specimens were stored at –20°C, thawed to room temperature before testing, and, using clinical and radiographic evaluation, screened for abnormalities.

Each specimen was positioned with the arm draped in the lateral decubitus position, as in typical olecranon fracture surgery. A standard posterior approach to the olecranon was made with a midline posterior longitudinal skin incision. Subcutaneous flaps were developed, and the subcutaneous border of the proximal olecranon was exposed, preserving the medial and lateral collateral ligaments as well as the extensor mechanism. Baseline maximum flexion and extension of the elbow as well as olecranon length were measured with fluoroscopy (BV Pulsera, Philips) and ImageJ software (National Institutes of Health). 

To ensure reproducible anatomical reduction during plating, a 3.5-mm 4-hole nonlocking periarticular anatomically contoured plate (Zimmer Biomet) was applied posteriorly to the intact olecranon through a longitudinal slit in the distal triceps tendon. The plate was predrilled to house 4 nonlocking screws, 2 proximal and 2 distal.

Fracture Generation and Testing of Fixation Constructs

Analysis

ImageJ software was used to analyze the C-arm radiographs. Measurements were divided into 4 groups of joint surface loss caused by the resections: 0% to 20%, 20% to 40%, 40% to 60%, and >60%. Differences in ROM between the BP and AS constructs were analyzed with a Wilcoxon signed rank test with statistical significance set at P < .05 (Prism 6; GraphPad Software).

Results

As many as 6 serial resections were made before the proximal fragment of the olecranon was judged too small to be secured to a plate with at least 2 screws. Only 7 specimens were large enough for the fifth cut, and only 4 were large enough for the sixth cut. After the final resection, mean loss of olecranon length was 77.3% (range, 63.7%-88%; median, 80.6%). All elbow specimens remained stable to manual valgus and varus testing in full extension, 30° of flexion, and full flexion in both supination and pronation. There was no medial or lateral opening of the ulnohumeral joint on fluoroscopy throughout testing, for either the BP or the AS constructs. There was no anterior or posterior subluxation throughout the entire ROM.

Discussion

Our goal in this study was to determine the maximum articular surface loss that can be tolerated before a BP construct becomes unstable. This finding applies to situations in which the degree of comminution makes reconstruction of the articular surface impossible. Contrary to our hypothesis, the ulnohumeral joint remained stable despite extensive loss of congruity within the sigmoid notch. In 1 specimen, the joint remained stable at 88% loss of olecranon. However, the 2 constructs had different ROM results: ROM was significantly lower at more resections with AS but remained unchanged from baseline with BP.

Dorsal plating has become standard treatment for comminuted olecranon fractures, and many studies, both clinical and biomechanical, have reported favorable results, good functional outcomes, and acceptable ROM.^{3,7,10,13,18-20,25} However, the multiple studies on the use of various plates in comminuted olecranon fractures did not address whether articular congruity was maintained during reductions or how much articular surface was reconstructed. Although we may reasonably assume larger studies included cases with some unmeasured loss of articular congruity, it is difficult to directly compare our findings with those of other studies. In addition, it is possible those studies did not include fractures that were deemed unfit for BP (because of very severe comminution) and underwent AS instead. Only 1 case series has focused on BP without complete articular reconstruction.8 The cases in that series had good outcomes with good stability—consistent with our finding of extreme comminution in a worst-case scenario. 

Complete elbow stability after AS is consistent with findings in the literature.^4,6,12,14,16 As AS is reserved for severely comminuted fractures and bone resections,^21,23,26 our findings can be compared with the earlier findings. In AS, either the proximal pieces or the intermediate pieces are removed to create a smaller but congruent articular surface, with less concern for nonunion.²¹ When the proximal piece is removed, the triceps muscle is advanced to the ulnar shaft, creating a slinglike structure for the trochlea.^4,11,16,23 When the intermediate piece is removed, the proximal piece is advanced to the shaft along with the triceps.^12,14,27 In either technique, the triceps muscle is advanced distally, potentially affecting its extensibility and moment arm.²³

Although small in numbers, case series and retrospective reviews have found that AS has good outcomes,^4,14,16 whereas our study found significantly decreased ROM. A few patients in these studies lost ROM or triceps strength,^12,14,16 but the cause, AS or fracture severity, is unclear. It is possible only 0% to 20% of the olecranon was resected in those cases, whereas our study found no significant change in ROM. It is also possible that cadaveric muscles do not stretch as well as muscles in vivo. Biomechanical studies have demonstrated changes in triceps stretch and strength,^23,26 but perhaps these changes are subclinical or overcome with therapy and time.^12,14 There are no data regarding whether patients who undergo AS (vs another fixation method) need more physical therapy. In extreme resection, some reduction in ROM is expected.¹³

The ulnohumeral joint is a primary static stabilizer of the elbow joint.28-30 Recent studies on the role of the ulnohumeral joint in elbow stability have focused mainly on the coronoid process in the setting of dislocation.^28,29,31,32 According to these studies, 50% of the coronoid must remain intact for the elbow to be stable when all other stabilizers are intact.³² In our study, resections preserved the coronoid and the ligamentous stabilizers of the elbow. It is therefore possible that the elbow joint remained stable despite the considerable articular surface loss. Although the term ulnohumeral joint refers to both the coronoid and the remaining articular surface, our findings support the coronoid as a primary stabilizer and the remaining articular surface as a secondary static stabilizer.

This study had several limitations. First, its fractures were simulated by serial resection of only the middle portion of the olecranon. In reality, comminution could extend farther proximally or distally and involve the surrounding tissues, which help stabilize the elbow. However, our focus was on loss of articular surface and stability, so keeping surrounding structures intact avoided confounding factors that could contribute to stability. A second possible limitation is that the implant used here may be different from the implant used in a clinical setting. However, our focus was not on fixation quality, and stability alone should not be affected by plate type. Third, stability was measured not quantitatively but instead subjectively under manual stress and fluoroscopy. We chose this method because it mimics what happens during surgery and is the clinical standard for stability assessment.²⁴ Fourth, soft-tissue properties of the cadaver models used in this biomechanical study may differ from soft-tissue properties in vivo. This study could not evaluate possible long-term complications, such as posttraumatic arthritis and heterotopic ossification.^5,10 There are no long-term studies comparing BP and other olecranon fixation methods in terms of postoperative elbow arthritis.

Conclusion

The ulnohumeral joint can tolerate substantial articular surface loss without compromising stability. As a result, in the management of highly comminuted olecranon fractures, BP may be considered before AS is performed. Quality and amount of intact proximal bone, rather than degree of comminution, may be more important factors in deciding which fixation method to use.

This biomechanical study is the first to focus on olecranon fracture BP without complete reconstruction of the articular surface. When treating a highly comminuted olecranon fracture that has an unreconstructible articular surface, surgeons may consider BP with or without bone graft, as well as AS. Our study findings suggest that, though both constructs maintain elbow stability, BP may have the advantage of maintaining ROM too. BP can avoid effects on triceps and elbow ROM, which may be more important in younger, more active patients. Clinical correlates are needed to validate these findings, as overall outcomes may be affected by concurrent fractures and injuries to surrounding structures.

Take-Home Points

• The ulnohumeral joint can tolerate substantial articular surface loss without compromising stability.
• Consider BP as an alternative to AS in unreconstructable olecranon fractures.
• Both BP and AS of olecranon fractures maintain elbow stability.
• BP has the advantage of maintaining elbow range of motion.

Olecranon fractures constitute about 10% of all forearm fractures.¹ Many are low-energy fractures in osteoporotic bone in the elderly.^1,2 Unstable fractures require operative fixation in which the goal is restoration of articular congruity and stability.³ Various fixation methods are used to treat unstable olecranon fractures, and outcomes are good overall.^3-21 However, severely comminuted olecranon fractures, especially in osteoporotic bone, pose a unique challenge, where reconstruction may not be feasible.9 Although the articular surface can be reconstructed in most cases, reconstruction is not feasible with severe comminution or low bone mineral density. When articular congruity is no longer possible, the primary goal of fixation becomes elbow stability. Postoperative stability is linked to favorable outcomes, as it allows patients to engage in early range-of-motion (ROM) exercises, which improves joint function.^5,21,22

When treating these severely comminuted olecranon fractures, surgeons have 2 options: bridge plating (BP) and acute shortening (AS). In BP, a plate is used to restore the length of the olecranon. The plate is spanned over the comminuted segment with fixation at proximal and distal pieces but without open reduction of the comminuted pieces.⁸ This process may be performed with or without bone grafting.²¹ Although any bony defect between the proximal and distal pieces may be filled, there is now a gap in articular congruity within the sigmoid notch. One concern with this fixation method is that joint stability is lost when this gap becomes too large. Surgeons therefore may decide to forgo BP and perform AS instead, as long as the coronoid is intact.²¹ In AS, often referred to as olecranon excision, comminuted fragments are removed and the triceps muscle advanced distally. AS constructs, often reserved for older, less active patients, yield acceptable results in this population.⁵ However, the long-term effects of AS in young, active patients are unclear, and biomechanical studies suggest reduced triceps muscle strength.²³

Surgeons have had no studies guiding them in deciding which construct to use, BP or AS, in severely comminuted olecranon fractures in which the articular surface cannot be reconstructed.

We conducted a biomechanical study to determine the percentage loss of articular surface at which a BP construct becomes significantly clinically unstable. We also compared BP stability and AS stability for each percentage loss of articular surface and compared initial elbow ROM with the 2 methods. We hypothesized that, at a certain percentage loss of articular congruity, the BP construct would become too unstable and would require conversion to the AS construct.

Materials and Methods

Specimen Preparation

Eight fresh-frozen paired cadaveric upper limbs (2 male, 2 female; mean age, 61.8 years; age range, 56-74 years) were obtained from donors with no history of elbow trauma or prior surgery. Specimens were stored at –20°C, thawed to room temperature before testing, and, using clinical and radiographic evaluation, screened for abnormalities.

Each specimen was positioned with the arm draped in the lateral decubitus position, as in typical olecranon fracture surgery. A standard posterior approach to the olecranon was made with a midline posterior longitudinal skin incision. Subcutaneous flaps were developed, and the subcutaneous border of the proximal olecranon was exposed, preserving the medial and lateral collateral ligaments as well as the extensor mechanism. Baseline maximum flexion and extension of the elbow as well as olecranon length were measured with fluoroscopy (BV Pulsera, Philips) and ImageJ software (National Institutes of Health). 

To ensure reproducible anatomical reduction during plating, a 3.5-mm 4-hole nonlocking periarticular anatomically contoured plate (Zimmer Biomet) was applied posteriorly to the intact olecranon through a longitudinal slit in the distal triceps tendon. The plate was predrilled to house 4 nonlocking screws, 2 proximal and 2 distal.

Fracture Generation and Testing of Fixation Constructs

Analysis

ImageJ software was used to analyze the C-arm radiographs. Measurements were divided into 4 groups of joint surface loss caused by the resections: 0% to 20%, 20% to 40%, 40% to 60%, and >60%. Differences in ROM between the BP and AS constructs were analyzed with a Wilcoxon signed rank test with statistical significance set at P < .05 (Prism 6; GraphPad Software).

Results

As many as 6 serial resections were made before the proximal fragment of the olecranon was judged too small to be secured to a plate with at least 2 screws. Only 7 specimens were large enough for the fifth cut, and only 4 were large enough for the sixth cut. After the final resection, mean loss of olecranon length was 77.3% (range, 63.7%-88%; median, 80.6%). All elbow specimens remained stable to manual valgus and varus testing in full extension, 30° of flexion, and full flexion in both supination and pronation. There was no medial or lateral opening of the ulnohumeral joint on fluoroscopy throughout testing, for either the BP or the AS constructs. There was no anterior or posterior subluxation throughout the entire ROM.

Discussion

Our goal in this study was to determine the maximum articular surface loss that can be tolerated before a BP construct becomes unstable. This finding applies to situations in which the degree of comminution makes reconstruction of the articular surface impossible. Contrary to our hypothesis, the ulnohumeral joint remained stable despite extensive loss of congruity within the sigmoid notch. In 1 specimen, the joint remained stable at 88% loss of olecranon. However, the 2 constructs had different ROM results: ROM was significantly lower at more resections with AS but remained unchanged from baseline with BP.

Dorsal plating has become standard treatment for comminuted olecranon fractures, and many studies, both clinical and biomechanical, have reported favorable results, good functional outcomes, and acceptable ROM.^{3,7,10,13,18-20,25} However, the multiple studies on the use of various plates in comminuted olecranon fractures did not address whether articular congruity was maintained during reductions or how much articular surface was reconstructed. Although we may reasonably assume larger studies included cases with some unmeasured loss of articular congruity, it is difficult to directly compare our findings with those of other studies. In addition, it is possible those studies did not include fractures that were deemed unfit for BP (because of very severe comminution) and underwent AS instead. Only 1 case series has focused on BP without complete articular reconstruction.8 The cases in that series had good outcomes with good stability—consistent with our finding of extreme comminution in a worst-case scenario. 

Complete elbow stability after AS is consistent with findings in the literature.^4,6,12,14,16 As AS is reserved for severely comminuted fractures and bone resections,^21,23,26 our findings can be compared with the earlier findings. In AS, either the proximal pieces or the intermediate pieces are removed to create a smaller but congruent articular surface, with less concern for nonunion.²¹ When the proximal piece is removed, the triceps muscle is advanced to the ulnar shaft, creating a slinglike structure for the trochlea.^4,11,16,23 When the intermediate piece is removed, the proximal piece is advanced to the shaft along with the triceps.^12,14,27 In either technique, the triceps muscle is advanced distally, potentially affecting its extensibility and moment arm.²³

Although small in numbers, case series and retrospective reviews have found that AS has good outcomes,^4,14,16 whereas our study found significantly decreased ROM. A few patients in these studies lost ROM or triceps strength,^12,14,16 but the cause, AS or fracture severity, is unclear. It is possible only 0% to 20% of the olecranon was resected in those cases, whereas our study found no significant change in ROM. It is also possible that cadaveric muscles do not stretch as well as muscles in vivo. Biomechanical studies have demonstrated changes in triceps stretch and strength,^23,26 but perhaps these changes are subclinical or overcome with therapy and time.^12,14 There are no data regarding whether patients who undergo AS (vs another fixation method) need more physical therapy. In extreme resection, some reduction in ROM is expected.¹³

The ulnohumeral joint is a primary static stabilizer of the elbow joint.28-30 Recent studies on the role of the ulnohumeral joint in elbow stability have focused mainly on the coronoid process in the setting of dislocation.^28,29,31,32 According to these studies, 50% of the coronoid must remain intact for the elbow to be stable when all other stabilizers are intact.³² In our study, resections preserved the coronoid and the ligamentous stabilizers of the elbow. It is therefore possible that the elbow joint remained stable despite the considerable articular surface loss. Although the term ulnohumeral joint refers to both the coronoid and the remaining articular surface, our findings support the coronoid as a primary stabilizer and the remaining articular surface as a secondary static stabilizer.

This study had several limitations. First, its fractures were simulated by serial resection of only the middle portion of the olecranon. In reality, comminution could extend farther proximally or distally and involve the surrounding tissues, which help stabilize the elbow. However, our focus was on loss of articular surface and stability, so keeping surrounding structures intact avoided confounding factors that could contribute to stability. A second possible limitation is that the implant used here may be different from the implant used in a clinical setting. However, our focus was not on fixation quality, and stability alone should not be affected by plate type. Third, stability was measured not quantitatively but instead subjectively under manual stress and fluoroscopy. We chose this method because it mimics what happens during surgery and is the clinical standard for stability assessment.²⁴ Fourth, soft-tissue properties of the cadaver models used in this biomechanical study may differ from soft-tissue properties in vivo. This study could not evaluate possible long-term complications, such as posttraumatic arthritis and heterotopic ossification.^5,10 There are no long-term studies comparing BP and other olecranon fixation methods in terms of postoperative elbow arthritis.

Conclusion

The ulnohumeral joint can tolerate substantial articular surface loss without compromising stability. As a result, in the management of highly comminuted olecranon fractures, BP may be considered before AS is performed. Quality and amount of intact proximal bone, rather than degree of comminution, may be more important factors in deciding which fixation method to use.

This biomechanical study is the first to focus on olecranon fracture BP without complete reconstruction of the articular surface. When treating a highly comminuted olecranon fracture that has an unreconstructible articular surface, surgeons may consider BP with or without bone graft, as well as AS. Our study findings suggest that, though both constructs maintain elbow stability, BP may have the advantage of maintaining ROM too. BP can avoid effects on triceps and elbow ROM, which may be more important in younger, more active patients. Clinical correlates are needed to validate these findings, as overall outcomes may be affected by concurrent fractures and injuries to surrounding structures.

SAN FRANCISCO – Pursue a deep remission that allows a patient to stay treatment free for some period of time, or go for long-term disease control that might not allow for a drug holiday?

It’s a key decision facing physicians in the frontline setting of chronic lymphocytic leukemia, William Wierda, MD, PhD, said at the annual congress on Hematologic Malignancies held by the National Comprehensive Cancer Network.

SAN FRANCISCO – Pursue a deep remission that allows a patient to stay treatment free for some period of time, or go for long-term disease control that might not allow for a drug holiday?

It’s a key decision facing physicians in the frontline setting of chronic lymphocytic leukemia, William Wierda, MD, PhD, said at the annual congress on Hematologic Malignancies held by the National Comprehensive Cancer Network.

SAN FRANCISCO – Pursue a deep remission that allows a patient to stay treatment free for some period of time, or go for long-term disease control that might not allow for a drug holiday?

It’s a key decision facing physicians in the frontline setting of chronic lymphocytic leukemia, William Wierda, MD, PhD, said at the annual congress on Hematologic Malignancies held by the National Comprehensive Cancer Network.

Take-Home Points

• Clinical and radiographic outcomes of patients treated with non-spanning external fixation are comparable to those treated with open reduction and internal volar locked plate fixation.
• Non-spanning external fixation can lead to satisfactory outcomes based on the following features: fragment specific fixation, subchondral support, fixed angle strength, limited dissection, distraction/length adjustment, joint distraction avoidance, and ability to perform early rehabilitation.
• Non-spanning external fixation should be considered as a treatment option for complicated unstable comminuted intra-articular distal radius fractures, specifically in the elderly.

In the United States, distal radius fractures (DRFs) are among the most common fractures, comprising about 15% of all extremity fractures.¹ With a DRF, the primary treatment goal is anatomical reduction with restoration of radiographic parameters and stable fixation of the fracture to restore wrist function.

This fracture type has a variety of treatment alternatives, including nonoperative closed reduction and casting of stable fractures, open reduction and internal fixation (ORIF) with dorsal or volar locking plates, and external fixation. Optimal surgical management of unstable DRFs remains controversial.² Closed reduction with percutaneous pinning or external fixation has become less common with a trend toward using volar locking plates for internal fixation.³

External fixation of DRFs traditionally has involved either spanning or simple nonspanning devices. Spanning fixation is particularly useful in open or highly comminuted fractures with an unstable soft-tissue envelope. In the past, nonspanning external fixation typically was reserved for fractures with a noncomminuted extra-articular distal fragment to which several large pins or Kirschner wires (K-wires) could be secured. The Non-Bridging External Fixator (NBX; Nutek Orthopaedics) may be used in cases that traditionally might be treated with locked plating or fragment-specific fixation. Specifically, this device is indicated for comminuted intra-articular DRFs in which bone quality may be less than ideal. The NBX, also suitable in open fractures with a stable soft-tissue envelope, can restore and maintain articular alignment by providing subchondral support and stability with fragment-specific fixation. A key advantage of this type of external fixation is that it involves percutaneous fixation and allows for early postoperative range of motion (ROM).

Numerous studies have found excellent outcomes of treating unstable DRFs with ORIF with volar locking plates.^4-6 However, few studies have compared the clinical and radiographic outcomes of ORIF with those of nonspanning external fixation in the treatment of unstable comminuted intra-articular DRFs. Windolf and colleagues⁷ found that, in cadaveric unstable intra-articular DRFs, nonspanning external fixation with multiplanar K-wires had biomechanical characteristics comparable to those of volar locking plates. Other suitable DRF treatment options have been found: an alternative nonbridging external fixator with multiplanar K-wires (Gradl and colleagues⁸) and the Cross-Pin Fixation system (A.M. Surgical) (Mirza and colleagues⁹).

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular DRFs treated with a nonspanning external fixation device (NBX) with outcomes achieved with volar locking plates in a historical control group.

Materials and Methods

This retrospective case-control study was approved by our Institutional Review Board and conducted at 2 institutions. Included in the study were 25 consecutive patients (2 institutions) who underwent closed reduction and external fixation (CREF) with NBX as treatment for unstable DRFs (diagnosis based on radiographic parameters or inability to maintain acceptable alignment after closed reduction and casting). Of these 25 patients, 11 were available for clinical follow-up and medical records review; the other 14 were not available for followup but had their charts reviewed for radiographic data and treatment details. Six of the 14 patients declined to participate in the study, and the other 8 were lost to follow-up because of nonstandardized follow-up protocols. Patients were excluded from the study if their final follow-up had not occurred, or if it occurred before 6 months. For their participation in clinical follow-up, patients received nominal time compensation and mileage reimbursement through a grant from the NBX manufacturer.

The 25 patients underwent CREF with NBX between November 2008 and March 2013. Indications for external fixation consideration were intra-articular extension or significant comminution in patients with poor soft tissue or in patients who wanted to avoid invasive surgery or a permanent implant. Of the 11 patients who agreed to participate in the study, 7 were women and 4 were men; mean age was 64 years (range, 15-81 years). Of the 14 patients unable to follow up, 11 were women and 3 were men; mean age was 63 years (range, 26-89 years). At the last available follow-up, each of the 25 patients was doing well, was satisfied with treatment received and function regained, and had a healed DRF. In almost every case, the mechanism of injury was a fall onto an outstretched hand; most fractures were type C per AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification (Table 1).

The surgical technique for this nonspanning external fixator involves closed reduction with longitudinal traction using ligamentotaxis to grossly align the fracture fragments, with small adjustments made throughout the procedure. A dorsally placed radiolucent fixator is used with fluoroscopic guidance to percutaneously affix a subchondral raft of smooth bicortical .062-inch K-wires. The fixator’s abundant pin holes allow for each specific distal fragment to be captured by pins that are a part of the external fixation construct. Furthermore, radially based pins that use a side bar allow for a “weave” of fixation. Radial length is then obtained and maintained by attaching the distal complex to proximal pins in the radial diaphysis. After pins are cut and wrist and digits are taken through full ROM to ensure smooth tracking, fluoroscopy is used to confirm final fracture fixation and alignment (Figure 1).

In ideal scenarios with good fixation, patients can begin gentle ROM exercises within 1 week after surgery. This regimen can progress to more aggressive motion exercises and even light strengthening (Figure 2).

The 11 clinical follow-up patients underwent directed clinical examination, including ROM and strength evaluation, by Dr. Dwyer and Dr. Crosby. Follow-up also included completion of questionnaires and review of radiographs.

During the clinical follow-up, a standard goniometer was used to evaluate active ROM (wrist flexion and extension and wrist radial and ulnar deviation, measured down the long axis of the forearm and the index ray), and forearm pronation and supination were measured from the 90° elbow flexion position using the humerus as the reference point with the shoulders in 0° of flexion, abduction, and external rotation. In addition, a calibrated dynamometer (Sammons Preston) was used to measure grip strength (position 3) and key pinch strength, and the average of 3 trials of each strength test was calculated. ROM and strength values were calculated as percentages of the contralateral (uninjured) side, as these ratios are more sensitive in detecting clinical changes.¹⁰ A 10% adjustment for dominant hand grip strength in right-handed patients was used for this comparison.¹¹

Union (osseous bridging across fracture site on 2 of 3 views), radial height, radial inclination, and volar tilt were measured on standard posteroanterior and lateral radiographs taken at several points: time of injury, postreduction and/or preoperative, initial postoperative, and final follow-up. All radiographic measurements were independently taken by Dr. Dwyer and Dr. Crosby, who used a digital goniometer and ruler (Siemens Medical Solutions) or, when necessary, manual instruments. Means of the original and independent measurements were used for calculations.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo wrist score, and the patient-rated wrist evaluation were used to assess activities of daily living, pain, and quality of life after surgery. Mayo wrist scores were adjusted for unemployed patients; work status was replaced with return to normal activities. 

Complications of surgical treatment were evaluated. Major complications evaluated were loss of reduction, malunion, nonunion, deep infection, neuropathy, and tendon rupture. Minor complication possibilities were transient extensor tendon irritation, superficial infection, and finger stiffness. Also noted were 1 patient who subsequently required another procedure and 7 patients who were immobilized after external fixation removal.

We compared our study group’s outcomes with those of historical control patients who underwent fixation with internal volar locking plates. The 2 groups had similar demographic characteristics. To obtain the historical controls, we used the key words distal, radi*, volar, and plat* in a PubMed search. From the 169 citations found, we removed biomechanical cadaver studies, studies that focused on patients with demographics and fracture types dissimilar from our patient population’s, and studies that focused on special circumstances, such as complications or patient characteristics. Eight studies remained for historical comparison.

Results

Radiographic Outcomes

On the injury radiographs, mean volar tilt was –16.7° (range, 2° to –42°), mean radial inclination was 14.1° (range, –1° to 44°), and mean radial height was 5.3 mm (range, –2 mm to 11 mm). Minor improvement after reduction was noted. All patients had intraoperative or postoperative radiographs with external fixation in place (Figure 3).

On the final (post-fixation removal) radiographs, mean volar tilt was 3.3° (range, –16° to 21°), mean radial inclination was 20.7° (range, 0° to 31°), and mean radial height was 7.5 mm (range, 0 mm to 13 mm). Comparison of the injury and final means revealed correction of ~20° for volar tilt, 6° for radial inclination, and 2 mm for radial height. All but 5 patients had type C fractures (AO classification).

Clinical Outcomes

Eleven patients underwent clinical evaluation (functional assessment, physical examination). Mean DASH score was 11.4 (SD, 10.5; range, 0-27.3), mean Mayo wrist score was 79.0 (SD, 12.2; range, 65-100), and mean patient-rated wrist evaluation was 12.2 (SD, 11.9; range, 0-25.5). There was no statistical difference in DASH scores between this group and the historical control group (Table 3). ROM was measured under active effort. In our group, mean wrist flexion was 69.3° (86% of contralateral side), and mean extension was 64.0° (94%). Mean radial deviation of the wrist was 47.4° (135% of relative normal for patient), and mean ulnar deviation was 29.2° (101%). Mean (SD) pronation was 84.6° (4.7°), and mean (SD) supination was 82.3° (8.5°), or about 100% of contralateral pronosupination.

For each hand, 3 grip strength values and 3 key pinch strength values were obtained. These values were averaged, and the injury and contralateral sides were compared. Mean grip strength was 49.6 pounds (85% of contralateral), and mean key pinch strength was 14.0 pounds (97%).

Complications

Of the 25 patients, 6 (24%) had a pin-tract infection treated with oral antibiotics. One of these infections resulted in the removal of the entire fixator. One (4%) of the 25 patients reported transient hypoesthesia of the dorsal first webspace, and 3 (12%) reported pain at the pin sites.

Although all fractures achieved complete bony union, 1 patient (4%) had a refracture on the same fracture line after a fall within 6 weeks after fixator removal; this refracture was successfully treated with a cast worn for 6 weeks. Of the 3 patients with complete follow-up (27%) who lost reduction with external fixation in place, 2 had radiographic parameters maintained within acceptable limits, and 1 (9%) had a malunion with –16° volar tilt.

Our study patients had no tendon rupture, tendon irritation, or stiffness. By contrast, fixation with volar locking plates has been associated with extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure.¹⁹ Flexor pollicis longus ruptures that occur after volar plate fixation of DRFs are often attributed to plate positioning.^20-22

Discussion

With volar locking plate internal fixation on the rise, CREF has become less widely used.³ This is especially true for comminuted and intra-articular fractures—most earlier external fixators required either spanning of the wrist or limited fixation in the distal articular fragment. Although many studies have found excellent outcomes of ORIF with volar locking plates in the treatment of unstable DRFs,^4,6 few studies have compared volar locking plate ORIF with nonspanning external fixation for unstable comminuted intra-articular DRFs. Both Gradl and colleagues,⁸ using a nonbridging external fixator with multiplanar K-wires, and Mirza and colleagues,9 using the Cross-Pin Fixation system, found wrist function, quality-of-life, and radiographic outcomes similar to those of volar plate fixation in the treatment of DRFs. A comparative meta-analysis by Margaliot and colleagues¹⁷ revealed no superiority of internal fixation over external fixation for unstable DRFs, given the similarity in wrist function, radiographic, and subjective outcomes.

At a mean follow-up of 12.8 months (range, 6-23 months), our retrospective study found that the functional and radiographic outcomes of treating unstable comminuted DRFs with a nonspanning external fixator were similar to those reported in similarly matched control studies. Although followup of >2 years has been shown to be unnecessary,^23-25 small differences may have been detected with interval results over these 2 years. The effect of selection bias on our study results should be considered in light of patients’ involvement in selecting fixation type. Our results parallel those of the temporal studies of Rozental and colleagues5 and Wei and colleagues¹² (Table 2) while allowing for patients to return to function with limited morbidity and complications, similar to Orbay and Fernandez¹⁵ though with a less invasive procedure.

Although we found patient-rated outcome measure values analogous to those of the volar plate fixation group and bridging external fixator group in the study by Wright and colleagues,⁶ we did not measure intra-articular step-off. Another variable not addressed here was operative time. The nonspanning external fixator treatment that we investigated should undergo further study. A randomized prospective study that includes the additional outcome measures of intra-articular step-off and operative time is warranted. 

We found that our study patients, who had their comminuted intra-articular DRFs treated with a nonspanning external fixator, and similar historical control patients, treated with volar locking plate internal fixation, had similar clinical and radiographic outcomes at final follow-up. There was no statistically significant difference in measured outcomes—wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, DASH scores—between the 2 groups. Compared with the historical control group, the external fixator group had significantly more postoperative ulnar deviation.

Given the functional and radiographic outcomes found at final follow-up in this study, we recommend considering a nonspanning external fixator in the treatment of unstable complex comminuted intra-articular DRFs, particularly those that occur in the elderly.

Take-Home Points

• Clinical and radiographic outcomes of patients treated with non-spanning external fixation are comparable to those treated with open reduction and internal volar locked plate fixation.
• Non-spanning external fixation can lead to satisfactory outcomes based on the following features: fragment specific fixation, subchondral support, fixed angle strength, limited dissection, distraction/length adjustment, joint distraction avoidance, and ability to perform early rehabilitation.
• Non-spanning external fixation should be considered as a treatment option for complicated unstable comminuted intra-articular distal radius fractures, specifically in the elderly.

In the United States, distal radius fractures (DRFs) are among the most common fractures, comprising about 15% of all extremity fractures.¹ With a DRF, the primary treatment goal is anatomical reduction with restoration of radiographic parameters and stable fixation of the fracture to restore wrist function.

This fracture type has a variety of treatment alternatives, including nonoperative closed reduction and casting of stable fractures, open reduction and internal fixation (ORIF) with dorsal or volar locking plates, and external fixation. Optimal surgical management of unstable DRFs remains controversial.² Closed reduction with percutaneous pinning or external fixation has become less common with a trend toward using volar locking plates for internal fixation.³

External fixation of DRFs traditionally has involved either spanning or simple nonspanning devices. Spanning fixation is particularly useful in open or highly comminuted fractures with an unstable soft-tissue envelope. In the past, nonspanning external fixation typically was reserved for fractures with a noncomminuted extra-articular distal fragment to which several large pins or Kirschner wires (K-wires) could be secured. The Non-Bridging External Fixator (NBX; Nutek Orthopaedics) may be used in cases that traditionally might be treated with locked plating or fragment-specific fixation. Specifically, this device is indicated for comminuted intra-articular DRFs in which bone quality may be less than ideal. The NBX, also suitable in open fractures with a stable soft-tissue envelope, can restore and maintain articular alignment by providing subchondral support and stability with fragment-specific fixation. A key advantage of this type of external fixation is that it involves percutaneous fixation and allows for early postoperative range of motion (ROM).

Numerous studies have found excellent outcomes of treating unstable DRFs with ORIF with volar locking plates.^4-6 However, few studies have compared the clinical and radiographic outcomes of ORIF with those of nonspanning external fixation in the treatment of unstable comminuted intra-articular DRFs. Windolf and colleagues⁷ found that, in cadaveric unstable intra-articular DRFs, nonspanning external fixation with multiplanar K-wires had biomechanical characteristics comparable to those of volar locking plates. Other suitable DRF treatment options have been found: an alternative nonbridging external fixator with multiplanar K-wires (Gradl and colleagues⁸) and the Cross-Pin Fixation system (A.M. Surgical) (Mirza and colleagues⁹).

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular DRFs treated with a nonspanning external fixation device (NBX) with outcomes achieved with volar locking plates in a historical control group.

Materials and Methods

This retrospective case-control study was approved by our Institutional Review Board and conducted at 2 institutions. Included in the study were 25 consecutive patients (2 institutions) who underwent closed reduction and external fixation (CREF) with NBX as treatment for unstable DRFs (diagnosis based on radiographic parameters or inability to maintain acceptable alignment after closed reduction and casting). Of these 25 patients, 11 were available for clinical follow-up and medical records review; the other 14 were not available for followup but had their charts reviewed for radiographic data and treatment details. Six of the 14 patients declined to participate in the study, and the other 8 were lost to follow-up because of nonstandardized follow-up protocols. Patients were excluded from the study if their final follow-up had not occurred, or if it occurred before 6 months. For their participation in clinical follow-up, patients received nominal time compensation and mileage reimbursement through a grant from the NBX manufacturer.

The 25 patients underwent CREF with NBX between November 2008 and March 2013. Indications for external fixation consideration were intra-articular extension or significant comminution in patients with poor soft tissue or in patients who wanted to avoid invasive surgery or a permanent implant. Of the 11 patients who agreed to participate in the study, 7 were women and 4 were men; mean age was 64 years (range, 15-81 years). Of the 14 patients unable to follow up, 11 were women and 3 were men; mean age was 63 years (range, 26-89 years). At the last available follow-up, each of the 25 patients was doing well, was satisfied with treatment received and function regained, and had a healed DRF. In almost every case, the mechanism of injury was a fall onto an outstretched hand; most fractures were type C per AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification (Table 1).

The surgical technique for this nonspanning external fixator involves closed reduction with longitudinal traction using ligamentotaxis to grossly align the fracture fragments, with small adjustments made throughout the procedure. A dorsally placed radiolucent fixator is used with fluoroscopic guidance to percutaneously affix a subchondral raft of smooth bicortical .062-inch K-wires. The fixator’s abundant pin holes allow for each specific distal fragment to be captured by pins that are a part of the external fixation construct. Furthermore, radially based pins that use a side bar allow for a “weave” of fixation. Radial length is then obtained and maintained by attaching the distal complex to proximal pins in the radial diaphysis. After pins are cut and wrist and digits are taken through full ROM to ensure smooth tracking, fluoroscopy is used to confirm final fracture fixation and alignment (Figure 1).

In ideal scenarios with good fixation, patients can begin gentle ROM exercises within 1 week after surgery. This regimen can progress to more aggressive motion exercises and even light strengthening (Figure 2).

The 11 clinical follow-up patients underwent directed clinical examination, including ROM and strength evaluation, by Dr. Dwyer and Dr. Crosby. Follow-up also included completion of questionnaires and review of radiographs.

During the clinical follow-up, a standard goniometer was used to evaluate active ROM (wrist flexion and extension and wrist radial and ulnar deviation, measured down the long axis of the forearm and the index ray), and forearm pronation and supination were measured from the 90° elbow flexion position using the humerus as the reference point with the shoulders in 0° of flexion, abduction, and external rotation. In addition, a calibrated dynamometer (Sammons Preston) was used to measure grip strength (position 3) and key pinch strength, and the average of 3 trials of each strength test was calculated. ROM and strength values were calculated as percentages of the contralateral (uninjured) side, as these ratios are more sensitive in detecting clinical changes.¹⁰ A 10% adjustment for dominant hand grip strength in right-handed patients was used for this comparison.¹¹

Union (osseous bridging across fracture site on 2 of 3 views), radial height, radial inclination, and volar tilt were measured on standard posteroanterior and lateral radiographs taken at several points: time of injury, postreduction and/or preoperative, initial postoperative, and final follow-up. All radiographic measurements were independently taken by Dr. Dwyer and Dr. Crosby, who used a digital goniometer and ruler (Siemens Medical Solutions) or, when necessary, manual instruments. Means of the original and independent measurements were used for calculations.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo wrist score, and the patient-rated wrist evaluation were used to assess activities of daily living, pain, and quality of life after surgery. Mayo wrist scores were adjusted for unemployed patients; work status was replaced with return to normal activities. 

Complications of surgical treatment were evaluated. Major complications evaluated were loss of reduction, malunion, nonunion, deep infection, neuropathy, and tendon rupture. Minor complication possibilities were transient extensor tendon irritation, superficial infection, and finger stiffness. Also noted were 1 patient who subsequently required another procedure and 7 patients who were immobilized after external fixation removal.

We compared our study group’s outcomes with those of historical control patients who underwent fixation with internal volar locking plates. The 2 groups had similar demographic characteristics. To obtain the historical controls, we used the key words distal, radi*, volar, and plat* in a PubMed search. From the 169 citations found, we removed biomechanical cadaver studies, studies that focused on patients with demographics and fracture types dissimilar from our patient population’s, and studies that focused on special circumstances, such as complications or patient characteristics. Eight studies remained for historical comparison.

Results

Radiographic Outcomes

On the injury radiographs, mean volar tilt was –16.7° (range, 2° to –42°), mean radial inclination was 14.1° (range, –1° to 44°), and mean radial height was 5.3 mm (range, –2 mm to 11 mm). Minor improvement after reduction was noted. All patients had intraoperative or postoperative radiographs with external fixation in place (Figure 3).

On the final (post-fixation removal) radiographs, mean volar tilt was 3.3° (range, –16° to 21°), mean radial inclination was 20.7° (range, 0° to 31°), and mean radial height was 7.5 mm (range, 0 mm to 13 mm). Comparison of the injury and final means revealed correction of ~20° for volar tilt, 6° for radial inclination, and 2 mm for radial height. All but 5 patients had type C fractures (AO classification).

Clinical Outcomes

Eleven patients underwent clinical evaluation (functional assessment, physical examination). Mean DASH score was 11.4 (SD, 10.5; range, 0-27.3), mean Mayo wrist score was 79.0 (SD, 12.2; range, 65-100), and mean patient-rated wrist evaluation was 12.2 (SD, 11.9; range, 0-25.5). There was no statistical difference in DASH scores between this group and the historical control group (Table 3). ROM was measured under active effort. In our group, mean wrist flexion was 69.3° (86% of contralateral side), and mean extension was 64.0° (94%). Mean radial deviation of the wrist was 47.4° (135% of relative normal for patient), and mean ulnar deviation was 29.2° (101%). Mean (SD) pronation was 84.6° (4.7°), and mean (SD) supination was 82.3° (8.5°), or about 100% of contralateral pronosupination.

For each hand, 3 grip strength values and 3 key pinch strength values were obtained. These values were averaged, and the injury and contralateral sides were compared. Mean grip strength was 49.6 pounds (85% of contralateral), and mean key pinch strength was 14.0 pounds (97%).

Complications

Of the 25 patients, 6 (24%) had a pin-tract infection treated with oral antibiotics. One of these infections resulted in the removal of the entire fixator. One (4%) of the 25 patients reported transient hypoesthesia of the dorsal first webspace, and 3 (12%) reported pain at the pin sites.

Although all fractures achieved complete bony union, 1 patient (4%) had a refracture on the same fracture line after a fall within 6 weeks after fixator removal; this refracture was successfully treated with a cast worn for 6 weeks. Of the 3 patients with complete follow-up (27%) who lost reduction with external fixation in place, 2 had radiographic parameters maintained within acceptable limits, and 1 (9%) had a malunion with –16° volar tilt.

Our study patients had no tendon rupture, tendon irritation, or stiffness. By contrast, fixation with volar locking plates has been associated with extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure.¹⁹ Flexor pollicis longus ruptures that occur after volar plate fixation of DRFs are often attributed to plate positioning.^20-22

Discussion

With volar locking plate internal fixation on the rise, CREF has become less widely used.³ This is especially true for comminuted and intra-articular fractures—most earlier external fixators required either spanning of the wrist or limited fixation in the distal articular fragment. Although many studies have found excellent outcomes of ORIF with volar locking plates in the treatment of unstable DRFs,^4,6 few studies have compared volar locking plate ORIF with nonspanning external fixation for unstable comminuted intra-articular DRFs. Both Gradl and colleagues,⁸ using a nonbridging external fixator with multiplanar K-wires, and Mirza and colleagues,9 using the Cross-Pin Fixation system, found wrist function, quality-of-life, and radiographic outcomes similar to those of volar plate fixation in the treatment of DRFs. A comparative meta-analysis by Margaliot and colleagues¹⁷ revealed no superiority of internal fixation over external fixation for unstable DRFs, given the similarity in wrist function, radiographic, and subjective outcomes.

At a mean follow-up of 12.8 months (range, 6-23 months), our retrospective study found that the functional and radiographic outcomes of treating unstable comminuted DRFs with a nonspanning external fixator were similar to those reported in similarly matched control studies. Although followup of >2 years has been shown to be unnecessary,^23-25 small differences may have been detected with interval results over these 2 years. The effect of selection bias on our study results should be considered in light of patients’ involvement in selecting fixation type. Our results parallel those of the temporal studies of Rozental and colleagues5 and Wei and colleagues¹² (Table 2) while allowing for patients to return to function with limited morbidity and complications, similar to Orbay and Fernandez¹⁵ though with a less invasive procedure.

Although we found patient-rated outcome measure values analogous to those of the volar plate fixation group and bridging external fixator group in the study by Wright and colleagues,⁶ we did not measure intra-articular step-off. Another variable not addressed here was operative time. The nonspanning external fixator treatment that we investigated should undergo further study. A randomized prospective study that includes the additional outcome measures of intra-articular step-off and operative time is warranted. 

We found that our study patients, who had their comminuted intra-articular DRFs treated with a nonspanning external fixator, and similar historical control patients, treated with volar locking plate internal fixation, had similar clinical and radiographic outcomes at final follow-up. There was no statistically significant difference in measured outcomes—wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, DASH scores—between the 2 groups. Compared with the historical control group, the external fixator group had significantly more postoperative ulnar deviation.

Given the functional and radiographic outcomes found at final follow-up in this study, we recommend considering a nonspanning external fixator in the treatment of unstable complex comminuted intra-articular DRFs, particularly those that occur in the elderly.

Take-Home Points

• Clinical and radiographic outcomes of patients treated with non-spanning external fixation are comparable to those treated with open reduction and internal volar locked plate fixation.
• Non-spanning external fixation can lead to satisfactory outcomes based on the following features: fragment specific fixation, subchondral support, fixed angle strength, limited dissection, distraction/length adjustment, joint distraction avoidance, and ability to perform early rehabilitation.
• Non-spanning external fixation should be considered as a treatment option for complicated unstable comminuted intra-articular distal radius fractures, specifically in the elderly.

In the United States, distal radius fractures (DRFs) are among the most common fractures, comprising about 15% of all extremity fractures.¹ With a DRF, the primary treatment goal is anatomical reduction with restoration of radiographic parameters and stable fixation of the fracture to restore wrist function.

This fracture type has a variety of treatment alternatives, including nonoperative closed reduction and casting of stable fractures, open reduction and internal fixation (ORIF) with dorsal or volar locking plates, and external fixation. Optimal surgical management of unstable DRFs remains controversial.² Closed reduction with percutaneous pinning or external fixation has become less common with a trend toward using volar locking plates for internal fixation.³

External fixation of DRFs traditionally has involved either spanning or simple nonspanning devices. Spanning fixation is particularly useful in open or highly comminuted fractures with an unstable soft-tissue envelope. In the past, nonspanning external fixation typically was reserved for fractures with a noncomminuted extra-articular distal fragment to which several large pins or Kirschner wires (K-wires) could be secured. The Non-Bridging External Fixator (NBX; Nutek Orthopaedics) may be used in cases that traditionally might be treated with locked plating or fragment-specific fixation. Specifically, this device is indicated for comminuted intra-articular DRFs in which bone quality may be less than ideal. The NBX, also suitable in open fractures with a stable soft-tissue envelope, can restore and maintain articular alignment by providing subchondral support and stability with fragment-specific fixation. A key advantage of this type of external fixation is that it involves percutaneous fixation and allows for early postoperative range of motion (ROM).

Numerous studies have found excellent outcomes of treating unstable DRFs with ORIF with volar locking plates.^4-6 However, few studies have compared the clinical and radiographic outcomes of ORIF with those of nonspanning external fixation in the treatment of unstable comminuted intra-articular DRFs. Windolf and colleagues⁷ found that, in cadaveric unstable intra-articular DRFs, nonspanning external fixation with multiplanar K-wires had biomechanical characteristics comparable to those of volar locking plates. Other suitable DRF treatment options have been found: an alternative nonbridging external fixator with multiplanar K-wires (Gradl and colleagues⁸) and the Cross-Pin Fixation system (A.M. Surgical) (Mirza and colleagues⁹).

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular DRFs treated with a nonspanning external fixation device (NBX) with outcomes achieved with volar locking plates in a historical control group.

Materials and Methods

This retrospective case-control study was approved by our Institutional Review Board and conducted at 2 institutions. Included in the study were 25 consecutive patients (2 institutions) who underwent closed reduction and external fixation (CREF) with NBX as treatment for unstable DRFs (diagnosis based on radiographic parameters or inability to maintain acceptable alignment after closed reduction and casting). Of these 25 patients, 11 were available for clinical follow-up and medical records review; the other 14 were not available for followup but had their charts reviewed for radiographic data and treatment details. Six of the 14 patients declined to participate in the study, and the other 8 were lost to follow-up because of nonstandardized follow-up protocols. Patients were excluded from the study if their final follow-up had not occurred, or if it occurred before 6 months. For their participation in clinical follow-up, patients received nominal time compensation and mileage reimbursement through a grant from the NBX manufacturer.

The 25 patients underwent CREF with NBX between November 2008 and March 2013. Indications for external fixation consideration were intra-articular extension or significant comminution in patients with poor soft tissue or in patients who wanted to avoid invasive surgery or a permanent implant. Of the 11 patients who agreed to participate in the study, 7 were women and 4 were men; mean age was 64 years (range, 15-81 years). Of the 14 patients unable to follow up, 11 were women and 3 were men; mean age was 63 years (range, 26-89 years). At the last available follow-up, each of the 25 patients was doing well, was satisfied with treatment received and function regained, and had a healed DRF. In almost every case, the mechanism of injury was a fall onto an outstretched hand; most fractures were type C per AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification (Table 1).

The surgical technique for this nonspanning external fixator involves closed reduction with longitudinal traction using ligamentotaxis to grossly align the fracture fragments, with small adjustments made throughout the procedure. A dorsally placed radiolucent fixator is used with fluoroscopic guidance to percutaneously affix a subchondral raft of smooth bicortical .062-inch K-wires. The fixator’s abundant pin holes allow for each specific distal fragment to be captured by pins that are a part of the external fixation construct. Furthermore, radially based pins that use a side bar allow for a “weave” of fixation. Radial length is then obtained and maintained by attaching the distal complex to proximal pins in the radial diaphysis. After pins are cut and wrist and digits are taken through full ROM to ensure smooth tracking, fluoroscopy is used to confirm final fracture fixation and alignment (Figure 1).

In ideal scenarios with good fixation, patients can begin gentle ROM exercises within 1 week after surgery. This regimen can progress to more aggressive motion exercises and even light strengthening (Figure 2).

The 11 clinical follow-up patients underwent directed clinical examination, including ROM and strength evaluation, by Dr. Dwyer and Dr. Crosby. Follow-up also included completion of questionnaires and review of radiographs.

During the clinical follow-up, a standard goniometer was used to evaluate active ROM (wrist flexion and extension and wrist radial and ulnar deviation, measured down the long axis of the forearm and the index ray), and forearm pronation and supination were measured from the 90° elbow flexion position using the humerus as the reference point with the shoulders in 0° of flexion, abduction, and external rotation. In addition, a calibrated dynamometer (Sammons Preston) was used to measure grip strength (position 3) and key pinch strength, and the average of 3 trials of each strength test was calculated. ROM and strength values were calculated as percentages of the contralateral (uninjured) side, as these ratios are more sensitive in detecting clinical changes.¹⁰ A 10% adjustment for dominant hand grip strength in right-handed patients was used for this comparison.¹¹

Union (osseous bridging across fracture site on 2 of 3 views), radial height, radial inclination, and volar tilt were measured on standard posteroanterior and lateral radiographs taken at several points: time of injury, postreduction and/or preoperative, initial postoperative, and final follow-up. All radiographic measurements were independently taken by Dr. Dwyer and Dr. Crosby, who used a digital goniometer and ruler (Siemens Medical Solutions) or, when necessary, manual instruments. Means of the original and independent measurements were used for calculations.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo wrist score, and the patient-rated wrist evaluation were used to assess activities of daily living, pain, and quality of life after surgery. Mayo wrist scores were adjusted for unemployed patients; work status was replaced with return to normal activities. 

Complications of surgical treatment were evaluated. Major complications evaluated were loss of reduction, malunion, nonunion, deep infection, neuropathy, and tendon rupture. Minor complication possibilities were transient extensor tendon irritation, superficial infection, and finger stiffness. Also noted were 1 patient who subsequently required another procedure and 7 patients who were immobilized after external fixation removal.

We compared our study group’s outcomes with those of historical control patients who underwent fixation with internal volar locking plates. The 2 groups had similar demographic characteristics. To obtain the historical controls, we used the key words distal, radi*, volar, and plat* in a PubMed search. From the 169 citations found, we removed biomechanical cadaver studies, studies that focused on patients with demographics and fracture types dissimilar from our patient population’s, and studies that focused on special circumstances, such as complications or patient characteristics. Eight studies remained for historical comparison.

Results

Radiographic Outcomes

On the injury radiographs, mean volar tilt was –16.7° (range, 2° to –42°), mean radial inclination was 14.1° (range, –1° to 44°), and mean radial height was 5.3 mm (range, –2 mm to 11 mm). Minor improvement after reduction was noted. All patients had intraoperative or postoperative radiographs with external fixation in place (Figure 3).

On the final (post-fixation removal) radiographs, mean volar tilt was 3.3° (range, –16° to 21°), mean radial inclination was 20.7° (range, 0° to 31°), and mean radial height was 7.5 mm (range, 0 mm to 13 mm). Comparison of the injury and final means revealed correction of ~20° for volar tilt, 6° for radial inclination, and 2 mm for radial height. All but 5 patients had type C fractures (AO classification).

Clinical Outcomes

Eleven patients underwent clinical evaluation (functional assessment, physical examination). Mean DASH score was 11.4 (SD, 10.5; range, 0-27.3), mean Mayo wrist score was 79.0 (SD, 12.2; range, 65-100), and mean patient-rated wrist evaluation was 12.2 (SD, 11.9; range, 0-25.5). There was no statistical difference in DASH scores between this group and the historical control group (Table 3). ROM was measured under active effort. In our group, mean wrist flexion was 69.3° (86% of contralateral side), and mean extension was 64.0° (94%). Mean radial deviation of the wrist was 47.4° (135% of relative normal for patient), and mean ulnar deviation was 29.2° (101%). Mean (SD) pronation was 84.6° (4.7°), and mean (SD) supination was 82.3° (8.5°), or about 100% of contralateral pronosupination.

For each hand, 3 grip strength values and 3 key pinch strength values were obtained. These values were averaged, and the injury and contralateral sides were compared. Mean grip strength was 49.6 pounds (85% of contralateral), and mean key pinch strength was 14.0 pounds (97%).

Complications

Of the 25 patients, 6 (24%) had a pin-tract infection treated with oral antibiotics. One of these infections resulted in the removal of the entire fixator. One (4%) of the 25 patients reported transient hypoesthesia of the dorsal first webspace, and 3 (12%) reported pain at the pin sites.

Although all fractures achieved complete bony union, 1 patient (4%) had a refracture on the same fracture line after a fall within 6 weeks after fixator removal; this refracture was successfully treated with a cast worn for 6 weeks. Of the 3 patients with complete follow-up (27%) who lost reduction with external fixation in place, 2 had radiographic parameters maintained within acceptable limits, and 1 (9%) had a malunion with –16° volar tilt.

Our study patients had no tendon rupture, tendon irritation, or stiffness. By contrast, fixation with volar locking plates has been associated with extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, loss of reduction, and hardware failure.¹⁹ Flexor pollicis longus ruptures that occur after volar plate fixation of DRFs are often attributed to plate positioning.^20-22

Discussion

With volar locking plate internal fixation on the rise, CREF has become less widely used.³ This is especially true for comminuted and intra-articular fractures—most earlier external fixators required either spanning of the wrist or limited fixation in the distal articular fragment. Although many studies have found excellent outcomes of ORIF with volar locking plates in the treatment of unstable DRFs,^4,6 few studies have compared volar locking plate ORIF with nonspanning external fixation for unstable comminuted intra-articular DRFs. Both Gradl and colleagues,⁸ using a nonbridging external fixator with multiplanar K-wires, and Mirza and colleagues,9 using the Cross-Pin Fixation system, found wrist function, quality-of-life, and radiographic outcomes similar to those of volar plate fixation in the treatment of DRFs. A comparative meta-analysis by Margaliot and colleagues¹⁷ revealed no superiority of internal fixation over external fixation for unstable DRFs, given the similarity in wrist function, radiographic, and subjective outcomes.

At a mean follow-up of 12.8 months (range, 6-23 months), our retrospective study found that the functional and radiographic outcomes of treating unstable comminuted DRFs with a nonspanning external fixator were similar to those reported in similarly matched control studies. Although followup of >2 years has been shown to be unnecessary,^23-25 small differences may have been detected with interval results over these 2 years. The effect of selection bias on our study results should be considered in light of patients’ involvement in selecting fixation type. Our results parallel those of the temporal studies of Rozental and colleagues5 and Wei and colleagues¹² (Table 2) while allowing for patients to return to function with limited morbidity and complications, similar to Orbay and Fernandez¹⁵ though with a less invasive procedure.

Although we found patient-rated outcome measure values analogous to those of the volar plate fixation group and bridging external fixator group in the study by Wright and colleagues,⁶ we did not measure intra-articular step-off. Another variable not addressed here was operative time. The nonspanning external fixator treatment that we investigated should undergo further study. A randomized prospective study that includes the additional outcome measures of intra-articular step-off and operative time is warranted. 

We found that our study patients, who had their comminuted intra-articular DRFs treated with a nonspanning external fixator, and similar historical control patients, treated with volar locking plate internal fixation, had similar clinical and radiographic outcomes at final follow-up. There was no statistically significant difference in measured outcomes—wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, DASH scores—between the 2 groups. Compared with the historical control group, the external fixator group had significantly more postoperative ulnar deviation.

Given the functional and radiographic outcomes found at final follow-up in this study, we recommend considering a nonspanning external fixator in the treatment of unstable complex comminuted intra-articular DRFs, particularly those that occur in the elderly.

SAN DIEGO – You get a call from the emergency department at 3 a.m. A 48-year-old woman is presenting with fever, nausea, vomiting, and left upper quadrant pain. And the patient says she had a gastric bypass procedure 3 years ago.

Time to panic? Not necessarily, but things can, and occasionally do, go bad for these patients, even if they have had a long-stable bypass, Jennifer Choi, MD, FACS, said in a video interview at the annual clinical congress of the American College of Surgeons.

“We do have to remember that our bariatric surgery patients can develop all of the same kinds of problems that anyone else can,” said Dr. Choi, a general surgeon at Indiana University, Indianapolis. “Appendicitis, diverticulitis, abdominal wall hernias, and other common things do happen.”

In her book, though, a patient with a gastric bypass who presents with a combination of small-bowel obstruction and pain has an internal herniation until proven otherwise.

“The symptoms can be subtle, and they can either have been building for several weeks or have an acute onset,” Dr. Choi said. These can include nausea, dry heaves, bloating, or nonbilious vomiting. Pain is typically located in the left upper quadrant or mid-back, especially if the hernia is located at one of the two most common spots: Petersen’s defect. This is the point where the biliopancreatic loop tends to slip under the alimentary loop and become trapped. Imaging will show a typical swirling of blood vessels around the herniation, accompanied by dilated small bowel at the point of obstruction.

At the other common herniation point, the site of the jejunojejunostomy, the alimentary loop can slip under the biliopancreatic loop. On imaging, jejunum will be seen in the upper right quadrant.

Both of these can be surgical emergencies, Dr. Choi said. “This needs an operation sooner, rather than later. It needs to be reduced and repaired.”

She typically performs this laparoscopically, but said that some surgeons prefer an open approach, which is a perfectly sound option.

“The key to a successful repair is to start at the ileocecal valve, because it is consistent and fixed, and run the bowel from distal to proximal to reduce the internal hernia. Then close the defect with a permanent suture,” she said.

Chylous ascites is almost always present in these cases because the herniation traumatizes the lymphatic system, Dr. Choi added. “It doesn’t all always have to be removed at the time of surgery, but just be aware that this is definitely something we do see, almost all the time in bariatric patients with these internal hernias.”

Dr. Choi had no financial disclosures.

[email protected]

On Twitter @alz_gal

SAN DIEGO – You get a call from the emergency department at 3 a.m. A 48-year-old woman is presenting with fever, nausea, vomiting, and left upper quadrant pain. And the patient says she had a gastric bypass procedure 3 years ago.

Time to panic? Not necessarily, but things can, and occasionally do, go bad for these patients, even if they have had a long-stable bypass, Jennifer Choi, MD, FACS, said in a video interview at the annual clinical congress of the American College of Surgeons.

“We do have to remember that our bariatric surgery patients can develop all of the same kinds of problems that anyone else can,” said Dr. Choi, a general surgeon at Indiana University, Indianapolis. “Appendicitis, diverticulitis, abdominal wall hernias, and other common things do happen.”

In her book, though, a patient with a gastric bypass who presents with a combination of small-bowel obstruction and pain has an internal herniation until proven otherwise.

“The symptoms can be subtle, and they can either have been building for several weeks or have an acute onset,” Dr. Choi said. These can include nausea, dry heaves, bloating, or nonbilious vomiting. Pain is typically located in the left upper quadrant or mid-back, especially if the hernia is located at one of the two most common spots: Petersen’s defect. This is the point where the biliopancreatic loop tends to slip under the alimentary loop and become trapped. Imaging will show a typical swirling of blood vessels around the herniation, accompanied by dilated small bowel at the point of obstruction.

At the other common herniation point, the site of the jejunojejunostomy, the alimentary loop can slip under the biliopancreatic loop. On imaging, jejunum will be seen in the upper right quadrant.

Both of these can be surgical emergencies, Dr. Choi said. “This needs an operation sooner, rather than later. It needs to be reduced and repaired.”

She typically performs this laparoscopically, but said that some surgeons prefer an open approach, which is a perfectly sound option.

“The key to a successful repair is to start at the ileocecal valve, because it is consistent and fixed, and run the bowel from distal to proximal to reduce the internal hernia. Then close the defect with a permanent suture,” she said.

Chylous ascites is almost always present in these cases because the herniation traumatizes the lymphatic system, Dr. Choi added. “It doesn’t all always have to be removed at the time of surgery, but just be aware that this is definitely something we do see, almost all the time in bariatric patients with these internal hernias.”

Dr. Choi had no financial disclosures.

[email protected]

On Twitter @alz_gal

SAN DIEGO – You get a call from the emergency department at 3 a.m. A 48-year-old woman is presenting with fever, nausea, vomiting, and left upper quadrant pain. And the patient says she had a gastric bypass procedure 3 years ago.

Time to panic? Not necessarily, but things can, and occasionally do, go bad for these patients, even if they have had a long-stable bypass, Jennifer Choi, MD, FACS, said in a video interview at the annual clinical congress of the American College of Surgeons.

“We do have to remember that our bariatric surgery patients can develop all of the same kinds of problems that anyone else can,” said Dr. Choi, a general surgeon at Indiana University, Indianapolis. “Appendicitis, diverticulitis, abdominal wall hernias, and other common things do happen.”

In her book, though, a patient with a gastric bypass who presents with a combination of small-bowel obstruction and pain has an internal herniation until proven otherwise.

“The symptoms can be subtle, and they can either have been building for several weeks or have an acute onset,” Dr. Choi said. These can include nausea, dry heaves, bloating, or nonbilious vomiting. Pain is typically located in the left upper quadrant or mid-back, especially if the hernia is located at one of the two most common spots: Petersen’s defect. This is the point where the biliopancreatic loop tends to slip under the alimentary loop and become trapped. Imaging will show a typical swirling of blood vessels around the herniation, accompanied by dilated small bowel at the point of obstruction.

At the other common herniation point, the site of the jejunojejunostomy, the alimentary loop can slip under the biliopancreatic loop. On imaging, jejunum will be seen in the upper right quadrant.

Both of these can be surgical emergencies, Dr. Choi said. “This needs an operation sooner, rather than later. It needs to be reduced and repaired.”

She typically performs this laparoscopically, but said that some surgeons prefer an open approach, which is a perfectly sound option.

“The key to a successful repair is to start at the ileocecal valve, because it is consistent and fixed, and run the bowel from distal to proximal to reduce the internal hernia. Then close the defect with a permanent suture,” she said.

Chylous ascites is almost always present in these cases because the herniation traumatizes the lymphatic system, Dr. Choi added. “It doesn’t all always have to be removed at the time of surgery, but just be aware that this is definitely something we do see, almost all the time in bariatric patients with these internal hernias.”

Dr. Choi had no financial disclosures.

[email protected]

On Twitter @alz_gal

PARIS—The Expanded Timed Get Up and Go (ETGUG) may be a more sensitive predictor of disability in multiple sclerosis (MS) than the Timed 25-Foot Walk (T25FW), according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting.

The 355 study participants were part of the New York State MS Consortium, a 20-year longitudinal registry. The researchers compared the ETGUG, T25FW, and Expanded Disability Status Scale (EDSS) using Spearman’s Rank correlations. They performed receiver operating characteristic (ROC) analyses with 80% specificity to determine the ETGUG and T25FW cutoff score and associated sensitivity predicting an EDSS score of 4.0 or greater.

Of the 355 participants, 121 (34.1%) had an EDSS score of 4.0 or higher. Both ETGUG and T25FW were highly correlated with EDSS. Correlations with EDSS were stronger for ETGUG and T25FW among subjects with an EDSS score of 4.0 or greater than among people with MS with EDSS scores of less than 4.0. At the predetermined specificity, an ETGUG score of 23.5 seconds or more had a 91.7% sensitivity of identifying subjects with an EDSS of 4.0 or greater. Completing the T25FW in 6.4 seconds or more, however, had a lower sensitivity of 82.7%.

“Prospectively captured data are required to determine the sensitivity of the ETGUG to longitudinal change and its usefulness in predicting disability progression and risk of falling, especially in the patients with higher disability,” said the researchers.

PARIS—The Expanded Timed Get Up and Go (ETGUG) may be a more sensitive predictor of disability in multiple sclerosis (MS) than the Timed 25-Foot Walk (T25FW), according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting.

The 355 study participants were part of the New York State MS Consortium, a 20-year longitudinal registry. The researchers compared the ETGUG, T25FW, and Expanded Disability Status Scale (EDSS) using Spearman’s Rank correlations. They performed receiver operating characteristic (ROC) analyses with 80% specificity to determine the ETGUG and T25FW cutoff score and associated sensitivity predicting an EDSS score of 4.0 or greater.

Of the 355 participants, 121 (34.1%) had an EDSS score of 4.0 or higher. Both ETGUG and T25FW were highly correlated with EDSS. Correlations with EDSS were stronger for ETGUG and T25FW among subjects with an EDSS score of 4.0 or greater than among people with MS with EDSS scores of less than 4.0. At the predetermined specificity, an ETGUG score of 23.5 seconds or more had a 91.7% sensitivity of identifying subjects with an EDSS of 4.0 or greater. Completing the T25FW in 6.4 seconds or more, however, had a lower sensitivity of 82.7%.

“Prospectively captured data are required to determine the sensitivity of the ETGUG to longitudinal change and its usefulness in predicting disability progression and risk of falling, especially in the patients with higher disability,” said the researchers.

PARIS—The Expanded Timed Get Up and Go (ETGUG) may be a more sensitive predictor of disability in multiple sclerosis (MS) than the Timed 25-Foot Walk (T25FW), according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting.

The 355 study participants were part of the New York State MS Consortium, a 20-year longitudinal registry. The researchers compared the ETGUG, T25FW, and Expanded Disability Status Scale (EDSS) using Spearman’s Rank correlations. They performed receiver operating characteristic (ROC) analyses with 80% specificity to determine the ETGUG and T25FW cutoff score and associated sensitivity predicting an EDSS score of 4.0 or greater.

Of the 355 participants, 121 (34.1%) had an EDSS score of 4.0 or higher. Both ETGUG and T25FW were highly correlated with EDSS. Correlations with EDSS were stronger for ETGUG and T25FW among subjects with an EDSS score of 4.0 or greater than among people with MS with EDSS scores of less than 4.0. At the predetermined specificity, an ETGUG score of 23.5 seconds or more had a 91.7% sensitivity of identifying subjects with an EDSS of 4.0 or greater. Completing the T25FW in 6.4 seconds or more, however, had a lower sensitivity of 82.7%.

“Prospectively captured data are required to determine the sensitivity of the ETGUG to longitudinal change and its usefulness in predicting disability progression and risk of falling, especially in the patients with higher disability,” said the researchers.

PARIS—Among patients with neuromyelitis optica (NMO), early disability predicts late disability, consistent with favorable effects of early treatment on disability, according to a literature review presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. Additionally, outcomes are worse in nonwhite patients and Hispanic patients. Visual outcomes are worse in young-onset NMO, and motor outcomes are worse in late-onset NMO.

Noting that there is limited literature regarding long-term outcomes in NMO spectrum disorder (NMOSD) since the discovery of aquaporin-4 immunoglobulin G (AQP4–IgG), Zahra Nasr, a medical student at Isfahan University of Medical Sciences in Isfahan, Iran, and colleagues sought to perform a systematic literature review on long-term outcomes in NMOSD in the era of AQP4-IgG.

The researchers conducted a database search that included studies in Cochrane Collaboration Database, PubMed, SCOPUS, Web of Knowledge, and Embase through April 2017. They used the search terms “neuromyelitis optica” or “Devic’s disease,” and “clinical features,” “outcome,” “natural history,” “prognosis,” “mortality,” “morbidity,” “incidence,” “prevalence,” “epidemiology,” and “demography.” They included in their analysis English language studies that used 1999, 2006, or 2015 Wingerchuk criteria and reported AQP4-IgG status.

Twenty percent to 30% of patients had residual motor and visual disability after the initial attack; early disability was positively associated with long-term disability. After five to six years, 11% to 18% of individuals had visual acuity of 20/200 or less in at least one eye, and 7% to 23% were wheelchair confined.

Nonwhite patients and Hispanic patients had higher relapse rates and worse outcomes. Younger patients and men had worse visual outcomes, whereas older patients had poor motor outcomes. In addition, long-term immunosuppressive treatment reduced attack-related disability. AQP4-IgG serostatus was not associated with outcome.

Survival improved in contemporary studies (91% to 98% survival after five years), compared with survival reported prior to the discovery of AQP4-IgG (68% to 75% survival). A higher attack frequency during the first two years, older age at onset, lack of recovery from first attack, blindness, and history of other autoimmune disease were associated with higher mortality rates, but race, gender, and type of attack at onset were not.

The researchers concluded that contemporary studies report more favorable outcomes than pre-AQP4-IgG series.

PARIS—Among patients with neuromyelitis optica (NMO), early disability predicts late disability, consistent with favorable effects of early treatment on disability, according to a literature review presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. Additionally, outcomes are worse in nonwhite patients and Hispanic patients. Visual outcomes are worse in young-onset NMO, and motor outcomes are worse in late-onset NMO.

Noting that there is limited literature regarding long-term outcomes in NMO spectrum disorder (NMOSD) since the discovery of aquaporin-4 immunoglobulin G (AQP4–IgG), Zahra Nasr, a medical student at Isfahan University of Medical Sciences in Isfahan, Iran, and colleagues sought to perform a systematic literature review on long-term outcomes in NMOSD in the era of AQP4-IgG.

The researchers conducted a database search that included studies in Cochrane Collaboration Database, PubMed, SCOPUS, Web of Knowledge, and Embase through April 2017. They used the search terms “neuromyelitis optica” or “Devic’s disease,” and “clinical features,” “outcome,” “natural history,” “prognosis,” “mortality,” “morbidity,” “incidence,” “prevalence,” “epidemiology,” and “demography.” They included in their analysis English language studies that used 1999, 2006, or 2015 Wingerchuk criteria and reported AQP4-IgG status.

Twenty percent to 30% of patients had residual motor and visual disability after the initial attack; early disability was positively associated with long-term disability. After five to six years, 11% to 18% of individuals had visual acuity of 20/200 or less in at least one eye, and 7% to 23% were wheelchair confined.

Nonwhite patients and Hispanic patients had higher relapse rates and worse outcomes. Younger patients and men had worse visual outcomes, whereas older patients had poor motor outcomes. In addition, long-term immunosuppressive treatment reduced attack-related disability. AQP4-IgG serostatus was not associated with outcome.

Survival improved in contemporary studies (91% to 98% survival after five years), compared with survival reported prior to the discovery of AQP4-IgG (68% to 75% survival). A higher attack frequency during the first two years, older age at onset, lack of recovery from first attack, blindness, and history of other autoimmune disease were associated with higher mortality rates, but race, gender, and type of attack at onset were not.

The researchers concluded that contemporary studies report more favorable outcomes than pre-AQP4-IgG series.

PARIS—Among patients with neuromyelitis optica (NMO), early disability predicts late disability, consistent with favorable effects of early treatment on disability, according to a literature review presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. Additionally, outcomes are worse in nonwhite patients and Hispanic patients. Visual outcomes are worse in young-onset NMO, and motor outcomes are worse in late-onset NMO.

Noting that there is limited literature regarding long-term outcomes in NMO spectrum disorder (NMOSD) since the discovery of aquaporin-4 immunoglobulin G (AQP4–IgG), Zahra Nasr, a medical student at Isfahan University of Medical Sciences in Isfahan, Iran, and colleagues sought to perform a systematic literature review on long-term outcomes in NMOSD in the era of AQP4-IgG.

The researchers conducted a database search that included studies in Cochrane Collaboration Database, PubMed, SCOPUS, Web of Knowledge, and Embase through April 2017. They used the search terms “neuromyelitis optica” or “Devic’s disease,” and “clinical features,” “outcome,” “natural history,” “prognosis,” “mortality,” “morbidity,” “incidence,” “prevalence,” “epidemiology,” and “demography.” They included in their analysis English language studies that used 1999, 2006, or 2015 Wingerchuk criteria and reported AQP4-IgG status.

Twenty percent to 30% of patients had residual motor and visual disability after the initial attack; early disability was positively associated with long-term disability. After five to six years, 11% to 18% of individuals had visual acuity of 20/200 or less in at least one eye, and 7% to 23% were wheelchair confined.

Nonwhite patients and Hispanic patients had higher relapse rates and worse outcomes. Younger patients and men had worse visual outcomes, whereas older patients had poor motor outcomes. In addition, long-term immunosuppressive treatment reduced attack-related disability. AQP4-IgG serostatus was not associated with outcome.

Survival improved in contemporary studies (91% to 98% survival after five years), compared with survival reported prior to the discovery of AQP4-IgG (68% to 75% survival). A higher attack frequency during the first two years, older age at onset, lack of recovery from first attack, blindness, and history of other autoimmune disease were associated with higher mortality rates, but race, gender, and type of attack at onset were not.

The researchers concluded that contemporary studies report more favorable outcomes than pre-AQP4-IgG series.

ORLANDO – Patients diagnosed with celiac disease subsequently showed a high incidence of autoimmune endocrinopathies in a review of 249 patients in a longitudinal, population-based database.

The finding that celiac disease patients developed autoimmune endocrinopathies (AE) at a rate of 9.14 cases per person-year of follow-up suggests that “screening for AEs is recommended in treated celiac disease patients,” Imad Absah, MD, said at the World Congress of Gastroenterology at ACG 2017.

Mitchel L. Zoler/Frontline Medical News

This article was updated 10/30/17.

[email protected]

On Twitter @mitchelzoler

ORLANDO – Patients diagnosed with celiac disease subsequently showed a high incidence of autoimmune endocrinopathies in a review of 249 patients in a longitudinal, population-based database.

The finding that celiac disease patients developed autoimmune endocrinopathies (AE) at a rate of 9.14 cases per person-year of follow-up suggests that “screening for AEs is recommended in treated celiac disease patients,” Imad Absah, MD, said at the World Congress of Gastroenterology at ACG 2017.

Mitchel L. Zoler/Frontline Medical News

This article was updated 10/30/17.

[email protected]

On Twitter @mitchelzoler

ORLANDO – Patients diagnosed with celiac disease subsequently showed a high incidence of autoimmune endocrinopathies in a review of 249 patients in a longitudinal, population-based database.

The finding that celiac disease patients developed autoimmune endocrinopathies (AE) at a rate of 9.14 cases per person-year of follow-up suggests that “screening for AEs is recommended in treated celiac disease patients,” Imad Absah, MD, said at the World Congress of Gastroenterology at ACG 2017.

Mitchel L. Zoler/Frontline Medical News

This article was updated 10/30/17.

[email protected]

On Twitter @mitchelzoler

PARIS—Benign multiple sclerosis (MS) appears to be rare. Its estimated prevalence is less than 4%, according to a study described at the Seventh Joint ECTRIMS–ACTRIMS Meeting.

The existence of benign MS has been proposed, but it remains controversial. Neurologists are uncertain about the frequency and pathologic explanation for a favorable outcome in MS. Identifying and studying individuals with benign MS would have “considerable implications for patient management and for our understanding of the biology of the disease,” said Emma Tallantyre, BMBS, PhD, Clinical Senior Lecturer in the Division of Psychological Medicine and Clinical Neurosciences at Cardiff University in the United Kingdom, and colleagues.

Most definitions of benign MS are focused on walking ability after 10 or 15 years, despite the far wider effects of MS on ability. Dr. Tallantyre and colleagues screened a prevalent population of more than 2,000 people with MS and found 275 individuals who had unlimited walking ability after 15 or more years from onset. The investigators undertook detailed assessments of 56 of the individuals within this group (ie, those recorded to have unlimited walking ability after the longest disease durations). Assessment incorporated scores of cognition, fatigue, mood, vision, bladder symptoms, and arm and leg function.

All patients were considered to have relapsing-remitting MS, but they showed a wide range of relapse frequency and severity. In a group of 32 patients who fulfilled a contemporary definition of benign MS based on the Expanded Disability Status Scale, the researchers considered less than 25% to be truly benign, which was defined as having normal function in all domains. Patient-reported scores of MS impact correlated strongly with the outcomes of clinical assessment, but patients’ own perceptions of their condition was more benign than clinicians’ perceptions.

MR imaging was used to explore the biology underlying benign MS using a global approach and a tract-based approach. The study provides early insights into the phenotypic and imaging characteristics of benign MS and could provide information about the biologic mechanisms of a favorable outcome in MS, said Dr. Tallantyre.

PARIS—Benign multiple sclerosis (MS) appears to be rare. Its estimated prevalence is less than 4%, according to a study described at the Seventh Joint ECTRIMS–ACTRIMS Meeting.

The existence of benign MS has been proposed, but it remains controversial. Neurologists are uncertain about the frequency and pathologic explanation for a favorable outcome in MS. Identifying and studying individuals with benign MS would have “considerable implications for patient management and for our understanding of the biology of the disease,” said Emma Tallantyre, BMBS, PhD, Clinical Senior Lecturer in the Division of Psychological Medicine and Clinical Neurosciences at Cardiff University in the United Kingdom, and colleagues.

Most definitions of benign MS are focused on walking ability after 10 or 15 years, despite the far wider effects of MS on ability. Dr. Tallantyre and colleagues screened a prevalent population of more than 2,000 people with MS and found 275 individuals who had unlimited walking ability after 15 or more years from onset. The investigators undertook detailed assessments of 56 of the individuals within this group (ie, those recorded to have unlimited walking ability after the longest disease durations). Assessment incorporated scores of cognition, fatigue, mood, vision, bladder symptoms, and arm and leg function.

All patients were considered to have relapsing-remitting MS, but they showed a wide range of relapse frequency and severity. In a group of 32 patients who fulfilled a contemporary definition of benign MS based on the Expanded Disability Status Scale, the researchers considered less than 25% to be truly benign, which was defined as having normal function in all domains. Patient-reported scores of MS impact correlated strongly with the outcomes of clinical assessment, but patients’ own perceptions of their condition was more benign than clinicians’ perceptions.

MR imaging was used to explore the biology underlying benign MS using a global approach and a tract-based approach. The study provides early insights into the phenotypic and imaging characteristics of benign MS and could provide information about the biologic mechanisms of a favorable outcome in MS, said Dr. Tallantyre.

PARIS—Benign multiple sclerosis (MS) appears to be rare. Its estimated prevalence is less than 4%, according to a study described at the Seventh Joint ECTRIMS–ACTRIMS Meeting.

The existence of benign MS has been proposed, but it remains controversial. Neurologists are uncertain about the frequency and pathologic explanation for a favorable outcome in MS. Identifying and studying individuals with benign MS would have “considerable implications for patient management and for our understanding of the biology of the disease,” said Emma Tallantyre, BMBS, PhD, Clinical Senior Lecturer in the Division of Psychological Medicine and Clinical Neurosciences at Cardiff University in the United Kingdom, and colleagues.

Most definitions of benign MS are focused on walking ability after 10 or 15 years, despite the far wider effects of MS on ability. Dr. Tallantyre and colleagues screened a prevalent population of more than 2,000 people with MS and found 275 individuals who had unlimited walking ability after 15 or more years from onset. The investigators undertook detailed assessments of 56 of the individuals within this group (ie, those recorded to have unlimited walking ability after the longest disease durations). Assessment incorporated scores of cognition, fatigue, mood, vision, bladder symptoms, and arm and leg function.

All patients were considered to have relapsing-remitting MS, but they showed a wide range of relapse frequency and severity. In a group of 32 patients who fulfilled a contemporary definition of benign MS based on the Expanded Disability Status Scale, the researchers considered less than 25% to be truly benign, which was defined as having normal function in all domains. Patient-reported scores of MS impact correlated strongly with the outcomes of clinical assessment, but patients’ own perceptions of their condition was more benign than clinicians’ perceptions.

MR imaging was used to explore the biology underlying benign MS using a global approach and a tract-based approach. The study provides early insights into the phenotypic and imaging characteristics of benign MS and could provide information about the biologic mechanisms of a favorable outcome in MS, said Dr. Tallantyre.

Barbara Lee Bass, MD, FACS, FRCS(Hon) the John F. and Carolyn Bookout Distinguished Endowed Chair and chair, department of surgery, Houston Methodist Hospital, TX, was installed as President of the American College of Surgeons (ACS) at the October 22 Convocation Ceremony at Clinical Congress 2017 in San Diego, CA.

Barbara Lee Bass, MD, FACS, FRCS(Hon) the John F. and Carolyn Bookout Distinguished Endowed Chair and chair, department of surgery, Houston Methodist Hospital, TX, was installed as President of the American College of Surgeons (ACS) at the October 22 Convocation Ceremony at Clinical Congress 2017 in San Diego, CA.

Barbara Lee Bass, MD, FACS, FRCS(Hon) the John F. and Carolyn Bookout Distinguished Endowed Chair and chair, department of surgery, Houston Methodist Hospital, TX, was installed as President of the American College of Surgeons (ACS) at the October 22 Convocation Ceremony at Clinical Congress 2017 in San Diego, CA.

At the Convocation Ceremony at Clinical Congress 2017 in San Diego, CA, the American College of Surgeons (ACS) presented the 2017 Dr. Mary Edwards Walker Inspiring Women in Surgery Award to SreyRam Kuy, MD, MHS, FACS. This award was established by the ACS Women in Surgery Committee (WiSC) and is presented annually at the Clinical Congress in recognition of an individual’s significant contributions to the advancement of women in the field of surgery.

The award is named in honor of Mary Edwards Walker, MD. Dr. Walker volunteered to serve with the Union Army at the outbreak of the American Civil War and was the first female surgeon ever employed by the U.S. Army. Dr. Walker is the only woman to have ever received the Congressional Medal of Honor, the highest U.S. Armed Forces decoration for bravery. Through Dr. Walker’s example of perseverance, excellence, and pioneering behavior, she paved the way for today’s women surgeons.

Dr. Kuy’s career embodies the spirit of this award and demonstrates her personal determination, professional excellence, and commitment to public service.
 

Inspiration to practice

Dr. Kuy was born in a labor camp in Cambodia in 1978 during the Cambodian genocide known as the Killing Fields. Following the overthrow of the Khmer Rouge, her family fled to a refugee camp in Thailand where Dr. Kuy, her sister, and her mother were severely injured by a grenade. All three lives were saved by surgeons volunteering at the refugee camp. These volunteer surgeons helped inspire Dr. Kuy to pursue a career in medicine.

Her family moved to the U.S. in 1981 and settled in Oregon. Dr. Kuy attended Oregon State University, Corvallis, and went on to complete medical school at Oregon Health & Sciences University, Portland. She earned her master’s degree in health policy, public health, and outcomes research at Yale University School of Medicine, New Haven, CT, as a Robert Wood Johnson Clinical Scholar.
 

An accomplished early career

As associate chief of staff, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX, Dr. Kuy oversees 5,000 staff in a complex VA hospital with the busiest emergency department and operating rooms in the VA system. Dr. Kuy previously served as chief medical officer for Medicaid in the Louisiana Department of Health, Baton Rouge. Under her leadership, Louisiana was the first state to develop a Zika prevention strategy for pregnant Medicaid patients. Dr. Kuy also led initiatives that enabled women with breast cancer to have access to reconstructive surgery and testing, led efforts to coordinate medical disaster relief efforts during the historic Louisiana flooding of 2016, and led Louisiana Medicaid’s initiative to tackle the opioid epidemic.

Dr. Kuy developed statewide health performance metrics, pay-for-performance incentives, and novel Medicaid Expansion Early Wins measures, which enabled the state of Louisiana to assess how access to care directly affects lives. Before serving as Chief Medical Officer for Louisiana Medicaid, Dr. Kuy served in numerous leadership roles in the VA system, including the following: director, Center for Innovations in Quality, Outcomes and Patient Safety; assistant chief, general surgery; and chair, Systems Redesign Committee. She also was a member, Quality, Safety & Value Board, Overton Brooks VA Medical Center, Shreveport, LA.

Dr. Kuy’s successful efforts to reduce patient mortality and morbidity and decrease adverse events were profiled by the VA National Center for Patient Safety. Her work in increasing veterans’ access to care through clinic efficiency was profiled by the Association for VA Surgeons, and the templates she developed were disseminated for implementation at VA medical centers across the country. Dr. Kuy has served on the National Quality Forum, the National Board of Medical Examiners, and the Accreditation Council for Continuing Medical Education.

In 2017, Dr. Kuy was selected to be a Presidential Leadership Scholar, a joint, bipartisan leadership program taught by Presidents George W. Bush, William J. Clinton, and George H. W. Bush. She subsequently delivered the keynote commencement address at the Bush Institute. Dr. Kuy received the Greater Baton Rouge Business Report’s 40 Under 40 Award for her work to improve health care quality in the Louisiana Medicaid population, the Ford Foundation’s Gerald E. Bruce Community Service Award for her work serving veterans, and Random Acts’ Caught in the Act national public service award. Dr. Kuy also was selected for the Early Career Achievement Award in 2017 by Oregon Health & Sciences University School of Medicine.

Dr. Kuy is grateful for the many incredible mentors and teachers who have inspired her on her journey, and she is proud to be a part of the surgical family. She has dedicated her career to improving the quality of medical care and increasing the public’s access to quality care. The College is proud to have Dr. Kuy as a member and looks forward to what challenges she will tackle next.

At the Convocation Ceremony at Clinical Congress 2017 in San Diego, CA, the American College of Surgeons (ACS) presented the 2017 Dr. Mary Edwards Walker Inspiring Women in Surgery Award to SreyRam Kuy, MD, MHS, FACS. This award was established by the ACS Women in Surgery Committee (WiSC) and is presented annually at the Clinical Congress in recognition of an individual’s significant contributions to the advancement of women in the field of surgery.

The award is named in honor of Mary Edwards Walker, MD. Dr. Walker volunteered to serve with the Union Army at the outbreak of the American Civil War and was the first female surgeon ever employed by the U.S. Army. Dr. Walker is the only woman to have ever received the Congressional Medal of Honor, the highest U.S. Armed Forces decoration for bravery. Through Dr. Walker’s example of perseverance, excellence, and pioneering behavior, she paved the way for today’s women surgeons.

Dr. Kuy’s career embodies the spirit of this award and demonstrates her personal determination, professional excellence, and commitment to public service.
 

Inspiration to practice

Dr. Kuy was born in a labor camp in Cambodia in 1978 during the Cambodian genocide known as the Killing Fields. Following the overthrow of the Khmer Rouge, her family fled to a refugee camp in Thailand where Dr. Kuy, her sister, and her mother were severely injured by a grenade. All three lives were saved by surgeons volunteering at the refugee camp. These volunteer surgeons helped inspire Dr. Kuy to pursue a career in medicine.

Her family moved to the U.S. in 1981 and settled in Oregon. Dr. Kuy attended Oregon State University, Corvallis, and went on to complete medical school at Oregon Health & Sciences University, Portland. She earned her master’s degree in health policy, public health, and outcomes research at Yale University School of Medicine, New Haven, CT, as a Robert Wood Johnson Clinical Scholar.
 

An accomplished early career

As associate chief of staff, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX, Dr. Kuy oversees 5,000 staff in a complex VA hospital with the busiest emergency department and operating rooms in the VA system. Dr. Kuy previously served as chief medical officer for Medicaid in the Louisiana Department of Health, Baton Rouge. Under her leadership, Louisiana was the first state to develop a Zika prevention strategy for pregnant Medicaid patients. Dr. Kuy also led initiatives that enabled women with breast cancer to have access to reconstructive surgery and testing, led efforts to coordinate medical disaster relief efforts during the historic Louisiana flooding of 2016, and led Louisiana Medicaid’s initiative to tackle the opioid epidemic.

Dr. Kuy developed statewide health performance metrics, pay-for-performance incentives, and novel Medicaid Expansion Early Wins measures, which enabled the state of Louisiana to assess how access to care directly affects lives. Before serving as Chief Medical Officer for Louisiana Medicaid, Dr. Kuy served in numerous leadership roles in the VA system, including the following: director, Center for Innovations in Quality, Outcomes and Patient Safety; assistant chief, general surgery; and chair, Systems Redesign Committee. She also was a member, Quality, Safety & Value Board, Overton Brooks VA Medical Center, Shreveport, LA.

Dr. Kuy’s successful efforts to reduce patient mortality and morbidity and decrease adverse events were profiled by the VA National Center for Patient Safety. Her work in increasing veterans’ access to care through clinic efficiency was profiled by the Association for VA Surgeons, and the templates she developed were disseminated for implementation at VA medical centers across the country. Dr. Kuy has served on the National Quality Forum, the National Board of Medical Examiners, and the Accreditation Council for Continuing Medical Education.

In 2017, Dr. Kuy was selected to be a Presidential Leadership Scholar, a joint, bipartisan leadership program taught by Presidents George W. Bush, William J. Clinton, and George H. W. Bush. She subsequently delivered the keynote commencement address at the Bush Institute. Dr. Kuy received the Greater Baton Rouge Business Report’s 40 Under 40 Award for her work to improve health care quality in the Louisiana Medicaid population, the Ford Foundation’s Gerald E. Bruce Community Service Award for her work serving veterans, and Random Acts’ Caught in the Act national public service award. Dr. Kuy also was selected for the Early Career Achievement Award in 2017 by Oregon Health & Sciences University School of Medicine.

Dr. Kuy is grateful for the many incredible mentors and teachers who have inspired her on her journey, and she is proud to be a part of the surgical family. She has dedicated her career to improving the quality of medical care and increasing the public’s access to quality care. The College is proud to have Dr. Kuy as a member and looks forward to what challenges she will tackle next.

At the Convocation Ceremony at Clinical Congress 2017 in San Diego, CA, the American College of Surgeons (ACS) presented the 2017 Dr. Mary Edwards Walker Inspiring Women in Surgery Award to SreyRam Kuy, MD, MHS, FACS. This award was established by the ACS Women in Surgery Committee (WiSC) and is presented annually at the Clinical Congress in recognition of an individual’s significant contributions to the advancement of women in the field of surgery.

The award is named in honor of Mary Edwards Walker, MD. Dr. Walker volunteered to serve with the Union Army at the outbreak of the American Civil War and was the first female surgeon ever employed by the U.S. Army. Dr. Walker is the only woman to have ever received the Congressional Medal of Honor, the highest U.S. Armed Forces decoration for bravery. Through Dr. Walker’s example of perseverance, excellence, and pioneering behavior, she paved the way for today’s women surgeons.

Dr. Kuy’s career embodies the spirit of this award and demonstrates her personal determination, professional excellence, and commitment to public service.
 

Inspiration to practice

Dr. Kuy was born in a labor camp in Cambodia in 1978 during the Cambodian genocide known as the Killing Fields. Following the overthrow of the Khmer Rouge, her family fled to a refugee camp in Thailand where Dr. Kuy, her sister, and her mother were severely injured by a grenade. All three lives were saved by surgeons volunteering at the refugee camp. These volunteer surgeons helped inspire Dr. Kuy to pursue a career in medicine.

Her family moved to the U.S. in 1981 and settled in Oregon. Dr. Kuy attended Oregon State University, Corvallis, and went on to complete medical school at Oregon Health & Sciences University, Portland. She earned her master’s degree in health policy, public health, and outcomes research at Yale University School of Medicine, New Haven, CT, as a Robert Wood Johnson Clinical Scholar.
 

An accomplished early career

As associate chief of staff, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX, Dr. Kuy oversees 5,000 staff in a complex VA hospital with the busiest emergency department and operating rooms in the VA system. Dr. Kuy previously served as chief medical officer for Medicaid in the Louisiana Department of Health, Baton Rouge. Under her leadership, Louisiana was the first state to develop a Zika prevention strategy for pregnant Medicaid patients. Dr. Kuy also led initiatives that enabled women with breast cancer to have access to reconstructive surgery and testing, led efforts to coordinate medical disaster relief efforts during the historic Louisiana flooding of 2016, and led Louisiana Medicaid’s initiative to tackle the opioid epidemic.

Dr. Kuy developed statewide health performance metrics, pay-for-performance incentives, and novel Medicaid Expansion Early Wins measures, which enabled the state of Louisiana to assess how access to care directly affects lives. Before serving as Chief Medical Officer for Louisiana Medicaid, Dr. Kuy served in numerous leadership roles in the VA system, including the following: director, Center for Innovations in Quality, Outcomes and Patient Safety; assistant chief, general surgery; and chair, Systems Redesign Committee. She also was a member, Quality, Safety & Value Board, Overton Brooks VA Medical Center, Shreveport, LA.

Dr. Kuy’s successful efforts to reduce patient mortality and morbidity and decrease adverse events were profiled by the VA National Center for Patient Safety. Her work in increasing veterans’ access to care through clinic efficiency was profiled by the Association for VA Surgeons, and the templates she developed were disseminated for implementation at VA medical centers across the country. Dr. Kuy has served on the National Quality Forum, the National Board of Medical Examiners, and the Accreditation Council for Continuing Medical Education.

In 2017, Dr. Kuy was selected to be a Presidential Leadership Scholar, a joint, bipartisan leadership program taught by Presidents George W. Bush, William J. Clinton, and George H. W. Bush. She subsequently delivered the keynote commencement address at the Bush Institute. Dr. Kuy received the Greater Baton Rouge Business Report’s 40 Under 40 Award for her work to improve health care quality in the Louisiana Medicaid population, the Ford Foundation’s Gerald E. Bruce Community Service Award for her work serving veterans, and Random Acts’ Caught in the Act national public service award. Dr. Kuy also was selected for the Early Career Achievement Award in 2017 by Oregon Health & Sciences University School of Medicine.

Dr. Kuy is grateful for the many incredible mentors and teachers who have inspired her on her journey, and she is proud to be a part of the surgical family. She has dedicated her career to improving the quality of medical care and increasing the public’s access to quality care. The College is proud to have Dr. Kuy as a member and looks forward to what challenges she will tackle next.