Jeffrey N Lawton

University of Michigan, Ann Arbor, Michigan, United States

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Publications (22)32.82 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). Prospective cohort followed for 1 year. Clinics at five study sites. Patients diagnosed with UNE (N=55). All subjects had simple decompression surgery. The primary outcome measure was patient-reported outcomes such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. Multiple regression models with the change in the overall MHQ score as the dependent variable showed that at 3 months post-operative time, patients with less than 3 months duration of symptoms showed 12 points (95% CI = 0.9, 23.5) greater improvement in MHQ scores than those with 3 months or longer symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI = 2.9, 24.0) greater improvement in MHQ scores at 6 months post-op, but it was no longer associated with better outcomes at 12 months. Worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coeff=-0.38, 95% CI = -0.67, -0.09), and baseline MHQ score was the only significant predictor of 12-month MHQ scores (coeff=-0.40, 95% CI=-0.79, -0.01). Subjects with less than 3 months of symptoms and worse baseline MHQ scores, showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.
    Archives of physical medicine and rehabilitation 11/2013; · 2.18 Impact Factor
  • Nikhil Oak, Jeffrey N Lawton
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    ABSTRACT: Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries.
    Hand clinics 11/2013; 29(4):535-49. · 0.69 Impact Factor
  • Article: Preface.
    Jeffrey N Lawton
    Hand clinics 11/2013; 29(4):xi. · 0.69 Impact Factor
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    ABSTRACT: BACKGROUND:: Although numerous studies have investigated long-term outcomes after surgical treatment of ulnar neuropathy at the elbow with simple decompression, no study has evaluated the trend of postoperative recovery. The authors assessed timing of recovery after simple decompression for ulnar neuropathy at the elbow. METHODS:: The five-center Surgery of the Ulnar Nerve Study Group prospectively recruited 58 consecutive subjects with ulnar neuropathy at the elbow and treated them with simple decompression. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient-rated outcomes questionnaires included the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire. Functional tests used were grip strength, key pinch strength, two-point discrimination, and Semmes-Weinstein monofilament testing. Postoperative improvement was assessed at each time point to establish the trend of recovery in reaching a plateau. RESULTS:: Significant patient-reported symptomatic and functional recovery occurred over the first 6 weeks postoperatively as represented by improvements in questionnaire scores. Symptomatic recovery occurred earlier than functional recovery as measured by sensory and strength testing and the work domain of the Michigan Hand Questionnaire. Improvement in patient-reported outcomes continued and reached a plateau at 3 months, whereas measured strength and sensory recovery continued over 12 months. CONCLUSION:: The greatest clinical improvement after simple decompression for ulnar neuropathy at the elbow, according to questionnaire scores, occurs in the first 6 weeks postoperatively and reaches a plateau by 3 months. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
    Plastic and reconstructive surgery 04/2013; 131(4):563e-573e. · 2.74 Impact Factor
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    ABSTRACT: BACKGROUND:: Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE:: We measured patient outcomes following ulnar nerve decompression to 1) identify the most appropriate outcomes tools for UNE and 2) describe outcomes following ulnar nerve decompression. METHODS:: Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively, 6-weeks, 3-months, 6-months, and 12-months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament (SWM), and 2-point discrimination (2PD) were measured. Construct validity was calculated using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS:: Key pinch (p=0.008) and SWM testing of the ulnar ring (p<0.001) and small finger (radial: p=0.004; ulnar: p<0.001) improved following decompression. 2PD improved significantly across the radial (p=0.009) and ulnar (p=0.007) small finger. Improved symptoms and function were noted by the CTQ (Preoperative CTQ symptom score 2.73 vs. 1.90 postoperatively, p<0.001), DASH (p<0.001), and MHQ: function (p<0.001), activities of daily living (p=0.003), work (p=0.006), pain (p<0.001), and satisfaction (p<0.001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION:: Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.
    Neurosurgery 02/2013; · 2.53 Impact Factor
  • John J Lee, Jeffrey N Lawton
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    ABSTRACT: Management of coronal shear fractures of the distal humerus has evolved considerably over the past 3 decades, with an increased appreciation of the complexity of these fractures, improvements in internal fixation techniques, and the use of more extensile exposures. Nearly all of these fractures are displaced, given the paucity of soft tissue attachments and correspondingly, nonsurgical management is fraught with complications including chronic pain, mechanical symptoms, and instability and is not recommended. Good to excellent outcomes can be achieved in the majority of patients with open reduction internal fixation, particularly when the fracture is limited to the radiocapitellar joint. Outcomes are worst for those with considerable medial extension or comminution. Computed tomography is highly recommended to guide surgical planning. The presence of posterior comminution or extension to the medial column might require more extensile exposures and supplemental fixation for adequate stability. Arthroscopic reduction and fixation techniques have been described for the simple fracture. Those not amenable to fixation might do better with total elbow arthroplasty in a select population. Long-term data demonstrate the durability of these elbows following open reduction internal fixation. Complications other than stiffness are rare. Radiographic avascular necrosis does not appear to affect outcome. Radiographic mild to moderate arthritis was observed in half of patients at 17-year follow-up.
    The Journal of hand surgery 11/2012; 37(11):2412-7. · 1.33 Impact Factor
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    ABSTRACT: To evaluate and compare the biomechanical properties of 8 different locked fixed-angle volar distal radius plates under conditions designed to reflect forces seen in early fracture healing and postoperative rehabilitation. We evaluated the Acumed Acu-Loc (Acumed, Hillsboro, OR), Hand Innovations DVR (Hand Innovations, Miami, FL), SBi SCS volar distal radial plate (Small Bone Innovations, Morrisville, PA), Synthes volar distal radius plate and EA extra-articular volar distal radius plate (Synthes, Paoli, PA), Stryker Matrix-SmartLock (Stryker Leibinger, Kalamazoo, MI), Wright Medical Technology Locon VLS (Wright Medical Technology, Arlington, TN), and Zimmer periarticular distal radius locking plate (Zimmer, Warsaw, IN). After affixing each plate to a synthetic corticocancellous radius, we created a standardized dorsal wedge osteotomy. Each construct had cyclic loading of 100 N, 200 N, and 300 N for a total of 6000 cycles. Outcomes, including load deformation curves, displacement, and ultimate yield strengths, were collected for each construct. The Wright plate was significantly stiffer at the 100 N load than the Zimmer plate and was stiffer at the 300 N load than 4 other plates. The Zimmer and Hand Innovations plates had the highest yield strengths and significantly higher yield strengths than the Wright, SBi, Stryker, and Synthes EA plates. Given the biomechanical properties of the plates tested, in light of the loads transmitted across the native wrist, all plate constructs met the anticipated demands. It seems clear that fracture configuration, screw placement, cost, and surgeon familiarity with instrumentation should take priority in selecting a plating system for distal radius fracture treatment. This study provides further information to surgeons regarding the relative strengths of different plate options for the treatment of distal radius fractures.
    The Journal of hand surgery 04/2012; 37(7):1381-7. · 1.33 Impact Factor
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    ABSTRACT: Heterotopic ossification (HO) about the elbow has been described after surgery, trauma, and burns. Even limited deposits can lead to significant functional deficits. Little data exist regarding outcomes of patients treated with radiation therapy (RT) after elbow surgery. We report here the Cleveland Clinic experience with single-fraction radiation following surgery to the elbow. The primary endpoint was the rate of new HO after RT. Secondary endpoints were range of motion, functional compromise, and toxicity. From May 1993 to July 2006, 36 patients underwent elbow surgery followed by single-fraction RT. Range of motion data were collected before and during surgery and at last follow-up. Radiographs were reviewed for persistent or new HO. Patient and treatment factors were analyzed for correlation with development of HO or functional compromise. Median follow-up was 8.7 months, median age was 42 years, and 75% of patients were male. Twenty-six (72%) patients had HO prior to surgery. All patients had significant limitations in flexion/extension or pronation/supination at baseline. Thirty-one (86%) patients had prior elbow trauma, and 26 (72%) patients had prior surgery. RT was administered a median of 1 day postoperatively (range, 1-4 days). Thirty-four patients received 700 cGy, and 2 patients received 600 cGy. Three (8%) patients developed new HO after RT. All patients had improvement in range of motion from baseline. No patient or treatment factors were significantly associated with the development of HO or functional compromise. Single-fraction RT after surgery to the elbow is associated with favorable functional and radiographic outcomes.
    International journal of radiation oncology, biology, physics 08/2010; 77(5):1493-9. · 4.59 Impact Factor
  • Michael Darowish, Jeffrey N Lawton, Peter J Evans
    Cleveland Clinic Journal of Medicine 06/2009; 76(5):306-8. · 3.40 Impact Factor
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    ABSTRACT: The elbow is as prone to stiffness as it is essential for upper-extremity function. The elbow is a highly constrained synovial hinge joint that frequently becomes stiff after injury. Elbow contracture is challenging to treat, and therefore prevention is of paramount importance. When this approach fails, nonoperative followed by operative treatment modalities can be pursued. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved.
    The Journal of hand surgery 05/2009; 34(4):769-78. · 1.33 Impact Factor
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    ABSTRACT: Elbow motion is essential for upper extremity function to position the hand in space. Unfortunately, the elbow joint is prone to stiffness following a multitude of traumatic and atraumatic etiologies. Elbow stiffness can be diagnosed with a complete history and physical exam, supplemented with appropriate imaging studies. The stiff elbow is challenging to treat, and thus, its prevention is of paramount importance. When this approach fails, non-operative followed by operative treatment modalities should be pursued. Upon initial presentation in those who have minimal contractures of 6-month duration or less, static and dynamic splinting, serial casting, continuous passive motion, occupational/physical therapy, and manipulation are non-operative treatment modalities that may be attempted. A stiff elbow that is refractory to non-operative management can be treated surgically, either arthroscopically or open, to eliminate soft tissue or bony blocks to motion. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved. Our purpose was to review the etiologies, classification, evaluation, prevention, operative, and non-operative treatment of the stiff elbow.
    Hand 05/2009; 4(4):368-79.
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    ABSTRACT: Distal biceps tendon ruptures typically occur with biceps contraction against resistance with the elbow flexed at 90 degrees. Anatomic repair is the gold standard in active patients. Numerous surgical techniques are available; however, the Endobutton might offer several advantages. We describe a novel technique for chronic distal biceps reconstruction using a modification of the Endobutton technique with an anterior cruciate ligament (ACL) drill guide as well as tendoachilles allograft. The Endobutton technique might offer several advantages, including direct tendon-to-bone healing, less bony debris to limit heterotopic ossification, less heating of the bone, ease of use, a biomechanical superiority, and excellent clinical outcomes.
    The Journal of hand surgery 04/2009; 34(3):545-52. · 1.33 Impact Factor
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    ABSTRACT: Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.
    Hand 03/2009; 4(3):330-4.
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    ABSTRACT: The metacarpophalangeal (MP) joint is resistant to injury due to its strong capsuloligamentous structures, which include the volar plate and deep transverse metacarpal and collateral ligaments. Complex MP joint dislocations are, by definition, irreducible by closed means and require open reduction, as the volar plate becomes entrapped between the metacarpal head and proximal phalanx. The dorsal approach may offer the following advantages: 1) reduced risk to palmarly displaced neurovascular structures, 2) facilitated management of osteochondral fractures, and 3) full exposure of the volar plate. However, the dorsal approach requires splitting of the volar plate for adequate reduction, which may delay recovery.
    Orthopedics 12/2008; 31(11):1099. · 1.05 Impact Factor
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    ABSTRACT: Extensor tendon irritation and attritional tendon ruptures are potentially serious complications after open reduction and internal fixation of distal radius fractures. These complications are well recognized after dorsal plating of distal radii; and these are now being reported after errant screw placement during volar fixed-angle plating. Intraoperative detection of improper screw placement is critical, as corrective action can be taken before completion of the operative procedure. The purpose of this study was to define the extensor tendon compartments at risk secondary to dorsal screw penetration and to compare pronation and supination fluoroscopic images with standard lateral images in demonstrating dorsal screw prominence during volar locked plating. Eight fresh-frozen human cadaveric upper extremities underwent fixation with a volar, fixed-angle distal radius locked plate (Wright Medical Technology, Arlington, TN). Three fluoroscopic views (lateral, supinated, and pronated) followed by dorsal wrist dissections were compared to determine accuracy in detecting dorsal screw prominence and extensor tendon compartment violation. Subsequently, screws measuring 2, 4, 6, 8, and 10(mm longer than the measured depths were sequentially inserted into each distal locking screw, with each image deemed either "in" (completely inside the bone) or "out" (prominent screw tip dorsally-would typically be exchanged for a shorter screw intraoperatively). The radial most distal locking screw (position 1) violated either the first (25%) or second (75%) extensor tendon compartments. The average screw prominence required for radiographic detection was: 6.5(mm for lateral views and 2(mm for supinated views. Pronated views did not identify prominent screws. Screws occupying plate position 2 consistently entered Lister's tubercle, with 5/8 exiting the apex and 3/8 exiting the radial base. The average screw prominences for radiographic detection were: 2.75(mm-lateral views and 3.0(mm-supinated views. Although the screws entered the second dorsal compartment, they did not encroach upon either of the tendons. Screws occupying plate position 3 violated the third extensor tendon compartment in 7/8 specimens with 1/8 exiting the Ulan base of Lister's tubercle. The average screw prominences for radiographic detection were: 3.5(mm-lateral views and 2.5(mm-pronated views. Supinated views did not identify prominent hardware. Screws occupying plate position 4 all violated the IV dorsal extensor compartment-2/8 screws were noted to tent the posterior interosseous nerve. The average screw prominences required for radiographic detection were: 4.0(mm-lateral views and 2.5(mm-pronated views. The supinated views did not identify prominent screws. Volar fixed-angle plating has shown great promise in the advancement of distal radius fracture management. We have seen in our referral practices and in the literature an increase in the number of extensor tendon complications arising from unrecognized dorsally prominent screws, pegs, or tines. Standard PA and lateral radiographs cannot adequately visualize screw position and length secondary to the complex geometry of the dorsal cortex. We believe this study supports the routine application of intraoperative, oblique pronosupination fluoroscopic imaging for enhanced confirmation of distal locking screw position and length.
    Hand 10/2007; 2(3):144-50.
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    ABSTRACT: A Munster thumb-spica cast may play a role in the conservative treatment of non-displaced scaphoid fractures by allowing some elbow motion during the long immobilization period.
    Orthopedics 09/2007; 30(8):612-4. · 1.05 Impact Factor
  • Steven D Maschke, William Seitz, Jeffrey Lawton
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    ABSTRACT: Radial longitudinal deficiency encompasses a spectrum of upper limb dysplasias and hypoplasias. The bony abnormalities of the thumb and radius are the most pronounced, but deficiencies of the accompanying muscles, nerves, vessels, and joints also greatly influence the ultimate upper extremity function. The striking clinical presentation of the involved upper limb is often more obvious than the potentially life-threatening associated systemic conditions. All children presenting with radial longitudinal deficiency, regardless of severity, require a renal ultrasound, echocardiogram, and complete blood count to evaluate the potential for associated systemic conditions; these include Fanconi's anemia, the Holt-Oram syndrome, and the VATER (vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal agenesis) syndrome or VACTERL (vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal agenesis, and limb defects) association. The overall health of the child, as well as the severity of the osseous and soft-tissue deformities of the affected limb, guides the long-term treatment plans.
    The Journal of the American Academy of Orthopaedic Surgeons 02/2007; 15(1):41-52. · 2.46 Impact Factor
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    ABSTRACT: The relationship of the posterior interosseous nerve (PIN) to the radius was studied to determine the change in position associated with forearm motion because of the risk of injury during surgical exposure of the lateral elbow. The distance from the PIN to the radiocapitellar joint (RCJ) was measured in 24 cadaveric specimens in pronation, neutral rotation, and supination. The mean distance from the PIN to the RCJ was 4.6 +/- 0.5 cm, 5.3 +/- 0.6 cm, and 5.7 +/- 0.7 cm in supination, neutral rotation, and pronation, respectively. In pronation, there was substantial variation of this distance, with a minimum distance of 4.3 cm. In supination, the minimum distance was 4.0 cm. On the basis of limited PIN distal translation, noted with pronation, as well as the variation between individuals, we recommend limiting dissection to 4.0 cm from the RCJ during a lateral approach without formal identification of the PIN. This safe zone is recommended regardless of forearm rotation, in contrast to the recommendation of prior authors, as pronation does not reliably increase the distance of the PIN to the RCJ.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 01/2007; 16(4):502-7. · 1.93 Impact Factor
  • Michael J DeFranco, Jeffrey N Lawton
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    ABSTRACT: A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients. It is the most common peripheral nerve injury associated with this fracture. Although treatment for this injury pattern is a controversial subject among upper-extremity surgeons, certain principles of management need to be applied in all cases. As our understanding of the pathoanatomy of the humerus and surrounding neurovascular structures has evolved, surgeons have adapted their strategies to improve outcome and avoid long-term morbidity. The principles of management and the clinical outcomes of various treatment strategies, defined in the literature, are reviewed in this article.
    The Journal Of Hand Surgery 05/2006; 31(4):655-63. · 1.57 Impact Factor
  • Orthopedics 02/2003; 26(1):26, 111-2. · 1.05 Impact Factor

Publication Stats

142 Citations
32.82 Total Impact Points


  • 2012–2013
    • University of Michigan
      • Department of Orthopaedic Surgery
      Ann Arbor, Michigan, United States
  • 2008–2010
    • Cleveland Clinic
      • Department of Orthopaedic Surgery
      Cleveland, Ohio, United States
  • 2001
    • University of Kentucky
      • Department of Orthopaedic Surgery and Sports Medicine
      Lexington, Kentucky, United States