Evaluation of the Seesaw Test as New Diagnostic Test for Thumb CMC Osteoarthritis.

BACKGROUND: The seesaw test consists of flexion and extension of the thumb metacarpal on the trapezium, with continuous axial pressure to keep the metacarpal base reduced in the carpometacarpal (CMC) joint. We aim to evaluate this maneuver compared with the grind test. METHODS: We prospectively enrolled 80 participants from March 2017 to March 2018 at a single institution, excluding those who had previous thumb surgery or pathology. Each participant underwent both seesaw and grind tests by 2 independent examiners. We included 24 patients with a mean age of 73 years in the CMC osteoarthritis group (Eaton stages 2-4) and 44 patients with a mean age of 66 years in the control group (Eaton stages 0 and 1). We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and multirater κ measure. RESULTS: The seesaw test had a higher sensitivity than the grind test (42%-71% vs 13%-17%), but a lower specificity (82%-86% vs 91%-98%). The PPV was more consistent between examiners for the seesaw test (63%-68% vs 42%-80%), and the NPV was higher (73%-84% vs 66%-68%). There was a slight agreement between the attending surgeon and the fellow performing the grind test (κ = 0.08) and a moderate agreement between the attending surgeon and the fellow performing the seesaw test (κ = 0.59). CONCLUSIONS: The seesaw test is superior to the grind test, with a much higher sensitivity, slightly lower specificity, more consistent PPV, and slightly higher NPV. Therefore, the seesaw test could be a valuable addition or even replacement for the grind test, and we recommend considering it in daily practice.

Does a Brief Mindfulness Exercise Improve Outcomes in Upper Extremity Patients? A Randomized Controlled Trial.

BACKGROUND: Mindfulness-based interventions are useful in reducing psychologic distress and pain intensity in patients with chronic pain. However, most mindfulness-based interventions are resource-intensive, lengthy, and not feasible for busy orthopaedic surgical practices. QUESTIONS/PURPOSES: The purpose of this study was to determine if a 60-second personalized mindfulness-based video exercise is (1) associated with improved pain intensity, emotional distress, and state anxiety compared with an attention placebo control (a time-matched educational pamphlet about pain and stress); and (2) feasible and acceptable for patients with upper extremity injury in an orthopaedic practice. METHODS: This was a single-center, single-blind randomized controlled trial of the mindfulness-based video exercise (60 seconds duration, free online) versus an attention placebo control (an educational pamphlet about pain and stress presented to patients to read over 60 seconds). One hundred forty-nine patients presenting for a new or followup appointment at the office of one of two orthopaedic hand and upper extremity outpatient surgical practices at an urban academic hospital were invited to participate between September 2016 and December 2016. Of 149 patients screened, 125 patients were randomized and completed a demographic questionnaire, the Numeric Rating Scale to assess pain intensity, the State Anxiety subscale of the State Trait Anxiety Inventory to assess state anxiety, and Emotion Thermometers to assess anxiety, anger, and depression before and after the interventions. Postintervention, patients also completed the Client Satisfaction Questionnaire Scale-3 to assess the acceptability. A mean score of 21 or higher is considered acceptable. Feasibility was determined based on number of patients approached who refused participation. The intervention was defined as feasible if refusal rate was lower than 25%. Analysis of covariance was used to test comparative improved pain intensity on the NRS, psychologic distress on the Emotion Thermometers, and state anxiety on the State Anxiety Subscale of the State Trait Anxiety Index after controlling for respective baseline scores. A 1-point minimal clinically important difference (MCID) was used on the NRS for pain intensity. RESULTS: Adjusted for the baseline means, compared with patients who received the attention placebo control, patients who participated in the mindfulness-based video exercise demonstrated improved pain intensity (mindfulness-based video exercise: 3.03 ± 0.12; control: 3.49 ± 0.12; mean difference: 0.46 [0.12-0.80]; p = 0.008); state anxiety (mindfulness-based video exercise: 32.35 ± 0.59; control: 35.29 ± 0.59; mean difference: 2.94 [1.29-4.59]; p = 0.001); anxiety symptoms (mindfulness-based video exercise: 1.49 ± 0.19; control: 2.10 ± 0.19; mean difference: 0.61 [0.08-1.14]; p = 0.024); depression (mindfulness-based video exercise: 1.03 ± 0.10; control: 1.47 ± 0.11; mean difference: 0.44 [0.15-0.73]; p = 0.004); and anger (mindfulness-based video exercise: 0.76 ± 0.12; control: 1.36 ± 0.12; mean difference: 0.60 [0.26-0.94]; p = 0.001). However, the observed differences in pain intensity were below 1 point on the NRS, which is the MCID established in patients with chronic pain. No MCID is available for the other measures. The mindfulness-based video exercise was feasible based on a dropout rate of 0%, and acceptability reached the medium range with similar scores in both groups (mindfulness-based video exercise: 20.70 ± 5.48; control: 20.52 ± 6.42). CONCLUSIONS: A 60-second mindfulness-based video exercise is feasible to implement and acceptable to patients in busy orthopaedic practices. This video exercise is also effective in improving momentary pain, anxiety, depression, and anger in this population, but it is unclear whether these improved pain and distress levels are meaningful to patients who present with low levels of pain and psychologic distress. Future studies should seek to discern whether the improved pain and distress levels we observed are clinically important or whether the intervention delivers larger effects in subgroups of patients experiencing greater pain intensity and if the improved pain and distress levels are durable. Such studies might also assess cost-effectiveness, because this mindfulness-based tool takes little time and few resources to use, and the effects and durability of multiple sessions of a mindfulness-based video exercise. LEVEL OF EVIDENCE: Level II, therapeutic study.

The Incidence of Arthroplasty After Initial Arthroscopy for Trapeziometacarpal Arthrosis.

BACKGROUND: It remains unclear how many patients undergo secondary surgery after initial arthroscopy for trapeziometacarpal (TMC) arthrosis. We studied the factors related to secondary TMC arthroplasty after TMC arthroscopy. We also examined secondary questions of: (1) what percentage of patients underwent secondary TMC arthroplasty; and (2) how much time elapsed from initial arthroscopy to arthroplasty. METHODS: In this retrospective study, we included all adult patients who were treated with arthroscopy of the TMC joint at 2 level I hospitals and affiliates. Factors were assessed for their independent association with secondary TMC arthroplasty using bivariate and multivariable analyses. RESULTS: Fourteen of 84 (17%) thumbs underwent secondary TMC arthroplasty an average of 11 months after the initial arthroscopy. Synovectomy alone and smoking tobacco were independently associated with secondary TMC arthroplasty when compared with arthroscopic (partial) trapeziectomy with additional tendon interposition or allograft. CONCLUSIONS: This study demonstrated that 1 in 6 thumbs underwent secondary TMC arthroplasty, an average of 11 months after the initial arthroscopy. Coupling arthroscopy with partial trapeziectomy, interposition, or extension osteotomy may be a preferable strategy to isolated synovectomy. In addition, smoking tobacco is associated with inferior outcomes regardless of surgical procedure.

Online Health Information Seeking in Hand and Upper Extremity Surgery.

PURPOSE: Information gathering is a key component of shared decision making and has a measurable effect on treatment decisions. Access to health information might improve quality of care in hand surgery. Our purpose was to identify socio-demographic, condition-related, and psychosocial factors associated with online information-seeking behavior in patients with hand and upper-extremity conditions. METHODS: From June 2015 to February 2016, we enrolled 134 patients with an upper-extremity condition who presented to an outpatient hand surgery office at an urban level I trauma center in this cross-sectional study. Participants provided socio-demographic information and completed online questionnaires assessing their online information-seeking behavior, pain intensity, symptoms of depression, and pain interference, and an upper extremity-specific, patient-reported outcome measure. RESULTS: A total of 57 patients (43%) sought information regarding their condition online before their visit. Compared with patients with no online information-seeking behavior, patients who sought information online were more educated. Psychosocial and condition-related factors were not associated with online information seeking. In multivariable analysis, education in years and involvement of the dominant upper limb were independently associated with online information-seeking behavior. CONCLUSIONS: Education in years and involvement of the dominant upper limb were independently associated with online information-seeking behavior but psychosocial and condition-related factors were not. CLINICAL RELEVANCE: As health information seeking is becoming an integral part of the modern day clinical experience, efforts to make online information more appealing and useful to people of all education levels are merited.

Stable mixed hematopoietic chimerism permits tolerance of vascularized composite allografts across a full major histocompatibility mismatch in swine.

This study tested the hypothesis that vascularized composite allografts (VCA) could be accepted in a robust model of hematopoietic chimerism by injecting allogeneic bone marrow cells (BMC) into swine fetuses. Outbred Yorkshire sows and boars were screened to ensure the absence of the major histocompatibility (MHC) allele SLA(cc) of inbred MGH miniature swine and then mated. Bone marrow harvested from an SLA(cc) swine donor was T-cell depleted and injected intravenously into the fetuses between days 50-55 of gestation. After birth, the piglets were studied with flow cytometry to detect donor cells and mixed lymphocyte reactions (MLR) and cell-mediated lympholysis (CML) assays to assess their response to donor. Donor-matched VCAs from SLA(cc) donors were performed on four chimeric and two nonchimeric swine. The results showed donor cell engraftment and multilineage macrochimerism after the in utero transplantation of adult BMC, and chimeric animals were unresponsive to donor antigens in vitro. Both control VCAs were rejected by 21 days and were alloreactive. Chimeric animals accepted the VCAs and never developed antidonor antibodies or alloreactivity to donor. These results confirm that the intravascular, in utero transplantation of adult BMC leads to donor cell chimerism and donor-specific tolerance of VCAs across a full MHC barrier in this animal model.

Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins.

PURPOSE: Arterialized venous free flaps with a single straight venous axis may require redirection of either the efferent or afferent vein for anastomosis to the digital vessels. To simplify these flaps, the authors propose use of an arterialized venous free flap having 2 parallel veins that does not require redirection of the veins. METHODS: The authors performed 44 arterialized venous free flaps having 2 parallel veins for the reconstruction of digital soft tissue defects. The mean area of coverage was 6.5 cm(2). The donor sites included the volar aspect of the distal forearm in 35 cases, the thenar area in 8 cases, and the dorsal aspect of the foot in 1 case. RESULTS: Thirty-nine of the 44 flaps survived. Complete flap necrosis occurred in 5 cases, and flap congestion was seen in 28 cases. CONCLUSIONS: The authors had satisfactory results using arterialized venous free flaps having 2 parallel veins. By using these flaps, the authors were able to simplify the technique of arterialized venous flaps. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A histologic analysis of the effects of stainless steel and titanium implants adjacent to tendons: an experimental rabbit study.

PURPOSE: The current trend is to treat distal radius fractures with open reduction and internal fixation with either titanium or stainless steel plates. Both provide stable fixation; however, there is minimal evidence concerning the soft-tissue response to these materials. Our objective was to evaluate the response of adjacent extensor tendons to titanium and stainless steel in a rabbit in vivo model and to evaluate the influence of time. METHODS: Forty rabbits were divided into 5 groups of 8 rabbits each. Groups I and II had unilateral osteotomy of the distal radius followed by dorsal fixation with titanium and stainless steel plates, respectively. Groups III and IV had fixation with titanium and stainless steel, respectively, but without osteotomy. Group V had surgical dissection without osteotomy or plates. Two animals per group were killed at 1, 4, 12, and 24 weeks. The specimens (distal radius, plate, overlying soft tissue, and extensor tendon) were harvested en bloc for histologic analysis. For interface preservation between implant and tissues the specimens were embedded in methylmethacrylate, sectioned, and stained with hematoxylin-eosin. RESULTS: Histologic analysis showed a fibrous tissue layer formed over both implants between the plate and the overlying extensor tendons in the groups treated with plating independently of the material and the presence or absence of osteotomy. This fibrous layer contained the majority of debris. Metallic particles were not observed in the tendon or muscle substance of any animals; however, they were visualized in the tenosynovium. Hematoxylin-eosin-stained sections of groups I through IV showed proliferative fibroblasts and metallic particles; however, this layer was not observed in group V. Statistical analysis did not show differences between the groups regarding the number of cells or metallic particles. CONCLUSIONS: Our results indicate that both implants generated adjacent reactive inflammatory tissue and particulate debris. There was no difference in cell or particle number produced by both materials. There is a statistically significant increase in inflammatory cells with increasing time of implantation.