Vasoactive and Antifibrotic Properties of Cannabinoids and Applications to Vasospastic/Vaso-Occlusive Disorders: A Systematic Review.

BACKGROUND: Management of vasospastic and vaso-occlusive disorders is a complex challenge, with current treatments showing varied success. Cannabinoids have demonstrated both vasodilatory and antifibrotic properties, which present potential mechanisms for therapeutic relief. No existing review examines these effects in peripheral circulation in relation to vasospastic and vaso-occlusive disorders. This study aims to investigate vasodilatory and antifibrotic properties of cannabinoids in peripheral vasculature for application in vasospastic and vaso-occlusive disorders affecting the hand. METHODS: A systematic search was conducted by 2 independent reviewers across PubMed, Cochrane, Ovid MEDLINE, and CINAHL to identify studies in accordance with the determined inclusion/exclusion criteria. Information regarding study design, medication, dosage, and hemodynamic or antifibrotic effects were extracted. Descriptive statistics were used to summarize study findings as appropriate. RESULTS: A total of 584 articles were identified, and 32 were selected for inclusion. Studies were grouped by effect type: hemodynamic (n = 17, 53%) and antifibrotic (n = 15, 47%). Vasodilatory effects including reduced perfusion pressure, increased functional capillary density, inhibition of vessel contraction, and increased blood flow were reported in 82% of studies. Antifibrotic effects including reduced dermal thickening, reduced collagen synthesis, and reduced fibroblast migration were reported in 100% of studies. CONCLUSION: Overall, cannabinoids were found to have vasodilatory and antifibrotic effects on peripheral circulation via both endothelium-dependent and independent mechanisms. Our review suggests the applicability of cannabis-based medicines for vasospastic and vaso-occlusive disorders affecting the hand (eg, Raynaud disease, Buerger disease). Future research should aim to assess the effectiveness of cannabis-based medicines for these conditions.

Mental Health Trends in Patients With Symptomatic Macromastia After Reduction Mammoplasty.

BACKGROUND: Symptomatic macromastia can significantly affect both physical and mental health. Although previous studies suggested that breast reduction (BR) improves quality of life and mental health conditions, they were limited to smaller sample sizes and largely based on survey feedback. This study aims to further assess the impact of BR on mental health outcomes, specifically looking at prescribing patterns for common antidepressants. METHODS: A national insurance-based database was utilized for data collection. Patients with a diagnosis of macromastia (ICD-10 N62) between the years 2010 and 2021 that either underwent bilateral BR (CPT 19318) or did not undergo BR were included in the study. Demographics and medical comorbidities were compared. Among those who underwent BR, preoperative and postoperative rates of mental health diagnoses and antidepressant use were compared. Logistic regression analysis was performed to determine variables associated with surgery. RESULTS: Patients with a history of macromastia with a history of BR were compared with those with a history of macromastia without BR. A significantly higher percentage of patients in the BR group reported a history of depression (48.5%), obesity (55.7%), and selective serotonin reuptake inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor (SNRI) use (55.3%) when compared with that of the no-reduction group (46.3%, 50.8%, and 52.6%). Patients with history of depression and obesity were more likely to undergo BR (odds ratio of 1.11 and 1.31). Patients who underwent BR had significantly reduced rates of mental health outcomes including depression (38.6% to 27.4%), anxiety (4.3% to 3.1%), and SSRI or SNRI prescriptions (46.3% to 29.5%) postoperatively. CONCLUSIONS: Patients who underwent BR for symptomatic macromastia showed significantly reduced rates of depression, anxiety, and most importantly, rates of SSRI/SNRI prescriptions postoperatively when compared to those who did not undergo BR for symptomatic macromastia.

Determinants of pressure injury development in patients with COVID-19.

OBJECTIVE: Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19. METHOD: A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement. RESULTS: A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage. CONCLUSION: PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Traditional Neuroma Management Strategies: A Systematic Review.

BACKGROUND: In this systematic review, the authors discuss traditional management strategies of neuromas. Surgical management can be described as either passive and ablative or active and reconstructive. Our aim was to evaluate the evidence supporting traditional management strategies in patients affected by neuromas. METHODS: The systematic literature search was conducted in PubMed/MEDLINE databases using search terms related to neuromas and their surgical management. Studies involving targeted muscle reinnervation or regenerative peripheral nerve interface were excluded. Two reviewers selected the studies, evaluated their methodological quality, and retrieved data independently. This review was conducted in a manner consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Selected studies were analyzed for pain and functional outcomes. RESULTS: A total of 1064 articles were identified, and 22 studies were selected for review. Passive or ablative modalities for treatment of neuromata include excision of neuroma, excision with implantation into adjacent tissue, nerve caps, vein cap, and relocation nerve grafting. Active or reconstructive modalities that allow for nerve regeneration include hollow tube reconstruction, reconstruction with an allograft, and centrocentral nerve anastomosis. CONCLUSIONS: Passive treatment modalities can offer reliable pain relief in appropriately selected patients but do not allow for nerve regeneration. As such active, reconstructive modalities should be used when possible.

Fabricating Stiffness-Matched Three Dimensional -Printed Metal Implants for Total Wrist Arthroplasty.

BACKGROUND: Total wrist arthroplasty (TWA) is a motion-sparing treatment for pancarpal arthritis; however, complication rates up to 50% have limited widespread use. Implant micromotion, stress shielding, and periprosthetic osteolysis result in implant failure and revision to arthrodesis. Metal 3-dimensional (3D) printing allows for more accurate matching of surrounding bone biomechanical properties, theoretically reducing periprosthetic osteolysis. Herein, we use computed tomography to characterize the relationship of relative stiffness along the length of the distal radius with patient demographic factors. METHODS: After institutional review, wrist computed tomography scans at a single institution between 2013 and 2021 were identified. Exclusion criteria were history of radius or carpal trauma or fracture. Collected demographics included age, sex, and comorbidities (including osteoporosis/osteopenia). Scans were analyzed using Materialize Mimics Innovation Suite 24.0 (Leuven, Belgium). Distal radius cortical density (in Hounsfield units) and medullary volume (in cubic millimeters) with relation to distance from the radiocarpal joint were recorded. Average values for each variable were used to 3D-printed distal radius trial components with stiffness matched to bone density by length. RESULTS: Thirty-two patients met inclusion criteria. Distal radius cortical bone density progressively increased proximal to the radiocarpal joint, whereas medullary volume decreased; changes in both plateaued 20 mm proximal to the joint. Distal radius material properties differed by age, sex, and comorbidities. Total wrist arthroplasty implants were fabricated to match these variables as proof of concept. CONCLUSIONS: Distal radius material properties vary along the bone length; conventional implants do not account for this variance. This study showed 3D-printed implants can be created to match bone properties along the length of the implant.

The Mechanism of Cannabichromene and Cannabidiol Alone Versus in Combination in the Alleviation of Arthritis-Related Inflammation.

BACKGROUND: Patients suffering from arthritis have limited treatment options for nonoperative management. In search of pain relief, patients have been taking over-the-counter cannabinoids. Cannabidiol (CBD) and cannabichromene (CBC) are minor cannabinoids with reported analgesic and anti-inflammatory properties and have been implicated as potential therapeutics for arthritis-related pain. To this end, we utilized a murine model to investigate the effectiveness of and mechanism by which CBC alone, CBD alone, or CBD and CBC in combination may provide a reduction in arthritis-associated inflammation. METHODS: Forty-eight mice were included in the study, which were separated into 4 groups: control group (n = 12), treatment with CBD alone (n = 12), treatment with CBC alone (n = 12), and treatment with CBD + CBC (n = 12). We induced inflammation in each mouse utilizing the collagen-induced arthritis model. At scheduled timepoints, mice were clinically assessed for weight gain, swelling, and arthritis severity. In addition, inflammation-associated serum cytokine levels were analyzed for each animal. RESULTS: Thirty-five of 48 mice survived the duration of the study resulting in the following group numbers: control group (n = 8), treatment with CBD alone (n = 9), treatment with CBC alone (n = 9), and treatment with CBD + CBC (n = 9). Animals treated with CBC and CBD + CBC showed significant weight gain between 3 and 5 weeks. Irrespective of treatment, regression analysis comparing all cytokine measurement and physical outcomes found a significant positive correlation between levels of 5 individual cytokines and both arthritis scores and swelling. Animals treated with CBD + CBC showed a significant decrease in swelling between 3 and 5 weeks compared with the control group. Cannabinoid treatment selectively affected the gene expression of eotaxin and lipopolysaccharide-induced CXC chemokine with combined treatment of CBC + CBD. CONCLUSION: Treatment with cannabinoids resulted in decreased clinical markers of inflammation. Further, the anti-inflammatory effect of CBC and CBD in conjunction was associated with a greater anti-inflammatory effect than either minor cannabinoid alone. Future work will elucidate the possibility of synergistic or entourage effects of minor cannabinoids used in combination for the treatment of arthritis-related pain and inflammation.

Thematic and Demographic Analysis of Crowdsourcing Practices for Plastic Surgery.

BACKGROUND: In this study, we investigate the characterization of medical crowdsourcing on GoFundMe for plastic surgery procedures, with overall funds raised being the primary end point. HYPOTHESIS: Certain demographic factors such as sex and race mentioned in campaign narratives are associated with the effectiveness of medical crowdfunding campaigns. METHODS: Search terms were used to aggregate fundraising campaigns for plastic surgery medical procedures on GoFundMe. These studies were then stratified by demographics based on campaign text or author consensus, and were further subdivided into categories based on procedure type. RESULTS: Men were found to have higher median shares than women-raising an average of $609 more than female counterparts ( P < 0.05). Fundraising for themes such as lack of insurance, travel costs, lifesaving treatment, and end-of-life expenses were more successful than the theme of psychosocial effects of disease or social impairment. In addition, those that included a smiling picture of the recipient and those created by a friend/relative raised more funds. Although no significant difference was found in fundraising between demographics based on race, a majority (72.8%) of campaigners were White. Across ~2000 plastic surgery campaigns, a total of $10,186,687 were raised from these data. CONCLUSIONS: We identified both modifiable and nonmodifiable factors that influence success. These successful campaigns can serve as a learning opportunity for many who have been marginalized by the medical and pharmaceutical industry, and they demonstrate a promising area for demographic studies.

Assessment of Medical Cannabis in Patients With Osteoarthritis of the Thumb Basal Joint.

PURPOSE: With the increasingly widespread availability of cannabidiol-derived products, more patients with hand and wrist pain are seeking evidence for use of these products. We explored current utilization practices of medical cannabis for treatment of pain in patients with a diagnosis of thumb basal joint arthritis. Secondary aims were to determine patient and thumb arthritis disease characteristics of cannabis users and nonusers and to investigate patient perceptions of the efficacy of medical cannabis in various formulations for the treatment of thumb arthritis pain. METHODS: Patients with thumb basal joint arthritis were identified using International Classification of Diseases, Tenth Revision codes between May and June 2020. All patients received an invitation to complete a survey regarding perceptions of cannabis and related products. Medical records were retrospectively reviewed to gather demographic information and thumb basal joint arthritis factors, including laterality, date of initial diagnosis, and prior treatment. RESULTS: The survey was completed by 103 patients. Twenty-five percent reported a history of oral medical cannabis use, and 21% reported topical medical cannabis use. Twelve of 25 oral users and 7 of 21 topical users believed that the product was effective in relieving pain and consequently worth the financial cost. Of the patients surveyed, 69% would be interested in trialing an oral formulation and 80% would be interested in trialing a topical formulation for treatment of their thumb pain. CONCLUSIONS: Patients with thumb basal joint arthritis use cannabis-related products, with mixed reports on efficacy. Large numbers of these patients would be interested in trialing either oral or topical formulations of medical cannabis for treatment of their thumb basal joint pain. CLINICAL RELEVANCE: It is important for medical providers to understand the current data available regarding analgesic properties of cannabidiol-related products to respond to patient inquiries about the use of cannabinoids in treating medical conditions.

Distal Radioulnar Achilles Allograft Interposition Arthroplasty: Does It Solve the Problem of Persistent Pain?

PURPOSE: Pain and instability following distal ulnar resection for distal radioulnar joint (DRUJ) arthritis is a problem without a clear solution. We investigated the outcomes of DRUJ interposition arthroplasty for the management of symptomatic radioulnar convergence. METHODS: A retrospective review was performed for all patients who underwent Achilles tendon allograft interposition arthroplasty following the failure of distal ulna resection between October 2009 and January 2015. Records were reviewed for demographics, comorbidities, surgical history, pre- and postoperative pain, range of motion, grip strength, and complications. Radiographs and computed tomography scans were evaluated for distal radioulnar instability, distal ulnar absorption, ulnar scalloping, radioulnar convergence, and allograft subluxation. Reconstructive failure was defined as the presence of moderate-to-severe persistent distal radioulnar pain, instability with radiographic evidence of radioulnar convergence or allograft subluxation on radiographs or computed tomography scans, or the need for revision arthroplasty procedure. RESULTS: Ten patients met the inclusion criteria. The mean age was 49 ± 10 years. The average follow-up after interposition arthroplasty was 76 ± 23 months. The preoperative means of grip strength, arc of pronosupination, flexion, and extension were similar after surgery. The mean arc of pronosupination improved by 26.5°, and the wrist flexion-extension arc in patients without arthrodesis improved by 22.6°. The grip strength increased by 1.7 kg. Seven of 10 patients had continued symptoms of pain and instability related to symptomatic allograft subluxation and/or radioulnar convergence. Five patients underwent revision surgery; the mean time to revision was 26 months. CONCLUSIONS: Mid- to long-term follow-up of patients after salvage allograft interposition arthroplasty of the DRUJ resulted in minimal functional improvement in terms of arc of motion and grip strength. Persistent radioulnar pain was common, with half of the patients requiring revision operations following allograft interposition. Given this high failure rate, alternative procedures should be considered for the management of chronic pain and instability of the DRUJ. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Trends in Physician Payments for Hand Surgery Consultations and Clinic Visits.

PURPOSE: The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings. METHODS: The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and by physician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care. RESULTS: In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations. CONCLUSIONS: This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation. LEVEL OF EVIDENCE: Economic Analysis IV.

Cannabinoids and Pain for the Plastic Surgeon: What Is the Evidence?

BACKGROUND: Since the passage of the 2018 Farm Bill, practitioners have encountered more patients self-treating pain with over-the-counter topical cannabidiol (CBD) derived from hemp-Cannabis sativa with less than 0.3% delta-9-tetrahydrocannabinol-with reported improvements in pain control and activities of daily living. Cannabidiol has been touted for its capacity to improve inflammatory, arthritic, and neuropathic pain conditions, and increasing numbers of patients are exploring its use as potential replacement for opioids. However, limited rigorous clinical trials have been performed evaluating the safety and efficacy of cannabinoids for the treatment of pain. METHODS: A systematic search of PubMed was performed using the Medical Subject Headings (MeSH) terms "cannabinoid" or "CBD" or "cannabidiol" or "cannabis" or "medical marijuana" and "pain." It yielded 340 article titles. Twelve full-text primary studies of oral or topical CBD for chronic pain were selected for review, including 6 animal (2 randomized clinical trial and 4 prospective trials) and 6 human (4 randomized clinical trial and 2 prospective trials) studies. RESULTS: With respect to the safety and efficacy of oral and topical CBD for treating pain, animal and human studies have shown early positive results with limited minor side effects. However, all human studies may be underpowered with small sample sizes. CONCLUSIONS: With respect to the safety and efficacy of oral and topical CBD for treating pain, the evidence remains inconclusive in that we have a paucity of data to share with our patients who are considering the use of these products, which may be associated with significant costs.

Estimating the Impact of Postamputation Pain.

BACKGROUND: Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation. METHODS: Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities. RESULTS: There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain. CONCLUSIONS: Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.

Intraoperative Fluorescence Angiography in Implant-Based Breast Reconstruction: Identifying Risk Factors and Outcomes.

BACKGROUND: Intraoperative fluorescence angiography (FA) has been described as a useful adjunct to physical examination in predicting mastectomy skin flap viability for immediate breast reconstruction. Its use has been described as a screening tool for mastectomy skin flap viability as well as a test used only for patients at high risk for mastectomy skin flap loss. We performed a national database review of implant-based breast reconstruction surgeries to determine the practice patterns of FA in this patient cohort and to determine if this technology impacted clinical outcomes. METHODS: A national insurance claims database was reviewed to select patients having undergone direct-to-implant (DTI) and immediate tissue expander (TE) placement with and without intraoperative FA as well as patients who had FA at the time of mastectomy without reconstruction. Patient characteristics that prompted FA and postoperative outcomes with and without FA were evaluated to determine its clinical impact in the observed practice pattern. RESULTS: Of the 48,464 patients identified, 836 had FA. More than twice as many patients undergoing DTI had FA than patients undergoing immediate TE placement (10.4% vs 5%, P < 0.0001). Twelve percent of patients receiving FA at the time of mastectomy had reconstruction delayed. Fluorescence angiography was associated with a trend toward lower overall complication rates in DTI patients (8.0% vs 11.9% without FA) but a significantly higher overall complication rate with immediate TE placement (13.8% vs 10.5% without FA, P = 0.018) and was associated with higher reoperation (12.0% vs 8.3% without FA, P = 0.037) in the TE group. There was no difference in other individual complications, readmission, or explantation for either clinical group with and without FA. Regression analysis identified obesity (odds ratio, 1.32; P < 0.001) and younger age (odds ratio, 1.74; P < 0.001) to be associated with performing FA, whereas obesity, diabetes, and tobacco use were associated with higher complication rates. CONCLUSIONS: Younger and otherwise healthier obese patients were more likely to have FA. A greater proportion of DTI patients had FA than TE patients with improved outcomes in the former group and worse outcomes in the latter group. Obesity, tobacco use, and diabetes were associated with worse outcomes, whereas only obesity was associated with FA use.

A Randomized Controlled Trial of Topical Cannabidiol for the Treatment of Thumb Basal Joint Arthritis.

PURPOSE: Since the passage of the Agricultural Improvement Act of 2018, hand surgeons have increasingly encountered patients seeking counseling on over-the-counter, topical cannabidiol (CBD) for the treatment of pain. To this end, we designed a human clinical trial to investigate the therapeutic potential of CBD for the treatment of pain associated with thumb basal joint arthritis. METHODS: Following Food and Drug Administration and institutional approval, a phase 1 skin test was completed with 10 healthy participants monitored for 1 week after twice-daily application of 1 mL of topical CBD (6.2 mg/mL) with shea butter. After no adverse events were identified, we proceeded with a phase 2, double-blinded, randomized controlled trial. Eighteen participants with symptomatic thumb basal joint arthritis were randomized to 2 weeks of twice-daily treatment with CBD (6.2 mg/mL CBD with shea butter) or shea butter alone, followed by a 1-week washout period and then crossover for 2 weeks with the other treatment. Safety data and physical examination measurements were obtained at baseline and after completion of each treatment arm. RESULTS: Cannabidiol treatment resulted in improvements from baseline among patient-reported outcome measures, including Visual Analog Scale pain; Disabilities of the Arm, Shoulder, and Hand; and Single Assessment Numeric Evaluation scores, compared to the control arm during the study period. There were similar physical parameters identified with range of motion, grip, and pinch strength. CONCLUSIONS: In this single-center, randomized controlled trial, topical CBD treatment demonstrated significant improvements in thumb basal joint arthritis-related pain and disability without adverse events. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

How to Be An Antiracist Hand Surgery Educator.

Racism that unjustly marginalizes black people in the United States is not a new concept. It underlies nearly every aspect of American history, leading to the systemic racism that is ingrained in our society today. With the recurrent theme of people of color having worse health outcomes than the majority community, it is important for hand surgeons to employ cultural competence and antiracist education to provide better care and support for patients, staff, students, and colleagues. In this article, we will provide a definitional framework, clinical examples, and practical pearls to promote change. To reduce racial and ethnic health care inequities and diversify the field of hand surgery, we must advocate on behalf of black and brown colleagues, staff, students, and/or friends to address racist policies and procedures.

Racial and Gender Discrimination in Hand Surgery Letters of Recommendation.

PURPOSE: We sought to evaluate hand surgery applicants' letters of recommendations to understand whether applicant and letter writer demographics contribute to racial and gender bias. METHODS: All applications submitted through the American Society for Surgery of the Hand match to a single institution fellowship program for the 2017 to 2019 application cycles were analyzed using validated text analysis software. Race/ethnicity information was derived from an analysis of applicant photos using the Face Secret Pro software. Primary outcome measures were differences in communal and agentic language used in letters of recommendation, stratified by both race/ethnicity and gender. RESULTS: A total of 912 letters of recommendation were analyzed for 233 applicants (51 female and 172 male). Of these, 88 were written by female letter writers and 824 were written by male letter writers. There were 8 Black, 12 Hispanic, 36 Asian, and 167 White applicants. Letter writers used more agentic language with Asian applicants and non-White applicants overall. Female letter writers used more communal terms and were not associated with applicant race or gender. CONCLUSIONS: Letters of recommendation in hand surgery demonstrate disparities in language based on race and gender. CLINICAL RELEVANCE: Alerting letter writers to the role of implicit bias will hopefully spur a discussion on tools to mitigate the use of biased language and provide a foundation for an equitable selection process. Efforts to improve policies and procedures pertaining to diversity and inclusion are paramount to ensuring that fellows more completely represent the population hand surgeons wish to serve.

Patient-Generated Actigraphy Data as a Novel Outcomes Instrument in Carpal Tunnel Syndrome.

BACKGROUND: Currently, we lack objective measures to quantify outcomes in carpal tunnel syndrome. Instead, surgeons rely on patient-reported outcomes measures (PROMs) to assess the effect of carpal tunnel release (CTR). We assessed the validity and reliability of wearable activity monitors to objectively characterize the functional and sleep impact of CTR. We hypothesized that actigraphy could detect changes in sleep and activity and would demonstrate short-term impairment due the operative procedure. METHODS: This pilot, prospective, cohort study compared validated PROMS with actigraphy data obtained via wearable activity monitors (ActiGraph Link; ActiGraph Corp, Pensacola, Fla). Subjects completed baseline questionnaires and wore their device for 1 week preoperatively as a baseline. Subjects then underwent open CTR, wearing actigraphy devices for 4 weeks and completing questionnaires at 2 and 4 weeks postoperatively. Preintervention and postintervention data were compared using paired-sample t test. The Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire data were analyzed in accordance with published PROMIS scoring manuals and raw scores were converted to standardized T scores. RESULTS: Twenty subjects (5 males, 15 females) with moderate or severe carpal tunnel syndrome were enrolled. The mean age was 57.7 years. The PROMIS 29 average cumulative T score was 42.9 with average change of -0.072 preoperatively versus postoperatively. Average sleep disturbance T score was 38.9 preoperatively and 41.4 postoperatively. There was no statistically significant difference in T score in any domain. The mean actigraphy activity data demonstrated near immediate return to baseline activity. Actigraphy sleep data demonstrate improvement in sleep fragmentation and decreased duration of awakenings. CONCLUSIONS: Overall, patient-generated data detected differences in sleep and activity preoperatively versus postoperatively and demonstrated only a short period of activity disruption after CTR, which may be used when counseling patients. These data support actigraphy as a viable adjunct to traditional PROMS to evaluate the impact of surgical intervention and therefore may be useful in the study of other diseases affecting the upper extremity.

Granulocytic Sarcoma: A Rare Cause of Wrist Pain.

Septic, inflammatory, or crystal-induced arthritis are common etiologies of wrist pain without antecedent trauma associated with pain, loss of motion, swelling, redness, and warmth. In this report, we detail the case of granulocytic sarcoma of the wrist that presented as acute wrist pain, swelling, and limitation in motion. Granulocytic sarcoma is an exceedingly rare extramedullary tumor associated with acute myeloblastic leukemia. It may be found in any part of the body; however, upper extremity involvement is uncommon. To our knowledge, this is the first description of granulocytic sarcoma occurring in the wrist joint.

Injectable Microannealed Porous Scaffold for Articular Cartilage Regeneration.

BACKGROUND: The purpose of this study is to assess the feasibility of a novel microporous annealed particle (MAP) scaffolding hydrogel to enable both articular cartilage and subchondral bone biointegration and chondrocyte regeneration in a rat knee osteochondral defect model. METHODS: An injectable, microporous scaffold was engineered and modified to match the mechanical properties of articular cartilage. Two experimental groups were utilized-negative saline control and MAP gel treatment group. Saline and MAP gel were injected into osteochondral defects created in the knees of Sprague-Dawley rats. Photo-annealing of the MAP gel was performed. Qualitative histologic and immunohistochemical analysis was performed of the treated defects at 2, 4, and 8 weeks postsurgery. RESULTS: The injectable MAP gel successfully annealed and was sustained within the osteochondral defect at each timepoint. Treatment with MAP gel resulted in maintained size of the osteochondral defect with evidence of tissue ingrowth and increased glycosaminoglycan production, whereas the control defects presented with evidence of disorganized scar tissue. Additionally, there was no significant inflammatory response to the MAP gel noted on histology. CONCLUSIONS: We have demonstrated the successful delivery of an injectable, flowable MAP gel scaffold into a rat knee osteochondral defect with subsequent annealing and stable integration into the healing wound. The flowable nature of this scaffold allows for minimally invasive application, for example, via an arthroscopic approach for management of wrist arthritis. The MAP gel was noted to fill the osteochondral defect and maintain the defect dimensions and provide a continuous and smooth surface for cartilage regeneration, suggesting its ability to provide a stable scaffold for tissue ingrowth. Future chemical, mechanical, and biological gel modifications may improve objective evidence of cartilage regeneration.

Quantifying Burn Injury-Related Disability and Quality of Life in the Developing World: A Primer for Patient-Centered Resource Allocation.

BACKGROUND: Untreated or undertreated burns are commonly encountered by plastic surgeons on medical trips in India and represent a major cause of disability. We sought to utilize validated patient-reported outcomes instruments to identify the patient population with the greatest burn-related disability in order to appropriately allocate plastic surgery resources to those in greatest need. METHODS: The Quick Disability of the Arm, Shoulder, and Hand, RAND 36-Item Short Form Health Survey, and Burn-Specific Health Scale-Revised, Brief, and Adapted questionnaires were administered via an interpreter during a plastic surgery trip to Jharkhand, India, in January 2018. Demographics, comorbidities, and burn-specific history were recorded. RESULTS: Twenty-eight postburn patients were surveyed (mean age, 17.0 ± 9.2 years; male:female ratio, 1:2.5). Mean time from injury was 4.74 years. No patient had received formal, primary burn care. Mechanism of injury: flame (39%), oil (32%), scalding water (14%), and other (14%). Fifty-four percent were extremity burns; 25%, facial; and 18%, neck burns. The Burn-Specific Health Scale-Revised, Brief, and Adapted demonstrated that the most significantly impacted domains for all patients were body image and skin sensitivity, with more than 80% of patients complaining of issues with skin sensitivity. In addition, children (aged <18 years) had diminished body image domain scores. RAND SF-36 scores were lowest in the energy (73.1 ± 25.0) and general health (76.5 ± 13.8) domains, and females with extremity burns demonstrated statistically significant decreases in their physical limitation domain scores (85.9 ± 17.3, P < 0.05). Females with extremity burns also had statistically significant lower scores in the energy domain (64.09 ± 25.75) as compared with their male counterparts with extremity burns (100 ± 0, P = 0.045). In general, females scored lower than did males in multiple domains, and those results reached statistical significance in the energy (65.9 ± 24.6 vs 93.6 ± 10.9), emotional (77.2 ± 21.5 vs 95.4 ± 11.2), and general health domains (71.1 ± 11.9 vs 90.0 ± 7.5) with P < 0.05. Children demonstrated significantly diminished scores in the emotional (75.5 ± 24.6) and general health (79.1 ± 11.8) domains. CONCLUSION: These data demonstrate the significant impact on quality of life that untreated burns have in this population. Male and female children with extremity burns and adult women with extremity burns were most significantly affected in multiple domains. Consequently, children and adult women with extremity burns appear to be the patient cohort with the greatest opportunity to impact their quality of life. These data may be utilized to improve patient triage and resource allocation for future surgical trips but could also be of significant benefit to internal health agencies and ministries for the same purpose.