Quantitative Analysis of the Volar Ulnar Corner of the Distal Radius: A Reference for Intraoperative Distal Radius Fracture Reduction.

PURPOSE: The reduction of distal radius fractures using volar locking plate fixation can be performed by securing the plate to the distal fragments and then levering the plate to the radial shaft. Oblique placement of the plate on the radial shaft may lead to malreduction. The aim of this study was to evaluate parameters that can be used for the assessment of intraoperative distal radius fracture reduction using "distal-first" volar plate fixation, especially the geometry of the ulnar corner. The prevalence of Tolat distal radioulnar joint (DRUJ) types was determined, and the angles of the volar corner were quantitatively described. METHODS: Three hundred seventy-five adult patients with a conventional wrist radiograph in their medical chart were identified. From this cohort, 50 radiographs of each Tolat DRUJ type were quantitatively analyzed using 4 angles. The probability density of each angle was described using Kernel density estimation graphs. A multivariable analysis was used to study the association between the 4 angles and Tolat DRUJ types and other patient factors. RESULTS: One hundred fifty-one patients (40%) had a wrist with type 1 DRUJ, 147 (39%) had a wrist with type 2 DRUJ, and 77 (21%) had a wrist with type 3 DRUJ. The measurements of the distal ulnar corner, volar ulnar corner, and DRUJ angulation were significantly different among each Tolat DRUJ type. The median lunate facet inclination, relative to the axis of the radial shaft, measured 14° (interquartile range, 12°-16°) across all the Tolat DRUJ types. CONCLUSIONS: The prevalence of Tolat type 1, 2, and 3 DRUJ was 40%, 39%, and 21%, respectively. The angles of the volar ulnar corner varied with each DRUJ type. CLINICAL RELEVANCE: Because the lunate facet inclination was relatively consistent among all the Tolat DRUJ types, this angle may be useful as a reference for "distal-first" distal radius volar plating.

A Quantitative Analysis of Subchondral Bone Density Around Osteochondritis Dissecans Lesions of the Capitellum.

PURPOSE: In capitellar osteochondritis dissecans (OCD), unstable lesions generally demonstrate signs of subchondral sclerosis. We postulate that OCD lesions have abnormal subchondral bone density. We aimed to quantify the subchondral bone thickness around OCD lesions using conventional computed tomography (CT) imaging. METHODS: This retrospective study included 15 patients with capitellar OCD (OCD group) and 12 patients with an unaffected radio-capitellar joint (control group). We constructed 3-dimensional humerus models using CT data and quantified the bone density with colored contour mapping to determine the subchondral bone thickness. We measured the thickness relative to the condylar height at the centroid and lateral, medial, superior, and inferior edge points of the OCD lesion, and compared the findings between the groups. We then correlated the CT measurements with the magnetic resonance imaging measurements. RESULTS: Subchondral bone thickness at the centroid and lateral, medial, superior, and inferior edges in the OCD group was significantly higher than that in the control group. Correlation analyses revealed that the magnetic resonance imaging measurements highly correlated with the CT subchondral bone measurements. CONCLUSIONS: We found that there is a zone of increased subchondral bone thickness around OCD lesions that should be considered during drilling, microfracture, or other reconstruction methods. We observed a high correlation with low errors between the measurements taken from conventional CT images and the measurements from magnetic resonance imaging, suggesting that both modalities are useful in clinical decision making. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty.

BACKGROUND: Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA. METHODS: We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores. RESULTS: Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS. CONCLUSION: Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

The Performance of Diagnostic Tests for Identifying Periprosthetic Joint Infection After Failed Partial Knee Arthroplasty.

BACKGROUND: Indications for unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty are expanding. Despite the lower published infection rates for UKA and patello-femoral arthroplasty than total knee arthroplasty, periprosthetic joint infection (PJI) remains a devastating complication and diagnostic thresholds for commonly utilized tests have not been investigated recently. Thus, this study evaluated if diagnostic thresholds for PJI in patients who had a failed partial knee arthroplasty (PKA) align more closely with previously reported thresholds specific to UKA or the 2018 International Consensus Meeting on Musculoskeletal Infection. METHODS: We identified 109 knees in 100 patients that underwent PKA with eventual conversion to total knee arthroplasty within a single healthcare system from 2000 to 2021. Synovial fluid nucleated cell count and synovial polymorphonuclear percentage in addition to preoperative serum erythrocyte sedimentation rate, serum C-reactive protein, and serum white blood cell count were compared with Student's t-tests between septic and aseptic cases. Receiver operating characteristic curves and Youden's index were used to assess diagnostic performance and the optimal cutoff point of each test. RESULTS: Synovial nucleated cell count, synovial polymorphonuclear percentage, and serum C-reactive protein demonstrated excellent discrimination for diagnosing PJI with an area under the curve of 0.97 and lower cutoff values than the previously determined UKA specific criteria. Serum erythrocyte sedimentation rateESR demonstrated good ability with an area under the curve of 0.89. CONCLUSION: Serum and synovial fluid diagnostic thresholds for PJI in PKAs align more closely with the thresholds established by the 2018 International Consensus Meeting as compared to previously proposed thresholds specific to UKA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Long-Term Opioid Use Following Surgery for Symptomatic Neuroma.

BACKGROUND: Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery. METHODS: After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments. RESULTS: Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3, p = 0.013). CONCLUSION: Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.

Joint-sparing versus nonjoint-sparing reconstruction of the radius following oncologic resection: A systematic review.

BACKGROUND AND OBJECTIVES: Reconstructions of the distal radius are uncommon procedures. This systematic review compares joints-sparing (JS) versus nonjoint-sparing (NJS) reconstructions following oncologic resection of the distal radius. METHODS: A search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Collected outcomes included patient-reported outcome measures (PROMs), range of motion and grip strength, and complication and reoperation rates. RESULTS: A total of 52 nonrandomized cohort studies (n = 715) were included. PROMs were comparable between the cohorts, while the range of flexion-extension was greater in JS reconstructions (78.1° vs. 25.6°) and the range of pronation-supination was greater in NJS reconstructions (133.6° vs. 109.8°). Relative grip strength was greater following JS reconstruction (65.0% vs. 56.4%). About one in sixteen of the JS reconstructions were eventually revised to an NJS construct. CONCLUSIONS: This systematic review demonstrates that JS reconstructive techniques can offer satisfying results in patients treated for oncologic distal radius defects. However, about 6% of JS reconstructions are eventually revised to a NJS construct. Further investigation is warranted to identify factors that affect or predict these findings, to aid in future in treatment selection and reduce the common need for reoperations following these procedures.

Osteoarticular allograft reconstruction after distal radius tumor resection: Reoperation and patient reported outcomes.

BACKGROUND: The aims of this study are to evaluate the rate of wrist joint preservation, allograft retention, factors associated with reoperation and to report the patient reported outcomes after osteoarticular allograft reconstruction of the distal radius. METHODS: Retrospective chart review identified 33 patients who underwent distal radius resection followed by osteoarticular allograft reconstruction, including 27 giant cell tumors and 6 primary malignancies. Ten patients with a preserved wrist joint completed the QuickDASH, PROMIS-CA physical function, and Toronto extremity salvage score (TESS) at a median of 13 years postoperatively. RESULTS: The allograft retention rate was 89%, and an allograft fracture predisposed to conversion to wrist arthrodesis. The reoperation rate was 55% and 36% underwent wrist arthrodesis at a median of 4.2 years following index surgery. The use of locking plate fixation was associated with lower reoperation and allograft fracture rates. Patients reported a median QuickDASH of 10.2 (range: 0-52.3), a mean PROMIS physical function of 57.8 (range: 38.9-64.5) and the median TESS was 95.5 (range: 67.0-98.4). CONCLUSION: Osteoarticular allograft reconstruction results in acceptable long-term patient reported outcomes, despite a high revision rate. Allograft fixation with locking plates seems to reduce the number of reoperations and allograft fractures, along with reduction in wrist arthrodesis rates.

Factors associated with 30-day soft tissue complications following upper extremity sarcoma surgery.

BACKGROUND AND OBJECTIVES: The incidence of soft tissue complications following sarcoma surgery in the upper extremity is reportedly high. Therefore, this study assessed the National Surgical Quality Improvement Program (NSQIP) database to identify independent risk factors, while also reporting the incidence of soft tissue complications in the first 30 days after surgery. METHODS: A total of 620 patients that underwent surgical treatment for upper extremity sarcoma were included from the NSQIP database. Soft tissue complications were defined as surgical site infection, wound dehiscence, or soft-tissue related reoperations. Clinically relevant patient and treatment characteristics were selected and analyzed. RESULTS: The 30-day soft tissue complication rate was 4.7%. In the multivariable analysis, higher body mass index (p = .047) and longer operative times (p = .002) were independently associated with soft tissue complications. CONCLUSIONS: Higher body mass index and longer operative times are risk factors for soft tissue complications following upper extremity sarcoma surgery. The soft-tissue complication rate following resection of upper extremity tumors is low in this national cohort, possibly due to the relatively small tumor size and low prevalence of radiotherapy.

Surface osteosarcoma: Predictors of outcomes.

BACKGROUND AND OBJECTIVES: The subtypes of surface osteosarcomas include well-differentiated, low-grade parosteal osteosarcoma (POS), intermediate-grade periosteal osteosarcoma (PerOS), high-grade surface osteosarcoma (HGSO), and high-grade, dedifferentiated POS (dPOS). We aimed to determine disease progression, defined as local recurrence and metastatic disease, and overall (OS) and disease-specific survival (DSS). We identify outcome predictive factors and report functional results. METHODS: This retrospective study evaluated patients with primary surface osteosarcoma at our hospital from 1992 to 2019. Fifty-one patients had a median follow-up of 6.1 years (range: 0.1-25.2). Histologic subtypes included 32 POS, 11 PerOS, 4 HGSO, and 3 dPOS. Bone and soft tissue margins were classified using the American Joint Committee on Cancer residual tumor classification (Rx = Not evaluable; R0 = negative margin; R1 = microscopic positive margin; and R2 = macroscopic positive margin) and the modified R classification (mRx = not evaluable; mR0 = negative margin >1 mm; mR1 = negative margin ≤1 mm; mR1-dir: Positive microscopic margin locally; mR2a: Positive macroscopic margin locally; mR2b: positive macroscopic margin distally; and mR2C: positive macroscopic margin locally and distally). Forty-one patients had functional outcomes. RESULTS: Three POS patients developed recurrence: two had R0 margins and one an intralesional resection. Five patients developed lung metastases (POS: 3, dPOS: 2). Four patients died. The only significant disease progression predictor was age. OS at 10 years was 97%. 48 patients had negative bone margins (R0 or mR0 and mR1) and 47 patients had negative soft-tissue margins (R0 or mR0 and mR1). The average MSTS score was 88.43 (range: 34.29-100). CONCLUSIONS: We advocate surgery for POS and believe R0 (mR0 and mR1 resections) or planned R1 (mR1-dir) to preserve function are acceptable. We favor chemotherapy and surgery for PerOS, though a chemotherapeutic response is highly variable. High-grade tumors are the most infrequent subtype, but HGSO and dPOS seem to portend a poorer prognosis. Good function can be obtained.

Long-term patient-reported outcome measures following limb salvage with complex reconstruction or amputation in the treatment of upper extremity sarcoma.

BACKGROUND AND OBJECTIVES: This study compares long-term patient-reported outcomes between patients that underwent limb-salvage surgery with complex reconstruction by free or pedicled flap (LS) or amputation. Additionally, the need for revision surgery is compared. METHODS: A total of 43 patients were studied at a median follow-up of 9.54 years. Sixteen patients completed questionnaires regarding functional outcome and mental wellbeing. Functional outcomes were measured by using the Toronto Extremity Salvage Score (TESS), QuickDASH, and PROMIS Upper Extremity instruments. Mental wellbeing was assessed using the PROMIS Anxiety and Depression instruments. Revision surgery was assessed for the entire follow-up. RESULTS: The median TESS scores were 96.0 versus 71.7 (p = 0.034) and the PROMIS Upper Extremity scores were 50.1 versus 40.3 (p = 0.039) for the LS and amputation cohorts, respectively. No significant difference was found regarding symptoms of anxiety (52.7 vs. 53.8; p = 0.587) or depression (52.0 vs. 50.5; p = 0.745). Of the patients in the LS cohort 51.6% required at least one reoperation compared to 8.33% in the amputation cohort. CONCLUSIONS: LS surgery maintains functional benefits over amputation after almost a decade of follow-up. Still, mental wellbeing seems to be comparable between these patients, whereas LS procedures are associated with a sixfold increased need for reoperations.

Degenerative changes in the elbow joint after radial head excision for fracture: quantitative 3-dimensional analysis of bone density, stress distribution, and bone morphology.

HYPOTHESIS AND BACKGROUND: Some investigators speculate that excision may lead to elbow arthritis and associated problems; however, evidence supporting this theory is limited. It is hypothesized that radial head excision causes bone density changes as a result of asymmetrical stress distributions, consequently leading to osteophyte formation. In this study, we sought to quantitatively compare the 3-dimensional (3D) bone density and stress distributions between operative and nonoperative elbows in patients who underwent radial head excision. Furthermore, we aimed to quantify the bone morphologic changes using 3D models in the same cohort. METHODS: After retrospective identification, this study enrolled 6 patients who had undergone radial head excision for radial head fractures. We created 3D bone models using computed tomography data obtained from the injured and uninjured elbows. Humerus and ulna models were divided into anatomic regions, and the bone density of each region was assessed and described by its percentage of high-density volume (%HDV). We also constructed finite element models and measured the stress values in each region. Furthermore, we compared the bone morphology by superimposing the operative elbow onto the mirror image of the nonoperative elbow. RESULTS: The mean interval from radial head excision to examination was 8.4 ± 3.3 years. The %HDV on the operative side was higher than that of the nonoperative side at the anterolateral trochlea (77.5% ± 6.5% vs. 64.6% ± 4.0%, P = .028) and posterolateral trochlea (70.7% ± 7.8% vs. 63.1% ± 3.8%, P = .034) regions of the distal humerus. Reciprocal changes were observed in the proximal ulna, as %HDV was higher in the lateral coronoid (52.6% ± 9.6% vs. 34.2% ± 6.6%, P = .007). The stress distributions paralleled the bone density measurements. The operative elbows demonstrated an enlarged capitellum and a widened and deepened trochlea with osteophyte formation compared with the nonoperative side. DISCUSSION AND CONCLUSION: In elbows treated with radial head excision, we identified asymmetrical bone density and stress alterations on the lateral side of the ulnohumeral joint and bone morphologic changes across the joint. These data support the theory that radial head excision contributes to ulnohumeral arthritis over the long term.

Bone resorption of the greater tuberosity after open reduction and internal fixation of complex proximal humeral fractures: fragment characteristics and intraoperative risk factors.

HYPOTHESIS AND BACKGROUND: In complex proximal humeral fractures, bone resorption of the greater tuberosity is sometimes observed after open reduction and internal fixation (ORIF). However, this has not been well characterized, and risk factors for resorption are not completely understood. We aimed (1) to identify the risk factors associated with bone resorption of the greater tuberosity and (2) to quantify the geometric and bone density characteristics associated with bone resorption using 3-dimensional computed tomography models in complex proximal humeral fractures treated with ORIF. METHODS: We identified a retrospective cohort of 136 patients who underwent ORIF of 3- or 4-part proximal humeral fractures; greater tuberosity resorption developed after ORIF in 30 of these patients. We collected demographic, fracture-related, and surgery-related characteristics and performed multivariable logistic regression analysis to identify factors independently associated with the development of greater tuberosity resorption. Furthermore, we identified 30 age- and sex-matched patients by use of propensity score matching to perform quantitative fragment-specific analysis using 3-dimensional computed tomography models. After the fragment of the greater tuberosity was identified, the number of fragments, the relative fragment volume to the humeral head, and the relative bone density to the coracoid process were calculated. Measurements were compared between matched case-control groups. RESULTS: We found that an unreduced greater tuberosity (odds ratio [OR], 10.9; P < .001), inadequate medial support at the calcar (OR, 15.0; P < .001), and the use of an intramedullary fibular strut (OR, 4.5; P = .018) were independently associated with a higher risk of bone resorption. Quantitative fragment-specific analysis showed that greater tuberosities with a larger number of fragments (5 ± 2 vs. 3 ± 2, P = .021), smaller fragments (9.9% ± 3.8% vs. 18.6% ± 4.7%, P < .001), and fragments with a lower bone density (66.4% ± 14.3% vs. 88.0% ± 18.4%, P = .001) had higher rates of resorption. DISCUSSION AND CONCLUSION: An unreduced greater tuberosity or inadequate medial support increases the risk of greater tuberosity resorption, as do a larger number of fracture fragments, smaller fragments, and lower bone density. Additionally, fibular strut grafting is an independent risk factor for tuberosity resorption. Further study is needed, but alternatives to strut grafting such as femoral head allograft may warrant serious consideration.

Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation.

BACKGROUND: Active treatment (targeted muscle reinnervation [TMR] or regenerative peripheral nerve interfaces [RPNIs]) of the amputated nerve ends has gained momentum to mitigate neuropathic pain following amputation. Therefore, the aim of this study is to determine the predictors for the development of neuropathic pain after major upper extremity amputation. METHODS: Retrospectively, 142 adult patients who underwent 148 amputations of the upper extremity between 2000 and 2019 were identified through medical chart review. All upper extremity amputations proximal to the metacarpophalangeal joints were included. Patients with a follow-up of less than 6 months and those who underwent TMR or RPNI at the time of amputation were excluded. Neuropathic pain was defined as phantom limb pain or a symptomatic neuroma reported in the medical charts at 6 months postoperatively. Most common indications for amputation were oncology (n = 53, 37%) and trauma (n = 45, 32%), with transhumeral amputations (n = 44, 30%) and shoulder amputations (n = 37, 25%) being the most prevalent. RESULTS: Neuropathic pain occurred in 42% of patients, of which 48 (32%) had phantom limb pain, 8 (5.4%) had a symptomatic neuroma, and 6 (4.1%) had a combination of both. In multivariable analysis, traumatic amputations (odds ratio [OR]: 4.1, p = 0.015), transhumeral amputations (OR: 3.9, p = 0.024), and forequarter amputations (OR: 8.4, p = 0.003) were independently associated with the development of neuropathic pain. CONCLUSION: In patients with an upper extremity amputation proximal to the elbow or for trauma, there is an increased risk of developing neuropathic pain. In these patients, primary TMR/RPNI should be considered and this warrants a multidisciplinary approach involving general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.

What Factors Are Associated With Response Rates for Long-term Follow-up Questionnaire Studies in Hand Surgery?

BACKGROUND: Long-term follow-up studies are an important tool in the evaluation of orthopaedic illness and its treatment options. However, a patient's participation in a follow-up study may be affected by several factors, leading to variability in response rates and the risk of selection bias. QUESTIONS/PURPOSES: (1) What is the average response rate in hand surgery questionnaire studies? (2) What factors are associated with higher and lower response rates to research questionnaires? (3) What factors are associated with higher and lower contact, initial participation, and completion rates? METHODS: We included 798 adult patients who were enrolled in one of 12 questionnaire follow-up studies in the hand and upper extremity service of our institution. All included studies evaluated patient-reported outcomes for the surgical treatment of upper extremity conditions using questionnaires and all used the same enrollment design. Patients were invited by letter to ask if they would be willing to participate, and we informed them that they would be contacted by telephone at least three times if they did not respond to the letter. Patients were contacted at a median of 6.6 years (interquartile range [IQR] 3.7 to 11) after surgery. The successful response rate was 49% (390 of 798 patients). We manually reviewed records to collect data on patient characteristics, and we performed bivariate analysis and multivariable logistic regression analysis to identify factors associated with the contact rate (percentage of patients reached by either mail, phone, or email), initial response rate (percentage of reached patients who initiated participation), completion rate (percentage of patients who initiated participation and completed the entire follow-up questionnaire), and our primary outcome successful response rate (percentage of patients who were contacted and who completed the entire questionnaire). RESULTS: The average response rate in hand surgery questionnaire studies was 49% (390 of 798 patients). In the multivariable analysis, enrollment of women (odds ratio 1.43 [95% confidence interval 1.03 to 1.97]; p = 0.031) was independently associated with higher response rates. On the contrary, a longer follow-up time from surgery (OR 0.95; 95% CI 0.92 to 0.99]; p = 0.015) and multiple researchers contacting patients (OR 0.51 [95% CI 0.37 to 0.71]; p < 0.001) were independently associated with lower response rates. The contact rate was higher for women (OR 1.46 [95% CI 1.03 to 2.06]; p = 0.034) and patients with higher income (OR 1.000007 [95% CI 1.000001 to 1.000013]; p = 0.019). The contact rate was lower in patients with a longer follow-up time from surgery (OR 0.93 [95% CI 0.90 to 0.97]; p = 0.001). The initial participation rate was lower when patients were contacted by multiple researchers (OR: 0.34 [95% CI 0.23 to 0.52]; p < 0.001). Studies with a lower number of questions (36; IQR 22 to 46) were completed more frequently than studies with a higher number of questions (51; IQR 39 to 67; p = 0.044). CONCLUSIONS: Studies assessing long-term outcomes that have a large proportion of men and longer follow-up time tend to have lower response rates. When performing a follow-up study, it seems beneficial to have one researcher contact the patients and use a shorter questionnaire. Results of this study can help clarify the response rates in hand surgery follow-up questionnaire studies and help with the planning of future follow-up studies. LEVEL OF EVIDENCE: Level II, prognostic study.

PROMIS Function Scores Are Lower in Patients Who Underwent More Aggressive Local Treatment for Desmoid Tumors.

BACKGROUND: Desmoid tumors of the extremities often present with pain and functional limitation, but treatment can lead to morbidity and recurrence is common. The impact of treatment with respect to traditional "oncologic" metrics (such as recurrence rate) has been studied extensively, with a shift in recent years away from local therapies as first-line management; however, little is known about the association between treatment modality and long-term functional outcomes for patients with this benign disease. QUESTIONS/PURPOSES: In a retrospective review of consecutive patients treated at two institutions, we asked: (1) Is event-free survival (EFS) different between patients who undergo local treatment and those who do not for primary as well as for recurrent desmoid tumors? (2) What treatment-related factors are associated with worse Patient-reported Outcomes Measurement Information System (PROMIS) function scores at a minimum of 1 year after treatment? METHODS: Between 1991 and 2017, 102 patients with desmoid tumors of the extremities (excluding those of the hands and feet) were treated at two institutions; of those, 85 patients with 90 tumors were followed clinically for at least 1 year (median [range] 59 months follow-up [12 to 293]) and were included in the present analysis. We attempted to contact all patients for administration of PROMIS function (Physical Function Short Form [SF] 10a and Upper Extremity SF v2.0 7a) and Pain Interference (SF 8a) questionnaires. Complete survey data (minimum 1 year follow-up) were available for 46% (39 of 102) of patients with 40 tumors at a median of 125 months follow-up; only these patients were included in PROMIS data analyses. Though there was no formal institutional treatment algorithm in place during the study period, surgical resection typically was the preferred modality for primary tumors; radiation therapy and systemic treatments (including cytotoxic or hormonal agents earlier in the study period, and tyrosine kinase inhibitors later) were often added for recurrent or very symptomatic disease. We coded treatment for each patient into discrete episodes, each defined by a particular treatment strategy: local treatment only (surgery and/or radiation), systemic treatment only, local plus systemic treatment, or observation; treatment episodes rendered at other institutions (that is, before referral) were not included in the analyses. Treatment failure was defined as recurrence after surgical resection, or clinically significant radiologic and/or symptomatic progression after systemic treatment, and EFS was defined as time from treatment initiation to treatment failure or final follow-up. Episodes of treatment for recurrent tumors were analyzed in a pooled fashion, wherein discrete treatment episodes for patients with multiple recurrences were included separately as independent events. We analyzed 56 primary tumors (54 patients), and 101 discrete treatment episodes for recurrent tumors (88 patients). Kaplan-Meier survival curves were constructed separately for the primary and recurrence cohorts, both comparing EFS among patients who received any local treatment (local treatment and local plus systemic treatment groups) versus those who did not (systemic treatment and observation groups). PROMIS function data were analyzed on the bases of patient- and treatment-specific variables, including the PROMIS Pain Interference score as a potential explanatory variable. RESULTS: Within both the primary and recurrence cohorts, there were no differences between the local treatment, systemic treatment, and local plus systemic treatment groups with respect to gender, age, axillary/hip girdle location, or tumor volume. Among primary tumors, 5-year EFS was 44% (95% CI 24 to 80) for the systemic-only group versus 15% (95% CI 5 to 44) for the local treatment group (p = 0.087). Within the pooled recurrence treatment episode cohort, 5-year EFS after systemic-only treatment was 70% (95% CI 52 to 94) versus 56% among patients receiving any local treatment (95% CI 44 to 70; p = 0.46). PROMIS function scores were lowest among patients who underwent two or more resections (39 versus 51 versus 47 for ≥2, 1, and 0 resections, respectively; p = 0.025); among those who received both surgery and radiation at any point, either concurrently or in separate treatment episodes, as compared with those who did not (39 versus 46; p = 0.047); and among those with higher levels of pain interference (38 versus 47 for pain interference scores > 50 versus < 50; p = 0.006). CONCLUSIONS: Patients treated with local modalities (surgery and/or radiation, with or without additional systemic therapy) did not experience improved EFS as compared with those treated without local modalities; this was the case for both the primary and the recurrent tumor cohorts. However, PROMIS function scores were lowest among patients who underwent two or more surgical interventions and among those treated with surgery and radiation at any time, suggesting that more aggressive local treatment may be associated with poorer long-term functional outcomes. Prospective collection of patient-reported outcomes data at multiple time points will allow for more direct correlations between treatment modality and impact on function and will help to elucidate the ideal management strategy for these benign but often-symptomatic tumors. LEVEL OF EVIDENCE: Level III, therapeutic study.

Factors Associated With Reoperation and Conversion to Wrist Fusion After Proximal Row Carpectomy or 4-Corner Arthrodesis.

PURPOSE: Proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA) are common salvage procedures for the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse. This study aimed to assess rates of reoperation and conversion to wrist fusion and to assess the factors associated with reoperation and conversion to wrist fusion for patients treated with PRC and FCA. METHODS: A retrospective chart review was performed evaluating 266 adult patients undergoing PRC or FCA at a single institutional system from 2002 to 2016. Demographic data, patient- and injury-specific data, reoperation and conversion rates, and complications were collected. Potential factors associated with reoperation or wrist fusion were evaluated using a bivariate, followed by a multivariable, analysis. RESULTS: Reoperation was more commonly performed in FCA (34%) than in PRC (11%) (odds ratio [OR], 3.4; 95% confidence interval [95% CI], 1.7-6.8) and occurred at a shorter postoperative interval. In a multivariable analysis for reoperation, manual labor was associated with reoperation in patients undergoing FCA (OR, 5.4; 95% CI, 1.5-19.1). In those undergoing PRC, anterior interosseous nerve (AIN) and/or posterior interosseous nerve (PIN) neurectomy was associated with a lower rate of reoperation (OR, 0.18; 95% CI, 0.06-0.57). In a multivariable analysis for conversion to wrist arthrodesis, intraoperative AIN and/or PIN neurectomy (OR, 0.18; 95% CI, 0.06-0.57) was associated with a lower rate of conversion to wrist fusion, and smoking (OR, 4.9; 95% CI, 1.8-13.5) was associated with a higher rate of conversion to wrist fusion. In the subanalysis of patients who underwent PRC, only AIN and/or PIN neurectomy was associated with lower rates of conversion to wrist arthrodesis (OR, 0.15; 95% CI, 0.04-0.56). CONCLUSIONS: In our cohort, we observed that AIN and/or PIN neurectomy reduced the risk of reoperation and conversion to wrist arthrodesis after PRC. Smoking increased the odds of conversion to wrist arthrodesis in the combined PRC/FCA cohort; however, it is unclear whether this was due to smoking itself or whether the indications for PRC or FCA were affected, leading to this result. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Giant Cell Tumors of the Upper Extremity: Predictors of Recurrence.

PURPOSE: Giant cell tumors (GCT) of the distal radius are thought to be more aggressive than in other locations. Therefore, the aim of this study was to investigate factors associated with recurrence of GCTs in the upper extremity. METHODS: We retrospectively identified 82 patients who underwent primary surgical treatment for an upper extremity GCT. Tumors were located in the radius (n = 47), humerus (n = 17), ulna (n = 9), and hand (n = 9). Treatment consisted of either wide resection or amputation or intralesional resection with or without adjuvants. A multivariable logistic regression was performed including tumor grade, type of surgery, and tumor location, from which the percentage of contribution to the model of each variable was calculated. RESULTS: The recurrence rate after intralesional resection was 48%; after wide resection or amputation, it was 12%. Two patients developed a pulmonary metastasis (2.4%). In multivariable analysis, intralesional resection was independently associated with recurrence. Intralesional resection had a 77% contribution to predict recurrence and the distal radius location had a 16% contribution in the predictive model. CONCLUSIONS: As expected, intralesional resection was the strongest independent predictor of recurrence after surgical treatment for GCT. The distal radius location contributed to the prediction of giant cell tumor recurrence to a lesser extent. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review.

BACKGROUND: Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. METHODS: A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. RESULTS: A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. CONCLUSION: Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

Is malnutrition associated with postoperative complications in patients with primary bone sarcomas?

BACKGROUND: Modifiable risk factors that can be optimized to minimize postoperative complications in patients with bone sarcomas are yet to be identified. METHODS: We retrospectively identified 275 patients aged 18 and older who underwent surgery for primary bone sarcomas who also had albumin values recorded within 4 weeks before surgery. Postoperative complications were defined as infection, hematoma, need for additional surgery, or wound complications. RESULTS: In the multivariate analysis, age (P = 0.049) and neoadjuvant radiotherapy (P = 0.008) were independently associated with postoperative complications. We then performed a subanalysis of patients without a pelvic tumor who also did not receive radiotherapy (n = 178). In this population, albumin less than 2.8 g/dL was found to be independently associated with postoperative complications (odds ratio [OR], 4.69. 95% confidence intervals [CI], 1.03-21.97; P = 0.046). CONCLUSIONS: This study demonstrates that hypoalbuminemia (albumin < 2.8 g/dL) is associated with postoperative complications in patients with nonpelvic bone sarcomas who do not receive radiation. Future studies are necessary to further elucidate the role of nutrition, and they may show that nutritional status is a modifiable risk factor that can be optimized to improve the outcome of surgery for primary bone sarcomas.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury.

BACKGROUND: Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking. QUESTIONS/PURPOSES: (1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures? METHODS: Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made. RESULTS: Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138). CONCLUSIONS: Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery. LEVEL OF EVIDENCE: Level III, diagnostic study.