Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation.

PURPOSE: To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures. METHODS: A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated. RESULTS: There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation. CONCLUSIONS: Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Reevaluation of the Scaphoid Fracture: What Is the Current Best Evidence?

Scaphoid fractures are common and notorious for their troublesome healing. The aim of this review is to reevaluate the current best evidence for the diagnosis, classification, and treatment of scaphoid fractures and nonunions. MRI and CT are used to establish a "definitive diagnosis" with comparable diagnostic accuracy although neither is 100% specific. Current classifications cannot reliably predict union or outcomes; hence, a descriptive analysis of fracture location, type, and extent of displacement remains most useful. Treatment of a nondisplaced scaphoid waist fracture remains an individualized decision based on shared decision-making. Open reduction and internal fixation may be preferred when fracture displacement exceeds 1 mm, and the fracture is irreducible by closed or percutaneous means. For unstable nonunions with carpal instability, either non-vascularized cancellous graft with stable internal fixation or corticocancellous wedge grafts will provide a high rate of union and restoration of carpal alignment. For nonunions characterized with osteonecrosis of the proximal pole, vascularized bone grafting can achieve a higher rate of union.

Survival and Long-Term Outcomes of Thumb Metacarpal Extension Osteotomy for Symptomatic Carpometacarpal Laxity and Early Basal Joint Arthritis.

PURPOSE: To evaluate the survival and long-term outcomes of thumb metacarpal extension osteotomy for early carpometacarpal (CMC) arthritis. METHODS: Patients who underwent a thumb extension osteotomy between years 2000 and 2011 were identified. Patient demographics, complications, and reoperations were recorded. The Kaplan-Meier survival analysis was used with subsequent CMC surgery defined as failure. Patients who had undergone surgery 10 years or more before the study date underwent radiographic assessment, grip and pinch strength testing, and completed the Patient Rated Wrist/Hand Evaluation (PRWHE) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires. RESULTS: Thirty-two procedures in 7 males and 21 females were performed (mean age, 44.8 y). There were no cases of nonunion. Nine of 32 thumbs developed pin site erythema and were treated with oral antibiotics. Two thumbs developed osteomyelitis. Seven of 32 thumbs (22%) required reoperation. The Kaplan-Meier analysis indicated a 70% probability that patients who have this procedure will not require additional CMC surgery up to 14 years. Seven patients with a mean follow-up of 12.3 years (minimum 10 y) returned for clinical evaluation. The mean PRWHE and QuickDASH scores were 32.1 and 27.7, respectively. Examination revealed 124% pinch and 98% grip strength relative to the preoperative values. One thumb did not progress from stage II disease; 2 thumbs progressed from stage I to stage II; 1 thumb progressed from stage II to stage III; 1 thumb progressed from stage II to stage IV; 1 thumb did not have disease progression at the CMC joint, but developed scaphotrapeziotrapezoidal arthritis. CONCLUSIONS: Although reoperation rates and superficial infections with the described method of fixation were relatively high, thumb metacarpal osteotomy provides some degree of pain relief and improvement of function. This procedure may have utility as a temporizing measure in younger patients as it does not compromise future reconstructive procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Distal radius volar locking plate design and associated vulnerability of the flexor pollicis longus.

PURPOSE: Flexor pollicis longus (FPL) tendon rupture is a well-documented complication related to the use of distal radius volar locking plates (VLPs). The final common pathway of flexor tendon rupture appears to involve implants prominent at the watershed line. We hypothesized that significant differences in VLP prominence exist between various plate designs. METHODS: Ten fresh frozen specimens were dissected to identify the path of the FPL in relationship to the distal radius at the watershed line. Five VLP designs were fixed to each specimen based on their anatomic fit, and slid distally until the distal edge of the plate reached the watershed line. The position of each fixed plate was evaluated by fluoroscopy. We used a 3-dimensional laser scanner to create computer models. The total surface area of plate prominence volar to the watershed line and the prominent area beneath the FPL were measured in the axial plane using computer software. RESULTS: At the watershed line, the FPL was located at 54% of the maximal width of the radius, as measured from its volar-ulnar corner. There were no significant differences in the location of plate fixation on lateral view radiographs according to the classification of Soong et al. The mean total surface area of plate prominence was 36 mm(2). The mean prominent area beneath the FPL was 10 mm2. Significant differences in plate prominence were noted for various designs. CONCLUSIONS: Despite optimal plate placement, various VLP designs were observed to have prominent profiles volar to the watershed line, to varying extents. CLINICAL RELEVANCE: The results raise concerns regarding interference between all of the analyzed VLP designs and the FPL. This study may help guide both implant design considerations and assist the surgeon in better understanding implant morphology as it relates to iatrogenic flexor tendon injury.

Little finger carpometacarpal arthroplasty technique and result in 3 cases.

PURPOSE: To present our surgical technique and results for the treatment of posttraumatic arthritis of the little finger carpometacarpal (CMC) joint. METHODS: We performed a retrospective review of 3 patients who underwent our surgical technique. All patients had previously sustained intra-articular fractures of the base of the little finger metacarpal and presented with painful posttraumatic arthritis of the fifth metacarpal-hamate joint. Patients were treated with little finger CMC arthroplasty and extensor carpi ulnaris suspensionplasty. RESULTS: We observed the 3 patients in the office over a mean of 21 months and by telephone for a mean for 51 months postoperatively. They had improvements in wrist motion and grip strength. Finger motion remained stable. Pain and tenderness at the little finger CMC joint were eliminated. CONCLUSIONS: Our technique provided satisfactory pain relief and motion preservation for posttraumatic arthritis of the little finger CMC joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Thumb-Sparing Surgery for Digital Papillary Adenocarcinoma: A Case Report.

Digital papillary adenocarcinoma (DPA) is a rare eccrine sweat gland tumor that often appears as a solitary, non-painful, gradually enlarging mass. Clinically, DPA presents considerable challenges due to its high likelihood of recurrence and its tendency to spread to the lymph nodes and lungs. This case report focuses on the surgical treatment of a unique case of DPA located on the dorsal thumb in a 46-year-old male. The patient initially underwent wide local excision with temporary wound coverage, and once final histopathological findings confirmed negative margins, a second procedure consisting of thumb interphalangeal joint fusion and first dorsal metacarpal artery flap coverage was performed. Eighteen months later, the patient continued to work in landscaping, performing the physically demanding tasks required by the job. This case demonstrates the feasibility of thumb preservation in the setting of soft tissue malignancy once negative margins are obtained.

Triceps brachii insertional footprint: Under-estimated complexity.

Background: The detailed complexity of triceps brachii insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures. The purpose of this study is to describe the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow. Methods: 22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. The insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described. Results: The mean width and surface area of the lateral segment was greater in males than in females (30.07 mm vs. 24.37 mm, p = 0.0339 and 282.1 mm vs. 211. 56 mm, p = 0.0181, respectively). No other statistically significant differences between the sexes were noted. The triceps insertional footprint was "crescent-shaped" and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension. Discussion: These findings can help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies. Clinical Relevance: Basic Science, anatomy study, cadaver dissection.

A quality and readability comparison of artificial intelligence and popular health website education materials for common hand surgery procedures.

INTRODUCTION: ChatGPT and its application in producing patient education materials for orthopedic hand disorders has not been extensively studied. This study evaluated the quality and readability of educational information pertaining to common hand surgeries from patient education websites and information produced by ChatGPT. METHODS: Patient education information for four hand surgeries (carpal tunnel release, trigger finger release, Dupuytren's contracture, and ganglion cyst surgery) was extracted from ChatGPT (at a scientific and fourth-grade reading level), WebMD, and Mayo Clinic. In a blinded and randomized fashion, five fellowship-trained orthopaedic hand surgeons evaluated the quality of information using a modified DISCERN criteria. Readability and reading grade level were assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) equations. RESULTS: The Mayo Clinic website scored higher in terms of quality for carpal tunnel release information (p = 0.004). WebMD scored higher for Dupuytren's contracture release (p < 0.001), ganglion cyst surgery (p = 0.003), and overall quality (p < 0.001). ChatGPT - 4th Grade Reading Level, ChatGPT - Scientific Reading Level, WebMD, and Mayo Clinic written materials on average exceeded recommended reading grade levels (4th-6th grade) by at least four grade levels (10th, 14th, 13th, and 11th grade, respectively). CONCLUSIONS: ChatGPT provides inferior education materials compared to patient-friendly websites. When prompted to provide more easily read materials, ChatGPT generates less robust information compared to patient-friendly websites and does not adequately simplify the educational information. ChatGPT has potential to improve the quality and readability of patient education materials but currently, patient-friendly websites provide superior quality at similar reading comprehension levels.

The effect of a therapy protocol for increasing correction of severely contracted proximal interphalangeal joints caused by dupuytren disease and treated with collagenase injection.

PURPOSE: To determine the effect of a specific orthotic intervention and therapy protocol on proximal interphalangeal (PIP) joint contractures of greater than 40° caused by Dupuytren disease and treated with collagenase injections. METHODS: All patients with PIP joints contracted at least 40° by Dupuytren disease were prospectively invited to participate in the study. Following standard collagenase injection and cord rupture by a hand surgeon, a certified hand therapist evaluated and treated each patient based on a defined treatment protocol that consisted of orthotic intervention to address residual PIP joint contracture. In addition, exercises were initiated emphasizing reverse blocking for PIP joint extension and distal interphalangeal joint flexion exercises with the PIP joint held in extension to lengthen a frequently shortened oblique retinacular ligament. Patients were assessed before injection, immediately after injection, and 1 and 4 weeks later. There were 22 fingers in 21 patients. The mean age at treatment was 63 years (range, 37-80 y). RESULTS: The mean baseline passive PIP joint contracture was 56° (range, 40° to 80°). At cord rupture, the mean PIP joint contracture became 22° (range, 0° to 55°). One week after cord rupture and therapy, the contracture decreased further to a mean of 12° (range, 0° to 36°). By 4 weeks, the mean contracture was 7° (range, 0° to 35°). The differences in PIP joint contracture were statistically significant at all time points except when comparing the means at 1 week and 4 weeks. The results represent an 88% improvement of the PIP joint contracture. CONCLUSIONS: In the short term, it appears that severe PIP joint contractures benefit from specific, postinjection orthotic intervention and targeted exercises. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Complications following one-bone forearm surgery for posttraumatic forearm and distal radioulnar joint instability.

PURPOSE: To present the outcomes after one-bone forearm (OBF) surgery for chronic posttraumatic forearm and distal radioulnar joint instability. METHODS: We conducted a retrospective chart review to study patients who underwent OBF surgery because of a traumatic etiology. We collected patient demographics, surgical technique, preoperative and postoperative range of motion, final grip strength, and complications from the medical records. Patients were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, a 0- to 10-point pain scale, and a 0- to 10-point treatment satisfaction scale. RESULTS: There were 5 male and 5 female patients, with a mean age of 32 years at the time of OBF surgery (range, 17-44 y). The mean number of procedures before OBF surgery was 3.6 (range, 2-7); 4 patients had undergone a Darrach procedure and 3 patients had undergone a Sauvé-Kapandji procedure. The median clinical follow-up duration was 6 years (range, 1-17 y). Wrist and elbow range of motion did not change remarkably before and after surgery. Of 8 primary OBF surgeries, 3 resulted in nonunion. Of 10 patients, 4 experienced painful impingement of the remaining proximal radius on adjacent bone and soft tissue and required a total of 7 procedures after OBF surgery. The median follow-up duration for patient-rated outcomes was 10 years (range, 5-21 y; n = 7). The median Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 77, the median pain score was 7, and the median satisfaction score was 7. CONCLUSIONS: In our experience, complications after OBF surgery are common. Although wrist and elbow range of motion were spared, pain persisted and functional outcomes were poor. One-bone forearm surgery is our last resort for a chronically painful and unstable forearm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clavicle morphometry revisited: a 3-dimensional study with relevance to operative fixation.

BACKGROUND: The advocacy for operative fixation of midshaft clavicle fractures has prompted a reemergence of interest in clavicle anatomy. Three-dimensional (3D) anatomical studies provide more information than 2-dimensional studies, but are currently rare. MATERIAL AND METHODS: Twenty-five skeletonized clavicles were digitized using a laser scanner. Three-dimensional computer software was used to analyze the data. Clavicles were divided into medial, middle, and lateral segments based on the medial and lateral apices of curvature and their lengths and midpoint cortical diameter measured. The angles of medial and lateral curvatures were measured in standardized axial and coronal planes. The medial and lateral curvatures were fitted with circles and the radii of curvature measured. Correlations between the intrinsic dimensions of the clavicle were assessed. RESULTS: The mean length was 136.7 mm. The medial, middle, and lateral segments had mean lengths of 48, 56, and 32.7 mm, respectively. In the axial plane, the mean medial and lateral angles were 149.5° and 145.8°, respectively. In the coronal plane, the mean medial and lateral angles were 178.2° and 174.2°, respectively. The mean midpoint cortical diameter was 10.9 mm. The mean medial and lateral radii of curvature were 66.4 and 33.5 mm, respectively. The length and cortical diameter and length and medial radius of curvature were found to positively correlate, R(2) = .355 and .184, respectively. CONCLUSION: Using standardized measurements, we were able to accurately characterize the dimensions of the clavicle. We found that the length of the clavicle correlates with the midpoint cortical diameter and with the radius of medial curvature.

Analysis of age-related degenerative changes of the biceps brachii distal footprint.

The purpose of this study is to qualitatively and quantitatively describe the morphology of the biceps insertion on the radial tuberosity. Twenty-four preserved human elbows were carefully dissected and the insertions of the biceps conserved. The radius and the shape of the biceps insertion on the radial tuberosity were computerized using a three-dimensional digitizer. The length, width, and surface area of the footprints were measured. The soft tissue status of the muscle insertions and shape of the footprints were qualitatively described. The mean length of the biceps footprint was 24.1 ± 2.4 mm, the mean width was 11.1 ± 2.6 mm, and the mean area of the footprint was 219.0 ± 60.2 mm(2). Avascular, degenerate tissue fibers, consistent with tissue fibrosis were observed in 46% of the specimens. These changes may demonstrate natural changes of the distal biceps tendon and may improve our understanding of biceps tendinopathy and its prevalence.

Predatory Journals in Orthopaedic Surgery.

The prevalence of predatory journals in orthopaedic surgery continues to increase. These journals directly solicit authors, offering the advantages of open access and quick publication rates. Solicitation typically occurs in the form of e-mail communications, and the targets are usually identified as authors who have published other works in conventional publications. These predatory journals process manuscripts without peer review and plagiarism checks and often for a substantial publication fee. As a result, the scientific value of these publications is grossly suspect and has been considered a substantial threat to the quality of scientific discourse and scholarship. This affects not only the layperson reading the works but also investigators tricked into publishing in these venues. It has been estimated that several million US dollars per year are spent on these publications and, in many instances, using monies granted by agencies such as the National Institutes of Health. This review aims to study the types of solicitation, evaluate the increasing prevalence in orthopaedic surgery, and offer methods to authors and readers to identify these journals to mitigate their negative effects.

Three-Dimensional Analysis of Metacarpal Head Articular Defects Created by Headless Screws.

Objectives: Headless screw fixation used to treat metacarpal neck and metacarpal shaft fractures is gaining popularity. The aim of the study is to determine the proportion of the metacarpal head articular surface that is compromised during retrograde insertion of headless screws. Methods: Metacarpal screw fixation through a metacarpal head starting point was performed using fluoroscopic guidance on 14 metacarpals. Headless compression screws, with a tail diameter of 3.6mm, were used. The specimens were subsequently skeletonized and digitized using a 3-dimensional surface scanner. The articular surface defects created by the screws were then determined using computer software. Screw position in the dorsal aspect of the metacarpal head was expressed as a percentage of the total volar-to-dorsal distance. Results: The 14 metacarpals studied consisted of 2 index, 4 long, 4 ring and 4 small metacarpals, taken from 4 hands. The average total metacarpal head surface area was 284.6 mm2 (range, 151.0-462.2 mm2); the average screw footprint in the metacarpal head was 13.3 mm2 (range, 10.3-17.4 mm2), which compromised a mean of 5.0% (3.0-7.8%) of the total cartilaginous metacarpal head surface area. In the sagittal plane, screw placement was found to lie in the dorsal 37.4% of the metacarpal head (range, 20.7-58.6%). Conclusion: The proportion of the articular surface area injured with retrograde insertion of headless compression screws into the metacarpal head is 5.0%. Screw placement is generally in the dorsal 37% of the metacarpal head.

Clavicle anatomy and the applicability of intramedullary midshaft fracture fixation.

BACKGROUND: This study investigated the morphologic safety and applicability of intramedullary fixation of midshaft clavicle fractures by analyzing the pertinent clavicle anatomy using 3-dimensional computer simulation. MATERIALS AND METHODS: Computed tomography was used to scan 22 skeletonized clavicles. Computer software was used to simulate middle-segment fracture fixation by fitting a cylindrical corridor within the clavicle in the area that intramedullary devices normally cross during surgery. The cylindrical corridor crossed the fracture line on both sides, and the number of cortical diameters that were bypassed was recorded. We assumed that 1 to 2 cortical diameters had to be bypassed to achieve adequate fixation. The medial and lateral exit points of the cylindrical corridor were measured and described in relation to the sternoclavicular and acromioclavicular ends respectively. RESULTS: Simulation revealed that 15 of 22 clavicles could be bypassed by 2 cortical diameters on either side of the midline fracture, 6 clavicles could be bypassed by 1 cortical diameter medial to the fracture line, and 1 clavicle could not be bypassed by any cortical diameters medial to the fracture line. The medial exit point of the cylindrical corridor was anterior in 20 of 22 cases and an average of 44.2 mm lateral to the sternoclavicular end. The lateral exit point of the cylindrical corridor was posterosuperior in 16 of 22 cases and an average of 26.5 mm medial to the acromioclavicular end. CONCLUSION: In most clavicles, straight intramedullary fixation appears to be a morphologically safe and effective method of fixation.

Infirmity and injury complexity are risk factors for surgical-site infection after operative fracture care.

BACKGROUND: Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear. QUESTIONS/PURPOSE: We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery. PATIENTS AND METHODS: We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI. RESULTS: Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3-3.8); (2) number of operations OR 3.4, 95% CI (2.0-6.0); (3) diabetes, OR 2.1, 95% CI (1.2-3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3-6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3-4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1-4.7). CONCLUSION: The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain). LEVEL OF EVIDENCE: Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence.

Fingertip Injuries in Athletes, Musicians, and Other Special Cases.

Management of fingertip injuries in athletes is optimized by consideration of the sport, the playing position, the timing within the season, the level of competition, and the patient's goals. Mallet and jersey fingers are common injuries in athletes and may be treated in several different ways, based on the nature of the injury and the timing of presentation, as well as the athlete's demands. Management of fingertip injuries in musicians is optimized by consideration of how the musician handles his or her instrument and the specific requirements of the injured digit in the context of musical performance.

Mycobacterial Infections in the Hand and Wrist.

Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical débridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease.

Emerging Technologies in Distal Radius Fracture Fixation.

PURPOSE OF REVIEW: To provide an overview of emerging fixation constructs and materials used in the operative management of distal radius fractures. RECENT FINDINGS: The indications, advantages, and disadvantages of relatively new implants and devices used to treat distal radius fractures are discussed. These include the intramedullary nail, intramedullary cage, radiolucent volar locking plate, distal radius hemiarthroplasty, and bone graft substitutes. The spectrum of distal radius fracture patterns may make it impossible to depend on a single device for fixation, and surgeons managing distal radius fractures should be adept at using various surgical approaches, techniques, and hardware systems. Additional studies demonstrating the cost-effectiveness, biomechanical properties, and clinical outcomes will be useful in determining the utility of the described techniques.

A review of mallet finger and jersey finger injuries in the athlete.

PURPOSE OF REVIEW: The purposes of this review are to discuss the diagnosis and management of mallet and jersey finger injuries in athletes and to highlight how treatment impacts return to play. RECENT FINDINGS: Mallet finger: although numerous non-operative and operative techniques have been described, there continues to be little consensus regarding the optimal procedure. Jersey finger: ultrasound appears to be a cost-effective imaging modality that may be useful for preoperative planning. Wide-awake surgery offers optimal intraoperative assessment of the tendon repair. Tendon repair with volar plate augmentation has been shown to improve the strength of the repair in the laboratory, and early clinical results are encouraging. Most mallet finger injuries will heal with non-operative treatment over a period of 8-12 weeks, even when treatment is delayed up to 3-4 months. An acute diagnosis of jersey finger requires surgical treatment and generally means 8-12 weeks of inability to compete in most contact sports.