E2F5 Targeted by Let-7d-5p Facilitates Cell Proliferation, Metastasis and Immune Escape in Gallbladder Cancer.

BACKGROUND: Gallbladder cancer (GBC) remains a serious cause of cancer-related mortality across the globe. E2F5 has been identified to as a known oncogene in various cancers. However, the special functions of E2F5 have not been investigated in GBC. AIMS: To explore the regulatory functions of E2F5 and its related molecular regulatory mechanism in GBC progression. METHODS: The expression of genes were examined through qRT-PCR, western blot and IHC assay. The cell proliferation was assessed through CCK-8 and EDU assays. The cytotoxicity was tested through LDH assay. The percentage of CD8+ T cells and cell apoptosis were evaluated through flow cytometry. The binding ability was detected through luciferase reporter assay. The tumor growth was assessed through in vivo assays. RESULTS: In this study, it was demonstrated that E2F5 expression was evaluated in GBC, and resulted into poor prognosis. Bioinformatics analysis revealed E2F5 as a target for let-7d-5p, which when overexpressed, suppressed the metastasis and proliferation of GBC through the downregulation of E2F5. It was discovered that E2F5 activates JAK2/STAT3 signaling which is suppressed by let-7d-5p, implicating this pathway as one of the effectors of the oncogenic effects of ESF5 in GBC. E2F5 had been confirmed to aggravate tumor growth in vivo. CONCLUSION: E2F5 targeted by let-7d-5p facilitated cell proliferation, metastasis and immune escape in GBC through the JAK2/STAT3 pathway.

Professionalism in Hand Surgery: Treating the Noncompliant Patient.

Every practicing hand surgeon has had the challenging experience of treating a patient who demonstrates difficulty with, or inability to comply with medical advice. Patient noncompliance can lead to not only poor patient outcomes but also deterioration in the therapeutic relationship, physician burnout, high cost of care, and medical-legal risk. The guiding principles in the ethical practice of medicine render it important to consider noncompliance as a potentially modifiable risk factor, and every attempt should be made to work with these noncompliant patients to achieve the best possible outcomes. Data suggest that noncompliance may be affected by socioeconomic status and race; many of these patients are among the vulnerable. However, in some instances, treatment options may warrant alteration or adjustment to reflect the noncompliance of the patient. Rarely, it may be reasonable for a physician to discharge a patient from care once any urgent problems have been managed. Ethical and responsible management of a noncompliant patient requires a thoughtful and measured approach.

The significance of subjective mechanical symptoms in rotator cuff pathology.

BACKGROUND: The presence of subjective mechanical symptoms, such as clicking or popping, is common in patients presenting for shoulder pain and dysfunction, with unclear clinical significance. The primary objective of this study was to assess whether subjective mechanical symptoms in the affected shoulder were associated with full-thickness rotator cuff tearing in a consecutive, prospective cohort of patients undergoing shoulder magnetic resonance imaging (MRI) for suspected rotator cuff pathology. METHODS: A prospective cohort study was performed of 100 consecutive patients with suspected rotator cuff tendinopathy and/or tearing who underwent shoulder MRI. The presence of subjective shoulder mechanical symptoms, including clicking or popping, was documented prior to MRI. Indications for MRI included weakness on isolated testing of rotator cuff muscle(s) or symptoms refractory to conservative treatment including at least a 6-week course of physical therapy. The primary outcome variable was the presence of full-thickness rotator cuff tearing; secondary outcome variables included any (full-thickness or partial-thickness) rotator cuff tearing and biceps long head subluxation. Radiographic parameters, including critical shoulder angle, Goutallier grade, tear retraction, and tear size were quantified. One patient was lost to follow-up, and 99 patients completed MRI imaging. RESULTS: In our cohort, 60% of patients reported subjective mechanical symptoms in the affected shoulder. Full-thickness rotator cuff tearing was identified in 42% of patients, any rotator cuff tearing in 69% of patients, and biceps long head subluxation in 14% of patients. Subjective mechanical symptoms were not associated with full-thickness rotator cuff tearing, any rotator cuff tearing, biceps long head subluxation, critical shoulder angle, Goutallier grade, tear size, or tear retraction. Older age was associated with full-thickness and any rotator cuff tearing. As a diagnostic test for full-thickness rotator cuff tearing, subjective shoulder mechanical symptoms has a sensitivity of 64%, a specificity of 44%, and Youden's index of 0.08, consistent with poor diagnostic accuracy. CONCLUSIONS: Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. Patients may be reassured that a sensation of clicking or popping alone does not necessarily entail structural shoulder derangement.

Musculoskeletal manifestations associated with transthyretin-mediated (ATTR) amyloidosis: a systematic review.

BACKGROUND: Hereditary and wild-type transthyretin-mediated (ATTRv and ATTRwt) amyloidoses result from the misfolding of transthyretin and aggregation of amyloid plaques in multiple organ systems. Diagnosis of ATTR amyloidosis is often delayed due to its heterogenous and non-specific presentation. This review investigates the association of musculoskeletal (MSK) manifestations with ATTR amyloidosis and the delay from the onset of these manifestations to the diagnosis of ATTR amyloidosis. METHODS: This systematic review utilized Medline and EMBASE databases. Search criteria were outlined using a pre-specified patient, intervention, comparator, outcome, time, study (PICOTS) criteria and included: amyloidosis, ATTR, and MSK manifestations. Publication quality was assessed utilizing Joanna Briggs Institute (JBI) critical appraisal checklists. The search initially identified 7,139 publications, 164 of which were included. PICOTS criteria led to the inclusion of epidemiology, clinical burden and practice, pathophysiology, and temporality of MSK manifestations associated with ATTR amyloidosis. 163 publications reported on ATTR amyloidosis and MSK manifestations, and 13 publications reported on the delay in ATTR amyloidosis diagnosis following the onset of MSK manifestations. RESULTS: The MSK manifestation most frequently associated with ATTR amyloidosis was carpal tunnel syndrome (CTS); spinal stenosis (SS) and osteoarthritis (OA), among others, were also identified. The exact prevalence of different MSK manifestations in patients with ATTR amyloidosis remains unclear, as a broad range of prevalence estimates were reported. Moreover, the reported prevalence of MSK manifestations showed no clear trend or distinction in association between ATTRv and ATTRwt amyloidosis. MSK manifestations precede the diagnosis of ATTR amyloidosis by years, and there was substantial variation in the reported delay to ATTR amyloidosis diagnosis. Reports do suggest a longer diagnostic delay in patients with ATTRv amyloidosis, with 2 to 12 years delay in ATTRv versus 1.3 to 1.9 years delay in ATTRwt amyloidosis. CONCLUSION: These findings suggest that orthopedic surgeons may play a role in the early diagnosis of and treatment referrals for ATTR amyloidosis. Detection of MSK manifestations may enable earlier diagnosis and administration of effective treatments before disease progression occurs.

Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score.

BACKGROUND: The aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF). MATERIALS AND METHODS: A retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle. RESULTS: Only the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96-1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1-1.15], p < 0.001; OR = 0.54, [95% CI, 0.3-0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%. CONCLUSION: Age and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.

Collagenase Treatment Versus Needle Fasciotomy for Single-Digit Dupuytren Contractures: A Meta-Analysis of Randomized Controlled Trials.

PURPOSE: The objective of this systematic review and meta-analysis was to synthesize the available randomized controlled trial data comparing needle fasciotomy and collagenase treatment for single-digit Dupuytren contractures with a minimum of 3-year follow-up and determine whether one treatment is superior regarding contracture correction and functional outcomes. METHODS: A systematic review and meta-analysis was conducted by searching four databases for randomized controlled trials investigating the single-digit treatment outcomes for Dupuytren contracture comparing collagenase treatment and needle fasciotomy with a minimum of 3-year follow-up. The risk of bias of included studies was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed using a random effects model in anticipation of unobserved heterogeneity. The primary outcome measure was contracture recurrence. Secondary outcome measures included final fixed flexion contracture (FFC), Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores, and Unité Rhumatologique des Affections de la Main (URAM) scores. RESULTS: After screening 264 articles, 4 randomized clinical trials were eligible for final inclusion. One trial had a high risk of bias, and two trials had some concern for bias. The final meta-analysis included 347 patients, 169 who underwent collagenase treatment and 178 who underwent needle fasciotomy. No significant differences were noted between the groups in contracture recurrence, FFC, and URAM scores. The pooled data showed a higher QuickDASH score in the collagenase treatment group compared with the needle fasciotomy group, but the observed difference was less than what would be expected to be clinically relevant. CONCLUSIONS: Needle fasciotomy and collagenase treatment have similar outcomes with regards to contracture recurrence, final FFC, QuickDASH scores, and URAM scores for the single-digit treatment for Dupuytren contracture at a minimum of 3-year follow-up. Relevant factors that may be considered during the shared decision-making process for treatment selection include surgeon and patient preferences, costs of treatment, and the disparate complication profiles of these two treatments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The Environmental Impact of Open Versus Endoscopic Carpal Tunnel Release.

PURPOSE: The environmental impact of common ambulatory hand surgeries has been an area of growing interest in recent years. There were 2 objectives of this study: (1) to quantify the carbon footprint of carpal tunnel surgery and its principal driving components; and (2) to compare the carbon footprints of open carpal tunnel release (oCTR) and endoscopic carpal tunnel release (eCTR). METHODS: We performed a life cycle assessment to quantify the environmental impacts of 2 surgical procedures: oCTR and eCTR. Patients were retrospectively identified by querying the Mass General Brigham institutional billing database. Fourteen oCTR procedures and 14 eCTR procedures in 28 patients were included in the life cycle assessment. The boundaries of the life cycle assessment were the start and end times of the procedures. The environmental impacts were estimated using the carbon footprint, expressed in the equivalent mass of carbon dioxide released into the atmosphere (kgCO2-eq). The facility-related, processing-related, solid waste-related, and total kgCO2-eq were calculated. RESULTS: The average carbon footprint of carpal tunnel release was 83.1 kgCO2-eq and was dominated by processing-related and facilities-related factors. The average carbon footprint of eCTR (106.5 kgCO2-eq) was significantly greater than that of oCTR (59.6 kgCO2-eq). CONCLUSIONS: Endoscopic carpal tunnel release leaves a greater carbon footprint than oCTR, and its environmental impact is dominated by facility-related and central processing-related factors. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses IV.

Utility of Routine Pathologic Examination for Fasciectomy for Dupuytren Contracture.

PURPOSE: The objective of this study was to examine the routine pathologic examination of surgical specimens obtained during fasciectomy for Dupuytren contracture. METHODS: A total of 376 consecutive patients who underwent surgical limited fasciectomy with the excised tissue sent for histopathologic evaluation were identified. Patients were excluded for miscoded procedures, cases where no tissue was sent for pathologic review, and excisions of nodules only. Repeat surgeries in the same patient during the study period were excluded. The rates of concordant, discrepant, and discordant diagnoses were reported. Discrepant diagnoses were defined as different clinical diagnosis and pathologic diagnosis that did not change clinical management. Discordant diagnoses were defined as a different clinical diagnosis and a pathologic diagnosis that altered the treatment plan. The reference standard for final clinical decision-making was the pathologic diagnosis. RESULTS: The prevalence of concordant diagnoses was 97.1% (365 of 376), of discrepant diagnoses was 2.9% (11 of 376), and there were no discordant diagnoses. Of 376 patients, 43 underwent previous surgical fasciectomy before the study surgery, and pathologic examination was obtained in 10 of these patients. All 10 patients had concordant diagnoses. CONCLUSIONS: Our results suggest that routine pathologic examination did not alter the future treatment plan for patients who underwent limited fasciectomy. Discrepant diagnoses were encountered infrequently, and rarely in the setting of revision fasciectomy. Discordant diagnoses did not occur. Given the cost associated with pathologic evaluation, this raises the question of whether routine pathologic evaluation is necessary for Dupuytren surgery, where the capability of the treating surgeon to make a clinical diagnosis accurately may render confirmatory pathologic assessment redundant. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Factors Associated With Implant Removal Following Plate-and-Screw Fixation of Isolated Metacarpal Fractures.

PURPOSE: The incidence of and associated risk factors for implant removal following the plate-and-screw fixation of metacarpal shaft fractures have not been well described. The primary objective of our study was to identify implant-related radiographic parameters associated with implant removal in patients treated with the plate-and-screw fixation of isolated, displaced metacarpal fractures at 2 years of follow-up. The secondary objective of our study was to identify patient-related factors associated with implant removal. METHODS: A retrospective study of all patients who underwent open treatment of a metacarpal fracture with a plate-and-screw construct from January 1, 2000, to April 30, 2019, at 2 level-1 trauma centers was conducted. After the application of exclusion criteria, we identified 138 patients with a single isolated metacarpal fracture of a nonthumb digit treated with open reduction and internal fixation using a plate-and-screw construct. Our study endpoint was the removal of the plate-and-screw construct or a minimum of 2 years of follow-up without the removal of the hardware. Twenty-three patients achieved our study endpoint as determined using their electronic medical records, and 58 additional patients were reached via telephone to confirm their implant removal status. A bivariate analysis was used to screen for factors associated with implant removal, and variables significant in the bivariate screen were included in a multivariable stepwise logistic regression model. RESULTS: Twenty-three out of 81 patients (28%) in our final cohort underwent implant removal by the final follow-up visit. In the logistic regression analysis, the distance between the plate and metacarpophalangeal joint, the distance between the plate and carpometacarpal joint, and active smoking were independently associated with implant removal. CONCLUSIONS: The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Patient-Perceived Outcomes of Recovery After Trigger Digit Release.

PURPOSE: Trigger finger release (TFR) is one of the most commonly performed hand surgeries; nevertheless, the time until patients subjectively feel recovered has not been well documented. The limited literature on patient perceptions of recovery after any type of surgery has described that patients and surgeons may have differing views on the time until full recovery. Our primary study question was to determine how long it takes for patients to subjectively feel fully recovered after TFR. METHODS: In this prospective study, patients who underwent isolated TFR completed questionnaires before surgery and at multiple time points following surgery until they reported full recovery. Patients completed visual analog scale (VAS) pain scores and QuickDASH (Disabilities of the Arm, Shoulder, and Hand) and were asked if they felt fully recovered at 4 weeks, 6 weeks, and 3, 6, 9, and 12 months. RESULTS: The average time to self-reported full recovery was 6.2 months (SD 2.6), and the median time to self-reported full recovery was 6 months (IQR 4 months). At 12 months, four out of 50 patients (8%) did not feel fully recovered. QuickDASH and VAS pain scores improved significantly from preoperative assessment to final follow-up. All patients reported improvement in both VAS pain scores and QuickDASH scores greater than the minimal clinically important difference between 6 weeks and 3 months after surgery. Higher preoperative VAS and QuickDASH scores were associated with failure to fully recover by 12 months after surgery. CONCLUSIONS: The length of time after surgery until patients felt fully recovered after isolated TFR is longer than the senior authors' expectations. This suggests that patients and surgeons may consider distinctly different parameters when discussing recovery. Surgeons should be aware of this discrepancy when discussing recovery after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Risk Factors for Failure of Nonsurgical Management of Ulnar Shaft Fractures.

PURPOSE: Isolated ulnar shaft fractures are frequently managed nonsurgically. However, rates of nonsurgical treatment failure remain substantial, and risk factors for the failure of nonsurgical management are not well described. This study investigated radiographic and patient-specific risk factors for the failure of nonsurgical management of isolated ulnar shaft fractures. METHODS: A retrospective review of patients with ulnar shaft fractures initially treated nonsurgically was performed at two tertiary referral centers over a 19-year period from 2001 to 2020. Patient- and injury-related variables, surgical interventions, and plain radiographic measurements were recorded. The outcome of interest was failure of nonsurgical management, defined as failure to achieve fracture union nonsurgically within 3 months of injury. RESULTS: One hundred fifty four patients initially treated nonsurgically for isolated ulnar shaft fractures were included. Twenty six patients (17%) experienced failure of nonsurgical management; these included five nonunions, 16 delayed unions, and 10 conversions to surgical management. Patients who experienced failure of nonsurgical management had a higher prevalence of diabetes mellitus, a higher employment rate, and fractures with higher initial median posteroanterior and lateral translations, fracture gap, and angulation; 83% of the patients with an initial fracture gap of ≥4 mm and 41% of the patients with an initial fracture angulation of >10° failed nonsurgical management. CONCLUSIONS: Although most ulnar shaft fractures heal successfully with nonsurgical management, a substantial percentage of these fractures do not. Patients who are currently working, have diabetes mellitus, or have fractures with an initial fracture gap of ≥4 mm or an initial fracture angulation of > 10° may be more likely to fail nonsurgical treatment, although additional studies with larger sample sizes are needed to confirm these associations. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Characteristics and outcomes of patients who undergo fasciotomies for upper arm compartment syndrome.

PURPOSE: Describe the demographic, injury-related, treatment-related, and outcome-related characteristics of patients who undergo fasciotomies for acute upper arm compartment syndrome (ACS). METHODS: From January 1, 2006, to June 30, 2015, 438 patients with a diagnosis code of upper extremity (including hand, forearm, arm, and shoulder) compartment syndrome at two tertiary care centers were identified. Of those patients, 423 were excluded for a diagnosis other than upper arm ACS or incomplete documentation. A final cohort of 15 adult patients with acute upper arm compartment syndrome treated with fasciotomy was included. The electronic medical record for patient-related variables, lab data, mechanism of injury, presence of additional injuries, and treatment-related variables were reviewed. RESULTS: The mean age of our cohort was 52 years, and 73% were male. The most common mechanisms of injury were blunt trauma (20%), vascular injury (20%), oncologic resection (13%), and infection related to intravenous drug use (13%). Humerus fractures and biceps tendon ruptures were associated with 13 and 27% of the cases, respectively. More than two-thirds of the patients had elevated international normalized ratios (INR). While 27% of cases underwent fasciotomy within 6 h after injury, seven patients (47%) underwent fasciotomy more than 24 h after injury. Six patients had no major deficits, while 7 patients had long-term deficits. CONCLUSION: Upper arm ACS is a potentially devastating condition that can be seen after blunt trauma, vascular injury, oncologic resection, and intravenous drug use. Clinicians should have high suspicion in cases of elevated INR and biceps tendon rupture.

Subtotal gastrectomy pancreaticoduodenectomy versus conventional pancreaticoduodenectomy in the incidence of delayed gastric emptying: single-center retrospective cohort study.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). There is currently no widely accepted procedure for PD to reduce the incidence of DGE. Our institution attempts to perform subtotal gastrectomy in patients undergoing PD to reduce DGE. Here we aimed to evaluate the effectiveness and safety of PD with subtotal gastric resection. METHODS: Patients who underwent PD between January 2014 and December 2021 were reviewed. They were stratified by extent of gastrectomy into a conventional PD group (PD that resected approximately 1/3 of the distal stomach) and a subtotal gastrectomy PD group (PD that resected approximately 3/4 of the distal stomach), which were compared in terms of intraoperative and postoperative parameters. RESULT: From January 2014 to December 2021, a total of 512 patients underwent PD in the Department of Hepatobiliary Surgery, Peking University People's Hospital. Nineteen patients were excluded from this study due to benign disease. A total of 493 patients were included, with 378 in the conventional PD group and 115 in the subtotal gastrectomy PD group. Compared with the conventional PD group, the subtotal gastrectomy PD group had a lower incidence of DGE (8.7% vs. 17.7%, p = 0.019), and a shorter hospital stay. Multivariate analysis showed that conventional PD and higher body mass index were independent risk factors for grade B/C DGE. CONCLUSION: This study showed that, compared with conventional PD, subtotal gastrectomy PD can reduce the incidence of DGE and shorten the length of hospital stay. At the same time, subtotal gastrectomy PD is comparable to conventional PD in terms of surgical safety. Furthermore, high BMI is an independent risk factor for postoperative DGE.

Association of Economic Well-Being With Comorbid Conditions in Patients Undergoing Carpal Tunnel Release.

PURPOSE: Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR. METHODS: Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study-confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease, hypertension, hypothyroidism, cervical radiculopathy, tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities. RESULTS: Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered. CONCLUSIONS: Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Readability of Online Hand Surgery Patient Educational Materials: Evaluating the Trend Since 2008.

PURPOSE: Online patient educational materials have historically been written at a higher-than-recommended sixth grade reading level. The objectives of this study were to assess the readability of online hand surgery patient educational materials from the official online patient resource website of the American Society for Surgery of the Hand (ASSH) and to compare changes in the readability of the current ASSH online patient educational materials with those in 2008 and 2015. METHODS: An internet-based study of all 88 English language patient educational materials on HandCare.org, the official online patient resource website of the ASSH, was performed. The readability of each article was assessed using the Flesch reading ease formula, Flesch-Kincaid grade level, Coleman-Liau index, Gunning-Fog index, and Simple Measure of Gobbledygook grade level. To evaluate the trend in the readability of ASSH online hand surgery patient educational materials, the Flesch-Kincaid grade levels of articles published in 2020 were compared with those of data published in 2008 and 2015. RESULTS: The average Flesch reading ease score of the patient educational materials was 57.6, which is at the high-school reading level. The average reading grade level of patient educational materials ranged from 9.0 to 12.3 depending on the readability metric used. The average Flesch-Kincaid grade level of all the ASSH patient educational materials was 9.8 in 2020, which is significantly better than 10.4 in 2008 but significantly worse than 8.5 in 2015. CONCLUSIONS: Online hand surgery patient educational materials continue to be written for the general public at a higher-than-recommended reading grade level. There has been no substantial improvement in the readability of online hand surgery patient educational materials since 2008. CLINICAL RELEVANCE: Improvements are needed in the readability of online patient educational materials to ensure that patients with all health literacy levels are able to comprehend and benefit from health information.

Forequarter Replantation.

Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.

Conflicts of interest among patients: do they exist and can they bias patient-reported outcome measures? A survey of shoulder and elbow patients.

BACKGROUND: Potential conflicts of interest (COIs) are common among physicians and may bias physician-reported outcome assessment in orthopedic research. It is unclear whether patients have COIs and whether these COIs could affect patient-reported outcome measures (PROMs). The purposes of this study were to investigate (1) the existence of COIs among patients and (2) the potential of these COIs to bias PROMs with a pseudonymized survey among consecutive shoulder and elbow patients. MATERIALS AND METHODS: Between February and May 2021, 144 shoulder and elbow patients who underwent consultation at our outpatient clinic were included in the survey study. Of these patients, 79.2% (n = 114) completed the 11-item questionnaire. Variables including sex, existence of chronic diseases, level of education, and economic status were also assessed to investigate any association between these variables and patients' perceptions of COIs. RESULTS: Whereas 33.3% of respondents (n = 38) believe that COIs exist among patients and 28.1% (n = 32) believe that COIs could bias PROMs in general, fewer patients admit to personal COIs (24.6%, n = 28) and COIs biasing their self-assessment (23.7%, n = 27). Patients more frequently suggest COIs in their personal environment, such as among family members or friends (27.2%, n = 31), than in their own medical treatment. Financial factors such as sick pay (34.2%, n = 39) are thought to be the most likely reason for having COIs, followed by interpersonal reasons such as maintaining medical affection or bonds (29.8%, n = 34). Of respondents, 42.1% (n = 48) believe that sole usage of PROMs poses risks in treatment evaluation and only 21% (n = 24) consider PROMs reliable. In addition, 43% of respondents (n = 49) believe that patients should disclose COIs routinely in medical treatment. Multinomial logistic regression analysis revealed that wealthier patients are more likely to believe COIs could bias PROMs (odds ratio for poor vs. middle class, 0.23 [95% confidence interval, 0.053-0.963]; odds ratio for lower-middle class vs. middle class, 0.19 [95% confidence interval, 0.052-0.677]). CONCLUSIONS: Although the majority of shoulder and elbow patients deny having self-experienced COIs and deny biased PROMs due to COIs in their own medical treatment, a considerable number of patients admit to having experienced both. Further studies might be justified to investigate the actual clinical relevance of patients' COIs and their impact on value-based health care.

Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?

BACKGROUND: The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (>30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables. METHODS: We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables. RESULTS: Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51). CONCLUSIONS: Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.

What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?

BACKGROUND: Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. QUESTIONS/PURPOSES: (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. METHODS: In an institutional review board-approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. RESULTS: The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. CONCLUSION: Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. LEVEL OF EVIDENCE: Level IV, therapeutic study.

What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

BACKGROUND: Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation. QUESTIONS/PURPOSES: (1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries? METHODS: Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow. RESULTS: Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]). CONCLUSION: The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options. LEVEL OF EVIDENCE: Level III, therapeutic study.