Surgical Treatment of Scaphoid Fractures: Recommendations for Management.

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

Lateral Femoral Condyle Allograft in the Treatment of Elbow Capitellar Avascular Necrosis: A Case Report.

CASE: A 27-year-old woman developed capitellar osteonecrosis after long-term corticosteroid use to treat non-Hodgkin lymphoma. She underwent an osteochondral reconstruction using a lateral femoral condyle (LFC) allograft. This graft was selected because it has a similar radius of curvature to the capitellum. The patient had osseous integration, painless, near full range of motion of her elbow 6 months postoperatively and good shoulder function 1.0 year postoperatively. CONCLUSION: The LFC allograft should be considered a viable option in treating capitellar osteonecrosis.

Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release.

BACKGROUND: We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs). METHODS: The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources. RESULTS: A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin. CONCLUSIONS: There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.

The therapeutic effects of gingival mesenchymal stem cells and their exosomes in a chimeric model of rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis is a chronic systemic autoimmune disease that involves transformation of the lining of synovial joints into an invasive and destructive tissue. Synovial fibroblasts become transformed, invading and destroying the bone and cartilage of the affected joint(s). Due to the significant role these cells play in the progression of the disease process, developing a therapeutic strategy to target and inhibit their invasive destructive nature could help patients who are afflicted with this debilitating disease. Gingival-derived mesenchymal stem cells are known to possess immunomodulatory properties and have been studied extensively as potential cell-based therapeutics for several autoimmune disorders. METHODS: A chimeric human/mouse model of synovitis was created by surgically implanting SCID mice with a piece of human articular cartilage surrounded by RASF. Mice were injected once with either GMSC or GMSCExo at 5-7 days post-implantation. Histology and IHC were used to assess RASF invasion of the cartilage. Flow cytometry was used to understand the homing ability of GMSC in vivo and the incidence of apoptosis of RASF in vitro. RESULTS: We demonstrate that both GMSC and GMSCExo are potent inhibitors of the deleterious effects of RASF. Both treatments were effective in inhibiting the invasive destructive properties of RASF as well as the potential for these cells to migrate to secondary locations and attack the cartilage. GMSC home to the site of the implant and induce programmed cell death of the RASF. CONCLUSIONS: Our results indicate that both GMSC and GMSCExo can block the pathological effects of RASF in this chimeric model of RA. A single dose of either GMSC or GMSCExo can inhibit the deleterious effects of RASF. These treatments can also block the invasive migration of the RASF, suggesting that they can inhibit the spread of RA to other joints. Because the gingival tissue is harvested with little difficulty, relatively small amounts of tissue are required to expand the cells, the simple in vitro expansion process, and the increasing technological advances in the production of therapeutic exosomes, we believe that GMSCExo are excellent candidates as a potential therapeutic for RA.

Total Wrist Fusion with an Intramedullary Device: A Single-Institution Series with a Minimum of One Year Follow-Up.

Objective The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods A single institution study was performed, which entailed in-person reexamination of 18 patients ( n = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n I = 38 wrists) were noted. Results In the 18 patients, age was 47.6 ± 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74-294). The VAS score was 0 ± 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 ± 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF. Level of Evidence This is a Level IV, therapeutic study.

Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship-trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, "How soon after your carpal tunnel surgery did you notice an improvement in your sleep?" Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

Reduction of Opioid Use After Upper-Extremity Surgery through a Predictive Pain Calculator and Comprehensive Pain Plan.

PURPOSE: For outpatient hand and upper-extremity surgeries, opioid prescriptions may exceed the actual need for adequate pain control. The purposes of this study were to (1) determine rates of opioid wasting and consumption after these procedures and (2) create and implement a patient-specific calculator for opioid requirements with a detailed multimodal analgesic plan to guide postoperative prescriptions. METHODS: Patients undergoing hand and upper-extremity surgery at a single ambulatory surgery center were recruited before (n = 305) and after (n = 221) implementation of a postoperative pain control program. On the first postoperative visit, patients were given a questionnaire regarding opioid use and pain control satisfaction. Demographic and procedural data were collected via chart review. With these data from the first cohort, we developed a patient-specific opioid calculator and pain plan that was implemented for the second cohort of patients. Bivariate analysis and multivariable regression analysis were used to determine the effect of the intervention. RESULTS: Pre-intervention data suggested that younger age; baseline opioid use; use of regional block; unemployment; procedures involving bony, tendinous, or ligamentous work (as opposed to soft tissue alone); and longer procedure time were predictive of higher opioid consumption. Pre- and post-intervention cohorts had similar age and sex distributions as well as procedure length. After the intervention, opioids prescribed decreased 63% from a mean of 32.0 ± 15.0 pills/surgery or 194.5 ± 120.2 morphine milligram equivalents (MMEs) to 11.7 ± 8.9 pills/surgery or 86.4 ± 67.2 MMEs. Opioid consumption decreased 58% from a mean of 21.7 ± 25.0 pills/surgery (137.7 ± 176.4 MMEs) to 9.3 ± 16.7 (64.4 ± 113.4 MMEs). Opioid wastage decreased 62% from 13.8 ± 13.5 pills/surgery (62.8 ± 138.0 MMEs) to 5.2 ± 10.3 (24.8 ± 89.9 MMEs). Implementation of the pain plan and calculator did not affect the odds of unsatisfactory patient-rated pain control or unplanned opioid refills. CONCLUSIONS: With implementation of a comprehensive pain plan for ambulatory upper-extremity surgery, it is possible to reduce opioid prescription, consumption, and wastage rates without compromising patient satisfaction with pain control or increasing rates of unplanned pain medication refills. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Multi-Modal Pain Control in Ambulatory Hand Surgery.

We evaluated postoperative pain control and narcotic usage after thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of the distal radius in patients given opiates with or without other non-opiate medication using a specific dosing regimen. A prospective, randomized study of 79 patients undergoing elective CMC arthroplasty or ORIF of the distal radius evaluated postoperative pain in the first 5 postoperative days. Patients were divided into 4 groups: Group 1, oxycodone and acetaminophen PRN; Group 2, oxycodone and acetaminophen with specific dosing; Group 3, oxycodone, acetaminophen, and OxyContin with specific dosing; and Group 4, oxycodone, acetaminophen, and ketorolac with specific dosing. During the first 5 postoperative days, we recorded pain levels according to a numeric pain scale, opioid usage, and complications. Although differences in our data did not reach statistical significance, overall pain scores, opioid usage, and complication rates were less prevalent in the oxycodone, acetaminophen, and ketorolac group. Postoperative pain following ambulatory hand and wrist surgery under regional anesthesia was more effectively controlled with fewer complications using a combination of oxycodone, acetaminophen, and ketorolac with a specific dosing regimen.

Hand Surgery Questions on the Orthopaedic In-Training Examination: Analysis of Content and Reference.

PURPOSE: To provide an updated analysis of the hand surgery section of the Orthopaedic In-Training Examination (OITE) from 2009 to 2015. The goal was to contribute to the existing literature on the analysis of OITE questions, to aid both residents and residency programs in preparation for the OITE and board examination. METHODS: The authors analyzed all OITE questions pertaining to hand surgery between 2009 and 2015. Hand questions were analyzed for category and subcategory of content, cited reference, treatment intervention, and imaging modality used. RESULTS: Hand-related questions comprised 157 of the 1,872 OITE questions (8.4%). Nine general topic areas were identified, the most common of which were fracture-dislocation, tendon/ligament, nerve, congenital, and amputation. Trends existed in the recommended references; the 5 journals and 2 textbooks that were consistently cited included the Journal of Hand Surgery (American Volume), the Journal of the American Academy of Orthopaedic Surgeons, the Journal of Bone and Joint Surgery (American Volume), the Journal of Hand Surgery (European Volume), Hand Clinics, Orthopaedic Knowledge Update, and Green's Operative Hand Surgery, respectively. CONCLUSIONS: Knowledge regarding topics and resources used for OITE hand questions could be mutually beneficial to both residents and residency programs. This information would consolidate resident OITE and board examination study time. Furthermore, this analysis could help residency programs develop or improve educational conferences and journal clubs. CLINICAL RELEVANCE: An understanding of question content and sources should enable efficient learning and improved scores on this section of the examination.

Surgeon Preference, Influence, and Treatment of Thumb Carpometacarpal Arthritis.

BACKGROUND: The purpose of this study was to evaluate current surgical practice patterns, the factors that influence these patterns, and overall trends in the treatment of thumb carpometacarpal osteoarthritis. METHODS: An online survey containing 14 questions was sent to all active members of the American Society for Surgery of the Hand. Information on demographics and treatments was collected. Results were anonymously uploaded to an online spreadsheet. RESULTS: A total of 823 responses were recorded. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) using whole flexor carpi radialis was the most popular technique at 37.44%. In all, 26.38% of surgeons with fewer than 5 years of experience utilize trapeziectomy with suture suspension (bone anchor based or tendon based); 55.76% choose a particular procedure because of "Personal Clinical Experience" over "Current Evidence" and "Training." In addition, 24.17% of surgeons who have been practicing for longer than 5 years have changed procedures in the last 5 years. In the United States, 97.2% of hand surgeons prescribe either oxycodone or hydrocodone postoperatively compared with just 23.75% of international hand surgeons. CONCLUSIONS: The results show that trapeziectomy with LRTI remains the most popular treatment of choice. The use of trapeziectomy with suture suspension is on the rise, particularly in younger surgeons. International hand surgeons rely more on current evidence, utilize less postoperative therapy and opioid medications, and change procedures more often than US hand surgeons.

Use of a Bicortical Button to Safely Repair the Distal Biceps in a Two-Incision Approach: A Cadaveric Analysis.

PURPOSE: No consensus has been reached on the most effective anatomic approach or fixation method for distal biceps repair. It is our hypothesis that, using a cortical biceps button through a 2-incision technique, the distal biceps can be safely and anatomically repaired. METHODS: A 2-incision biceps button distal biceps repair was completed on 10 fresh-frozen cadavers. The proximity of the guide pin to the critical structures of the forearm, including the posterior interosseous nerve and recurrent radial artery, was measured. The location of repair was mapped and compared with anatomic insertion. RESULTS: The average distance from the tip of the guide pin to the posterior interosseous nerve was 11.4 mm (range, 8-14 mm). The average distance from the tip of the guide pin to the recurrent radial artery was 12.5 mm (range, 8-19 mm). The distal biceps tendon was repaired to the anatomic insertion site on the tuberosity using the biceps button technique in all specimens. CONCLUSIONS: The 2-incision biceps button repair described here allows safe and accurate repair of the tendon to the radial tuberosity in this cadaveric study. CLINICAL RELEVANCE: The goal of distal biceps repair is to safely, securely, and anatomically repair the torn biceps tendon to the radial tuberosity. The most commonly performed techniques (single anterior incision with cortical button and the double-incision procedure with bone tunnels and trough) have limitations. A 2-incision button repair safely and anatomically repairs the distal biceps tendon.

Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand.

PURPOSE: To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. METHODS: An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N = 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. RESULTS: 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). CONCLUSIONS: When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis V.

Outcomes after injury to the thumb ulnar collateral ligament--a systematic review.

OBJECTIVES: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction. DATA SOURCES: A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. MAIN RESULTS: Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Complications after surgery were rare. CONCLUSIONS: This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Assessment of musculoskeletal physical examination skills and attitudes of orthopaedic residents.

BACKGROUND: Although the musculoskeletal physical examination is an essential part of patient encounters, we believe that it is underemphasized in residency education and that residents' physical examination skills may be lacking. We sought to assess attitudes regarding teaching of the physical examination in orthopaedic residencies, to assess physical examination knowledge and skills among residents, and to develop a method to track the skill level of residents in order to improve our physical examination curriculum. METHODS: We created a thirty-question multiple-choice musculoskeletal physical examination test and administered it to our residents. We created a five-question survey assessing attitudes toward physical examination teaching in orthopaedic residencies and distributed it to U.S. orthopaedic department chairs We developed an Objective Structured Clinical Examination (OSCE), in which standardized patients enact four clinical scenarios, to observe and assess physical examination skills. RESULTS: The mean score on the multiple-choice physical examination test was 76% despite the fact that our residents consistently scored above 90% on the Orthopaedic In-Training Examination. Department chairs and residents agreed that, although learning to perform the physical examination is important, there is not enough time in the clinical setting to observe and critique a resident's patient examination. The overall score of our residents on the OSCE was 66%. CONCLUSIONS: We have exposed a deficiency in the physical examination knowledge and skills of our residents. Although the musculoskeletal physical examination is a vital practice component, our data indicate that it is likely underemphasized in training. Clinic time alone is likely insufficient for the teaching and learning of the musculoskeletal physical examination.