The Association Between Depression and Antidepressant Use and Outcomes After Operative Treatment of Distal Radius Fractures at 1 Year.

PURPOSE: Depression has been linked to inferior clinical outcomes among upper extremity patients. It often is challenging to distinguish the symptoms of depression, symptoms of injury, and the interaction between these 2 entities after a patient has been injured. We aimed to study the differences in clinical outcomes after surgical fixation of distal radius fractures between patients with and without a documented history and treatment for depression. METHODS: All subjects with an isolated, acute distal radius fracture undergoing operative fixation in a 10-year period at a level 1 academic trauma center were screened. Baseline demographic data were collected, and psychiatric history and antidepressant use were recorded and verified with a pharmacy database. Quick Disability of the Arm, Shoulder and Hand (QuickDASH), range of motion, and grip strength were assessed at 12 months after surgery. Multivariable linear regression analysis was used to assess the association of depression with QuickDASH scores at 1 year after surgery. RESULTS: A total of 211 patients were available for 1-year follow-up, 50 of whom were being treated actively for depression with medication at the time of injury and 161 were without a known diagnosis of, or treatment for, depression. Demographic and injury characteristics were similar between both groups. In a multivariable linear regression model controlling for age, sex, and a history of osteoporosis, active treatment for depression was associated with a slight mean increase in QuickDASH scores, 6.5 (1.3-11.8), 1 year after surgery. CONCLUSIONS: This study demonstrates a small increase in QuickDASH scores between subjects with a confirmed diagnoses of depression compared with all others after surgical fixation of distal radius fracture at 1-year follow-up. We suggest that a history of depression may portend worse clinical outcomes, although other factors, such as underreporting of depression may influence results. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Association of AUSCAN and PRWHE Patient-reported Outcome Measures With Radiographic Progression of Early Thumb Carpometacarpal Arthritis at 36-Month Follow-up Is Limited to Subtle Changes in the Pain Subscale.

BACKGROUND: There is a paucity of literature that examines how patient-reported outcomes correspond to early radiographic progression of thumb carpometacarpal (CMC) osteoarthritis (OA). This study examines how Australian/Canadian Osteoarthritis Hand Index (AUSCAN) and Patient-Rated Hand and Wrist Evaluation (PRWHE) scores change over 36 months in subjects with early CMC OA. METHODS: Ninety-one subjects with symptomatic early thumb CMC OA were enrolled. Differences in AUSCAN and PRWHE scores were measured between subjects at baseline and at 18-month follow-up, and between the subjects at baseline and at 36-month follow-up. Radiographic progression was defined as an increase in modified Eaton Stage. Differences in AUSCAN and PRWHE scores were compared between these 2 groups in order to determine if radiographic progression was associated with a greater change in AUSCAN and PRWHE at 18- and 36-month follow-up. RESULTS: At 18- and 36-month follow-up visits, there were no significant differences in AUSCAN or PRWHE compared to baseline. Multivariable logistic regression analysis did not reveal any significant differences between subjects with radiographic progression to subjects without radiographic progression at 18-month follow-up. At 36-month follow-up, this analysis did demonstrate that subjects with evidence of radiographic progression had a significant increase in the PRWHE pain subscale. CONCLUSION: AUSCAN and PRWHE scores were not found to significantly progress at 18-month and 36-month follow-up. However, when comparing the subset of subjects with and without radiographic OA, subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up.

Adhesive Taping Shows Better Cosmetic Outcomes Than Tissue Adhesives for Sutured Upper Extremity Incisions: A Single-Blind Prospective Randomized Controlled Trial.

Adhesive taping is commonly used to reinforce wound closure and approximate minor lacerations. Recently, tissue adhesives such as 2-octylcyanoacrylate have gained popularity because of their high tensile strength, bacteriostatic properties, and spontaneous peeling. We sought to evaluate the cosmetic result of upper extremity incisions closed primarily by subcuticular suture, randomizing the application of tissue adhesive vs adhesive taping to different halves of the same surgical incision. Subjects were recruited from patients undergoing common procedures at the senior surgeon's hand surgery clinic. After primary closure, we applied either quarter-inch adhesive tape or tissue adhesive to the proximal and distal aspects of the wounds, based on a preoperative randomization protocol. We assessed the scars at approximately 3 months (range, 2-5 months). Subjects completed a validated scar assessment questionnaire, and a blinded photograph was obtained to allow 2 independent surgeons to assess the scar. Mean age was 63 years (SD, 11.8 years; range, 21-88 years); 56% of patients were women, and 44% were men. Most of the incisions were open carpal tunnel release and thumb carpometacarpal arthroplasty (14 each). Adhesive taping showed a better overall mean score based on evaluation by the hand surgeons, a finding that was statistically significant. The greatest differences were observed between color and size, but no subcategories were significantly different. Patients reported nonstatistical, but slightly better overall cosmetic outcomes with adhesive taping rather than tissue adhesive. Adhesive strips provide a modest but significant improvement in cosmetic outcomes vs more expensive tissue adhesive. Future evaluation of closure methods that evaluate cost, speed of application, suture technique, and dressing will optimize scar appearance. [Orthopedics. 2022;45(1):e42-e46.].

Understanding and Addressing Psychiatric Comorbidities and Upper-Extremity Trauma: Surgeons in a Multidisciplinary Care Model.

Psychiatric disorders are a common cause of disability and represent an important risk factor for upper-extremity trauma. The review provides an overview of psychiatric illnesses as both contributors and sequelae of 4 major injury patterns: self-inflicted wrist lacerations, self-amputation, upper-extremity fractures, and burns. The authors develop a multidisciplinary model for upper-extremity surgeons to care for patients with psychiatric disorders, with an overview of capacity assessment, optimal psychiatric comanagement, and collaboration with allied health professionals.

Agreement and Reliability of Lateral Patellar Tilt and Displacement following Total Knee Arthroplasty with Patellar Resurfacing.

Patellar position and alignment may be measured on routine axial radiographs by various techniques; however, the agreement and reliability of such measurements with a resurfaced patella remain unknown. This study evaluated the range and reliability of lateral patellar tilt and lateral patellar displacement following total knee arthroplasty (TKA) with a resurfaced patella among three observers on 45° Merchant view in 139 TKAs. Intraclass correlation coefficient (ICCs) were used to evaluate intraobserver agreement (IOA) and inter-rater reliability (IRR). IRR was high between each of the observers for lateral patellar tilt (ICC = 0.8) and lateral patellar displacement (ICC = 0.87). IOA was also high upon repeat measurement for the same observer for lateral patellar tilt (ICC ≥ 0.90) and lateral patellar displacement (ICC ≥ 0.86). Therefore, lateral patellar tilt and lateral patellar displacement are reproducible measurements of patellar position on a Merchant axial radiograph following a well-functioning TKA with a resurfaced patella.

Radiographic Progression of Thumb CMC Osteoarthritis: A Systematic Review.

Purpose: Thumb carpometacarpal (CMC) osteoarthritis (OA) is a prevalent disease that causes pain and disability. Determining the progression of CMC OA is problematic given the lack of consensus for classifications and scoring systems. We performed a systematic review to (1) determine which imaging modalities or scoring systems are used to evaluate CMC OA progression, and (2) describe the progression of CMC OA through available metrics. Methods: This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English language literature search was performed in July 2019 and included studies evaluating CMC OA progression with an imaging modality or radiographic scoring system, with a minimum 1-year follow-up. Studies were analyzed with respect to their methodology, scoring systems, and relevant findings. Results: The initial search yielded 4,097 articles, 10 of which met inclusion criteria. Study size varied from 32 to 289 subjects; many subjects were included in multiple cohorts. Eight studies used radiography whereas 2 used scintigraphy. Estimates of progression varied from 20% to 70% (with large variation in follow-up time); the magnitude of progression varied from 3% to 48% (joint space narrowing) and from 0.6 to 1 points (Kellgren-Lawrence scale). The percentage of subjects who progressed and the progression degree varied widely and depended on follow-up length and the scoring system used. Conclusions: A paucity of literature exists to measure CMC OA progression; there is a lack of uniformly accepted imaging modality, scoring system, or follow-up interval. This absence provides the opportunity to determine consensus techniques and metrics to assess the natural history of thumb CMC OA. Type of study/level of evidence: Diagnostic III.

Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review.

BACKGROUND: Musculoskeletal trauma represents a large source of morbidity in low and middle human development index countries (LMHDICs). Open reduction and internal fixation (ORIF) of traumatic long bone fractures definitively manages these injuries and restores function when conducted safely and effectively. Surgical site infections (SSIs) are a common complication of operative fracture fixation, although the risks of infection are ill-defined in LMHDIC. PATIENTS AND METHODS: This study reviewed systematically all studies describing SSI after ORIF in LMDHICs. Studies were reviewed based on their qualitative characteristics, after which a quantitative synthesis of weighted pooled infection rates based on available patient-level data was performed to estimate published incidence of SSI. RESULTS: Forty-two studies met criteria for qualitative review and 32 studies comprising 3,084 operations were included in the quantitative analysis. Among 3,084 operations, the weighted pooled SSI rate was 6.4 infections per 100 procedures (95% confidence interval [CI] 4.6-8.2 infections per 100 procedures). Higher rates of infection were noted among the sub-group of open fractures (95% CI 13.9-23.0 infections per 100 procedures). Lower extremity injuries and procedures utilizing intra-medullary nails also had slightly higher rates of infection versus upper extremity procedures and other fixation devices. CONCLUSIONS: Reported rates of SSI after ORIF are higher in LMHDICs, and may be driven by high rates of infection in the sub-group of open fractures. This study provides a baseline SSI rate obtained from literature produced from LMHDICs. Infection rates are highly dependent on fracture sub-types.

The AUSCAN and PRWHE Demonstrate Comparable Internal Consistency and Validity in Patients With Early Thumb Carpometacarpal Osteoarthritis.

BACKGROUND: The Australian/Canadian Osteoarthritis Hand Index (AUSCAN) and Patient-Rated Wrist-Hand Evaluation (PRWHE) are 2 patient-related outcome measures to assess pain and disability in patients with osteoarthritis (OA). The purpose of this study was to evaluate the AUSCAN and PRWHE in a large-scale, longitudinal cohort of patients with early thumb carpometacarpal (CMC) OA. METHODS: We obtained baseline data on 135 individuals (92 with early CMC OA participants and 43 asymptomatic controls) and at follow-up (year 1.5) on 83 individuals. We assessed the internal consistency using Cronbach alpha, and construct and criterion validity using other pain scales and objective measures of strength, respectively. We also examined the correlation between the AUSCAN and PRWHE and correlation coefficients at baseline and follow-up, as well as the correlation between changes in these instruments over the follow-up period. RESULTS: Internal consistency was high for both AUSCAN and PRWHE totals and subscales (Cronbach α > 0.70). Both instruments demonstrated construct validity compared with the Verbal Rating Scale ( r = 0.52-0.60, P < .01), an assessment of pain, and moderate criterion validity compared with key pinch and grip strength ( r = -.24 to -.33, P < .05). These instruments were highly correlated with each other at baseline and follow-up time points ( r = 0.76-.94, P < .01), and changes in a patient's total scores over time were also correlated ( r = 0.83, P < .01). CONCLUSIONS: The AUSCAN and PRWHE are both valid assessments for pain and/or disability in patients with early thumb CMC OA.

Changes in Local Bone Density in Early Thumb Carpometacarpal Joint Osteoarthritis.

PURPOSE: Thumb carpometacarpal (CMC) osteoarthritis (OA) represents a major source of functional morbidity. The effects of early CMC OA on loading and use patterns potentially lead to changes in local bone density and microarchitecture. Hounsfield units (HU), a quantitative attenuation coefficient obtained from computed tomography (CT) scans, have been shown to be a reliable marker of bone density. We hypothesized that early CMC OA is associated with lower local bone density about the CMC joint as assessed by HU. METHODS: We examined HU units from CT scans in 23 asymptomatic subjects and 91 patients with early CMC OA. The HU measurements were obtained within cancellous portions of the trapezium, capitate, first and third metacarpal bases, and distal radius. Linear regression models, with age and sex included as covariates, were used to assess the relationship between CMC OA and HU values at each anatomical site. RESULTS: Early OA patients had significantly lower HU than asymptomatic subjects within the trapezium (mean, 377 HU vs 436 HU) and first metacarpal bases (265 HU vs 324 HU). No significant group differences were noted at the capitate, third metacarpal, or distal radius. Male sex and younger age were associated with significantly higher HU at all the anatomical sites, except the first metacarpal base, where age had no significant effect. CONCLUSIONS: Subjects presenting with early CMC OA had significantly lower bone density as assessed with HU at the thumb CMC joint (trapezium and first metacarpal base). Early thumb CMC OA and discomfort may lead to diminished loading across the basal joint, producing focal disuse osteopenia. These findings in symptomatic early arthritis suggest a relationship between symptoms, functional use of the CMC joint, and local bone density. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014.

PURPOSE: Congenital hand differences are infrequent phenomena, and their treatment represents a relatively small fraction of cases performed by hand surgeons. Little is known about the incidence of wound complications and acute postoperative problems given the relative rarity of these procedures. This study sought to characterize the incidence of complications within 30 days of surgery for congenital hand differences. METHODS: The National Surgical Quality Improvement Program (NSQIP) contains prospective data regarding 30-day morbidity from 64 pediatric centers across the United States. Data from all available years (2012-2014) were queried for Current Procedural Terminology (CPT) codes pertinent to the treatment of congenital hand differences. Bivariate statistics, Fisher exact tests and Poisson 95% confidence intervals (95% CI) were used to assess the incidence of complications and examine risk factors for these outcomes. RESULTS: We identified a total of 1,656 congenital hand cases that represented 4 different CPT codes, including surgery for simple syndactyly, complex syndactyly, and polydactyly. The overall incidence of complications was 2.2% (95% CI, 1.6%-3.1%; n = 37) with the most common complication being superficial surgical site infection (1.7%; 95% CI, 1.1%-2.4%) followed by related readmission (0.3%; 95% CI, 0.1%-0.7%). There was a higher incidence of complications observed in patients undergoing complex syndactyly repair (5.2% for complex syndactyly repair vs 2.3% for all others). CONCLUSIONS: The rate of acute complications following procedures to correct syndactyly and polydactyly is low, the most common of which is superficial surgical site infection. The incidence of acute complications may be helpful in counseling patients and families. We suggest that further research must prioritize collecting data on long-term functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Weaker Functional Pinch Strength Is Associated With Early Thumb Carpometacarpal Osteoarthritis.

BACKGROUND: The thumb carpometacarpal (CMC) joint orchestrates pinch in its various positions, and thumb CMC osteoarthritis (OA) is a major source of orthopaedic morbidity. Self-reported pain, weakness, and physical examination may not correspond to radiographic findings when diagnosing early thumb CMC OA. Weakness is a prominent feature of the disease, but little evidence exists to quantify self-reported loss of strength with time, or to compare weakness with that of a nonarthritic population during early disease. QUESTIONS/PURPOSES: We asked: (1) Is pinch strength in subjects with early thumb CMC OA less than that in asymptomatic control subjects; and (2) weakness in which pinch position (key, tripod, or tip pinch) has the strongest association with early OA diagnosis? METHODS: For this case-control study, we recruited 23 subjects who were asymptomatic and 91 with early OA for comprehensive history, physical examination, strength measurements, pain surveys, and radiographic evaluation. We used multivariate logistic regression to quantify the association between declining pinch strength and early OA diagnosis after controlling for age, sex, and BMI. This analysis was performed for three different pinch positions (key, tripod, and tip pinch) to evaluate which measurement was most closely associated with diagnosis. RESULTS: Pinch strength was less in patients with early thumb CMC OA. Key pinch had the most robust association with OA diagnosis, in which a 20% decrease in key pinch strength from the control subjects' baseline was associated with a 10% increase in the OA diagnosis (95% CI, 3%-16%; p = 0.004). This had a stronger association with OA diagnosis than tip pinch, in which a 20% decrease in strength was associated with a 6% increase in early CMC OA (95% CI, 1.0%-11%; p = 0.031). Tripod pinch also was associated to a lesser extent; a 20% reduction in tripod pinch led to a 5% increase in OA (95% CI, 1.3%-9%; p = 0.048). CONCLUSIONS: Decreasing pinch strength, especially key pinch, is associated with early CMC arthritis before the development of extensive radiographic disease. CLINICAL RELEVANCE: Weakness in pinch strength, especially key pinch, is an important feature in the pathogenesis of early CMC OA and may appear before radiographic disease is present or advanced. These findings suggest a role for intervention in early disease for promoting nonoperative joint protection and strengthening, and designing surgical procedures aimed to delay or prevent clinical and radiographic progression.