Phalangeal fractures: A retrospective comparison of open reduction and internal fixation vs. closed reduction and percutaneous pinning.

The treatment of phalangeal fractures is guided by fracture characteristics, patient factors and surgeon judgment. This study retrospectively compares characteristics of phalangeal fractures treated with closed reduction percutaneous pinning (CRPP) with those of fractures treated with open reduction internal fixation (ORIF) to identify risk factors associated with reoperation. A total of 901 phalangeal fractures were included and treated operatively by either CRPP (748 fractures, 83 â€‹%) or ORIF (153 fractures, 17 â€‹%). Demographics, surgical management, and complication data were collected. Statistical analyses were performed to stratify risk associations and identify potential predictors of reoperation. With multivariate analysis and bootstrapped LASSO regression, fractures addressed by means of ORIF (vs. CRPP), work-related fractures, and open fractures were found to be independently associated with reoperation. These findings can be used to guide patient selection, surgical planning and timing of fracture repair. Level of evidence: Level III, Therapeutic.

Apollo Next Generation Sample Analysis (ANGSA): an Apollo Participating Scientist Program to Prepare the Lunar Sample Community for Artemis.

As a first step in preparing for the return of samples from the Moon by the Artemis Program, NASA initiated the Apollo Next Generation Sample Analysis Program (ANGSA). ANGSA was designed to function as a low-cost sample return mission and involved the curation and analysis of samples previously returned by the Apollo 17 mission that remained unopened or stored under unique conditions for 50 years. These samples include the lower portion of a double drive tube previously sealed on the lunar surface, the upper portion of that drive tube that had remained unopened, and a variety of Apollo 17 samples that had remained stored at -27 °C for approximately 50 years. ANGSA constitutes the first preliminary examination phase of a lunar "sample return mission" in over 50 years. It also mimics that same phase of an Artemis surface exploration mission, its design included placing samples within the context of local and regional geology through new orbital observations collected since Apollo and additional new "boots-on-the-ground" observations, data synthesis, and interpretations provided by Apollo 17 astronaut Harrison Schmitt. ANGSA used new curation techniques to prepare, document, and allocate these new lunar samples, developed new tools to open and extract gases from their containers, and applied new analytical instrumentation previously unavailable during the Apollo Program to reveal new information about these samples. Most of the 90 scientists, engineers, and curators involved in this mission were not alive during the Apollo Program, and it had been 30 years since the last Apollo core sample was processed in the Apollo curation facility at NASA JSC. There are many firsts associated with ANGSA that have direct relevance to Artemis. ANGSA is the first to open a core sample previously sealed on the surface of the Moon, the first to extract and analyze lunar gases collected in situ, the first to examine a core that penetrated a lunar landslide deposit, and the first to process pristine Apollo samples in a glovebox at -20 °C. All the ANGSA activities have helped to prepare the Artemis generation for what is to come. The timing of this program, the composition of the team, and the preservation of unopened Apollo samples facilitated this generational handoff from Apollo to Artemis that sets up Artemis and the lunar sample science community for additional successes.

Factors Associated With Reoperation After Distal Radius Nonunion Repair.

PURPOSE: This study aimed to evaluate the incidence of, and factors associated with, reoperation after distal radius nonunion repair. METHODS: We conducted a retrospective cohort study at a multicenter academic institution and identified adult patients who underwent open reduction and internal fixation for distal radius nonunion between January 2005 and August 2021. Thirty-three patients were included in this study. The cohort consisted of 13 males (13/33) and had a median age of 56 years (interquartile ranges: 49-64). Median follow-up was 59 months (interquartile ranges: 23-126). RESULTS: Unplanned reoperations occurred in eight of 33 patients. The most common reasons for reoperation were irrigation and debridement for infection, revision surgery for persistent nonunion, and unplanned hardware removal. In total, 10 complications occurred in nine patients. The most common complications were infection and persistent nonunion; both occurred in three cases. CONCLUSIONS: Complications after distal radius nonunion repair are common. Reoperation after distal radius nonunion repair is required in approximately one of four cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Psychosocial and functional impact of successful digital replantation - A cohort study of 36 patients with a median follow-up of 6 years.

INTRODUCTION: This study aims to evaluate the long-term psychosocial and functional outcomes of successful digital replantation following traumatic amputation. METHODS: Patients that underwent successful replantation (i.e. no secondary amputation following replantation) of one or more traumatically amputated digits between January 2009 and April 2019 were invited to participate in this study. In addition to a custom questionnaire on psychosocial and socioeconomic aspects of life, various Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires regarding global health, upper extremity function, and depressive symptoms were completed. Bivariate analyses were performed to identify significant associations between outcomes and explanatory variables. RESULTS: Thirty-six patients were successfully enrolled and completed the questionnaires at a median follow-up of 6.1 years. The median PROMIS score for Upper Extremity Function (40.6) was considerably different from the score that is typically found in the general population (all PROMIS instruments are calibrated with a control group score of 50.0), but the median PROMIS scores for Global Health - Physical (49.0), Global Health - Mental (50.7), and Depression (45.6) were comparable to those among the general population. Dominant hand injury, a greater number of injured digits, higher age at the time of injury, and the need for neuropathic pain medication were associated with lower Upper Extremity Function scores (all p < 0.05). Additionally, the presence of neuroma was associated with negative changes in both household finances and mental well-being (p < 0.05). CONCLUSIONS: At long-term follow-up, a majority of patients that underwent replantation of traumatically amputated digits seem to cope well based on psychosocial and functional outcomes. However, neuropathic pain and the presence of neuroma are strong negative factors. Specific attention to digital nerves at the time of surgery is crucial in the management of traumatic amputations.

Single-use Duodenoscope: The Cleaner Standard.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the endoscopic management of biliary disease. An average of 700,000 ERCPs are performed every year, and most are performed using a reusable flexible duodenoscope. The innovation of disposable duodenoscopes has changed the dynamic in the advanced endoscopy field of study to primarily reduce or eliminate the risk of cross-contamination between patients. Many factors affect whether institutions can convert from standard reusable duodenoscopes to single-use duodenoscopes including the cost of the devices, reimbursement from insurance companies for the new devices, and the overall environmental impact. However, the reduction of cross-contamination leading to active infection in patients, environmental waste produced with high-level disinfection procedures, staff and equipment required for reprocessing, and the inability to frequently upgrade duodenoscopes for optimal performance are all factors that favor transitioning to single-use duodenoscopes. As these devices are new to the field of gastroenterology, the purpose of this review is to analyze the advantages and disadvantages of transitioning to single-use devices and a brief mention of alternative options for institutions unable to make this change.

Anatomy of the Lumbrical Muscles: Implications for Mechanical Advantage.

BACKGROUND: The lumbrical muscles comprise 4 intrinsic muscles of the hand and are involved in flexion of the metacarpophalangeal joint (MCPJ) and extension of the proximal interphalangeal and distal interphalangeal joints. The purpose of this study was to investigate the anatomical mechanics of the lumbrical muscles of the index, middle, ring, and small fingers. METHODS: We evaluated 25 cadaver arms and measured the distance between the MCPJ and fingertip, the distance between the MCPJ and lumbrical muscle insertion, and the distance between the MCPJ and the most proximal lumbrical muscle origin. With these measurements we calculated the needed force, insertion ratio (length of the proximal, middle, and distal phalanx divided by the MCPJ to insertion distance), and lumbrical muscle length. RESULTS: We found that the force was significantly different between all fingers, except for the comparison of the index and ring finger (P = .34). In addition, we found that muscle length was significantly different between most the fingers, except for the comparison between the index and middle fingers (P = .24), and index and ring fingers (P = .20). There was no significant difference in insertion ratio. CONCLUSIONS: Our study suggests that the anatomical mechanics for the motor function of the lumbrical muscles are similar in all fingers. This could further imply that movements are equally precise in all fingers resulting in coordination with one another and, therefore, adequate hand function. LEVEL OF EVIDENCE: IV.

How Does ChatGPT Use Source Information Compared With Google? A Text Network Analysis of Online Health Information.

BACKGROUND: The lay public is increasingly using ChatGPT (a large language model) as a source of medical information. Traditional search engines such as Google provide several distinct responses to each search query and indicate the source for each response, but ChatGPT provides responses in paragraph form in prose without providing the sources used, which makes it difficult or impossible to ascertain whether those sources are reliable. One practical method to infer the sources used by ChatGPT is text network analysis. By understanding how ChatGPT uses source information in relation to traditional search engines, physicians and physician organizations can better counsel patients on the use of this new tool. QUESTIONS/PURPOSES: (1) In terms of key content words, how similar are ChatGPT and Google Search responses for queries related to topics in orthopaedic surgery? (2) Does the source distribution (academic, governmental, commercial, or form of a scientific manuscript) differ for Google Search responses based on the topic's level of medical consensus, and how is this reflected in the text similarity between ChatGPT and Google Search responses? (3) Do these results vary between different versions of ChatGPT? METHODS: We evaluated three search queries relating to orthopaedic conditions: "What is the cause of carpal tunnel syndrome?," "What is the cause of tennis elbow?," and "Platelet-rich plasma for thumb arthritis?" These were selected because of their relatively high, medium, and low consensus in the medical evidence, respectively. Each question was posed to ChatGPT version 3.5 and version 4.0 20 times for a total of 120 responses. Text network analysis using term frequency-inverse document frequency (TF-IDF) was used to compare text similarity between responses from ChatGPT and Google Search. In the field of information retrieval, TF-IDF is a weighted statistical measure of the importance of a key word to a document in a collection of documents. Higher TF-IDF scores indicate greater similarity between two sources. TF-IDF scores are most often used to compare and rank the text similarity of documents. Using this type of text network analysis, text similarity between ChatGPT and Google Search can be determined by calculating and summing the TF-IDF for all keywords in a ChatGPT response and comparing it with each Google search result to assess their text similarity to each other. In this way, text similarity can be used to infer relative content similarity. To answer our first question, we characterized the text similarity between ChatGPT and Google Search responses by finding the TF-IDF scores of the ChatGPT response and each of the 20 Google Search results for each question. Using these scores, we could compare the similarity of each ChatGPT response to the Google Search results. To provide a reference point for interpreting TF-IDF values, we generated randomized text samples with the same term distribution as the Google Search results. By comparing ChatGPT TF-IDF to the random text sample, we could assess whether TF-IDF values were statistically significant from TF-IDF values obtained by random chance, and it allowed us to test whether text similarity was an appropriate quantitative statistical measure of relative content similarity. To answer our second question, we classified the Google Search results to better understand sourcing. Google Search provides 20 or more distinct sources of information, but ChatGPT gives only a single prose paragraph in response to each query. So, to answer this question, we used TF-IDF to ascertain whether the ChatGPT response was principally driven by one of four source categories: academic, government, commercial, or material that took the form of a scientific manuscript but was not peer-reviewed or indexed on a government site (such as PubMed). We then compared the TF-IDF similarity between ChatGPT responses and the source category. To answer our third research question, we repeated both analyses and compared the results when using ChatGPT 3.5 versus ChatGPT 4.0. RESULTS: The ChatGPT response was dominated by the top Google Search result. For example, for carpal tunnel syndrome, the top result was an academic website with a mean TF-IDF of 7.2. A similar result was observed for the other search topics. To provide a reference point for interpreting TF-IDF values, a randomly generated sample of text compared with Google Search would have a mean TF-IDF of 2.7 ± 1.9, controlling for text length and keyword distribution. The observed TF-IDF distribution was higher for ChatGPT responses than for random text samples, supporting the claim that keyword text similarity is a measure of relative content similarity. When comparing source distribution, the ChatGPT response was most similar to the most common source category from Google Search. For the subject where there was strong consensus (carpal tunnel syndrome), the ChatGPT response was most similar to high-quality academic sources rather than lower-quality commercial sources (TF-IDF 8.6 versus 2.2). For topics with low consensus, the ChatGPT response paralleled lower-quality commercial websites compared with higher-quality academic websites (TF-IDF 14.6 versus 0.2). ChatGPT 4.0 had higher text similarity to Google Search results than ChatGPT 3.5 (mean increase in TF-IDF similarity of 0.80 to 0.91; p < 0.001). The ChatGPT 4.0 response was still dominated by the top Google Search result and reflected the most common search category for all search topics. CONCLUSION: ChatGPT responses are similar to individual Google Search results for queries related to orthopaedic surgery, but the distribution of source information can vary substantially based on the relative level of consensus on a topic. For example, for carpal tunnel syndrome, where there is widely accepted medical consensus, ChatGPT responses had higher similarity to academic sources and therefore used those sources more. When fewer academic or government sources are available, especially in our search related to platelet-rich plasma, ChatGPT appears to have relied more heavily on a small number of nonacademic sources. These findings persisted even as ChatGPT was updated from version 3.5 to version 4.0. CLINICAL RELEVANCE: Physicians should be aware that ChatGPT and Google likely use the same sources for a specific question. The main difference is that ChatGPT can draw upon multiple sources to create one aggregate response, while Google maintains its distinctness by providing multiple results. For topics with a low consensus and therefore a low number of quality sources, there is a much higher chance that ChatGPT will use less-reliable sources, in which case physicians should take the time to educate patients on the topic or provide resources that give more reliable information. Physician organizations should make it clear when the evidence is limited so that ChatGPT can reflect the lack of quality information or evidence.

Cause of Extensor Pollicis Longus Ruptures After Distal Radius Fracture Fixation Using a Volar Plate.

BACKGROUND: This research sought to analyze a cohort of patients with extensor pollicis longus (EPL) ruptures after volar locked plating of a distal radius fracture (DRF) to characterize the incidence of ruptures that are unlikely to be related to dorsal screw prominence. METHODS: This is a retrospective, observational, descriptive cohort study of adults with operative fixation of a closed DRF and an EPL rupture between 2002 and 2022. Eighteen patients with operative fixation using a volar plate of a closed DRF had an EPL rupture. The cohort consisted of 66% women with an average age of 57.5 years. Median follow-up was 14.5 months. RESULTS: The incidence of EPL rupture was 0.4% (18/4768). The average time from DRF and DRF fixation to EPL rupture was 3.7 and 3.4 months, respectively. Based on the operative record, in 2 of the 18 patients (11%), the rupture was directly attributable to prominent hardware; however, in 4 of the 18 patients (22%), the rupture was not related to prominent hardware, and the cause was indeterminate in 12 patients (67%). Radiologic analysis of those in the indeterminate group demonstrated that 5 of the 12 patients had screws that had a high probability of being prominent. CONCLUSIONS: The incidence of EPL rupture after volar plating of DRF is between 0% and 1% and usually occurs about 3 months after fixation. Approximately 50% of EPL ruptures are attributable to prominent dorsal screws. Although screw prominence is an important cause of EPL rupture, it is not the sole cause of rupture.

Complications and Unplanned Reoperation After Thumb Metacarpophalangeal Arthrodesis.

PURPOSE: Arthrodesis of the metacarpophalangeal (MCP) joint of the thumb is a common procedure to treat arthritis or instability. Studies reporting hardware complications and nonunion rates after thumb MCP joint arthrodesis report on small sample sizes. We aimed to describe the hardware complication rate, the nonunion rate, and the number of thumbs that achieve union among patients undergoing thumb MCP joint arthrodesis. METHODS: A database spanning 5 urban hospitals in a single metropolitan region in the United States was searched for patients who underwent thumb MCP joint arthrodesis between January 1, 2004 and January 1, 2020. After reviewing patient records, we identified 122 thumbs that underwent MCP joint arthrodesis and had a minimum follow-up of 90 days. The primary outcome was unplanned reoperation after hardware complications and nonunion. Second, the number of thumbs that achieved radiographic union was reported for the tension band and screw fixation arthrodesis group. RESULTS: Twenty-two (18%) out of 122 thumbs had hardware complications after thumb MCP joint arthrodesis, and 11 (9%) out of 122 thumbs developed a nonunion. Patients who underwent screw fixation arthrodesis had no events of hardware complications and subsequent hardware removal. The nonunion rate was 9/65 (14%) in the tension band arthrodesis group and 2 (4%) of 45 in the screw fixation arthrodesis group. Of the thumbs that had available radiographs to assess the healing of the arthrodesis, 34 (81%) of 42 were radiographically united in the tension band arthrodesis group and 29 (91%) of 32 in the screw fixation group. CONCLUSIONS: Our data suggest that screw fixation has fewer hardware complications and a lower reoperation rate than tension band arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis.

BACKGROUND: The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR. METHODS: The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire. RESULTS: A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery. CONCLUSION: Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

DRUJ Capsular Release for Forearm Rotational Limitation: Surgical Technique and Case Series.

BACKGROUND: Forearm stiffness can be caused by distal radioulnar joint (DRUJ) capsular contractures, which can occur after trauma such as a distal radius fracture. In this setting, a DRUJ capsular release may help improve forearm rotation, but the long-term functional outcomes remain unknown. The purpose of this case series is to investigate the short-term improvement in total pronosupination arc range of motion and long-term patient-reported outcomes (PROs) after DRUJ capsular release. METHODS: We performed a retrospective review of consecutive patients who underwent DRUJ capsular release. Range of motion prior to surgery and at final short-term follow-up was collected and analyzed with a Wilcoxon signed-rank test. Patient-reported outcomes including QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores were obtained as medians with interquartile range (IQR), while patient satisfaction was measured on a 4-point Likert scale. RESULTS: Five patients met the inclusion criteria with a median short-term follow-up of 5.5 (IQR: 4.3-10.3) months. The median preoperative supination was 25° (IQR: 0°-35°), and the median postoperative supination was 50° (IQR: 40°-60°; P = .03). The median preoperative pronation was 45° (IQR: 10°-60°), and the median postoperative pronation was 70° (IQR: 60°-80°; P = .04). After the long-term median follow-up of 10.9 (IQR 9.7-11.2) years, all the patients were satisfied or very satisfied with the results of the surgery. The median QuickDASH score was 13.6 (IQR: 9.1-20.5), and the median PROMIS UE score was 46.5 (IQR: 43.8-47.7). CONCLUSIONS: Distal radioulnar joint capsular release can improve pronation and supination in patients with posttraumatic forearm stiffness and is associated with high long-term patient satisfaction.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Operative Trends in Orthopaedic Hand Surgery Fellowships.

Objective Since 1958, more than 50 postresidency fellowship programs in hand surgery have been introduced within the United States. Ongoing changes in health care and medical education necessitate the evaluation of these fellowships. The purpose of this study is to identify trends in operative experience over time regarding procedure volume, surgery type, and anatomic region. Materials and Methods National Accreditation Council for Graduate Medical Education (ACGME) case logs of graduating orthopaedic hand surgery fellows were evaluated for years 2011 to 2019. Procedures were grouped according to ACGME-defined categories for hand surgery. The mean number of procedures per fellow in each category was trended over time using a Mann-Kendall test. Results All 1,257 fellows were included. The mean number of procedures completed annually by each fellow increased from 797.6 in 2011 to 945.6 in 2019 ( p < 0.01). Over the course of the study period, there were increases in the number of "soft tissue," "fracture," and "nerve" procedures ( p < 0.001), while the number of "congenital" procedures decreased ( p < 0.05). Additionally, small but statistically significant increases were found in "amputation," "Dupuytren's," and "decompression of tendon sheath/synovectomy/ganglions" procedures ( p < 0.01). Conclusion There has been an increase in the number of procedures performed by orthopaedic hand surgery fellows over the past decade. This appears to be due to the increase in nerve, fracture, and soft tissue categories, and there has been a decrease in the number of congenital cases completed. These data confirm that the operative experiences for most hand surgery fellows are robust and growing over time.

Multimodal assessment of non-alcoholic fatty liver disease with transmission-reflection optoacoustic ultrasound.

Non-alcoholic fatty liver disease (NAFLD) is an umbrella term referring to a group of conditions associated to fat deposition and damage of liver tissue. Early detection of fat accumulation is essential to avoid progression of NAFLD to serious pathological stages such as liver cirrhosis and hepatocellular carcinoma. Methods: We exploited the unique capabilities of transmission-reflection optoacoustic ultrasound (TROPUS), which combines the advantages of optical and acoustic contrasts, for an early-stage multi-parametric assessment of NAFLD in mice. Results: The multispectral optoacoustic imaging allowed for spectroscopic differentiation of lipid content, as well as the bio-distributions of oxygenated and deoxygenated hemoglobin in liver tissues in vivo. The pulse-echo (reflection) ultrasound (US) imaging further provided a valuable anatomical reference whilst transmission US facilitated the mapping of speed of sound changes in lipid-rich regions, which was consistent with the presence of macrovesicular hepatic steatosis in the NAFLD livers examined with ex vivo histological staining. Conclusion: The proposed multimodal approach facilitates quantification of liver abnormalities at early stages using a variety of optical and acoustic contrasts, laying the ground for translating the TROPUS approach toward diagnosis and monitoring NAFLD in patients.

Quantitative 3-D CT Demonstrates Distal Row Pronation and Translation and Radiolunate Arthritis in the SNAC Wrist.

BACKGROUND: In scaphoid nonunion advanced collapse (SNAC) wrist arthritis, we analyzed the 3-dimensional (3-D) deformity patterns of carpal alignment secondary to scaphoid nonunion and quantified subchondral arthritis by investigating alterations in bone density. METHODS: We constructed 3-D models of the carpal bones and radius from 51 patients with scaphoid nonunion (nonunion group) and 50 healthy controls (control group). We quantified the differences in 3-D geometric position of the distal carpal row relative to the distal radius in SNAC wrists versus controls. In addition, we assessed the bone density of anatomic regions of interest in the radiocarpal and capitolunate joints relative to the pisiform bone density to characterize degenerative changes in SNAC wrists. RESULTS: The distal carpal row pronated by a difference of 14° (7.2° versus -6.7°; p < 0.001), deviated ulnarly by a difference of 19° (7.7° versus -11.2°; p < 0.001), shifted dorsally by a difference of 17% of the dorsovolar width of the distal radius (21.0% versus 4.4%; p < 0.001), shifted radially by a difference of 8% of the radioulnar width of the distal radius (13.2% versus 5.3%; p < 0.001), and migrated proximally by a difference of 12% of the lunate height (96.3% versus 108.8%; p < 0.001) in the nonunion group compared with the control group. Additionally, it was found that bone density was greater at the capitolunate joint (capitate head: 140.4% versus 123.7%; p < 0.001; distal lunate: 159.9% versus 146.3%; p < 0.001), the radial styloid (157.0% versus 136.3%; p < 0.001), and the radiolunate joint (proximal lunate: 134.8% versus 122.7%; p < 0.001; lunate fossa: 158.6% versus 148.1%; p = 0.005) in the nonunion group compared with the control group. CONCLUSIONS: Scaphoid nonunion exhibited a unique deformity pattern and alteration in bone-density distributions. The distal carpal row not only shifted dorsally and migrated proximally but also pronated, deviated ulnarly, and shifted radially. Bone density was greater at the capitolunate joint, the radial styloid, and surprisingly, the radiolunate joint. Our findings give insight into the natural history and progression of arthritis of the SNAC wrist. Additionally, future studies may give insight into whether successful treatment of scaphoid nonunion arrests the progression of arthritis. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Revision Arthroplasty in the Challenging Elbow.

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA) has a higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty.

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty.

Background Higher rates of prolonged opioid use have been reported in patients who undergo thumb carpometacarpal (CMC) arthroplasty compared with other hand procedures. Therefore, the aim of this study is to identify the risk factors associated with prolonged postoperative opioid use after CMC arthroplasty, along with reporting the number of patients who filled an opioid prescription more than 30 days postoperatively. Materials and Methods Retrospectively, 563 opioid-naïve patients who underwent CMC arthroplasty were included. A manual chart review was performed to collect patient characteristics, and opioid use was determined based on opioid prescription by a physician. Prolonged opioid use was defined as an opioid prescription at 90 to 180 days postoperatively. A multivariable analysis was performed to identify independent factors associated with an opioid prescription at 90 to 180 days postoperatively. Patients had a median age of 60.4 years (interquartile range [IQR]: 55.5-66.9) and had a median follow-up of 7.6 years (IQR: 4.3-12.0). Results The rates of postoperative opioid use ranged from 6.2% (53 out of 563 patients) at 30 to 59 days postoperatively to 3.9% (22 out of 563 patients) at 150 to 180 days postoperatively. In total, 17.1% (96 out of 563 patients) received a second opioid prescription more than 30 days following surgery, of which 10.8% (61 out of 563 patients) were between 90 and 180 days postoperatively. Older age, defined as a median of 63 years (IQR: 57.10-69.88) ( p = 0.027, odds ratio [OR] = 1.04) and a history of psychiatric disease ( p = 0.049, OR = 1.86) were independently associated with prolonged opioid use. Conclusion A prolonged opioid use rate of roughly 11% was found in opioid-naïve patients who underwent CMC arthroplasty. In patients at risk (older patients or psychiatric history) of prolonged opioid use, careful postoperative pain management is recommended.

Outcomes of Flexor Pollicis Longus Reconstruction for Volar Plate Related Ruptures.

Aim A rare complication following volar plate fixation of a distal radius fracture is flexor pollicis longus (FPL) rupture. This study aims primarily to analyze the radiographic features and secondly to report the patient-reported outcomes of FPL reconstruction after volar plate fixation. Methods Ten patients were retrospectively identified and contacted for follow-up. Seven patients participated in the study and completed the numeric rating scale (NRS) for pain, patient-reported outcome measurement information system-upper extremity (PROMIS-UE), and quick disability of arm, shoulder, and hand (QuickDASH) questionnaires at a median of 3.4 years following FPL reconstruction. Soong grade was determined on preoperative radiographs. Results Six patients were classified as Soong grade 1 and two patients had a screw or wire protruding volarly. The median time to tendon rupture was 21.6 months. At final follow-up, the median NRS pain score was 0 (range: 0-7); the median PROMIS-UE score was 47.1 (range: 25.9-61); and the median QuickDASH-score was 12.5 (range: 4.5-75). Conclusions The outcome of FPL reconstruction after volar plate fixation is highly variable. All ruptures in our cohort occurred in patients with plate positioning classified as Soong grade 1 and occurred at up to 3 years following distal radius fixation.

Reintervention, PROMs, and Factors Influencing PROMs Following Surgery for de Quervain's Tenosynovitis.

Objective The aims of this study are to describe and identify the factors that influence patient reported outcomes following surgery of de Quervain's tenosynovitis. The secondary objective is to report the rate of reintervention following surgery of de Quervain's tenosynovitis. Patients and Methods Outcomes using the numerical rating scale (NRS) for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Rated Wrist Evaluation (PRWE), the Patients Reported Outcome Measurement Information System Pain Interference (PROMIS PI), and a custom de Quervain's questionnaire were obtained. A multivariable linear regression analysis was performed to identify independent factors associated with patient-reported outcomes. Results Seventy-six patients who underwent de Quervain's release participated. The average age was 52.8 years (95% confidence interval: 49.6-56.1) and median follow-up age was 7.0 years (interquartile range [IQR]: 4.3-12.0). Outcomes were: NRS of pain was 0 (IQR: 0.0-3.0), the median QuickDASH was 6.82 (IQR: 0.00-28.41), the median PRWE score was 4.0 (IQR: 0.00-18.50), and the median PROMIS PI score was 43.90 (IQR: 38.70-53.90). Eighteen (23.7%) of the patients reported pain with thumb activities, four of whom had a reintervention. Additionally, 21 (26.9%) patients reported decreased strength in the thumb compared to the contralateral side, of which two underwent a reintervention. In total, eight patients underwent reintervention of which seven had a second surgery and one had a cortisone injection. Conclusion Roughly 1 in 20 patients following de Quervain's release undergoes reintervention. Patients with high PROMIS PI scores report poor surgical outcomes more frequently. Patients with high PROMIS PI scores report higher NRS pain scores ( p < 0.05), higher QuickDASH scores ( p < 0.05), and higher PRWE scores ( p < 0.05). In practice, careful consideration of PROMIS PI scores and psychosocial factors are recommended before considering reintervention.