Bridge Plate Distraction for Complex Distal Radius Fractures: A Cohort Study and Systematic Review of the Literature.

Background Dorsal bridge plating (DP) of the distal radius is used as a definitive method of stabilization in complex fracture configurations and polytrauma patients. Questions/Purposes This review aims to summarize the current understanding of DP and evaluate surgical outcomes. Methods Four databases were searched following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered with PROSPERO. Papers presenting outcome or complication data for DP were included. These were reviewed using the National Institutes of Health Quality Assessment and Methodological Index for Non-Randomised Studies tools. Results were collated and compared to a local cohort of DP patients. Results Literature review identified 416 patients with a pooled complication rate of 17% requiring additional intervention. The most prevalent complications were infection/wound healing issues, arthrosis, and hardware failure. Average range of motion was flexion 46.5 degrees, extension 50.7 degrees, ulnar deviation 21.4 degrees, radial deviation 17.3 degrees, pronation 75.8 degrees, and supination 72.9 degrees. On average, DP removal occurred at 3.8 months. Quality assessment showed varied results. There were 19 cases in our local cohort. Ten displayed similar results to the systematic review in terms of range of motion and radiographic parameters. Higher QuickDASH scores and complication rates were noted. Local DP showed earlier plate removal at 2.9 months compared to previous studies. Conclusion DP is a valid and useful technique for treating complex distal radius fractures. It displays a lower risk of infection and pain compared to external fixation which is commonly used to treat similar injuries. Patients can recover well following treatment both in function and range of motion. Further high-quality studies are required to fully evaluate the technique.

The anoikis-related gene signature predicts survival and correlates with immune infiltration in osteosarcoma.

Anoikis is essential for the progression of many malignant tumors. However, the understanding of anoikis' roles in osteosarcoma remains scarce. This study conducted an extensive bioinformatics analysis to identify anoikis-related genes (ARGs), developed ARGs modeles for predicting OS and RFS, and evaluated the effect of these ARGs on osteosarcoma cell migration and invasion. The GSE16088 and GSE28425 datasets provided the differentially expressed genes (DEGs). The prognostic significance and functions of these DEGs were systematically investigated using several bioinformatics techniques. Transwell assays were conducted to determine the effect of OGT on osteosarcoma cell migration and invasion. Seven genes were identified as hub genes, including FN1, CD44, HRAS, TP53, PPARG, CTNNB1, and VEGFA, while 71 ARGs were identified as DEGs. Four ARGs-BRMS, COL4A2, FGF2, and OGT-were used to develop an RFS-predicting model, whereas seven ARGs-CD24, FASN, MMP2, EIF2AK3, ID2, PPARG, and PIK3R3-were used to develop an OS-predicting model in patients with osteosarcoma. In both the training and validation cohorts, high-risk group patients had significantly shorter OS and RFS duration than low-risk group patients. Furthermore, using the aforementioned ARGs, we developed clinically applicable nomograms for OS and RFS prediction. The proportion of tumor-infiltrating immune cells was significantly linked to risk scores. In vitro experiments revealed that knocking down OGT significantly inhibited the ability of MG63 and U2OS cells to invade and migrate. ARG-based gene signatures reliably predicted RFS and OS in osteosarcoma, and OGT showed promise as a potential biomarker. These findings contribute to a better understanding of ARGs' prognostic roles in osteosarcoma.

SLC17A9 expression levels in a pan­cancer panel and validation of the role of SLC17A9 as a novel prognostic biomarker for osteosarcoma.

Previous studies have demonstrated the involvement of the solute carrier family 17 member 9 (SLC17A9) in certain types of cancer; however, the precise role of SLC17A9 is not well defined. In the present study, a comprehensive analysis was performed to determine the involvement of SLC17A9 in a pan-cancer panel. First, data on SLC17A9 expression levels from publicly available databases were obtained to determine SLC17A9 expression profiles in various types of cancer. Next, the involvement of SLC17A9 in the prognosis of patients, stemness indices and the immune microenvironment was examined in 34 types of cancer. Furthermore, CCK-8 and colony-formation assays were performed to determine the effect of SLC17A9 on osteosarcoma (OSS) cells. In a pan-cancer panel, a difference in SLC17A9 expression levels was observed in the tumor tissues as compared with healthy tissues. Furthermore, survival analysis revealed a significant association between SLC17A9 expression levels and the prognosis of patients with various cancer types, including adrenocortical carcinoma, kidney renal clear cell carcinoma, glioblastoma, kidney renal papillary cell carcinoma, low grade glioma, liver hepatocellular carcinoma, mesothelioma, lung adenocarcinoma, skin cutaneous melanoma, uveal melanoma, stomach adenocarcinoma and OSS. The results of the present study revealed correlations between stemness indices, tumor immunity and SLC17A9 expression levels. Furthermore, univariate and multivariate Cox regression analyses indicated that SLC17A9 may be utilized as an independent risk factor for overall survival of patients with OSS. In vitro experiments demonstrated that SLC17A9 promotes the proliferation and viability of OSS cells. Taken together, the results of the present study suggest an association between SLC17A9 and the prognosis of patients as well as tumor immunity in various cancer types. SLC17A9 may serve as a novel prognostic biomarker and target for improving the prognosis of patients with OSS.

Long Thoracic Nerve Palsy: When Is Decompression Indicated.

Scapular winging due to long thoracic nerve palsy can occur through traumatic injuries and nontraumatic events. The traditional view is that most patients will achieve spontaneous recovery within 2 years of winging onset. However, there is evidence that points to a less clear-cut natural history, with residual winging, muscle weakness, and fatigability being exhibited in a significant percentage of patients. Reports from proponents of a more proactive approach have shown that the surgical decompression of the long thoracic nerve beyond 12 months, through thoracic, supraclavicular, or combined approaches, can yield satisfactory results. This review examines our current understanding of long thoracic nerve palsy and explores the varying treatment strategies with their reported outcomes.

Study on a Natural Silk Cocoon Membrane-Based Versatile and Stable Immunosensing Platform via Directional Immunoaffinity Recognition.

The development of immunosensing assays for in vitro diagnostics has attracted great attention in recent years. Various substrate materials and immobilization methods of biomolecules were exploited for immunosensors, but their bioactivity and longevity have been facing serious challenges. To address this limitation, we investigated a natural silk cocoon membrane as immunosensing substrate material. By using its intrinsic properties, the target biomolecules were immobilized on the membrane through directional immunoaffinity recognition. The silk cocoon membrane-based immunosensor showed great potential for both qualitative and quantitative immunoassays, through naked-eye observation or analyzing the change in red color intensity, respectively. The immunosensor exhibited significant detection capability for anti-D (titer 1:1024) sensitized red blood cells. The colorimetric responses of concentrations ranged from 1 µg/mL to 1 ng/mL, and the detection limit for anti-D was 3.4 ng/mL. The immunosensor also showed excellent stability for the immobilized antibodies when stored at 4 and 25 °C; the bioactivity remained unchanged or slightly declined within 40 weeks. Even at 37 °C, the bioactivity began to decline after 12 weeks. This current work highlights the potential of using the natural silk cocoon membrane as a substrate for a versatile and thermally stable immunosensing platform for application in immunoassays.

A novel ferroptosis-related gene signature to predict overall survival in patients with osteosarcoma.

OBJECTIVES: Ferroptosis plays vital roles in the pathogenesis of various malignant tumors. However, knowledge on roles of ferroptosis in osteosarcoma remains scarce. In the present study, a comprehensive bioinformatics analysis was performed aiming to identify ferroptosis-related genes (FRGs), construct a FRGs-based model predicting overall survival (OS), and assess the impact of these FRGs on the migration and invasion of osteosarcoma cells. METHODS: Initially, data regarding differentially expressed FRGs were obtained from the GSE160881 dataset. Prognostic significance and possible biological functions of these differentially expressed FRGs were comprehensively and systematically explored adopting a series of bioinformatics methods. The impact of cystathionine ß-synthase (CBS) on migration and invasion of osteosarcoma cells were assessed using transwell assays. RESULTS: A total of 50 FRGs were differentially expressed. Four FRGs including G6PD, VEGFA, CBS, and HMOX1 were used to construct a model predicting OS in osteosarcoma patients. In the training cohort, patients with high risk had significantly poorer OS than those with low risk, which was also demonstrated in validation cohorts (GSE16091 and GSE39058). Furthermore, we established a clinically useful nomogram predicting OS using the four FRGs mentioned above. Risk scores were significantly associated with the proportion of tumor-infiltrating immune cells. Additionally, we used the Cytoscape software to identify hub FRGs, and found that TP53, HMOX1, SLC7A11, HRAS, VEGFA, and TXNRD1 were hub FRGs. By performing in vitro cell culture experiments, we demonstrated that invasion and migration capability of Saos2 and HOS cells were significantly weakened after CBS knock down. CONCLUSIONS: In conclusion, gene signatures based on four FRGs were reliable in predicting OS in patients with osteosarcoma. Findings from this study will enable a better understanding of the prognostic significance of FRGs and tumor immunity in osteosarcoma.

Arthroscopic bone graft and fixation for proximal scaphoid nonunions.

AIMS: This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. METHODS: This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. RESULTS: Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients' subjective pain score. No peri- or postoperative complications were encountered. CONCLUSION: Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946-952.

Development and Validation of Novel Prognostic Models for Immune-Related Genes in Osteosarcoma.

Immunotherapy has shown excellent therapeutic effects on various malignant tumors; however, to date, immunotherapy for osteosarcoma is still suboptimal. In this study, we performed comprehensive bioinformatic analysis of immune-related genes (IRGs) and tumor-infiltrating immune cells (TIICs). Datasets of differentially expressed IRGs were extracted from the GEO database (GSE16088). The functions and prognostic values of these differentially expressed IRGs were systematically investigated using a series of bioinformatics methods. In addition, CCK8 and plate clone formation assays were used to explore the effect of PGF on osteosarcoma cells, and twenty-nine differentially expressed IRGs were identified, of which 95 were upregulated and 34 were downregulated. Next, PPI was established for Identifying Hub genes and biology networks by Cytoscape. Six IRGs (APLNR, TPM2, PGF, CD86, PROCR, and SEMA4D) were used to develop an overall survival (OS) prediction model, and two IRGs (HLA-B and PGF) were used to develop a relapse-free survival (RFS) prediction model. Compared with the low-risk patients in the training cohort (GSE39058) and TARGET validation cohorts, high-risk patients had poorer OS and RFS. Using these identified IRGs, we used OS and RFS prediction nomograms to generate a clinical utility model. The risk scores of the two prediction models were associated with the infiltration proportions of some TIICs, and the activation of memory CD4 T-cells was associated with OS and RFS. CD86 was associated with CTLA4 and CD28 and influenced the infiltration of different TIICs. In vitro experiments showed that the knockdown of PGF inhibited the proliferation and viability of osteosarcoma cells. In conclusion, these findings help us better understand the prognostic roles of IRGs and TIICs in osteosarcoma, and CD86 and PGF may serve as specific immune targets.

Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation.

PURPOSE: We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS: This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS: Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS: Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Predictors for poor outcome for conservatively treated traumatic triangular fibrocartilage complex tears.

AIMS: The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis. METHODS: This was a retrospective analysis of 89 wrists in 88 patients between January 2015 and January 2019. All patients were managed conservatively initially with either a short-arm or above-elbow custom-moulded thermoplastic splint for six weeks. Outcome measures recorded included a visual analogue scale for pain, Patient-Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand score, and the modified Mayo Wrist Score (MMWS). Patients were considered to have had a poor outcome if their final MMWS was less than 80 points, or if they required eventual surgical intervention. Univariate and logistic regression analyses were used to identify independent predictors for a poor outcome. RESULTS: In total, 76% of wrists (42/55) treated with an above-elbow splint had a good outcome, compared to only 29% (10/34) with a short-arm splint (p < 0.001). The presence of a complete foveal TFCC tear (p = 0.009) and a dorsally subluxated distal radioulnar joint (DRUJ) (p = 0.032) were significantly associated with a poor outcome on univariate analysis. Sex, age, energy of injury, hand dominance, manual occupation, ulnar variance, and a delay in initial treatment demonstrated no significant association. Multiple logistic regression revealed that short-arm immobilization (p < 0.001) and DRUJ subluxation (p = 0.020) were significant independent predictive factors of an eventual poor outcome. CONCLUSION: Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation. Early surgery should be considered for patients with dorsal ulnar subluxation treated with short-arm splints to prevent prolonged morbidity. Cite this article: Bone Joint J 2021;103-B(8):1386-1391.

Scapular winging secondary to serratus anterior dysfunction: analysis of clinical presentations and etiology in a consecutive series of 96 patients.

BACKGROUND: This study aimed to establish the relative incidence of etiologies causing serratus anterior (SA) dysfunction in patients with proven abnormality on needle electromyography. METHODS: This was a retrospective review of patients with scapular winging secondary to SA dysfunction. Each patient underwent a detailed clinical, radiological, and neurophysiological assessment to arrive at the precise etiological diagnosis. Patients with atypical clinical features were referred for a neurologist's assessment. Hematological and genetic testing were requested at the discretion of the neurologist. A scapular winging severity score based on clinical signs was devised to aid clinical grading. RESULTS: Between 2014 and 2020, a consecutive series of 108 patients with suspected SA dysfunction were assessed, of whom 96 met the inclusion criteria. There were 34 females and 62 males, with a mean age of 38 years (range, 15-77 years). Winging affected the right scapulae in 69 patients, the left scapulae in 17 patients, and was bilateral in 10 patients. This was caused by a myopathic disorder in 12 (12%) patients. Eighty-four (88%) patients had a long thoracic nerve lesion, caused by cervical pathology (2), iatrogenic injury (2), trauma (33), and neuralgic amyotrophy (NA) (47). Among those with NA, winging resolved spontaneously within 3 years of onset in 22 patients (mean duration, 16 months; range, 3-36 months). No patients recovered fully if their duration of winging lasted longer than 3 years. Patients with palsy secondary to NA tended to have a worse severity of winging than those due to a traumatic cause (P = .04). CONCLUSION: NA accounted for approximately half of the patients with SA dysfunction; therefore, it is essential to also consider the differentials of myopathy, trauma, iatrogenic injury, and spinal pathology. We recommend the judicious employment of ancillary tests and a low threshold of referral to a neurologist, in order to arrive at the exact diagnosis to accurately guide patient treatment.

Initial Outcomes of a Novel High-Visibility Endoscopic Carpal Tunnel Release Technique.

Background A large variety of endoscopic carpal tunnel release methods have been described in efforts to shorten recovery time, reduce scar discomfort, and allow earlier return to work. The majority of existing techniques are the modifications of the Agee, Chow, and Menon techniques, all of which require dedicated equipment that can increase facility and surgical fees for the patient and institution. We present a novel high-visibility endoscopic carpal tunnel release technique that uses common hand surgery instruments available in all surgical units, without requiring disposable or custom devices. Description of Technique The cases were performed under local anesthesia using routine reusable instruments and a conventional 2.5-mm 30-degree small joint arthroscope. Following proximal dissection, a clear, colorless, plastic shield was created from a standard syringe that offered a 360-degree vision of the carpal tunnel and protection of the median nerve. Release of the transverse carpal ligament was performed under full arthroscopic vision using Metzenbaum dissection scissors. Methods This pilot study analyses the first nine cases in eight patients who were operated on using this technique, with a minimum of 6 months of follow-up. Results No peri- or postoperative complications were encountered. All patients demonstrated significant improvements in the Disabilities of the Arm, Shoulder, and Hand score, the Boston Carpal Tunnel Questionnaire score, and a visual analog score for pain. Conclusion The high-visibility endoscopic carpal tunnel release technique is safe and effective, and offers a viable cost-reducing alternative to the existing endoscopic methods for carpal tunnel syndrome. Future comparative trials are required to validate these findings in a larger series. Level of Evidence This is a Level IV study.

Arthroscopic ligament-specific repair for triangular fibrocartilage complex foveal avulsions: a minimum 2-year follow-up study.

This study reports the arthroscopic ligament-specific repair of the triangular fibrocartilage complex (TFCC) that anatomically restores both the volar and dorsal radioulnar ligaments into their individual foveal footprints. Twenty-five patients underwent arthroscopic ligament-specific repair with clinical and radiological diagnoses of TFCC foveal avulsions. The mean age was 28 years (range 14-47) and the mean follow-up was 31 months (range 24-47). Following arthroscopic assessment, 20 patients underwent double limb radioulnar ligament repairs and five had single limb repairs. At final follow-up, there were significant improvements in wrist flexion-extension, forearm pronation-supination and grip strength. There were also significant improvements in pain and patient-reported outcomes as assessed by the patient-rated wrist evaluation, Disabilities of the Arm, Shoulder and Hand score and modified Mayo wrist scores. Arthroscopic ligament-specific repair of the TFCC does not require specialist dedicated equipment or consumables and offers a viable method of treating these injuries.Level of evidence: IV.

Outcomes and Early Recurrence Following Enzymatic (Collagenase) Treatment of Moderate and Severe Dupuytren Contractures.

PURPOSE: We offer collagenase Clostridium histolyticum (CCH) injections to all patients with a Dupuytren contracture and a palpable cord. We assessed whether more severe contractures respond less well or recur more frequently. METHODS: From a database of 502 CCH injections, 386 (77%) had a complete dataset with minimum 1-year face-to-face follow-up. Contracture severity was assessed using the Tubiana system: grade 1 (27%), grade 2 (49%), grade 3 (19%), and grade 4 (5%). Patients received a single intralesional injection of 0.58 mg CCH followed by manipulation. Finger position was measured at 6 to 12 weeks, 6 months, and 1 year. Failure to break the cord, skin tears, and any adverse events were noted. Recurrence was defined as a failure to maintain any prior correction to within 20°. RESULTS: There were 17 failures (4%) and 6 allergic reactions (1%). We found 31% corrected completely, with approximately half remaining corrected at 1 year. We achieved 43° (95% confidence interval, 40°-46°) correction of combined deformity, with 11° (95% confidence interval, 9°-13°) correction attrition over 1 year. Sixteen percent of treated digits experienced a recurrence with no difference between Tubiana grades, and one-third chose further treatment. Following treatment, Tubiana grade 1 contractures improved by 78% in comparison with higher grade contractures (55%-67% relative correction). By 1 year, all grades had a similar mean 46% relative correction. A complete correction was seen in 61% of grade 1 contractures, with more severe contractures less likely to correct completely (9%-24%). A 31% skin tear rate had no impact on outcome, recurrence, or long-term morbidity. CONCLUSIONS: CCH may treat any Dupuytren cord regardless of severity. Although contracture may recur, few patients pursue further treatment within 1 year. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sensory Nerve Transfer for Lower Roots Brachial Plexus Injury: Superficial Radial Nerve to the Dorsal Cutaneous Branch and the Superficial Branch of the Ulnar Nerve.

In the treatment of brachial plexus injury to lower nerve roots, the priority is to restore motor function to the paralyzed hand. In addition, it is also important to consider sensory reconstruction, which is crucial to the optimal restoration of prehensile function. We report the surgical technique and sensory recovery of a nerve transfer in a case in which the superficial radial nerve was transferred to the dorsal cutaneous branch and the superficial branch of the ulnar nerve in a patient with C7, C8, and T1 roots injury. The nerve transfer successfully restored sensation in the ulnar one and a half digits as well as the ulnar border of the hand, with minimal donor site deficit. This technique provides a useful sensory reconstructive option in patients with brachial plexus injury to lower roots.

The Authors' Technique for Volar Plating of Scaphoid Nonunion.

Internal fixation of the scaphoid using a plate has been reported in the literature as far back as 1977. Recently, a specific plate designed for scaphoids has been developed, which provides considerably more buttress support than intramedullary headless screws, and offers a reliable method of rigid internal fixation for complex fractures. Indications to use such a plate include complex acute fractures, such as those with significant waist comminution or steep reverse oblique fractures, and complex nonunions with central bone loss resulting from failed previous headless screw fixation. This is now the authors' preferred treatment for these injuries.

Robot-assisted percutaneous scaphoid fracture fixation: a report of ten patients.

This study reports the technique, efficacy and safety of robotic-assisted, computer-navigated, percutaneous fixation of scaphoid fractures. Ten males with acute undisplaced waist fractures underwent fixation with this method using a commercially available three-dimensional fluoroscopy unit and robotic navigation system. The mean total operative duration was 40 minutes, which comprised of a set-up time of 18 minutes and planning and surgical time of 22 minutes. All patients required only a single guidewire insertion attempt, and there were no screw protuberances or other complications. All fractures united at a mean of 8 weeks. At a mean follow-up of 6.5 months (range 6-8), the mean Mayo wrist score was 96, patient-rated wrist evaluation was 2, flexion-extension arc was 96% and grip strength was 91% of the contralateral side. We conclude from our patients that robotic-assisted percutaneous scaphoid fixation is feasible, safe and accurate, and is a satisfactory method for treating these injuries. Level of evidence: IV.

Wrist arthroscopy for the treatment of scaphoid delayed or nonunions and judging the need for bone grafting.

This study reports outcomes of arthroscopy in the treatment of delayed or nonunions of 25 scaphoids (25 patients). The surgery was performed between 8 and 43 weeks after injury. Intraoperatively, 11 fractures were deemed stable to probing and underwent percutaneous screw fixation only; 14 were unstable and received arthroscopic bone grafting with percutaneous screw fixation. All fractures united. At a mean follow-up of 21 months (range 12-48), the mean Mayo wrist score was 96, and patient-rated wrist evaluation was 4, and the flexion-extension arc was 90% of the contralateral wrist. We conclude that arthroscopy is valuable in the treatment of scaphoid delayed or nonunions and in judging the need for bone grafting. Our data indicate that regardless of cystic formation in the scaphoid, bone grafting is not always necessary. Percutaneous fixation alone is sufficient when scaphoid delayed or nonunions are between 8 weeks and 1 year following injury, without scaphoid nonunion advanced collapse or dorsal intercalated segment instability, and when forceful probing confirms stability of the scaphoid arthroscopically. Level of evidence: IV.

The Goosebump Sign.

Nerve injury may occur following shoulder trauma. However, joint or bony damage can often dominate the clinical picture such that signs of nerve injury are overlooked. We describe the "goosebump sign" as a hitherto undescribed objective clinical finding of sympathetic dysfunction in peripheral nerve palsy, which can be a useful complementary sign to the standard assessment of muscle power and sensibility.

SRVis: Towards Better Spatial Integration in Ranking Visualization.

Interactive ranking techniques have substantially promoted analysts' ability in making judicious and informed decisions effectively based on multiple criteria. However, the existing techniques cannot satisfactorily support the analysis tasks involved in ranking large-scale spatial alternatives, such as selecting optimal locations for chain stores, where the complex spatial contexts involved are essential to the decision-making process. Limitations observed in the prior attempts of integrating rankings with spatial contexts motivate us to develop a context-integrated visual ranking technique. Based on a set of generic design requirements we summarized by collaborating with domain experts, we propose SRVis, a novel spatial ranking visualization technique that supports efficient spatial multi-criteria decision-making processes by addressing three major challenges in the aforementioned context integration, namely, a) the presentation of spatial rankings and contexts, b) the scalability of rankings' visual representations, and c) the analysis of context-integrated spatial rankings. Specifically, we encode massive rankings and their cause with scalable matrix-based visualizations and stacked bar charts based on a novel two-phase optimization framework that minimizes the information loss, and the flexible spatial filtering and intuitive comparative analysis are adopted to enable the in-depth evaluation of the rankings and assist users in selecting the best spatial alternative. The effectiveness of the proposed technique has been evaluated and demonstrated with an empirical study of optimization methods, two case studies, and expert interviews.