Assessment of Pronator Quadratus Repair Integrity Using Dynamic Ultrasonography Following Volar Plate Fixation for Distal Radius Fractures.

Background: Previous work evaluating the pronator quadratus (PQ) muscle following volar plate fixation (VPF) of distal radius fractures (DRF) suggests that PQ repair often fails in the postoperative period. The purpose of this investigation was to assess PQ repair integrity following VPF of DRF using dynamic musculoskeletal ultrasonography. Methods: Twenty adult patients who underwent VPF of DRF with repair of the PQ with a minimum follow-up of 3 months underwent bilateral dynamic wrist ultrasonography. The integrity of the PQ repair, wrist range of motion (ROM) and strength, and functional outcome scores were assessed. Results: Mean patient age at the time of surgery was 59 ± 14 years, and 50% underwent VPF of their dominant wrist. Patients were evaluated at a mean 9 ± 4 months after VPF. All patients had an intact PQ repair. The volar plate was completely covered by the PQ in 55% of patients and was associated with a larger PQ when compared to patients with an incompletely covered volar plate (P = .026). The flexor pollicis longus tendon was in contact with the volar plate in 20% of patients, with those patients demonstrating a trend toward significantly increased wrist flexion (P = .053). No difference in ROM, strength, or outcome scores was noted among wrists with completely or incompletely covered volar plates. Conclusions: The PQ demonstrates substantial durability after repair following VPF. Wrist ROM, strength, and functional outcomes are similar in wrists in which the volar plate is completely or incompletely covered by the repaired PQ.

Factors Affecting Operative Duration in Isolated Open Carpal Tunnel Release.

Background Open carpal tunnel release (CTR) is one of the most commonly performed operative procedures with operative duration being a primary metric of operating room efficiency. The purpose of this study was to identify factors associated with prolonged operative duration, in performing CTR. Materials and Methods CTR cases performed by a single surgeon from September 2013 to October 2015 were reviewed. Patient age at the time of surgery, sex, location of surgery (specialty orthopaedic hospital versus ambulatory surgery center), body mass index (BMI), American Society of Anesthesiologists classification, total operative duration (TOD), and procedure time (PT) were recorded. Obesity was defined as BMI > 30 and morbid obesity was defined as BMI > 35. Data were analyzed to identify factors associated with prolonged TOD or PT. Results One hundred and nine consecutive patients underwent isolated CTR. Mean age at time of surgery was 62 years (range: 24-92 years). Nonobese patients were found to have significantly shorter TOD than obese patients (22.3 vs. 24.4 minutes). Similarly, patients who were not morbidly obese had significantly shorter TOD than morbidly obese patients (22.6 vs. 26 minutes). No other factors were associated with prolonged TOD. No difference in PT was found between normal weight, obese, and morbidly obese groups. Conclusions TOD, but not procedure time, is significantly affected by obesity. Our findings are relevant when scheduling and preparing obese patients for surgery, which may have a significant impact on health resource utilization. Level of Evidence This is a Level III, economic/decision analysis study.

Radial Shaft Convergence in Distal Radius Fractures: Diagnosis and Treatment.

Radial shaft convergence in distal radius fractures is often misdiagnosed. This common deformation is often associated with a radial translation of the distal fragment. This parameter has to be corrected because of the increased risk of distal radioulnar joint instability due to detensioning of the distal interosseous membrane if there is an associated triangular fibrocartilage complex lesion. A new radiologic sign for diagnosis of proximal radius convergence during distal radius fracture is presented as well as technical tips for correction of this deformity.

Variation in pediatric orthopedic case volume among residents: an assessment of Accreditation Council for Graduate Medical Education case logs.

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

Orthopedic Oncology Caseload Among Orthopedic Surgery Residents.

Despite educational focus regarding orthopedic oncology during residency, assessment of resident orthopedic oncology caseload has not been performed. The purpose of this study was to evaluate orthopedic oncology caseload trends and variation among residents. The Accreditation Council for Graduate Medical Education case log reports for orthopedic surgery residents were reviewed for graduating years 2007 to 2013. Trends in orthopedic oncology cases and variation in the median number of cases performed by residents in the 90th, 50th, and 10th percentiles of caseload were evaluated. The proportion of orthopedic oncology caseload among all cases performed by residents increased significantly (P = 0.005) from 2007 to 2013. Likewise, the mean number of adult (P = 0.002), pediatric (P = 0.003), and total orthopedic oncology cases increased significantly (P = 0.002). On average, residents in the 90th, 50th, and 10th percentiles performed 83, 28, and 3 cases, respectively. The current study demonstrates a significant increase in adult, pediatric, and total orthopedic oncology caseload. There is also evidence of substantial caseload variation among residents. Caseload variation may influence the education and technical proficiency of orthopedic residents.

Assessment of Forearm Rotational Control Using 4 Upper Extremity Immobilization Constructs.

BACKGROUND: Forearm immobilization techniques are commonly used to manage distal radius, scaphoid, and metacarpal fractures. The purpose of our study was to compare the degree of rotational immobilization provided by a sugar-tong splint (STS), short arm cast (SAC), Munster cast (MC), and long arm cast (LAC) at the level of the distal radioulnar joint (DRUJ), carpus, and metacarpals. METHODS: Seven cadaveric upper extremity specimens were mounted to a custom jig with the ulnohumeral joint fixated in 90° of flexion. Supination and pronation were unrestricted. K-wires were placed in the distal radius, scaphoid, and metacarpals using fluoroscopic guidance to measure the total arc of rotation referenced to the ulnar ex-fix pin. Baseline measurements followed by sequential immobilization with well-molded STS, SAC, MC, and LAC were obtained with 1.25, 2.5, and 3.75 ft-lb of supination and pronation force directed through the metacarpal K-wire. Each condition was tested 3 times. Digital photographs were taken perpendicular to the ulnar axis to analyze the total arc of motion. RESULTS: The most effective constructs from least to greatest allowed rotational arcs were LAC, MC, SAC, and STS. Above-elbow constructs (MC, LAC) demonstrated superior immobilization compared with below-elbow constructs (SAC) ( P < .001). Circumferential constructs (SAC, MC, LAC) were superior to the noncircumferential construct (STS) ( P < .001). There were no significant differences between the MC and LAC in all conditions tested. CONCLUSIONS: Both circumferential and proximally extended immobilization independently improved rotational control of the wrist. However, extending immobilization proximal to the epicondyles did not confer additional stability.

Information on Orthopedic Trauma Fellowships: Online Accessibility and Content.

The internet is a popular resource for orthopedic fellowship applicants. We conducted a study to assess the accessibility of orthopedic trauma fellowship (OTF) program websites and to evaluate the content on the sites. We queried the online database of the Orthopaedic Trauma Association (OTA) and the online Fellowship and Residency Electronic Interactive Database (FREIDA) to assess available OTF program links. We used Google to assess how accessible the sites are from outside the databases. We then analyzed accessible sites for content pertinent to OTF applicants. Of the 49 OTF programs identified, 42 (86%) had their websites accessible from Google and FREIDA links. The OTA database had no OTF website links. Analysis of the 42 accessible OTF sites revealed they had an average of 40% (range, 0%-75%) of assessed content, with operative experience on 88% of sites and a program description on 93% of sites. OTF programs with >1 fellow had significantly more education content (48% vs 33%; P = .043) and total content (46% vs 37%; P = .01) on their sites than OTF programs with 1 fellow. Accessibility and content of OTF websites are highly variable and largely deficient. OTF programs should focus on improving their website accessibility and content.

Microsurgery Case Volume During Orthopedic Surgery Residency: A 7-Year Assessment.

BACKGROUND: Microsurgery is a specialized surgical technique with wide clinical application. The purpose of this study was to analyze case logs of graduating orthopedic surgery residents to assess trends in case volume for microsurgery procedures. METHODS: Accreditation Council for Graduate Medical Education case log reports were analyzed for microsurgery experience from 2007 to 2013. The mean number of adult, pediatric, and total microsurgery cases was noted. In addition, the median number of microsurgery procedures performed by the 90th, 50th, and 10th percentiles of residents (by case volume) was recorded. Temporal changes in case volume were calculated utilizing linear regression analyses. RESULTS: The proportion of microsurgery procedures increased significantly (1.3% to 2%; P = .024). The mean number of adult (24.5 to 41.9; P = .01), pediatric (1.9 to 3.4; P = .011), and total (26.3 to 45.3; P = .01) microsurgery procedures also increased significantly. Similarly, residents in both the 90th (63 to 109; P = .01) and 50th (10 to 21; P = .036) percentiles sustained significant increases in the median number of microsurgery procedures. No change was noted for residents in 10th percentile (0 to 0; P > .999). Graduating residents in the 90th percentile performed over 6 times more microsurgery procedures than residents in the 50th percentile. CONCLUSIONS: Microsurgical caseload is increasing among graduating orthopedic residents. However, there is substantial variability in resident microsurgery case volume. Future investigations are needed to explore the educational implications of these findings and should seek to correlate microsurgical caseload with competency.

Dorsal and Volar Surgical Approaches to the Metacarpophalangeal Joint: A Comparative Anatomic Study.

BACKGROUND: We compared 3 surgical approaches to the MP joint: a dorsal extensor tendon-splitting approach, a dorsal extensor tendon-reflecting parasagittal approach, and the volar A1 pulley approach. We quantitatively compared each of these approaches by measuring the amount of articular cartilage exposed on the base of the proximal phalanx. We hypothesize that visualization of the articular cartilage of the proximal phalangeal base is enhanced with the volar approach. METHODS: The MP joints of the 32 available digits were randomly assigned to 1 of 3 surgical approaches: extensor tendon splitting (A), extensor tendon reflecting (B), or volar approach (C). After each approach, the visible articular surface of the base of the proximal phalanx was stained with methylene blue. The MP joints were then disarticulated, and the proximal phalanges were digitally mapped using a 3-dimensional digitizer. Three-dimensional computer software was used to analyze and calculate the dyed exposed surface area and total surface area of each specimen. RESULTS: The mean % exposed joint surface area for the dorsal extensor splitting, dorsal extensor reflecting and volar approaches were 62%, 67% (over the dorsal side of the proximal phalanx) and 54% (over the volar side of the proximal phalanx), respectively. Multiple linear regression showed statistical significance for a smaller percentage of articular surface area exposed with the volar approach. However, this was not clinically significant. A significant association was found between location in the small finger and greater % exposed joint surface, compared to approaches in the index finger. In all volar approach specimens, the collateral insertion site was visible, but not in the dorsal approach specimens. CONCLUSIONS: Knowledge of the limits of each exposure is essential for planning the most appropriate surgical approach. The A1 pulley approach provided greater access to the volar 50% of the joint and collateral ligament insertion without violating the extensor mechanism. The amount of joint surface visualized through all 3 approaches was not significantly different. However, based on the accessibility to the collateral ligament insertion site among three different approaches, we recommend the volar A1 pulley approach for treatment of avulsion fractures of the base of the proximal phalanx. For other injuries of the MP joint, including the intra-articular proximal phalanx base fractures, and metacarpal head fractures, the dorsal approaches are still indicated.

Nonunion of greater trochanter following total hip arthroplasty: Treated by an articulated hook plate and bone grafting.

BACKGROUND: Trochanteric osteotomy still has an important role in hip arthroplasty in cases of (1) preexisting developmental hip dysplasia with superior subluxation, (2) revision arthroplasty, specifically with acetabular component revision in the face of well-fixed femoral component, and (3) recurrent dislocation without component loosening or malalignment, in treatment of complicated trochanteric fixation in osteoporotic bone and nonunions may be difficult. This study reports the clinical outcomes of trochanteric fixation following total hip arthroplasty (THA) utilizing a hook plate construct in a cohort of ten patients. MATERIALS AND METHODS: The Arbeitsgemeinschaft für Osteosynthesefragen (AO) articulated hook plate was used in nine cases of established approach related nonunion following THA and in one case of osteopenic bone during primary THA. All ten patients returned for interviews and clinical examination. The average time for clinical followup was 35 months (range 5-48 months). The mean age of the study cohort was 65 years (range 56-74 years). Time to union and incidence of postoperative complications were assessed. RESULTS: Union occurred in all ten cases at an average of 3.3 months postoperatively. One patient developed symptomatic trochanteric bursitis and required plate removal. Another patient developed a superficial infection which was successfully treated with local wound debridement and antibiotics. A third patient developed a symptomatic neuroma at the site of the iliac crest bone harvest and was successfully treated with excision of the neuroma. No catastrophic implant failures occurred. CONCLUSIONS: The articulated design of the plate allows for ease in application and functional construct stability. The articulated hook plate is an option for fixation of osteopenic bone fragments and established nonunions of the greater trochanter.

Total Wrist Arthroplasty Versus Wrist Fusion: Utilization and Complication Rates as Reported by ABOS Part II Candidates.

BACKGROUND: The aim of this study was to assess national trends in the utilization and complication rates of total wrist arthroplasty (TWA) and total wrist fusion (WF) as identified via review of the American Board of Orthopedic Surgery (ABOS) Part II candidate database. METHODS: The ABOS Part II candidate database is a collection of cases reported by candidates of the ABOS Part II board certification oral exam. The ABOS database was queried for all TWA and WF cases performed from 2005 to 2014. Linear regression analyses were used to assess trends in procedure utilization. Treatment diagnoses, patient characteristics, and reported complications were also compared between the 2 treatment cohorts. RESULTS: No significant increases in the proportion of candidates performing TWA or WF, number of TWA or WF cases, nor the number of TWA or WF cases performed per candidate performing those procedures were noted during the study period. Significantly less TWA cases were performed when compared with WF cases (68 vs 327; P = .006). Patients undergoing TWA were significantly older ( P = .005), more likely female ( P < .001), and more likely to have a diagnosis of osteoarthritis ( P = .003) than patients undergoing WF. There were no significant differences in complication rates, including postoperative infection, nerve palsy, or rate of secondary surgery, between the TWA and WF cohorts. CONCLUSIONS: Utilization of both TWA and WF has remained unchanged among emerging career orthopedic surgeons. Although WF is performed nearly 5 times more frequently than TWA, our short-term findings suggest that TWA compares favorably with WF.

Early Complications Following Osteosynthesis of Distal Radius Fractures: A Comparison of Geriatric and Nongeriatric Cohorts.

BACKGROUND: Distal radius fractures (DRFs) are common geriatric fractures with the overall incidence expected to increase as the population continues to age. The purpose of this investigation was to compare the short-term complication rates in geriatric versus nongeriatric cohorts following osteosynthesis of DRFs. METHODS: The American Board of Orthopaedic Surgery (ABOS) part II database was queried for adult DRF cases performed from 2007 to 2013. Current Procedural Terminology codes were used to identify cases treated via osteosynthesis. Patient demographic information and reported complication data were analyzed. Comparisons between geriatric (age ≥65 years) and nongeriatric (age <65 years) patients were performed. RESULTS: From 2007 to 2013, a total of 9867 adult DRFs were treated via osteosynthesis by ABOS part II candidates. Geriatric patients comprised 28% of the study cohort. Mean age of the geriatric and nongeriatric cohorts was 74 ± 7 and 46 ± 13 years, respectively. There was a greater proportion of female patients (P < .001) in the geriatric cohort as compared with the nongeriatric cohort. The geriatric cohort demonstrated higher rates of anesthetic complications (P = .021), iatrogenic bone fracture (P = .021), implant failure (P = .031), loss of reduction (P = .001), unspecified medical complications (P = .007), and death (P = .017) than the nongeriatric cohort. The geriatric cohort also showed lower rates of nerve palsy (P = .028) when compared with the nongeriatric cohort, though no differences in rates of secondary surgery were noted between the two cohorts. CONCLUSION: Increased rates of complications related to poor bone quality and poor health status may be expected among geriatric patients following osteosynthesis of DRFs. However, geriatric and nongeriatric patients have similarly low rates of secondary surgery. Future studies are needed to delineate the economic, functional, and societal impact of geriatric DRFs treated via osteosynthesis.

Foot and Ankle Fellowship Websites: An Assessment of Accessibility and Quality.

BACKGROUND: The Internet has been reported to be the first informational resource for many fellowship applicants. The objective of this study was to assess the accessibility of orthopaedic foot and ankle fellowship websites and to evaluate the quality of information provided via program websites. METHODS: The American Orthopaedic Foot and Ankle Society (AOFAS) and the Fellowship and Residency Electronic Interactive Database (FREIDA) fellowship databases were accessed to generate a comprehensive list of orthopaedic foot and ankle fellowship programs. The databases were reviewed for links to fellowship program websites and compared with program websites accessed from a Google search. Accessible fellowship websites were then analyzed for the quality of recruitment and educational content pertinent to fellowship applicants. RESULTS: Forty-seven orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 7 (15%) fellowship websites with the independent Google search yielding direct links to 29 (62%) websites. No direct website links were provided in the FREIDA database. Thirty-six accessible websites were analyzed for content. Program websites featured a mean 44% (range = 5% to 75%) of the total assessed content. The most commonly presented recruitment and educational content was a program description (94%) and description of fellow operative experience (83%), respectively. CONCLUSIONS: There is substantial variability in the accessibility and quality of orthopaedic foot and ankle fellowship websites. CLINICAL RELEVANCE: Recognition of deficits in accessibility and content quality may assist foot and ankle fellowships in improving program information online. LEVELS OF EVIDENCE: Level IV.

Volar-Ulnar Approach for Fixation of the Volar Lunate Facet Fragment in Distal Radius Fractures: A Technical Tip.

The volar Henry approach is most commonly used for surgical fixation of distal radius fractures. However, this approach is limited in achieving adequate exposure for the fixation of the volar-ulnar portion of the distal radius, rendering it difficult for the ideal placement of the fixation construct. We propose the use of the extensile volar-ulnar approach for fixation of distal radius fracture involving a small volar-ulnar fragment. This approach allows optimal reduction of the sigmoid notch and the volar lunate facet, which anatomically reduces both the radiocarpal joint and the sigmoid notch. In addition, extension of this approach may safely be performed if concomitant carpal tunnel release is necessary.

Surgical Treatment of Symptomatic Congenital Type I Lunotriquetral Coalition: Technique and a Report of 4 Cases.

Lunotriquetral (LT) synchondrosis is an uncommon variant of congenital LT coalition. Unlike complete LT fusions, this incomplete pseudoarthrosis-like coalition can become symptomatic. Surgical LT arthrodesis is a described treatment for this variant of LT coalition (Minnaar type I). We report 4 patients who underwent LT fusion with a second-generation headless compression screw and distal radius cancellous autograft. Fusion was achieved in all cases at an average of 2.5 months postoperatively. All the patients were satisfied with complete pain relief in 2 patients and minimal pain in 2 patients, and all improved their range of motion. We recommend this procedure, and report the techniques for this limited wrist arthrodesis as treatment for the symptomatic LT synchondrosis.

Accessory Slip of the Extensor Carpi Ulnaris: A Cadaveric Assessment.

Background An accessory slip arising from the extensor carpi ulnaris (ECU) tendon that inserts on the fifth metacarpal bone has been identified. We describe the frequency of this accessory slip arising from the ECU tendon and provide both qualitative and quantitative description of the slip via cadaveric examination. Methods Fifty (28 males and 22 females) cadaveric upper extremity specimens were examined after loupe-aided dissection of the dorsoulnar wrist and hand with identification of the ECU tendon. The presence of an accessory slip arising from the ECU tendon was noted. The insertion and morphology of the accessory slip was also described. Results An accessory slip arising from the ECU tendon at the level of the radiocarpal joint was found to insert on the fifth metacarpal bone in 11 (22%) specimens. Nine accessory slips inserted at the base of the fifth metacarpal (Nakashima Type A) and two inserted at the fifth metacarpal head (Nakashima Type C). Mean width of the accessory slip was 1.2 ± 0.4 mm. No evidence of sexual dimorphism was found regarding the morphology of the accessory slip. Conclusion The current study demonstrates the relative frequency and morphology of the accessory slip arising from the ECU tendon. This variant should be of diagnostic consideration in ailments of the dorsoulnar wrist and hand. Hand surgeons should be aware of this anatomic variant and its potential for clinical manifestation.

Hand Society and Matching Program Web Sites Provide Poor Access to Information Regarding Hand Surgery Fellowship.

The Internet is a common resource for applicants of hand surgery fellowships, however, the quality and accessibility of fellowship online information is unknown. The objectives of this study were to evaluate the accessibility of hand surgery fellowship Web sites and to assess the quality of information provided via program Web sites. Hand fellowship Web site accessibility was evaluated by reviewing the American Society for Surgery of the Hand (ASSH) on November 16, 2014 and the National Resident Matching Program (NRMP) fellowship directories on February 12, 2015, and performing an independent Google search on November 25, 2014. Accessible Web sites were then assessed for quality of the presented information. A total of 81 programs were identified with the ASSH directory featuring direct links to 32% of program Web sites and the NRMP directory directly linking to 0%. A Google search yielded direct links to 86% of program Web sites. The quality of presented information varied greatly among the 72 accessible Web sites. Program description (100%), fellowship application requirements (97%), program contact email address (85%), and research requirements (75%) were the most commonly presented components of fellowship information. Hand fellowship program Web sites can be accessed from the ASSH directory and, to a lesser extent, the NRMP directory. However, a Google search is the most reliable method to access online fellowship information. Of assessable programs, all featured a program description though the quality of the remaining information was variable. Hand surgery fellowship applicants may face some difficulties when attempting to gather program information online. Future efforts should focus on improving the accessibility and content quality on hand surgery fellowship program Web sites.

Trends in Upper Extremity Fracture Caseload Reporting During Orthopaedic Residency.

BACKGROUND: The objectives of this investigation were to report temporal trends in resident performed upper extremity fracture procedures and analyze case volume variability. METHODS: Orthopaedic resident case logs from the Accreditation Council for Graduate Medical Education were reviewed for graduating years 2007 to 2014. The mean number of wrist, forearm, elbow, humerus, and shoulder fracture-dislocation procedures performed by residents was analyzed. The median number of procedures reported by the top 30% and bottom 30% of residents (by case volume) was also recorded. Linear regression modeling was used to assess temporal trends. RESULTS: The mean number of wrist and forearm fracture cases performed per resident fell from 55.3 in 2007 to 46.7 in 2014 (p = 0.325) while the number of elbow and humerus fracture procedures remained relatively constant (45.6 to 45.4; p = 0.224). The mean number of shoulder fracture cases increased significantly (14.7 to 22.5; p < 0.001). Over the 8-year period, residents in the 70th percentile of caseload performed significantly more wrist and forearm (62.6 versus 39.5; p < 0.001), elbow and humerus (55 versus 34.9; p < 0.001), and shoulder (23 versus 12.9; p < 0.001) fracture procedures than residents in the 30th percentile. CONCLUSION: Resident case volume for wrist, forearm, elbow, and humerus fractures is constant or falling. However, shoulder fracture caseloads are increasing. Regardless, there is substantial disparity in upper extremity fracture case volume among residents. Further investigation is needed to assess possible educational effects of resident caseload disparity.

Trends in the Utilization of Total Wrist Arthroplasty versus Wrist Fusion for Treatment of Advanced Wrist Arthritis.

BACKGROUND: Total wrist arthroplasty (TWA) provides the requisite range of motion to accomplish activities of daily living, especially for low-demand patients with bilateral wrist arthritis. However, there are no large epidemiologic studies to evaluate nationwide trends of TWA and wrist fusion (WF). QUESTIONS/PURPOSES: To analyze data collected from the National Inpatient Sample (NIS) to compare utilization, demographic, and outcome data among patients undergoing TWA versus total WF. We hypothesized that utilization rates of TWA have significantly increased over the prior decade in the United States. METHODS: NIS data from 2001 to 2010 were reviewed. Procedures were identified by ICD-9-CM codes 81.73 (TWA) and 81.25 (WF). Utilization rates, primary treatment diagnoses, patient demographic and medical comorbidity data, and procedure costs were compared between TWA and WF. RESULTS: There was a decrease in the number of procedures per year for TWA, while the number of WF remained relatively unchanged. There was, however, a transient increase in the frequency of TWA procedures performed from 2005 to 2008, following a decline in 2005. Patients with traumatic arthritis were more likely to receive WF. Rheumatoid patients were more likely to receive TWA. Patients receiving TWA tended to be older, female, be insured by Medicare, have a greater comorbidity burden, and have rheumatologic disease. CONCLUSION: WF was performed nearly four times more frequently than TWA. A trend was demonstrated toward a decreasing number of TWA being implanted, and in patients with more underlying comorbidities. TWA was associated with a higher hospitalization charge, which may be expected given the higher implant costs associated with arthroplasty. LEVEL OF EVIDENCE: Level II, prognostic study.

Mechanical Evaluation of Four Internal Fixation Constructs for Scaphoid Fractures.

BACKGROUND: The objective of this study was to compare the mechanical performance of 4 different constructs for fixation of oblique scaphoid fractures. METHODS: Twenty-eight synthetic scaphoids underwent an oblique osteotomy along the dorsal sulcus. Each was randomly assigned to fixation by 1 of 4 methods: two 1.5-mm headless compression screws, one 2.2-mm screw, one 3-mm screw, or a 1.5-mm volar variable-angle plate. After fixation, scaphoids were potted at a 45° angle and loaded at the distal pole by a hydraulically driven mechanical testing system plunger until the fixation failed. Excursion and load were measured with a differential transformer and load cell, respectively. From these data, the stiffness, load-to-failure, and maximum displacement of each construct were calculated. RESULTS: The 2.2-mm screw demonstrated the highest stiffness and the two 1.5-mm screws had the lowest. However, there were no significant differences among the fixation methods in terms of stiffness. Both 2.2- and 3-mm screw constructs had significantly higher loads-to-failure than two 1.5-mm screws. The maximum load for the plate approached, but did not achieve, statistical significance compared with the 1.5-mm screws. There was no significant difference among constructs in displacement. CONCLUSIONS: All constructs demonstrated similar mechanical properties that may provide sufficient stability for effective clinical use. Given their significantly higher loads-to-failure, a 2.2- or 3-mm screw may be superior to two 1.5-mm screws for fixation of unstable scaphoid fractures. The volar plate did not have superior mechanical characteristics to the compression screws.