Hand Surgeons Are Tackling Tougher Scaphoids: A Study of ABOS Candidate Data.

BACKGROUND: This study will evaluate whether those who have completed a hand fellowship treat a disproportionate number of scaphoid fractures based on recent American Board of Orthopaedic Surgery (ABOS) data. We hypothesize that surgeons who have completed a fellowship in hand surgery will address most surgically treated scaphoid fractures, particularly those with fracture nonunions or requiring graft. METHODS: We queried the ABOS database for case log information submitted for part II of the ABOS examination. This search included all cases with Current Procedural Terminology codes for procedures related to scaphoid fixation. Demographic information, case volume, type of case, and complication rate were compared for hand fellowship-trained surgeons and those who had completed other fellowships as well as non-fellowship-trained surgeons. RESULTS: During the study period, 1686 surgeons reported treating 4244 scaphoid fractures. Of these surgeons, 1180 had completed a hand surgery fellowship. Hand fellowship-trained surgeons were shown to have operatively treated more scaphoid fractures both in total volume and on a per-surgeon basis. Hand fellowship-trained surgeons were also found to have performed a significantly higher proportion of difficult cases, which were those listed as being a malunion/nonunion or those incorporating a pedicle graft. There was no difference in the complication rate between the 2 groups. CONCLUSION: Among those orthopedic surgeons reporting case information for part II of the ABOS certification examination, statistically significant differences exist in case volume and case difficulty among surgeons with different areas of fellowship training. Complication rates increase with patient age and examination year.

Analysis of the Quality of Prospective Randomized Controlled Trials for Treatment of Boxer's Fractures.

BACKGROUND: This study aimed to review level I and II therapeutic studies on boxer's fractures to measure variation in quality among the highest level study designs. METHODS: We used quantitative measures of study quality to evaluate prospective randomized controlled trials (RCTs) of treatments of boxer's fractures. A search of PubMed, using terms "boxer's fracture" and "fifth metacarpal neck fracture" identified 164 articles from 1961 to 2019. From this list, we identified 6 RCTs. Two observers classified each trial according to 3 systems: the Oxford Levels of Evidence, the modified Coleman Methodology Score, and the revised Consolidated Standards of Reporting Trials (CONSORT) score. RESULTS: The 2 reviewers were consistent in their use of the Oxford Levels of Evidence (100% agreement). The differences between the average modified Coleman Methodology scores and the average CONSORT scores assigned by the 2 observers were not significant (46.2 vs 45.3 points, κ = 0) and (13.7 vs 14.3 points, κ = 0.33), respectively. Both observers rated all the studies as level I and as unsatisfactory according to the Coleman Methodology Score (100% and 100%), and less than half as unsatisfactory according to the CONSORT score (50% and 17%). Areas of deficiency included randomization, blinding, group comparability, clinical effect measurements, and allocation into treatment arms. CONCLUSION: Classifying orthopedic scientific reports according to the levels of evidence implies a degree of respect for level I and II studies that may not always be merited. Our data suggest that the quality of higher level studies, namely those involving boxer's fractures, varies and may often be unsatisfactory when critically evaluated.

Treatment patterns of ABOS part II candidates: A decline of operative management among geriatric proximal humerus fractures over the decade (2010-2020).

BACKGROUND: The purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010-2020 decade. METHODS: This retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region. RESULTS: A total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010-2015, 263.2 +/- 13.4) and the second half of the decade (2016-2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010-2015, 34.4 +/-11.7) and (2016-2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%). CONCLUSION: Despite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010-2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast.

Bone Morphogenic Protein-2 Use for the Surgical Treatment of Acute Scaphoid Fractures and Scaphoid Nonunions.

BACKGROUND: Bone morphogenic protein-2 has demonstrated promise as an adjunct to surgically treating fractures. Its reported use in the upper extremity is limited. This study reports union rates, outcomes, and complications of scaphoid fractures treated with adjunctive bone morphogenic protein-2 to further characterize bone morphogenic protein-2 use in the hand and wrist. METHODS: Retrospective review of scaphoid fractures treated surgically in one region of the Military Health System from 2009 to 2019 was conducted to identify cases using bone morphogenic protein-2. Fracture healing was determined by computed tomography. Primary outcomes were union rate, time to union, and complications. Secondary outcomes included union rates for prior nonunions, union rates at 4 and 6 weeks, and functional outcomes. RESULTS: Fourteen patients met inclusion criteria. Nonunions accounted for 50 percent of included fractures. The total union rate was 93 percent. Mean time to union was 6.2 weeks. All acute fractures healed with a mean time to union of 4.8 weeks. Nonunions had a union rate of 86 percent, with a mean time to union of 7.7 weeks. Four patients (29 percent) developed radiographic heterotopic ossification; however, no significant decrease in motion was appreciated. Thirteen patients (93 percent) resumed the push-ups portion of the military fitness test. No major complications were identified during follow-up. CONCLUSIONS: Adjunctive use of bone morphogenic protein-2 in operative fixation of scaphoid fractures resulted in desirable union rates without major complications. Larger, prospective studies are needed to assess whether adjunctive bone morphogenic protein-2 use in scaphoid fractures provides significant benefit compared with other treatments. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ten-Year Trends in Level of Evidence in Hand Surgery.

BACKGROUND: The purposes of this study were to analyze the trends in Oxford level of evidence (LOE), LOE of most-cited articles, and association between LOE and journal impact factor (IF) and SCImago Journal Rank (SJR) over a 10-year period (2009-2018) in 3 prominent hand surgery journals, specifically HAND, Journal of Hand Surgery (American Volume) (JHS), and Journal of Hand Surgery (European Volume) (JHSE). METHODS: All articles published from 2009 to 2018 in HAND, JHS, and JHSE were reviewed for assigned or available LOE. Data were pooled and analyzed for trends in LOE; relationship among IF, SJR, and LOE; and citation density. RESULTS: A total of 3921 total publications were tabulated from 2009 to 2018, with the majority of studies being level V (1700, 43%) and fewer studies being level I (146, 4%). Over the 10-year study period, there was no significant change in frequency of level I studies for any journal. HAND trended significantly toward higher LOE, JHS trended toward higher LOE, and JHSE trended toward decreased LOE without significance. Among all journals, the annual number of articles and the average LOE were independent significant predictors of IF and SJR. Statistically significant correlations were found between citation density and LOE for JHS and HAND. CONCLUSIONS: Higher quality evidence is becoming more prevalent in the hand surgery literature over the past 10 years. Annual articles, average LOE, and level I and II and level IV articles were significant predictors of increasing IF and SJR.

The Epidemiology of Hand and Finger Lacerations in United States Emergency Departments.

BACKGROUND: Hand and finger lacerations presenting to U.S. emergency departments (EDs) are common, although the burden of these injuries is not well understood. OBJECTIVE: Our aim is to describe the epidemiology and causes of hand and finger lacerations in U.S. EDs. METHODS: This National Electronic Injury Surveillance System database review investigates hand and finger lacerations presenting to EDs in the United States from 2015 to 2019. RESULTS: Annually, hand and finger lacerations account for 243,844 and 587,451 ED visits, respectively. Affected patients are frequently White (70.5%), male (63.4%), and aged 18 through 44 years (46.3%). The top three products linked to hand and finger lacerations are knives (30.5%), metal containers (4.2%), and drinkware (3.8%), and men are less likely to have injuries from these products than women, especially knives (odds ratio 0.76; 95% confidence interval 0.60-0.96; p < 0.02). Although a minority of hand and finger lacerations involve alcohol (1.2%), men have greater rates of alcohol involvement than women (χ21 = 11.7; p < 0.001). Lacerations frequently occur in the home (61.3%). Many patients (44.2%) present to very large hospitals, and nearly one-half of patients younger than 5 years and one-third of patients aged 5 through 17 years present to pediatric hospitals. Most patients (97.4%) are treated and released without admission and 0.2% are transferred to another hospital. Patients with alcohol, drug, or medication involvement are more likely to leave against medical advice, be admitted, or held for observation (p < 0.001). CONCLUSIONS: Hand and finger lacerations result in a significant number of ED visits. A better understanding of injury trends and presentations can guide injury prevention in manufacturing, education, and public health.

Treatment trends in distal humerus fractures between ABOS part II candidates.

PURPOSE: The purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF). METHODS: The American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications. RESULTS: There were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%). CONCLUSION: Our data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF. LEVEL OF EVIDENCE: III.

There Is No Role for Damage Control Orthopedics Within the Golden Hour.

INTRODUCTION: Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour." MATERIALS AND METHODS: The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour. RESULTS: Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified. CONCLUSIONS: Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.

Post-operative Immobilization in Total Elbow Arthroplasty for Rheumatoid Arthritis: A Systematic Review of Outcomes.

The purpose of this analysis is to determine the effect of length of immobilization following total elbow arthroplasty (TEA) for rheumatoid arthritis on the outcomes, complications, and survival of the implant. A review of TEA literature was performed. Post-operative motion was categorized into three groups: no post-operative immobilization (group 1), short-term 2-5 days immobilization (group 2), and extended 7-14 days immobilization (group 3). Thirty-six articles reporting on 43 studies involving 2,346 elbows in 2015 patients were included. Total complication rates were 23% at 8.9 years for group 1, 31% at 6.8 years for group 2, and 31% at 6.9 years for group 3. Survival rates were 79% at 15.3 years, 75% at 10.4 years, and 92% at 9.1 years for each group, respectively. Total complication rates were lowest in elbows without post-operative immobilization. However, survival rates were greatest in elbows with extended post-operative immobilization. (Journal of Surgical Orthopaedic Advances 31(4):209-217, 2022).

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Three-Dimensional Modeling of the Structural Microenvironment in Post-Traumatic War Wounds.

BACKGROUND: The development of post-traumatic heterotopic ossification (HO) is a common, undesirable sequela in patients with high-energy (war-related) extremity injuries. While inflammatory and osteoinductive signaling pathways are known to be involved in the development and progression of post-traumatic HO, features of the structural microenvironment within which the ectopic bone begins to form remain poorly understood. Thus, increasing our knowledge of molecular and structural changes within the healing wound may help elucidate the pathogenesis of post-traumatic HO and aid in the development of specific treatment and/or prevention strategies. METHODS: In this study, we performed high-resolution microscopy and biochemical analysis of tissues obtained from traumatic war wounds to characterize changes in the structural microenvironment. In addition, using an electrospinning approach, we modeled this microenvironment to reconstitute a three-dimensional type I collagen scaffold with non-woven, randomly oriented nanofibers where we evaluated the performance of primary mesenchymal progenitor cells. RESULTS: We found that traumatic war wounds are characterized by a disorganized, densely fibrotic collagen I matrix that influences progenitor cells adhesion, proliferation and osteogenic differentiation potential. CONCLUSION: Altogether, these results suggest that the structural microenvironment present in traumatic war wounds has the potential to contribute to the development of post-traumatic HO. Our findings may support novel treatment strategies directed towards modifying the structural microenvironment after traumatic injury.

C-terminal domain small phosphatase 1 (CTDSP1) regulates growth factor expression and axonal regeneration in peripheral nerve tissue.

Peripheral Nerve Injury (PNI) represents a major clinical and economic burden. Despite the ability of peripheral neurons to regenerate their axons after an injury, patients are often left with motor and/or sensory disability and may develop chronic pain. Successful regeneration and target organ reinnervation require comprehensive transcriptional changes in both injured neurons and support cells located at the site of injury. The expression of most of the genes required for axon growth and guidance and for synapsis formation is repressed by a single master transcriptional regulator, the Repressor Element 1 Silencing Transcription factor (REST). Sustained increase of REST levels after injury inhibits axon regeneration and leads to chronic pain. As targeting of transcription factors is challenging, we tested whether modulation of REST activity could be achieved through knockdown of carboxy-terminal domain small phosphatase 1 (CTDSP1), the enzyme that stabilizes REST by preventing its targeting to the proteasome. To test whether knockdown of CTDSP1 promotes neurotrophic factor expression in both support cells located at the site of injury and in peripheral neurons, we transfected mesenchymal progenitor cells (MPCs), a type of support cells that are present at high concentrations at the site of injury, and dorsal root ganglion (DRG) neurons with REST or CTDSP1 specific siRNA. We quantified neurotrophic factor expression by RT-qPCR and Western blot, and brain-derived neurotrophic factor (BDNF) release in the cell culture medium by ELISA, and we measured neurite outgrowth of DRG neurons in culture. Our results show that CTDSP1 knockdown promotes neurotrophic factor expression in both DRG neurons and the support cells MPCs, and promotes DRG neuron regeneration. Therapeutics targeting CTDSP1 activity may, therefore, represent a novel epigenetic strategy to promote peripheral nerve regeneration after PNI by promoting the regenerative program repressed by injury-induced increased levels of REST in both neurons and support cells.

Wartime Military Orthopaedics.

Military orthopaedic surgeons are faced with hardship and decreased morale. Surgeons have frequent deployments and practice inefficiencies resulting in poor retention rates. The purpose of this analysis is to report demographics and factors effecting military retention. A survey was sent to all members of the Society of Military Orthopedic Surgeons. The survey obtained demographic information, as well as factors affecting retention and termination of service. Data was compared between subset groups within the total respondent population. Of active-duty personnel, 38.5% plan on staying in the military until retirement. Most surgeons entered into the military due to a desire to serve their country, while most people leave service due to higher pay as a civilian. A minority of military orthopaedic surgeons achieve military retirement; however, increased pay, increased control over practice, and decreased frequency of deployments are factors that could improve retention rates. (Journal of Surgical Orthopaedic Advances 30(2):116-119, 2021).

Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review.

Background Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence This is a Level IC, therapeutic interventional study.

Epidemiology and Long-Term Outcomes of Wrist Sprains in Military Academy Cadets.

BACKGROUND: The American Society for Surgery of the Hand advises patients that symptoms after wrist sprains resolve in 6 weeks and that recovery is usually excellent; however, there is scant supporting evidence for this reassurance. PURPOSE: To describe the epidemiology and report long-term outcomes of wrist sprains. STUDY DESIGN: Descriptive epidemiology study. METHODS: The US Department of Defense Military Health System Management Analysis and Reporting Tool was queried for wrist sprain International Classification of Diseases, Ninth Revision, codes between 2005 and 2008 among US Military Academy cadets. The electronic medical records were reviewed to obtain demographic information, mechanism of injury, and patient characteristics. A telephone survey was conducted to collect Single Assessment Numeric Evaluation (SANE) score, the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and ability to return to full military duty. RESULTS: Of the 90 patients identified, 49 patients (50 wrists) met the final inclusion criteria. The mean patient age was 21 years, the majority were male (86%), and most sprains occurred during athletics (65%) and military activities (20%). Most patients (61%) had radiographs taken after index wrist sprain, and few (14%) underwent magnetic resonance imaging (MRI). After a mean follow-up of 10.4 years, most patients (78%) had no further wrist injury. The average SANE and QuickDASH scores were 88 and 7.5, respectively. Two patients (4%) ultimately were treated with surgical repair. Most patients (96%) were on an upper extremity profile, limiting military duty for a median of 14 days. All patients ultimately returned to full military duty. CONCLUSION: Patients with a wrist sprain diagnosis were followed for an average of 10 years. Although the majority (96%) of patients required a median of 14 days with limited upper extremity function, MRI is rarely indicated in the acute setting and most patients will never have another wrist injury and can expect excellent wrist recovery outcomes.

Incidence of Scaphoid Fractures and Associated Injuries at US Trauma Centers.

Backgound The scaphoid is the most commonly fractured carpal bone and often presents as a diagnostic challenge. Fractures can often go unnoticed on initial radiographic evaluation and clinical presentation can vary significantly among patients. Awareness of high-risk cohorts assists practitioners in making the appropriate clinical diagnosis of acute scaphoid fracture. Materials and Methods The National Trauma Data Bank is the world's largest trauma data repository. Utilizing the 2016 public use file, we isolated scaphoid fractures by anatomic fracture location by utilizing International Classification of Diseases, 10th revision coding. Reported cases of distal pole (S62.01), waist (S62.02), and proximal pole (S62.03) were included. This data was then queried to determine trends in mechanism of injury, demographic information, and associated injuries. Results There were a total of 968,665 patients with 2,769 cases of reported scaphoid fractures resulting in 286 scaphoid fractures per 100,000 person-years. Males were more likely to sustain a scaphoid fracture than females. The most commonly encountered associated injuries were distal radius fractures, distal ulnar fractures, and nonscaphoid carpal bone fractures, respectively. Conclusions Scaphoid fractures presenting to trauma centers are more commonly reported among males and those involved in motor vehicle accidents or falls. Appropriate scaphoid-specific radiographic imaging should be obtained as well as wrist and elbow images to evaluate for concomitant injuries, especially distal radius fractures.

Flexor Tendon Repair with Adjunctive Botulinum Toxin Administration: A Systematic Review.

Chemical denervation with Botulinum toxin has been proposed as an augment therapy to flexor tendon repairs to decrease complications including adhesions and re-rupture. We compiled and analyzed the results and complications for chemical denervation with Botulinum toxin in augmentation of flexor tendon repairs. Reviewed studies were from 1990-2018 and contained a minimum 3-month follow-up. A total of 26 patients were included in this review. All patients were reported to have excellent or good outcomes by the Strickland or Kleinert criteria. Complications were present in 9.3% of fingers including one with a flexion contracture, one with postoperative swelling, one with bowstringing, one with residual hypesthesia and first web contracture. Only one patient required re-operation. There were no cases of re-rupture or adhesions reported. All complications were unrelated to the use of Botulinum toxin. We conclude that Botulinum toxin therapy is a safe and efficacious augmentation to flexor tendon repair. (Journal of Surgical Orthopaedic Advances 30(1):036-039, 2021).

Multifocal calcific periarthritis with distinctive clinical and radiological features in patients with CD73 deficiency.

OBJECTIVES: Arterial calcification due to deficiency of CD73 (ACDC) is a hereditary autosomal recessive ectopic mineralization syndrome caused by loss-of-function mutations in the ecto-5'-nucleotidase gene. Periarticular calcification has been reported but the clinical characterization of arthritis as well as the microstructure and chemical composition of periarticular calcifications and SF crystals has not been systematically investigated. METHODS: Eight ACDC patients underwent extensive rheumatological and radiological evaluation over a period of 11 years. Periarticular and synovial biopsies were obtained from four patients. Characterization of crystal composition was evaluated by compensated polarized light microscopy, Alizarin Red staining for synovial fluid along with X-ray diffraction and X-ray micro tomosynthesis scanner for periarticular calcification. RESULTS: Arthritis in ACDC patients has a clinical presentation of mixed erosive-degenerative joint changes with a median onset of articular symptoms at 17 years of age and progresses over time to the development of fixed deformities and functional limitations of small peripheral joints with, eventually, larger joint and distinct axial involvement later in life. We have identified calcium pyrophosphate and calcium hydroxyapatite (CHA) crystals in SF specimens and determined that CHA crystals are the principal component of periarticular calcifications. CONCLUSION: This is the largest study in ACDC patients to describe erosive peripheral arthropathy and axial enthesopathic calcifications over a period of 11 years and the first to identify the composition of periarticular calcifications and SF crystals. ACDC should be considered among the genetic causes of early-onset OA, as musculoskeletal disease signs may often precede vascular symptoms.

Lower Extremity Combat Sustained Peripheral Nerve Injury in US Military Personnel.

Since the civil war, combat sustained peripheral nerve injuries (CSPNI) have been documented during wartime. Warfare has evolved and current combat involves a greater severity of blast injuries secondary to increased use of improvised explosive devices. The purpose of this study was to describe CSPNI and report outcomes after evaluation and treatment. We hypothesize that a shorter time to evaluation will improve outcomes. METHODS: A database including all active duty service members who sustained a CSPNI and were treated by the PNC between 2004 and 2009 was used. Service member demographic information, injury mechanism, CSPNI description, and Medical Research Council (MRC) final motor and sensory outcomes were queried from this database. RESULTS: One hundred and four military service members sustained 144 PNIs. The average age was 26.7 years, and nearly all were men (98.1%). There was no correlation between Sunderland classification and age, specific PNI, injury type, or time to evaluation. Higher Sunderland classifications were found to be correlated with worse final motor (r = 0.51, P < 0.001) and final sensory (r = 0.41, P < 0.001) scores. Final motor and sensory scores were not associated with specific nerve injury, mechanism of injury, initial EMG, or surgical procedure. Shorter time to initial assessment was associated with improved final motor and sensory scores, but was not found to be statistically significant. CONCLUSIONS: As the complexity of CSPNIs progress as combat weaponry evolves, a firm understanding of treatment factors is important. Our study demonstrates in recent conflict that military service members' initial injury severity is a key factor in expected outcome.