Appropriateness and Reliability of an Online Artificial Intelligence Platform's Responses to Common Questions Regarding Distal Radius Fractures.

PURPOSE: Chat Generative Pre-Trained Transformer (ChatGPT) is a novel artificial intelligence chatbot that is changing the way humans gather information online. The purpose of this study was to investigate ChatGPT's ability to appropriately and reliably answer common questions regarding distal radius fractures. METHODS: Thirty common questions regarding distal radius fractures were presented in an identical manner to the online ChatGPT-3.5 interface three separate times, yielding 90 unique responses because ChatGPT produces an original answer with each query. All responses were graded as "appropriate," "appropriate but incomplete," or "inappropriate" by a consensus discussion among three hand surgeon reviewers. The questions were additionally subcategorized into one of four domains based on Bloom's cognitive learning taxonomy, and descriptive statistics were reported. RESULTS: Seventy of the 90 total responses (78%) produced by ChatGPT were "appropriate," and 29 of the 30 questions (97%) had at least one response considered appropriate (of the three possible). However, only 17 of the 30 questions (57%) were answered appropriately on all three iterations. The test-retest reliability of ChatGPT was poor with an intraclass correlation coefficient of 0.12. Finally, ChatGPT performed best answering questions requiring lower-order thinking skills (Bloom's levels 1-3) and less well on level 4 questions. CONCLUSIONS: This study found that although ChatGPT has the capability to answer common questions regarding distal radius fractures, caution should be taken before implementing its use, given ChatGPT's inconsistency in providing a complete and accurate response to the same question every time. CLINICAL RELEVANCE: As the popularity and technology of ChatGPT continue to grow, it is important to understand the potential and limitations of this platform to determine how it may be best implemented to improve patient care.

Patient and Caregiver Impressions of the Impact of Madelung Deformity: A CoULD Registry Analysis.

PURPOSE: This study seeks to investigate demographics of patients with Madelung deformity in a large, geographically diverse sample and understand patient and caregiver perceptions of the impact of this condition. We hypothesized that patients with untreated Madelung deformity have greater pain and lower function compared to the normal population but are less affected than the chosen control group, namely, patients with proximal radioulnar synostosis (PRUS). METHODS: This retrospective study queried the Congenital Upper Limb Differences (CoULD) Registry, a multicenter registry of patients treated in tertiary care pediatric hospitals. We searched patients enrolled as of July 2022 and identified 3,980 total patients and 66 (1.7%) with a diagnosis of Madelung deformity. We reviewed demographics and Patient-Reported Outcomes Measurement Information System (PROMIS; peer relations, depressive symptoms, pain interference, and upper extremity function domains) scores at time of enrollment. We used a matched cohort comparison with propensity scoring for 50 patients with Madelung deformity and 50 patients with PRUS (control cohort). RESULTS: Patients with Madelung deformity presented at an average age of 13.1 years (± 2.1 years). Ninety-eight percent were female, and 82% were White. Seventy-four percent had distal radius-only deformity. Upper extremity PROMIS scores in both the Madelung deformity and the PRUS groups were significantly "worse" than normal, confirming our hypothesis. The Madelung deformity and PRUS cohort scores were not consistently different from one another. PROMIS scores from all other domains, including pain interference, were similar to, or better than normal for both groups, disproving the second part of our hypothesis. CONCLUSIONS: Patients with Madelung deformity averaged 13 years of age and were nearly all female, and the majority had only distal involvement of the radius. Patients with Madelung deformity had lower function based on PROMIS scores, similar to the control cohort, whereas all other PROMIS measures were similar to or better when compared to normal values. Pain interference scores in both cohorts were lower than normal values. Patients with Madelung deformity have decreased function, similar to the comparative cohort of patients with PRUS, but do not present with increased pain. TYPE OF STUDY/LEVEL OF EVIDENCE: Symptom Prevalence III.

Radiographic Features of the Metacarpal in Blauth Type III Thumb Hypoplasia.

PURPOSE: The purpose of this study was to investigate whether radiographs can be used to aid in the determination of Blauth IIIA and IIIB thumbs. METHODS: Six pediatric hand surgeons were asked to evaluate the radiographs of 77 thumbs and classify the thumb as IIIA or IIIB and indicate which morphologic features influenced their decision. Quantitative measurements and ratios of radiographs were obtained and compared between IIIA and IIIB thumbs. RESULTS: The radiographic features selected for type IIIA thumbs include near-normal length and near-normal width and for type IIIB thumbs, abnormally short, tapered proximal end, and round proximal end. The six surveyed surgeons reached consensus in 82% (63/77) of thumbs, and this matched the enrolling surgeon's classification in 77% (59/77) cases. The ratio of the length of the thumb metacarpal compared with the length of the index metacarpal was different between IIIA and IIIB thumbs (66% ± 0.08% and 46% ± 0.18%, respectively). The ratio of the width of the thumb metacarpal shaft at its narrowest aspect to the width of the thumb metacarpal base was notably different between IIIA and IIIB (68% ± 0.13% and 95% ± 0.28%, respectively). CONCLUSIONS: Near-normal length and near-normal width of the metacarpal were used to predict IIIA and abnormally short, abnormally narrow, and a round or tapered base of the metacarpal were used to predict IIIB classification. The length of the thumb metacarpal relative to the index metacarpal is on average 66% of the length of the index metacarpal in IIIA thumbs compared with 46% in IIIB thumbs. The width of the shaft of the thumb metacarpal at its narrowest is 68% of the width of the thumb metacarpal base in IIIA thumbs, indicating a flared base. In IIIB thumbs, the shaft width was on average 95% of the base width, indicating a tapered base. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic level III.

Reliability of Wrist Arthroscopy in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Tears.

PURPOSE: Wrist arthroscopy is considered the gold standard for diagnosis of intra-articular wrist conditions including triangular fibrocartilage complex (TFCC) tears; however, the ability to reliably diagnose TFCC pathology during wrist arthroscopy is unclear. The purpose of this study was to assess the reliability of the diagnosis of TFCC tears on wrist arthroscopy videos. METHODS: Five hand surgeons reviewed 43 cases on a secure web-based platform at two time points separated by 4-6 weeks. Each case included a deidentified clinical vignette and wrist radiographs with ulnar variance measurements and an arthroscopy video of ulnar wrist pathology, averaging 42 seconds. Surgeons were queried on the presence of TFCC tear and Palmer and Atzei classifications. Interobserver/intraobserver reliabilities were determined using kappa coefficients. RESULTS: The interobserver reliability regarding the presence/absence of TFCC tear was fair-good, with kappa coefficients of 0.596 in the first round of case review and 0.708 in the second round. The overall intraobserver reliability for the presence/absence of TFCC tear was also fair-good, with a kappa coefficient of 0.567. For cases with central TFCC tears, the interobserver reliability regarding the presence of TFCC tear was perfect, with a kappa coefficient of 1.0. When central tears were excluded, the kappa coefficients decreased to 0.322 and 0.368 in each round. The interobserver reliability for the Palmer and Atzei classifications was low, with kappa coefficients of 0.220 and 0.121 in the first round and 0.222 and 0.123 in the second round. CONCLUSIONS: Experienced wrist arthroscopy surgeons demonstrated fair-good interobserver reliability for the diagnosis of TFCC tear on wrist arthroscopy. However, when central TFCC tears were excluded, interobserver reliability was poor. These findings demonstrate a need for a focus on education for wrist arthroscopy anatomy. CLINICAL RELEVANCE: This investigation demonstrated poor agreement in surgeon identification and classification of TFCC tears, aside from central TFCC tears. The low reliability has a direct bearing on treatment considerations for TFCC tears.

A Prospective Randomized Pilot Study: One-Year Outcomes of Ligament Reconstruction Tendon Interposition Versus Suture Tape Suspensionplasty for Thumb Carpometacarpal Joint Arthritis.

PURPOSE: We performed a randomized controlled trial assessing patient-reported outcome measures following trapeziectomy with ligament reconstruction and tendon interposition (LRTI) or suture tape suspensionplasty (STS) for treatment of thumb carpometacarpal joint osteoarthritis. METHODS: Patients undergoing surgery for thumb carpometacarpal joint osteoarthritis were prospectively randomized to LRTI or STS. Outcome measures were collected at 2 weeks, 4 weeks, 3 months, and 1 year and included visual analog scale pain, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity, return to work/activity, range of motion, grip/pinch strength, and complications. RESULTS: Thirty-one patients (32 thumbs) were randomized from 51 patients offered participation over two years. One-year follow-up was 97%. Both groups had a decrease in visual analog scale pain scores at all postoperative time points. The trajectory of postoperative Patient-Reported Outcomes Measurement Information System Upper Extremity scores was similar, and both groups achieved the meaningful clinically important difference for improvement in PROMIS Upper Extremity by three months. Grip strength was substantially increased in both groups at one year. Return to work/activity and surgical complications favored the LRTI group. CONCLUSIONS: Our study did not suggest any clinically relevant differences in the postoperative patient-reported outcome measures or objective clinical measurements between LRTI and STS, although LRTI patients had a faster return to work/activity and lower complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IIB.

The Role of Routine Pathologic Assessment After Pediatric Osteochondroma Excision.

BACKGROUND: Osteochondromas are benign osseous lesions often excised for pain, growth abnormalities, and aesthetic concerns. While characteristic clinical and radiographic features leave little diagnostic ambiguity in most cases of osteochondroma, pathologic analysis to confirm the diagnosis and screen for malignancy is routinely performed following surgical excision. The purpose of this study was to determine the clinical and economic value of routine pathologic analysis after osteochondroma excision in a pediatric population. METHODS: A retrospective review of clinical records from 2 pediatric orthopaedic hospitals (St. Louis Children's Hospital and Shriner's Hospital for Children, St. Louis) identified 426 osteochondroma lesions surgically resected from 201 patients. Patients with solitary and multiple lesions were included. Clinical, radiographic, and surgical data were recorded for each resection surgery. Pathologic reports were evaluated. Costs incurred for routine pathologic assessment was also noted. RESULTS: Totally, 132 patients were treated with surgical resection of a solitary osteochondroma lesion, while an additional 291 lesions were resected from 69 patients with multiple lesions. Average age at the time of surgical resection was 13.0 years (2.1 to 17.9). The most common anatomic locations of excised lesions included the distal femur (110, 25.8%), proximal tibia/fibula (95, 22.3%), and distal radius/ulna (58, 13.6%). All resected specimens were sent for pathologic analysis. The average size of the resected lesions was 19.9 mm 3 (0.02 to 385.0 mm 3 ). In all cases, the histologic diagnosis confirmed benign osteochondroma. The total charges of pathologic analysis including processing and interpretation fees was ∼$755.00 for each lesion assessed, for a total cohort charge of $321,630. CONCLUSION: We propose that in most cases of pediatric osteochondroma excision procedures, postoperative histologic analysis is not strictly indicated as it rarely, if ever, alters diagnosis or management. We suggest using a "gross only" analysis in these cases. However, we do believe that with preoperative diagnostic ambiguity, or if patients present with concerning features such as rapidly expansile lesions or cortical destruction, have axial skeleton or pelvic involvement, or enlarged cartilaginous caps, full histologic evaluation of the excised lesions will continue to be prudent. LEVEL OF EVIDENCE: Level IV-case series.

Study Characteristics and Impact of Pediatric Orthopaedic Society of North America Annual Meeting's "Best Papers" From 2009 to 2019.

OBJECTIVE: Award-winning abstracts are selected every year at the Pediatric Orthopaedic Society of North America (POSNA) annual meeting as "best paper" or poster. It is unknown how many achieve publication in peer-reviewed journals and the impact they have. We sought to determine the characteristics, including the level of evidence (LoE), publication rates, and the impact of award-winning abstracts on pediatric orthopaedic surgery practice from 2009 to 2019. METHODS: Award-winning abstracts or "best papers" from 2009 to 2019 were retrospectively reviewed from the POSNA website from abstract publication to manuscript publication. A search across Pubmed was used to match abstracts to their publications by comparing author names, titles, study design and methodology, results, and conclusions. Area of focus, abstract authors, institutions, publication status, LoE, time to publication, authors of publication, journals of publication, and the journal's latest Hirsch Index and impact factor were recorded. RESULTS: There have been 54 "best papers" at the POSNA annual meeting from 2009 to 2019. Of those, 39 have been published across 17 different journals for a publication rate of 72%. The average time from abstract presentation to publication was 21.2 months with a range of 0 to 121 months. Of the published award-winning abstracts, 64% (25) were published within 2 years, 87% (34) within 3 years, and 95% (37) within 4 years. Out of the published abstracts, 26% (10) were in the Journal of Pediatric Orthopaedics , 23% (9) were in the Journal of Bone and Joint Surgery , and 10% (4) were in the Journal of Child Orthopaedics . The median number of abstract authors was 4 and increased to a median of 6 authors once published. Most award-winning abstracts had a LoE of 3. The average journal impact factor for all publications was 4; the average Hirsch Index for the corresponding author was 29.9, and the average number of citations for a publication was 41 with a range of 0 to 270. CONCLUSIONS: The majority of the "best papers" presented at POSNA annual meetings from 2009 to 2019 were published in peer-reviewed journals within 2 years of presentation, with approximately half being published in the Journal of Pediatric Orthopaedics or Journal of Bone and Joint Surgery . The publication rate of "best papers" at the POSNA annual meeting was found to be higher than rates reported for abstracts presented at the annual meetings of POSNA, American Society for Surgery of the Hand and European Pediatric Orthopaedic Society, but similar to the rates observed for American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, and Orthopaedic Trauma Association. Most of the selected "best papers" at the POSNA annual meeting are published and have a substantial impact on pediatric orthopaedic surgery practice. LEVEL OF EVIDENCE: Level IV.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome.

PURPOSE: The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome. METHODS: A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods. RESULTS: A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error. CONCLUSIONS: The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms. CLINICAL RELEVANCE: Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Outcomes of Acute Repair Versus Nonrepair of Zone I Flexor Digitorum Profundus Tendon Injuries.

PURPOSE: The aim of this study was to determine whether the clinical results of zone I flexor digitorum profundus (FDP) tendon injuries managed with acute surgical repair are comparable to the clinical results of those managed without repair (eg, primary FDP excision or observation). METHODS: Patients aged ≥18 years presenting to a level 1 trauma center between 2015 and 2020 with zone I FDP tendon injury were identified with retrospective chart review. We assessed the following data: age, sex, physical therapy visits, surgical intervention, surgical complications (including infection, repeat surgery after the primary intervention, and rupture of repair), and patient-reported outcomes measurement information system scores. RESULTS: Twenty-six patients met the inclusion criteria. Group 1 (N = 15 patients, 23 fingers) patients were treated with acute surgical repair. Group 2 (N = 11 patients, 11 fingers) patients were managed without surgical repair, including FDP excision (N = 7) or observation alone (N = 4). In group 1, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.6 cm (range, 0-4 cm). Fourteen of the 15 patients participated in >3 therapy visits. The following complications occurred: 4 fingers with rerupture (2 patients), 4 fingers with surgical wound dehiscence (2 patients), 3 infections (2 patients), and 4 repeat surgeries for these complications. In group 2, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.1 cm (range, 0.5-3 cm). There were no infections, episodes of wound dehiscence, or repeat surgeries. At the final follow-up, both groups showed clinically meaningful improvement on Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and physical function scores, with similar PROMIS domain scores between groups. CONCLUSIONS: Patients treated without FDP tendon repair had similar outcomes to, and fewer complications than, patients treated with acute tendon repair. Our data suggest that the notable commitment of health care costs, time, and adherence to protocols/restrictions after surgical repair may not confer functional benefit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum.

PURPOSE: Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients. METHODS: This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance. RESULTS: Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI. CONCLUSIONS: This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play.

PURPOSE: This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes. METHODS: NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded. RESULTS: There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position. CONCLUSIONS: Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Do Nails and Nubbins Matter? A Comparison of Symbrachydactyly and Transverse Deficiency Phenotypes.

PURPOSE: Transverse deficiency (TD) and symbrachydactyly may be difficult to distinguish due to shared phenotypes and a lack of pathognomonic features. The 2020 Oberg-Manske-Tonkin classification update modified these anomalies to include "with ectodermal elements" for symbrachydactyly and "without ectodermal elements" for TD as a defining differentiating characteristic. The purpose of this investigation was to characterize ectodermal elements and the level of deficiency and to examine whether ectodermal elements versus the level of deficiency was a greater determining factor for Congenital Upper Limb Differences (CoULD) surgeons making the diagnosis. METHODS: This was a retrospective review of 254 extremities from the CoULD registry with a diagnosis of symbrachydactyly or TD by pediatric hand surgeons. Ectodermal elements and the level of deficiency were characterized. A review of the registry radiographs and photographs was used to classify the diagnosis and compare it with the diagnosis given by the pediatric hand surgeons. The presence/absence of nubbins versus the level of deficiency as the determining factor to differentiate the pediatric hand surgeons' diagnosis of symbrachydactyly (with nubbins) versus TD (without nubbins) was analyzed. RESULTS: Based on radiographs and photographs of the 254 extremities, 66% had nubbins on the distal end of the limb; of the limbs with nubbins, nails were present on 51%. The level of deficiency was amelia/humeral (n = 9), <1/3 transverse forearm (n = 23), 1/3 to 2/3 transverse forearm (n = 27), 2/3 to full forearm TD (n = 38), and metacarpal/phalangeal (n = 103). The presence of nubbins was associated with a four times higher likelihood of a pediatric hand surgeon's diagnosis of symbrachydactyly. However, a distal deficiency is associated with a 20-times higher likelihood of a diagnosis of symbrachydactyly than a proximal deficiency. CONCLUSIONS: Although both the level of deficiency and ectodermal elements are important, the level of deficiency was a greater determining factor for a diagnosis of symbrachydactyly versus TD. Our results suggest that the level of deficiency and nubbins should both be described to help provide greater clarity in the diagnosis of symbrachydactyly versus TD. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Donor Foot Morbidity Following Nonvascularized Toe Phalanx Transfer Utilizing a New Reconstruction Technique.

BACKGROUNDS: Nonvascularized toe phalanx transfer is an accepted surgical option for short and hypoplastic digits in congenital hand abnormalities. However, one of the criticisms of this technique is the donor site morbidity. The purpose of this study was to evaluate donor foot morbidity after nonvascularized toe phalanx transfer using a new donor site reconstruction technique. METHODS: We retrospectively reviewed 116 nonvascularized toe phalanx transfers in 69 children between 2001 and 2020 in whom the donor foot was reconstructed with a new technique using iliac osteochondral bone graft with periosteum. Feet treated with an isolated donor proximal phalanx of the fourth toe were selected and morbidity was assessed both subjectively and objectively at a minimum of 2 years after surgery. Motion, stability, and alignment of the metatarsophalangeal joint were clinically evaluated. The relative length of the fourth toe to the third toe was measured on a roentgenogram. The satisfaction of the parents for overall function and appearance was evaluated using a visual analog scale. RESULTS: Ninety-four operated feet in 65 patients, including 43 boys and 22 girls, were included. The right foot was evaluated in 52 patients and the left foot in 42 patients. The mean age at operation was 2 years and the mean follow-up period was 7.6 years. Motion at the metatarsophalangeal joint was good at 69% with an average extension of 45 degrees and flexion of 25 degrees. Stability and alignment were good at 95% and 84%, respectively. Only 4 toes had gross instability and 4 toes with poor alignment required revision surgery. Sixty-two toes (66%) maintained proportional length and 9 toes were graded as short. Parental satisfaction was high for appearance as well as function. CONCLUSIONS: This newly described technique of using iliac osteochondral bone graft with periosteum to reconstruct toe phalanx donors provided satisfactory results. The function and appearance of the donor foot after a nonvascularized toe phalanx transfer was well preserved. LEVEL OF EVIDENCE: Level IV; therapeutic.

Functional Outcomes and Health-Related Quality of Life of Adults With Congenital Below-Elbow Amputation in North America.

PURPOSE: Congenital below-elbow amputation (BEA) is a common upper-extremity anomaly and generally encompasses 2 diagnoses, symbrachydactyly and transverse deficiency. Little is known about the physical, mental, and social well-being of adults with congenital BEA. A deeper understanding of longitudinal outcomes within this population may help guide family conversations and counseling for patients with congenital BEA. METHODS: The Shriners Hospitals for Children Health Outcomes Network was queried to identify all patients currently >18 years of age who had been seen as a child between 1975 and 2019 for congenital BEA at 1 of 20 Shriners Hospitals across North America. A unique health survey examining physical functioning, mental health, social outcomes, and health-related quality of life was constructed and sent by mail or in electronic form to eligible patients. RESULTS: A total of 64 questionnaires were completed. Patients ranged between 18 and 34 years of age, and 70% were female. Nearly two-thirds of patients (64%) reported that a prosthesis was not required and only 14% reported daily prosthetic use. Although respondents reported below-average Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity scores, there were no differences in Short-Form 12 or Quick Disabilities of the Arm, Shoulder, and Hand scores relative to the US general population. Study participants had lower PROMIS Pain Intensity and higher PROMIS satisfaction with social roles and activities scores than the US general population, translating to clinically meaningful differences. CONCLUSIONS: Although adults with congenital BEA report lower upper-extremity functional scores than the general population, they report no clear differences from normative values in self-efficacy, psychosocial well-being, health-related quality of life, or global life satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Iliac Crest Top Hat Bone Graft for Challenging Metacarpal Nonunion.

Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a "top hat" bone graft harvested from the iliac crest. The graft is carefully shaped to create a cancellous "crown," which is inserted into the nonunion site, and cortical "brims," which are used to secure the graft to the metacarpal. This has been successful in treating 2 cases of metacarpal nonunion that failed to heal with first-line intervention.

The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release.

PURPOSE: Considering the cost of, discomfort with, and time required for nerve conduction testing, the Carpal Tunnel Syndrome-6 (CTS-6) is often used to determine the likelihood of the presence of carpal tunnel syndrome. We sought to determine whether the CTS-6, designed as a diagnostic instrument, could serve a dual purpose and predict the outcome of carpal tunnel release (CTR) based on postoperative changes in the Boston Carpal Tunnel Questionnaire (BCTQ) score. METHODS: This prospective observational study enrolled 118 adults before they underwent open CTR at a tertiary center. A primary regression analysis was used to determine the association between preoperative CTS-6 scores and changes in the BCTQ score at ≥6 months after surgery. Additional demographic, social, electrodiagnostic, and mental health variables were assessed for associations with changes in the BCTQ score. The secondary outcomes included single questions rating satisfaction with the result of CTR as well as symptom changes and the Decision Regret Scale. Noneffective CTR was defined as a BCTQ score change of <1.0 point or reported dissatisfaction. RESULTS: Postoperatively, the BCTQ score improvement averaged 1.38 ± 0.77. Although 102 of 109 patients (94%) noted symptom improvement, 94 of 109 (86%) were satisfied with the result of CTR, and 78 of 109 patients (72%) demonstrated a meaningful change in the BCTQ score. Preoperative CTS-6 scores were not correlated with changes in BCTQ scores. CTS-6 scores were not associated with Decision Regret Scale scores, reported satisfaction, or the single-question assessment of symptom changes. Satisfaction, decision regret, and the single symptom change question were correlated with changes in the BCTQ score and each other. Dissatisfied patients were distinguished by a differential improvement in the BCTQ score (1.5 vs 0.7), but no preoperative variable consistently predicted noneffective CTR. CONCLUSIONS: The CTS-6 score does not predict changes in BCTQ scores after CTR. Patient satisfaction with surgical results is associated with postoperative changes in carpal tunnel symptoms but is not predictable using preoperative information. A single question of symptom change may offer an efficient assessment of CTR outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The Oberg, Manske, and Tonkin Classification of Congenital Upper Limb Anomalies: A Consensus Decision-Making Study for Difficult or Unclassifiable Cases.

PURPOSE: An ideal classification system promotes communication and guides treatment for congenital upper limb differences (CULDs). The Oberg, Manske, and Tonkin (OMT) classification utilizes phenotypic presentation and knowledge of developmental biology for the classification of CULDs. In this consensus decision-making study, we hypothesized that CULDs that are difficult to classify would be identically classified by a group of experienced pediatric hand surgeons. METHODS: An international consortium of 14 pediatric hand surgeons in 3 countries contributed a group of 72 difficult-to-classify CULD cases. These were identified from the clinical practices of the surgeons and from associated registries. Through a Delphi-type process, repeated efforts were made to obtain consensus for the correct OMT classification of each case utilizing clinical images and radiographs. RESULTS: The first round of discussion yielded a universal consensus for 57 cases. The remaining 15 cases continued to be put through additional rounds of the Delphi-type process. The repeat classification and discussion resulted in a final yield of 93% complete consensus in classification by the OMT. The primary challenge in diagnosis was differentiating cleft hand from ulnar longitudinal deficiency, identified as group A. Five cases were in this group, yet 2 remained without a clear consensus. Another controversial group, group B, was termed "brachy-polydactyly" and consisted of 3 cases where diagnoses varied between sympolydactyly, symbrachydactyly, or complex syndactyly. CONCLUSIONS: The Delphi-type process was feasible and effective and allowed a 93% consensus in the diagnosis of difficult-to-classify cases by the OMT Classification. There remain limitations and controversies with the OMT system, especially when classifying hands with less than 5 skeletal digits, syndactyly, and those with diagnostic overlap between ulnar longitudinal deficiency and cleft hand and those considered "brachypolydactyly." An improved understanding of the underlying etiology may be needed to determine the final diagnosis in difficult-to-classify conditions. CLINICAL RELEVANCE STATEMENT: A consensus-seeking approach is effective and feasible in addressing difficult-to-classify CULDs.

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair.

PURPOSE: To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair. METHODS: We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes. RESULTS: There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage. CONCLUSIONS: Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

An Analysis of Associated Conditions and the Relationship Between the Severity of Hand Manifestations With That of the Forearm in Ulnar Longitudinal Deficiency.

PURPOSE: A deeper investigation of medical and musculoskeletal conditions in patients with ulnar longitudinal deficiency (ULD) is needed. The association between the severity of the manifestations of ULD in the hands and forearms has not been firmly established. The purpose of this study was to describe the medical and musculoskeletal conditions associated with ULD and examine the relationship between hand and forearm anomalies. METHODS: The Congenital Upper Limb Differences registry was queried for all patients with a diagnosis of ULD, as defined by the Oberg-Manske-Tonkin classification system, between 2014 and 2020. The patients' demographic information, medical and musculoskeletal comorbidities, radiographs, and clinical images were reviewed. The participants were classified using the Bayne, Cole and Manske, and Ogino classification systems. RESULTS: Of 2,821 patients from the Congenital Upper Limb Differences registry, 75 patients (2.7%) with ULD (14 bilateral), with 89 affected extremities, were included. Hand anomalies were present in 93% of the patients. Approximately 19% of the patients had an associated medical comorbidity, and 20% of the patients had an associated musculoskeletal condition. Cardiac anomalies were present in 8.0% of the patients, and 12% of the patients had a lower extremity abnormality. Radial head dislocation was observed in 13 of 18 patients with Bayne type II or III ULD compared with 8 of 43 patients with other types of unilateral ULD. There was a significant positive association among the Bayne and Ogino, Bayne and Cole/Manske, and Ogino and Cole/Manske classification systems in patients with unilateral ULD. CONCLUSIONS: Associated medical and musculoskeletal conditions are common in patients with ULD, of which cardiac and lower extremity abnormalities are most frequently observed. There is a significant positive association between the severity of forearm anomalies and that of hand anomalies in patients with unilateral ULD. All patients with ULD should undergo a thorough cardiac evaluation by their pediatrician or a pediatric cardiologist. TYPE OF STUDY/LEVEL OF EVIDENCE: Symptom prevalence study III.

Pediatric Hand Fractures and Congenital Differences: An Analysis of Data From the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery.

PURPOSE: Pediatric patients with hand trauma and congenital differences are treated across multiple surgical subspecialties. The purpose of this study was to assess operative trends over an 11-year period using the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases to better understand which surgeons were caring for pediatric hand fractures and birth differences in the first 2 years of their practice. METHODS: We queried the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases for surgical procedures performed by applicants for the oral examinations between 2004 and 2014. Candidates self-identified as general orthopedic surgeon, pediatric orthopedic surgeon, hand surgeon (orthopedic and plastic), and general plastic surgeon. This included a total of 2,453 Board applicants. A total of 6,835 surgeries for birth differences or hand trauma were identified and reviewed for patients <18 years of age. RESULTS: There were 5,759 trauma and 1,076 congenital difference surgeries. A total of 4,786 (70%) surgeries were performed by orthopedic surgeons. Fellowship-trained hand surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Pediatric orthopedic surgeons performed 608 (9%) surgeries. Over the 11 years, general orthopedic surgeons performed 4.2 fewer surgeries per year, whereas surgeons in hand orthopedics and pediatric orthopedics performed 10.8 and 4.7 additional surgeries per year. There were 3.1 fewer general orthopedic surgeons per year, whereas there were 3.6 and 1.4 additional surgeons in hand orthopedics and pediatric orthopedics each year, respectively. The number of surgeries and the number of surgeons submitting surgeries did not significantly change for those in general plastics or hand plastics. CONCLUSIONS: This analysis of early practice patterns over 11 years demonstrates that the increasing numbers of surgeons in pediatric orthopedics and hand orthopedics are performing more surgeries compared with other fields. CLINICAL RELEVANCE: The care of children with hand injuries and congenital differences is evolving, with direct implications for residency and fellowship education.