Treatment and Outcomes of Missed Perilunate Dislocations: A Case Series

Background  Perilunate dislocations are devastating injuries that occur relatively rarely, accounting for only 7% of injuries to the carpus. Unfortunately, approximately 25% of these injuries are missed on initial evaluation. Acutely diagnosed perilunate dislocations may be successfully treated with ligament and osseous repair, depending on the injury pattern. Chronic dislocations, however, are primarily treated with salvage procedures. This case series was performed to investigate the outcomes of patients who sustained a perilunate dislocation that was diagnosed in a delayed fashion and look for any treatment patterns that could be more widely applied to future patients. Methods  Patients presenting to a single institution between 2016 and 2018 with a perilunate injury that either presented in a delayed fashion or was missed on initial assessment were identified and their characteristics were evaluated. The surgical management of these patients was assessed as was their postoperative course at their 2-week, 6-week, 3-month, and 6-month clinic follow-up visits. Results  Eight patients were identified with perilunate dislocations that were diagnosed in a delayed fashion. On average, these dislocations were diagnosed 133 days following the date of injury. All patients were males and 7/8 of them were between 17 and 20 years of age at the time of their injury (mean age: 25.5). They were treated with either primary repair, wrist fusion, proximal row carpectomy, or scaphoid excision and four-corner fusion (SEFCF). Both pain and range of motion improved following surgical management of these injuries. Conclusion  Perilunate dislocations are rare injuries that are notorious for being diagnosed late, at which point primary repair is oftentimes no longer feasible. Salvage procedures are able to improve the range of motion and pain of patients who are found to have chronic dislocations. Our case series highlights the importance of treating each missed perilunate injury individually and avoiding a "one-size-fits-all" approach.

An Introduction to the Orthopaedic Diversity Leadership Consortium: Advancement of Our Orthopaedic Leaders of Diversity, Equity, and Inclusion Through Networking, Strategy, and Innovation

Achievement of diversity, equity, and inclusion (DEI) is an ongoing discussion that has evolved over time in the field of orthopaedic surgery. To enhance and highlight commitments to diversity, many academic department and health organizations have designated individuals to serve as their DEI leader. However, suboptimal structure and support of this specific leadership position have limited its potential and have led to increased position turnover and stagnation in progress. To mitigate these challenges, the Orthopaedic Diversity Leadership Consortium (ODLC) was formed as a growing network of orthopaedic diversity leaders from around the United States as well as international members and industry affiliates. The mission of ODLC is to optimize the sustainability of DEI efforts by providing professional development support and best-practice solutions to leaders serving in this capacity. The efforts of the organization are guided by 3 key objectives: leadership development, design of strategic plan models for diversity, and interprofessional education for perioperative care teams on inclusion. Through this powerful network and its educational offerings, ODLC works to increase role efficacy and to encourage sustainable creation of diverse, equitable, and inclusive environments for our patients, colleagues, and team members.

Traumatic Osteonecrosis of the Distal Ulna

A 46-year-old male was referred to our clinic for persistent ulnar-sided wrist pain 9 weeks after sustaining a traumatic injury while playing volleyball. The patient unsuccessfully underwent nonoperative management for a suspected injury to the triangular fibrocartilage complex. After magnetic resonance imaging revealed a lesion of the distal ulna, he was treated with diagnostic wrist arthroscopy and Bowers hemiresection. The diagnosis of osteonecrosis was confirmed through histology. While traumatic osteonecrosis of the carpal bones has been described, no previous literature was found on traumatic osteonecrosis of the distal ulna. Treatment with diagnostic wrist arthroscopy and Bowers hemiresection resulted in an excellent outcome at 12 months after surgery.

Racial and Gender Discrimination in Hand Surgery Letters of Recommendation

PURPOSE

We sought to evaluate hand surgery applicants' letters of recommendations to understand whether applicant and letter writer demographics contribute to racial and gender bias.

METHODS

All applications submitted through the American Society for Surgery of the Hand match to a single institution fellowship program for the 2017 to 2019 application cycles were analyzed using validated text analysis software. Race/ethnicity information was derived from an analysis of applicant photos using the Face Secret Pro software. Primary outcome measures were differences in communal and agentic language used in letters of recommendation, stratified by both race/ethnicity and gender.

RESULTS

A total of 912 letters of recommendation were analyzed for 233 applicants (51 female and 172 male). Of these, 88 were written by female letter writers and 824 were written by male letter writers. There were 8 Black, 12 Hispanic, 36 Asian, and 167 White applicants. Letter writers used more agentic language with Asian applicants and non-White applicants overall. Female letter writers used more communal terms and were not associated with applicant race or gender.

CONCLUSIONS

Letters of recommendation in hand surgery demonstrate disparities in language based on race and gender.

CLINICAL RELEVANCE

Alerting letter writers to the role of implicit bias will hopefully spur a discussion on tools to mitigate the use of biased language and provide a foundation for an equitable selection process. Efforts to improve policies and procedures pertaining to diversity and inclusion are paramount to ensuring that fellows more completely represent the population hand surgeons wish to serve.

How to Be An Antiracist Hand Surgery Educator

Racism that unjustly marginalizes black people in the United States is not a new concept. It underlies nearly every aspect of American history, leading to the systemic racism that is ingrained in our society today. With the recurrent theme of people of color having worse health outcomes than the majority community, it is important for hand surgeons to employ cultural competence and antiracist education to provide better care and support for patients, staff, students, and colleagues. In this article, we will provide a definitional framework, clinical examples, and practical pearls to promote change. To reduce racial and ethnic health care inequities and diversify the field of hand surgery, we must advocate on behalf of black and brown colleagues, staff, students, and/or friends to address racist policies and procedures.

Motion and Strength Analysis of 2-Tine Staple and K-Wire Fixation in Scapholunate Ligament Stabilization in a Cadaver Model

Purpose

Previous studies have demonstrated the benefits of 2- and 4-tine staple fixation in scapholunate interosseous ligament (SLIL) reconstruction, including improved rotational control and avoidance of the articular surface. This study compared scaphoid and lunate kinematics after SLIL fixation with traditional Kirschner wire (K-wire) fixation or 2-tine staple fixation.

Methods

Eight fresh frozen cadaver arms with normal scapholunate (SL) intervals were included. Infrared motion capture was used to assess kinematics between the scaphoid and lunate as the wrists were moved through a simulated dart-throw motion. Kinematic data were recorded for each wrist in 4 states: SLIL intact, SLIL sectioned, K-wire fixation across SL interval and scaphocapitate joint, and 2-tine Nitinol staple fixation across SL interval. Strength of the SL staple fixation was evaluated using an axial load machine to assess load to failure of the staple construct.

Results

Range of motion of the scaphoid and lunate with SLIL intact and SLIL sectioned were similar. K-wire fixation across the SL interval significantly decreased the overall wrist range of motion as well as scaphoid and lunate motion in all planes except for scaphoid flexion. Conversely, scaphoid and lunate motion after staple fixation was similar to that in normal wrists, except for a significant decrease in scaphoid extension. Under axial load simulating a ground-level fall, 3 of 8 arms demonstrated no failure, and none of the failures was due to direct failure of the 2-tine staple.

Conclusions

This study demonstrates 2-tine staple fixation across the SL interval is effective in providing initial stability and maintaining physiologic motion of the scaphoid and lunate compared with K-wire fixation after SLIL injury.

Clinical relevance

This study demonstrates an alternate technique for the stabilization of the SL interval in repair of acute SLIL injuries using 2-tine staple fixation, which maintains near physiologic motion of the scaphoid and lunate after SLIL injury.

Race, Gender, and Residency: a Survey of Trainee Experience

BACKGROUND

Racial minority and female trainees undergo residency attrition at significantly higher rates than their counterparts. We hypothesize that racial minority, and female trainees will report significantly different training experiences from non-minority and male trainees, respectively. Further, we hypothesize that thoughts of withdrawal and summative description of residency experience will be significantly impacted by access to mentorship and feelings of isolation.

METHODS

A link to a Qualtrics survey was sent to program officials from all residency programs registered with the ACGME to be distributed to their trainees. It was live from June through August of 2019 and collected data about respondent's demographics and posed questions addressing some of the key elements of the residency experience.

RESULTS

Minority trainees reported lower scores for ease of execution of orders placed compared to non-minority trainees 2.12 vs. 2.28 (p = 0.030). Females reported more frequently being mistaken for staff at lower training levels and more frequently feeling overwhelmed than male trainees, 3.29 vs. 1.64 (p < 0.001) and 3.57 vs. 3.16 (p < 0.001). Racial minority and female trainees had numerical but nonsignificant differences in scores for access to mentorship and feelings of isolation compared to non-minority, and male trainees, respectively. Trainees who had thoughts of withdrawal reported less access to mentorship (3.12 vs. 3.88 p < 0.001) and more feelings of isolation (2.22 vs. 1.68 p < 0.001). Trainees reporting more positive experiences had greater access to mentorship and lower feelings of isolation than those who reported a neutral or negative experience, 3.89 vs. 3.14 vs. 2.79 (p < 0.001) and 1.60 vs. 2.21 vs. 2.82 (p < 0.001), respectively. Greater access to mentorship and more frequent family contact both significantly decreased feelings of isolation p < 0.001 and p = 0.035.

CONCLUSION

Minority status and female gender impact some of the key elements of the residency experience, manifesting as decreased respect afforded to these trainees. Thoughts of withdrawal and overall residency experience are significantly impacted by access to mentorship and feelings of isolation during residency. Attention should be paid to ensuring that high risk trainees have adequate access to mentorship, making deliberate efforts to cultivate a sense of community and camaraderie among residents, and emphasizing the value of diversity and inclusion.

Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A Review of 417 Patients From a Level 1 Trauma Center

Background: Unstable distal radius fractures that undergo surgical stabilization have varying complication rates in the literature. Smoking is known to affect bone healing and implant fixation rates but has never been definitively shown to affect postoperative outcomes of surgically managed distal radius fractures. Methods: A retrospective review was performed of patients with surgically treated distal radius fractures at a Level 1 Trauma Center who had at least 6 weeks of follow-up over a 5-year period. Charts were reviewed for basic demographic information, comorbidities, details about the operative procedure, and early complications. Notable physical examination findings were noted, such as wrist stiffness and distal radius tenderness to palpation. Statistical analysis was performed to compare the smoking and nonsmoking groups. To control for confounding differences, a hierarchical multivariable regression analysis was performed. Results: Four hundred seventeen patients were included in the study, and 24.6% were current smokers at the time of surgery. The overall complication rate for smokers was 9.8% compared with 5.6% in nonsmokers. The smoking cohort showed significantly higher rates of hardware removal, nonunion, revision procedures, wrist stiffness, and distal radius tenderness. When controlling for the confounding variables of diabetes and obesity, smokers still had significantly higher rates of the same complications. Conclusion: Patients who smoke have a statistically significant higher rate of postoperative distal radius tenderness, wrist stiffness, nonunion, hardware removal, and revision procedures compared with those who do not smoke in a review of 417 total patients undergoing surgical fixation for distal radius fractures.

Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A Review of 417 Patients From a Level 1 Trauma Center

Background: Unstable distal radius fractures that undergo surgical stabilization have varying complication rates in the literature. Smoking is known to affect bone healing and implant fixation rates but has never been definitively shown to affect postoperative outcomes of surgically managed distal radius fractures. Methods: A retrospective review was performed of patients with surgically treated distal radius fractures at a Level 1 Trauma Center who had at least 6 weeks of follow-up over a 5-year period. Charts were reviewed for basic demographic information, comorbidities, details about the operative procedure, and early complications. Notable physical examination findings were noted, such as wrist stiffness and distal radius tenderness to palpation. Statistical analysis was performed to compare the smoking and nonsmoking groups. To control for confounding differences, a hierarchical multivariable regression analysis was performed. Results: Four hundred seventeen patients were included in the study, and 24.6% were current smokers at the time of surgery. The overall complication rate for smokers was 9.8% compared with 5.6% in nonsmokers. The smoking cohort showed significantly higher rates of hardware removal, nonunion, revision procedures, wrist stiffness, and distal radius tenderness. When controlling for the confounding variables of diabetes and obesity, smokers still had significantly higher rates of the same complications. Conclusion: Patients who smoke have a statistically significant higher rate of postoperative distal radius tenderness, wrist stiffness, nonunion, hardware removal, and revision procedures compared with those who do not smoke in a review of 417 total patients undergoing surgical fixation for distal radius fractures.

A Cadaveric Study of the Mean Distance of the Radial Artery During the Approach to the First Carpometacarpal Joint

Multiple surgical procedures have been described to treat first carpometacarpal (CMC) arthritis. Although the superiority of one procedure over the others continues to be a controversial topic, they all approach the trapezium and require careful attention to the surrounding structures. One potential complication is injury to the radial artery, which lies in close proximity to the trapezium and is often encountered during surgical approach. Using cadaveric specimens, the authors dissected to identify and isolate the radial artery as it travels in the forearm, wrist, and hand while being careful not to disturb its native course. The authors then measured the shortest distance interval from the radial artery to the first CMC joint and from the radial artery to the scaphotrapeziotrapezoidal joint. Descriptive statistics were calculated from these measurements and averaged over the various specimens. The mean distance of the radial artery to the closest segment of the volar CMC joint was 11.6±2.5 mm. The mean distance of the radial artery to the closest segment of the volar scaphotrapeziotrapezoidal joint was 1.6±1.8 mm. A precise understanding of nearby anatomy is paramount to a successful surgical treatment for first CMC arthritis and to avoid iatrogenic complications. The authors describe the mean distance from the radial artery to 2 major landmarks used during surgical treatment and provide insight to surgeons who perform these CMC reconstruction procedures to decrease the risk of intraoperative radial artery injury. [Orthopedics. 2018; 41(4):e541-e544.].

Trigger digit release: rates of surgery and complications as indicated by a United States Medicare database

A United States insurance database was examined for trigger digit release using International Classification of Diseases, 9th Revision diagnoses and procedures or Current Procedural Terminology codes. Complications after trigger digit release, including stiffness, infection and revision surgery, were assessed. A total of 209,634 patients who underwent trigger digit release were included. The rate of trigger digit release increased significantly from 2005 to 2012, with the middle finger the most frequently released. The rate of postoperative stiffness was low, ranging from 0.8% to 1.6% depending on the operated digit. The rate of postoperative infection was lower, ranging from 0.5% to 0.6%. The need for revision within 3 years of initial trigger digit release was also low, ranging from 0.3% to 0.8%. Complications, including infection, stiffness and revision surgery, occur infrequently, but certain factors, including diabetes, Dupuytren's disease, smoking, rheumatoid arthritis, obesity and age, increase risk.

LEVEL OF EVIDENCE

Therapeutic Level III, Retrospective comparative study.

Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005-2011

We conducted a study to investigate current trends in carpometacarpal (CMC) interposition arthroplasty across time, sex, age, and region of the United States; per-patient charges and reimbursements; and the association between this procedure and concomitantly performed carpal tunnel syndrome (CTS) and carpal tunnel release (CTR). Patients who underwent CMC interposition arthroplasty (N = 41,171) were identified in a national database. Between 2005 and 2011, the number of patients who had CMC interposition arthroplasty increased 46.2%. Females had the procedure more frequently than males at all time points, though the percentage of patients who were male increased throughout the study period. Of the patients who had CMC interposition arthroplasty, 40.9% also had a diagnosis of CTS. Between 15.5% and 17.3% of these patients had CTR performed concomitantly. Despite a lack of evidence that thumb CMC interposition arthroplasty is superior to other surgical treatment options, the number of patients who are having this procedure has increased significantly. The impetus for these trends requires additional investigation.

Osteochondral autograft plug transfer for treatment of osteochondritis dissecans of the capitellum in adolescent athletes

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive overhead sports and can profoundly affect ability to return to play and long-term elbow function. Treatment of large, unstable defects in the elbow with osteochondral autograft plug transfer has not been adequately studied.

METHODS

We retrospectively identified 11 teenaged patients with large (>1 cm(2)) capitellar OCD treated with osteochondral autograft plug transfer. Average age at the time of surgery was 14.5 years (range, 13-17 years). Outcome measures obtained included return to play, preoperative and postoperative elbow range of motion, Disabilities of Arm, Shoulder and Hand (DASH; Institute for Work and Health, Toronto, ON, Canada) by telephone interview, and osseous integration on radiographs. All 11 patients were available for evaluation at an average of 22.7 months (range, 6-49 months) postoperatively.

RESULTS

All patients were involved in competitive high school athletics and returned to at least their preinjury level of play. Average return to play was 4.4 months (range 3-7 months). The average final DASH was 1.4 (95% confidence interval, 0.6-2.1), and the average final sport-specific DASH was 1.7 (95% confidence interval -1.8 to 5.2). Elbow range of motion significantly improved, including improvement in flexion from a preoperative average of 126° to a postoperative average of 141° (P = .009) and improvement in extension from a preoperative average of 21° to a postoperative average of 5° (P = .006).

CONCLUSIONS

Treatment of large, unstable OCD lesions of the capitellum in adolescent athletes allows reliable return to play, is safe, and has good clinical outcomes at short-term follow-up.

Indolent infectious tenosynovitis afflicting rheumatoid patients treated with tumor necrosis factor inhibitors: case report

Tumor necrosis factor (TNF) is a cytokine associated with the pathogenesis of rheumatoid arthritis. Tumor necrosis factor inhibitors have become important biological treatments that favorably alter the natural history of rheumatoid disease. Side effects include an increased risk of malignancy and infection, particularly tuberculosis. We present 2 patients with rheumatoid arthritis on TNF inhibitors in whom flares of wrist tenosynovitis, initially diagnosed as rheumatoid disease exacerbations, were caused by infections with uncommon opportunistic pathogens. Diagnostic and treatment recommendations for this subset of rheumatoid patients are discussed.

Uni- and multi-variate analysis of risk factors for early and late hepatic artery thrombosis after liver transplantation

BACKGROUND

Hepatic artery thrombosis (HAT) is a significant cause of morbidity after liver transplantation. The aims of this study are to identify and compare risk factors that might contribute to HAT.

METHODS

A total of 424 liver transplants performed at the University of Virginia were reviewed. HAT was defined as complete disruption of arterial blood flow to the allograft and was identified in 29 cases (6.8%). HAT was classified as early (less than 1 month posttransplant, 9 cases: 2.1%) or late (more than 1 month posttransplant, 20 cases: 5.4%). Possible risk factors for HAT were analyzed using Pearson chi2 test for univariate analysis and logistic regression for multivariate analysis.

RESULTS

Multiple transplants, recipient/donor weight ratio >1.25, biopsy-proven rejection within 1 week of transplant, recipient negative cytomegalovirus (CMV) status, arterial anastomosis to an old conduit (defined as a previously constructed aorto-hepatic artery remnant using donor iliac artery), and CMV negative patients receiving allograft from CMV positive donors were found to be significant risk factors for developing early HAT. After logistic regression, factors independently predicting early HAT included arterial anastomosis to an old conduit [odds ratio (OR)=7.33], recipient/donor weight ratio >1.25 (OR=5.65), biopsy-proven rejection within 1 week posttransplant (OR=2.81), and donor positive and recipient negative CMV status (OR=2.66). Female donor, the combination of female donor and male recipient, recipient hepatitis C-related liver disease, donor negative CMV status, and the combination of recipient CMV negative and donor CMV negative were found to be significant risk factors for late HAT. Factors independently predicting late HAT by logistic regression included negative recipient and donor CMV status (OR=2.26) and the combination of a female donor and male recipient (OR=1.97).

CONCLUSION

Therefore, in nonemergency situations attention to these factors in donor allocation may minimize the possibility of HAT.