Technique for Minimally Invasive, Arthroscopic-assisted Distal Radius Fracture Fixation

Distal radius fractures are common injuries that often require surgical intervention. Commonly, these fractures are fixed using open reduction internal fixation with plating and screws. This often requires a more extensive soft tissue dissection and exposure. In contrast for certain cases, percutaneous headless compression screws may be appropriate. We present a technique for minimally invasive arthroscopic-assisted reduction and percutaneous screw fixation with an extremity traction device. A case is provided to demonstrate the technique as a viable option for the treatment of intra-articular distal radius fractures.

Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures

BACKGROUND

Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position.

METHODS

Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position.

RESULTS

A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs.

CONCLUSION

Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures.

LEVEL OF EVIDENCE

Level III, therapeutic.

Optimal Position of the Bone Anchor for the Internal Brace Suspensionplasty Technique for Thumb Basal Joint Arthroplasty

PURPOSE

Ligament reconstruction and tendon interposition is a common technique for thumb basal joint arthroplasty. Recently, a variation of this technique, a suture suspensionplasty, has been introduced. The goal of our study was to assess the optimal position of the bone anchor in the thumb metacarpal. We hypothesized that an anchor placed in the radial aspect of the thumb metacarpal base would provide improved stability and resist subsidence more effectively than an ulnar-based thumb anchor.

METHODS

Eight fresh-frozen cadaver arms were imaged fluoroscopically in anteroposterior and lateral views centered over the thumb carpometacarpal joint before and after trapeziectomy and after the placement of radial-based and ulnar-based bone anchors. The intermetacarpal angle between the thumb and index metacarpals was measured on all images after the application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, and adduction were measured. Subsidence was calculated as the percentage loss of the trapezial space.

RESULTS

Both radially and ulnarly placed internal brace constructs allowed more radial abduction, opposition, and palmar abduction than the pretrapeziectomy constructs. They both also reduced subsidence by approximately 20% to 29% compared with the posttrapeziectomy constructs. Comparing radial to ulnar constructs, motion and subsidence were similar.

CONCLUSIONS

There was immediate stability of the thumb with respect to axial load and subsidence after anchor placement, and this was independent of the anchor position. The position of the bone anchor in the thumb metacarpal base did not affect the range of motion. Although the device can limit subsidence, it does not appear to restrict any range of motion of the thumb, irrespective of anchor position.

CLINICAL RELEVANCE

This cadaver study can help hand surgeons understand the effect of positioning of bone anchors when performing a specific suture suspensionplasty technique.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study

Background  Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes  Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods  The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results  The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion  The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance  Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Use of Telemedicine Among Hand Surgeons and Their Patients

PURPOSE

Initially designed to address geographic obstacles to patient care, reliance on telemedicine rapidly increased during the coronavirus pandemic. The purpose of this study was to analyze the proficiency of computer and mobile device usage among a cohort of surgeons and their patients who either used telemedicine or had in-person visits.

METHODS

We retrospectively identified patients who had an outpatient telemedicine visit (T group), or in-person visit (NT group) with a hand and wrist orthopedic surgeon, between March 2020 and July 2020. These patients and their surgeons were sent the Computer Proficiency Questionnaire (CPQ-12) and the Mobile Device Questionnaire (MDPQ-16) via email. A total of 602 survey responses were collected, 279 of which belonged to patients in the T group and 323 to patients in the NT group.

RESULTS

The two groups were similar in demographics, including age and sex. Scores on the CPQ-12 and MDPQ-16 did not significantly differ between the two groups. In the patient sample, there was no correlation between CPQ-12 and MDPQ-16 scores and the proportion of telehealth visits. The orthopedic surgeon group also had no observed correlation between the CPQ-12 and MDPQ-16 scores and number or proportion of telemedicine visits.

CONCLUSIONS

Overall proficiency with computer and mobile devices was not correlated with the likelihood of patients or orthopedic surgeons using telemedicine visits. Patient selection appears to be driven by other factors, which could include limitations in transportation, convenience, and time constraints.

CLINICAL RELEVANCE

Orthopedic surgeons should continue to offer telehealth visits to their patients regardless of estimated capabilities with electronic devices of both the patient and the surgeon.

Evaluating the Efficacy of a Thermoresponsive Hydrogel for Delivering Anti-Collagen Antibodies to Reduce Posttraumatic Scarring in Orthopedic Tissues

Excessive posttraumatic scarring in orthopedic tissues, such as joint capsules, ligaments, tendons, muscles, and peripheral nerves, presents a significant medical problem, resulting in pain, restricted joint mobility, and impaired musculoskeletal function. Current treatments for excessive scarring are often ineffective and require the surgical removal of fibrotic tissue, which can aggravate the problem. The primary component of orthopedic scars is collagen I-rich fibrils. Our research team has developed a monoclonal anti-collagen antibody (ACA) that alleviates posttraumatic scarring by inhibiting collagen fibril formation. We previously established the safety and efficacy of ACA in a rabbit-based arthrofibrosis model. In this study, we evaluate the utility of a well-characterized thermoresponsive hydrogel (THG) as a delivery vehicle for ACA to injury sites. Crucial components of the hydrogel included N-isopropylacrylamide, poly(ethylene glycol) diacrylate, and hyaluronic acid. Our investigation focused on in vitro ACA release kinetics, stability, and activity. Additionally, we examined the antigen-binding characteristics of ACA post-release from the THG in an in vivo context. Our preliminary findings suggest that the THG construct exhibits promise as a delivery platform for antibody-based therapeutics to reduce excessive scarring in orthopedic tissues.

The Effect of Percutaneous Retrograde Metacarpal Intramedullary Screw Insertion on the Extensor Tendon

PURPOSE

Both limited-open and percutaneous techniques have been described for retrograde insertion of intramedullary metacarpal screws. The percutaneous approach does not allow direct visualization of the starting point at the metacarpal head. However, it limits soft tissue dissection and expedites the procedure. The purpose of our study was to determine whether percutaneous, retrograde intramedullary screw fixation causes substantial iatrogenic damage to the extensor tendon. We also investigated whether larger sized screws would cause greater tendon injury compared to smaller screws.

METHODS

Eight fresh frozen cadaver hands were used for percutaneous, retrograde intramedullary screw insertion of the index, long, ring, and small finger metacarpals of each specimen. Three different types of headless compression screws were used: a small fully threaded screw, a large fully threaded screw, and a Herbert-style partially threaded screw. After insertion, dissection was carried down to the screw entry site. Extensor tendon damage was evaluated, including tendon defect size and any irregularities noted in the tendon.

RESULTS

There was no statistical difference with respect to how frequently a screw perforated the extensor tendons between all four finger metacarpals. Overall, the defect width caused by the screw was minimal, ranging from 0.66 mm to 1.89 mm for all finger and screw types. The large style screw did cause the greatest mean defect width, however, this was not statistically significant. When normalized to total tendon width, the defect was less than 28% of the total tendon width, with an average of 20% for all finger and screw types. Upon gross inspection, there was no fraying or irregularity noted at the screw-tendon insertion site, and it was often difficult to identify the screw entry site through the tendon by direct visualization alone. No tendon ruptures were noted.

CONCLUSIONS

This study found that percutaneous insertion of a retrograde, intramedullary metacarpal screw causes minimal extensor tendon injury. In contrast to the limited-open approach, the percutaneous technique requires less soft tissue dissection and the possibility of reduced swelling, scarring, and risk of adhesions. Moreover, it has the potential to allow for early functional rehabilitation and reduced operative time. Interestingly, none of the tendons demonstrated fraying or rupture, as one might expect to occur with blind passage of a drill and screw through a tendon. Overall, the percutaneous, retrograde intramedullary screw technique appears to cause minimal iatrogenic injury to the extensor tendon.

Proximity of the Ulnar Neurovascular Structures in Endoscopic Carpal Tunnel Release Surgery: A Cadaveric Study

PURPOSE

To evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR).

METHODS

Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade's proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible.

RESULTS

The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4-20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0-15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1-7.8) and to the median nerve was 3.3 mm (range, 0-6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures.

CONCLUSIONS

There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR.

CLINICAL RELEVANCE

These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device.

Perioperative Management of Oral Anticoagulants and Antiplatelet Therapy in Hand and Wrist Surgery

There is wide variability in the management of patients on antithrombotic therapy requiring surgery of the hand and wrist. There are no specific guidelines regarding whether to temporarily cease or continue oral anticoagulants and antiplatelet agents. Discontinuation of these medications before surgery can lead to perioperative thromboembolic or ischemic events. On the other hand, continuation can lead to intraoperative or postoperative bleeding complications. This review discusses various anticoagulants and antiplatelet agents with special considerations for their management, analyzes the current literature, summarizes current recommendations, and provides direction for additional research.

Remote fit wrist braces through artificial intelligence

INTRODUCTION

Physical boundaries to access skilled orthotist or hand therapy care may be hindered by multiple factors, such as geography, or availability. This study evaluated the accuracy of fitting a prefabricated wrist splint using an app on a smart device. We hypothesize that remote brace fitting by artificial intelligence (AI) can accurately determine the brace size the patient needs without in-person fitting.

METHODS

Healthy volunteers were recruited to fit wrist braces. Using 2 standardized calibrated images captured by the smart device, each subject's image was loaded into the machine learning software (AI). Later, hand features were extracted, calibrated, and measured the application, calculated the correct splint size, and compared with the splint chosen by our subjects to improve its own accuracy. As a control (control 1), the subjects independently selected the best brace fit from an array of available splints. Subject selection was recorded and compared with the AI fit splint. As the second method of fitting (control 2), we compared the manufacturer recommended brace size (based on measured wrist circumference and provided sizing chart/insert brochure) with the AI fit splint.

RESULTS

A total of 54 volunteers were included. Thirty-two splints predicted by the algorithm matched the exact size chosen by each subject yielding 70% accuracy with a standard deviation of 10% ( p < 0.001). The accuracy increased to 90% with 5% standard deviation if the splints were predicted within the next size category. Fit by manufacturer sizing chart was only 33% in agreement with participant selection.

CONCLUSION

Remote brace fitting using AI prediction model may be an acceptable alternative to current standards because it can accurately predict wrist splint size. As more subjects were analyzed, the AI algorithm became more accurate predicting proper brace fit. In addition, AI fit braces are more than twice as accurate as relying on the manufacturer sizing chart.

Anatomic Relationship of Hand Intrinsic Tendons at the Metacarpal Head as It Relates to the Diagnosis of Saddle Syndrome: A Cadaveric Study

PURPOSE

The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity-posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation.

METHODS

Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or "true tendon," were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as "pseudotendon." Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion.

RESULTS

The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits.

CONCLUSIONS

There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas.

CLINICAL RELEVANCE

These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML in vivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice.

Appropriateness of Self-Scheduled Office Visits in Outpatient Hand Surgery

PURPOSE

Our practice recently implemented a system that enables patients to self-schedule outpatient visits through an online portal. The purpose of this study was to evaluate the appropriateness of self-scheduled appointments in the Hand and Wrist Surgery Division of our practice.

METHODS

Outpatient visit notes from 128 new patient visits among 18 fellowship-trained hand and upper extremity surgeons were collected; 64 visits were self-scheduled online, and 64 were scheduled using the traditional call center system. The notes were deidentified and divided among 10 hand and upper extremity surgeons, such that each note was reviewed by two different reviewers. The surgeons scored each visit on a scale of 1-10, with 1 representing a completely inappropriate visit for a hand surgeon and 10 representing a completely appropriate visit. Primary diagnoses and treatment plans were recorded, including whether surgery was planned during the visit. The final score for each visit resulted from the average of the two separate scores. The average appropriateness score for all self-scheduled visits was compared with the average score for all traditionally scheduled visits with a two-sample t test.

RESULTS

The average appropriateness score for self-scheduled visits was 8.4 of 10, with seven visits resulting in a planned surgery (10.9%). Traditionally scheduled visits had an average appropriateness score of 8.4 of 10, with eight visits resulting in a planned surgery (12.5%). The average difference in the scores between reviewers for all visits was 1.7.

CONCLUSIONS

In our practice, the appropriateness of visits that are self-scheduled is nearly identical to the appropriateness of traditionally scheduled visits.

CLINICAL RELEVANCE

Implementation of self-scheduling systems may allow for greater patient autonomy and access to care and reduce administrative burden on office staff.

Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case-control study

OBJECTIVES

To evaluate extensor carpi ulnaris (ECU) tendon pathology and ulnar styloid process bone marrow edema (BME) as diagnostic MRI markers for peripheral triangular fibrocartilage complex (TFCC) tears.

METHODS

One hundred thirty-three patients (age range 21-75, 68 females) with wrist 1.5-T MRI and arthroscopy were included in this retrospective case-control study. The presence of TFCC tears (no tear, central perforation, or peripheral tear), ECU pathology (tenosynovitis, tendinosis, tear or subluxation), and BME at the ulnar styloid process were determined on MRI and correlated with arthroscopy. Cross-tabulation with chi-square tests, binary logistic regression with odds ratios (OR), and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to describe diagnostic efficacy.

RESULTS

On arthroscopy, 46 cases with no TFCC tear, 34 cases with central perforations, and 53 cases with peripheral TFCC tears were identified. ECU pathology was seen in 19.6% (9/46) of patients with no TFCC tears, in 11.8% (4/34) with central perforations and in 84.9% (45/53) with peripheral TFCC tears (p < 0.001); the respective numbers for BME were 21.7% (10/46), 23.5% (8/34), and 88.7% (47/53) (p < 0.001). Binary regression analysis showed additional value from ECU pathology and BME in predicting peripheral TFCC tears. The combined approach with direct MRI evaluation and both ECU pathology and BME yielded a 100% positive predictive value for peripheral TFCC tear as compared to 89% with direct evaluation alone.

CONCLUSIONS

ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to diagnose tears.

KEY POINTS

• ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to confirm the presence of TFCC tears. • If there is a peripheral TFCC tear on direct MRI evaluation and in addition both ECU pathology and BME on MRI, the positive predictive value is 100% that there will be a tear on arthroscopy compared to 89% with direct evaluation alone. • If there is no peripheral TFCC tear on direct evaluation and neither ECU pathology nor BME on MRI, the negative predictive value is 98% that there will be no tear on arthroscopy compared to 94% with direct evaluation alone.

Extracellular Targets to Reduce Excessive Scarring in Response to Tissue Injury

Excessive scar formation is a hallmark of localized and systemic fibrotic disorders. Despite extensive studies to define valid anti-fibrotic targets and develop effective therapeutics, progressive fibrosis remains a significant medical problem. Regardless of the injury type or location of wounded tissue, excessive production and accumulation of collagen-rich extracellular matrix is the common denominator of all fibrotic disorders. A long-standing dogma was that anti-fibrotic approaches should focus on overall intracellular processes that drive fibrotic scarring. Because of the poor outcomes of these approaches, scientific efforts now focus on regulating the extracellular components of fibrotic tissues. Crucial extracellular players include cellular receptors of matrix components, macromolecules that form the matrix architecture, auxiliary proteins that facilitate the formation of stiff scar tissue, matricellular proteins, and extracellular vesicles that modulate matrix homeostasis. This review summarizes studies targeting the extracellular aspects of fibrotic tissue synthesis, presents the rationale for these studies, and discusses the progress and limitations of current extracellular approaches to limit fibrotic healing.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains

PURPOSE

Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain.

METHODS

This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy.

RESULTS

Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10.

CONCLUSIONS

It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Risk of Noise-Induced Hearing Loss for Orthopaedic Surgeons

BACKGROUND

Noise-induced hearing loss (NIHL) affects the ability of an individual to communicate and can negatively impact quality of life. The risk to orthopaedic surgeons of developing NIHL as a result of occupational exposures in the operating room (OR) is currently unknown. Hearing protection is recommended for levels of >85 decibels (dB), irrespective of length of exposure. The primary goal of the present study was to determine whether orthopaedic surgeons are exposed to harmful noise levels in the OR that puts them at risk for developing NIHL.

METHODS

A prospective review was conducted with use of intraoperative audio recordings across 6 orthopaedic subspecialties. Recordings were made in ORs prior to the surgical start time to serve as baseline controls. Decibel levels were reported as the maximum dB level (MDL), defined as the highest sound pressure level during the measurement period, and as the time-weighted average (TWA), defined as the average dB level projected over an 8-hour time period. Noise doses were reported as the percentage of maximum allowable daily noise (dose) and as the measured dose projected forward over 8 hours (projected dose).

RESULTS

Three hundred audio recordings were made and analyzed. The average MDL ranged from 96.9 to 102.0 dB, with noise levels for all subspeciality procedures being significantly greater compared with the control recordings (p < 0.001). Overall, MDLs were >85 dB in 84% of cases and >100 dB in 35.0% of cases. The procedure with the highest noise dose was a microdiscectomy, which reached 11.3% of the maximum allowable daily noise and a projected dose of 104.1%. Among subspecialties, adult reconstruction had the highest dose and projected dose per case among subspecialties.

CONCLUSIONS

The present results showed that orthopaedic surgeons are regularly exposed to damaging noise levels (i.e., >85 dB), putting them at risk for permanent hearing loss. Further investigation into measures to mitigate noise exposure in the OR and prevent hearing loss in orthopaedic surgeons should be undertaken.

CLINICAL RELEVANCE

Orthopaedic surgeons are at risk for NIHL as a result of occupational exposures in the OR.

Blocking Screw Technique for Maintaining Reduction during Intramedullary Screw Fixation of Oblique Metacarpal Fractures

Intramedullary screw fixation provides a less-invasive means of surgically managing metacarpal fractures. While there are advantages to using this technique compared to CRPP and ORIF, disadvantages of intramedullary screw fixation include loss of reduction intraoperatively due to sagittal and coronal plane translation. The blocking screw technique has been previously described as a solution for this problem in intramedullary fixation of long bone fractures. We describe the blocking screw technique as applied to aid intramedullary screw fixation of metacarpals.

Safety and Duration of Low-Dose Adjuvant Dexamethasone in Regional Anesthesia for Upper Extremity Surgery: A Prospective, Randomized, Controlled Blinded Study

BACKGROUND

Orthopedic procedures concerning the upper extremity commonly use a brachial plexus nerve block to achieve postoperative analgesia. The addition of dexamethasone to peripheral nerve blocks has been shown to significantly prolong its effect. We hypothesize that 1 mg doses of dexamethasone will prolong brachial plexus nerve block with similar efficacy to 4 mg and better than ropivacaine alone.

METHODS

Seventy-nine patients who received a brachial plexus nerve block prior to undergoing upper extremity surgery were randomized to 1 of 4 treatment groups: group 1 received only 30 mL of 0.5% ropivacaine without dexamethasone (control); groups 2, 3, and 4 received 4, 2, and 1 mg of dexamethasone, respectively, added to 30 mL of 0.5% ropivacaine.

RESULTS

Comparison of block duration, specifically "first signs of the block wearing off" to the 0-mg group, referencing the 1-, 2-, and 4-mg groups (P = .02, .04, and .01, respectively) that received steroid adjuvant therapy demonstrated a significant increase in time until the block began to wear off. All study groups receiving steroids also demonstrated a significant increase in duration of the block prior to its effects being completely gone when compared with the control group (P < .01 for all groups).

CONCLUSIONS

Our findings demonstrate that adjuvant dexamethasone can prolong brachial plexus nerve blocks effectively at low doses compared with high doses, in addition to prolonging analgesia compared with local anesthetic alone.

A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study

BACKGROUND

Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively.

METHODS

Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain.

RESULTS

From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing.

CONCLUSIONS

The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.

New Evaluation and Management Code Level Selection Trends in Hip and Knee Osteoarthritis Patients

BACKGROUND

On January 1, 2021, the American Medical Association implemented changes regarding the outpatient Evaluation and Management (E/M) criteria dictating Current Procedural Terminology code level selection to help diminish administrative burden and emphasize medical decision-making as the primary determinant in E/M level of service (EML). The goal of this study was to describe EML coding trends in outpatient visits for hip and knee osteoarthritis after the 2021 Centers for Medicare and Medicaid Services changes to the E/M system.

METHODS

All outpatient visits for primary hip and knee osteoarthritis within the divisions of Joint Replacement, Operative Sports Medicine, and Nonoperative Sports Medicine at a single orthopaedic practice were retrospectively analyzed during 2 separate 10-month timeframes in 2019 and 2021. The primary endpoint was the visit EML (1 through 5) based on Current Procedural Terminology E/M codes.

RESULTS

In 2019, 7.8% of all visits were billed as level 2, 85.8% of all visits were billed as level 3, and 6.3% of all visits were billed as level 4. In 2021, 2.8% of visits were billed as level 2, 54% of visits were billed as level 3, and 41.3% of visits were billed as level 4. Level 1 and Level 5 visits did not exceed 2% in either year. Across all 3 divisions, level 2 and 3 visits decreased significantly (P < .05), while level 4 visits increased significantly (P < .05).

CONCLUSION

Since the E/M coding criteria overhaul in 2021, there has been a significant trend towards higher level of service code selection across multiple divisions in our orthopaedic practice.

Effectiveness of Quickcast Versus Custom-Fabricated Thermoplastic Orthosis Immobilization for the Treatment of Mallet Fingers: A Randomized Clinical Trial

BACKGROUND

Mallet finger is a common injury involving a detachment of the terminal extensor tendon from the distal phalanx. This injury is usually treated with immobilization in a cast or splint. The purpose of this study is to compare outcomes of mallet fingers treated with either a cast (Quickcast) or a traditional thermoplastic custom-fabricated orthosis.

METHODS

Our study was a prospective, assessor-blinded, single-center randomized clinical trial of 58 consecutive patients with the diagnosis of bony or soft tissue mallet finger treated with immobilization. Patients were randomized to either an orfilight thermoplastic custom-fabricated orthosis or a Quickcast orthosis. Patients were evaluated at 3, 6, and 10 weeks for bony and 4, 8, and 12 weeks for soft tissue mallets. Skin complications, pain with orthosis, compliance, need for surgical intervention, and extensor lag were compared between the 2 groups.

RESULTS

Both bony and soft tissue mallet finger patients experienced significantly less skin complications (33% vs 64%) and pain (11.2 vs 21.6) when using Quickcast versus an orfilight thermoplastic custom-fabricated orthosis. The soft tissue mallet group revealed a greater difference in pain, favoring Quickcast (6.2 vs 22). No significant difference in final extensor droop or need for secondary surgery was found between the 2 groups.

CONCLUSIONS

Quickcast immobilization for the treatment of mallet finger demonstrated fewer skin complications and less pain compared with orfilight custom-fabricated splints.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care

BACKGROUND

Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant.

METHODS

Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types.

RESULTS

Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures.

CONCLUSIONS

These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

Biomechanical comparison of elbow stability constructs

BACKGROUND

Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined.

METHODS

Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct.

RESULTS

Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight.

CONCLUSION

The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients

BACKGROUND

Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice.

METHODS

We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use.

RESULTS

There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001).

CONCLUSION

Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Efficacy of Waterproof Cast Protectors and Their Ability to Keep Casts Dry

PURPOSE

The purpose of the study was to compare the efficacy of 6 different commercially available waterproof cast protectors in their ability to maintain a dry environment and evaluate whether cast protectors perform better than a plastic bag secured with tape in keeping casts dry.

METHODS

We enrolled 23 adult participants to test 6 different commercially available cast protectors and a plastic bag. Participants trialed all cast protectors twice, with and without motion, by fully submerging each cast protector in water with a paper towel held between their index and middle fingers. Moisture accumulation within the cast protectors was estimated by the change in weight of paper towel. An analysis of variance test was performed to compare differences between cast protectors in their ability to maintain a dry internal environment.

RESULTS

The plastic bag showed an average moisture accumulation of 5.50 g without motion compared with all other cast protectors, which had 0.0 g of moisture accumulation. One cast protector and the plastic bag had an average moisture accumulation of 0.46 g and 4.51 g with motion compared to all other cast protectors. The plastic bag was ranked the worst by 100% of participants.

CONCLUSION

Cast protectors appear to offer superior protection from moisture compared with a plastic bag.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Contactless Remote 3D Splinting during COVID-19: Report of Two Patients

We used calibrated 2D images uploaded by patients to an online platform to generate a 3D digital model of the limb. This was used to 3D print a splint. This method of 3D printing of splints was used for two patients who were not able to visit the hospital in person due to restrictions placed by the COVID-19 pandemic. Both patients were satisfied with the splint. We feel that this technology could be used to offer additional options to conventional splinting that allows contactless splint fitting. Level of Evidence: Level V (Therapeutic).

Optimal Position of the Suture Button Suspensionplasty (TightRope) for Thumb Basal Joint Arthritis

Background: Surgical treatment of basal joint arthritis commonly consists of trapeziectomy followed by various suspensionplasty techniques to provide stability to the thumb ray. Our study goal was to assess the motion and stability of the thumb ray after trapeziectomy and placement of a suture button (Mini TightRope®, Arthrex, Naples, Florida) in a high- or low-angle trajectory. We hypothesized that a low-angle trajectory would yield the greatest stability while providing maximal motion of the thumb. Methods: Eleven fresh-frozen cadaver arms were imaged fluoroscopically in anterior-posterior and lateral views before and after trapeziectomy, and after placement of low- and high-angle suture buttons. The intermetacarpal angle between the thumb and index metacarpals was measured after application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, adduction, and subsidence were measured. Results: Compared to posttrapeziectomy constructs, low- and high-angle TightRope constructs demonstrated less subsidence, low-angle TightRopes had less palmar abduction, and high-angle TightRope constructs had less radial abduction and adduction. High-angle TightRopes allowed more palmar abduction than low-angle constructs. The high-angle TightRopes trended toward more subsidence than low-angle constructs, although it was not significant. Conclusions: Both TightRope constructs provided improved axial stability after trapeziectomy while not excessively limiting any one motion of the thumb. Compared to the high-angle trajectory, the low-angle TightRope placement provided a more stable construct with respect to subsidence and angular motion. Given the concern for excessive motion of the first metacarpal base with the high-angle construct, we recommend a low-angle trajectory TightRope placement.

The Effects of Distal Pole Scaphoid Resection on Wrist Biomechanics

BACKGROUND

Distal pole scaphoid resection (DPSR) is an effective way to manage chronic scaphoid non-union with limited degenerative arthritis. Studies have reported positive results in terms of pain relief, wrist range of motion and grip strength, and patient satisfaction. However, the biomechanical consequences of DPSR remain unclear. This study evaluates the effects of DPSR on carpal mechanics by assessing changes in radiographic parameters with varying quantities of scaphoid removal.

METHODS

Six fresh frozen cadaveric upper extremities were used. Resections of 25%, 50%, and 75% of the length of each scaphoid were performed under fluoroscopic image guidance. For the intact scaphoid and each resection level, the following radiographic parameters were assessed: radiolunate and capitolunate angles; carpal height and first metacarpal subsidence ratios, and ulnar carpal translation. Measurements were then repeated for grip and pinch as well as radial and ulnar wrist deviation positions. Radial styloid to trapezium distance in wrist radial deviation was also measured to assess for impingement.

RESULTS

There was a statistically significant increase in the mean radiolunate angle with increasing scaphoid resection quantities. No statistically significant correlations were found between radial styloid clearance and increasing scaphoid resection percentages. Changes in the remaining variables did not reach statistical significance.

CONCLUSION

Increasing levels of scaphoid resection is associated with progressive signs of carpal malalignment best depicted by increasing radiolunate angles. Diminishing radial styloid clearance was clinically evident as more scaphoid was resected. For this, prophylactic radial styloidectomy may be considered to avoid bony impingement.

Scaphotrapezoid Assessment during Thumb Carpometacarpal Arthroplasty: A Cadaveric Study

Background  Due to limited sensitivity of radiographs for scaphotrapeziotrapezoid (STT) arthritis and the high rate of concurrence between thumb carpometacarpal (CMC) and STT arthritis, intraoperative visualization of the STT joint is recommended during CMC arthroplasty. Purpose  We quantified the percentage of trapezoid facet of the scaphotrapezoid (ST) joint that could be visualized during this approach, and compared it to the degree of preoperative radiographic STT arthritis. Methods  We performed dorsal surgical approach to the thumb CMC joint after obtaining fluoroscopic anteroposterior, lateral, and oblique wrist radiographs of 11 cadaver wrists. After trapeziectomy, the ST joint was inspected and the visualized portion of the trapezoid articulation marked with an electrocautery. The trapezoid was removed, photographed, and the marked articular surface area and total surface area were independently measured by two authors using an image analysis software. The radiographs were analyzed for the presence of STT arthritis. Results  The mean visualized trapezoid surface area during standard approach for CMC arthroplasty was 60.3% (standard deviation: 24.6%). The visualized percentage ranged widely from 16.7 to 96.5%. There was no significant correlation between degree of radiographic arthritis and visualized percentage of the joint ( p  = 0.77). Conclusions:  On average, 60% of the trapezoid joint surface was visualized during routine approach to the thumb CMC joint, but with very large variability. Direct visualization of the joint did not correlate with the degree of radiographic STT arthritis. Clinical Relevance  A combination of clinical examination, pre- and intraoperative radiographs, and intraoperative visualization should be utilized to assess for STT osteoarthritis and determine the need for surgical treatment. Level of Evidence  This is a Cadaveric Research Article.

Overall Opioid Consumption Is Not Associated With the Amount of Opioids Administered and Prescribed on the Day of Upper Extremity Surgery

Background: Orthopedic surgeons need to better understand the effect their opioid-prescribing habits have on patients. The purpose of our study was to evaluate whether the type of procedure or initial amount of opioids prescribed postoperatively leads to increased consumption of opioids. Methods: Consecutive patients undergoing upper extremity surgery were enrolled. The medical record and Pennsylvania Prescription Drug Monitoring Program Web site were used to record all prescriptions of controlled substances consumed intraoperatively, in the recovery room, and in prescriptions filled 6 months postoperatively. Morphine equivalent units (MEUs) were used to quantify the amount of opioids. Results: Two hundred ninety patients were included in the study. The mean MEU administered intraoperatively was 25.1 (0-50). The MEU provided in the recovery room was 2.9 (0-60). The MEU prescribed on the day of surgery was 155.6 (137-178). We used the Pearson correlation coefficient of r = 0, meaning no/weak correlation, and r = 1, meaning a strong correlation. Neither MEUs provided intraoperatively or in recovery, nor MEUs prescribed postoperatively correlated with prescriptions filled (r = 0.13, 0.02, 0.09, respectively). Although patients undergoing bony procedures were prescribed more opioids (P < .001), opioid consumption intraoperatively, in recovery, and in prescriptions filled was not significantly different. Conclusions: The MEUs administered and prescribed on the day of surgery did not affect the amount of prescriptions filled postoperatively. Finally, patients undergoing bony procedures were prescribed more opioids than those undergoing soft tissue procedures, but they did not consume or fill more opioids postoperatively.

Three Dimensionally Printed Versus Conventional Casts in Pediatric Wrist Fractures

Background and objective With significant advancement in the field of biomaterials, alternatives to conventional fiberglass casts such as customized three-dimensional (3D) orthotics have been developed. However, there is a scarcity of reported experience regarding 3D-printed orthoses. The purpose of this study was to compare radiographic outcomes and patient satisfaction with fractures treated with either conventional or 3D-printed casts. Materials and methods We included 23 limbs from 22 patients, who were aged between 8-18 years, and with a diagnosis of an acute nondisplaced wrist or forearm fracture. Patients were randomized into two groups: consisting of those treated with a 3D-printed orthosis and those with conventional fiberglass cast. Outcomes included X-ray alignment and healing, cast fit, the appearance of the skin, ease of care, and overall satisfaction. Results Of note, 10/11 (91%) in the 3D cast group healed in an excellent position, and 1/11 healed in an acceptable position. Also, 11/12 (92%) in the conventional cast group healed in an excellent position, and 1/12 healed in an acceptable position. Radiographically, 11/11 (100%) of the fractures in the 3D group and 11/12 (92%) in the conventional cast group were found to be fully healed. No differences were found in terms of skin irritation by a blinded hand therapist. Patients reported significant differences in skin irritation, comfort, satisfaction, and cast care favoring 3D casts (p<0.05). Conclusions 3D orthoses offer a promising opportunity to improve patients' experiences with upper extremity casting while also providing appropriate immobilization.

Time to Improvement After Corticosteroid Injection for Trigger Finger

Purpose

Trigger finger is a commonly occurring hand condition that presents with symptoms of pain, clicking, locking, and catching of the finger. A common non-operative management option is corticosteroid injection. The purpose of this study was to evaluate the short-term patient response to corticosteroid injections for trigger finger. 

Methods

The patients of six fellowship-trained orthopedic hand surgeons who underwent a corticosteroid injection for trigger finger between June 2019 and October 2019 were invited to participate in this study. Patients were contacted by phone at one week, two weeks, and three weeks after the injection to complete a questionnaire regarding their pain and triggering symptoms. Medical records were also reviewed to collect basic demographic data.

Results

A total of 452 patients were included in the study. At the final follow-up, 82.4% of patients reported complete pain relief, 16.3% had partial relief, and 1.2% had no relief from their pain. For their triggering symptoms, 65.9% reported complete triggering relief, 30.4% had partial relief, and 3.5% had no triggering relief. It took an average of 6.6 days following injection for patients to experience complete pain relief, and an average of 8.1 days for patients to experience complete triggering relief.

Conclusions

This analysis found that most patients experience relief of pain and triggering at three weeks following corticosteroid injection. The majority of patients experienced some pain relief within the first week following corticosteroid injection, while improvement in triggering appeared to lag behind pain relief.

An Evaluation of the Bacterial Adherence to Casting Materials

Introduction: The purpose of this study was to evaluate bacterial adherence to common casting materials including plaster of Paris (plaster), fiberglass, three-dimensional (3D) printed plastic, and silicone-coated 3D printed plastic.

Methods: The minimal inhibitory concentration of a phosphate-free detergent (Palmolive) needed to achieve total bacterial kill off was determined. 3D printed polylactic acid plastic samples were coated with silicone. Plaster, fiberglass, plastic, and silicone-coated plastic samples were inoculated with Staphylococcus aureus. After bacterial inoculation, scanning electron microscopy of the samples was performed to visualize bacterial adherence to the materials' surface. Using either sterile water or a 5% detergent solution, the materials were subjected to washings. Each material was run in 30 replicates: 6 without washing, 6 with sterile water for 1 minute, 6 with detergent for 1 minute, 6 with sterile water for 3 minutes, and 6 with detergent for 3 minutes. The replicates that did not undergo a washing trial represented the initial bacterial inoculation. Samples were then rinsed and sonicated in polysorbate to isolate the remaining adherent bacteria on the materials’ surface. The sonicated solutions were plated, incubated, and counted for quantification of colony forming units (CFU) of bacteria. This protocol was repeated for a total of four trials.

Results: During inoculation, there were significantly less bacteria that adhered to silicone-coated 3D printed plastic (58879 CFU) compared to plastic (217479 CFU), plaster (140063 CFU), and fiberglass (550546 CFU). Silicone coating showed further superiority. Silicone-coated 3D printed plastic was able to be decontaminated as demonstrated by significantly fewer remaining bacteria (9.3%) on its surface after being washed with a 5% detergent solution (1797 CFU) compared to sterile water (19321 CFU). The mean remaining bacteria on silicone-coated 3D printed plastic was significantly less than that remaining on all other materials when washed with either sterile water or a detergent solution for both durations of 1 minute and 3 minutes.

Conclusions: The current study demonstrates that significantly less bacteria adhere to the surface of 3D printed plastic with silicone coating showing added protection and that this material can be decontaminated to a greater degree with washing than conventional casting materials. These results provide evidence that 3D printed casts can be washed and successfully decontaminated during a patient’s period of immobilization, which is advantageous especially during an infectious crisis such as the coronavirus disease 2019 (COVID-19) pandemic.

Mechanisms of reducing joint stiffness by blocking collagen fibrillogenesis in a rabbit model of posttraumatic arthrofibrosis

Posttraumatic fibrotic scarring is a significant medical problem that alters the proper functioning of injured tissues. Current methods to reduce posttraumatic fibrosis rely on anti-inflammatory and anti-proliferative agents with broad intracellular targets. As a result, their use is not fully effective and may cause unwanted side effects. Our group previously demonstrated that extracellular collagen fibrillogenesis is a valid and specific target to reduce collagen-rich scar buildup. Our previous studies showed that a rationally designed antibody that binds the C-terminal telopeptide of the α2(I) chain involved in the aggregation of collagen molecules limits fibril assembly in vitro and reduces scar formation in vivo. Here, we have utilized a clinically relevant arthrofibrosis model to study the broad mechanisms of the anti-scarring activity of this antibody. Moreover, we analyzed the effects of targeting collagen fibril formation on the quality of healed joint tissues, including the posterior capsule, patellar tendon, and subchondral bone. Our results show that blocking collagen fibrillogenesis not only reduces collagen content in the scar, but also accelerates the remodeling of healing tissues and changes the collagen fibrils’ cross-linking. In total, this study demonstrated that targeting collagen fibrillogenesis to limit arthrofibrosis affects neither the quality of healing of the joint tissues nor disturbs vital tissues and organs.

Recurrence of Ganglion Cysts Following Re-excision

Background

The recurrence of ganglion cysts after surgical excision has a reported rate of 4% to 40%. Recurrence rate after revision surgical excision is unknown. The purpose of this study was to define the incidence of recurrent ganglion cysts in patients who underwent a secondary excision procedure.

Methods

With Institutional Review Board approval, we retrospectively identified by CPT code and reviewed charts of patients who had recurrent ganglion cyst excision performed over a five-year period (2010 - 2014). Recurrence was defined as reappearance of a cyst in the same area as it was previously. Demographic information including recurrences and revision surgeries was collected in addition to outcome variables such as patient satisfaction, pain levels, and functional limitations.

Results

Out of the 42 revision cases identified 20 patients were reached. Mean time to recurrence of the cyst after the first ganglion cyst excision was 2.5 years (range: 1 month - 12 years). After the second ganglion cyst excision, three patients (15%) had a recurrence, each occurring within one year (mean: 11 months; range: 9-12). One of the three patients underwent a third successful ganglion cyst excision. The other two patients declined surgical intervention to date. Patients without a second recurrence (n=17) reported an average pain score of 0.1 (range: 0-2) on a scale of 1-10. Three (18%) reported some difficulty with day-to-day activities due to their scar. Seven (41%) patients reported at least transient numbness or tingling. Mean satisfaction was 9.8 on a scale of 1-10, and 100% reported that they would undergo another ganglion cyst excision should they ever have another recurrence.

Conclusion

Patients should be advised about the risk of recurrence after re-excision of ganglion cysts, which was noted to be 15% in our cohort. This rate of recurrence is similar to that of primarily excised cysts.

The Accuracy of 3D Printed Carpal Bones Generated from Cadaveric Specimens

Background

Computer assisted three-dimensional (3D) printing of anatomic models using advanced imaging has wide applications within orthopaedics. The purpose of this study is to evaluate the 3D printing accuracy of carpal bones.

Methods

Seven cadaveric wrists underwent CT scanning, after which select carpal bones (scaphoid, capitate, lunate, and trapezium) were dissected in toto. Dimensions including length, circumference, and volume were measured directly from the cadaver bones. The CT images were converted into 3D printable stereolithography (STL) files. The STL files were converted into solid prints using a commercially available 3D printer. The 3D printed models' dimensions were measured and compared to those of the cadaver bones. A paired t-test was performed to determine if a statistically significant difference existed between the mean measurements of the cadavers and 3D printed models. The intraclass correlation coefficients (ICC) between the two groups were calculated to measure the degree of agreement.

Results

On average, the length and circumference of the 3D printed models were within 2.3 mm and 2.2 mm, respectively, of the cadaveric bones. There was a larger discrepancy in the volume measured, which on average was within 0.65 cc (15.9%) of the cadaveric bones. These differences were not statistically significant (P > 0.05). There was strong agreement between all measurements except the capitate's length and lunate's volume.

Conclusion

3D printing can add value to patient care and improve outcomes. This study demonstrates that 3D printing can both accurately and reproducibly fabricate boney models that closely resemble the corresponding cadaveric anatomy.

Patient Perceptions of COVID-19 Precautions and Their Effects on Experiences With Hand Surgery

Purpose

The purpose of this study is to evaluate patient perceptions of COVID-19 precautions and how these precautions have affected their hand and upper extremity surgery experience.

Methods

We sent an 18-item survey to 1,213 patients who underwent elective hand and upper extremity surgery at 1 academic institution from October 2020 to January 2021. The survey consisted of questions related to patient demographics, treatment delays due to COVID-19, and patient perceptions of COVID-19 precautions. Descriptive statistics were performed to analyze the survey responses. Responses for patients aged 18–50 and 51+ were compared using a chi-square analysis for categorical variables and a Student t-test for continuous variables.

Results

Out of 1,213 invitations, 384 survey respondents completed the survey (31.6%). Of the respondents, 16.8% reported delaying medical treatment for an average of 123.2 days because of COVID-19. The preventative measures were found to be adequate by 95% of patients. Only 2.6% of patients reported experiencing surgical delays due to preoperative COVID-19 testing or other COVID-19-related precautions. COVID-19 testing was seen as necessary by 88% of patients, and 74% did not find COVID-19 testing to be a barrier to their surgery. Patients aged 51+ were more likely to delay seeking medical treatment than younger patients (19.3% vs 9.1%, respectively). Furthermore, those that did delay seeking treatment waited longer on average than their younger counterparts (136.1 vs 72.9 days, respectively).

Conclusions

In conclusion, patients undergoing hand and upper extremity surgery typically do not find COVID-19 precautions to be a significant barrier to care and understand their importance. Despite this, many patients, particularly older ones, are delaying medical care for extended periods of time. It is important for hand surgeons to acknowledge their patients’ perspectives and work to educate patients on evolving surgical safety guidelines.

Clinical relevance

Patient perspectives of current COVID-19 precautions can help inform hand surgeons on areas for continued patient education.

The Use of 3D Printed Customized Casts in Children with Upper Extremity Fractures: A Report of Two Cases

3D printing is an evolving technology which has a potential application in the treatment pediatric forearm fractures. Very little has been published with regard to 3D casting in children. We present two cases in which upper extremity fractures in pediatric patients were treated by wearing a custom made 3D printed cast. At latest follow-up at least one year post-injury, the clinical outcomes were excellent. Orthopaedic surgeons may benefit from familiarizing themselves with the potential of 3D printing technology and utilizing its current applications, as well as devising future applications, in clinical practice.

Sterility of Ethyl Chloride Spray After Use in the Clinic

Background: Ethyl chloride spray is used frequently in the outpatient setting as a local anesthetic for injections and aspirations with varying consensus about the sterility of the spray. We hypothesize that ethyl chloride spray remains sterile and would show no bacterial growth during routine clinical use. Methods: Thirteen ethyl chloride bottles were collected for testing. Two unopened bottles were used as controls. Eleven unopened bottles were placed in orthopedic clinics and recollected after varying duration of use. The final volume and duration of use were recorded. Each bottle was sprayed in a separate test tube and allowed to evaporate. Trypticase soy broth was added to each tube and incubated for 48 hours. Control test tubes with broth alone were prepared and incubated under the same conditions. Cultures were evaluated at 24 and 48 hours. Results: The mean duration of ethyl chloride bottle use prior to culturing was 26 days. The average volume used per day was 1.9 mL. Each ethyl chloride bottle had an initial volume of 103.5 mL. Using the average daily volume usage, an extrapolated lifespan of each bottle was estimated at 7.7 weeks. None of the samples showed bacterial or fungal growth at 24 or 48 hours. Conclusion: Ethyl chloride bottles used in the clinical settings showed no bacterial or fungal contamination through their shelf life and routine use. The duration and amount of use did not affect sterility. Although the antimicrobial activity of ethyl chloride spray on skin is debated, ethyl chloride itself remains sterile through clinical use.

An Evaluation of Complications Following Ultrasound-Guided Regional Block Anesthesia in Outpatient Hand Surgery

Background: Ultrasound-guided (USG) assistance has contributed to the acceptance of regional anesthesia as a safe and efficient alternative to traditional general anesthesia. However, limited data exist regarding the safety of supraclavicular blocks used in common hand surgery procedures. The purpose of this retrospective study was to evaluate a large sample of cases to determine the effectiveness and complication rate of supraclavicular nerve blocks and confirm the safety of its use within the ambulatory surgery center (ASC) setting. Methods: Nerve blocks for the upper extremity were performed via the supraclavicular approach using the USG technique. Records were analyzed for all patients monitored during the immediate postoperative recovery and step-down phases at the ASC and contacted by phone or evaluated within 2 weeks at their first postoperative visit. Adverse outcomes related to the regional block anesthesia were identified via phone interview or postoperative surgical visit and documented. Results: In all, 713 records were reviewed with 56% female (n = 398) and 44% male (n = 315) patients. Of the 713 cases, 4 adverse events were identified (0.6%, 95% confidence interval [%]), including 2 abnormal reactions to the nerve block and 2 incomplete blocks with inadequate pain control. Conclusions: This study is the first report to evaluate a large sample of outpatient hand procedures at a high-volume ASC. We can report no clinically significant pulmonary or neurovascular complications with the use of USG supraclavicular nerve block techniques, further supporting its establishment as a safe and efficient procedure, yielding a low complication rate.

Low Rate of Complications Following Intramedullary Headless Compression Screw Fixation of Metacarpal Fractures

Background: There has been a recent increase in the use of headless compression screws for fixation of metacarpal neck and shaft fractures as they offer several advantages, and minimal complications have been reported. This study aimed to evaluate the clinical complications and their solutions following retrograde intramedullary headless compression screw fixation of metacarpal fractures. We describe complications and the approach to their management. Methods: We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by 3 fellowship-trained hand surgeons. Patient demographics, implant used, type of complication, pre- and postoperative radiographs, operative reports, and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy, and any repeat surgical intervention. Results: Four complications (2.5%) were identified through the review of 160 total metacarpal fractures. One complication was a nickel allergy, one was a broken screw after repeat trauma, and 2 patients had bent intramedullary screws. Screw removal in 3 patients was simple and without complications or persistent limitations. One bent screw with a refracture was left in place. No serious complications were seen. Conclusion: Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed.

Ultrasound Evaluation for Incomplete Carpal Tunnel Release

Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Collagen-rich deposit formation in the sciatic nerve after injury and surgical repair: A study of collagen-producing cells in a rabbit model

INTRODUCTION

Posttraumatic scarring of peripheral nerves produces unwanted adhesions that block axonal growth. In the context of surgical nerve repair, the organization of the scar tissue adjacent to conduits used to span the gap between the stumps of transected nerves is poorly understood. The goal of this study was to elucidate the patterns of distribution of collagen-rich scar tissue and analyze the spatial organization of cells that produce fibrotic deposits around and within the conduit's lumen.

METHODS

Employing a rabbit model of sciatic nerve transection injury, we studied the formation of collagen-rich scar tissue both inside and outside conduits used to bridge the injury sites. Utilizing quantitative immunohistology and Fourier-transform infrared spectroscopy methods, we measured cellular and structural elements present in the extraneural and the intraneural scar of the proximal and distal nerve fragments.

RESULTS

Analysis of cells producing collagen-rich deposits revealed that alpha-smooth muscle actin-positive myofibroblasts were only present in the margins of the stumps. In contrast, heat shock protein 47-positive fibroblasts actively producing collagenous proteins were abundant within the entire scar tissue. The most prominent site of transected sciatic nerves with the highest number of cells actively producing collagen-rich scar was the proximal stump.

CONCLUSION

Our findings suggest the proximal region of the injury site plays a prominent role in pro-fibrotic processes associated with the formation of collagen-rich deposits. Moreover, they show that the role of canonical myofibroblasts in peripheral nerve regeneration is limited to wound contracture and that a distinct population of fibroblastic cells produce the collagenous proteins that form scar tissue. As scarring after nerve injury remains a clinical problem with poor outcomes due to incomplete nerve recovery, further elucidation of the cellular and spatial aspects of neural fibrosis will lead to more targeted treatments in the clinical setting.

Telemedicine Evaluation and Techniques in Hand Surgery

The demand for telemedicine has been increasing over the past several years with the growth of technology and digital connectivity in our daily lives. With the impact of the global coronavirus disease 2019 pandemic, telemedicine implementation has become a necessity for many specialties because social distancing measures have greatly affected access to routine medical care. This article presents a detailed and systematic approach to conducting a hand physical examination during a video telemedicine encounter. Although the telemedicine physical examination has limitations, most components of the normal physical examination can be completed remotely with a systematic approach. We enumerate modifications to maximize examination remotely and present considerations for improved delivery of telemedicine care. These methods may be beneficial to providers incorporating telemedicine into their practice.

Safety and Efficacy of Casting during COVID-19 Pandemic: A Comparison of the Mechanical Properties of Polymers Used for 3D Printing to Conventional Materials Used for the Generation of Orthopaedic Orthoses

To reduce the risk of spread of the novel coronavirus (COVID-19), the emerging protocols are advising for less physician-patient contact, shortening the contact time, and keeping a safe distance. It is recommended that unnecessary casting be avoided in the events that alternative methods can be applied such as in stable ankle fractures, and hindfoot/midfoot/forefoot injuries. Fiberglass casts are suboptimal because they require a follow up for cast removal while a conventional plaster cast is amenable to self-removal by submerging in water and cutting the cotton bandages with scissors. At present, only fiberglass casts are widely available to allow waterproof casting. To reduce the contact time during casting, a custom-made 3D printed casts/splints can be ordered remotely which reduces the number of visits and shortens the contact time while it allows for self-removal by the patient. The cast is printed after the limb is 3D scanned in 5-10 seconds using the commercially available 3D scanners. In contrast to the conventional casting, a 3D printed cast/splint is washable which is an advantage during an infectious crisis such as the COVID-19 pandemic.

Predictive Factors for Return to Driving following Volar Plate Fixation of Distal Radius Fracture

Background  A common query by patients undergoing distal radius fracture (DRF) repair is when (s)he can resume driving postoperatively. A prospective cohort analysis was performed to assess fracture and patient factors on a patient's self-reported ability to return to driving to better inform patients and surgeons. Methods  Consecutive patients undergoing DRF repair with locking volar plate were enrolled. Preoperative demographic and radiographic characteristics, and postoperative time to return to driving were collected. Data collected included age, sex, hand dominance, body mass index (BMI), level of education, concomitant ulnar fracture, fracture setting prior to surgery, and AO fracture classification. Results  A total of 131 patients were enrolled (108 women, 23 men) with 36 AO type A, 22 AO type B, and 73 AO type C DRFs, with an average age of 59.5 years. Fracture severity by classification did not significantly affect time to return to driving. However, BMI, sex, and age were found to significantly affect time to return to driving. Patients aged 19 to 59 years, 60 to 75 years, and over 75 years returned to driving 13.1, 15.4, and 30.1 days following surgery, respectively ( p  < 0.01). Classified by BMI, patients that were normal weight, overweight, and obese returned to driving 11.5, 13.1, and 21.0 days following surgery, respectively ( p  < 0.05). Men returned to driving 8.8 days and women 17.3 days postoperatively ( p  = 0.001). Conclusion  Patients severity of fracture as determined by AO fracture type did not affect time to driving, while increased BMI, female sex, and increased age were found to be significant factors in patients' return to driving time after distal radius fracture repair. Level of Evidence  This is a Level II, prospective cohort study.

On Emerging Technology: What to Know When Your Patient Has a Microchip in His Hand

Radio-frequency identification (RFID) technology uses an antenna to respond to an incoming signal by sending an outgoing message. This technology has been in use for over 50 years and is common in daily activities such as tapping a credit card to a reader, swiping an ID badge to open a door, paying highway tolls, and operating keyless entry cars. This technology can be implanted, such as in the microchips used to identify domestic pets. Since 1998, RFID chips have also been implanted in humans. This practice is little studied but appears to be increasing; rice-sized implants are implanted by hobbyists and even offered by some employers for uses ranging from access to emergency medical records to entry to secured workstations. These implants are of special concern to hand surgeons because they are most commonly placed in the subcutaneous dorsal first web space. The US Food and Drug Administration first approved this technology in 2004, with stated potential risks including adverse tissue reaction, migration of the implanted transponder, compromise of information security, electrical hazards, and magnetic resonance imaging incompatibility. Here, we explain implanted RFID technology, its potential uses, and what is and is not known about its safety. We present images of a patient with an RFID chip who presented to our clinic for acute metacarpal and phalangeal fractures, to demonstrate the clinical and radiographic appearance of these chips.

Telemedicine Evaluation and Techniques in Hand Surgery

The demand for telemedicine has been increasing over the past several years with the growth of technology and digital connectivity in our daily lives. With the impact of the global coronavirus disease 2019 pandemic, telemedicine implementation has become a necessity for many specialties because social distancing measures have greatly affected access to routine medical care. This article presents a detailed and systematic approach to conducting a hand physical examination during a video telemedicine encounter. Although the telemedicine physical examination has limitations, most components of the normal physical examination can be completed remotely with a systematic approach. We enumerate modifications to maximize examination remotely and present considerations for improved delivery of telemedicine care. These methods may be beneficial to providers incorporating telemedicine into their practice.