Effective Treatment of Simultaneous Distal Radius and Scaphoid Fractures.

Background There is an increasing trend for most surgeons to choose open reduction and internal fixation of simultaneous distal radius and scaphoid fractures; however, it is not clear if there is any evidence to support this. Case Description The purpose of this systematic review was to investigate the evidence for management of simultaneous distal radius and scaphoid fractures. Literature Review We performed searches of the EMBASE and MEDLINE databases (CRD42020167403). We included a total of 20 studies, involving 178 patients with 182 simultaneous fractures of the distal radius and scaphoid. The distal radius fractures were mostly intra-articular (112/182). The scaphoid fractures were mostly undisplaced (120/148) and at the scaphoid waist (152/178). All distal radius fractures went on to unite, and just 2 of 182 scaphoid fractures went on to nonunion. All included studies were retrospective case series, and therefore all were found to have a critical risk of bias due to confounding. The union rate for both the distal radius and scaphoid fractures is high with both operative and nonoperative treatments. Clinical Relevance Although there are no comparative studies to evaluate the most effective treatment, there is evidence to support operative management. Level of Evidence This is a Level IV, systematic review study.

MRI Findings in Patients Undergoing Triangular Fibrocartilage Complex Repairs Versus Patients Without Ulnar-Sided Wrist Pain.

Background: The clinical picture of ulnar-sided wrist pain is oftentimes confusing because various pathologies may be coexistent. In this study, we aimed: (1) to compare the prevalence of potential causes of ulnar-sided wrist pain on magnetic resonance imaging (MRI) in patients who underwent triangular fibrocartilage complex (TFCC) repair and control subjects: and (2) to evaluate whether inferior clinical results were associated with specific patient characteristics or other potential causes of ulnar-sided wrist pain. Methods: We included 67 patients who underwent a TFCC repair and 67 control subjects. The MRI scans were examined for sources of ulnar-sided wrist pain. After TFCC repair, 42 patients (63%) completed surveys, including Quick Disabilities of the Arm, Shoulder and Hand and pain scores. Bivariate analysis was performed to compare our groups and to identify factors associated with our outcomes. Results: We found significantly higher rates of distal radioulnar joint (DRUJ) arthritis (P = .033), extensor carpi ulnaris (ECU) pathology (P = .028), and ulnar styloid fractures (P = .028) in patients with TFCC repairs. With increasing age, increasing pathology in the pisotriquetral joint (P = .040), more ulnocarpal abutment (P = .0081), and more degenerative tears (P < .001) were seen in both groups. No demographic characteristics or MRI findings were significantly associated with our outcomes. Conclusions: We observed higher rates of DRUJ arthritis and ECU pathology in patients with TFCC tears undergoing repair compared with age- and sex-matched controls. This may be due to damage to the TFCC itself altering relationships of the DRUJ and the ECU subsheath, or it may reflect various pathologies that cause ulnar-sided wrist pain and drive patients toward surgery.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Simple trapeziectomy versus trapeziectomy with flexor carpi radialis suspension: a 17-year follow-up of a randomized blind trial.

The purpose of this study was to investigate if there were any significant differences in the long-term outcomes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy with ligament reconstruction and tendon interposition (LRTI). Sixty-five patients were invited for a follow-up visit at a mean of 17 years (range 15-20) postoperatively. Twenty-eight patients attended, who had 34 operations, 14 trapeziectomy alone and 20 with LRTI. There were no statistically significant differences between the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements showing minimal or no differences in means between the two groups. There was no difference in the space between the metacarpal and scaphoid. Radial abduction was the only parameter that was significantly greater in the patients with simple trapeziectomy (median 79°) compared with trapeziectomy with LRTI (median 71°) (p = 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for thumb carpometacarpal joint osteoarthritis.Level of evidence: I.

Long-Term Results of Pisiformectomy in a Cohort of 57 Patients.

Background Excision of the pisiform is an infrequently used option for pisotriquetral joint dysfunction when nonoperative treatment is ineffective. This study reviews the patient-reported outcomes of patients treated with pisiformectomy, and furthermore focuses on the complications and the need for and time to revision procedure. Materials and Methods Medical records of 57 patients were manually reviewed and assessed for complications, rate of unplanned reoperations, and type of reoperations. Thirty-seven patients (65%) completed patient-rated outcomes surveys at a median of 10 years after their procedure. Results The complication rate was 13% ( n = 7). Ulnar nerve symptoms were noted in three patients. No reoperations were performed after the pisiform excision. Out of the 16 patients who had preoperative symptoms of ulnar nerve compression at the wrist, 10 patients reported that their symptoms had completely resolved after the surgery. The median Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after surgery was 4.5 (2.3-16), median score for pain 0 (interquartile range [IQR]: 0-2), and median score for overall satisfaction 10 (IQR: 8-10). Conclusions Pisiformectomy is a surgery used sparingly in cases with refractory pain associated with arthrosis of the pisotriquetral joint or enthesopathy of the flexor carpi ulnaris/pisiform interface. When utilized in this fashion, patients report limited disability on patient-rated outcome measures, low pain scores, and high satisfaction at mid- to late follow-up.

Three-ligament tenodesis for chronic scapholunate injuries: short-term outcomes in 203 patients.

In this cohort study, we report on short-term outcomes of 203 patients (203 wrists) who underwent scapholunate ligament reconstruction using a three-ligament tenodesis technique between December 2013 and December 2017. Patients completed the Patient Rated Wrist Evaluation questionnaire and a visual analogue scale for pain online before surgery and at 3 months and 1 year after surgery. We also measured the range of movement before surgery, in 150 patients 3 months after surgery, and in 90 patients 1 year after surgery. The patients reported clinically significant improvements in both pain and function postoperatively, with continuing improvement at both 3 and 12 months. We conclude that the short-term outcomes of this procedure are generally good in term of patients' function, satisfaction, and pain relief, but about 20% of the operated wrists did not improve. Our data may help patients and surgeons in joint decision-making regarding treatment for chronic scapholunate injuries. Level of evidence: III.

What are the Implications of Excessive Internet Searches for Medical Information by Orthopaedic Patients?

BACKGROUND: Cyberchondria may be defined as heightened distress evoked through excessive searches of the internet for medical information. In healthy people, cyberchondria is associated with a greater intolerance of uncertainty and greater health anxiety. These relationships are likely bidirectional. People who have a greater intolerance of uncertainty may be more likely to search the internet for medical information and have greater health anxiety. This greater health anxiety may lead to an increased likelihood of engaging in further internet searches and greater intolerance of uncertainty. These three constructs are important for patients because they impact patient function and health care costs. We were specifically interested in understanding the role of cyberchondria in the association between intolerance of uncertainty and health anxiety among orthopaedic patients because it has not been explored before and because knowledge about these interactions could inform treatment recommendations. QUESTIONS/PURPOSES: Does cyberchondria mediate (that is, explain) the association between intolerance of uncertainty and health anxiety in orthopaedic patients searching for medical information on the internet, after controlling for potentially confounding variables? METHODS: This was a cross-sectional study of 104 patients who had searched the internet for any medical information about their current condition. A research assistant approached 155 patients attending two orthopaedic outpatient clinics, one hand and upper extremity service and one sports medicine clinic, during a 3-month period. Ten patients declined to participate and 41 patients were excluded, predominantly because they had never searched for medical information online. The patients completed the Cyberchondria Severity Scale, Intolerance of Uncertainty Scale-short version, Short Health Anxiety Inventory, and a numerical rating scale for pain intensity at baseline, as well as demographic and clinical questionnaires. We performed a series of linear regression analyses to determine whether a greater intolerance of uncertainty predicts greater cyberchondria (mediator) and whether cyberchondria predicts greater health anxiety. Although it is more appropriate to use the language of association (such as "whether cyberchondria is associated with health anxiety") in many observational studies, here, we opted to use the language of causation because this is the conventional language for studies testing statistical mediation. RESULTS: After controlling for potentially confounding variables including pain intensity, multiple pain conditions, and education, cyberchondria explained 33% of the variance of the effect of intolerance of uncertainty on health anxiety (95% CI, 6.98 to 114.72%; p < 0.001). CONCLUSIONS: Among orthopaedic patients who search the internet for medical information, a greater intolerance of uncertainty is associated with greater cyberchondria, which is associated with greater anxiety about health. Identifying patients with an intolerance of uncertainty and educating them about the negative role of compulsive searches for medical information may improve the success of orthopaedic treatment. Orthopaedic surgeons should also consider making referrals for cognitive behavioral therapy in these instances to increase the patient's tolerance of uncertainty, decrease internet searching habits, and reduce anxiety about health. LEVEL OF EVIDENCE: Level III, prognostic study.

Which Psychological Variables Are Associated With Pain and Function Before Surgery for de Quervain's Tenosynovitis? A Cross-sectional Study.

BACKGROUND: Depression, anxiety, and pain catastrophizing have been associated with worse pain and function in studies of patients with de Quervain's tenosynovitis. Illness perceptions are the patient's thoughts and feelings about their illness. More negative perceptions of the illness such as the illness having a long duration or serious consequences are associated with worse physical function in patients with hand osteoarthritis. It is currently unknown whether these psychological factors play a similar role in de Quervain's. We chose to study patients who have tried nonoperative management and have chosen surgical decompression due to persistent symptoms. Psychological factors may be associated with their ongoing pain and impaired function, so it is particularly important to investigate the role of psychosocial factors that may be targeted with non-invasive interventions. QUESTIONS/PURPOSES: Which psychological variables are independently associated with baseline pain and function in patients undergoing surgical treatment for de Quervain's tenosynovitis, after controlling for clinical and demographic variables? METHODS: This cross-sectional study included data from a longitudinally maintained database on 229 patients who had surgery for de Quervain's tenosynovitis between September 2017 and October 2018. All management options were discussed with patients, but many had already tried nonoperative management and chose surgery once referred to our institution. Our database included 958 patients with de Quervain's, with 69% (659) managed nonoperatively and 34% (326 of 958) who underwent surgical decompression. A total of 70% (229 of 958) completed all questionnaires and could be included in the study. With the numbers available, we found no differences between those included and those not analyzed in terms of age, gender, duration of symptoms, BMI, smoking status, and workload.Patients completed the Patient-Rated Wrist/Hand Evaluation (PRWHE), Patient Health Questionnaire for emotional distress, Pain Catastrophizing Scale (PCS), and the Brief Illness Perception Questionnaire. We investigated the relative contribution of patient demographics and individual psychosocial factors using a hierarchical multivariable linear regression model. In the first step we considered how demographic factors were associated with the baseline PRWHE score. In the second step we investigated the effect of pain catastrophizing and emotional distress on the baseline PRWHE score after accounting for confounding demographic factors. In the final step, the effect of illness perceptions on baseline PRWHE were considered after accounting for the confounding effects of demographic factors as well as pain catastrophizing and emotional distress. RESULTS: After controlling for confounding variables including workload and emotional distress, a more negative patient perception of the consequences of their condition and worse pain catastrophizing were associated with worse pain and function (consequences, ß = 0.31; p < 0.01, pain catastrophizing ß = 0.17; p = 0.03). A hierarchical multivariable regression analysis found that 11% of variance in baseline pain and function was explained by pain catastrophizing and emotional distress. Illness perceptions brought the total explained variance of the final model to 34%. CONCLUSIONS: More negative perceptions of the consequences of de Quervain's tenosynovitis and worse pain catastrophizing are associated with worse pain and reduced function at baseline in patients awaiting surgical decompression of de Quervain's tenosynovitis. In light of these findings, future studies might explore interventions to reduce pain catastrophizing and lower the perceived consequences of the condition. This may reduce the number of patients choosing surgical decompression or may also improve surgical outcomes. Further work should consider if these psychological factors are also associated with postoperative patient-reported outcomes. LEVEL OF EVIDENCE LEVEL: III, therapeutic study.

The Effect of Early Active Mobilization on Union Rate after Ulnar Shortening Osteotomy.

Background Ulnocarpal impaction occurs when there is excessive loading between the ulnar carpus and the distal ulna. Ulnar shortening osteotomies (USOs) decompress the ulnocarpal joint. Many studies have evaluated USO but none have considered the effect of early active mobilization on union rate. Questions Does early active mobilization affect rate of union following USO? Does early active mobilization affect rate of complications following USO? Patients and Methods We performed a retrospective review of 15 consecutive patients that underwent 16 USOs between 2011 and 2015. There were seven males and eight females. Median age at time of shortening osteotomy was 47 years (range: 11-63 years). The median time of the procedure was 62 minutes (range: 45-105 minutes) and the median change in ulnar variance was 5.5 mm (range: 0-10.5 mm). Six patients were initially immobilized in incomplete plaster casts postoperatively, while the remainder had only wool and crepe dressings. Early active mobilization commenced after the first postoperative visit at 12 days. Results There was a 100% union rate in our series and 12 patients were pain-free at final follow-up. However, three of the patients with the longest times to union were smokers. Additionally, some patients may have achieved union between follow-up clinic visits. Conclusion Early active mobilization after USO does not affect union rate. Prospective, randomized studies are required to investigate the effect of early active mobilization in light of factors known to increase time to union, such as smoking. Level of Evidence This is a Level IV, case series.

Validated repeatability of patient-reported outcome measures following primary total hip replacement: a mode of delivery comparison study with randomized sequencing.

Background and purpose - Patient-reported outcome measures (PROMs) are used to understand better the outcomes after total hip replacement (THR). These are administered in different settings using a variety of methods. We investigated whether the mode of delivery of commonly used PROMs affects the reported scores, 1 year after THR. Patients and methods - A prospective test-retest mode comparison study with randomized sequence was done in 66 patients who had undergone primary THR. PROMs were administered by 4 modes: self-administration, face-to-face interview, telephone interview, and postal questionnaire. PROMs included: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Hip Score (OHS), EQ5D-3L (EQ5D), and Self-Administered Patient Satisfaction Scale (SAPS). Linear regression was used to estimate relationships between the mean scores for PROMs by mode. Individual paired differences by mode were calculated, relationships between modes were identified, and results adjusted by time delay and participant age. Results - There was no statistically significant difference between the mean PROM scores recorded for each mode of delivery for each score. Statistically significant differences in the individual paired differences were detected between modes for the WOMAC stiffness subscale, OHS, EQ5D, and SAPS. OHS difference in individual paired means between face-to-face and telephone interview exceeded the minimal clinically important difference. Interpretation - PROMs mode of administration can affect the recorded results. Modes should not be mixed and may not be comparable between studies. It should not be assumed that different modes will obtain the same results and where not already established this should be checked by researchers before use.

Reliability of two techniques and training level of the observer in measuring the correction angle when planning a high tibial osteotomy.

BACKGROUND: In high tibial osteotomy, planning is critical for achieving successful realignment. Any method selected needs to be reliable, with inter-observer and intra-observer correlation. A literature review demonstrated two distinct methods of planning for high tibial osteotomy. HYPOTHESIS: Both methods are precise and show excellent inter and intra-observer correlation. METHOD: Fifty consecutive weight-bearing long leg alignment antero-posterior (AP) radiographs were identified and planning undertaken on suitable radiographs using the methods of Puddu (method 1) and Miniaci (method 2). Two observers, one junior trainee and one Specialist Knee Fellow, recorded measurements to calculate inter and intra-observer correlation. RESULTS: Thirty-two radiographs were included. Inter-observer and intra-observer correlation, and correlation between the two methods were all greater than 0.97 (p<0.0001). CONCLUSION: Our results show excellent correlation between both methods and both observers. Both methods are reliable for planning and can be performed by both junior trainees and subspecialists. Further work should consider how planning can ensure adequate intraoperative correction.

Posterior approach to optimise patient-reported outcome from revision hip arthroplasty.

INTRODUCTION: Most total hip arthroplasties (THAs) in the UK are performed through a posterior or lateral surgical approach. We aimed to investigate any difference in outcome from revision THA according to the approach at primary and revision THA surgery. METHODS: A retrospective cohort study of 205 patients who underwent revision THA for aseptic loosening. Patients rated their pain from 0-10 and completed the Self-Administered Patient Satisfaction Scale (SAPS), Oxford Hip Score (OHS), WOMAC and Short form-12 questionnaires. RESULTS: 205 patients (209 hips) from a cohort of 238 patients (243 hips, 86%) were available for analysis. The mean follow-up was 5 years (SD 1.71). Grouping by approach 20% (43/209) had both primary and revision procedures via a lateral approach, 20% (43/209) had their primary surgery via a lateral approach and their revision surgery via a posterior approach, whilst 60% (123/209) had both procedures via a posterior approach.The WOMAC and OHS were significantly better in patients who had a posterior approach for both primary and revision surgery, compared to those that did not (OHS p = 0.028, WOMAC p = 0.026). We found no significant differences in pain, satisfaction or health-related quality of life between the groups. DISCUSSION: Choice of approach for revision hip arthroplasty is influenced by a number of factors, but in clinical situations where either a lateral or posterior approach could be used, the posterior approach appears to be associated with better joint-specific outcomes. Registry data may help further explore the associations between surgical approach and the outcome from revision THA.

Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals.

BACKGROUND: The General Medical Council states that effective note keeping is essential and records should be clear, accurate and legible. However previous studies of operation notes have shown they can be variable in quality and affect patient safety. This study compares the quality of operation notes against the National Standards set by the Royal College of Surgeons of England and the British Orthopaedic Association (BOA) for improving patient safety. METHODS: Information from Orthopaedic operation notes was collected prospectively over a 2-week period. All elective and trauma operations performed were included and trainees from the region coordinated data collection in 9 hospitals. RESULTS: Data from 1092 operation notes was reviewed. A number of important standards were nearly met including legibility (98.4 %), the name of the operating surgeon (99.3 %) and the operation title (99.1 %). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8 %), documentation of type of anaesthetic used (78.6 %), diagnosis (73.4 %) and findings (80.1 %). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7 % and 48.8 % of cases respectively. CONCLUSIONS: The quality and content of operation notes studied across the region in this period was variable. Use of software programmes in some hospitals for creating operation notes meant that some centres had better results for elements such as date, time and patient identification details. Following this study, greater awareness of the standards combined with additional local measures may improve the quality of operation notes.

24,25-Dihydroxyvitamin D3 cooperates with a stable, fluoromethylene LPA receptor agonist to secure human (MG63) osteoblast maturation.

Vitamin D receptor (VDR) agonists supporting human osteoblast (hOB) differentiation in the absence of bone resorption are attractive agents in a bone regenerative setting. One potential candidate fulfilling these roles is 24,25-dihydroxy vitamin D3 (24,25D). Over forty years ago it was reported that supraphysiological levels of 24,25D could stimulate intestinal calcium uptake and aid bone repair without causing bone calcium mobilisation. VDR agonists co-operate with certain growth factors to enhance hOB differentiation but whether 24,25D might act similarly in promoting cellular maturation has not been described. Given our discovery that lysophosphatidic acid (LPA) co-operated with VDR agonists to enhance hOB maturation, we co-treated MG63 hOBs with 24,25D and a phosphatase-resistant LPA analog. In isolation 24,25D inhibited proliferation and stimulated osteocalcin expression. When co-administered with the LPA analog there were synergistic increases in alkaline phosphatase (ALP). These are encouraging findings which may help realise the future application of 24,25D in promoting osseous repair.

Lysophosphatidic acid, human osteoblast formation, maturation and the role of 1α,25-Dihydroxyvitamin D3 (calcitriol).

The simplest signalling lipid Lysophosphatidic acid (LPA) elicits pleiotropic actions upon most mammalian cell types. Although LPA has an established role in many biological processes, particularly wound healing and cancer, the function of LPA for human osteoblast (hOB) biology is still unravelling. Early studies, identified in this review, gave a reliable indication that LPA, via binding to one of several transmembrane receptors, stimulated multiple intracellular signalling networks coupled to changes in cell growth, fibronectin binding, maturation and survival. The majority of studies exploring the actions of LPA on hOB responses have done so using the lipid in isolation. Our own research has focussed on the co-operation of LPA with the active vitamin D3 metabolite, 1α25,dihydroxycholecalciferol (calcitriol), in light of a serendipitous discovery that calcitriol, in a serum-free culture setting, was unable to promote hOB maturation. We subsequently learnt that the serum-borne factor co-operating with calcitriol to enhance hOB differentiation was LPA bound to the albumin fraction of whole serum. Recent studies from our laboratory have identified that LPA and calcitriol are a potent pairing for securing hOB formation from their stem cell progeny. Greater understanding of the ability of LPA to influence, for example, hOB growth, maturation and survival could be advantageous in developing novel strategies aimed at improving skeletal tissue repair and regeneration. Herein this review provides an insight into the diversity of studies exploring the actions of a small lipid on a major cell type key to bone tissue health and homeostasis. This article is part of a Special Issue entitled Advances in Lysophospholipid Research.