Pyrocarbon Lunate Arthroplasty: An Option for the Young Patient with Advanced Kienbock Disease.

Kienbock disease, or avascular necrosis of the lunate, is an uncommon cause of a painful and stiff wrist. Management options range from conservative treatment in the form of immobilization and corticosteroid injections to a wide variety of surgical treatments that depend on the structural integrity of the lunate, intercarpal relationships, and the condition of the articular cartilage of the wrist. A particularly difficult problem lies in the management of young patient in whom vascularized bone grafting of the lunate has failed but in whom arthritis has not yet developed. Pyrocarbon lunate implant arthroplasty is a newer treatment option for such a patient, and allows the preservation of the remainder of the proximal carpal row while directly addressing the degenerative lunate. This article describes the evidence and surgical technique for lunate implant arthroplasty and presents an illustrative case example.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act.

Importance: Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear. Objective: To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA. Design, Setting, and Participants: This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023. Exposures: Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods. Main Outcomes and Measures: Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA. Results: Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change. Conclusions and Relevance: Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Complications and Reoperation Following Surgery for Concurrent Carpal Tunnel and Cervical Spine Compression.

BACKGROUND: Patients with carpal tunnel syndrome (CTS) may also have cervical radiculopathy (CR) or vice versa, potentially requiring carpal tunnel release (CTR) and anterior cervical discectomy and fusion (ACDF). This study evaluates whether there is an increased risk of complications following CTR or ACDF in patients with concurrent CTS and CR (CTS-CR) compared with those with only CTS or CR. METHODS: A multipayer database was used to identify patients with CTS-CR. From this cohort, patients who underwent CTR and/or ACDF were identified. Patients with CTS-CR undergoing surgery were compared with those undergoing surgery with only CTS or CR. Multivariable logistic regression was used to compare matched populations to assess postoperative complications and risk of undergoing both procedures. RESULTS: A total of 110 379 patients with CTS-CR were identified. Carpal tunnel release was performed in 21 152 patients (19.2%) with CTS-CR, from which 835 (0.76%) underwent ACDF. Anterior cervical discectomy and fusion was performed in 6960 patients (6.31%) with CTS-CR followed by CTR in 1098 patients (0.99%). Patients with CTS-CR were at greater risk of reoperation and complex regional pain syndrome following CTR. In ACDF, patients with CTS-CR were at greater risk of reoperation. Obesity and tobacco use were significant risk factors in patients with CTS-CR who underwent both CTR and ACDF rather than a single surgery. CONCLUSIONS: Examination of more than 100 000 patients with CTS-CR found a greater likelihood of reoperation and perioperative complications following surgery than those without concurrent diagnoses. Obesity and smoking increased the risk for patients undergoing both procedures. Patients presenting with CTS-CR are high risk and should be counseled on risk of complication and reoperation and optimized to reduce risk of undergoing both CTR and ACDF.

Long-term Orthopedic Manifestations of COVID-19: Heterotopic Ossification and Digital Necrosis.

Despite its classification as an atypical pneumonia, COVID-19 is a disease that is capable of inflicting damage beyond the respiratory system. The wide range of musculoskeletal complications secondary to acute COVID-19 are a significant source of morbidity in hospitalized patients. We present the case of a 23-year-old woman with severe COVID-19 who required intubation and had a prolonged hospital course that was complicated by partial-thickness necrosis of her fingers and heterotopic ossification of the distal thigh. We review current treatments for these orthopedic conditions in the setting of SARS-CoV-2 infection as well as highlight areas for future research. Additionally, we discuss the subacute musculoskeletal complications of COVID-19, which are among the most common long-term manifestations of the disease and are increasingly important for a growing number of COVID-19 survivors.

Radiocarpal Fusion: Indications, Technique, and Modifications.

Degenerative disorders of the wrist may affect isolated joints and inhibit normal functions of the wrist secondary to pain and stiffness. These processes that affect only the radiocarpal joint may be secondary to posttraumatic osteoarthritis, primary osteoarthritis, or rheumatoid arthritis. Radiocarpal wrist arthrodesis may help preserve some of the native wrist kinematics while alleviating pain and improving the range of motion. However, the surgeon must ensure that the patient's pathologic process primarily affects the radiocarpal articulations while relatively sparing the midcarpal articulations. Depending on the location of the pathology, isolated radiolunate or radioscapholunate arthrodesis have been described to preserve some motion in the midcarpal joint. To maximize motion in the midcarpal joint after radiocarpal arthrodesis, techniques for distal scaphoid and triquetrum excision have been described. We report patient outcomes for various techniques and describe our preferred technique for radioscapholunate arthrodesis using distal scaphoid excision.

Comparison of Initial Stability of Oblong, Large Circular, and Multiple-Plug "Snowman" Osteochondral Autografts for Elongated Focal Cartilage Lesions: A Biomechanical Study in a Porcine Model.

BACKGROUND: Distal femoral osteochondral allograft transplantation (OAT) is an effective treatment of osteochondral lesions in the knee measuring >2 cm2 in select patients. Prior studies have demonstrated that the morphology of the plug can affect graft-host interference fit. To our knowledge, there are no data comparing the initial biomechanical stability of standard cylindrical plugs with multiple-plug and oblong-plug morphologies. HYPOTHESIS: Large cylindrical single-plug (LCSP) and oblong single-plug (OSP) grafts will have greater pull-out strength, and therefore greater initial stability, than multiple-plug (MP) grafts in a cadaveric porcine femur model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 55 porcine distal femurs were divided into 3 groups-LCSP (n = 18), OSP (n = 19), and MP (n = 18)-according to the plug morphology used. The method of graft harvesting and implantation was based on technique guides for the respective implant systems. The sizes (length × width × depth) of the osteochondral defects created in each of the groups were approximately 20.2 × 20.2 × 9.4-mm for the LCSP group, 14.4 × 30.5 × 7.9-mm for the OSP group, and 14.8 × 14.8 × 9.9-mm for the MP group. Tensile testing was performed on each graft to determine pull-out strength. RESULTS: The pull-out strength was significantly lower in the OSP group (65.7 N) versus the LCSP (133 N; P = .0005) and the MP (117.6 N; P = .001) groups. There was no statistically significant difference in pull-out strength between the LCSP and MP groups (P = .42). There were no statistically significant differences in displacement at maximum load among any 2 of the 3 groups. CONCLUSION: These findings suggest that while initial stability may play a role in the clinical outcomes of osteochondral allograft (OCA) implantation, the biological milieu in vivo for each graft setting perhaps has a greater impact on the success of an OAT procedure. Further study is needed on the relationship between OCA biomechanics and clinical outcomes of OAT.

Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: The purpose of this study was to systematically review and quantitatively analyze outcomes in operative versus nonoperative management of displaced midshaft clavicle fractures in pediatric and adolescent patients. DATA SOURCES: Using the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, systematic searches of PubMed and EMBASE were conducted to identify English-language studies reporting outcomes in displaced pediatric midshaft clavicle fractures from 1997 to 2018. STUDY SELECTION: Studies that reported on outcomes of operative and/or nonoperative treatment of displaced midshaft clavicle fractures in patients younger than 19 years were included. DATA EXTRACTION: Patient and treatment characteristics, union rates, time to union, time to return to activity, patient-reported outcome measures, and complications were extracted. DATA SYNTHESIS: All extracted data were recorded and qualitatively compared. QuickDASH (Quick Disabilities of the Arm, Shoulder, and Hand) scores and Constant scores were pooled using random-effects modeling and compared among studies, which adequately reported data for hypothesis testing. CONCLUSIONS: Three thousand eight hundred ten articles were identified, and 12 met inclusion criteria. These studies encompassed 497 patients with an average age of 14.1 years (8-18 years, range). Both operative and nonoperative management of displaced midshaft clavicle fractures in this population provide excellent rates of union and patient-reported outcome measures. Compared with nonoperative management, operative management yielded faster return to activity, superior Constant scores, and equal QuickDASH scores. Operative management had higher complication rates and complications that required secondary operative treatment (mostly related to implant prominence). LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Therapeutic Benefits of Saline Solution Injection for Lateral Epicondylitis: A Meta-analysis of Randomized Controlled Trials Comparing Saline Injections With Nonsurgical Injection Therapies.

PURPOSE: To quantify the effect of saline solution injections on patient-reported outcome measures (PROMs) and to determine whether this effect is clinically relevant by comparing it with minimal clinically important difference (MCID) criteria. METHODS: A systematic search identified randomized controlled trials of lateral epicondylitis interventions comparing saline solution injections with nonsurgical injection therapies. Among included studies, saline solution was compared with platelet-rich plasma, autologous conditioned plasma, corticosteroid, and botulinum toxin injections. By use of data from included studies, a random-effects model was used to calculate overall mean differences (MDs) in pre- and post-injection PROMs in a pair-wise fashion. Calculated MDs were then compared with MCID criteria. RESULTS: Of 458 identified studies, 10 met the inclusion criteria and encompassed 283 patients. At 1, 3, 6, and 12 months, statistically significant improvements in MDs in visual analog scale (VAS) scores were noted as follows: MD of 16.11 (95% confidence interval [CI], 8.29-23.93) at 1 month; MD of 22.50 (95% CI, 11.45-33.55) at 3 months; MD of 40.40 (95% CI, 27.48-53.32) at 6 months; and MD of 47.04 (95% CI, 39.43-54.66) at 12 months. At 6 months, Disabilities of the Arm, Shoulder and Hand scores showed a statistically significant improvement (MD, 23.92; 95% CI, 9.47-38.37). CONCLUSIONS: Improvements in Disabilities of the Arm, Shoulder and Hand scores at 6 months (23.92) surpassed MCID criteria for conservatively managed upper-extremity musculoskeletal pathology (10.83)-suggesting that saline solution injections have a clinically relevant effect. VAS MCID criteria are poorly established, but VAS scores at 6 and 12 months surpassed MCID criteria for conservative treatments for common orthopaedic conditions. In all but 1 study, no statistically significant difference in PROMs was found between saline solution and non-saline solution injections. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I and II randomized controlled trials.

Lack of Sleep and Sports Injuries in Adolescents: A Systematic Review and Meta-analysis.

BACKGROUND: Although sleep has been identified as an important modifiable risk factor for injury, the effect of decreased sleep on sports injuries in adolescents is poorly studied. The objective of this study was to quantitatively and qualitatively review published literature to examine if a lack of sleep is associated with sports injuries in adolescents and to delineate the effects of chronic versus acute lack of sleep. METHODS: PubMed (includes MEDLINE) and EMBASE databases were systematically searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported statistics regarding the relationship between sleep and sports injury in adolescents aged 19 years or younger published between January 1, 1997 and December 21, 2017. From these included studies, the following information was extracted: bibliographic and demographic information, reported outcomes related to injury and sleep, and definitions of injury and decreased sleep. A random effects model was then created to quantify the odds of injury with decreased sleep in adolescents. RESULTS: Of 907 identified articles, 7 met inclusion criteria. Five studies reported that adolescents who chronically slept poorly were at a significantly increased likelihood of experiencing a sports or musculoskeletal injury. Two studies reported on acute sleep behaviors. One reported a significant positive association between acutely poor sleep and injury, whereas the other study reported no significant association. In our random effects model, adolescents who chronically slept poorly were more likely to be injured than those who slept well (OR, 1.58; 95% CI, 1.05-2.37; P=0.03). CONCLUSIONS: Chronic lack of sleep in adolescents is associated with greater risk of sports and musculoskeletal injuries. Current evidence cannot yet definitively determine the effect of acute lack of sleep on injury rates. LEVEL OF EVIDENCE: Level IV-systematic review of level II studies and one level IV study.

Patterns in Outcomes Reporting of Operatively Managed Pediatric Patellofemoral Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Traumatic patellofemoral dislocation is a common injury in pediatric patients, and surgical treatment is often recommended. Increasingly, it has been recognized that clinical studies need to report age-appropriate treatment outcomes. However, the variability and appropriateness of outcomes reporting in the youth patellar instability literature are unknown. PURPOSE: To analyze the patterns of outcomes reporting in studies published in high-impact orthopaedic journals after operative management of pediatric patellar instability. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Six high-impact orthopaedic journals were searched using PubMed and EMBASE to identify studies reporting outcomes of operative management of pediatric patellar instability. Studies containing adults were excluded. Clinical and radiographic outcomes were recorded from included articles. Descriptive statistics were calculated for overall instability recurrence rates, return-to-activity rates, and changes in Kujala and Tegner scores. RESULTS: Of 545 identified articles, 8 studies met the inclusion criteria. These studies encompassed 213 patients and 230 knees (mean age, 13.2 years; range, 4.5-18.3 years). Seven of 8 studies reported patients' physeal status, but only 4 studies limited their outcomes reporting to patients with open physes. Two studies reported postoperative radiographic measures, and 5 studies reported preoperative radiographic findings. Six studies reported patient-reported outcome measures (PROMs). Seven unique PROMs were reported. All but one study reported complication rates and types of complications. The mean postoperative change in Tegner scores was -0.07 (range, -0.6 to 1.0). Among studies examining medial patellofemoral ligament reconstruction with adequate data, the mean return-to-activity rate was 86% (range, 81%-92%), the instability recurrence rate was 3% ± 20%, and the mean improvement in Kujala scores postoperatively was 22.1 (range, 19.9-26). CONCLUSION: There is a need for more pediatric-specific outcomes studies regarding operatively managed traumatic patellofemoral instability. Of the outcomes reported, both radiographic outcomes and PROMs should be standardized. Among radiographic outcomes, there is a need for more studies that report tibial tubercle-trochlear groove distances and use Caton-Deschamps and/or Blackburne-Peel indices to assess patellar height. Among PROMs, there is a need for studies that use PROMs validated in pediatric populations, such as the International Knee Documentation Committee Pediatric Form or the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Utility of Prolotherapy for Upper Extremity Pathology.

Prolotherapy is a method of treatment of painful musculoskeletal conditions whereby a sclerosing agent is injected into an area of tendinosis or osteoarthritis to strengthen and repair painful connective tissue. It is a safe, effective, and relatively inexpensive nonsurgical treatment modality. This article provides a history of prolotherapy, discusses its proposed mechanisms of action, and provides a review of the existing literature on prolotherapy as a treatment for upper extremity pathologies, specifically, hand osteoarthritis, lateral epicondylitis, and rotator cuff disease.

A surgical approach algorithm for transverse posterior wall fractures aids in reduction quality.

BACKGROUND: Transverse posterior wall fractures are difficult to treat and historically have been associated with stiffness, posttraumatic arthritis, and pain, which correlate with the reduction. The Kocher-Langenbeck approach is used most often, whereas the extended iliofemoral approach has been reserved for more complex injury patterns. The latter approach has substantially more risks. No data to our knowledge exist on the use of sequential anterior and posterior approaches for this pattern. QUESTIONS/PURPOSES: The purpose of this study is to evaluate an algorithmic method to determine the choice of surgical approach(es) for transverse posterior wall fractures. The main question is: will this approach-based algorithm allow for adequate reduction and stabilization to union? Our secondary endpoints were Merle d'Aubigne scores, reoperations, and radiographic sequelae including arthritis, avascular necrosis, and heterotopic ossification. METHODS: A retrospective study was conducted in which patients were drawn from an existing database. The inclusion criterion was transverse posterior wall fractures with adequate imaging treated by one surgeon. All but one patient were treated within 2 weeks of injury. Mean followup was 23 months (range, 3 months to 11 years). Between November 5, 1999, and August 22, 2012, 74 patients were treated with open reduction internal fixation for this injury; nine were excluded as a result of percutaneous treatment or inadequate preoperative imaging. The remaining 65 patients (88%) comprised the study group. All patients were treated by the senior surgeon with an algorithm that consisted of either a Kocher-Langenbeck or sequential approach based on the location, magnitude, and direction of displacement of the ischiopubic segment. Indomethacin was prescribed to all patients for heterotopic ossification prophylaxis for a total of 6 weeks postoperatively. Based on the algorithm, 82% (53 patients) were treated with Kocher-Langenbeck and 18% (12 patients) with the sequential approach. Adequacy of reduction was measured using AP and Judet views of the pelvis; union was determined empirically by pain-free weightbearing and lack of displacement over time. Outcomes were the Merle d'Aubigne score and radiographic findings of avascular necrosis or arthrosis. RESULTS: The algorithm resulted in 100% reduction within 1 mm on plain radiographs. Initial displacement was greater in the patients undergoing the sequential approach (p=0.01, 7.7 versus 12.4 mm). The average d'Aubigne score was 15.3. Radiographic arthritis scores were 68% excellent/good. Avascular necrosis developed in five patients (8%). Five patients (8%) went on to THA, and four patients (6%) developed superficial or deep infection. Only one patient developed Brooker III heterotopic ossification and this was not symptomatic. CONCLUSIONS: This algorithm helps guide appropriate selection of the surgical approach and results in accurate reduction with functional and radiographic results that are comparable with existing series while avoiding extended approaches. However, like any operative decision, the choice of approach should not depend entirely on an algorithm; rather, the algorithm is best used as a guide to understand the factors involved in treating these rare and complex injuries and to help make an appropriate choice for an individual patient. LEVEL OF EVIDENCE: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.