Altered Ulnar Variance With Full-Body Weight-bearing During Handstands With Upper Extremity Weight-bearing CT.

PURPOSE: Ulnar variance (UV) is a radiographic measurement relating the articular surface heights of the distal radius and ulna. Abnormal UV increases the risk for wrist pathology; however, it only provides a static measurement of an inherently dynamic bony relationship that changes with wrist position and loading. The purpose of this study was to investigate how full-body weight-bearing affects UV using weight-bearing computed tomography (WBCT). METHODS: Ten gymnasts completed two 45-second scans inside a WBCT machine while performing a handstand on a flat platform (H) and parallettes (P). A non-weight-bearing CT scan was collected to match clinical practice (N). Differences in UV between weight-bearing conditions were evaluated separately for dominant and nondominant sides, and then, UV was compared between weight-bearing conditions on pooled dominant/nondominant data. RESULTS: Pooled analyses comparing weight-bearing conditions revealed a significant increase in UV for H versus N (0.58 mm) and P versus N (1.00 mm), but no significant change in UV for H versus P (0.43 mm). Significant differences in UV were detected for H versus N, P versus N, and H versus P for dominant and nondominant extremities. The change from N to H was significantly greater in the dominant versus nondominant side, but greater in the nondominant side from N to P. CONCLUSIONS: Ulnar variance changed with the application of load and position of the wrist. Differences in UV were found between dominant and nondominant extremities. CLINICAL RELEVANCE: Upper extremity loading patterns are affected by hand dominance as defined by a cartwheel and suggest skeletal consequences from repetitive load on a dominantly used wrist. Although statistically significant, subtle changes detected in this investigational study do not necessarily bear clinical significance. Future WBCT research can lead to improved diagnostic measures for wrist pathologies affected by active loading and rotational wrist behavior.

Efficacy of Ultrasonic Tenotomy and Debridement and Platelet-Rich Plasma Injections for Lateral Elbow Tendinopathy.

Purpose: To determine the efficacy of treatment of lateral elbow tendinopathy (LET) with platelet-rich plasma (PRP) injection and ultrasonic tenotomy and debridement (USTD) as well as risk factors for treatment failure. Methods: This was a retrospective study including patients treated for LET with PRP or USTD between January 2018 and December 2021. The efficacy of both procedures was assessed using pain-related patient-reported outcome measures at the 12-week follow-up. Baseline subject characteristics and diagnostic ultrasound findings were analyzed as risk factors for failure of treatment. Failure was classified as a surgical indication for LET within a year of the PRP or USTD. Results: Ultrasonic tenotomy and debridement and PRP both led to significant improvement in patient pain within the 12-week follow-up period. There was no significant difference in efficacy between the two procedures. Common extensor tendon tearing on ultrasound and Worker's Compensation cases were found to be risk factors for failure of USTD. Lateral collateral ligament complex involvement and injection were found to be risk factors for failure of PRP. Conclusions: Platelet-rich plasma and USTD are both effective interventions for LET. They have separate risk factors for failure that should be taken in consideration while deciding the treatment approach. These procedures are minimally invasive alternatives to some of the more invasive surgical options to treat LET. Type of study/level of evidence: Therapeutic III.

Ulnar Variance in Athletes: A Scoping Review.

CONTEXT: Ulnar variance (UV) is a measurement of the relative locations of the radius and ulna that may become perturbed in athletic populations. Positive UV can be associated with wrist pathologies often treated conservatively or surgically and may result in interruption of sports participation. OBJECTIVE: This scoping review aims to summarize diagnostic measures of UV in athletes, describe its relation to separate wrist conditions, and present treatment strategies for symptomatic UV. DATA SOURCES: A systematic search was created and modified for PubMed, CINAHL, Embase, and SPORTDiscus including articles from inception until February 2, 2022. STUDY SELECTION: Articles including UV characterization, imaging modality style, and an athletic population were searched across multiple databases. STUDY DESIGN: A scoping review was designed to identify the methods for imaging UV in athletic populations following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: The specific athletic population, imaging modality, measurement style, wrist pathology association, and surgical management of UV were extracted. RESULTS: A total of 4321 records were screened independently for eligibility: 22 met inclusion criteria. Eight sports comprised the analysis. All studies referenced conventional radiography to diagnose UV; 50% specified the posteroanterior, 18.2% anteroposterior, and 13.6% pronated, gripping radiographs. Hafner's method (7×), Palmer's technique (2×), and the method of perpendiculars (3×) were used to measure UV. Athletes displayed more positive UV than nonathletes and UV became more positive over time in longitudinal studies. Triangular fibrocartilage complex tears, focal lunate necrosis, and ulnar abutment were associated with positive UV. Ulnar shortening osteotomy was the most performed operation for positive UV. CONCLUSION: Conventional radiography is the gold standard for imaging UV in athletes. Hafner's method is the most commonly used radiograph measurement technique. Wrist pathology in athletic populations may indicate positive UV in need for operative management.

Outcomes of Surgical Treatment for Sural Neuritis: A Retrospective Case Series.

BACKGROUND: Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN). METHODS: Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests. RESULTS: The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis. CONCLUSION: Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Early Versus Delayed Surgery for Midshaft Clavicle Fractures: A Systematic Review.

Background: Orthopaedic surgeons debate the timing of and necessity for surgical intervention when treating displaced midshaft clavicle fractures (MCFs). This systematic review evaluates the available literature regarding functional outcomes, complication rates, nonunion, and reoperation rates between patients undergoing early versus delayed surgical management of MCFs. Methods: Search strategies were applied in PubMed (Medline), CINAHL (EBSCO), Embase (Elsevier), Sport Discus (EBSCO), and Cochrane Central Register of Controlled Trials (Wiley). Following an initial screening and full-text review, demographic and study outcome data was extracted for comparison between the early fixation and delayed fixation studies. Results: Twenty-one studies were identified for inclusion. This resulted in 1158 patients in the early group and 44 in the delayed. Demographics were similar between groups except for a higher percentage of males in the early group (81.6% vs. 61.4%) and longer time to surgery in the delayed group (4.6 days vs. 14.5 months). Disability of the arm, shoulder, and hand scores (3.6 vs. 13.0) and Constant-Murley scores (94.0 vs. 86.0) were better in the early group. Percentages of initial surgeries resulting in complication (33.8% vs. 63.6%), nonunion (1.2% vs. 11.4%), and nonroutine reoperation (15.8% vs. 34.1%) were higher in the delayed group. Conclusion: Outcomes of nonunion, reoperation, complications, DASH scores, and CM scores favor early surgery over delayed surgery for MCFs. However, given the small cohort of delayed patients who still achieved moderate outcomes, we recommend a shared decision-making style for treatment recommendations regarding individual patients with MCFs. Level of Evidence: II.

Comparison of Early versus Late Below Knee Amputation After Trauma With Standardized Prosthetic Care.

Background: High energy, lower extremity trauma is associated with longstanding pain and functional limitations. The clinical decision to proceed with early amputation or limb salvage is often controversial. This study was designed to compare differences in complications, costs, and clinical outcomes of below knee amputation (BKA) performed early after injury or after attempted limb salvage in a hospital with standardized prosthetic care following amputation. Methods: This is a retrospective comparative study of subjects who underwent BKA for a traumatic injury at a single level 1 trauma center and received standardized prosthetic care from a single manufacturer from 1999-2016 with minimum 2-year post-amputation follow up. Outcomes collected included demographics, surgical management, unplanned re-operations, and hospital and prosthetic cost data 2 years from time of injury. Results: Overall, 79 subjects met criteria. Early amputation (EA) was defined by median duration between injury and amputation (6 weeks) with 41 subjects in the EA group and 38 subjects in the late amputation (LA) group. Subjects in the EA group were more likely to have open fractures, high energy mechanism, and less likely to have medical comorbidities. Post-amputation infection was common in both groups (17/41 (42%) vs 17/38 (45%), p=0.77). Subjects undergoing EA were more likely to require unplanned post-amputation revision, 22/41 (54%) versus 10/38 (27%), p=0.017. Hospital costs and prosthetics/orthotics costs from the time of injury to two years following amputation were comparable, with mean hospital EA costs $136,044 versus LA costs $125,065, p=0.38. Mean prosthetics/orthotics costs of EA subjects were $33,252 versus LA costs $37,684, p=0.59. Conclusion: Unplanned post-amputation revision surgeries were more common when BKA was performed early after trauma. Otherwise, outcomes and cost were comparable when amputation was performed early versus late. Level of Evidence: IV.

The Rurality of Lower Extremity Firearm Injuries.

Background: To highlight the unique spectrum of lower extremity firearm injuries seen at a rural, Midwestern level 1 trauma center to provide insight into prevalence, mechanism of injury, and identify modifiable factors that contribute to firearm injuries of the lower extremity. It is our belief that the creation of our database will help future trauma and firearm databases improve documentation and understand the relationship between anatomic location of injury and outcomes. Methods: A retrospective review of lower extremity firearm injuries from a rural, Midwestern level 1 trauma center was collected from January 2011 to December 2019. Data acquired included injury description; demographics, injury mechanism/ description/ location, firearm used, toxicology, and information regarding hospitalization. Data was analyzed using Chi-squared analysis and Fisher's exact test for categorical data and the Wilcoxon rank sum test for continuous data. Results: 69 patients with lower extremity firearm injuries were identified. Average age was 30.14 years, 89.86% were males, and one fatality were identified. 47.83% (33) of these injuries were assaults, followed by unintentional injuries at 42.03% (29). Law enforcement-related and self-inflicted injuries contributed minimally. Handguns were the most common type of firearm, used in 72.5% of cases. Nearly 1/3 of the unintentional firearm injuries occurred during November or December, the active deer hunting months in the community of study. Conclusion: The lower extremity is uniquely vulnerable to both assaults and unintentional injury in our rural environment, differing from what we have previously published regarding the upper extremity. Lower extremity gunshot wounds increased during the winter months, offering a correlation to deer hunting season. Our findings display that not all firearm injuries are created equal, and that there is a need to improve documentation of and additional study in order to optimally tailor firearm prevention measures based on the ruralityurbanicity spectrum. Level of Evidence: III.

Menstrual hormone-induced cyclic thumb CMC instability and degeneration in women: a systematic review.

BACKGROUND: Relaxin is a hormone which peaks during the luteal phase of the menstrual cycle, and a known collagenolytic promoter that has been shown to avidly bind tissues supporting the trapeziometacarpal (TMC) joint in women. We hypothesize a causal linkage between cyclic binding of relaxin to the supporting tissues of the female TMC joint; and to the earlier onset of more severe TMC osteoarthritis (OA) commonly seen in women. METHODS: A systematic literature review was performed per PRISMA guidelines, qualitatively and quantitatively assessing papers regarding relaxin-TMC joint stability interactions. The primary outcome variable was TMC joint degeneration/loss of function; the "late stage" consequences of relaxin-induced instability. The secondary outcome variable was presence of early signs of relaxin-induced instability; specifically asymptomatic TMC joint laxity in young women. RESULTS: In healthy young women, menstrual cycle relaxin peaks corresponded with asymptomatic TMC joint instability. Immunohistochemical studies of TMC arthroplasty patients showed avidly increased relaxin binding to supporting tissues around the TMC joint in women but not men. Demographic analysis of patients from the TMC arthroplasty studies show a predominantly female cohort, who were on average significantly younger than the male surgical patients. CONCLUSIONS: Each relaxin peak during the menstrual cycle can target receptors on the soft tissues supporting the TMC joint, including-critically-the main stabilizing ligament: the anterior oblique. The cyclic instability is typically asymptomatic for years after menarche, but causes cumulative chondral microtrauma. This likely causes the early-onset, high severity TMC joint OA clinically pervasive among female patients at orthopedic hand clinics. Further research is indicated to develop risk assessment strategies and potential interventional options before and after the onset of hormonal laxity-induced OA.

The Rurality of Upper Extremity Firearm Injuries.

BACKGROUND: To highlight the unique spectrum of hand and upper extremity firearm injuries seen at a rural, Midwestern level 1 trauma center and identify modifiable factors that contribute to firearm injuries of the hand and upper extremity. METHODS: A retrospective review of upper extremity firearm injuries from a rural, Midwestern level 1 trauma center was collected from January 2002 to December 2019. Data acquired included injury description, demographics, injury mechanism/description/location, firearm used, toxicology, and information regarding hospitalization. Data was analyzed using Chi-squared analysis and Fisher's exact test for categorical data and the Wilcoxon rank sum test for continuous data. RESULTS: 55 patients with upper extremity firearm injuries were identified. Average age was 33.3 ± 13.0 years, 81.8% were males, and zero fatalities were identified. 58% (38) of these injuries were unintentional firearm injuries, followed by assaults at 34.6% (19). Law enforcement-related and self-inflicted injuries contributed minimally. Handguns were the most common type of firearm, used in 43.6% of cases. 7.3% (4) of injuries occurred while hunting, with 21.8% (12) total during November or December, the active deer hunting months. 92.7% (51) of all firearm injuries presented with fracture, among which 92.2% (47) met a Gustilo-Anderson classification score of at least 3A. Alcohol was detected in 20% (11) of the patients, while other drugs of abuse were detected in 36.4% (20). CONCLUSION: Our data suggests that upper extremity firearm injuries in a rural population are unique from urban injuries in that they are predominately unintentional, isolated, and non-fatal. We identify a distinct rural cohort that may benefit from better directed interventions to prevent firearm injuries and ultimately guide firearm education and public policy.Level of Evidence: III.

Safety and Efficacy of Forearm Tourniquet Compared to Upper Arm Tourniquet for Local Intravenous Regional Anesthesia in Hand Surgery: A Randomized Clinical Trial.

BACKGROUND: Forearm tourniquets may offer decreased doses of anesthetic, shorter procedure times, and less pain compared to upper arm tourniquets. There is limited data comparing the clinical efficacy of forearm Bier blocks to conventional upper arm Bier blocks. The purpose of this study was to assess the effectiveness, complications, duration, cost, and patient satisfaction between forearm and upper arm Bier blocks during surgery. METHODS: Sixty-six carpal tunnel release, ganglion excision, or trigger finger procedures were performed. Patients were randomized to 3 groups: upper arm tourniquet for 25 minutes, forearm tourniquet for 25 minutes, or forearm tourniquet with immediate deflation following the procedure (<25 minutes). The efficacy of surgical anesthesia, tourniquet discomfort, and supplementary local anesthetic administration were recorded. Pain was assessed intraoperatively and postoperatively. Patient satisfaction was assessed on the first postoperative day. RESULTS: No difference was observed between groups with respect to pain, satisfaction, or administration of supplemental medication. The tourniquet time for the group with immediate deflation following procedure was shorter by an average of 9.3 minutes. Total hospital charges were 9.95% cheaper with immediate tourniquet deflation compared to procedures where the tourniquet remained inflated for at least 25 minutes. CONCLUSION: The forearm Bier block is a safe, efficient, cost-effective technique for intravenous regional anesthesia during hand surgery, and tourniquet deflation immediately following the procedure (<25 minutes) does not increase incidence of complications. The forearm tourniquet reduces the dose of local anesthetic and therefore risk for systemic toxicity, with similar effectiveness as compared to the upper arm technique.Level of Evidence: II.

Does Removing the Photograph and Name Change the Reviewer's Perception of Orthopaedic Residency Applicants?

INTRODUCTION: Orthopaedic surgery remains the least diverse field in medicine regarding female and minority representation. Scarce literature exists evaluating the role of implicit bias in the residency application process. We hypothesized that applicants perceived as underrepresented minorities in orthopaedic surgery (URMs) based on their photograph or name would have a decreased likelihood of being invited to interview. METHODS: Data from the 2018 to 2019 orthopaedic residency application cycle were collected from a single institution. Applications were classified URM or non-URM. After the application cycle was completed, the URM applications were propensity matched with non-URM applicants. Photographs and names were removed, and the applications were rereviewed by the Residency Applicant Review committee. Rank-in-group and the likelihood of being invited for an interview were compared. RESULTS: Four hundred eleven applications were included with 27.5% URM and 72.5% non-URM. During the regular application cycle, 34.7% of those invited to interview were URM and 50% of those who were ranked-to-match range were URM. After propensity matching, 90 matched pairs were rereviewed with their photograph and name removed. In the regular application cycle, the URM applicant was 3.8 times more likely to get an interview than the matched non-URM applicant (odds ratio, 3.8, 95% confidence interval, 1.7 to 8.8, P = 0.0014). In the "blinded" condition, the URM candidate was 2.5 times more likely to get an interview than the non-URM candidate (odds ratio, 2.5, 95% confidence interval, 1.1 to 6.2 P = 0.034). In the unblinded condition, the URM candidate had a higher ranking within their group than the corresponding non-URM applicant (P = 0.0005). DISCUSSION: Contrary to our initial hypothesis, URM applicants were invited to interview at a higher rate than non-URM applicants, both in the regular application cycle and in the propensity-matched "blinded" condition. This suggests that implicit bias based on the picture or name is not negatively affecting URM students during the application review process at our institution. LEVEL OF EVIDENCE: 3.

Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications.

OBJECTIVES: To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). DESIGN: Retrospective comparative cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). INTERVENTION: Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. MAIN OUTCOME MEASURE: Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI). RESULTS: Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). CONCLUSIONS: Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.