Direct Variable Cost Comparison of Monitored Anesthesia Care Versus Wide Awake Local Anesthesia No Tournique Carpal Tunnel Release: A Time-Driven Activity-Based Costing Analysis.

PURPOSE: Time-driven activity-based costing (TDABC) provides a more accurate and granular estimation of direct variable costs compared with traditional accounting methods. This study used TDABC to quantitatively compare the same-day facility costs of open carpal tunnel release (CTR) performed under monitored anesthesia care (MAC) versus wide awake local anesthesia no tourniquet (WALANT). METHODS: We retrospectively identified 474 unilateral CTR (182 MAC and 292 WALANT) performed at an orthopedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, surgical characteristics, and itemized costs were compared between those treated under MAC (MAC-CTR) and WALANT (WALANT-CTR). Multivariable regression was performed to determine the independent effect of MAC on true facility costs. RESULTS: Total facility costs were $170 higher in MAC-CTR compared with WALANT-CTR ($652 vs $482). Monitored anesthesia care-CTR cases had higher personnel costs ($537 vs $394), likely because of higher surgery personnel ($303 vs $185) and postanesthesia care unit personnel costs ($117 vs $95). Monitored anesthesia care-CTR cases also had higher supply costs ($119 vs $81). When controlling for demographics and comorbidities, MAC-CTR was independently associated with an increase in personnel costs by $150.65 (95% CI, $131.09-$170.21), supply costs by $24.99 (95% CI, $9.40-$40.58), and total facility costs by $175.66 (95% CI, $150.18-$201.09) per case. CONCLUSIONS: Using TDABC, MAC-CTR was found to be 35% more costly to the facility compared with WALANT-CTR. Notably, WALANT-CTR facility costs presented here do not include additional cost savings from anesthesiologist service fees or preoperative laboratory clearance required for MAC-CTR surgeries. To reduce costs related to CTR surgery, greater efforts should be made to reduce the number of intraoperative personnel and maximize the use of WALANT-CTR in an outpatient setting. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

Understanding Changing Demographic and Treatment Trends of Distal Radius Fractures: A TriNetX Database Contemporary Analysis of 32,912 Patients.

Purpose: Distal radius fractures (DRF) are among the most commonly encountered fractures. The population of the United States is rapidly growing, aging, and diversifying. This study was undertaken to better understand current incidences and treatment trends across all ages, gender, and races to inform resource allocation and to potentially address treatment inequities. Methods: The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from 2017 to 2022. Cohorts were defined by inclusion and exclusion of Current Procedural Terminology procedure codes and categorized into operative and nonsurgical groups. Statistical analysis was performed to determine differences in management among demographic groups across the 6-year time period. Results: Incidence rates of operative intervention for DRF increased from 19.6% in 2017 to 23.6% in 2022. Incidence rates of operative intervention increased from 21.7% to 25.2% for females and from 15.3% to 19.7% for males. A bimodal distribution was observed in females with more fractures occurring in the pediatric and geriatric ages, but this distribution was not observed in males. All demographic groups had an overall higher incidence of nonsurgical intervention. Patients aged 40-64 years were more likely to undergo operative intervention than patients 18-39 years. Females were more likely to undergo operative intervention than males. White patients were more likely to undergo operative intervention than Black patients and Asian patients. Conclusions: The incidence of DRFs continues to climb, as does their rate of operative management. The classic bimodal distribution was observed in females, but not males. However, differences in management of DRFs were also observed across different demographic groups with ongoing racial disparities. Future consideration should be taken into optimizing treatment disparities relative to demographic status. Type of Study/Level of Evidence: Prognosis IV.

The Effect of Anticoagulant and Antiplatelet Medications on Wide-Awake Hand Surgery: An Analysis of 2,162 Cases.

PURPOSE: The purpose of the study was to determine if perioperative prescription anticoagulant (AC) or antiplatelet (AP) medication use increases the rate of revision surgeries or complications following wide-awake hand surgery performed under local anesthesia. METHODS: All patients who underwent outpatient wide-awake hand surgery under local anesthesia without a tourniquet by two fellowship-trained orthopedic hand surgeons at a single academic practice over a 3-year period were included. Prescription history was reviewed to determine if any prescriptions were filled for an AC/AP drug within 90 days of surgery. All cases requiring revision were identified. Office notes were reviewed to determine postoperative complications and/or postoperative antibiotics prescribed for infection concerns. The number of revisions, complications, and postoperative antibiotic prescriptions were compared between patients who did, and did not, use perioperative AC/AP drugs. RESULTS: A total of 2,162 wide-awake local anesthesia surgeries were included, and there were 128 cases (5.9%) with perioperative AC/AP use. Of the 2,162 cases, 19 cases required revision surgery (18 without AC/AP use and one with AC/AP use). Postoperative wound complications occurred in 42 patients (38 without AC/AP use and four with AC/AP use). Of the wound complications, four were related to postoperative bleeding, one case of incisional bleeding, and three cases of incisional hematomas (three without AC/AP use and one with AC/AP use). None of these patients required additional intervention; their incisional bleeding or hematoma was resolved by their subsequent office visit. Sixty-five patients received postoperative antibiotics for infection concerns (59 without AC/AP use and six with AC/AP use). CONCLUSIONS: Prescription AC/AP medication use in the perioperative period for wide-awake hand surgery performed under local anesthesia was not associated with an increased risk for revision surgery or postoperative wound complications. This study demonstrates the safety of continuing patients' prescribed AC/AP medications during wide-awake hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Preliminary Outcomes of Scapholunate Ligament Augmentation with Internal Brace Technique.

Purpose: Injury to the scapholunate (SL) interosseous ligament (SLIL) is a common cause of carpal instability. Internal brace augmentation has been used in various ligament repair procedures; however, further investigation of its outcomes in hand surgery is needed. This study aimed to examine outcomes for patients who underwent SLIL repair with internal brace augmentation. Methods: Patients who underwent SLIL repair with the internal brace technique and had at least 1 year of follow-up were contacted. Available patients returned for an in-person evaluation with new radiographs and physical examination. If patients could not be contacted but had x-rays and physical examinations performed at greater than 1 year after surgery, these data were collected from their medical records. Participating patients completed the QuickDASH and Patient-Rated Wrist Evaluation surveys and rated their satisfaction with the surgery. Outcomes assessed included wrist range of motion, grip strength, scaphoid shift test, SL gap, SL angle, and radiographic evidence of radiocarpal arthritis. Results: We collected outcomes for 14 SLIL repairs among 13 patients (12 male). Mean length of the follow-up was 41 months (n = 14, 17-64). Mean QuickDASH and Patient-Rated Wrist Evaluation scores were 6.1 (0-43.2) and 9.6 (0-65), respectively. Radiographic measurements remained stable from immediate to latest follow-up, and no radiocarpal arthritic changes were noted. However, SL gap decreased from a mean of 5.33 mm (3.4-6.7) before surgery to 3.34 mm (2-4.6) at the latest follow-up, and SL angle decreased from a mean of 79.5° (67°-97°) before surgery to 67.3° (51°-85°) at the latest follow-up. All scaphoid shift tests were stable. Conclusions: Therefore, SL internal brace augmentation has favorable short-term results with improvements in pain, function, satisfaction, and carpal alignment at greater than 1 year postoperatively. This technique can be an effective option for the management of SL instability in the short term. Type of study/level of evidence: Therapeutic IV.

Management of Lunate Facet Escape after Distal Radius Fracture Volar Plating: Surgical Technique.

Fractures involving the lunate facet of the distal radius (commonly called the volar ulnar corner or "critical corner") are often difficult to recognize radiographically. "Lunate facet escape" refers to the displacement of this fragment after attempted distal radius fracture closed or open reduction methods. Lunate facet escape can have severe consequences including carpal collapse with pain, instability, and arthritis. Challenges to lunate facet fixation include irregular cortical contour that makes plate fixation difficult, as well as deforming forces by inserting structures. The goal of the management of a distal radius fracture with lunate facet involvement is first identification, then adequate stabilization until osseous healing occurs. However, subsequent lunate facet escape can pose a challenging clinical and surgical dilemma. Here we discuss our preferred approach to treat lunate facet escape after distal radius fracture volar locking plating failure.

Orthopaedic Hand Surgical Simulation Training: A Review.

In recent years, new orthopaedic surgical simulation and virtual reality (VR) training models have emerged to provide unlimited education medium to an unlimited number of trainees with no time limit, especially in response to trainee work-hour restrictions. Surgical simulators range from simple wooden boxes to animal and cadaver models to three-dimensional-printed and VR simulators. The coronavirus disease 2019 pandemic further highlighted the need for at-home learning tools for orthopaedic surgical trainees. Advancement in simulating shoulder and knee arthroscopies using VR simulators surpasses the other fields in orthopaedic surgery. Despite the high degree of precision needed to operate at a microscopic level involving vessels, nerves, and the small bones of the hand, the simulation tools have limited advancement in the field of orthopaedic hand surgery. This narrative review summarizes the status of surgical simulation and training techniques available to orthopaedic hand surgical trainees, factors affecting their application, and areas in hand surgery that still lag behind their surgical subspecialty counterparts.

Incidence and Treatment of Carpal Tunnel Syndrome Following Distal Radius Fractures: A TriNetX Analysis of 39,603 Patients.

Purpose: Distal radius fractures (DRFs) are among the most common fractures and occur among all age groups. Carpal tunnel syndrome (CTS) is a known sequela of DRFs, but its incidence is poorly understood. This study was undertaken to determine the incidence of CTS following a DRF, with the hypothesis being that CTS occurs more commonly after nonsurgical treatment of a DRF. Methods: The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from January 2016 to December 2022. Cohorts were defined by inclusion and exclusion of the procedure Current Procedural Terminology codes into surgical and nonsurgical groups and subsequent ICD-10 diagnosis codes of CTS. Statistical analysis was performed to determine differences in management across the study period. Results: A total of 39,603 patients met inclusion with a diagnosis of a DRF. The incidence of CTS within one year of a DRF was 5.3%. Among all DRF cases, 10,279 (26%) patients underwent surgical treatment, whereas 29,324 (74%) patients underwent nonsurgical treatment. The incidence of CTS in the surgical group was 1194 (12%), whereas the incidence of CTS in the nonsurgical group was 915 (3%). Patients undergoing surgical treatment for a DRF had a 9% risk of developing CTS, whereas patients undergoing nonsurgical treatment had a 5% risk. Among all the patients having been diagnosed with CTS, 63% of those with an operatively treated DRF underwent surgical release, whereas 23% of those with a nonoperatively treated DRF underwent surgical release for CTS. Conclusions: Patients having undergone surgical treatment for DRF had a four times higher rate of developing CTS, compared with those having undergone nonsurgical treatment. Among patients who underwent surgical treatment of a DRF with the subsequent development of CTS, there was a nearly three times higher rate of surgical release of CTS. Type of study/level of evidence: Prognostic III.

Forearm Fracture Fixation with Locking Plates: Does Size Matter?

Purpose: Forearm shaft fractures of the radius and/or ulna are typically repaired with plates and screws, with 3.5 mm nonlocking screws being generally recommended. However, smaller plates and screws, either nonlocking or locking, can also be applied. The purpose of this study was to retrospectively review whether fracture healing rates and related complications are affected by plate size and type. Methods: Patient demographic and descriptive data were retrospectively collected for all patients with a forearm shaft fracture treated with repair of the radial shaft and/or ulna shaft between 2017 and 2021 at a multiprovider and multilocation single institution. Inclusion criteria involved use of a locking plate with a minimum radiographic follow-up of 60 days and/or until fracture union was confirmed. Results: A total of 110 patients met inclusion criteria. There were 45 (40.9%) females and 65 (59.1%) males included with the mean age at time of injury being 47 years (± 22). There were 34 (30.1%) isolated radius fractures, 50 (45.5%) isolated ulna fractures, and 26 (23.6%) both bone forearm fractures. Screw sizes consisted of 3.5 mm (small fragment) screws in 57 (52%) cases, whereas 2.7 mm/2.5 mm/2.4 mm (mini fragment) screws were used in 53 (48%) cases. Fracture union was confirmed in 108 (98%) cases. Among the two nonunion cases, one case (50%) involved a small fragment, and one case (50%) involved a mini fragment plate. Conclusions: This study confirms that fracture union is high following any size plate fixation of radius and/or ulna fractures. Moreover, smaller screw sizes did not affect fracture union rates. Choice of plate type and screw diameter should be based on patient characteristics and surgeon preference and need not be limited to only 3.5 mm plate and screws. Type of Study/Level of Evidence: Prognosis IIb.

The Effect of Nonsteroidal Anti-inflammatory Drugs on Union Rates Following Joint Arthrodesis: A Meta-Analysis.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used and prescribed medications because of their important role in reducing inflammation and pain, in addition to their non-addictive properties and safety profiles. However, some studies have documented an association between NSAIDs and delayed union or nonunion of joint arthrodesis procedures due to a potential inhibition of the bone's inflammatory healing response. As a result, some orthopedic surgeons hesitate to prescribe NSAIDs after an arthrodesis procedure. The purpose of this meta-analysis is to review all relevant literature regarding the effect of NSAIDs on union rates after arthrodesis and determine if NSAID therapy increases the risk of non-union in the setting of arthrodesis procedures. The study hypothesis was that NSAIDs would not have a significant effect on the risk of nonunion after arthrodesis. A thorough systematic review of Medline, Embase, the Cochrane Database of Systematic Reviews, and the Web of Science identified 3,050 articles to be screened. The variables of interest encompassed demographic factors, procedural details, type and administration of NSAIDs, the number of patients exposed to NSAIDs with and without successful union (case group), as well as the number of patients who did not receive NSAIDs with and without successful union (control group). All the data were analyzed using a maximum likelihood random-effects model. The number of non-union events versus routine healing from each study was used to calculate the odds ratio (OR) of successful healing after arthrodesis procedures with versus without NSAID therapy. Thirteen articles met the inclusion criteria for the meta-analysis. NSAID exposure showed an increased risk of nonunion, delayed union, or both following arthrodesis procedures; however, this did not meet statistical significance (OR, 1.48; confidence interval [CI], 0.96 to 2.30). A sub-analysis of pediatric and adult studies showed a significant increase in non-union risk in adults (OR, 1.717; CI, 1.012 to 2.914) when removing the pediatric cohort (p = 0.045). This meta-analysis provides evidence that NSAIDs can increase the risk of nonunion, delayed union, or both following arthrodesis procedures in adults. However, the study did not identify a risk of nonunion, delayed union, or both following arthrodesis procedures in the pediatric population.

The Efficacy of Preoperative Video-Based Opioid Counseling on Postoperative Opioid Consumption After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: There are myriad strategies to reduce opioid consumption after total knee arthroplasty (TKA). Recent studies have suggested that preoperative counseling may reduce opioid use after a variety of orthopedic procedures. The purpose of this study was to investigate whether preoperative video-based patient education regarding opioid use and abuse reduces opioid consumption after TKA. METHODS: In this prospective randomized controlled trial, patients were randomized before TKA to either receive preoperative video-based counseling or not. Counseling involved a pretaped 5-minute video that educated patients on statistics regarding the "opioid epidemic" and discussed safe use and alternatives to opioids after TKA. There were no significant differences in baseline patient demographics between groups. All patients received a similar multimodal perioperative pain management protocol and completed a daily diary for 2 weeks postoperatively. Diary records measured pain levels using a visual analog score, opioid consumption, side effects experienced, and patient opinion and satisfaction regarding their pain control. RESULTS: Patients in the counseling group consumed significantly less morphine milligram equivalents on postoperative days 0 to 3 (78.8 versus 106.1, P = .020) and in week one postoperatively (129.9 versus 180.7, P = .028), with a trend of less consumption over 2 weeks postoperatively (186.9 versus 239.1, P = .194). There were no significant differences in the number of patients requiring refills, side effects, or daily pain levels between the 2 groups. CONCLUSIONS: This study found significantly decreased opioid consumption within the first week after TKA in patients who received preoperative video counseling.

Understanding the Orthopedic Conditions for Which Patients Are Seeking Medical Cannabis Certification.

BACKGROUND: Amid the ongoing national crisis of opioid misuse in the United States, medical cannabis (MC) has emerged as a potential alternative for chronic pain conditions. This study was performed to understand which orthopedic conditions patients are seeking MC certification for. METHODS: This prospective study was conducted at the Department of Medical Cannabis, Rothman Orthopaedic Institute, Philadelphia, PA, USA. It included consecutive patients with chronic musculoskeletal noncancer pain who were certified for MC, following the Pennsylvania state certification process. Data collected included demographic data, diagnoses, anatomic site of pain, and Patient-Reported Outcomes Measurement Information System (PROMIS) global health scale. The outcome measures from the PROMIS global health scale were used to generate Global Physical Health (GPH) quality of life (QoL) T scores and Global Mental Health (GMH) QoL T scores. RESULTS: A total of 78 patients were available for analysis following initial MC certification, with 50 (64%) being female and 28 (36%) male. The average age was 63 years with 60% of patients in the 65+ age group. Ethnically, 73 (92%) identified as White, and 70 (90%) were not of Hispanic or Latino origin. The most common reason for seeking MC certification was low back pain (56%), followed by neck pain (21%) and then extremity complaints. The mean GPH QoL T score was 43.71 with a standard deviation of ± 9.86 (p-value = 0.001), while the mean GMH QoL T score was 46.85 with a standard deviation of 8.28 (p-value = 0.0015). CONCLUSION: MC cannabis certification was more often sought by women than men and most common for spinal complaints, specifically lower back followed by cervical spine concerns.. This cohort of patients had lower GPH QoL and GMH QoL T scores compared the US general population, representing a significant reduction in the overall physical and mental health.

Multimodal Pain Management After Outpatient Orthopedic Hand Surgery: A Prospective Randomized Trial.

Purpose: Opioid stewardship ensures effective pain management while avoiding overprescribing of opioids after surgery. This prospective randomized study investigates the efficacy of a multimodal postoperative pain regimen compared to a traditional opioid-only pain regimen following elective outpatient orthopedic hand surgery. We hypothesized that patients receiving multimodal pain management would consume fewer opioids and report greater satisfaction than patients receiving only opioids. Methods: Consecutive patients undergoing outpatient hand and upper extremity surgery performed by two board-certified fellowship-trained orthopedic hand surgeons at one institution were recruited and randomized into either a study or control group. The study group received a standing multimodal postoperative regimen consisting of scheduled oral acetaminophen and naproxen as well as oxycodone to be taken as needed. The control group received only oxycodone to be taken as needed. Postoperatively, daily pain levels, medication usage, refills, satisfaction, and adverse events were recorded. Descriptive statistics were performed. Results: Of the 112 patients enrolled, 54 were randomized to the control group, and 58 were randomized to the study group. Study and control group patients did not differ significantly based on daily average pain scores or daily worst pain scores. However, study group patients reported fewer average daily oxycodone intake and total oxycodone pill count (7.0 vs 2.4 total pills, P <.005). In addition, the study group patients were more likely to report satisfaction with their postoperative pain control than control regimen patient's and were more likely to use the same pain regimen again if required. Conclusion: A multimodal postoperative pain regimen reduces opioid usage and has higher patient satisfaction rates in comparison to traditional opioid-only regimens. Use of multimodal pain regimens that use nonopioids, such as acetaminophen and naproxen, over an opioid should be considered for postoperative pain after orthopedic hand surgery. Level of Evidence: Therapeutic II.

Outcomes Following Fully Threaded Intramedullary Nailing of Metacarpal Fractures.

Purpose: Intramedullary screw fixation has emerged as a popular approach for the treatment of displaced metacarpal fractures. The purpose of this study was to investigate the functional and radiographic outcomes of a newly designed, headless noncompressive fully threaded intramedullary nail (TIMN) for the treatment of metacarpal fractures. Methods: A retrospective chart review was performed on patients who were treated with the INnate TIMN (ExsoMed) at a single academic institution with a minimum of 1-year follow-up. Patient-reported functional outcomes included Quick Disabilities for the Arm, Shoulder, and Hand (QuickDASH) questionnaires, return to work and physical activity time, and overall satisfaction. Radiographs were retrospectively reviewed to determine radiographic union, change in angulation, and metacarpal shortening. Results: A total of 49 patients (58 fractures) with a mean age of 36 years (range: 17-75 years) were included. The mean follow-up time was 2.7 years (range: 1.4-4.3 years). Overall, the mean patient satisfaction rating was 4.9 of 5 (range: 3-5). The mean return to work time was 7.2 weeks (range: 0.14-28 weeks), and the mean return to sport or activity was 8.3 weeks (range: 1-28 weeks). Average QuickDASH scores across all patients were 4 (range: 0-56.9). The median radiographic healing time was 6.1 weeks (range: 4.7-15.4 weeks). Mean postoperative shortening in the fifth metacarpal fracture was 3 mm (range: -4.2 to 8 mm) at the initial postoperative visit and 3.6 mm (range: -3.3 to 7.9 mm) at the final radiographic follow-up. Subgroup analysis showed that postoperative shortening was similar, regardless of the fracture pattern. The following four complications were reported: one case of persistent pain and stiffness, one case of carpal tunnel syndrome, one nonunion, and one fractured intramedullary nail. Conclusions: Our findings suggest that the TIMN allows for a reliable return to work and physical activity, high patient satisfaction, low complication rate, and minimal shortening at the final radiographic follow-up. Type of study/level of evidence: Therapeutic IV.

Metacarpal Fracture Repair: Early Reoperation Rates and Characteristics.

Purpose: Metacarpal fractures are common injuries of the hand that often require operative repair. However, there is a paucity of data regarding the rate of reoperation and circumstances following metacarpal repair. Methods: A retrospective review of all metacarpal fracture cases performed at a single academic institution between 2017 and 2021 was performed. All patients with isolated, acute metacarpal fractures were included for review. Data on patient demographics, fracture morphology, surgical technique, rate of early reoperation, and reason for reoperation were collected. Results: A total of 499 patients were identified to have undergone operative treatment for an isolated metacarpal fracture with an average follow-up of 4.2 months. The rate of unplanned early reoperation was 8.0% (n = 40), with seven patients requiring revision fracture surgery and 33 patients undergoing removal of symptomatic hardware. Mean and median time to reoperation was 2.1 and 1.5 months, respectively. The rate of reoperation for fractures of the metacarpal shaft was significantly lower than that of other fracture locations. Among the 40 revision cases, one case was following percutaneous fixation while 39 cases were following open reduction and internal fixation. Other demographic factures and fracture characteristics failed to show significant correlations to the rate of reoperation. Conclusions: An unplanned early reoperation rate of 8.0% after operative fixation of acute metacarpal fractures was observed with the majority involving cases of removal of symptomatic hardware and an average time to reoperation of approximately 2.1 months. This information can be used to counsel patients and set expectations about the potential for metacarpal fracture surgeries. Type of Study/Level of Evidence: Prognosis 2b.

Trigger Finger Release: Are Sutures Requiring Removal Necessary?

Purpose: There is no consensus regarding optimal closure for trigger finger release (TFR) surgery. The purpose of this study was to compare the number of postoperative visits and complications following TFR closure with nonabsorbable sutures versus those following TFR closure with absorbable sutures and skin glue. The hypothesis was that wound closure with absorbable sutures and glue will result in fewer postoperative visits, while having similar complication rates as that with nonabsorbable sutures. Methods: A retrospective review identified all patients undergoing open TFR over a 3-year period performed by two hand surgery fellowship-trained hand surgeons who adhered to an identical surgical protocol except for incisional closure. Patients were divided into two groups: a control group with nonabsorbable 4-0 monofilament sutures requiring removal ("suture" group) and a study group with buried absorbable 4-0 monofilament sutures not requiring removal as well as skin glue ("glue" group). The data collected included age, sex, number of postoperative visits, wound complications, infections, antibiotic use, prescribed hand therapy, hospital admission, and reoperation. Results: A total of 305 open TFR surgeries in 278 patients were included in the study, with 155 digits in the "suture" group and 150 in the "glue" group. Both groups were similar in age and sex. The "suture" group had significantly more total postoperative visits (185 vs 42, respectively, P < .001) and postoperative visits within the first 2 weeks (155 vs 10, respectively, P < .001) than the "glue" group. Additional postoperative visits beyond 2 weeks of surgery were similar between the two groups. Three (1.9%) patients in the "suture" group and two (1.3%) patients in the "glue" group developed a superficial surgical site infection within 30 days after surgery. Neither had deep infections requiring hospitalization or reoperation. Both groups required similar rates of postoperative hand therapy. Conclusions: Absorbable sutures afford fewer postoperative visits while having a similar complication rate as nonabsorbable sutures requiring removal. Type of study/level of evidence: Therapeutic IV.

Intramedullary K-wires versus Alternate Techniques for Metacarpal Shaft and Neck Fractures: A Systematic Review and Meta-analysis.

Intramedullary K-wire (IMKW) fixation is one of the mainstays for surgically treating metacarpal shaft and neck fractures. However, there remains a lack of literature comparing outcomes of the various available surgical repair techniques in all indicated metacarpals. Therefore, we conducted a systematic review and meta-analysis to investigate the clinical advantages and drawbacks of IMKW compared with alternate fracture repair techniques. A comprehensive systematic literature review was performed to identify studies that compared clinical outcomes of IMKW to alternate metacarpal fixation modalities. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH/ quick DASH) scores, grip strength, union rate, visual analog scale pain, operative time, and complications. A random-effects model was used to compare IMKW to the pooled effect of other fixation techniques. A total of 10 studies were included in our analysis, comprising 497 metacarpal fractures (220 shafts and 277 necks). IMKW fixation was identified as the control group in all studies. The pooled experimental group included plates, transverse K-wires (TKWs), interfragmentary screws (IFSs), and K-wire cross-pinning (CP). In treating metacarpal shaft fractures, IMKW showed significantly shorter operative time ( p = 0.04; mean difference = - 13; 95% confidence interval = -26 to -0.64). No significant differences were observed in treating metacarpal neck fractures for disability, grip strength, healing rate, pain, operative time, or complication rate. This systematic review and meta-analysis found no difference in clinical outcomes among various surgical techniques for treating metacarpal shaft and neck fractures. Further high evidence studies are required that investigate the efficacy and safety of IFS, CP, TKW, and intramedullary screws versus IMKW for treating closed, unstable metacarpal fractures.

Rate of Complications After Capitellum Fracture Fixation: A Systematic Review and Meta-Analysis.

PURPOSE: This systematic review aimed to determine the incidence of complications following surgical fixation of an acute capitellum fracture. We secondarily aimed to compare the complication rate between anterior-to-posterior (A-P) versus posterior-to-anterior (P-A) screw insertion. METHODS: PubMed, EMBASE, and Scopus were searched to identify studies on surgical fixation of capitellum fractures in skeletally mature patients. The main outcome was the rate of complication after fracture fixation. Subgroup analysis was performed to assess the impact of the fixation technique on the outcomes after surgery. An inverse variance method using random or fixed effects models was used to perform a meta-analysis based on the degree of heterogeneity between studies. Study heterogeneity was evaluated using Q statistics to calculate the I2 index. RESULTS: We included 42 studies in the final analysis. The most reported complications after surgical fixation of capitellum fractures included elbow pain (21%), radiocapitellar arthritis (19%), hardware removal (17%), and heterotopic ossification (13%). When groups were stratified based on the direction of screw insertion, the mean rate of avascular necrosis was higher in the P-A direction (29% vs 11%). In comparison, the rate of revision fixation (2.9% vs 6.7%) and heterotopic ossification (7.3% vs 22%) were higher in the A-P direction. Transient posterior interosseous nerve palsy was reported in four patients in four studies, of whom three patients had A-P screw fixation. CONCLUSION: Fixation of a displaced capitellum fracture is recommended when possible. However, patients should be counseled about the potential risk of complications and chances of undergoing an unplanned surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparative Bending Strength of Metacarpal Neck Fractures Fixed with Two Types of Intramedullary Screws.

Objectives: Intramedullary (IM) screw fixation of metacarpal fractures is a technique, which has gained in popularity owing to its simplicity, speedy rehabilitation, and good functional outcomes. A new, larger diameter, non-compression screw designed specifically for IM metacarpal fixation was recently introduced which could provide better fracture stability and reduce the risk of hardware failure. Our goal was to evaluate the strength of this screw compared to a first-generation screw. Methods: This mechanical study was designed to compare a 4.5 mm metacarpal headless screw (MCHS) to data from our prior research evaluating a 3.0 mm headless screw (HS). Accordingly, we used identical bone models, testing constructs, equipment, and protocols. A metacarpal neck osteotomy was created in 10 Sawbones models. A 4.5 mm x 50 mm MCHS was inserted retrograde to stabilize the fracture. Flexion bending strength was measured through a cable tension construct on a materials testing machine. Failure mechanism and strength was recorded and compared to data with a 3.0 mm screw construct. Results: Eight models failed by bending of the intramedullary screw. Two models failed by rotation of the metacarpal head. Failure occurred at an average of 539 N (Range 315 - 735 N). The MCHS demonstrated a significantly greater load to failure compared to the previously studied 3.0 mm HS at 215 N (P<0.05). Conclusion: A larger, 4.5 mm metacarpal-specific headless screw is more than twice as strong as a 3.0 mm diameter screw in a metacarpal neck fracture model.

A Multicenter Prospective Randomized Comparison of Conduits Versus Decellularized Nerve Allograft for Digital Nerve Repairs.

PURPOSE: While there are advantages and disadvantages to both processed nerve allografts (PNA) and conduits, a large, well-controlled prospective study is needed to compare the efficacy and to delineate how each of these repair tools can be best applied to digital nerve injuries. We hypothesized that PNA digital nerve repairs would achieve superior functional recovery for longer length gaps compared with conduit-based repairs. METHODS: Patients (aged 18-69 years) presenting with suspected acute or subacute (less than 24 weeks old) digital nerve injuries were recruited to prticipate at 20 medical centers across the United States. After stratification to short (5-14 mm) and long (15-25 mm) gap subgroups, the patients were randomized (1:1) to repair with either a commercially available PNA or collagen conduit. Baseline and outcomes assessments were obtained either before or immediately after surgery and planned at 3-, 6-, 9-, and 12-months after surgery. All assessors and patients were blinded to the treatment arm. RESULTS: In total, 220 patients were enrolled, and 183 patients completed an acceptable last evaluable visit (at least 6 months and not more than 15 months postrepair). At last follow-up, for the short gap repair groups, average static two-point discrimination was 7.3 ± 2.8 mm for PNA and 7.5 ± 3.1 mm for conduit repairs. For the long gap group, average static two-point discrimination was significantly lower at 6.1 ± 3.3 mm for PNA compared with 7.5 ± 2.4 mm for conduit repairs. Normal sensation (American Society for Surgery of the Hand scale) was achieved in 40% of PNA long gap repairs, which was significantly more than the 18% observed in long conduit patients. Long gap conduits had more clinical failures (lack of protective sensation) than short gap conduits. CONCLUSIONS: Although supporting similar levels of nerve regeneration for short gap length digital nerve repairs, PNA was clinically superior to conduits for long gap reconstructions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.