Intramedullary Threaded Nail Fixation Versus Plate and Screw Construct in Metacarpal Neck Fractures: A Biomechanical Study.

BACKGROUND: Indicated surgical management of metacarpal neck fractures varies with techniques, including Kirschner wire fixation, plate fixation, intramedullary fixation, and headless compression screw fixation, without demonstrated superiority. This study compares intramedullary threaded nail (ITN) fixation with a locking plate construct. METHODS: Index through small finger metacarpals were harvested from 10 embalmed cadavers. After application of appropriate exclusion criteria, remaining metacarpals underwent neck fracture creation by a three-point load to failure. Eight samples were randomly allocated to fixation with ITN fixation, and six were stabilized with a 2.3-mm seven-hole locking plate. Samples were then subjected to a second round of biomechanical testing using the same apparatus. Ultimate load between the intact tissue and the subsequently stabilized fracture was analyzed with a paired Student t -test. Percentage change in ultimate load in the intact tissue and stabilized tissue was calculated, and the magnitude of relative difference between the two groups was analyzed using unpaired Student t -tests. Statistical difference was defined by a P value of < 0.05. RESULTS: Both groups demonstrated the ability to handle a biomechanical load; however, both were significantly weaker than the intact tissue (paired Student t -test p ITN-fixed versus p ITN-intact = 0.006; p plate-fixed versus p plate-intact = 0.002). ITN samples demonstrated a higher load to failure (unpaired Student t -test p ITN-fixed versus p plate-fixed = 0.039). CONCLUSION: ITN provides a biomechanically stronger fixation constructed for vertically oriented metacarpal neck fractures compared with locking plate fixation. Both ITN and locking plate constructs provide stabilization capable of tolerating a biomechanical load; however, both fixation modalities are weaker than the native tissue.

Quantifying the Impact of COVID-19 on Hand and Wrist Surgery Procedural Volume: A National Analysis of 381,046 Cases.

Purpose: To quantify and describe the impact of the COVID-19 pandemic on procedural volume trends in hand and wrist surgery from 2020 to early 2022 at multiple centers. Methods: In this retrospective comparative study, a real-time, national, federated research database was used to identify patients of interest from 56 health care organizations across the United States. Patients were queried from March 1, 2018, to February 28, 2022. Current Procedural Terminology codes were chosen using the Accreditation Council for Graduate Medical Education's hand fellowship procedure requirements. Results: Common hand and wrist surgeries exhibited substantial fluctuations in procedural volume per health care organization during the COVID-19 pandemic. Time periods with considerable procedural volume decreases corresponded with surges in increased COVID-19 caseloads and emergence of COVID-19 variants. Periods of procedural volume increase occurred in the summer of 2020 and immediately following distribution of the COVID-19 vaccine to the public. Fixation of metacarpal fracture, fixation of phalangeal fracture, tendon transfer, flexor tendon repair, and extensor tendon repair consistently showed decreased volumes over the study period. In contrast, ulnar nerve decompression was the only procedure to experience a statistically significant increase in volume over an entire year (2021, +19.2%, P < .001), as compared to before the pandemic. Conclusions: Major milestones of the COVID-19 pandemic correlated with fluctuations in the number of hand and wrist procedures performed across the United States. Future studies should seek to evaluate the impact of patient backlogs and individual procedure fluctuations on financial impacts, patient outcomes, and orthopedic trainee experience. Type of study/level of evidence: Economic/Decision Analysis IV.

Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels.

BACKGROUND: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables. QUESTIONS/PURPOSES: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians? METHODS: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized ß coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics. RESULTS: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did. CONCLUSION: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases. CLINICAL RELEVANCE: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.

Biomechanical Strength of Scaphoid Partial Unions.

Background It remains unknown how much force a partially united scaphoid can sustain without refracturing. This is critical in determining when to discontinue immobilization in active individuals. Purpose The purpose of this study was to test the biomechanical strength of simulated partially united scaphoids. We hypothesized that no difference would exist in load-to-failure or failure mechanism in scaphoids with 50% or more bone at the waist versus intact scaphoids. Materials and Methods Forty-one cadaver scaphoids were divided into four groups, three experimental osteotomy groups (25, 50, and 75% of the scaphoid waist) and one control group. Each was subjected to a physiologic cantilever force of 80 to 120 N for 4,000 cycles, followed by load to failure. Permanent deformation during physiologic testing and stiffness, max force, work-to-failure, and failure mechanism during load to failure were recorded. Results All scaphoids survived subfailure conditioning with no significant difference in permanent deformation. Intact scaphoids endured an average maximum load to failure of 334 versus 321, 297, and 342 N for 25, 50, and 75% groups, respectively, with no significant variance. There were no significant differences in stiffness or work to failure between intact, 25, 50, and 75% groups. One specimen from each osteotomy group failed by fracturing through the osteotomy; all others failed near the distal pole loading site. Conclusion All groups behaved similarly under physiologic and load-to-failure testing, suggesting that inherent stability is maintained with at least 25% of the scaphoid waist intact. Clinical Relevance The data provide valuable information regarding partial scaphoid union and supports mobilization once 25% union is achieved.

Charcot shoulder and elbow: a review of the literature and update on treatment.

Charcot arthropathy of the shoulder and elbow is a rare disease process initially described in the 1700s; however, it was not until the 19th century that physicians understood its association with other disease processes such as cervical spine pathology and diabetes. A primary complaint is painful or painless joint dysfunction, meaning the orthopedic surgeon is regularly the first physician to evaluate the patient. Frequently, the condition of these patients is misdiagnosed. Although the pathogenesis of the disease is controversial, the etiology is commonly due to syringomyelia. The key to successful management is a thorough history and examination along with a workup including specific laboratory testing and imaging to rule out other disease processes. Most neuropathic shoulders and elbows have historically been managed conservatively because of poor outcomes with operative interventions. Newer data have emerged hinting that early neurosurgical intervention can stabilize this degenerative process. If clinical and radiographic stabilization occurs, recent studies have outlined surgical indications that can provide surgeons with a guide as to patients in whom successful operative outcomes can be achieved in the face of failed conservative management.

Can facet joint fluid on MRI and dynamic instability be a predictor of improvement in back pain following lumbar fusion for degenerative spondylolisthesis?

PURPOSE: To investigate the relationship between lumbar facet fluid and dynamic instability in degenerative spondylolisthesis (DS), as well as the relationship between facet fluid and patient-reported outcomes following a posterior lumbar fusion. METHODS: We analyzed consecutive patients with degenerative spondylolisthesis undergoing single level posterior lumbar fusion from December 2010 to January 2013 at a single academic institution. We investigated the relationship between fluid in the facet joint as measured on axial MRI and the presence of dynamic instability. We investigated the impact of facet fluid, Modic changes, and dynamic instability on patient-reported outcomes. RESULTS: There was a significant association between the amount of facet joint fluid and the presence of dynamic instability (p = 0.03); as facet fluid increases, the probability of dynamic instability also increases. For every 1 mm of facet fluid, there was a 41.6 % increase (95 % CI 1.8-97) in the odds of dynamic instability. A facet fluid amount less than 0.5 mm gave a 90 % probability that there was no dynamic instability. The presence of facet fluid and dynamic instability were associated with achieving minimal clinical important difference (MCID) in low back pain following lumbar fusion (p = 0.04 and 0.05, respectively). CONCLUSION: Facet joint fluid is associated with the presence of dynamic instability in DS. The presence of facet fluid and dynamic instability may predict increased likelihood of achieving MCID for improvement in back pain following posterior lumbar fusion.

Intramedullary Nailing Compared with Spica Casts for Isolated Femoral Fractures in Four and Five-Year-Old Children.

BACKGROUND: Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age). METHODS: A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables. RESULTS: Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p < 0.001), were heavier (mean, 21.5 versus 18.0 kg; p < 0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p > 0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p < 0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p < 0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p < 0.001), primarily for elective implant removal. CONCLUSIONS: Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.

Incidence and reasons for hardware removal following operative fixation of distal radius fractures.

PURPOSE: To determine the incidence and reasons for hardware removal after operative fixation of distal radius fractures. METHODS: We retrospectively reviewed 33 patients who underwent removal of a volar distal radius plate from 2007 to 2013. We recorded the primary reason for plate removal, patient sex, body mass index, AO fracture type, and plate manufacturer. The total number of both distal radius plating procedures and implant removals was analyzed. RESULTS: Of the 33 patients who underwent implant removal, the most common reasons for removal were pain (30%), tenosynovitis (27%), malunion (24%), infection (12%), nonunion (6%), and tendon rupture (3%). The most common AO fracture types requiring plate removal were A2, C2, and C3 (7 each). A total of 517 distal radius fractures received plate fixation at our institution from 2007 to 2009, a number that rose to 610 from 2010 to 2012. The number of distal radius plate removals over that same time was relatively constant at 17 and 16, respectively. CONCLUSIONS: We advise continued review of reasons for implant removal to limit future hardware complications related to volar plating of distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Olecranon fractures: factors influencing re-operation.

PURPOSE: We evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures. METHODS: Four hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF. RESULTS: One hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group. CONCLUSIONS: Our results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.

Flexor tendon repair rehabilitation protocols: a systematic review.

PURPOSE: To systematically review various flexor tendon rehabilitation protocols and to contrast those using early passive versus early active range of motion. METHODS: We searched PubMed and Cochrane Library databases to identify articles involving flexor tendon injury, repair, and rehabilitation protocols. All zones of injury were included. Articles were classified based on the protocol used during early rehabilitation. We analyzed clinical outcomes, focusing on incidence of tendon rupture and postoperative functional range of motion. We also analyzed the chronological incidence of published tendon rupture with respect to the protocol used. RESULTS: We identified 170 articles, and 34 met our criteria, with evidence ranging from level I to level IV. Early passive motion, including both Duran and Kleinert type protocols, results included 57 ruptures (4%) and 149 fingers (9%) with decreased range of motion of 1598 tendon repairs. Early active motion results included 75 ruptures (5%) and 80 fingers (6%) with decreased range of motion of 1412 tendon repairs. Early passive range of motion protocols had a statistically significantly decreased risk for tendon rupture but an increased risk for postoperative decreased range of motion compared to early active motion protocols. When analyzing published articles chronologically, we found a statistically significant trend that overall (passive and active rehabilitation) rupture rates have decreased over time. CONCLUSIONS: Analyzing all flexor tendon zones and literature of all levels of evidence, our data show a higher risk of complication involving decreased postoperative digit range of motion in the passive protocols and a higher risk of rupture in early active motion protocols. However, modern improvements in surgical technique, materials, and rehabilitation may now allow for early active motion rehabilitation that can provide better postoperative motion while maintaining low rupture rates.

Upper extremity myonecrosis caused by Edwardsiella tarda resulting in transhumeral amputation: case report.

Necrotizing soft tissue infections are rapidly progressive infections with a high rate of mortality. One type of necrotizing soft tissue infection is caused by marine gram-negative bacteria and commonly occurs in immunocompromised hosts. These types of infections are more common in patients with chronic liver disease, possibly because of impaired iron metabolism. We present the case of a rapidly progressive necrotizing soft tissue infection caused by Edwardsiella tarda, a marine gram-negative pathogen common in catfish. Few extraintestinal infections of E tarda have been described previously. Our patient had hepatitis C and was exposed to the bacteria by a puncture injury from a wild catfish. His infection required multiple debridements and ultimately required a transhumeral amputation for local control of the infection.

Mitochondrial permeability transition in liver ischemia and reperfusion: role of c-Jun N-terminal kinase 2.

The mitochondrial permeability transition (MPT) mediates hepatic necrosis after ischemia and reperfusion (I/R). Here, we studied the role of c-Jun N-terminal kinase 2 (JNK2) in MPT-induced liver injury. Wildtype (WT) and JNK2 knockout (KO) mice underwent 70% liver ischemia for 1 hr followed by reperfusion for 8 hr, after which hepatocyte injury and animal survival was assessed. Compared with WT, JNK2 KO mice had 38% less alanine transaminase release and 39% less necrosis by histology. Survival out to 14 days was also greater in JNK2 KO mice (57% vs. 11%), and overall Kaplan-Meier survival was improved. No difference in apoptosis was observed. Intravital multiphoton microscopy of potential-indicating rhodamine 123 after reperfusion revealed depolarized mitochondria in 82% of WT hepatocytes, which decreased to 43% in JNK2 KO hepatocytes. In conclusion, JNK2 contributes to hepatocellular injury and death after I/R in association with increased mitochondrial dysfunction via the MPT.