Thumb-Sparing Surgery for Digital Papillary Adenocarcinoma: A Case Report.

Digital papillary adenocarcinoma (DPA) is a rare eccrine sweat gland tumor that often appears as a solitary, non-painful, gradually enlarging mass. Clinically, DPA presents considerable challenges due to its high likelihood of recurrence and its tendency to spread to the lymph nodes and lungs. This case report focuses on the surgical treatment of a unique case of DPA located on the dorsal thumb in a 46-year-old male. The patient initially underwent wide local excision with temporary wound coverage, and once final histopathological findings confirmed negative margins, a second procedure consisting of thumb interphalangeal joint fusion and first dorsal metacarpal artery flap coverage was performed. Eighteen months later, the patient continued to work in landscaping, performing the physically demanding tasks required by the job. This case demonstrates the feasibility of thumb preservation in the setting of soft tissue malignancy once negative margins are obtained.

Triceps brachii insertional footprint: Under-estimated complexity.

Background: The detailed complexity of triceps brachii insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures. The purpose of this study is to describe the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow. Methods: 22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. The insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described. Results: The mean width and surface area of the lateral segment was greater in males than in females (30.07 mm vs. 24.37 mm, p = 0.0339 and 282.1 mm vs. 211. 56 mm, p = 0.0181, respectively). No other statistically significant differences between the sexes were noted. The triceps insertional footprint was "crescent-shaped" and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension. Discussion: These findings can help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies. Clinical Relevance: Basic Science, anatomy study, cadaver dissection.

A quality and readability comparison of artificial intelligence and popular health website education materials for common hand surgery procedures.

INTRODUCTION: ChatGPT and its application in producing patient education materials for orthopedic hand disorders has not been extensively studied. This study evaluated the quality and readability of educational information pertaining to common hand surgeries from patient education websites and information produced by ChatGPT. METHODS: Patient education information for four hand surgeries (carpal tunnel release, trigger finger release, Dupuytren's contracture, and ganglion cyst surgery) was extracted from ChatGPT (at a scientific and fourth-grade reading level), WebMD, and Mayo Clinic. In a blinded and randomized fashion, five fellowship-trained orthopaedic hand surgeons evaluated the quality of information using a modified DISCERN criteria. Readability and reading grade level were assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) equations. RESULTS: The Mayo Clinic website scored higher in terms of quality for carpal tunnel release information (p = 0.004). WebMD scored higher for Dupuytren's contracture release (p < 0.001), ganglion cyst surgery (p = 0.003), and overall quality (p < 0.001). ChatGPT - 4th Grade Reading Level, ChatGPT - Scientific Reading Level, WebMD, and Mayo Clinic written materials on average exceeded recommended reading grade levels (4th-6th grade) by at least four grade levels (10th, 14th, 13th, and 11th grade, respectively). CONCLUSIONS: ChatGPT provides inferior education materials compared to patient-friendly websites. When prompted to provide more easily read materials, ChatGPT generates less robust information compared to patient-friendly websites and does not adequately simplify the educational information. ChatGPT has potential to improve the quality and readability of patient education materials but currently, patient-friendly websites provide superior quality at similar reading comprehension levels.

Three-Dimensional Analysis of Metacarpal Head Articular Defects Created by Headless Screws.

Objectives: Headless screw fixation used to treat metacarpal neck and metacarpal shaft fractures is gaining popularity. The aim of the study is to determine the proportion of the metacarpal head articular surface that is compromised during retrograde insertion of headless screws. Methods: Metacarpal screw fixation through a metacarpal head starting point was performed using fluoroscopic guidance on 14 metacarpals. Headless compression screws, with a tail diameter of 3.6mm, were used. The specimens were subsequently skeletonized and digitized using a 3-dimensional surface scanner. The articular surface defects created by the screws were then determined using computer software. Screw position in the dorsal aspect of the metacarpal head was expressed as a percentage of the total volar-to-dorsal distance. Results: The 14 metacarpals studied consisted of 2 index, 4 long, 4 ring and 4 small metacarpals, taken from 4 hands. The average total metacarpal head surface area was 284.6 mm2 (range, 151.0-462.2 mm2); the average screw footprint in the metacarpal head was 13.3 mm2 (range, 10.3-17.4 mm2), which compromised a mean of 5.0% (3.0-7.8%) of the total cartilaginous metacarpal head surface area. In the sagittal plane, screw placement was found to lie in the dorsal 37.4% of the metacarpal head (range, 20.7-58.6%). Conclusion: The proportion of the articular surface area injured with retrograde insertion of headless compression screws into the metacarpal head is 5.0%. Screw placement is generally in the dorsal 37% of the metacarpal head.

Predatory Journals in Orthopaedic Surgery.

The prevalence of predatory journals in orthopaedic surgery continues to increase. These journals directly solicit authors, offering the advantages of open access and quick publication rates. Solicitation typically occurs in the form of e-mail communications, and the targets are usually identified as authors who have published other works in conventional publications. These predatory journals process manuscripts without peer review and plagiarism checks and often for a substantial publication fee. As a result, the scientific value of these publications is grossly suspect and has been considered a substantial threat to the quality of scientific discourse and scholarship. This affects not only the layperson reading the works but also investigators tricked into publishing in these venues. It has been estimated that several million US dollars per year are spent on these publications and, in many instances, using monies granted by agencies such as the National Institutes of Health. This review aims to study the types of solicitation, evaluate the increasing prevalence in orthopaedic surgery, and offer methods to authors and readers to identify these journals to mitigate their negative effects.

Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation.

PURPOSE: To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures. METHODS: A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated. RESULTS: There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation. CONCLUSIONS: Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Fingertip Injuries in Athletes, Musicians, and Other Special Cases.

Management of fingertip injuries in athletes is optimized by consideration of the sport, the playing position, the timing within the season, the level of competition, and the patient's goals. Mallet and jersey fingers are common injuries in athletes and may be treated in several different ways, based on the nature of the injury and the timing of presentation, as well as the athlete's demands. Management of fingertip injuries in musicians is optimized by consideration of how the musician handles his or her instrument and the specific requirements of the injured digit in the context of musical performance.

Mycobacterial Infections in the Hand and Wrist.

Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical débridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease.

Reevaluation of the Scaphoid Fracture: What Is the Current Best Evidence?

Scaphoid fractures are common and notorious for their troublesome healing. The aim of this review is to reevaluate the current best evidence for the diagnosis, classification, and treatment of scaphoid fractures and nonunions. MRI and CT are used to establish a "definitive diagnosis" with comparable diagnostic accuracy although neither is 100% specific. Current classifications cannot reliably predict union or outcomes; hence, a descriptive analysis of fracture location, type, and extent of displacement remains most useful. Treatment of a nondisplaced scaphoid waist fracture remains an individualized decision based on shared decision-making. Open reduction and internal fixation may be preferred when fracture displacement exceeds 1 mm, and the fracture is irreducible by closed or percutaneous means. For unstable nonunions with carpal instability, either non-vascularized cancellous graft with stable internal fixation or corticocancellous wedge grafts will provide a high rate of union and restoration of carpal alignment. For nonunions characterized with osteonecrosis of the proximal pole, vascularized bone grafting can achieve a higher rate of union.

Emerging Technologies in Distal Radius Fracture Fixation.

PURPOSE OF REVIEW: To provide an overview of emerging fixation constructs and materials used in the operative management of distal radius fractures. RECENT FINDINGS: The indications, advantages, and disadvantages of relatively new implants and devices used to treat distal radius fractures are discussed. These include the intramedullary nail, intramedullary cage, radiolucent volar locking plate, distal radius hemiarthroplasty, and bone graft substitutes. The spectrum of distal radius fracture patterns may make it impossible to depend on a single device for fixation, and surgeons managing distal radius fractures should be adept at using various surgical approaches, techniques, and hardware systems. Additional studies demonstrating the cost-effectiveness, biomechanical properties, and clinical outcomes will be useful in determining the utility of the described techniques.

Survival and Long-Term Outcomes of Thumb Metacarpal Extension Osteotomy for Symptomatic Carpometacarpal Laxity and Early Basal Joint Arthritis.

PURPOSE: To evaluate the survival and long-term outcomes of thumb metacarpal extension osteotomy for early carpometacarpal (CMC) arthritis. METHODS: Patients who underwent a thumb extension osteotomy between years 2000 and 2011 were identified. Patient demographics, complications, and reoperations were recorded. The Kaplan-Meier survival analysis was used with subsequent CMC surgery defined as failure. Patients who had undergone surgery 10 years or more before the study date underwent radiographic assessment, grip and pinch strength testing, and completed the Patient Rated Wrist/Hand Evaluation (PRWHE) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires. RESULTS: Thirty-two procedures in 7 males and 21 females were performed (mean age, 44.8 y). There were no cases of nonunion. Nine of 32 thumbs developed pin site erythema and were treated with oral antibiotics. Two thumbs developed osteomyelitis. Seven of 32 thumbs (22%) required reoperation. The Kaplan-Meier analysis indicated a 70% probability that patients who have this procedure will not require additional CMC surgery up to 14 years. Seven patients with a mean follow-up of 12.3 years (minimum 10 y) returned for clinical evaluation. The mean PRWHE and QuickDASH scores were 32.1 and 27.7, respectively. Examination revealed 124% pinch and 98% grip strength relative to the preoperative values. One thumb did not progress from stage II disease; 2 thumbs progressed from stage I to stage II; 1 thumb progressed from stage II to stage III; 1 thumb progressed from stage II to stage IV; 1 thumb did not have disease progression at the CMC joint, but developed scaphotrapeziotrapezoidal arthritis. CONCLUSIONS: Although reoperation rates and superficial infections with the described method of fixation were relatively high, thumb metacarpal osteotomy provides some degree of pain relief and improvement of function. This procedure may have utility as a temporizing measure in younger patients as it does not compromise future reconstructive procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A review of mallet finger and jersey finger injuries in the athlete.

PURPOSE OF REVIEW: The purposes of this review are to discuss the diagnosis and management of mallet and jersey finger injuries in athletes and to highlight how treatment impacts return to play. RECENT FINDINGS: Mallet finger: although numerous non-operative and operative techniques have been described, there continues to be little consensus regarding the optimal procedure. Jersey finger: ultrasound appears to be a cost-effective imaging modality that may be useful for preoperative planning. Wide-awake surgery offers optimal intraoperative assessment of the tendon repair. Tendon repair with volar plate augmentation has been shown to improve the strength of the repair in the laboratory, and early clinical results are encouraging. Most mallet finger injuries will heal with non-operative treatment over a period of 8-12 weeks, even when treatment is delayed up to 3-4 months. An acute diagnosis of jersey finger requires surgical treatment and generally means 8-12 weeks of inability to compete in most contact sports.

Enchondroma of the Hand: Evaluation and Management.

Enchondroma is the most common primary bone tumor of the hand. This benign, cartilaginous tumor often presents as a pathologic fracture. When hand enchondroma is suspected, less common conditions, such as multiple enchondromatosis syndromes and benign and malignant lesions, should be ruled out. Surgical management with curettage is the standard of care for symptomatic lesions. However, controversy surrounds the timing of surgery for pathologic fractures and the use of surgical adjuncts and postcurettage void management. Microscopically distinguishing hand enchondroma from low-grade hand chondrosarcoma is a diagnostic challenge for pathologists, but the primary surgical treatment for both conditions is curettage because the latter has a low metastatic potential. Postoperative complications are typically joint stiffness and soft-tissue[FIGURE DASH]related deformities, whereas recurrence and malignant degeneration of solitary lesions are much less common. Most patients return to full function after surgery.

Arthroscopic Trapeziectomy With Suture Button Suspensionplasty: A Retrospective Review of 153 Cases.

BACKGROUND: Arthroscopic trapeziectomy with suture button suspensionplasty (ATBS) is a relatively new surgical option for the treatment of thumb carpometacarpal (CMC) osteoarthritis. Although ATBS has many potential benefits over alternative surgical treatments for CMC arthritis, little data exist regarding its safety and complication rates. The purpose of this study was to demonstrate that ATBS is associated with a low risk of complications within 1 year of surgery. METHODS: A retrospective review of patients treated with ATBS by one senior hand surgeon over a span of 3 years was performed. RESULTS: A total of 153 cases of ATBS were performed in 136 patients. Ninety-seven cases involved arthroscopic hemitrapeziectomies, and 56 involved arthroscopic complete trapeziectomies. There were 44 males and 92 females with a mean age of 62. Thirty-eight percent of the cases were graded as Eaton stage IV, 46% stage III, and 14% stage II CMC arthritis, while 3 cases (2%) were performed as revisions. Mean follow-up duration was 58 weeks. Mean preoperative key pinch strength of the affected versus the unaffected side was 92% compared with 95% postoperatively. Revision surgery was performed in 9 out of 153 cases (<6%). Of those 9 cases, 5 had additional minor bony debridement with subsequent improvement in pain, 3 had the implant repositioned due to button prominence, and 1 patient presented with osteomyelitis of the first and second metacarpals that was successfully treated with button removal and an antibiotic regimen. CONCLUSIONS: ATBS is a safe, minimally invasive procedure for treatment of symptomatic stages II through IV thumb CMC arthritis.

Distal Insertional Footprint of the Brachialis Muscle: 3D Morphometric Study.

Objective. The purpose of this study is to describe the three-dimensional morphometry of the brachialis muscle at its distal attachment to the ulna. Methods. Fifty cadaveric elbows were dissected and the brachialis distal insertion was isolated on the ulna bone and probed with a three-dimensional digitizer, to create a three-dimensional model of the footprint. Measurements and analysis of each footprint shape were recorded and compared based on gender and size. Results. There was significant gender difference in the surface length (P= 0.002) and projected length (P= 0.001) of the brachialis footprint. The shapes of the footprint also differed among the specimens. Conclusion. The shape of the brachialis muscle insertion differed among all the specimens without significant variation in gender or sides. There was also a significant difference in muscle length between males and females with little difference in the width and surface area. Significance. The information obtained from this study is important for kinematic understanding and surgical procedures around the elbow joint as well as the understanding of the natural age related anatomy of the brachialis footprint morphology.

Inner Synovial Membrane Footprint of the Anterior Elbow Capsule: An Arthroscopic Boundary.

Introduction. The purpose of this study is to describe the inner synovial membrane (SM) of the anterior elbow capsule, both qualitatively and quantitatively. Materials and Methods. Twenty-two cadaveric human elbows were dissected and the distal humerus and SM attachments were digitized using a digitizer. The transepicondylar line (TEL) was used as the primary descriptor of various landmarks. The distance between the medial epicondyle and medial SM edge, SM apex overlying the coronoid fossa, the central SM nadir, and the apex of the SM insertion overlying the radial fossa and distance from the lateral epicondyle to lateral SM edge along the TEL were measured and further analyzed. Gender and side-to-side statistical comparisons were calculated. Results. The mean age of the subjects was 80.4 years, with six male and five female cadavers. The SM had a distinctive double arched attachment overlying the radial and coronoid fossae. No gender-based or side-to-side quantitative differences were noted. In 18 out of 22 specimens (81.8%), an infolding extension of the SM was observed overlying the medial aspect of the trochlea. The SM did not coincide with the outer fibrous attachment in any specimen. Conclusion. The humeral footprint of the synovial membrane of the anterior elbow capsule is more complex and not as capacious as commonly understood from the current literature. The synovial membrane nadir between the two anterior fossae may help to explain and hence preempt technical difficulties, a reduction in working arthroscopic volume in inflammatory and posttraumatic pathologies. This knowledge should allow the surgeon to approach this aspect of the anterior elbow compartment space with the confidence that detachment of this synovial attachment, to create working space, does not equate to breaching the capsule. Alternatively, stripping the synovial attachment from the anterior humerus does not constitute an anterior capsular release.

The surgical management of hand enchondroma without postcurettage void augmentation: authors' experience and a systematic review.

BACKGROUND: Postcurettage void augmentation in the management of hand enchondroma is a debated practice. The objectives of this study are to present the outcomes of hand enchondroma treatment by curettage without void augmentation at the authors' institution and to systematically review the literature pertinent to this aspect of management. METHODS: Initially, a retrospective case series of patients treated for hand enchondroma at the authors' institution was conducted to assess postoperative complications and radiographic consolidation. All patients were treated by curettage without void augmentation. Next, a systematic review was conducted. Postcurettage void management was categorized into four groups: (1) curettage alone, (2) curettage followed by augmentation with cancellous autograft, (3) curettage followed by augmentation with bioactive and osteoconductive materials other than autograft, and (4) curettage followed by augmentation with bone cements. Complication and recurrence rates were compared. RESULTS: The authors' series was composed of 24 patients with 26 lesions. The mean age was 38.9 years (range 14-61), and the mean follow-up was 26 months (range 3-120). There was one recurrence but no postoperative fractures or nonunions. As for the systematic review, a total of 22 studies involving 591 patients and 609 lesions were assessed. Complications occurred at an incidence of 0.7 % following curettage alone, 3.5 % following autograft, 0 % following augmentation with bioactive/osteoconductive materials, and 2.0 % following cement augmentation. No statistical differences were noted for complication or recurrence rates. CONCLUSIONS: Simple curettage is an effective and inexpensive technique that does not lead to increased complication rates in the treatment of most hand enchondromas.

Four-corner arthrodesis with a radiolucent locking dorsal circular plate: technique and outcomes.

BACKGROUND: Scaphoid excision and four-corner arthrodesis (FCA) is an acceptable motion sparing procedure used to treat wrist arthritis. Recently, a locking dorsal circular plate composed of polyether-ether-ketone has been introduced (Xpode®; TriMed Inc.). The purpose of this study is to assess the efficacy of this specific plate design with regard to FCA. METHODS: A retrospective chart review of all patients who underwent FCA with an Xpode® between January 1, 2008 and December 31, 2012 was conducted. Patients were contacted and asked to return to clinic for clinical and radiographic follow-up. Patient demographics, range of motion, grip strength, and complications were collected from medical records. Patients completed a patient-rated wrist evaluation (PRWE). A paired t test was used to compare means, and p values <0.05 were considered statistically significant. RESULTS: Twenty-six procedures (24 patients) were identified. One patient required full wrist fusion following the initial procedure. Of the 25 remaining wrists, arthrodesis was successfully achieved in 20 (80 %). Eleven patients (13 wrists, 52 %) returned to clinic for an average follow-up of 28 months. Mean wrist extension improved from 30 to 47°, and flexion decreased from 33 to 23°. Average grip strength was 77 % of the uninjured side. The mean PRWE scores for pain and function were 19.7 and 17.1, respectively. Five patients underwent additional operations (two hardware removals, two contracture releases, and one distal radial ulnar joint arthroplasty). CONCLUSIONS: FCA with the Xpode® yielded reasonable results for pain and function and demonstrated a fusion rate of 80 %.

Little finger carpometacarpal arthroplasty technique and result in 3 cases.

PURPOSE: To present our surgical technique and results for the treatment of posttraumatic arthritis of the little finger carpometacarpal (CMC) joint. METHODS: We performed a retrospective review of 3 patients who underwent our surgical technique. All patients had previously sustained intra-articular fractures of the base of the little finger metacarpal and presented with painful posttraumatic arthritis of the fifth metacarpal-hamate joint. Patients were treated with little finger CMC arthroplasty and extensor carpi ulnaris suspensionplasty. RESULTS: We observed the 3 patients in the office over a mean of 21 months and by telephone for a mean for 51 months postoperatively. They had improvements in wrist motion and grip strength. Finger motion remained stable. Pain and tenderness at the little finger CMC joint were eliminated. CONCLUSIONS: Our technique provided satisfactory pain relief and motion preservation for posttraumatic arthritis of the little finger CMC joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Distal radius volar locking plate design and associated vulnerability of the flexor pollicis longus.

PURPOSE: Flexor pollicis longus (FPL) tendon rupture is a well-documented complication related to the use of distal radius volar locking plates (VLPs). The final common pathway of flexor tendon rupture appears to involve implants prominent at the watershed line. We hypothesized that significant differences in VLP prominence exist between various plate designs. METHODS: Ten fresh frozen specimens were dissected to identify the path of the FPL in relationship to the distal radius at the watershed line. Five VLP designs were fixed to each specimen based on their anatomic fit, and slid distally until the distal edge of the plate reached the watershed line. The position of each fixed plate was evaluated by fluoroscopy. We used a 3-dimensional laser scanner to create computer models. The total surface area of plate prominence volar to the watershed line and the prominent area beneath the FPL were measured in the axial plane using computer software. RESULTS: At the watershed line, the FPL was located at 54% of the maximal width of the radius, as measured from its volar-ulnar corner. There were no significant differences in the location of plate fixation on lateral view radiographs according to the classification of Soong et al. The mean total surface area of plate prominence was 36 mm(2). The mean prominent area beneath the FPL was 10 mm2. Significant differences in plate prominence were noted for various designs. CONCLUSIONS: Despite optimal plate placement, various VLP designs were observed to have prominent profiles volar to the watershed line, to varying extents. CLINICAL RELEVANCE: The results raise concerns regarding interference between all of the analyzed VLP designs and the FPL. This study may help guide both implant design considerations and assist the surgeon in better understanding implant morphology as it relates to iatrogenic flexor tendon injury.