Anatomy of the Lumbrical Muscles: Implications for Mechanical Advantage.

BACKGROUND: The lumbrical muscles comprise 4 intrinsic muscles of the hand and are involved in flexion of the metacarpophalangeal joint (MCPJ) and extension of the proximal interphalangeal and distal interphalangeal joints. The purpose of this study was to investigate the anatomical mechanics of the lumbrical muscles of the index, middle, ring, and small fingers. METHODS: We evaluated 25 cadaver arms and measured the distance between the MCPJ and fingertip, the distance between the MCPJ and lumbrical muscle insertion, and the distance between the MCPJ and the most proximal lumbrical muscle origin. With these measurements we calculated the needed force, insertion ratio (length of the proximal, middle, and distal phalanx divided by the MCPJ to insertion distance), and lumbrical muscle length. RESULTS: We found that the force was significantly different between all fingers, except for the comparison of the index and ring finger (P = .34). In addition, we found that muscle length was significantly different between most the fingers, except for the comparison between the index and middle fingers (P = .24), and index and ring fingers (P = .20). There was no significant difference in insertion ratio. CONCLUSIONS: Our study suggests that the anatomical mechanics for the motor function of the lumbrical muscles are similar in all fingers. This could further imply that movements are equally precise in all fingers resulting in coordination with one another and, therefore, adequate hand function. LEVEL OF EVIDENCE: IV.

How Does ChatGPT Use Source Information Compared With Google? A Text Network Analysis of Online Health Information.

BACKGROUND: The lay public is increasingly using ChatGPT (a large language model) as a source of medical information. Traditional search engines such as Google provide several distinct responses to each search query and indicate the source for each response, but ChatGPT provides responses in paragraph form in prose without providing the sources used, which makes it difficult or impossible to ascertain whether those sources are reliable. One practical method to infer the sources used by ChatGPT is text network analysis. By understanding how ChatGPT uses source information in relation to traditional search engines, physicians and physician organizations can better counsel patients on the use of this new tool. QUESTIONS/PURPOSES: (1) In terms of key content words, how similar are ChatGPT and Google Search responses for queries related to topics in orthopaedic surgery? (2) Does the source distribution (academic, governmental, commercial, or form of a scientific manuscript) differ for Google Search responses based on the topic's level of medical consensus, and how is this reflected in the text similarity between ChatGPT and Google Search responses? (3) Do these results vary between different versions of ChatGPT? METHODS: We evaluated three search queries relating to orthopaedic conditions: "What is the cause of carpal tunnel syndrome?," "What is the cause of tennis elbow?," and "Platelet-rich plasma for thumb arthritis?" These were selected because of their relatively high, medium, and low consensus in the medical evidence, respectively. Each question was posed to ChatGPT version 3.5 and version 4.0 20 times for a total of 120 responses. Text network analysis using term frequency-inverse document frequency (TF-IDF) was used to compare text similarity between responses from ChatGPT and Google Search. In the field of information retrieval, TF-IDF is a weighted statistical measure of the importance of a key word to a document in a collection of documents. Higher TF-IDF scores indicate greater similarity between two sources. TF-IDF scores are most often used to compare and rank the text similarity of documents. Using this type of text network analysis, text similarity between ChatGPT and Google Search can be determined by calculating and summing the TF-IDF for all keywords in a ChatGPT response and comparing it with each Google search result to assess their text similarity to each other. In this way, text similarity can be used to infer relative content similarity. To answer our first question, we characterized the text similarity between ChatGPT and Google Search responses by finding the TF-IDF scores of the ChatGPT response and each of the 20 Google Search results for each question. Using these scores, we could compare the similarity of each ChatGPT response to the Google Search results. To provide a reference point for interpreting TF-IDF values, we generated randomized text samples with the same term distribution as the Google Search results. By comparing ChatGPT TF-IDF to the random text sample, we could assess whether TF-IDF values were statistically significant from TF-IDF values obtained by random chance, and it allowed us to test whether text similarity was an appropriate quantitative statistical measure of relative content similarity. To answer our second question, we classified the Google Search results to better understand sourcing. Google Search provides 20 or more distinct sources of information, but ChatGPT gives only a single prose paragraph in response to each query. So, to answer this question, we used TF-IDF to ascertain whether the ChatGPT response was principally driven by one of four source categories: academic, government, commercial, or material that took the form of a scientific manuscript but was not peer-reviewed or indexed on a government site (such as PubMed). We then compared the TF-IDF similarity between ChatGPT responses and the source category. To answer our third research question, we repeated both analyses and compared the results when using ChatGPT 3.5 versus ChatGPT 4.0. RESULTS: The ChatGPT response was dominated by the top Google Search result. For example, for carpal tunnel syndrome, the top result was an academic website with a mean TF-IDF of 7.2. A similar result was observed for the other search topics. To provide a reference point for interpreting TF-IDF values, a randomly generated sample of text compared with Google Search would have a mean TF-IDF of 2.7 ± 1.9, controlling for text length and keyword distribution. The observed TF-IDF distribution was higher for ChatGPT responses than for random text samples, supporting the claim that keyword text similarity is a measure of relative content similarity. When comparing source distribution, the ChatGPT response was most similar to the most common source category from Google Search. For the subject where there was strong consensus (carpal tunnel syndrome), the ChatGPT response was most similar to high-quality academic sources rather than lower-quality commercial sources (TF-IDF 8.6 versus 2.2). For topics with low consensus, the ChatGPT response paralleled lower-quality commercial websites compared with higher-quality academic websites (TF-IDF 14.6 versus 0.2). ChatGPT 4.0 had higher text similarity to Google Search results than ChatGPT 3.5 (mean increase in TF-IDF similarity of 0.80 to 0.91; p < 0.001). The ChatGPT 4.0 response was still dominated by the top Google Search result and reflected the most common search category for all search topics. CONCLUSION: ChatGPT responses are similar to individual Google Search results for queries related to orthopaedic surgery, but the distribution of source information can vary substantially based on the relative level of consensus on a topic. For example, for carpal tunnel syndrome, where there is widely accepted medical consensus, ChatGPT responses had higher similarity to academic sources and therefore used those sources more. When fewer academic or government sources are available, especially in our search related to platelet-rich plasma, ChatGPT appears to have relied more heavily on a small number of nonacademic sources. These findings persisted even as ChatGPT was updated from version 3.5 to version 4.0. CLINICAL RELEVANCE: Physicians should be aware that ChatGPT and Google likely use the same sources for a specific question. The main difference is that ChatGPT can draw upon multiple sources to create one aggregate response, while Google maintains its distinctness by providing multiple results. For topics with a low consensus and therefore a low number of quality sources, there is a much higher chance that ChatGPT will use less-reliable sources, in which case physicians should take the time to educate patients on the topic or provide resources that give more reliable information. Physician organizations should make it clear when the evidence is limited so that ChatGPT can reflect the lack of quality information or evidence.

Musculoskeletal Health Worsened from Carnitine Supplementation and Not Impacted by a Novel Individualized Treadmill Training Protocol.

INTRODUCTION: Chronic kidney disease (CKD) negatively affects musculoskeletal health, leading to reduced mobility, and quality of life. In healthy populations, carnitine supplementation and aerobic exercise have been reported to improve musculoskeletal health. However, there are inconclusive results regarding their effectiveness and safety in CKD. We hypothesized that carnitine supplementation and individualized treadmill exercise would improve musculoskeletal health in CKD. METHODS: We used a spontaneously progressive CKD rat model (Cy/+ rat) (n = 11-12/gr): (1) Cy/+ (CKD-Ctrl), (2) CKD-carnitine (CKD-Carn), and (3) CKD-treadmill (CKD-TM). Carnitine (250 mg/kg) was injected daily for 10 weeks. Rats in the treadmill group ran 4 days/week on a 5° incline for 10 weeks progressing from 30 min/day for week one to 40 min/day for week two to 50 min/day for the remaining 8 weeks. At 32 weeks of age, we assessed overall cardiopulmonary fitness, muscle function, bone histology and architecture, and kidney function. Data were analyzed by one-way ANOVA with Tukey's multiple comparisons tests. RESULTS: Moderate to severe CKD was confirmed by biochemistries for blood urea nitrogen (mean 43 ± 5 mg/dL CKD-Ctrl), phosphorus (mean 8 ± 1 mg/dL CKD-Ctrl), parathyroid hormone (PTH; mean 625 ± 185 pg/mL CKD-Ctrl), and serum creatinine (mean 1.1 ± 0.2 mg/mL CKD-Ctrl). Carnitine worsened phosphorous (mean 11 ± 3 mg/dL CKD-Carn; p < 0.0001), PTH (mean 1,738 ± 1,233 pg/mL CKD-Carn; p < 0.0001), creatinine (mean 1 ± 0.3 mg/dL CKD-Carn; p < 0.0001), cortical bone thickness (mean 0.5 ± 0.1 mm CKD-Ctrl, 0.4 ± 0.1 mm CKD-Carn; p < 0.05). Treadmill running significantly improves maximal aerobic capacity when compared to CKD-Ctrl (mean 14 ± 2 min CKD-TM, 10 ± 2 min CKD-Ctrl; p < 0.01). CONCLUSION: Carnitine supplementation worsened CKD progression, mineral metabolism biochemistries, and cortical porosity and did not have an impact on physical function. Individualized treadmill running improved maximal aerobic capacity but did not have an impact on CKD progression or bone properties. Future studies should seek to better understand carnitine doses in conditions of compromised renal function to prevent toxicity which may result from elevated carnitine levels and to optimize exercise prescriptions for musculoskeletal health.

Cause of Extensor Pollicis Longus Ruptures After Distal Radius Fracture Fixation Using a Volar Plate.

BACKGROUND: This research sought to analyze a cohort of patients with extensor pollicis longus (EPL) ruptures after volar locked plating of a distal radius fracture (DRF) to characterize the incidence of ruptures that are unlikely to be related to dorsal screw prominence. METHODS: This is a retrospective, observational, descriptive cohort study of adults with operative fixation of a closed DRF and an EPL rupture between 2002 and 2022. Eighteen patients with operative fixation using a volar plate of a closed DRF had an EPL rupture. The cohort consisted of 66% women with an average age of 57.5 years. Median follow-up was 14.5 months. RESULTS: The incidence of EPL rupture was 0.4% (18/4768). The average time from DRF and DRF fixation to EPL rupture was 3.7 and 3.4 months, respectively. Based on the operative record, in 2 of the 18 patients (11%), the rupture was directly attributable to prominent hardware; however, in 4 of the 18 patients (22%), the rupture was not related to prominent hardware, and the cause was indeterminate in 12 patients (67%). Radiologic analysis of those in the indeterminate group demonstrated that 5 of the 12 patients had screws that had a high probability of being prominent. CONCLUSIONS: The incidence of EPL rupture after volar plating of DRF is between 0% and 1% and usually occurs about 3 months after fixation. Approximately 50% of EPL ruptures are attributable to prominent dorsal screws. Although screw prominence is an important cause of EPL rupture, it is not the sole cause of rupture.

Complications and Unplanned Reoperation After Thumb Metacarpophalangeal Arthrodesis.

PURPOSE: Arthrodesis of the metacarpophalangeal (MCP) joint of the thumb is a common procedure to treat arthritis or instability. Studies reporting hardware complications and nonunion rates after thumb MCP joint arthrodesis report on small sample sizes. We aimed to describe the hardware complication rate, the nonunion rate, and the number of thumbs that achieve union among patients undergoing thumb MCP joint arthrodesis. METHODS: A database spanning 5 urban hospitals in a single metropolitan region in the United States was searched for patients who underwent thumb MCP joint arthrodesis between January 1, 2004 and January 1, 2020. After reviewing patient records, we identified 122 thumbs that underwent MCP joint arthrodesis and had a minimum follow-up of 90 days. The primary outcome was unplanned reoperation after hardware complications and nonunion. Second, the number of thumbs that achieved radiographic union was reported for the tension band and screw fixation arthrodesis group. RESULTS: Twenty-two (18%) out of 122 thumbs had hardware complications after thumb MCP joint arthrodesis, and 11 (9%) out of 122 thumbs developed a nonunion. Patients who underwent screw fixation arthrodesis had no events of hardware complications and subsequent hardware removal. The nonunion rate was 9/65 (14%) in the tension band arthrodesis group and 2 (4%) of 45 in the screw fixation arthrodesis group. Of the thumbs that had available radiographs to assess the healing of the arthrodesis, 34 (81%) of 42 were radiographically united in the tension band arthrodesis group and 29 (91%) of 32 in the screw fixation group. CONCLUSIONS: Our data suggest that screw fixation has fewer hardware complications and a lower reoperation rate than tension band arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis.

BACKGROUND: The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR. METHODS: The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire. RESULTS: A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery. CONCLUSION: Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

The Dietary Fiber Inulin Slows Progression of Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) in a Rat Model of CKD.

Chronic kidney disease (CKD)-mineral bone disorder (CKD-MBD) leads to fractures and cardiovascular disease. Observational studies suggest beneficial effects of dietary fiber on both bone and cardiovascular outcomes, but the effect of fiber on CKD-MBD is unknown. To determine the effect of fiber on CKD-MBD, we fed the Cy/+ rat with progressive CKD a casein-based diet of 0.7% phosphate with 10% inulin (fermentable fiber) or cellulose (non-fermentable fiber) from 22 weeks to either 30 or 32 weeks of age (~30% and ~15% of normal kidney function; CKD 4 and 5). We assessed CKD-MBD end points of biochemistry, bone quantity and quality, cardiovascular health, and cecal microbiota and serum gut-derived uremic toxins. Results were analyzed by two-way analysis of variance (ANOVA) to evaluate the main effects of CKD stage and inulin, and their interaction. The results showed that in CKD animals, inulin did not alter kidney function but reduced the increase from stage 4 to 5 in serum levels of phosphate and parathyroid hormone, but not fibroblast growth factor-23 (FGF23). Bone turnover and cortical bone parameters were similarly improved but mechanical properties were not altered. Inulin slowed progression of aorta and cardiac calcification, left ventricular mass index, and fibrosis. To understand the mechanism, we assessed intestinal microbiota and found changes in alpha and beta diversity and significant changes in several taxa with inulin, together with a reduction in circulating gut derived uremic toxins such as indoxyl sulfate and short-chain fatty acids. In conclusion, the addition of the fermentable fiber inulin to the diet of CKD rats led to a slowed progression of CKD-MBD without affecting kidney function, likely mediated by changes in the gut microbiota composition and lowered gut-derived uremic toxins. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

DRUJ Capsular Release for Forearm Rotational Limitation: Surgical Technique and Case Series.

BACKGROUND: Forearm stiffness can be caused by distal radioulnar joint (DRUJ) capsular contractures, which can occur after trauma such as a distal radius fracture. In this setting, a DRUJ capsular release may help improve forearm rotation, but the long-term functional outcomes remain unknown. The purpose of this case series is to investigate the short-term improvement in total pronosupination arc range of motion and long-term patient-reported outcomes (PROs) after DRUJ capsular release. METHODS: We performed a retrospective review of consecutive patients who underwent DRUJ capsular release. Range of motion prior to surgery and at final short-term follow-up was collected and analyzed with a Wilcoxon signed-rank test. Patient-reported outcomes including QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores were obtained as medians with interquartile range (IQR), while patient satisfaction was measured on a 4-point Likert scale. RESULTS: Five patients met the inclusion criteria with a median short-term follow-up of 5.5 (IQR: 4.3-10.3) months. The median preoperative supination was 25° (IQR: 0°-35°), and the median postoperative supination was 50° (IQR: 40°-60°; P = .03). The median preoperative pronation was 45° (IQR: 10°-60°), and the median postoperative pronation was 70° (IQR: 60°-80°; P = .04). After the long-term median follow-up of 10.9 (IQR 9.7-11.2) years, all the patients were satisfied or very satisfied with the results of the surgery. The median QuickDASH score was 13.6 (IQR: 9.1-20.5), and the median PROMIS UE score was 46.5 (IQR: 43.8-47.7). CONCLUSIONS: Distal radioulnar joint capsular release can improve pronation and supination in patients with posttraumatic forearm stiffness and is associated with high long-term patient satisfaction.

Arthroscopic-Assisted Fracture Fixation About the Elbow.

Arthroscopic-assisted fracture fixation can be used for some adult elbow fractures. In particular, for articular fractures of the anterior elbow (coronoid/capitellum), elbow arthroscopy can provide excellent visualization of fracture fragments using a less invasive surgical exposure. Meticulous adherence to safe techniques and utilization of specialized equipment can help maximize safety and facilitate reproducible surgical results.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Operative Trends in Orthopaedic Hand Surgery Fellowships.

Objective Since 1958, more than 50 postresidency fellowship programs in hand surgery have been introduced within the United States. Ongoing changes in health care and medical education necessitate the evaluation of these fellowships. The purpose of this study is to identify trends in operative experience over time regarding procedure volume, surgery type, and anatomic region. Materials and Methods National Accreditation Council for Graduate Medical Education (ACGME) case logs of graduating orthopaedic hand surgery fellows were evaluated for years 2011 to 2019. Procedures were grouped according to ACGME-defined categories for hand surgery. The mean number of procedures per fellow in each category was trended over time using a Mann-Kendall test. Results All 1,257 fellows were included. The mean number of procedures completed annually by each fellow increased from 797.6 in 2011 to 945.6 in 2019 ( p < 0.01). Over the course of the study period, there were increases in the number of "soft tissue," "fracture," and "nerve" procedures ( p < 0.001), while the number of "congenital" procedures decreased ( p < 0.05). Additionally, small but statistically significant increases were found in "amputation," "Dupuytren's," and "decompression of tendon sheath/synovectomy/ganglions" procedures ( p < 0.01). Conclusion There has been an increase in the number of procedures performed by orthopaedic hand surgery fellows over the past decade. This appears to be due to the increase in nerve, fracture, and soft tissue categories, and there has been a decrease in the number of congenital cases completed. These data confirm that the operative experiences for most hand surgery fellows are robust and growing over time.

Quantitative 3-D CT Demonstrates Distal Row Pronation and Translation and Radiolunate Arthritis in the SNAC Wrist.

BACKGROUND: In scaphoid nonunion advanced collapse (SNAC) wrist arthritis, we analyzed the 3-dimensional (3-D) deformity patterns of carpal alignment secondary to scaphoid nonunion and quantified subchondral arthritis by investigating alterations in bone density. METHODS: We constructed 3-D models of the carpal bones and radius from 51 patients with scaphoid nonunion (nonunion group) and 50 healthy controls (control group). We quantified the differences in 3-D geometric position of the distal carpal row relative to the distal radius in SNAC wrists versus controls. In addition, we assessed the bone density of anatomic regions of interest in the radiocarpal and capitolunate joints relative to the pisiform bone density to characterize degenerative changes in SNAC wrists. RESULTS: The distal carpal row pronated by a difference of 14° (7.2° versus -6.7°; p < 0.001), deviated ulnarly by a difference of 19° (7.7° versus -11.2°; p < 0.001), shifted dorsally by a difference of 17% of the dorsovolar width of the distal radius (21.0% versus 4.4%; p < 0.001), shifted radially by a difference of 8% of the radioulnar width of the distal radius (13.2% versus 5.3%; p < 0.001), and migrated proximally by a difference of 12% of the lunate height (96.3% versus 108.8%; p < 0.001) in the nonunion group compared with the control group. Additionally, it was found that bone density was greater at the capitolunate joint (capitate head: 140.4% versus 123.7%; p < 0.001; distal lunate: 159.9% versus 146.3%; p < 0.001), the radial styloid (157.0% versus 136.3%; p < 0.001), and the radiolunate joint (proximal lunate: 134.8% versus 122.7%; p < 0.001; lunate fossa: 158.6% versus 148.1%; p = 0.005) in the nonunion group compared with the control group. CONCLUSIONS: Scaphoid nonunion exhibited a unique deformity pattern and alteration in bone-density distributions. The distal carpal row not only shifted dorsally and migrated proximally but also pronated, deviated ulnarly, and shifted radially. Bone density was greater at the capitolunate joint, the radial styloid, and surprisingly, the radiolunate joint. Our findings give insight into the natural history and progression of arthritis of the SNAC wrist. Additionally, future studies may give insight into whether successful treatment of scaphoid nonunion arrests the progression of arthritis. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Revision Arthroplasty in the Challenging Elbow.

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA) has a higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty.

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty.

Background Higher rates of prolonged opioid use have been reported in patients who undergo thumb carpometacarpal (CMC) arthroplasty compared with other hand procedures. Therefore, the aim of this study is to identify the risk factors associated with prolonged postoperative opioid use after CMC arthroplasty, along with reporting the number of patients who filled an opioid prescription more than 30 days postoperatively. Materials and Methods Retrospectively, 563 opioid-naïve patients who underwent CMC arthroplasty were included. A manual chart review was performed to collect patient characteristics, and opioid use was determined based on opioid prescription by a physician. Prolonged opioid use was defined as an opioid prescription at 90 to 180 days postoperatively. A multivariable analysis was performed to identify independent factors associated with an opioid prescription at 90 to 180 days postoperatively. Patients had a median age of 60.4 years (interquartile range [IQR]: 55.5-66.9) and had a median follow-up of 7.6 years (IQR: 4.3-12.0). Results The rates of postoperative opioid use ranged from 6.2% (53 out of 563 patients) at 30 to 59 days postoperatively to 3.9% (22 out of 563 patients) at 150 to 180 days postoperatively. In total, 17.1% (96 out of 563 patients) received a second opioid prescription more than 30 days following surgery, of which 10.8% (61 out of 563 patients) were between 90 and 180 days postoperatively. Older age, defined as a median of 63 years (IQR: 57.10-69.88) ( p = 0.027, odds ratio [OR] = 1.04) and a history of psychiatric disease ( p = 0.049, OR = 1.86) were independently associated with prolonged opioid use. Conclusion A prolonged opioid use rate of roughly 11% was found in opioid-naïve patients who underwent CMC arthroplasty. In patients at risk (older patients or psychiatric history) of prolonged opioid use, careful postoperative pain management is recommended.

Outcomes of Flexor Pollicis Longus Reconstruction for Volar Plate Related Ruptures.

Aim A rare complication following volar plate fixation of a distal radius fracture is flexor pollicis longus (FPL) rupture. This study aims primarily to analyze the radiographic features and secondly to report the patient-reported outcomes of FPL reconstruction after volar plate fixation. Methods Ten patients were retrospectively identified and contacted for follow-up. Seven patients participated in the study and completed the numeric rating scale (NRS) for pain, patient-reported outcome measurement information system-upper extremity (PROMIS-UE), and quick disability of arm, shoulder, and hand (QuickDASH) questionnaires at a median of 3.4 years following FPL reconstruction. Soong grade was determined on preoperative radiographs. Results Six patients were classified as Soong grade 1 and two patients had a screw or wire protruding volarly. The median time to tendon rupture was 21.6 months. At final follow-up, the median NRS pain score was 0 (range: 0-7); the median PROMIS-UE score was 47.1 (range: 25.9-61); and the median QuickDASH-score was 12.5 (range: 4.5-75). Conclusions The outcome of FPL reconstruction after volar plate fixation is highly variable. All ruptures in our cohort occurred in patients with plate positioning classified as Soong grade 1 and occurred at up to 3 years following distal radius fixation.

Reintervention, PROMs, and Factors Influencing PROMs Following Surgery for de Quervain's Tenosynovitis.

Objective The aims of this study are to describe and identify the factors that influence patient reported outcomes following surgery of de Quervain's tenosynovitis. The secondary objective is to report the rate of reintervention following surgery of de Quervain's tenosynovitis. Patients and Methods Outcomes using the numerical rating scale (NRS) for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Rated Wrist Evaluation (PRWE), the Patients Reported Outcome Measurement Information System Pain Interference (PROMIS PI), and a custom de Quervain's questionnaire were obtained. A multivariable linear regression analysis was performed to identify independent factors associated with patient-reported outcomes. Results Seventy-six patients who underwent de Quervain's release participated. The average age was 52.8 years (95% confidence interval: 49.6-56.1) and median follow-up age was 7.0 years (interquartile range [IQR]: 4.3-12.0). Outcomes were: NRS of pain was 0 (IQR: 0.0-3.0), the median QuickDASH was 6.82 (IQR: 0.00-28.41), the median PRWE score was 4.0 (IQR: 0.00-18.50), and the median PROMIS PI score was 43.90 (IQR: 38.70-53.90). Eighteen (23.7%) of the patients reported pain with thumb activities, four of whom had a reintervention. Additionally, 21 (26.9%) patients reported decreased strength in the thumb compared to the contralateral side, of which two underwent a reintervention. In total, eight patients underwent reintervention of which seven had a second surgery and one had a cortisone injection. Conclusion Roughly 1 in 20 patients following de Quervain's release undergoes reintervention. Patients with high PROMIS PI scores report poor surgical outcomes more frequently. Patients with high PROMIS PI scores report higher NRS pain scores ( p < 0.05), higher QuickDASH scores ( p < 0.05), and higher PRWE scores ( p < 0.05). In practice, careful consideration of PROMIS PI scores and psychosocial factors are recommended before considering reintervention.

Functional outcomes and complications after treatment of distal radius fracture in patients sixty years and over: A systematic review and network meta-analysis.

AIM: This network meta-analysis aims to compare functional outcomes and complications between conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. METHODS: We searched the PubMed, EMBASE, and Web of Science databases for randomized controlled trials (RCTs) assessing the effect of conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. Primary outcomes included grip strength and overall complications. Secondary outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Patient-Rated Wrist Evaluation (PRWE) scores, wrist range of motion and forearm rotation, and radiographic assessment. All continuous outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and binary outcomes were assessed using odds ratio (OR) with 95% CIs. The surface under the cumulative ranking curve (SUCRA) was used to determine a hierarchy of treatments. Cluster analysis was performed for grouping treatments based on the SUCRA values of primary outcomes. RESULTS: Fourteen RCTs were included to compare conservative treatment, volar lockedplate (VLP), K-wires fixation, and external-fixation. VLP outperformed conservative treatment for 1-year and minimum 2-year grip strength (SMD; 0.28 [0.07 to 0.48] and 0.27 [0.02 to 0.53], respectively). VLP yielded the optimal grip strength at 1-year and minimum 2-year follow-up (SUCRA; 89.8% and 86.7%, respectively). In a subgroup analysis of patients aged 60 to 80 years old, VLP outperformed conservative treatment in DASH and PRWE scores (SMD, 0.33 [0.10, 0.56] and 0.23 [0.01, 0.45], respectively). In addition, VLP had the fewest complications (SUCRA = 84.3%). Cluster analysis suggested that VLP and K-wire fixation were more effective treatment groups. CONCLUSION: Evidence to date demonstrates that VLP provides measurable benefits in grip strength and fewer complications to those 60 years of age and over, and that benefit is not reflected in current practice guidelines. There is a subgroup of patients where K-wire fixation outcomes are similar to those of VLP; defining this subgroup may yield substantial societal benefits.

Assessing cortical bone porosity with MRI in an animal model of chronic kidney disease.

Chronic kidney disease (CKD) is characterized by secondary hyperparathyroidism and an increased risk of hip fractures predominantly related to cortical porosity. Unfortunately, bone mineral density measurements and high-resolution peripheral computed tomography (HR-pQCT) imaging have shortcomings that limit their utility in these patients. Ultrashort echo time magnetic resonance imaging (UTE-MRI) has the potential to overcome these limitations by providing an alternative assessment of cortical porosity. The goal of the current study was to determine if UTE-MRI could detect changes in porosity in an established rat model of CKD. Cy/+ rats (n = 11), an established animal model of CKD-MBD, and their normal littermates (n = 12) were imaged using microcomputed tomography (microCT) and UTE-MRI at 30 and 35 weeks of age (which approximates late-stage kidney disease in humans). Images were obtained at the distal tibia and the proximal femur. Cortical porosity was assessed using the percent porosity (Pore%) calculated from microCT imaging and the porosity index (PI) calculated from UTE-MRI. Correlations between Pore% and PI were also calculated. Cy/+ rats had higher Pore% than normal rats at both skeletal sites at 35 weeks (tibia = 7.13 % +/- 5.59 % vs. 0.51 % +/- 0.09 %, femur = 19.99 % +/- 7.72 % vs. 2.72 % +/- 0.32 %). They also had greater PI at the distal tibia at 30 weeks of age (0.47 +/- 0.06 vs. 0.40 +/- 0.08). However, Pore% and PI were only correlated in the proximal femur at 35 weeks of age (ρ = 0.929, Spearman). These microCT results are consistent with prior studies in this animal model utilizing microCT imaging. The UTE-MRI results were inconsistent, resulting in variable correlations with microCT imaging, which may be related to suboptimal bound and pore water discrimination at higher magnetic field strengths. Nevertheless, UTE-MRI may still provide an additional clinical tool to assess fracture risk without using ionizing radiation in CKD patients.