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.

Efficacy and Safety of Oral Tranexamic Acid vs. Other Routes in Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Total joint arthroplasty (TJA) is often associated with significant blood loss, leading to complications such as acute anemia and increased risk of infection and mortality. Tranexamic acid (TXA), an antifibrinolytic agent, has been recognized for effectively reducing blood loss during TJA. This systematic review and network meta-analysis aims to evaluate the efficacy and safety of oral TXA compared with other administration routes in TJA. METHODS: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, Embase, and Web of Science, focusing on randomized clinical trials involving oral TXA in TJA. The studies were assessed for quality using the Cochrane risk assessment scale. Data synthesis involved network meta-analyses, comparing outcomes including hemoglobin drop, estimated blood loss (EBL), transfusion rate, and deep vein thrombosis (DVT) rate. RESULTS: Our comprehensive literature search incorporated 39 studies with 7,538 participants, focusing on 8 TXA administration methods in TJA. The combination of oral and intra-articular (oral + IA) TXA markedly reduced hemoglobin drop more effectively than oral, intravenous (IV), and IA alone, but the difference was not significant. Oral + IA TXA significantly reduced EBL more effectively than oral + IV, IA + IV, and oral, IV, and IA alone. Perioperative transfusion rates with oral + IA TXA was significantly lower than that of oral, IA, and IV alone. The DVT rate with oral + IA was significantly lower than that with all other routes, including oral + IV, IA + IV, and oral, IA, and IV alone. CONCLUSION: Oral TXA, particularly in combination with IA administration, demonstrates significantly higher efficacy in reducing blood loss and transfusion rates in TJA, with a safety profile comparable with that of other administration routes. The oral route, offering lower costs and simpler administration, emerges as a viable and preferable option in TJA procedures. LEVEL OF EVIDENCE: Level I. See Instructions for Authors for a complete description of levels of evidence.

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.

Effectiveness of Arthroscopic Debridement, Trapeziectomy, and Joint Replacement for Trapeziometacarpal Joint Osteoarthritis: A Meta-Analysis of Pre and Postoperative Pain Scores.

Trapeziometacarpal joint osteoarthritis (TMJO) affects up to 33% of postmenopausal women, leading to pain, reduced mobility, and grip strength, with initial treatments focusing on non-surgical options like injections, orthoses, and exercises before considering surgery. A major challenge in managing TMJO involves selecting the optimal surgical strategy that is customized to individual clinical conditions. This study aimed to compare the effectiveness of three common surgical interventions for TMJO in relieving pain, including arthroscopic debridement (AD), trapeziectomy (TRAP), and joint replacement (JR). PubMed, Cochrane, Embase, and MEDLINE databases were queried according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies that presented pain outcomes following intervention for TMJO. Pain scores were reported preoperatively and postoperatively using the visual analog scale (VAS). Inclusion criteria included studies published in Q1 and Q2 journals and those with a follow-up of > six months. The final selection comprised 18 studies with 763 patients treated with AD (n = 102, 13%), TRAP (n = 428, 56%), and JR (n = 233, 31%) between 2010 and 2023, with a mean follow-up period of 38 ± 28 months. The studies included a total of 24 groups, five of which received AD, 13 of which received TRAP, and six of which received JR. The mean preoperative VAS was 6.7 ± 1.7, and the mean postoperative VAS was 1.7 ± 1.3 for all groups (P < 0.001). The meta-analysis demonstrated a mean preoperative pain score of 5.8 (95% CI, 4.1-7.5) for AD, 6.6 (95% CI, 5.7-7.5) for TRAP, and 7.8 (95% CI, 7.0-8.7) for JR. Postoperatively, there was a mean pain score of 2.2 (95% CI, 0.1-4.2) for AD, 1.4 (95% CI, 1.1-1.7) for TRAP, and 0.9 (95% CI, 0.6-1.2) for JR. This study showed that, if appropriately indicated, joint preservation with AD may be as effective as TRAP and JR for reducing pain associated with TMJO in the short term. However, the rate of conversion or revision should be assessed in future studies.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study.

Background Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Nonunion After Using Procedure-Specific Instrumentations for Ulnar Shortening Osteotomy.

Objectives: The primary purpose of this study was to compare the rates of nonunion among different osteotomy designs (company brand) and the rates of nonunion between oblique and transverse osteotomies. We secondarily aimed to assess the differences in reoperation and hardware removal rates after ulnar shortening osteotomy (USO). Methods: A retrospective cohort study of patients undergoing ulnar shortening osteotomy between 2015 and 2022 in our institute amongst 17 providers resulted in 92 consecutive patients. We included skeletally mature patients who underwent USO for the ulnar impingement abutment diagnosis. Demographic information was collected, including age, gender, race/ethnicity, BMI, and medical comorbidities. Six brand-specific devices were used and compared to the conventional plate fixation. Nonunion was determined based on the final available radiograph with a minimum follow-up of four months. Results: Of the 92 patients, 83 (90%) had a bone union. There is a remarkable difference in union among implant brands, although statistical analysis was not performed due to the small number of patients in each group. Transverse osteotomy was significantly related to a higher nonunion rate. Out of nine patients with resultant nonunion (10%), three healed after revision surgery (3.2%), two were lost to follow-up (2.2%), and four remained asymptomatic despite radiographic nonunion (4.6%). Plate removal was performed in four patients (4.3%), all of whom were in the union group. Conclusion: Patients should be informed about the nonunion rate with possible subsequent secondary surgery. Using procedure-specific devices may have mitigated the risk of nonunion.

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.

Is there any advantage between using continuous passive motion and conventional physical therapy in patients with primary adhesive capsulitis?: A systematic review and meta-analysis.

BACKGROUND: We are unsure if continuous passive motion (CPM) has any role in the nonoperative management of the Primary Stiff Shoulder (frozen shoulder). We hypothesized that there is no difference in pain improvement, range of motion, and function with or without CPM in patients with a primary stiff shoulder. METHOD: We searched the databases for clinical trials comparing CPM versus no-CPM physiotherapy. In the final step, we reviewed five randomized clinical trials. We collected the data of Constant Shoulder Score (CSS), the visual analog scale of pain, shoulder pain and disability index (SPADI), and range of motion (flexion, abduction, external and internal rotation). We used a random-effects model to analyze the data. RESULTS: Five studies with a total of 224 patients were included. There were 113 patients in the CPM arm and 111 in the control arm. Both the CPM and control groups showed significant improvements in all measured parameters compared to the first visit after 8-24 weeks. Meta-analysis of pooled data showed significant differences in pain improvement, forward flexion, and CSS favoring the CPM. Still, there was no significant difference in abduction, external and internal rotation, and SPADI. DISCUSSION: The CPM seems to be slightly effective in improving pain and motion in the short term, but its long-term efficacy is still under question. The extra cost and time must be considered when offering the CPM.

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.

Arthroscopic Capsular Release for Post-traumatic Elbow Stiffness.

BACKGROUND: Post-traumatic elbow stiffness (PTES) may substantially affect the patient's functional range of motion and quality of life. Open elbow release has been extensively studied, but arthroscopic techniques are limited, particularly in differentiating between post-traumatic and non-traumatic stiffness. The purpose of this study is to assess the clinical outcomes after arthroscopic release of PTES regarding the range of motion (ROM), pain, functional assessment, and complications. METHODS: A prospective cohort was conducted on adult patients who underwent arthroscopic arthrolysis for PTES, with 32 patients included in the final analysis. The ROM was measured using the orthopedic goniometer. Grip strength was measured using the Camry digital hand dynamometer (Camry, CA, USA) and compared to their contralateral side. The functional status of the patients was evaluated using the American Shoulder and Elbow Surgeons Score (ASES)andthe Mayo Elbow Performance Index (MEPI). All measurements were done before surgery and at the last follow-up visit. Pre-operative and post-operative changes in MEPI, ASES, and visual analog (VAS) scores were compared with the paired t-test. RESULTS: After surgery, the ROM significantly improved from 74 ± 11 to 110 ± 15 degrees (p<0.001). Additionally, the ASES score and MEPI index both significantly improved from 69 ± 3.4 to 79 ± 6.3 and from 64 ± 5.7 to 82 ± 8, respectively (p<0.001). VAS scores also significantly improved from 1.1 ± 0.87 to 0.31 ± 0.53 at rest (p<0.001). The complication rate was 12%, including three transient ulnar nerve paresthesia and one superficial infection. Post-traumatic elbow release was more offered in distal humerus fractures (53%), followed by proximal ulna fracture/dislocations (25%). CONCLUSION: We believe that arthroscopic arthrolysis is a safe and reliable treatment of PTES, which improves joint visibility and reduces pain. Patients can be counseled regarding the risk of a secondary surgery following distal humerus or proximal ulna fractures, including the expected recovery and complication rate.

Sliding Plate System: A Novel Method and Device for Shortening Osteotomy.

We report a novel sliding plate system (SPS) and its application for radial shortening osteotomy. We conceptualised, designed and introduced the SPS, which helps with precise shortening osteotomy in both radius and ulna. We implanted the SPS in a patient with Kienböck disease following a radius shortening osteotomy. The SPS was safe and efficient, and the surgical technique eliminated extra steps. The SPS affords precise shortening, optimum compression and anatomic alignment after radius shortening osteotomy. Level of Evidence: Level V (Therapeutic).

The second clinical study investigating the surgical method for the kineticomyographic control implementation of the bionic hand.

In 2018, during our first clinical study on the kineticomyographic (KMG)-controlled bionic hand, we implanted three magnetic tags inside the musculotendinous junction of three paired extensor-flexor transferred tendons. However, the post-operative tissue adhesions affected the independent movements of the implanted tags and consequently the distinct patterns of the obtained signals. To overcome this issue, we modified our surgical procedure from a one-stage tendon transfer to a two-stage. During the first surgery, we created three tunnels using silicon rods for the smooth tendon gliding. In the second stage, we transferred the same three pairs of the forearm agonist-antagonist tendons through the tunnels and implanted the magnetic tags inside the musculotendinous junction. Compared to our prior clinical investigation, fluoroscopy and ultrasound evaluations revealed that the surgical modification in the current study yielded more pronounced independent movements in two specific magnetic tags associated with fingers (maximum 5.7 mm in the first trial vs. 28 mm in the recent trial with grasp and release) and thumb (maximum 3.2 mm in the first trial vs. 9 mm in the current trial with thumb flexion-extension). Furthermore, we observed that utilizing the flexor digitorum superficialis (FDS) tendons for the flexor component in finger and thumb tendon transfer resulted in more independent movements of the implanted tags, compared with the flexor digitorum profundus (FDP) in the prior research. This study can help us plan for our future five-channel bionic limb design by identifying the gestures with the most significant independent tag displacement.

Elbow Arthroplasty: A Concise Literature Update.

Total elbow arthroplasty (TEA) is increasingly used, especially in patients with rheumatoid arthritis (RA) and distal humerus fractures (DHFs). This narrative review of the recent literature published in 2022 reached the following conclusions: 1) Age greater than 80 is not a contraindication for TEA. 2) The estimated 10-year survival reported for linked TEAs is 92%, and unlinked TEAs 84%. 3) For DHFs in the elderly, regarding the flexion/extension arc, TEA gives substantially better results than open reduction and internal fixation (ORIF). The reoperation and elbow stiffness rates are substantially lower in TEA than in ORIF. 4) Comparing distal humeral hemiarthroplasty (DHH) vs. TEA in individuals over 65 years with a non-reconstructable DHF favors DHH regarding the range of motion but with a similarly high rate of adverse events in the two surgical techniques. 5) The rate of eradication of periprosthetic joint infection (PJI) is 69-76% with two-stage, 71% with resection arthroplasty, 67% with one-stage, 58% with DAIR, and 40% with elbow arthrodesis.

Short- to Mid-term Results of Patient-Specific Polymethylmethacrylate Radial Head Prosthesis in Complex Radial Head Fractures Using 3-Dimensional Mold System.

Background: We used antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement to make a patient-specific radial head prosthesis (RHP) by applying the 3-dimensional (3D) designing technique in patients with Mason types 3 and 4 radial head fractures. The aim of this study is to report the short- to mid-term outcomes of this procedure. Methods: This is a prospective study of all patients who underwent a patient-specific PMMA bone cement RHP at our institute over a 1-year period from May 2017 to June 2018. The outcome measures included range of motion, grip strength, visual analogue scale (VAS) for pain at rest and at activity, disabilities of arm, shoulder and hand (DASH) score and Mayo elbow performance index (MEPI). Radiographs of the elbow ere obtained at final follow-up and any complications were also recorded. Results: Our study included eight patients with a mean follow-up of 18 months (13-20 months). The mean arc of extension-flexion and supination-pronation of the operated side was 86% and 96% of the unaffected side, respectively. Mean grip strength was 86% of the unaffected side. The mean VAS for pain at rest was 0 and during activity was 2 out of 10. The mean DASH score was 8 out of 100 (0-22), showing minimal disability and ability to cope with most living activities. MEPI showed four excellent, three good and one fair result. One patient complained of proximal forearm pain that appeared 1 year after surgery. No patient complained of ulnar nerve symptoms requiring intervention. No RHP was removed during the follow-up. Conclusions: PMMA RHP can be used safely as an alternative to metal prostheses to restore valgus and axial stability of the forearm. The use of 3D printing optimised the design and surgical technique of radial head arthroplasty, and we need further studies to assess the long-term follow-ups. Level of Evidence: Level IV (Therapeutic).

Abnormal Patterns of Biceps and Triceps Co-Contraction Following Elbow Surgery May Result in Elbow Stiffness.

Objectives: This study examines the pattern of muscular contraction and the intensity of this contraction of the biceps and triceps following elbow surgery. Methods: We performed a prospective electromyographic study of 16 patients undergoing 19 surgical procedures on the elbow joint. We measured the resting EMG signal intensity of the biceps and triceps of the operated and the normal sides at 90 degrees. We then calculated the peak EMG signal intensity during passive elbow flexion and extension of the operated side. Results: Seventeen of 19 elbows (89%) displayed a co-contraction pattern of the biceps and triceps near the end of flexion and extension during the passive range of motion. The co-contraction pattern was observed near the end of the range of motion in both flexion and extension. In addition to the observed co-contraction patterns, we detected higher contraction intensities for the biceps and triceps muscles in all patients in both flexion and extension for the elbows, which had been treated surgically. Further analysis suggests an inverse correlation between the biceps contraction intensity and the arc of motion measured at the latest follow-up. Conclusion: The co-contraction pattern and increased contraction intensity of periarticular muscle groups may result in internal splinting mechanisms, contributing to the development of elbow joint stiffness, which is frequently observed following elbow surgery.

Effectiveness of physiotherapy plus acupuncture compared with physiotherapy alone on pain, disability and grip strength in people with carpal tunnel syndrome: A randomized clinical trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome in the upper extremities. Acupuncture is often used as a treatment method in CTS and numerous studies consider it effective. However, no study has yet compared the efficacy of physical therapy including bone and neural mobilization, exercise and electrotherapy with and without acupuncture in CTS patients. PURPOSE: comparing the effect of physiotherapy plus acupuncture with physiotherapy alone on pain, disability and grip strength in CTS patients. METHOD: Forty patients with mild to moderate CTS were randomly divided into two equal groups. Both groups received exercise and manual techniques for 10 sessions. Patients in the physiotherapy plus acupuncture group also received 30 min of acupuncture in every session. The visual analog scale (VAS) score, the score on the Boston carpal tunnel questionnaire for functional status and symptom severity, shortened disability of arm, shoulder, hand (Quick-DASH) score and grip strength were evaluated at pre-test and post-test. RESULTS: According to ANOVA results, there is a significant interaction between group and time for VAS, BCTQ and Quick-DASH parameters. At the post-test, while the parameters of VAS, BCTQ and Quick-DASH in the physiotherapy plus acupuncture group had a statistically significant difference compared to the physiotherapy group, no significant difference was observed between the two groups in the pre-test. Moreover, there is no significant difference between groups in grip strength improvement. CONCLUSION: This study shows preliminary evidence that physiotherapy plus acupuncture, was more effective than physiotherapy alone in pain relief and improving disability of patients suffering from CTS.

Total Wrist Arthrodesis: An Update on Indications, Technique and Outcomes.

Painful end-stage wrist osteoarthritis (OA) unresponsive to conservative treatment is frequently managed with total wrist arthrodesis (TWA), which might render pain alleviation and ameliorate function, pain, and grip strength. Usual indications for TWA include inflammatory arthritis, idiopathic degenerative OA and posttraumatic OA, Kienböck's illness, brachial plexus palsy, cerebral paralysis, infraclavicular brachial plexus blocks and other spastic and contracture base illnesses, scapholunate advanced collapse, scaphoid nonunion advanced collapse, and failure of other surgical techniques such as after failed total wrist arthroplasty, four-corner fusion, proximal row carpectomy and severe ligament injuries (this procedure is carried out when all other treatment alternatives have failed to control the individual's symptoms). TWA is commonly carried out with a dorsal plate fixed from the distal radius to the third metacarpal. However, other surgical procedures have been reported, including intramedullary fixation and new implants that do not cross the third carpometacarpal joint or some procedures without utilizing hardware for example using a vascularized fibular grafting In individuals with rheumatoid arthritis. TWA has been shown to give persistent and painless stability for 20 years or more. The rate of adverse events for TWA ranges from 0.1% to 6.1%, though some authors have published that it can be as high as 27%. The most common adverse events are tendon ruptures, peri-implant fractures of the third metacarpal, the need for hardware removal, and constant pain at the third carpometacarpal joint. In idiopathic degenerative OA, the reoperation rate following TWA has been reported as high as 63%. While TWA can render foreseeable pain alleviation and ameliorate function, orthopedic surgeons should remember that this surgical technique is not without its risks and that the accessibility of many surgical procedures requires orthopedic surgeons to scrupulously contemplate the risks and benefits of each alternative for the individual in front of them.

The effect of outpatient web-based online scheduling versus traditional staff scheduling systems on progression to surgery and no-show rates.

Background: This study aimed to compare the rate of scheduled surgery and no-show rates between online-scheduled appointments and traditionally scheduled appointments. Materials and Methods: All scheduled outpatient visits at a single large multi-subspecialty orthopedic practice in three U.S. states (PA, NJ, and NY) were collected from February 1, 2022, to February 28, 2022. Visits were categorized as "online-scheduled" or "traditionally scheduled" and then further grouped as "no-show," "canceled," or "visited." Finally, visits were categorized as either "new patient" or "follow-up." Results: There was no significant difference between scheduling systems for patient progression to any procedure within 3 months of the initial visit (P = 0.97) and patient progression for surgery only within 3 months of the initial visit (P = 0.88). However, we found a significant difference with a higher rate of progression to surgery in traditionally scheduled than online-scheduled visits when accounting for only new patient visits that progressed to surgery within 3 months of the initial encounter (P = 0.036). No-show rates between scheduling systems were not significant (P = 0.79), but no-show rates were significant when comparing the practice's subspecialties (P < 0.001). Finally, no-show rates for online-scheduled compared to traditionally scheduled patients for both new and follow-up appointments were not significantly different (P = 0.28 and P = 0.94, respectively). Conclusion: Orthopedic practices should utilize online-scheduling systems as there was a higher progression to surgery of traditionally scheduled appointments compared to online. Depending on the subspecialty, no-show rates differed. Furthermore, online-scheduling allows for more patient autonomy and less burden on office staff.

Effect of Postoperative Ketorolac Administration on the Union Rate Following First Metatarsophalangeal Joint Arthrodesis.

BACKGROUND: To decrease postoperative opioid consumption, nonsteroidal anti-inflammatory drugs (NSAIDs), including ketorolac, are considered a proper substitute with few side effects. Our null hypothesis is that a standard-dose, short-term ketorolac exposure does not increase the nonunion rate of a first metatarsophalangeal joint (MTPJ) arthrodesis. METHODS: In a retrospective cohort study, we included 181 primary first MTPJ arthrodeses from 2016 to 2020 in a single surgeon practice. The surgical technique was identical using a dorsal locking plate after preparing the joint with the cup-and-cone technique. A 30 mg intravenous dose of ketorolac was administered perioperatively, followed by a post-operative oral course of 10 mg oral ketorolac every 6 hours for 5 consecutive days. Patients were placed in a heel weight-bearing CAM boot for a minimum of 6 weeks. Union was determined radiographically at 3 months postoperative. Radiographic nonunion was also categorized clinically as symptomatic versus asymptomatic. RESULTS: At 3 months postoperative, a nonunion occurred in 15 (8.3%) patients. Of the 15 radiographic nonunions, 7 (45%) were clinically asymptomatic, while the other 8 (55%) were symptomatic. Six (75%) of the 8 symptomatic nonunions ultimately underwent revision surgery. The nonunion rate in our study compared to that described in the literature (5.4%) was similar and showed no significant difference (P = .067). CONCLUSION: The use of a short course of oral ketorolac (40 mg/day or less for a maximum of 5 days) does not seem to affect the union rate after first MTPJ arthrodesis and can be used safely and effectively in the management of post-operative pain to decrease opioid consumption following this procedure. LEVELS OF EVIDENCE: Level 4.