Validation of Temperature Sensors to Monitor Thermoplastic Splint Wear in Hand Surgery Patients.

BACKGROUND: The aim of this study was to validate the use of temperature sensors to accurately measure thermoplastic volar forearm splint wear in a healthy cohort of volunteers using 5- and 15-minute temperature measurement intervals. METHODS: A prospective diagnostic study was performed to evaluate the diagnostic accuracy of temperature sensors in monitoring splint wear in 8 healthy volunteers between December 2022 and June 2023. Temperature sensors were molded into thermoplastic volar forearm splints. Volunteers who were familiar with the study aims were asked to keep an exact log of the time spent wearing the splint ("actual wear time"). Sensors recorded temperatures every 5 or 15 minutes, and separate algorithms were developed to determine the sensor-detected wear time compared with the actual wear time as the gold standard. The algorithms were then externally validated with the total population. RESULTS: The 5-minute and 15-minute algorithms demonstrated excellent sensitivity (99.1% vs 96.6%), specificity (99.9% vs 99.9%), positive (99.4% vs 99.5%) and negative (99.9% vs 99.3%) predictive value, and diagnostic accuracy (99.8% vs 99.3%), respectively. The 5-minute algorithm recorded 99.5% of the total splint hours, whereas the 15-minute algorithm recorded 96.1%. There was no significant difference between the actual time per wear session (5.4 ± 2.7 hours) and the time estimated by the 5-minute algorithm (5.4 ± 2.6 hours; P = .40), but there was a significant difference for the 15-minute algorithm (5.2 ± 2.6 hours; P < .001). CONCLUSION: Temperature sensors can be used to accurately monitor thermoplastic volar forearm splint wear. LEVEL OF EVIDENCE: Diagnostic II.

Pediatric Phalanx Fractures.

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

Hand Fractures-Management and the Complications That Inevitably Occur: Metacarpal Fractures.

Metacarpal fractures are among the most common hand fractures. To properly manage these injuries, surgeons must understand the anatomy, biomechanics, clinical assessment, surgical and nonsurgical treatment options, and potential complications. Metacarpal head fractures often require surgical treatment to restore the joint surface by using a variety of techniques. Metacarpal neck fractures are usually stable injuries that do not require surgical intervention, but surgeons must know when surgical intervention is indicated. Fractures of the metacarpal shaft can be treated surgically and nonsurgically and may be associated with large bone defects or soft-tissue injuries that require careful consideration. Finally, fractures involving the carpometacarpal joints must be promptly managed to avoid long-term complications, potentially requiring salvage procedures.

Proximal Interphalangeal Joint Fractures.

Multiple fracture patterns can occur around the proximal interphalangeal joint and require surgeons to have a thorough understanding of the anatomy, clinical and radiographic examination, common fracture patterns, surgical and nonsurgical treatment options, and potential complications. Proximal phalangeal condylar fractures are typically managed surgically, because even nondisplaced fractures have a propensity for displacement. Middle phalangeal base fractures most commonly present as a volar lip fracture with or without dorsal subluxation or dislocation. Treatment options include extension block splinting or pinning, transarticular pinning, open reduction and internal fixation, external fixation, volar plate arthroplasty, and hemihamate arthroplasty. Less common fractures include dorsal lip fractures with or without volar subluxation or dislocation (the central slip fracture), lateral plateau impaction or avulsion injuries, and pilon fractures. The main goals in the management of middle phalangeal base fractures are to restore articular congruency and initial early range of motion, which are more important than obtaining an anatomic reduction.

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.

Zone 1 Flexor Tendon Repairs: Laceration and Avulsion Injuries.

In contrast to other zones of the hand, zone 1 flexor tendon injuries include laceration as well as avulsion mechanisms. Although zone 1 tendon lacerations are treated similarly to other zones, with various suture configurations and techniques, zone 1 avulsion injuries often require repair of tendon to bone. Proximity of the repair site to the distal interphalangeal joint often results in persistent flexion contracture and stiffness. Despite these differences in injury mechanism and location, zone 1 flexor tendon repairs are well tolerated and often lead to fair-high patient satisfaction.

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.

Surveying the Use and Perceptions of Wrist Arthroscopy Among Upper Extremity Surgeons.

This study describes current trends in the skill acquisition and practice patterns for wrist arthroscopy among upper extremity surgeons. A survey was sent to the membership of the American Association for Hand Surgery (AAHS). A total of 104 responses were available for analysis. Of those respondents who did not use wrist arthroscopy, lack of educational training was cited as the most common reason. Of those who did use arthroscopy, fellowship training was credited as the primary source. However, most of those who completed an instructional course felt immediately able to perform arthroscopy. Triangular fibrocartilage complex tears were recorded as the most common indication. Surgeons frequently evaluated the midcarpal joint, but did not frequently use arthroscopy for distal radio-ulnar joint or carpometacarpal joint pathology. Ultimately, this highlights an area of improvement for residency and fellowship education. [Orthopedics. 2022;45(5):310-313.].

The Essex-Lopresti Injury:: Evaluation and Treatment Considerations.

This article describes evaluation and treatment considerations for Essex-Lopresti injuries. Specific information about pattern recognition and treatment options is provided.

Hand and Wrist Problems That Can Be Deceptive: Avoiding Snakes in the Grass.

In this chapter, the authors describe hand conditions that can be "bad actors" and provide specific clues to identify these problems, and strategies to assess and successfully treat them. We will review pediatric and adult hand fractures, fractures of the distal radius, and trigger digits.

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.

Tendinosis develops from age- and oxygen tension-dependent modulation of Rac1 activity.

Age-related tendon degeneration (tendinosis) is characterized by a phenotypic change in which tenocytes display characteristics of fibrochondrocytes and mineralized fibrochondrocytes. As tendon degeneration has been noted in vivo in areas of decreased tendon vascularity, we hypothesized that hypoxia is responsible for the development of the tendinosis phenotype, and that these effects are more pronounced in aged tenocytes. Hypoxic (1% O2 ) culture of aged, tendinotic, and young human tenocytes resulted in a mineralized fibrochondrocyte phenotype in aged tenocytes, and a fibrochondrocyte phenotype in young and tendinotic tenocytes. Investigation of the molecular mechanism responsible for this phenotype change revealed that the fibrochondrocyte phenotype in aged tenocytes occurs with decreased Rac1 activity in response to hypoxia. In young hypoxic tenocytes, however, the fibrochondrocyte phenotype occurs with concomitant decreased Rac1 activity coupled with increased RhoA activity. Using pharmacologic and adenoviral manipulation, we confirmed that these hypoxic effects on the tenocyte phenotype are linked directly to the activity of RhoA/Rac1 GTPase in in vitro human cell culture and tendon explants. These results demonstrate that hypoxia drives tenocyte phenotypic changes, and provide a molecular insight into the development of human tendinosis that occurs with aging.

Unplanned Reoperation After Surgery for Scapholunate Interosseous Ligament Insufficiency: A Retrospective Review of 316 Patients.

Background: The purpose of this study was to identify factors associated with unplanned reoperation after surgery for scapholunate interosseous ligament (SLIL) insufficiency. Methods: Using Current Procedural Terminology (CPT) codes from 3 hand surgery centers across 2 metropolitan areas, we identified 316 patients undergoing surgery for SLIL insufficiency from 2000 to 2014. Medical records were manually reviewed to collect data on factors that might be associated with unplanned reoperation, including age, sex, tobacco use, occupation, acuity of treatment, and reconstruction method. Results: Thirty-eight patients (12%) had an unplanned reoperation; most of them (65%) were a secondary reconstruction or salvage procedure (eg, 6 proximal row carpectomies, 9 revision reconstruction, and 10 partial carpal arthrodeses), while 5 (13%) were for unplanned screw removal. The median time between the index and second surgery was 16 months (range, 2-97 months). The type of index procedure was not associated with reoperation. The only factor associated with reoperation was cigarette smoking, and this association persisted when looking specifically at reoperations for revision or salvage. Conclusions: Patients should be counseled that smoking is associated with reoperation after SLIL surgery. Smoking cessation or decreasing nicotine usage may be beneficial prior to surgery. With the numbers available, there was no association between surgical technique and reoperation.

Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures: A Nationwide Survey Comparing Attending Surgeons and Trainees.

BACKGROUND: Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees. METHODS: Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure. RESULTS: A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons. CONCLUSIONS: Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.

Accidental Injection of Freund Complete Adjuvant With Mycobacterium Tuberculosis.

Accidental needlestick injuries are common in laboratory and health care workers. Injection of atypical pathogens, such as those encountered in the animal laboratory setting, may pose considerable problems at the site of inoculation. We present the case of an otherwise healthy laboratory worker who accidentally self-injected Freund complete adjuvant with heat-killed Mycobacterium tuberculosis into her hand, requiring multiple debridement operations over a prolonged treatment course.

Late Reconstruction of the Interosseous Membrane with Bone-Patellar Tendon-Bone Graft for Chronic Essex-Lopresti Injuries: Outcomes with a Mean Follow-up of Over 10 Years.

BACKGROUND: The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries. METHODS: We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores. RESULTS: IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to -1.6 mm (95% CI, -2.3 to -0.9 mm) immediately postoperatively and -1.1 mm (95% CI, -1.8 to -0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively. CONCLUSIONS: IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mid-term outcomes of routine proximal row carpectomy compared with proximal row carpectomy with dorsal capsular interposition arthroplasty for the treatment of late-stage arthropathy of the wrist.

AIMS: The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone. PATIENTS AND METHODS: A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups. RESULTS: At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes. CONCLUSION: PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197-204.

Mobilan: a recombinant adenovirus carrying Toll-like receptor 5 self-activating cassette for cancer immunotherapy.

Toll-like receptor 5 (TLR5) is considered an attractive target for anticancer immunotherapy. TLR5 agonists, bacterial flagellin and engineered flagellin derivatives, have been shown to have potent antitumor and metastasis-suppressive effects in multiple animal models and to be safe in both animals and humans. Anticancer efficacy of TLR5 agonists stems from TLR5-dependent activation of nuclear factor-κB (NF-κB) that mediates innate and adaptive antitumor immune responses. To extend application of TLR5-targeted anticancer immunotherapy to tumors that do not naturally express TLR5, we created an adenovirus-based vector for intratumor delivery, named Mobilan that drives expression of self-activating TLR5 signaling cassette comprising of human TLR5 and a secreted derivative of Salmonella flagellin structurally analogous to a clinical stage TLR5 agonist, entolimod. Co-expression of TLR5 receptor and agonist in Mobilan-infected cells established an autocrine/paracrine TLR5 signaling loop resulting in constitutive activation of NF-κB both in vitro and in vivo. Injection of Mobilan into primary tumors of the prostate cancer-prone transgenic adenocarcinoma of the mouse prostate (TRAMP) mice resulted in a strong induction of multiple genes involved in inflammatory responses and mobilization of innate immune cells into the tumors including neutrophils and NK cells and suppressed tumor progression. Intratumoral injection of Mobilan into subcutaneously growing syngeneic prostate tumors in immunocompetent hosts improved animal survival after surgical resection of the tumors, by suppression of tumor metastasis. In addition, vaccination of mice with irradiated Mobilan-transduced prostate tumor cells protected mice against subsequent tumor challenge. These results provide proof-of-concept for Mobilan as a tool for antitumor vaccination that directs TLR5-mediated immune response toward cancer cells and does not require identification of tumor antigens.