A Modification to the Brand Transfer for Claw Hand: The Four-Tailed Extensor Carpi Radialis Brevis to Lateral Band Transfer.

BACKGROUND: Claw deformity is a devastating consequence of low ulnar nerve palsy, resulting in loss of finger function. Traditionally, the Brand transfer is a favored intervention but requires lengthy grafts and bulky tenorrhaphies, risking adhesions in the lumbrical canal. We present a modified Brand tendon transfer, which extends the extensor carpi radialis brevis (ECRB) into 4 tails for individual grafting into the lateral band, decreasing adhesion risk and graft length need. METHODS: Nine consecutive patients with claw hand were examined in detail to confirm the diagnosis and appropriateness for claw-correction surgery by the senior author. All patients underwent our modified Brand transfer. Follow-up for a minimum of 6 months was pursued for each patient, with range of motion, grip strength, and pinch strength recorded at that time. RESULTS: Treated patients demonstrate maintained grip and pinch strength, coordinated grasp, and improvement in metacarpophalangeal posture. One patient required reoperation for extensive scarring and underwent tenolysis of the tendon grafts and revision grafting for the small finger. CONCLUSION: We concluded that our modified weave of a 4-tailed tendon graft through the ECRB is a synergistic transfer that maintains acceptable hand strength in the setting of a chronic low ulnar nerve palsy with a lower risk of tendon adhesion and length of grafting, offering an additional tool in the armamentarium of the hand surgeon approaching the ulnar nerve-injured hand.

Information exchange on adolescent scoliosis discussion forums among patients and caregivers: a thematic analysis.

PURPOSE: Online health-related support groups have increasingly become a regular resource for patients and caregivers; however, the content of these forums is largely unknown to medical teams. The purposes of this study were to (1) review posts from scoliosis discussion forums to establish common themes related to the care experience of patients with scoliosis and (2) understand how common themes vary among pediatric and adult patients, as well as caregivers. METHODS: Posts were collected from two public scoliosis forums. Analysis was performed using grounded theory-a methodology that relies on the repeated analyses of qualitative data to identify recurring concepts, which are then coded and grouped into categories and ultimately central themes that seek to synthesize the relationships between categories. Information posts were reviewed by a board-certified orthopedic surgeon who performs scoliosis surgery for factual basis or misinformation. RESULTS: Analysis of 911 posts revealed five central themes. The two most common themes among patients ≥ 18 and caregivers involve seeking out emotional support and information about surgical treatment. Patients < 18 frequently sought out emotional support but were also largely interested in information about bracing. The most prevalent theme among all contributors involved seeking out emotional support. There was very little medical misinformation found within posts. CONCLUSION: Scoliosis forums serve as an informal outlet where patients and families can offer emotional support and share experiences. Physicians should provide direct emotional support to patients and offer these forums as a resource, without significant concerns about propagating medical misinformation.

The Current Epidemiology of Revision Total Knee Arthroplasty in the United States From 2016 to 2022.

BACKGROUND: The number of revision total knee arthroplasties (TKAs) is projected to reach 268,200 cases annually by 2030 in the United States. The growing demand for revision TKA can be attributed to the successes of primary TKAs combined with an aging population, patient desires to remain active, as well as expanded indications for younger patients. Given the evolving nature of revision TKAs, an epidemiological analysis of: (1) etiologies; (2) demographics, including age and region; as well as (3) lengths of stay (LOS) offers a way to minimize the gap between appropriate understanding and effective intervention. METHODS: From 2016 to 2022, a national, all-payer database was queried. Incidences and indications were analyzed for a total of 135,983 patients who had revision TKA procedures. RESULTS: The most common etiologies for revision TKA procedures were infection (19.3%) and aseptic loosening (12.8%), followed by mechanical complications (7.9%). The largest age group was 65 to 74 years (34.9%) followed by 55 to 64 years (32.2%), then age >75 years (20.5%). The South had the largest total procedure cohort (39.8%), followed by the Midwest (28.6%), then the Northeast (18.6%), and the West (13.0%). The mean length of stay was 3.86 days (range, 1.0 to 15.0). CONCLUSIONS: Our study details the current status of revision TKA through 2022. While infection and aseptic loosening remain leading causes, we found a low aseptic loosening rate of 12.8%.

Biologic Disease-Modifying Antirheumatic Drugs Do Not Increase Risk for Prosthetic Joint Infection in Setting of Total Knee Arthroplasty.

Over 25% of patients with rheumatoid arthritis (RA) are expected to undergo a joint replacement during their lifetime. Current practice guidelines recommend withholding biologic therapy 1 week prior to total hip arthroplasty, given its immunosuppressive effects. Most patients are on a regimen including biologic and nonbiologic therapy; however, the individual influences of these therapies are not well understood in the setting of total knee arthroplasty (TKA). Therefore, we sought to compare biologic, nonbiologic, and recipients of both types of therapy in patients with RA undergoing TKA. We specifically assessed (1) medical complications at 90 days; (2) surgical complications up to 1 year; and (3) independent risk factors for prosthetic joint infections (PJIs).A retrospective review was conducted using a national, all-payer database for patients undergoing primary TKA from January 2010 to April 2020 (n = 1.97 million). Patients diagnosed with RA were then separated into at least 1-year users of biologic (n = 3,092), nonbiologic (28,299), or dual (n = 10,949) therapy. Bivariate analyses were utilized to assess for 90-day medical and up to 1-year surgical outcomes. Additionally, multivariate regression models were utilized to assess for independent risk factors.The incidence and odds ratio for medical/surgical outcomes were equivocal among the biologic, nonbiologic, and recipients receiving both types of therapy (p > 0.061). No differences were observed between the type of therapy as additional risk factors for infection (p > 0.505). However, glucocorticoids at 90 days and alcohol abuse, diabetes mellitus, obesity, as well as tobacco use were identified as additional risk factors for PJI(p < 0.036).No appreciable differences in medical or surgical outcomes were associated with the independent use of biologic, nonbiologic, or recipients of both types of therapy in patients with RA. Additionally, alcohol abuse, diabetes mellitus, glucocorticoids, obesity, and tobacco use conferred an increased risk of PJI. These results can serve as an adjunct to current practice guidelines.

Opportunities for Increasing Diversity in Orthopaedics Through Virtual Mentorship Programs.

Orthopaedic surgery lags in recruiting women and under-represented minorities (URMs). In addition, women and URMs hold fewer leadership roles across orthopaedic subspecialties. This inequity is geographically heterogeneous, with female URM residents and attendings being more concentrated in some areas of the country. For instance, practicing female orthopaedic surgeons are more prevalent in Northeast and Pacific programs. Mentorship and representation in leadership positions play a notable role in trainee recruitment. Video communication platforms offer a novel mechanism to reach historically under-represented students across the country. We reviewed five established mentorship programs focused on women and URMs. Each program emphasized a longitudinal relationship between mentors and mentees. In reviewing these programs, we sought to identify the successful components of each program. Leveraging and integrating effective components already established by conventional mentorship programs into virtual programming will aid in optimizing those programs and improve geographic equity in access to mentorship resources. It is critical to extend the principles of successful mentorship programs to technology-enabled programs moving forward.

Orthopaedic Surgery Subspecialty Podcast Effectively Disseminates Peer-reviewed Articles Relative to Traditional Online Publishing.

BACKGROUND: Podcasts have become increasingly utilized in medical education over the past decade, especially in orthopaedic surgery. Compared with more traditional learning tools, podcasts are easily accessible, free, and capable of use while multitasking. Despite these apparent benefits, the effectiveness of podcasts as a dissemination tool for emerging peer-reviewed literature is not well understood. The Peds Ortho Podcast is the official podcast of Pediatric Orthopedic Society of North America that highlights recently published peer-reviewed articles through author interviews and executive summaries of featured articles. The purpose of this study was to compare the distribution of the Peds Ortho Podcast to traditional media by comparing electronic access statistics between the podcast episodes and the journal articles they summarize. METHODS: Podcast episodes were reviewed to catalog the abstracts and articles discussed therein. Because podcasts and articles utilize different electronic metrics to track distribution, we established a common metric of an "access," which we defined as an "intent to consume the media." For articles, we defined an "access" as the largest value of a publisher's online metrics, be it abstract views, full text views, or article downloads. For podcast episodes, we defined an "access" as any play >0 seconds. Access data were analyzed using independent samples t test and analyses of variance. RESULTS: Eighty episodes of the Peds Ortho Podcast have featured 333 published, peer-reviewed articles to date, with 303 included in the final analysis with available article metrics. There were significantly more mean electronic accesses per podcast episode than featured articles (1236 vs. 482, P <0.001). Podcast consumption greatly varies in the first 30 days following episode release; however, recent episodes have a substantial proportion of accesses soon after publication. CONCLUSIONS: Given that podcast electronic access is greater than traditional media, podcasts appear to be a valuable tool for health care providers and trainees. Podcasts serve a complementary role to traditional media by quickly disseminating main points and raising awareness of emerging research.

Thematic analysis of online discussion forums for soft tissue sarcomas.

BACKGROUND AND OBJECTIVES: As there is an increasing reliance on the internet for medical information, patients diagnosed with rare diseases have turned to online community forums to share information about their diagnoses. These forums help patients to gather and share information about their experience with disease. Additionally, these platforms enable patients to build unique connections based on their shared experiences. The objective of this study was to review shared posts in online community forums by individuals with soft tissue sarcomas to better understand commonly discussed themes. This information may improve the physicians' understanding of patients' concerns and feelings at the time of diagnosis and treatment. METHODS: We entered "sarcoma discussion forum" in search engines to identify internet discussion boards. Four major discussion forums were analyzed, and posts written between January 1, 2017 through May 1, 2022 addressing soft tissue sarcomas present in the upper and lower extremities were collected. Each post was analyzed by the two investigators in three steps (open coding, axial coding, and selective coding). RESULTS: A total of 506 posts were included in the final analysis. We used twenty-seven axial codes and four selective codes. Emotional Aspects/Connecting with Others was the most common theme (77 % of posts) followed by Information Support: Treatment (38 % of posts), Information Support: Diagnosis (24 % of posts) and Information Support: Recovery (21 % of posts). CONCLUSIONS: The most prevalent theme was centered on emotional aspects of these patients' journeys, highlighting the importance of providing resources to address emotional support for patients with soft tissue sarcoma and their families. LEVEL IV: Qualitative research study.

Most Patients With Bone Sarcomas Seek Emotional Support and Information About Other Patients' Experiences: A Thematic Analysis.

BACKGROUND: Online discussion forums allow individuals who otherwise may be strangers to create a community where they can seek and share information. Patients with bone sarcomas and their support networks use discussion forums dedicated to cancer support. There is a paucity of published reports regarding the care experience of patients with bone sarcomas because studies on online discussion groups have primarily focused on some of the more common cancers, including breast and prostate cancer. Understanding commonly discussed themes among patients with bone sarcomas would allow treating physicians to have a better understanding of patient concerns when providing patient education and counseling. QUESTION/PURPOSE: We performed this study to review posts from bone sarcoma internet discussion boards to establish common themes related to the care experience of patients with sarcomas. METHODS: Online discussion forums were identified using the search term "sarcoma discussion forum." After identifying 12 websites, we excluded closed forum groups, websites with missing or invalid links to forums, and nonpublic forums, such as groups on Facebook. These websites include profiles and photos that are personal, and sufficient author anonymity could not be achieved for this study. Posts written between January 1, 2012, and May 1, 2022, posted on five discussion boards were reviewed and collected until we reached a point of data saturation in which we agreed that the collection of additional posts would not reveal new themes. Discussion threads were filtered to identify posts pertaining to the most common bone sarcomas: chondrosarcoma, Ewing sarcoma, and osteosarcoma. Grounded theory-the methodology of repeated analyses of qualitative data to identify recurring themes or concepts-was used to analyze posts. Caregiver posts were delineated from patient posts and categorized separately for subgroup analysis. Grounded theory, although a qualitative method, endeavors to integrate the strengths inherent in quantitative methods with qualitative approaches. Grounded theory categorizes words, language, and the meanings these imply and seeks to organize and reduce the data gathered into themes or essences, which, in turn, can be fed into descriptions, models, or theories. Our analysis used three reviews of text to assign and group codes based on repeating ideas or concepts. The first review (open coding) aims to assign codes based on the verbatim text included by the author to capture the specific thoughts and ideas of the post. The second review (axial coding) aims to consolidate the ideas of posts by applying broader concepts to each post. The third and final review (selective coding) aims to further consolidate the themes of each post by trying to embody the main message contained in a post. A total of 570 posts from 139 threads were collected and analyzed using grounded theory. Twenty-five axial codes and four selective codes were created. We defined data saturation by the absence of a new open code in the analysis of a block of 50 posts to ensure that signals of saturation were not accepted too early in the analysis. RESULTS: The four selective codes included emotional aspects or connecting with others, information support: diagnosis, information support: treatment, and information support: recovery. Of these four codes, emotional aspects and connecting with others was the most prevalent theme (78% [445 of 570] of posts) followed by information support: treatment (49% [282 of 570] of posts). Information support: diagnosis and information support: recovery were each captured in 15% of posts. CONCLUSION: Analysis of posts reveals that the two most common themes involve seeking out emotional support and information about the experiences of others with various treatment modalities. Although most of the posts we assessed contained experiential information and emotional support rather than directed medical advice, future studies should assess the accuracy of information shared among online sarcoma forums. CLINICAL RELEVANCE: Physicians caring for patients with sarcomas should not only address patient concerns related to medical care, but also provide emotional support directly and assist patients by providing resources to peer support outlets, including online discussion forums. Although we cannot ascertain the proportion of patients who use online sites given the anonymity of posts included, these findings suggest common experiential themes across patients with sarcomas outside their doctors' offices. It is important that providers be aware of reputable forums to provide as resources for their patients. The Musculoskeletal Tumor Society may further benefit from endorsing one or more of these forums and providing physician oversight to monitor misinformation.

Super-obese patients are associated with significant infection burden after total hip arthroplasty.

INTRODUCTION: Over ⅓ of the population in the United State is obese (body mass index [BMI] >30 kg/m2), with an increasing proportion being morbidly obese (BMI >40 kg/m2). As the obesity rate climbs, an increasing number have entered the super-obese category (BMI >50 kg/m2), theoretically increasing risk for complications after total hip arthroplasty (THA). This study compared complications in non-obese, obese, morbidly obese, and super-obese patients undergoing THA. We specifically assessed: (1) 1- and 2-year peri-prosthetic joint infection (PJI) rates; (2) complication rates; as well as (3) 1- and 2-year revision rates. METHODS: A database review identified patients undergoing primary THA from 01 January 2010 to 31 December 2019. Patients were stratified based on the presence of International Classification of Diseases, 9th and 10th revision diagnosis codes of non-obese (BMI <30 kg/m2) (n = 8680), obese (BMI <40 kg/m2) (n = 12,443), morbidly obese (BMI <50 kg/m2) (n = 5250), and super-obese (BMI >50 kg/m2) (n = 814) prior to THA. Complication rates at 90 days, 1 year, and 2 years were compared across groups. RESULTS: At all time points, super-obese patients were associated with higher rates of PJI, even when compared to morbidly obese patients. Complications such as sepsis, venous thrombo-embolism, and revision surgeries were found in higher numbers in super-obese as well as morbidly obese patients, compared to obese and non-obese patients. CONCLUSIONS: This study provides large-scale analyses demonstrating the association between super-obese and morbidly obese patients and higher infection rates, as well as complications, following THA. Importantly, the association of PJI is highest among super-obese patients, even when compared to morbidly obese patients. Attaining a BMI <40 kg/m2 prior to surgery may be an important goal discussed with patients to lower the chance of postoperative infections.

Moving the Needle: Directed Intervention by the American Society for Surgery of the Hand Is Effective in Encouraging Diversity in Expert Panel Composition.

Purpose: Recent efforts have been made by the American Society for Surgery of the Hand to encourage female inclusion in expert panels. We hypothesized that female representation on expert panels has increased over the past decade and that a directed intervention by the American Society for Surgery of the Hand would be associated with an increased percentage of submissions with female panelists. Methods: We performed a retrospective analysis of Instructional Course Lecture and Symposium submissions for the 2011 through 2021 American Society for Surgery of the Hand Annual Meetings. Authorship was reviewed, and the gender of the proposed authors was recorded. Additionally, the status of "all-male panel" was attributed to panels with no proposed female authors. Submissions were reviewed and compared with meeting programs to determine the status of accepted or rejected. Longitudinal analysis was performed to determine trends in the gender composition of expert panels. Results: In total, 1,687 submissions were reviewed, including 1,323 Instructional Course Lectures and 364 Symposia. Female authorship constituted 18% of authorship (1,170/6,663), and lead authorship was similarly distributed, with 18% being female (296/1,687). Overall, female representation has increased steadily over the past decade, with females constituting 13% (43/332) and 20% (163/818) of the submitted authors in 2011 and 2020, respectively. Similarly, all-male panels declined from 74% (76/103) to 46% (85/185) of panels over the same timeframe. Most strikingly, a sharp increase in gender representation was observed with the directed intervention noted in the 2021 Call for Abstracts, resulting in an increase in female authorship to 26% (295/1,124) and a decline in all-male panels to 29% (70/241). Conclusions: Gender representation among hand surgery expert panels moved toward increased equity over the past decade, which has been aided by directed interventions. Clinical relevance: Career development and trainee decision making are impacted by gender representation; directed and intentional interventions by professional organizations are effective in encouraging greater equity and diversity within the field.

Surgical Treatment of Foot Drop: Patient Evaluation and Peripheral Nerve Treatment Options.

Foot drop is a common clinical condition which may substantially impact physical function and health-related quality of life. The etiologies of foot drop are diverse and a detailed history and physical examination are essential in understanding the underlying pathophysiology and capacity for spontaneous recovery. Patients presenting with acute foot drop or those without significant spontaneous recovery of motor deficits may be candidates for surgical intervention. The timing, mechanism, and severity of neural injury resulting in foot drop influence the selection of the most appropriate peripheral nerve surgery, which may include direct nerve repair, neurolysis, nerve grafting, or nerve transfer.

Surgical Treatment of Foot Drop: Pathophysiology and Tendon Transfers for Restoration of Motor Function.

Foot drop is a common condition that may impact physical function and health-related quality of life. A detailed clinical history and physical examination are critical components of the initial evaluation of patients presenting with foot drop. Patients with refractory foot drop without spontaneous recovery of motor deficits, delayed presentation greater than 12 months from injury, or neural lesions that are not amenable to or have failed nerve reconstruction may be candidates for tendon transfers to restore active ankle dorsiflexion. The modified Bridle procedure is a dynamic tendon transfer that has demonstrated excellent functional outcomes in patients with refractory foot drop.

Graves' disease following administration of second dose of SARS-CoV-2 vaccine.

The SARS-CoV-2 vaccines have had an overwhelming success in curbing the COVID-19 global pandemic, accounting for countless lives saved. Adverse reactions are inevitable, given the vast scale of vaccination required to mitigate future surges of COVID-19. Hyperthyroid disorders have been reported as potential adverse reactions to SARS-CoV-2 vaccines in two patients with Graves' disease and a group of adults with subacute thyroiditis occurring in young women healthcare workers. We report a case of clinical Graves' disease in a woman with a previously stable multinodular goitre that occurred 14 days following her second dose of Pfizer-BioNTech SARS-CoV-2 vaccine.