Management of the Spastic Elbow Deformity in Adult Patients With Upper Motor Neuron Syndrome.

Spastic elbow deformity in patients with upper motor neuron injuries results from an imbalance of flexor and extensor forces across the ulnohumeral joint. Although not all deformities reflect the same underlying imbalances, the elbow most commonly rests in a flexed position. Patients may present with a combination of muscle spasticity, myostatic contracture, and/or joint contracture. A focused history and physical examination are essential for developing individualized surgical plans that account for variations in deformity severity and patient goals. Patients may present with or without volitional control; goals and treatment options differ depending on the degree of control present. Techniques include hyperselective neurectomy, tendon lengthening, muscle origin release, myotomy, tenotomy, periarticular soft tissue release, and skin rearrangement. This article presents a comprehensive review of the surgical approach to the volitional and nonvolitional spastic elbow deformities.

Motor Branching Pattern of the Radial Nerve for Hyperselective Neurectomy: From Anatomy to Clinical Translation.

PURPOSE: Predominant or isolated spasticity of the triceps following upper motor neuron injury is rare and often unmasked once the spastic elbow flexors are addressed. The purpose of this study was to delineate the motor branching pattern of the radial nerve to determine the feasibility of hyperselective neurectomies (HSN) for triceps spasticity. METHODS: Dissections of the motor branch to each triceps head were performed on 11 upper-extremity specimens. The numbers of trunks, branching patterns, and muscle entry points were recorded in reference to the acromion to interepicondylar line. Based on anatomic studies, 10 patients underwent a combined fractional lengthening and HSN procedure for triceps spasticity. Patient demographics, time from diagnosis, and complications were recorded. Preoperative and postoperative Modified Ashworth Scale (MAS) and total active elbow arc of motion were compared. RESULTS: The first branch from the radial nerve was consistently a single trunk to the long triceps head. There were many variations in the branching pattern and number of trunks to the lateral and medial heads of the triceps with motor entry points between 31% and 95% of the acromion to interepicondylar line distance. Ten patients (six men and four women; mean age: 48.5 years) underwent the combined procedure. Mean total active elbow arc of motion improved from 78° before surgery to 111° after surgery, with a 17.5° increase in active elbow flexion. Compared with a mean preoperative triceps MAS of 2.75, nine patients had triceps MAS of 0 at a mean of 10.2 months of follow-up. There was no loss of functional elbow extension and no directly related complications. CONCLUSIONS: Given the variable motor entry points, HSN to each triceps head would require extensive dissection. Therefore, a combined approach consisting of fractional lengthening of the long head and lateral head with HSN of the triceps medial head is recommended to address triceps spasticity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Primary 3-Month Outcomes of a Double-Blind Randomized Prospective Study (The QUEST Study) Assessing Effectiveness and Safety of Novel High-Frequency Electric Nerve Block System for Treatment of Post-Amputation Pain.

Purpose: This multicenter, randomized, double-blinded, active sham-controlled pivotal study was designed to assess the efficacy and safety of high-frequency nerve block treatment for chronic post-amputation and phantom limb pain. Patients and Methods: QUEST enrolled 180 unilateral lower-limb amputees with severe post-amputation pain, 170 of whom were implanted with the Altius device, were randomized 1:1 to active-sham or treatment groups and reached the primary endpoint. Responders were those subjects who received ≥50% pain relief 30 min after treatment in ≥50% of their self-initiated treatment sessions within the 3-month randomized period. Differences between the active treatment and sham control groups as well as numerous secondary outcomes were determined. Results: At 30-min, (primary outcome), 24.7% of the treatment group were responders compared to 7.1% of the control group (p=0.002). At 120-minutes following treatment, responder rates were 46.8% in the Treatment group and 22.2% in the Control group (p=0.001). Improvement in Brief Pain Inventory interference score of 2.3 ± 0.29 was significantly greater in treatment group than the 1.3 ± 0.26-point change in the Control group (p = 0.01). Opioid usage, although not significantly different, trended towards a greater reduction in the treatment group than in the control group. The incidence of adverse events did not differ significantly between the treatment and control groups. Conclusion: The primary outcomes of the study were met, and the majority of Treatment patients experienced a substantial improvement in PAP (regardless of meeting the study definition of a responder). The significant in PAP was associated with significantly improved QOL metrics, and a trend towards reduced opioid utilization compared to Control. These data indicate that Altius treatment represents a significant therapeutic advancement for lower-limb amputees suffering from chronic PAP.

Combined Wrist Extensor Tenodesis and Tendon Transfers for Severe Spastic Flexed Wrist Deformity: Surgical Technique and Case Series.

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review.

PURPOSE: To review the existing literature to (1) determine the diagnostic efficacy of artificial intelligence (AI) models for detecting scaphoid and distal radius fractures and (2) compare the efficacy to human clinical experts. METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried for studies investigating the development, validation, and analysis of AI for the detection of scaphoid or distal radius fractures. Data regarding study design, AI model development and architecture, prediction accuracy/area under the receiver operator characteristic curve (AUROC), and imaging modalities were recorded. RESULTS: A total of 21 studies were identified, of which 12 (57.1%) used AI to detect fractures of the distal radius, and nine (42.9%) used AI to detect fractures of the scaphoid. AI models demonstrated good diagnostic performance on average, with AUROC values ranging from 0.77 to 0.96 for scaphoid fractures and from 0.90 to 0.99 for distal radius fractures. Accuracy of AI models ranged between 72.0% to 90.3% and 89.0% to 98.0% for scaphoid and distal radius fractures, respectively. When compared to clinical experts, 13 of 14 (92.9%) studies reported that AI models demonstrated comparable or better performance. The type of fracture influenced model performance, with worse overall performance on occult scaphoid fractures; however, models trained specifically on occult fractures demonstrated substantially improved performance when compared to humans. CONCLUSIONS: AI models demonstrated excellent performance for detecting scaphoid and distal radius fractures, with the majority demonstrating comparable or better performance compared with human experts. Worse performance was demonstrated on occult fractures. However, when trained specifically on difficult fracture patterns, AI models demonstrated improved performance. CLINICAL RELEVANCE: AI models can help detect commonly missed occult fractures while enhancing workflow efficiency for distal radius and scaphoid fracture diagnoses. As performance varies based on fracture type, future studies focused on wrist fracture detection should clearly define whether the goal is to (1) identify difficult-to-detect fractures or (2) improve workflow efficiency by assisting in routine tasks.

Limb spasticity and telemedicine consultation for reconstructive surgery: patient perspectives of surgical assessment.

CONTEXT: Spasticity is characterized by increased muscle tone and stretch reflexes, often caused by an upper motor neuron (UMN) syndrome. Many patients live with their dysfunction of their upper or lower limbs for many years and are managed by a multidisciplinary team including physical medicine and rehabilitation specialists, neurologists, and/or physical therapists in an attempt to decrease their spasticity and enhance their quality of life. Reconstructive surgery is a treatment option for many patients living with spasticity. The goal of surgery is to permanently decrease their spastic tone and improve their quality of life. Spastic hemiplegia or hemiparesis is an area of orthopedic surgery that is uniquely suited to telemedicine evaluation. Telemedicine visits can lower the threshold for patients to obtain consultation, receive second opinions, and determine whether traveling for an in-person assessment might be worthwhile, particular to larger medical centers. OBJECTIVES: The objective of our study was to characterize patient perceptions of telemedicine consultation for spasticity surgery and to determine its effectiveness for indicating reconstructive procedures. METHODS: An electronic survey consisting of 16 questions was distributed to all patients after the virtual consultation from April 2020 to September 2022 as part of a neuro-orthopedic evaluation. Domains of inquiry included patient demographic and diagnosis information, satisfaction with provider assessment, ease of use, appointment preference, and whether surgery was eventually performed. Identifying information was voluntarily provided by patients and allowed for survey data to be linked to the medical record. Patients were included in the study if they were diagnosed with upper and/or lower extremity spasticity, were evaluated by telemedicine visit, and were over the age of 18. They were excluded from the study if they were evaluated for any condition aside from spasticity or returned an incomplete survey. Patients who completed the survey were prospectively followed through December 2022 to determine whether a subsequent in-person visit was pursued and/or reconstructive surgery was performed. RESULTS: A total of 19 of 36 patients completed surveys, for a response rate of 52.7 %. Nearly all (94.7 %, n=18) patients felt that the provider expressed maximal concern for patient questions/worries, included them in decisions regarding care, and appropriately discussed treatment strategies. Similarly, the majority (89.5 %, n=17) were maximally satisfied with explanations about their condition and would recommend the care provider to others. Most patients (84.2 %, n=16) also felt that the ease of communication via the virtual platform was very good. All patients were eventually indicated for and subsequently underwent reconstructive surgery for spasticity. CONCLUSIONS: Spasticity patients were overwhelmingly satisfied with their initial virtual consultation as an alternative to face-to-face visits. Telemedicine provides a clinical opportunity for seeking information about spasticity surgery and offers a cost-effective and convenient option for patients who find travel to specialty centers prohibitive.

Investigation Into the Effects of Intra-Articular Steroid on Post-Traumatic Osteoarthritis in Distal Radius Fractures: A Randomized Controlled Pilot Study.

PURPOSE: The aim of this prospective, randomized, controlled, double-blinded pilot study was to determine the rates of post-traumatic osteoarthritis and assess joint space width in the presence or absence of a single intra-articular injection of corticosteroid after an acute, intra-articular distal radius fracture (DRF). METHODS: Forty patients received a single, intra-articular, radiocarpal joint injection of 4 mg of dexamethasone (DEX) (n = 19) or normal saline placebo (n = 21) within 2 weeks of a surgically or nonsurgically treated intra-articular DRF. The primary outcome measure was minimum radiocarpal joint space width (mJSW) on noncontrast computed tomography scans at 2 years postinjection. Secondary outcomes were obtained at 3 months, 6 months, 1 year, and 2 years postinjection and included Disabilities of the Arm, Shoulder, and Hand; Michigan Hand Questionnaire; Patient-Rated Wrist Evaluation; wrist range of motion; and grip strength. RESULTS: At 2-year follow-up, there was no difference in mean mJSW between the DEX group (2.2 mm; standard deviation, 0.6; range, 1.4-3.2) and the placebo group (2.3 mm; standard deviation, 0.7; range, 0.9-3.9). Further, there were no differences in any secondary outcome measures at any postinjection follow-up interval. CONCLUSIONS: Radiocarpal joint injection of corticosteroid within 2 weeks of an intra-articular DRF does not appear to affect the development of post-traumatic osteoarthritis within 2 years follow-up in a small pilot cohort. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Combined Hyperselective Neurectomy and Fractional Lengthening Technique for Triceps Spasticity.

Triceps spasticity can occur in patients with upper motor neuron syndrome. It is often undetected when there is predominant elbow flexion spasticity and/or contracture. This condition can become apparent after surgery for elbow flexor spasticity, leading to impaired active elbow. Although triceps muscle-tendon lengthening procedures can be performed, these techniques do not directly address the issue of spasticity which is neurally mediated. This article presents a surgical technique for addressing triceps spasticity with a combined approach of hyperselective neurectomy of the medial head of the triceps and muscle-tendon lengthening of the long and lateral heads.

Expert consensus on the surgical evaluation and management of upper extremity spasticity in adults.

In the last decade there has been incredible interest and advancement in the surgical care of adult patients with upper motor neuron (UMN) injuries. Spasticity represents a prevalent and debilitating feature of UMN syndrome, which can result from cerebral palsy, spinal cord injury, cerebrovascular accident and traumatic or anoxic brain injury. While several diagnostic tools and management strategies have been described for upper limb spasticity, evidence-based practice guidelines do not currently exist due to low patient volume and a paucity of surgeons routinely performing surgeries in UMN syndrome patients. As such, expert consensus may help provide guidance for patients, therapists and clinicians alike. In this article an expert panel was assembled, and the Delphi method was utilized to present diagnostic considerations, define operative indications, discuss surgical treatment modalities and encourage a standard set of outcome measures for patients with upper extremity spasticity.

Outcome of Preoperative Asymptomatic or Minimally Symptomatic DRUJ Arthritis after Total Wrist Arthrodesis: A Single-Institution Case Series.

Background Concomitant severe radiocarpal (RC) arthritis with asymptomatic or minimally symptomatic distal radioulnar joint (DRUJ) arthritis can be debilitating for patients. Surgical management of these combined arthritides can pose a dilemma for surgeons and patients. The purpose of this study was to evaluate patients with concomitant RC and DRUJ arthritides who underwent only total wrist arthrodesis (TWA) to determine the need for subsequent surgical management of preoperative asymptomatic/minimally symptomatic DRUJ arthritis. Materials and Methods All patients who underwent TWA between 2008 and 2018 at a single institution were evaluated. Those patients who underwent TWA for degenerative, inflammatory, or posttraumatic arthritis with concomitant asymptomatic or minimally symptomatic DRUJ arthritis preoperatively were included. A retrospective review was performed for demographic variables, TWA indications, pre- versus post-TWA DRUJ symptoms, and severity of DRUJ arthritis on radiographs. Primary outcome measure was survivorship from subsequent DRUJ surgery for development of symptomatic arthritis after initial TWA. Results One hundred and eighty-three patients underwent TWA during the study period, of which 39 wrists met inclusion criteria. Indications for TWA included posttraumatic arthritis ( n = 22), avascular necrosis of the lunate ( n = 10), and inflammatory arthritis ( n = 7). The mean clinical follow-up was 5.7 years (range: 1.5-12.7 years). Four patients (10%) who underwent TWA ultimately required a subsequent procedure to address DRUJ arthritis at a mean time of 20 months (range: 3-60 months) after initial TWA. The initial indication for TWA in these patients included symptomatic posttraumatic arthritis ( n = 3) and lunate avascular necrosis ( n = 1). Conclusion In patients with symptomatic RC and asymptomatic or minimally symptomatic DRUJ arthritides undergoing TWA alone, 10% in this series required subsequent surgical management for progressive DRUJ arthritis. Clinical Relevance Surgical management of concomitant symptomatic RC and asymptomatic/minimally symptomatic DRUJ arthritides with TWA alone is a reasonable initial approach. Patients should be counseled preoperatively that subsequent surgical management of progressive DRUJ arthritis may be necessary in ∼10% of patients.

Safety of Cubital Tunnel Release Under General versus Regional Anesthesia.

Purpose: The aim of this study was to evaluate the occurrence of early (<6 weeks) post-operative complications following ulnar nerve decompressions at the cubital tunnel performed under regional anesthesia compared to those performed under general anesthesia. Methods: In situ ulnar nerve decompressions at the cubital tunnel performed at a single institution from 2012 through 2019 were retrospectively reviewed. Post-operative complications were compared between subjects who underwent the procedure with regional versus general anesthesia. Results: Ninety-one ulnar nerve in situ decompressions were included in the study, which were performed under regional anesthesia in 55 and general anesthesia in 36 cases. The occurrence of post-operative complications was not significantly different between patients who received regional (n = 7) anesthesia and general (n = 8) anesthesia. None of the complications were directly attributed to the type of anesthesia administered. The change in pre- and post-operative McGowan scores were not significantly different between anesthesia groups (p = 0.81). Conclusion: In situ ulnar nerve decompression at the cubital tunnel under regional anesthesia does not result in increased post-operative complications compared to those surgeries performed under general anesthesia. In situ ulnar nerve decompression performed under regional anesthesia is a safe and reliable option for patients who wish to avoid general anesthesia. Level of Evidence: III.

Optimal hand surgery fellowship interview format.

CONTEXT: The ideal format for residency and fellowship interviews has been consistently debated. Secondary to the COVID-19 pandemic, many institutions, including all hand surgery fellowship programs, transitioned interviews to an all-virtual format. In the past year, with ease of travel restrictions, some programs have transitioned back to in-person interviews, while others remain solely virtual. Hand surgery fellowship programs are continually assessing what are the best means for conducting these interviews, with little perspective regarding the applicant's preferences. OBJECTIVES: The purpose of this study was to examine hand surgery fellowship applicants' perspectives regarding in-person and virtual interviews. It was hypothesized that applicants would value interpersonal relationships between faculty when deciding upon their ideal hand surgery fellowship, which would be easier to appreciate in-person. METHODS: All hand fellowship interviewees at a single institution were given a voluntary, electronic survey. The survey consisted of questions examining different aspects of the program's interview day and supplemental resources. Responses were recorded after the in-person interview for the years 2018-2020. Questions were altered for the virtual 2021 and 2022 interviews. Questions were scored on a Likert scale. RESULTS: For the in-person interview cycles, there were 60/86 respondents (69.8 %). For the virtual interview cycles, there were 45/73 respondents (61.6 %). During the in-person interview cycles, applicants reported that the current fellows' perspective talk was the most helpful component. Many applicants commented that they enjoyed meeting their potential co-fellows. The virtual interviewees felt that they had the best understanding of the program's core values/culture and the worst understanding of faculty personalities and personal/family life. Twenty-nine (64.4 %) of virtual applicants would prefer an all in-person interview. Of the 16 respondents who did not advocate for a completely in-person interview, 56.3 % preferred the option for an in-person site visit. CONCLUSIONS: Hand surgery fellowship applicants desire interpersonal interactions to better understand prospective fellowship programs, which can be difficult to convey with an all-virtual interview. The results of this survey can help guide fellowship programs as they continue to optimize in-person, virtual, and hybrid interview formats and refine recruitment resources.

Radiographic Outcomes for Comminuted, Intra-articular Distal Radius Fractures Treated with Primary Distraction Bridge Plate Fixation.

Purpose: To determine if distraction bridge plate (DBP) fixation as the primary method of stabilization can effectively correct and maintain acceptable radiographic parameters in the treatment of comminuted, intra-articular distal radius fractures while allowing early load-bearing. Methods: A retrospective review was performed of all consecutive intra-articular distal radius fractures that underwent DBP fixation with or without supplemental fixation methods (fragment-specific implants or K-wires). Patients treated with a volar locked plate in addition to DBP were excluded. Radiographic outcomes measures included volar tilt (°), radial height (mm), radial inclination (°), articular step-off (mm), lunate-lunate facet ratio (LLFR), and teardrop angle (°) measured on post-reduction, immediately post-operative, prior to and after DBP removal. Results: Twenty-three comminuted, intra-articular distal radius fractures were treated with primary DBP fixation. Supplemental fixation was utilized in 10 fractures and included fragment-specific implants (n = 6) and/or K-wires (n = 5). Distraction bridge plates were removed after a mean of 13.6 weeks. At a mean radiographic follow-up of 11.4 weeks (range: 2-45 weeks) following DBP removal, all fractures had united with a mean volar tilt of 6.3° ± 5.8°, radial height of 11.3 ± 2.3 mm, radial inclination of 20.2° ± 4.5°, articular step-off of 0.6 mm ± 0.8, and LLFR of 1.05 ± 0.06. However, the teardrop angle could not be restored to a normal value with DBP fixation. Complications included 1 plate breakage and 1 peri-hardware radial shaft fracture. Conclusion: Distraction bridge plate fixation is a reliable method to stabilize highly comminuted, intra-articular distal radius fractures in patients with a well-aligned volar rim fragment of the lunate facet.

Toto, we're not in Kansas anymore: First reported case of M. persicum septic arthritis.

In this report, we describe a case of septic arthritis caused by the newly described Mycobacterium persicum (formerly Mycobacterium kansasii complex). The patient's only significant exposure was home gardening. To our knowledge, this represents the first documented case of M. persicum infection in the United States and first septic arthritis.

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia.

BACKGROUND: Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia. METHODS: Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures. RESULTS: Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management. CONCLUSIONS: Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Management of a Thumb-In-Palm Deformity in Adult Patients With Upper Motor Neuron Syndrome.

The thumb-in-palm (TIP) deformity in adults with upper motor neuron syndrome results from an imbalance of extrinsic and intrinsic muscular forces. Traditionally, the thumb is adducted against the index ray, and flexed to varying degrees at the metacarpophalangeal and interphalangeal joints. However, not all TIP deformities result from the same underlying imbalances. The severity of the deformity ranges over a spectrum dependent upon the involved muscle groups and underlying spasticity, myostatic contracture, and/or joint contractures. Surgical procedures for correcting a TIP deformity can be classified broadly as procedures used for functional, present volitional motor control, versus nonfunctional, absent motor control. Techniques include tenotomies, tenodeses, tendon lengthenings, tendon transfers, tendon reroutings, neurectomies, and joint releases. A focused physical examination is key in developing a patient-specific treatment algorithm.

Comparison of Patient Perception and Satisfaction of Face-to-Face Versus Telemedicine Encounters in Hand Surgery.

BACKGROUND: The coronavirus disease 2019 (COVID-19) surge has enabled the widespread usage of telemedicine (TM) and presents a unique opportunity to determine the hand surgery patients' perception of care using validated patient satisfaction scores. METHODS: Electronic surveys were distributed to patients aged 18 years and older who underwent a video TM encounter with a single surgeon at an academic medical center during the initial COVID-19 surge (March 23 to October 22, 2020). The study-specific questions were derived from the Press Ganey (PG) Medical Practice TM Survey and compared with institutional PG Outpatient Medical Practice Survey data. Three cohorts were defined: pre-COVID face-to-face, post-COVID TM, and post-COVID face-to-face. RESULTS: Thirty of 65 TM patients (46.2%) responded. No differences in sex, age, or visit type were identified between cohorts. The TM cohort was more likely to live greater than 300 miles from the institution. Median response for all cohorts for the PG care provider and overall experience responses were "very good," and no differences were identified between cohorts. Patient satisfaction with their TM experience was high with median satisfaction scores for arranging and connecting to a TM visit, talking with the provider over a video connection, and having the provider understand the clinical problem were "very good." Patients in the TM cohort reported no difference in preference for face-to-face or TM visits. CONCLUSIONS: Patients are satisfied with TM as a substitute for face-to-face visits suggesting that TM can possibly be used to deliver comparable patient experience for hand surgery encounters.

Does Proximal Row Carpectomy Improve Union in Wrist Arthrodesis? A Retrospective Cohort Study.

Background Some surgeons advocate for concomitant proximal row carpectomy (PRC) with total wrist arthrodesis (TWA), though there are limited data to support or oppose this view. Questions/Purposes Does concomitant PRC improve rates of union, revision, hardware loosening, hardware failure, and hardware removal in TWA? Patients and Methods A retrospective cohort study of patients who underwent TWA with and without concomitant PRC between January 2008 and December 2018 was undertaken. Patients were included if they underwent TWA using a dorsal spanning plate. Patients were excluded if they underwent partial wrist arthrodesis, revision TWA, or TWA with nondorsal spanning plate fixation. Results A total of 183 wrists in 180 patients were included in the study, 96 (52.5%) in the TWA only and 87 (47.5%) in the TWA + PRC groups. Median clinical and radiographic follow-up was 18.0 months (3.0-133.0 months) in the TWA + PRC group and 18.5 months (2.0-126.0 months) in the TWA only group ( p = 0.907). No difference in nonunion (TWA + PRC: 13/87 [14.9%], TWA only: 18/96 [18.8%], odds ratio: 0.76, p = 0.494), revision (TWA + PRC: 5/87 [5.75%], TWA only: 8/96 [8.33%], hazard ratio [HR]: 0.73, p = 0.586), loosening (TWA + PRC: 4/87 [4.60%], TWA only: 6/96 [6.25%], HR: 0.74, p = 0.646), failure (TWA + PRC: 5/87 [5.75%], TWA only: 4/96 [4.17%], HR: 1.55, p = 0.530), and removal (TWA + PRC: 12/87 [13.8%], TWA only: 16/96 [16.7%], HR: 0.84, p = 0.634) were identified. Conclusion Concomitant PRC might not improve rates of union or diminish complications in patient undergoing TWA. The role of PRC and the rationale for its use in TWA need to be individualized and discussed with patients prior to surgery. Level of Evidence This is a Level IV, therapeutic study.

Wound Complications with Multiple Wrist Incisions in Distal Radius Reconstruction.

Background Placement and spacing of skin incisions are important for maintaining soft tissue perfusion and viability, particularly in the setting of local trauma. Question/Purpose The aim of this article is to determine if multiple skin incisions in the surgical management of distal radius fractures result in an increased risk of postoperative wound complications, particularly in the setting of high-energy mechanisms of injury with substantial initial displacement and associated soft-tissue insult that require multiple incisions for distal radius reconstruction. Patients and Methods A multicenter, retrospective chart review was performed for all adult patients who underwent open reduction, internal fixation of a closed distal radius fracture with multiple (≥2) hand, and wrist incisions with minimum follow-up of 6 weeks. Primary outcome measures included wound healing complications such as partial or complete skin necrosis, dehiscence, delayed healing, and superficial or deep infections. Results For 118 wrists, a total of 305 incisions were utilized, averaging 2.6 incisions per patient (range: 2-6) with the flexor carpi radialis and dorsal distal radius approaches occurring in 86 and 78% of cases, respectively. One patient was identified as having a pyogenic granuloma along an incision. However, two patients were identified as having wound concerns, including fracture blisters ( n = 1) and wound margin epidermolysis ( n = 1) along the incision. There were no cases of skin bridge necrosis, delayed healing, wound dehiscence, or infection. Conclusions There is no increased risk of wound healing complications with the use of multiple skin incisions (≥2) in the surgical management of distal radius fractures, afforded by the abundant and robust angiosomes around the wrist. Surgeons should have the confidence to utilize the necessary number of skin incisions to effectively reconstruct distal radius fractures.