Faculty Bibliography

BACKGROUND:Corticosteroid injections are a first-line treatment of trigger finger and de Quervain's tenosynovitis. Little research has evaluated preinjection patient-reported outcomes as a predictive factor for treatment success following corticosteroid injection. We hypothesized that patients with less pretreatment impairment would demonstrate greater post-treatment improvement than patients whose function was more severely impaired. METHODS:We retrospectively reviewed prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) scores in patients undergoing corticosteroid injection for trigger finger or de Quervain's tenosynovitis from 2017 to 2023. Independent variables were patient baseline characteristics, comorbidities, and baseline PROMIS UE. The primary outcome was treatment success between 30 days and 12 weeks, defined as achieving the minimal clinically important difference for PROMIS UE without undergoing surgery. RESULTS:= .44). CONCLUSION/CONCLUSIONS:Corticosteroid injection provides meaningful improvement for a subset of trigger finger and de Quervain's tenosynovitis patients. Corticosteroid injection remains a first-line treatment for trigger finger and de Quervain's tenosynovitis patients, especially for those with more severe functional impairment.

The diagnosis and treatment of fast-flow arteriovenous malformations with or without dynamic arteriovenous fistulae in the upper limb can be both frustrating and daunting for the hand surgeon. The clinical presentation can vary from an incidental finding to a pulsating mass, threatening the entirety of the upper extremity and precipitating cardiac failure secondary to diverging vasculature. Non-operative treatment is appropriate for the small, minimally symptomatic mass. However, considerable controversy remains regarding the management of symptomatic lesions, specifically regarding the utility of embolization or sclerotherapy and the aggressiveness of surgical resection, concepts that are dependent primarily on both the size and location of the lesion. Although classification schemes exist, which attempt to stratify the severity of the lesion encountered by the upper-extremity surgeon, they make no attempt to categorize its location based on clinical relevance. Therefore, our purpose was to review the etiology, clinical presentation, and management of arteriovenous malformations in the upper limb and to refine the present classification to include present treatment options for this uncommonly encountered pathology.

INTRODUCTION/BACKGROUND:Frailty, a physiological decline in functional capacity, may influence nonunion risk. This study aimed to investigate the association between frailty, as measured by the modified Frailty Index-5 (mFI-5), and the likelihood of nonunion fractures of the upper extremity. METHODS:This retrospective cohort study utilized the national inpatient sample (NIS) from 2015 to 2019. Patients aged 18 and older with upper extremity fractures, identified by ICD-10-CM codes, were included. Patients were categorized into routine healing and nonunion groups. Frailty was assessed using the mFI-5, classifying patients as robust, prefrail, frail, or severely frail. Multivariate logistic regression, controlling for age, sex, and Injury Severity Score (ISS), was performed to determine the association between frailty and nonunion. RESULTS:The study included 21,618 patients, with 3782 presenting with nonunion fractures. The median age was 69 years, and 60.5% were female. The most common fracture types in the routine healing group were forearm (40.1%), clavicle (18.4%), and humerus (16.9%), while in the nonunion group, humerus (30.4%) and scapula (32.1%) were most common. Multivariate logistic regression showed that frail and severely frail patients had a decreased risk of nonunion (OR 0.751 and 0.705, respectively, p < 0.001). Each unit increase in mFI-5 score was associated with a decreased risk of nonunion (OR 0.868, p < 0.001). Sub-analysis revealed a decreased risk of nonunion with increasing frailty for humerus, clavicle, scapula, and phalanx fractures, but no significant association for wrist, forearm, or metacarpal fractures. CONCLUSION/CONCLUSIONS:Contrary to expectations, increasing frailty, as measured by the mFI-5, was associated with a decreased risk of nonunion fractures in the upper extremity. This paradoxical finding may be due to closer medical supervision and improved treatment compliance in frail patients. Further prospective studies are needed to explore the complex interplay between frailty, treatment adherence, and fracture healing.

INTRODUCTION/UNASSIGNED:Managing open distal radius fractures (DRFs) poses challenges. While preventing surgical site infection (SSI) involves prompt antibiotic administration and thorough irrigation and debridement, the impact of urgent intervention on reducing postoperative infection rates is debated. We hypothesize that timing of surgery does not significantly affect the incidence of SSI in open DRF treated within or after 24 hours from time of injury. METHODS/UNASSIGNED:We retrospectively analyzed the American College of Surgeons Trauma Quality Improvement Program from 2011 to 2021. We focused on outcome variables, including superficial SSI and deep SSI or osteomyelitis. To evaluate the relationship between time to operative intervention and SSI rates, we employed least absolute shrinkage and selection operator and multivariate regression models, adjusting for patient-specific factors and injury severity. RESULTS/UNASSIGNED:= .013) was significantly associated with increased rates of superficial SSI. CONCLUSIONS/UNASSIGNED:Extended time to surgery correlates with a modest rise in deep SSI incidence in open DRF. However, there was no heightened risk of superficial SSI in patients with delayed surgery. Polytrauma, alcohol use disorder, and diabetes were linked to elevated SSI rates in open DRF.

Incision of the dorsal side of the tendon sheath in release of De Quervain's tenosynovitis has traditionally been advocated to prevent the risk of volar tendon subluxation. We describe a novel technique of complete excision, rather than simple incision, of the first dorsal compartment tendon sheath. Over a 10-year period, 147 patients (154 wrists) underwent first dorsal compartment release using this technique of complete excision of the sheath. No postoperative immobilization is used. Patients were followed for a mean of 7.0 months. Records were assessed for any complications including reoperation, tendon subluxation, recurrence, wound complications, scar tenderness, and superficial radial sensory nerve paresthesias. There were no cases of recurrence, reoperation, or tendon subluxation after release with this technique. Postoperatively, 7 (4.5%) patients had scar tenderness and 5 (3.2%) of these patients also had superficial radial sensory nerve parasthesias, which all resolved at the time of final follow-up. Mean range of motion was 73±11 degrees of flexion and 69±10 degrees of extension. In contrast to simple incision, we propose that this technique provides a more complete release of the compartment without risk of symptomatic subluxation or bowstringing and provides a complete release of a separate extensor pollicis brevis subsheath or any concomitant retinacular cysts associated with the tendonitis. There is an immediate removal of the symptomatic swelling and visible, painful bump associated with the thickened retinaculum with this technique. Furthermore, no immobilization is required after surgery.

BACKGROUND:Corticosteroid injections are widely used for treating thumb carpometacarpal (CMC) arthritis, yet the accuracy of non-image-guided injections in expert hands is uncertain, with prior studies reporting intraarticular placement in about 60% of thumbs when performed by physicians with different levels of training. Despite their common use, there is a need to assess both the accuracy and the short-term clinical efficacy of these injections, particularly when performed without image guidance by fellowship-trained hand surgeons. QUESTIONS/PURPOSES:(1) What is the accuracy of thumb CMC injections performed without image guidance by fellowship-trained hand surgeons in an office setting? (2) What is the short-term efficacy of thumb CMC injections performed without image guidance? METHODS:We prospectively enrolled 33 patients with a mean ± SD age of 63 ± 12 years, 76% (25) of whom were female, with symptoms of basal joint arthritis that persisted despite conservative treatment, and we administered 1.5-mL corticosteroid injections without image guidance. We used descriptive statistics to analyze the outcomes, which included VAS, QuickDASH (Q-DASH), and Thumb Disability Examination (TDX) scores. Minimum clinically important differences (MCIDs) were defined as 0.9 points for the VAS, 18 points for Q-DASH, and 17 points for TDX. RESULTS:Of the 33 injections analyzed, 79% (26) were intraarticular. At 6 weeks, patients reported a mean improvement of 22 points in QuickDASH, 24 points in TDX, and 4 points in VAS scores. Importantly, 73% (24 of 33), 55% (18 of 33), and 82% (27 of 33) of the patients achieved the MCID in the patient-reported outcomes, respectively, suggesting that even without image guidance, corticosteroid injections can provide effective short-term relief for thumb CMC arthritis. CONCLUSION:We found that about 79% of injections were placed intraarticularly, which was comparable with the findings of previous studies using image guidance, and provided meaningful improvements in pain and function for 6 weeks. These findings suggest that for experienced fellowship-trained hand surgeons, non-image-guided injections remain a viable option. Future studies should explore long-term outcomes and the potential role of adjunctive treatments such as antiinflammatory medications and splinting to enhance patient care. LEVEL OF EVIDENCE:Level II, therapeutic study.

PURPOSE/OBJECTIVE:The purpose of this study was to conduct a systematic review evaluating the reported complications and outcomes of bone-anchored prostheses in digit and partial hand amputees. METHODS:A literature review of primary research articles on osseointegration and bone-anchored prostheses for digit and partial amputees was performed. The Medline, Embase, Scopus, and Cochrane Library databases were queried. Inclusion criteria were journal articles that evaluated osseointegration and bone-anchored prostheses in digit and partial hand amputees. The main outcome measures were reported complications and the need for revision surgery. Secondary outcomes included all reported outcome assessments. RESULTS:Fifteen articles were included with publication dates ranging from 1996 to 2022. The sample sizes ranged from single-patient case reports to a 13-patient retrospective study. Overall, 33 men and 16 women were reported with a mean age of 33.6 years (range: 12-68) and a total of 71 amputated digits. The median follow-up was 2.1 years (IQR: 1.1-6.8 years). A total of 24 complications were reported in 14 digits (19.7%). Complications included superficial infection in 6 digits (8.5%), abutment loosening or failure in 5 (7%), fixture aseptic loosening in 4 (5.6%), deep infection in 1 (1.4%), and soft tissue instability in 1 (1.4%). Sixteen revision surgeries or component changes were reported. CONCLUSIONS:Bone-anchored prostheses using osseointegrated implants in the hand are associated with favorable outcomes in the limited number of low-quality studies available for review. Superficial infections and implant-related failures were the most frequently reported complications. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Systematic review IV.

Scaphoid nonunions are a complex challenge that are frequently encountered by hand surgeons. Because of the tenuous blood supply of the scaphoid and secondary deformities that occur as a result of delayed or unsuccessful treatment, the treatment of scaphoid nonunions frequently requires the use of internal fixation and supplemental bone graft. There are multiple bone graft sources and techniques that can be employed based on the patient, the viability of the proximal pole fragment, and the presence of a deformity. Without osteonecrosis or disruption of the scaphoid blood supply, nonvascularized autologous grafts can be used from the distal radius, proximal ulna, or iliac crest. In cases where there is concern for an insufficient blood supply, vascularized bone graft sources can be employed, including pedicled local grafts and free flap grafts. When there is a nonviable and fragmented proximal pole, using osteochondral autografts has become increasingly used to reconstruct the scaphoid. Bone graft substitutes can additionally be used to supplement the fixation construct. This review focuses on the indications and role of bone grafts in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment.

BACKGROUND/UNASSIGNED:This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS/UNASSIGNED:Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS/UNASSIGNED:One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION/UNASSIGNED:Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE/UNASSIGNED:Level IV.

Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.