Faculty Bibliography

INTRODUCTION/BACKGROUND:Owing to the scaphoid's retrograde blood supply, fractures can compromise perfusion to the proximal pole, making it vulnerable to avascular necrosis (AVN) or irreversible bone death. Despite their differing prognoses, both conditions are evaluated using the same diagnostic methods. This review aims to determine the most reliable method of distinguishing between AVN and irreversible bone death, considering factors such as magnetic resonance imaging (MRI), computed tomography (CT), intraoperative findings, and histology. METHODS:A comprehensive literature search was conducted until November 2024. The diagnostic methods and criteria for AVN were collected, and the outcome was measured dichotomously as either resolution of AVN or irreversible bone death. Each AVN diagnostic method was categorized and the healing outcomes of all patients diagnosed with AVN in the study were compared. RESULTS:This systematic review included 27 studies and 423 patients. With regard to AVN healing, 195 out of 223 patients diagnosed with AVN via MRI eventually healed. Of those diagnosed with AVN via CT, nine out of 21 went on to heal, as did 308 out of 356 patients with no intraoperative punctate bleeding. Histologic evaluation had the lowest incidence of AVN resolution, with only six out of 19 patients healing. CONCLUSION/CONCLUSIONS:All diagnostic methods identified AVN resolution and irreversible bone death. However, all patients were solely diagnosed with AVN. There is no standardized method for diagnosing irreversible bone death because the existing literature conflates irreversible bone death with AVN, despite their distinct pathologies and prognoses. Consequently, our understanding of AVN and the point at which irreversible bone death occurs in the scaphoid is limited.

BACKGROUND:Avascular necrosis (AVN) of the proximal pole is a well-known complication of scaphoid fractures. Avascular necrosis is poorly understood, including the transition from ischemia to necrosis, optimal treatment, and why some AVN heals but others do not. The primary purpose of this study is to evaluate patient-related factors that are associated with healing outcomes in individuals with proximal pole AVN following scaphoid fractures. METHODS:This is a retrospective review of all patients diagnosed with scaphoid proximal pole AVN secondary to a fracture from 2018 to 2024 in a single center. Patient baseline characteristics and comorbidities at time of diagnosis were collected. If the patient underwent surgical management, procedural factors were collected. The primary outcome was AVN healing after 4 months of follow-up. RESULTS:= .886, respectively). CONCLUSIONS:Hyperlipidemia, elevated BMI, and advanced age are patient factors negatively associated with scaphoid proximal pole AVN healing-key information for accurately assessing patient prognosis. For surgical management, the choice of a vascularized bone, nonvascularized bone graft, or no graft does not significantly impact AVN healing.

BACKGROUND:This study examined whether the timing of total hip or knee arthroplasty (TJA) relative to elective hand surgery (HS) is associated with perioperative TJA outcomes, as both are among the most common orthopaedic procedures in the United States. METHODS:A retrospective cohort study was conducted of patients who underwent elective HS and TJA between 2011 and 2024. Patients were grouped by surgical order: HS first (HSF, n = 645) and TJA first (TJAF, n = 785). Differences between HSF and TJAF were assessed. Multivariable logistic regressions, Cox proportional hazards regressions, and linear regressions were used to adjust for patient demographics and comorbidities. The HSF patients were older (67.1 versus 64.3 years, P < 0.001), more prone to be discharged home (90.7 versus 83.8%, P < 0.001), and had a shorter length of stay (45.6 versus 60.4 hours, P < 0.001) compared to TJAF patients. RESULTS:Surgical order showed no association with 90-day emergency department visits and readmissions. Multivariable Cox regressions revealed that HSF was associated with a significantly higher hazard of aseptic revision (hazard risk (HR) = 2.65, P = 0.012). Functional TJA outcomes did not differ (P > 0.05) between groups. Although both groups improved in Patient-Reported Outcomes Measurements Information System (PROMIS) Pain Intensity and Pain Interference scores after TJA, HSF patients showed significantly less improvement in Pain Intensity at all timepoints (P < 0.05). Surgical order was not associated with improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Hip Injury and Osteoarthritis Outcome Score for Joint Replacement, or PROMIS Pain Interference scores. CONCLUSIONS:The timing of these elective surgeries is associated with TJA outcomes. While HSF is linked to a higher adjusted risk of aseptic revision, it is also independently associated with less adjusted improvement in PROMIS Pain Intensity. These findings suggest that although surgical order impacts specific recovery metrics, a patient's comorbidities may be the primary driver of complications.

The scapholunate ligament (SLL) is a critical stabilizer of the wrist joint. Disruption of the SLL leads to altered wrist kinematics, including scaphoid flexion, lunate extension, and increased stress on surrounding cartilage and ligaments, which can progress to dorsal intercalated segment instability and scapholunate advanced collapse. Despite predictable biomechanical changes, clinical outcomes vary widely because some patients develop significant functional limitations, whereas others remain asymptomatic. Nonoperative management, including immobilization, therapy, and bracing, remains the first-line treatment for partial tears or stable injuries. Surgical intervention, such as SLL repair with capsulodesis or reconstruction, is indicated for cases with persistent pain, instability, or functional deficits. Capsulodesis is a commonly used adjunct to SLL repair. Multiple surgical techniques exist for SLL repair in the acute setting and for reconstruction in the chronic setting when SLL is deemed irreparable. Although several surgical techniques are available for chronic injuries, a gold standard has not yet been established.

BACKGROUND:While radiographic outcomes after distal radius fractures (DRFs) are emphasized in clinical guidelines, several studies demonstrated that radiographic measures do not correlate with patient-reported outcomes (PROs), especially in patients aged ≥65 years. This study aims to determine whether fracture severity and radiographic parameters following fracture healing are prognostic of PROs, hypothesizing no strong association exists between these factors. METHODS:This study retrospectively reviewed prospectively collected Patient-Reported Outcomes Measurement Information System Upper Extremity Function (PROMIS UE) scores in patients sustaining acute DRF between January 2016 and January 2023 with a 6-month minimum follow-up. Independent variables were patient demographics, comorbidities, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification, and radiographic parameters following treatment. Multivariate linear regression analyzed associations between nonradiographic and radiographic parameters and PROMIS UE score. We performed subanalyses of patients treated operatively and nonoperatively and patients above and below the cohort's median age. RESULTS:In total, 385 patients were included, of which 193 were treated conservatively and 192 operatively. Multivariate analysis demonstrated no association of PROMIS UE score with AO/OTA fracture classification, ulnar variance, volar tilt, or radial inclination at 6 months. A subanalysis of patients aged ≤62 years showed that every degree increase in radial inclination was associated with 0.3-point decrease in PROMIS UE. CONCLUSIONS:This study found no robust relationship between patient-reported function and radiographic outcomes following DRF. Initial fracture severity, similarly, did not predict mid-term patient-reported function. Our findings support prior evidence that achieving reduction within the established range of radiographic parameters is sufficient for patient function. LEVEL OF EVIDENCE/METHODS:3, prognostic retrospective cohort 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.

BACKGROUND:This study aimed to evaluate the risk of fracture with weight-bearing after medial femoral condyle (MFC) harvest with varying harvest size and location using finite element analysis (FEA). METHODS:FEA evaluated the potential impact of MFC harvest on donor femur strength. Donor flaps were modeled as cubes of corticocancellous defects within the descending genicular angiosome (DGA). Stress and safety factors were recorded during simulated single-leg stance as a function of harvest size and location within the DGA. An S-N curve was used to determine the number of cycles to failure due to stress. RESULTS:cycles). CONCLUSIONS:Our results suggest that small corticocancellous flaps centered no more than 0.5 cm proximal to the medial epicondyle are the most favorable for harvest, resulting in physiologically tolerable stress values on the donor femur during single-leg stance. Caution and potential weight-bearing restrictions should be considered when harvesting larger and more proximally based flaps. LEVEL OF EVIDENCE/METHODS:Biomechanical study.

BACKGROUND:Severe proximal interphalangeal (PIP) contractures in Dupuytren disease significantly impair hand function and quality of life. Surgical correction is common, but the relationship between improved joint mobility and patient-reported outcomes remains unclear. This study evaluated surgical outcomes for severe PIP contractures and assessed patient-reported function using Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS:< .05). RESULTS:The study included 60 digits from 48 patients. Significant contracture reductions were observed across all groups, averaging more than 60%. However, PROMIS scores did not consistently reflect improvements in pain, activity interference, or upper extremity function. A significant decrease in upper extremity function was noted in group 3 (60°-89°). No operative complications or reoperations occurred. CONCLUSIONS:Surgical correction markedly improves joint contracture but does not consistently enhance PROMIS-reported outcomes. These results question PROMIS applicability in this context and highlight the need for alternative assessment tools to better address functional recovery in patients with severe PIP contractures.

BACKGROUND: While prior studies have recommended immediate flap coverage within 72 hours of injury for soft tissue reconstruction for traumatic extremity injuries, recent evidence in the setting of advanced wound care techniques de-emphasizes the need for immediate coverage. Negative-pressure wound therapy (NPWT) has been an essential tool for extending the time to definitive soft tissue coverage. This study sought to elucidate the impact of preoperative NPWT use on the success of microsurgical reconstruction. METHODS: A literature search was conducted using the following databases from their inception up to February 2023: PubMed, OVID databases (Embase and Cochrane Library), Web of Science, and Scopus. Of 801 identified articles, 648 were assessed and 24 were included. Cases were divided based on whether NPWT was used preoperatively or not. Timing to definitive coverage, injury details, and basic demographics were recorded. Rates of flap failure, infection, bone nonunion, reoperation, and complications were compared between groups. RESULTS: A total of 1,027 patients and 1,047 flaps were included, of which 894 (85.39%) received preflap NPWT. The average time to definitive coverage for the NPWT and non-NPWT groups was 16 and 18 days, respectively. The NPWT group experienced lower postoperative complication rates than the non-NPWT group in all reported complications except for deep infections. Compared with the non-NPWT group, the NPWT group experienced lower rates of any flap failure (3.69 vs. 9.80%) and partial flap failure (2.24 vs. 6.54%). CONCLUSION/CONCLUSIONS: Preoperative NPWT was associated with reduced postoperative complications, most importantly flap failure rates. This merits further investigation into the decision-making process for traumatic extremity reconstruction. Future prospective studies adopting standardized protocols with longer follow-up are required to better understand the potentially beneficial role of preoperative NPWT use in soft tissue reconstruction.