Faculty Bibliography

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.

The perception of patient reliability may create surgical decision-making biases amongst hand surgeons. In this study, anonymous surveys were distributed to hand surgeons to understand how patient 'reliability' is defined and how it alters treatment decisions. Participants rated the importance of patient factors in assessing reliability, then completed fictional clinical vignettes detailing histories of patients undergoing elective surgery. Suspected substance usage and history of mental illness were rated as important factors in determining reliability, while gender and race were rated as not important. Physicians were significantly less likely to recommend surgery and exhibited less confidence in their recommendations when presented with a patient with a history of mental illness (p < 0.001) or suspected substance usage (p = 0.003). These findings suggest that while race and gender may not explicitly impact surgical decision-making, biases related to mental illness and substance use do affect treatment decisions and confidence levels. Recognizing these biases is critical for ensuring equitable care, and future efforts should explore strategies to mitigate their impact on surgical recommendations. Level of evidence: IV.

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.

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.

Imaging plays an important role in evaluating peripheral nerves. In the preoperative setting, imaging helps overcome pitfalls of electrodiagnostic testing and provides key anatomical information to guide surgical management. In the postoperative setting, imaging also offers key information for treating physicians, although it comes with several challenges due to postsurgical changes and alteration of normal anatomy. This article reviews our approach to peripheral nerve imaging, including how we use imaging in the pre- and postoperative setting for several common indications.

BACKGROUND/UNASSIGNED:. In this video article, we present the exploration of a complex BPI in which the creation of a gracilis free flap is executed for elbow flexion reconstruction. We provide a comprehensive guide from markings, flap elevation, microsurgical technique, and inset, with educational operative pearls at every step. DESCRIPTION/UNASSIGNED:The procedure involves harvesting the gracilis muscle as a free functioning muscle transfer. The gracilis, which will become a type-II muscle flap, is carefully dissected with its pedicle and nerve preserved. The muscle is then transferred to the upper extremity, where its proximal origin is anchored to the clavicle and its distal tendon is inserted into the biceps tendon with use of a Pulvertaft weave. Vascular anastomoses are performed utilizing branches of the thoracoacromial trunk and venous couplers under a microscope. The muscle is innervated with the spinal accessory nerve and tensioned to ensure optimal elbow flexion. ALTERNATIVES/UNASSIGNED:Surgical alternatives include nerve transfers (e.g., Oberlin transfer), tendon transfers, or other free muscle transfers (e.g., latissimus dorsi transfer). Nonsurgical alternatives include orthotic devices to compensate for elbow flexion loss, and physical therapy to maximize existing function. RATIONALE/UNASSIGNED:. Unlike orthotic devices, this technique provides active elbow flexion, critical for functional independence. The long tendon and reliable vascular pedicle make the gracilis ideal for this purpose. EXPECTED OUTCOMES/UNASSIGNED:. These findings suggest that free gracilis muscle transfer provides reliable functional improvements, enabling meaningful elbow flexion restoration and enhancing quality of life. IMPORTANT TIPS/UNASSIGNED:Utilize Doppler ultrasound to confirm the location of a skin perforator over the gracilis to aid in postoperative monitoring.Preoperative markings are key. Mark the orientation of the gracilis muscle belly and pedicle preoperatively for efficient harvesting.The gracilis inserts distal to the knee, so extending the knee can help distinguish it from the adductor longus.Preserve all fascia over the gracilis muscle to optimize muscle gliding.Ensure proper resting tension during gracilis insertion to prevent over- or under-tightening, optimize function, and avoid complications like hyperextension or limited flexion.Position the elbow at 90° of flexion and the forearm in supination when tensioning.Make accommodation for any vessel size mismatch between the gracilis pedicle and recipient vessels to minimize complications.Confirm intraoperative vessel patency with use of Doppler flow checks after completing the anastomoses.Confirm nerve viability intraoperatively with use of nerve stimulation, ensuring a strong muscle contraction response.Secure the nerve repair without tension and with the appropriate coaptation in order to maximize reinnervation success.Utilize drains to avoid fluid collections that can create pressure on the pedicle.Place the gracilis tendon insertion precisely with use of the Pulvertaft weave technique, ensuring secure fixation and proper alignment with the biceps tendon. ACRONYMS AND ABBREVIATIONS/UNASSIGNED:BPI = brachial plexus injuryDASH = Disabilities of the Arm, Shoulder and HandDVT = deep vein thrombosisEMG = electromyographyFFMT = free functioning muscle transferFGMT = free gracilis muscle transferICN = intercostal nerve transferM3/M4 = muscle strength grade 3 or 4MCA = medial circumflex arteryMCN = musculocutaneous nerveNCS = nerve conduction studyPPX = prophylaxisSAN = spinal accessory nerveSF-36 = Short Form-36.