Journal of the American Academy of Orthopaedic Surgeons最新文献

Dorsal wrist spanning plating has proven to be an effective, reliable, and versatile tool in the treatment of distal radius fractures and numerous other carpal conditions. Despite its shortcomings including a necessary second procedure for implant removal, this technique remains a very useful option in the upper extremity surgeon's toolbox. This article reviews the historical development, expanding indications, and technical details of temporary wrist spanning plate fixation.

Background: There is no consensus on whether the benefits of participating in formal hand therapy outweigh the investment required for patients following basal joint arthroplasty. The purpose of this study was to compare patient-reported and functional outcome measures between patients who did and did not participate in formal hand therapy following basal joint arthroplasty. Furthermore, we evaluated the distance patients traveled and the financial burden associated with participating in formal hand therapy.

Methods: Using a retrospective cohort study design, patients who underwent primary basal joint arthroplasty by the fellowship-trained orthopaedic hand surgeons at our institution between 2021 and 2023 were included in this study. Patients who did not have complete data or had revision surgery were excluded. Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) scores, Kapandji scores, therapy data, and therapy costs were collected. Mann-Whitney U -tests, chi square tests, and Z-tests were used for statistical analysis. The cutoff for statistical significance was set at P < 0.05.

Results: A total of 73 surgeries in 70 patients were included in this study; 33 out of 73 surgical encounters participated in formal therapy after surgery. The median max Kapandji score and mean increase in PROMIS UE score were higher in the therapy users compared with nontherapy users. Although these differences in PROMIS UE scores were not statistically significant, they were greater than the proposed minimal clinically important difference. Formal hand therapy users did attend more postoperative clinic appointments than nontherapy users. Both the patient-reported and standardized estimated cost of therapy and postoperative clinic appointment cost were higher for therapy groups compared with nontherapy groups.

Conclusion: The results of this study suggest that although there is no statistically significant difference in PROMIS UE improvement between groups, formal hand therapy may provide a clinically meaningful benefit.

Background: There are many systemic or local factors that can disrupt wound healing process. The aim of the study is to evaluate the effect of serum vitamin D levels on the wound healing process after open carpal tunnel release surgery.

Methods: This study is a single-center retrospective analysis of patients treated between December 2022 and June 2024. Patients who underwent OCTR surgery under wide-awake local anesthesia with no tourniquet were included. Patients with comorbidities and risk factors known to negatively affect the wound healing process were excluded. Preoperative 25-hydroxyvitamin D levels were recorded. On the 14th postoperative day, patients were evaluated for wound healing status and categorized into two groups: "delayed wound healing" and "normal wound healing."

Results: Forty-six women (83.6%) and nine men (16.4%) with a mean age of 51.7 years were included. Normal wound healing was observed in 34 patients (61.8%), whereas delayed wound healing was observed in 21 patients (38.2%). The mean 25-hydroxyvitamin D level was 19.66 ng/mL in the normal wound healing group, whereas it was 11.05 ng/mL in the delayed wound healing group ( P = 0.001). Of the 12 patients with a 25(OH)D level ≥20 ng/mL, only one patient (8.3%) experienced delayed wound healing, whereas among the 43 patients with a level <20 ng/mL, 20 (46.5%) had delayed wound healing ( P = 0.02). The Boston Carpal Tunnel Questionnaire total scores at the postoperative 1st month were found to be superior in the normal wound healing group compared with the delayed wound healing group (2.04 ± 0.34 vs. 2.23 ± 0.33, respectively, P = 0.04). However, no significant difference was found in clinical scores at the 3rd postoperative month (1.62 ± 0.31 vs. 1.69 ± 0.35, P = 0.30).

Conclusion: There is an association between vitamin D deficiency and delayed wound healing after OCTR surgery.

Introduction: The surgical treatment of distal radius fractures is one of the most common procedures performed by orthopaedic surgeons. Intraarticular fracture patterns, specifically those involving the volar lunate facet, can be particularly problematic because this fragment is crucial to radiocarpal and distal radioulnar joint (DRUJ) stability. The problems associated with these patterns are attributed to the anatomy of the volar ulnar corner of the distal radius as well as the limitations of conventional volar distal radius implants and common surgical exposures.

Methods: This article will review the distal radius anatomy specific to the volar ulnar corner; a review of conventional distal radius volar plating technique; indications and associated complications of instability of the volar lunate facet; and techniques for volar lunate facet fixation.

Results: Fractures of the volar lunate facet are typically associated with fracture patterns involving the entire distal radius articular block with varying degrees of comminution, but it is not uncommon to encounter these fractures in isolation as well. There are many techniques and constructs available to treat these fractures, all of which involve careful preoperative planning and precise execution.

Discussion: The appropriate placement of volar distal radius plates is critical, and when performed, can address most intraarticular distal radius fractures that do not include the subset of fractures with smaller volar lunate facet fragments. Adequate intraoperative fluoroscopy with visualization of the incisura of the DRUJ should furthermore be achieved to avoid intraarticular penetration of the DRUJ. At the conclusion of fixation, lateral and inclined lateral fluoroscopic imaging should be obtained to confirm extraarticular screw placement proximal to the lunate and scaphoid facets, respectively. Consideration of an intraoperative assessment is warranted given the potential instability of these fractures.

Introduction: Acellular nerve allografts (ANAs) are increasingly used for peripheral nerve repair. However, the effect of industry sponsorship on reported outcomes remains unclear. This review evaluates functional outcomes following upper extremity nerve reconstruction with ANAs, stratified by conflict of interest (COI).

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided search of MEDLINE, PubMed, and Embase identified clinical studies using ANAs. Data extracted included study design, patient age, nerve gap length, outcome measures (Medical Research Council Classification, Disabilities of the Arm, Shoulder, and Hand, visual analog scale), and COI status. Outcomes were compared using independent t -tests.

Results: Twenty-eight studies met inclusion criteria. Non-COI studies involved older patients and longer nerve gaps. Motor recovery was markedly higher in COI studies compared with non-COI studies (69.8% vs. 14.1%; P < 0.001), whereas sensory recovery also differed markedly (25.9% vs. 80.4%; P < 0.001).

Discussion: These findings suggest that outcome reporting may be influenced by funding source. The use of subjective measures and study design limitations further complicate objective interpretation.

Conclusion: Although ANAs offer promise, current evidence is shaped by sponsorship bias. Future research should prioritize standardized, objective assessments, and independent, prospective studies to guide clinical decision making.

Background: Dorsal wrist spanning plate (DWSP) fixation is a technique used to treat distal radius fractures with severe metaphyseal comminution, diaphyseal extension, and other complex fracture patterns. One concern of this technique is the potential risk of stiffness due to prolonged immobilization. The purpose of our study was to examine the association of DWSP duration on range of motion (ROM) outcomes after plate removal.

Methods: Patients who underwent DWSP fixation for distal radius fracture with greater than 6 months of follow-up after DWSP removal at a single institution were retrospectively identified. Patients with a concomitant upper extremity injury were excluded. The primary outcome of interest was ROM. Secondary outcomes included visual analog scale pain scores and radiographic measurements. A piecewise regression analysis was run to evaluate for a nonlinear relationship between DWSP duration and ROM.

Results: Fifty-one patients were included for analysis. DWSP removal occurred at a mean of 110 days (range, 59-182 days). Median duration of follow-up after DWSP removal was 11.7 months (interquartile range = 8.2 months to 1.8 years). No significant association was observed between DWSP duration and visual analog scale ( P = 0.11), complication rate ( P = 0.45), radial inclination ( P = 0.57), radial height ( P = 0.74), or volar tilt ( P = 0.13). Piecewise regression demonstrated a statistically significant reduction in supination ( P = 0.001), pronation ( P = < 0.001), and wrist flexion ( P = 0.014) for DWSP >120 days when controlling for age, sex, polytrauma, duration of follow-up, and additional fixation.

Discussion: There is a nonlinear association between DWSP duration and wrist ROM (flexion, supination, and pronation). When DWSP duration is longer than 120 days, there is a negative correlation with ROM when controlling for covariates. When DWSP duration is less than or equal to 120 days, there is no correlation with ROM. Our findings suggest that patients with longer duration of DWSP duration (>120 days) are more likely to have range-of-motion limitations; additional research is necessary to determine whether implant retention longer than 120 days by itself or fracture or patient-specific factors which require longer implant retention are the causative agents for this motion limitation.

Level of evidence: Retrospective cohort, Level IV.

Background: Campanacci grade III and recurrent giant cell tumors (GCTs) of the distal radius are aggressive, but treatments are scare, and universally accepted surgical strategy has not been established. The purpose of this study was to compare the clinical outcomes of different surgical methods for these tumors.

Methods: We retrospectively analyzed 26 patients with Campanacci grade III or recurrent GCT of the distal radius between 2017 and 2023 in this study. Patients were divided into intralesional curettage group (n = 12) and wide excision group (n = 14). According to the different reconstruction methods, the wide excision group was further divided into two subgroups, including the arthroplasty subgroup (n = 8) and the arthrodesis subgroup (n = 6). All patients underwentsurgeries, and perioperative denosumab was recommended. Pre- and postoperative active range of motion (ROM) of the wrist, grip strength, visual analog score, Mayo wrist score and Musculoskeletal Tumor Society score were assessed. Postoperative complications, denosumab application, and tumor recurrence were also evaluated.

Results: The intralesional curettage group was superior to the wide excision group in reservation of ROM of the wrist but related to higher local recurrence rate (25% vs. 7.1%). Postoperative pain relief and satisfaction of the patients were more obvious in the wide excision group compared with the intralesional curettage group. Arthroplasty and arthrodesis following wide excision provided similar improvements in grip strength, visual analog score, Mayo wrist score, and Musculoskeletal Tumor Society scores after surgery. Arthroplasty better reserved ROM of the wrist but associated with more complications especially wrist instability and revision surgery than arthrodesis. Arthrodesis restricted flexion, extension, and radial and ulnar deviations of the wrist but related to few instability complications.

Conclusion: Wide excision was the preferred choice for Campanacci grade III and recurrent GCT of the distal radius considering adequate local control, good pain relief, and satisfaction. Extended intralesional curettage with postoperative denosumab administration was also a reasonable alternative with better functional outcomes but increased risk of recurrence and possibility of wide excision revision surgery in the future. Arthroplasty following wide excision could reserve the motion of wrist but associated with frequent wrist instability and relatively high revision surgery rate. Arthrodesis could ensure a more stable wrist, and it is recommended for manual workers.

Level of evidence: Level III; Retrospective Cohort Comparison; Treatment Study.

The sport of golf is recognized as a lifelong activity enjoyed by individuals of all ages, and part of its popularity with the aging population is due to its low impact nature. It has been shown to provide many mental and physical health benefits. With increasing participation, surgeons will encounter patients looking to return to sport after elective orthopaedic surgery. The aim of this review is to evaluate the effects of elective orthopaedic surgery on a patient's ability to return to golf. Total hip arthroplasty, hip arthroscopy, total knee arthroplasty total ankle arthroplasty, and total shoulder arthroplasty all have a return-to-play rate above 85% with slightly lower return-to-play rates for reverse shoulder arthroplasty, rotator cuff repair, and lumbar spinefusion. This review will elucidate how elective orthopaedic surgery on the primary joints affects individual return to play, the timeline of recovery, and how best to advise future patients on the recovery process.

Background: Volar plate fixation is a common surgical fixation method for distal radius fractures. The aim of the study was to perform a large-scale quantitative analysis of intact distal radius anatomy to (1) investigate the demographic and anatomical factors associated with lengths of locking screws for volar plate fixation and (2) determine the optimal screw distribution in a single-use distal radius set for the overall patient cohort, ensuring inclusion of all necessary screws while minimizing waste.

Methods: CT scans from 198 wrists with an intact distal radius were evaluated. An open-source software module was used to automatically segment the distal radius and assemble a 3-dimensional anatomy for each patient. A quantitative map was computed to represent thickness across the volar surface. Variation in thickness was assessed in quantiles at the articular surface of the distal radius, using multivariate mixed modeling with respect to metaphyseal screw length and patient demographics.

Results: Calculated across the entire patient cohort, the mean (95% percentile range) for each screw position was 10.2 (9.0 to 13.0) mm for the metaphyseal screw, 9.42 (6.7 to 13.8) mm for Qu1, 15.3 (11.4 to 20.5) mm for Qu2, 19.22 (15.6 to 22.3) mm for Qu3, 19.39 (16.2 to 23.0) mm for Qu4, and 16.22 (10.3 to 19.7) for Qu5. Female patients had a smaller mean thickness than male patients at Qu2 (-1.93 mm, P = 0.003), Qu3 (-1.90 mm, P = 0.003), Qu4 (-1.99 mm, P = 0.002), and Qu5 (-2.21 mm, P < 0.001). For every 1 mm decrement in metaphyseal screw length, thickness was estimated to decrease by 0.518 mm ( P < 0.001) at Qu2, 0.462 mm ( P = 0.002) at Qu3, and 0.462 mm ( P = 0.004) at Qu4.

Conclusion: A high-resolution, high-fidelity anterior to posterior quantitative thickness map was constructed. This was used to find an effect of sex and metaphyseal screw length on distal locking screw length and an overall 95% percentile distribution of screw lengths.

Introduction: Percutaneous needle fasciotomy (PNF) is a standard treatment for Dupuytren contracture. In some instances, clinicians administer intraoperative corticosteroids (ICS) and/or postoperative corticosteroids (PCS) alongside PNF to improve outcomes. However, few studies have systematically investigated the efficacy of ICS and/or PCS as adjuvant therapies to PNF. The purpose of this study was to review clinical outcomes between PNF alone and PNF with corticosteroid use in the treatment of Dupuytren contracture.

Methods: A systematic review was done in February 2024 using SCOPUS and OVID, including all level I-IV studies that reported outcomes of PNF, PNF/ICS, and PNF/PCS. Outcomes of interest included range-of-motion (ROM) improvement at the distal interphalangeal, proximal interphalangeal , and metacarpophalangeal joints of the affected digit, as well as complication rates. Secondary outcomes included Quick Disabilities of the Arm, Shoulder, and Hand scores and Unité Rhumatologique des Affections de la Main scores.

Results: Twenty-six studies were included (3,203 PNF patients, 840 PNF/ICS, 81 PNF/PCS, and 921 receiving general corticosteroid use). Twenty-one studies examined PNF alone, six examined PNF/ICS, and three studied PNF/PCS. In studies directly comparing groups, corticosteroid use was associated with greater ROM at final follow-up. PNF alone demonstrated the largest distal interphalangeal ROM gains and superior Disabilities of Arm, Shoulder, and Hand and Unité Rhumatologique des Affections de la Main scores but had the highest and most variable complication rates. PNF/ICS showed the greatest improvement in total joint ROM, while PNF/PCS yielded the largest metacarpal phalangeal and proximal interphalangeal ROM gains. General corticosteroid use showed superior ROM across all joints compared with PNF alone.

Discussion: Corticosteroid use alongside PNF improves objective ROM outcomes and reduces complication rates compared with PNF alone. However, subjective improvements favored PNF without corticosteroids. These findings suggest that corticosteroids may enhance functional outcomes while preserving the minimally invasive benefits of PNF.