Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Several statistical models have been developed to predict the stability of distal radius fractures after closed reduction, but their findings have not been consistently reproduced. We aimed to develop a machine learning (ML) model to predict radiographic outcomes of nonsurgically treated distal radius fractures based on pre-reduction and postreduction radiographic parameters and demographic variables.

Methods: Adults with displaced distal radius fractures at a single institution between 2012 and 2024 were identified through retrospective chart review. Inclusion criteria required closed reduction in the emergency department, with radiographs obtained before reduction, immediately after reduction, and 6 weeks after reduction. At 6 weeks, treatment outcomes were classified as "success" or "failure" based on American Academy of Orthopaedic Surgeons acceptable reduction parameters. Five ML models were trained to predict 6-week outcomes using demographic data and pre-reduction and postreduction radiographic measurements. The 10 parameters with highest Shapley values for predictive ability were used to create an interpretable composite model.

Results: Among 1,227 patients, 152 met the inclusion criteria (mean age: 61.4 ± 20.2 years; 75.7% female). The composite model correctly predicted outcomes in 25 of 31 patients, achieving an accuracy, precision, and recall of 81%; area under the curve of 0.84; and F1 score of 0.81. Restoration of postreduction palmar tilt, radial height, and excellent reduction based on the Lindstrom score were most predictive of 6-week radiographic outcomes. The best performing decision tree showed the following cutoffs predictive of treatment failure: +4.7 mm of pre-reduction ulnar variance, 8° of postreduction dorsal tilt, and <18.8° of postreduction radial inclination.

Conclusion: This study developed an ML model that accurately predicts 6-week radiographic outcomes in nonsurgically treated distal radius fractures. Postreduction parameters were the strongest predictors, underscoring the importance of a high-quality closed reduction. This study validates the potential of ML as a predictive tool in this setting.

Two-incision anterior cruciate ligament reconstruction (ACLR) is a well-established technique used to perform an arthroscopically assisted ACLR. Historically, this approach to ACLR was once considered the benchmark; however, with evolving arthroscopic technology and the rise of more minimally invasive techniques, this approach to ACLR has become less popular. The two-incision technique still has notable clinical utility because it can (1) increase the surgeon's ability to perform a single-stage revision ACLR and (2) help avoid graft-tunnel mismatch in primary ACLR with a patellar tendon autograft when encountering a long tendon. This technique, when coupled with metal screws and an autograft tendon, is also the lowest cost ACLR technique that allows independent femoral tunnel positioning and thus should be considered as an option for primary ACLR by surgeons prioritizing cost containment without compromising surgical outcomes.

Index through small carpometacarpal joint dislocations and fracture dislocations are injuries that require early recognition to prevent future pain and dysfunction. This review article discusses the anatomy, mechanism of injury, classification, clinical examination, radiographic evaluation, and treatment options for these particular injuries. The goal of this review article is to provide the best treatment options for general orthopaedic surgeons and hand surgeons in the care of these injuries. The authors preferred method of treatment is also discussed.

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.