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Background: Distal radius fractures (DRFs) are common upper extremity fractures and often require surgical fixation when they are intraarticular. Preoperative computed tomography (CT) has emerged as a surgical planning tool to evaluate intraarticular DRFs. Although CT affords additional details, patients receive higher radiation doses than standard radiographs. We aim to develop a low-dose CT (LDCT) protocol, relative to the institutional standard-dose CT wrist for intraarticular DRFs although providing adequate detail for surgical decision-making., Methods: A single-institution prospective study was conducted on patients with intraarticular DRFs who underwent closed reduction and below-elbow splinting who otherwise would undergo wrist CT. Observations were defined as total measurements taken, with each view undergoing 44 measurements. Patients underwent 2 scans with a standard dose and a 10× dose reduction. Articular step and gap measurements were recorded in the sagittal and coronal images., Results: A total of 11 patients were enrolled (7 women and 4 men). The mean age was 55 years (SD = 20.1). There were a total of 4 reviewers: 1 attending surgeon, 2 resident physicians, and 1 student. When comparing LDCT and conventional-dose CT (CDCT), there were no significant differences in step and gap measurements across all reviewers., Conclusion: This study demonstrated that LDCT provides comparable imaging quality for surgical planning as a CDCT without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure. These results suggest that LDCT is an opportunity to reduce effective radiation in patients although providing beneficial preoperative imaging., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C.S.K. is a paid consultant for Acumed LLC, a paid consult with stock options for Restore3d, and a paid consultant for Smith and Nephew. All other authors declare that they have no conflict of interest.

Background: Percutaneous pinning has been the predominant technique for fixation of proximal phalanx fractures, but stiffness is a reported complication. The introduction of intramedullary (IM) nail fixation of proximal phalanx fractures provides a stronger biomechanical fixation for amenable fracture patterns with the added benefit of not tethering the soft tissue. The goal of this study was to compare the surgical outcomes of IM nail and percutaneous pin fixation in isolated proximal phalanx fractures., Methods: A retrospective review was performed at our institution between the years 2018 and 2022 for patients treated for proximal phalanx fractures. Patients that underwent fixation with IM nails or percutaneous fixation for isolated extraarticular proximal phalanx fractures were included. Patients were excluded if they had concomitant hand fractures, tendon injury, or intraarticular extension., Results: A total of 50 patients were included in this study. Twenty-eight patients received percutaneous pin fixation, and 22 patients underwent IM nail or screw fixation. There was no significant difference in injury patterns or demographics between these two groups. Patients that underwent IM nail fixation had a significantly quicker return to active motion, shorter duration of orthosis treatment, and fewer occupational therapy visits. In addition, patients in the IM fixation group had significantly improved range of motion (ROM) at 6 weeks postoperatively., Conclusions: This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. The IM nail fixation group was able to have quicker return to mobilization, fewer required occupational therapy visits, and improved early ROM., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: D.S.R. has received royalties from Acumed and Zimmer and serves as a consultant for Acumed and Depuy Synthes. M.J.R. has received royalties from Acumed and Field Orthopaedics and serves as a consultant to Acumed, DJO Global, restor3d, and Zimmer Biomet. All other authors have no conflicts of interest.

Background: Scaphoid nonunion advanced collapse (SNAC) is a common form of wrist arthritis, the treatment of which depends on the arthritic stage. The Vender classification serves to describe SNAC arthritis based on a single posteroanterior (PA) radiograph. The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Vender classification, comparing multi versus single radiographic views. Methods: A retrospective review of patients with SNAC arthritis who underwent a proximal row carpectomy or a 4-corner fusion was performed. The included patients had 3 radiographic views of the pathologic wrist. Fifteen patients were analyzed by 5 blinded reviewers. Wrists were graded using the Vender classification first on the PA view and then using multiview radiographs. The intraobserver and interobserver agreement was determined using weighted kappa analysis. χ 2 tests were calculated comparing the evaluation between single- versus multiview radiographs and determining a higher Vender stage. Results: Multiview radiographs demonstrated a higher intraobserver κ w compared with single-view radiographs (0.72 vs 0.66), both representing substantial agreement. The average interobserver agreement was moderate (κ w of 0.48) for single view and slight (κ w of 0.30) for multiview evaluation. Evaluating multiview radiographs was 6.37 times more likely to demonstrate Vender stage 3 arthritis compared with single view (odds ratio = 6.37 [confidence interval, 3.81-10.64], P < .0001). Conclusion: Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification. The decreased interrater reliability in the multiview analysis is likely related to the increased number of articular surfaces evaluated. Using a single PA view may underestimate the severity of arthritis present.

Background: The general teaching is that increased number of vein repairs in digit replantation leads to improved venous outflow, resulting in lower need for iatrogenic bleeding, lower postoperative transfusion requirements, and better survival rates. The purpose of this study was to determine whether the traditional teaching that emphasizes the repair of multiple veins per arterial anastomosis results in superior survival rates. Methods: A retrospective review of a single urban replant center's single-digit replants distal to the mid-metacarpal level in adult patients from 2007 to 2017 was performed. Data on patient demographics, mechanism and level of injury, veins repaired, iatrogenic bleeding, postoperative transfusions, and replant survival were obtained. Results: There were a total of 54 single-digit replants. The most common mechanism was lacerations (N = 38), and the most common injury level was at the proximal phalanx (N = 21). All digits were replanted with a single arterial anastomosis-44% via grafting. In all, 0 to 3 veins were repaired per digit (mean = 1.5 veins). The mean transfusion requirement was 1.7 units. The survival rate was 50%. Digits with 1 or 2 veins repaired had lower transfusion requirements (1.1-1.3 units) and higher survival rates (56%-61%) compared with those replanted with 0 or 3 veins repaired (2.9-3.5 transfused units, 25%-29% survival). There were no differences between those digits replanted with either 1 or 2 veins repaired for transfusion requirements or survival. Conclusions: More veins repaired do not necessarily improve survival or possibly venous outflow, calling into question the traditional teaching that 2 veins should be repaired for every arterial anastomosis.

Background: It is common teaching that treatment of index finger alone is a relative contraindication for arthroplasty of the proximal interphalangeal joint (PIPJ). However, limited data exist reporting the digit-specific complication of PIPJ arthroplasty for the treatment of osteoarthritis or posttraumatic arthritis. The purpose of this article is to perform a systematic review and meta-analysis of the literature to assess whether the 3 ulnar digits may bear a similar instability and complication profile. Methods: Systematic searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases were performed for PIPJ arthroplasty specifying by digit. We reviewed both descriptive and quantitative data to: (1) report aggregate instability and instability-related complications after non-index digit PIPJ arthroplasty; and (2) perform statistical testing to assess relative rates by digit and compared with index digits. Results: Computerized search generated 385 original articles. Five studies reporting digit-specific instability-related outcomes of silicone, pyrocarbon, or metal surface arthroplasty on 177 digits were included in the review. Meta-analysis demonstrated a 29% instability rate for long digits (n = 65), 6% for ring digits (n = 53), and 6% for small digits (n = 17), compared with 33% for index digits (n = 42). There was no difference in the overall deformity, instability, and complication rates of long versus index fingers ( P = .65). Conclusions: Instability-related deformity and complication rates of long finger PIPJ arthroplasty may not be different from that of the index finger. Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty. Future biomechanical and clinical studies are needed.

Background: Over 500 000 carpal tunnel releases costing over $2 billion are performed each year in the United States. The study's purpose is to perform a cost-minimizing analysis to identify the least costly strategy for carpal tunnel syndrome treatment utilizing existing success rates based on previously reported literature., Methods: We evaluate the expected cost of various treatment strategies based on the likelihood of further treatments: (1) a single steroid injection followed by surgical release; (2) up to 2 steroid injections before surgical release; (3) 3 steroid injections before surgery, and (4) immediate surgical release. To reflect costs, we use our institution's billing charges to private payers and reimbursements from Medicare. A range of expected steroid injection success rates are employed based on previously published literature., Results: Immediate surgical release is the costliest treatment with an expected cost of $2149 to $9927 per patient. For immediate surgical release to cost less than a single injection attempt, the probability of surgery after injection would need to exceed 80% in the Medicare reimbursement model and 87% in the institutional billing model. A single steroid injection with subsequent surgery, if needed, amounts to a direct cost savings of $359 million annually compared with immediate surgical release. Three injections before surgery, with "high" expected success rates, represent the cost-minimizing scenario., Conclusions: Although many factors must be considered when deciding upon treatment for carpal tunnel syndrome, direct payer cost is an important component, and the initial management with steroid injections minimizes these direct payer costs.

Background: Microsurgery is a specialized surgical technique with wide clinical application. The purpose of this study was to analyze case logs of graduating orthopedic surgery residents to assess trends in case volume for microsurgery procedures., Methods: Accreditation Council for Graduate Medical Education case log reports were analyzed for microsurgery experience from 2007 to 2013. The mean number of adult, pediatric, and total microsurgery cases was noted. In addition, the median number of microsurgery procedures performed by the 90th, 50th, and 10th percentiles of residents (by case volume) was recorded. Temporal changes in case volume were calculated utilizing linear regression analyses., Results: The proportion of microsurgery procedures increased significantly (1.3% to 2%; P = .024). The mean number of adult (24.5 to 41.9; P = .01), pediatric (1.9 to 3.4; P = .011), and total (26.3 to 45.3; P = .01) microsurgery procedures also increased significantly. Similarly, residents in both the 90th (63 to 109; P = .01) and 50th (10 to 21; P = .036) percentiles sustained significant increases in the median number of microsurgery procedures. No change was noted for residents in 10th percentile (0 to 0; P > .999). Graduating residents in the 90th percentile performed over 6 times more microsurgery procedures than residents in the 50th percentile., Conclusions: Microsurgical caseload is increasing among graduating orthopedic residents. However, there is substantial variability in resident microsurgery case volume. Future investigations are needed to explore the educational implications of these findings and should seek to correlate microsurgical caseload with competency.