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Background: Intramedullary screw (IMS) fixation for metacarpal fractures is a relatively new fixation technique in comparison to plate and screw constructs. Our hypothesis evaluated whether IMS fixation for metacarpal fractures results in lower overall health care-associated costs in comparison to open reduction and internal fixation (ORIF)., Methods: A retrospective review of patients undergoing IMS fixation for metacarpal fractures at a single center during 2018 to 2022 was conducted. Health care-associated costs included primary operative costs (surgical time and implant(s)) and postoperative costs (therapy, splinting, and radiology). Costs were compared with age-matched and fracture pattern-matched controls who underwent ORIF with plate and screw construct. Subgroup analysis of cost outcomes excluding outliers was completed., Results: Eight subjects met the inclusion criteria and matched with an ORIF group. Primary operative costs were significantly higher in the ORIF group (mean difference of $1830, 95% CI: $1006 to $2653) The cost of an IMS at our institution was $584, whereas the average cost for plate and screw construct was $2538 (mean difference of $1953, 95% CI: $1665 to $2243). Total surgical costs were on average $3784 more for the ORIF group (95% CI: $2869 to $4700). There was no significant difference in outpatient follow-up costs (95% CI: -$441 to $3180). Total overall costs were significantly lower for the IMS group (95% CI: $2693 to $6513)., Conclusions: Total primary operative costs and overall health care-associated costs for IMS fixation of metacarpal fractures is significantly lower than ORIF. There was no statistical difference in follow-up care costs. To better determine the indirect costs for patients, high-powered prospective studies will be required., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Open articular fractures often include contaminated, devascularized osteoarticular fragments that are critical for joint reconstruction. Definitive treatment is often delayed such that decontamination and preservation of critical fragments for joint reconstruction is highly desirable. To validate decontamination and preservation protocols for safe and effective preservation of osteoarticular fragments for re-implantation, a preclinical animal model for inducing type 3 open articular fractures with contaminated, devascularized osteoarticular fragments was developed and validated., Materials and Methods: With IACUC approval, purpose-bred hounds (n = 5) were humanely euthanized. Immediately following euthanasia, a penetrating captive bolt pistol with 1.25 grain cartridge centered on the cranial aspect of each distal humerus was discharged to create open fractures in 3 dogs (6 elbows). In 2 dogs, matched osteoarticular tissues from non-injured elbows (controls) were retrieved for comparison. Distal humerus, proximal radius, and proximal ulna osteoarticular fragments (n = 27) were immediately placed in Missouri Osteochondral Preservation System (MOPS) solution and stored at room temperature. Radiographic, chondrocyte viability, and quantitative microbial culture assessments were performed immediately (time-0) and at 7 and 14 days of storage., Results: This preclinical canine model reliably produced type 3 open distal humeral fractures characterized by devascularized and contaminated osteoarticular fracture fragments. All fragments produced extensive microbial growth through 14 days of storage. Without decontamination, viable chondrocyte density in the fragments decreased significantly within 7 days, likely attributable to the profound contamination., Conclusion: These data highlight the importance of developing a reliable method for point-of-care decontamination and preservation of osteoarticular fracture fragments for safe and effective reimplantation of articular fracture fragments for joint reconstruction., Competing Interests: Co-authors James L. Cook and Aaron Stoker are patent holders in the MOPS system used in this research. They also receive IP royalties and research support from the Musculoskeletal Transplant Network (MTF Biologics), which has exclusive distribution rights to this preservation technology. Corresponding author Julia A.V. Nuelle receives research support from MTF. No other authors have disclosures in this study., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Peripheral nerve injuries are common injuries that often have a drastic effect on patient's activities of daily living and physical function. While techniques for the surgical repair of these injuries have improved over time, rehabilitation methods following these repairs have been non-standardized and under researched. Electronic searches were conducted in Ovid/Medline and SCOPUS to identify articles that discuss rehabilitation and exercise following peripheral nerve injury in animal models and its effects on peripheral nerve regeneration and recovery of function. Thirty-eight articles met inclusion criteria; all were prospective studies in animal models. This systematic review suggests that exercise is a useful tool in returning autonomy to the individual and has beneficial effects in the recovery from peripheral nerve injury. It is beneficial to use rehabilitation exercises following the repair of peripheral nerve injuries to promote regeneration, and timing of that exercise may be just as important as the exercise prescribed. However, further studies with standardized models and outcome measures need to be conducted before translation to clinical trials., (© 2024 Orthopaedic Research Society.)

Background: Increased utilization of artificial intelligence (AI)-driven search and large language models by the lay and medical community requires us to evaluate the accuracy of AI responses to common hand surgery questions. We hypothesized that the answers to most hand surgery questions posed to an AI large language model would be correct. Methods: Using the topics covered in Green's Operative Hand Surgery 8 th Edition as a guide, 56 hand surgery questions were compiled and posed to ChatGPT (OpenAI, San Francisco, CA). Two attending hand surgeons then independently reviewed ChatGPT's answers for response accuracy, completeness, and usefulness. A Cohen's kappa analysis was performed to assess interrater agreement. Results: An average of 45 of the 56 questions posed to ChatGPT were deemed correct (80%), 39 responses were deemed useful (70%), and 32 responses were deemed complete (57%) by the reviewers. Kappa analysis demonstrated "fair to moderate" agreement between the two raters. Reviewers disagreed on 11 questions regarding correctness, 16 questions regarding usefulness, and 19 questions regarding completeness. Conclusions: Large language models have the potential to both positively and negatively impact patient perceptions and guide referral patterns based on the accuracy, completeness, and usefulness of their responses. While most responses fit these criteria, more precise responses are needed to ensure patient safety and avoid misinformation. Individual hand surgeons and surgical societies must understand these technologies and interface with the companies developing them to provide our patients with the best possible care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Maximizing patient satisfaction is now a significant focus in many outpatient orthopedic clinics as it has been shown to affect many facets of healthcare. With this quality improvement study, we sought to determine the areas of the longest patient wait time during their clinical encounter and evaluate the effect of an identification card system on those times. We hypothesized that utilizing an identification card system would expedite the time patients spend in the clinic and decrease wait times., Methods: This quality improvement study was conducted in an orthopedic hand surgery clinic within a military treatment facility. Pre-intervention and intervention data collection consisted of a time sheet that was filled out by surgeons and clinic staff as the patient progressed through their appointment. The intervention consisted of a card system to track the patient throughout their encounter and mark their order in the queue., Results: There were a total of 130 patients in the pre-intervention group and 113 in the intervention group. Compared with the pre-intervention group, the intervention group patients had significantly less time from check-in to being roomed by the clinic staff with a mean of 13 ± 13  vs. 21 ± 19 minutes in the pre-intervention group (P < .001). In the pre-intervention cohort, the average clinic encounter was 66 ± 38 minutes compared to 57 ± 35 minutes in the intervention cohort, which was not statistically significant (P = .112). The time spent with the orthopedic surgeon and occupational therapists increased in the intervention group., Conclusion: We provided a simple way to decrease patient wait times and increase time with the healthcare team, utilizing our existing clinic space. Time with the orthopedic surgeon significantly increased because of our intervention, while the overall clinic time trended down., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To compare the semitendinosus and gracilis tendon lengths and diameters to the palmaris longus, plantaris, flexor digitorum profundus, and flexor pollicis longus (FPL) tendons in a cadaveric model to evaluate the feasibility of hamstring autograft use for staged flexor tendon reconstruction., Methods: Fifteen fresh cadavers were evaluated for surgical incisions about the knee, forearm, and hand. All flexor digitorum profundus (FDP), FPL, palmaris longus, plantaris, semitendinosus, and gracilis tendons were harvested from each specimen. Diameter and length were recorded and means with SDs were calculated. The mean diameters of the gracilis and semitendinosus were compared to the mean diameters of the FDP and FPL tendons. The hamstring tendon lengths were then compared in terms of percentage of the palmaris longus and plantaris tendon lengths., Results: The gracilis (18.0 cm) and semitendinosus (19.9 cm) means were notably longer than the palmaris longus (16.0 cm) and shorter than the plantaris (30.0 cm). The average gracilis tendon diameter (3.8 mm) was smaller than the flexor tendon diameters except for the little finger FDP (3.8 mm). The semitendinosus tendon diameter (4.8 mm) was larger than all flexor tendons with the exception of the middle finger FDP (4.6 mm). Average gracilis and semitendinosus tendon diameters were 3.7 mm and 4.5 mm in males, and 3.8 mm and 4.8 mm in females., Conclusions: This study showed the gracilis tendon to have adequate length and diameter for potential autograft use in staged flexor tendon reconstruction in all digits but the little finger. The semitendinosus is larger in diameter than the native flexor tendons, making it a poor autograft option in cases with an intact pulley system., Clinical Relevance: Common tendon autograft options for flexor tendon reconstruction are variably present, and the use of gracilis and semitendinosus autograft present potential graft options., (Copyright © 2023. Published by Elsevier Inc.)

Wrist arthroscopy has been established as a useful, minimally invasive tool for diagnosing and treating many different wrist conditions. The standard portals are located on the dorsum of the hand and wrist and are named for their relation to the extensor compartments. They include the radiocarpal and midcarpal portals. The radiocarpal portals are 3-4, 4-5, 6R, 6U, and 1-2. The midcarpal portals are STT (scaphotrapeziotrapezoidal), MCR (midcarpal radial), and MCU (midcarpal ulnar). Traditionally, wrist arthroscopy is performed with constant inflow of saline solution for joint insufflation and visualization. Dry wrist arthroscopy (DWA) is a technique that allows for arthroscopic exploration and instrumentation without infusing any fluid into the joints. Some advantages of DWA include lack of fluid extravasation, less obstruction by floating synovial villi, decreased risk of compartment syndrome, and the ability to perform concomitant open procedures more easily than with a wet technique. Additionally, the risk of fluid displacing carefully laid bone graft is much less without constant flow. DWA can be used in the assessment and management of triangular fibrocartilage complex (TFCC) and scapholunate interosseous ligament tears and other ligamentous injuries. DWA can also be used in fracture fixation to assist with reduction and restoration of articular surfaces. Moreover, it is used in more chronic settings to diagnose scaphoid nonunions. DWA does have its disadvantages such as generation of heat through the use of burrs and shavers and clogging of these instruments during debridement of tissue. DWA is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. With a minimal learning curve for surgeons who already perform wrist arthroscopy, DWA can be a useful addition to their practice., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Symptomatic myofascial herniations of the extremities occur infrequently; however, they can contribute to significant pain, weakness, and neuropathy with activity. Muscle herniation typically occurs through either a traumatic or congenital focal defect in the deep overlying fascia. Patients may present with an intermittently palpable subcutaneous mass and may have neuropathic symptoms, depending on the degree of nerve involvement. Patients are initially treated with conservative modalities, whereas surgery is reserved for patients who demonstrate persistent functional limitations and neurologic symptoms. Here, we demonstrate a technique for primary repair of a symptomatic lower-leg fascial defect., (© 2022 The Authors.)

Introduction: Blood flow restriction therapy (BFRT) is used in scenarios ranging from muscle building in athletic performance to decreasing recovery time in postoperative orthopedic rehabilitation. The efficacy of BFRT for treating diseases has been increasingly researched; however, there has been less literature focused on establishing the safety of this therapy., Materials and Methods: An extensive literature review pertaining to BFRT and any deleterious events related to its usage was completed by searching multiple databases, including PubMed, EMBASE, and Cochrane Library using the terms "blood flow restriction therapy" or "KAATSU.", Results: Ten case reports, five case series, two national surveys, two questionnaires, six randomized controlled studies, and one systematic review were included. A total of 1,672 individuals reported an adverse event following BFRT use out of 25,813 individuals. Commonly reported adverse events were numbness, dizziness, subcutaneous hemorrhage, and rhabdomyolysis. There were unique adverse effects of this therapy reported in individuals with comorbid conditions, such as hypertension and thoracic outlet syndrome, which included isolated cases of central retinal vein occlusion and Paget-Schroeder syndrome., Conclusion: Blood flow restriction provides tremendous opportunity with a potential for accelerated exercise rehabilitation and injury prevention. This modality could be used in the military setting to help injured active duty personnel expeditiously return to deployable status. Further prospective randomized controlled trials are warranted to further support BFRT safety; however, from this literature review, it can be concluded that BFRT can be utilized safely in the proper patient population when administered by qualified professionals who have undergone the appropriate training., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Over recent decades, the prevalence of women in surgical subspecialties has increased. There has been a significant rise in the percentage of women entering integrated plastic surgery programs and an increase, albeit smaller, in women entering orthopedic surgery training programs. Although female membership in the American Society for Surgery of the Hand has steadily increased, women remain in the vast minority within this professional society and many others within the field of hand surgery. In addition to underrepresentation in positions of leadership, women face challenges such as imposter syndrome, bullying, unfavorable work structure for work-family balance, macro and micro-aggressions, and lack of mentors at a higher rate than their male colleagues. As awareness rises of the additional challenges that women in hand surgery face, we must directly address them to improve equity within our subspecialty., Competing Interests: Conflict of Interest None declared., (Society of Indian Hand Surgery & Microsurgeons. All rights reserved.)

Snake bites are an uncommon injury requiring intervention by hand surgeons. While counteracting the effects of snake venom is the initial and urgent concern following a bite, infection caused by retention of a foreign body can present in a delayed fashion and may lead to increased morbidity. Standard radiographs of the injury should be carefully examined for foreign bodies, noting that retained snake teeth are somewhat radiolucent due to less mineralization as compared to bone and can be difficult to visualize. In our subject, a retained rattlesnake fang was found in association with a septic interphalangeal joint despite appropriate radiographic evaluation and thorough surgical irrigation and debridement upon initial presentation. This case report highlights a potential complication of snake bites, the importance of aggressive management, and the importance of increased suspicion for retained foreign bodies. Augmenting plain radiographs with additional imaging modalities, such as ultrasound, dark-field, and phase-contrast imaging, may aid in the diagnosis of retained foreign bodies after snake bites., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Despite the surgical advances in treatment of peripheral nerve injuries, consistent recovery of function is limited suggesting that a multimodal approach is required to optimize nerve regeneration. This approach should include advanced surgical repair techniques, as well as tissue engineering, cellular therapies, and application of local and systemic modulators of neuroregeneration. Further research is needed to advance these therapies from the laboratory to clinical practice, and to further understand how these treatments and techniques can act in concert to optimize functional nerve regeneration., Competing Interests: Disclosure AMS: Receives intellectual property royalties from the Musculoskeletal Transplant Foundation., (Copyright 2022 by the Missouri State Medical Association.)

Objective: The purpose of this study was to examine patient outcomes and the risk of recurrence of mucous cysts affecting the distal interphalangeal (DIP) joint in the absence of osteophytectomy using the described flap technique., Methods: A retrospective review of 143 records of patients who were treated for mucous cysts of the DIP joint by a single surgeon. Inclusion criteria included the absence of an osteophytectomy during treatment using the described dorsally based flap technique and a minimum of 12 months of follow-up., Results: A total of 143 mucous cysts affecting the DIP joint of 131 patients with an average age of 65.3 years were included. The average follow-up was 21.9 months (12 to 139). Postoperative DIP joint extension was less in the surgical digit compared with the same digit of the contralateral hand with a significant change from the preoperative motion (1.5° versus 0.3°; P = 0.05). No significant change in the postoperative flexion of the DIP joint was observed compared with that of the contralateral side (-1.4° versus -0.9°; P = 0.57). Recurrence occurred in 2 patients (1.4%). No infections or wound complications were identified., Conclusions: Using the described technique without an osteophytectomy seemed to be an effective treatment of mucous cysts originating from the DIP joint., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

This systematic review evaluates and synthesizes the available peer-reviewed evidence regarding the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on fracture healing in skeletally immature patients. Evidence supports the use of NSAIDs in this patient population for adequate pain control without increasing the risk of nonunion, particularly in long bone fractures and pseudoarthrosis after spine fusion. However, further clinical studies are needed to fill remaining gaps in knowledge, specifically with respect to the spectrum of available NSAIDs, dosage, and duration of use, in order to make broad evidence-based recommendations regarding the optimal use of NSAIDs during bone healing in skeletally immature patients.

Background: This study aimed to investigate if nonsteroidal anti-inflammatory drugs (NSAIDs) used in the acute phase of bone healing in children with fractures result in delayed union or nonunion as compared with patients who do not take NSAIDs for pain control during this same time period., Methods: In this prospective, randomized, parallel, single-blinded study, skeletally immature patients with long bone fractures were randomized to 1 of 2 groups for their postfracture pain management. The NSAID group was prescribed weight-based ibuprofen, whereas the control group was not allowed any NSAID medication and instead prescribed weight-based acetaminophen. Both groups were allowed to use oxycodone for breakthrough pain. The primary outcome was fracture healing assessed at 2, 6, and 10 weeks., Results: One-hundred-two patients were enrolled between February 6, 2014 and September 23, 2016. Ninety-five patients (with 97 fractures) completed a 6-month follow-up (46 patients with 47 fractures in the control group and 49 patients 50 fractures in the NSAID group). None achieved healing at 1 to 2 weeks. By 6 weeks, 37 of 45 patients (82%) of control group and 46 out of 50 patients (92%) of ibuprofen group had healed fractures (P=0.22). At 10 to 12 week follow-up, 46 (98%) of the control group fractures were healed and 50 (100%) of the ibuprofen group fractures were healed. All were healed by 6 months. Healing was documented at a mean of 40 days in the control group and 31 days in the ibuprofen group (P=0.76). The mean number of days breakthrough oxycodone was used was 2.4 days in the control group and 1.9 days in the NSAID group (P=0.48)., Conclusion: Ibuprofen is an effective medication for fracture pain in children and its use does not impair clinical or radiographic long bone fracture healing in skeletally immature patients., Level of Evidence: Level I-therapeutic.

Osteochondral injuries of the patella occur often in the setting of traumatic patellar dislocations. Early fixation of the displaced fragment(s) is paramount to maintaining the viability of the articular cartilage and the congruency of the patella. Multiple fixation techniques have been described to ensure stable fixation, including wires, screws, and all-suture techniques with both absorbable and nonabsorbable materials. We performed an open reduction and internal fixation of a large traumatic patellar osteochondral lesion using 3 bioabsorbable compression screws. The technique is straightforward and provides compression across the fragments, affording excellent stability, which allows early range of motion and ambulation., (© 2019 by the Arthroscopy Association of North America. Published by Elsevier.)

Introduction: Locked thumb metacarpophalangeal (MCP) joints due to entrapped radial sesamoids are rare injuries that commonly require open reduction, especially when the injury is delayed in presentation., Case Presentation: We present a case of a 24-year-old female with a subacute thumb MCP joint subluxation due to an incarcerated radial sesamoid. She underwent successful closed reduction but had persistent pain and difficulty gripping large objects necessitating eventual open volar plate repair despite therapy. She was able to achieve full motion, with little pain and disability, after undergoing delayed volar plate repair., Discussion: Delayed volar plate repair may be considered for those patients who fail to improve with conservative management and occupational therapy after a successful closed reduction for thumb MCP joint subluxation due to an incarcerated radial sesamoid.