Publications by authors named "David S Ruch"

127 Publications

"Suspensionplasty for Revision Thumb Carpometacarpal Osteoarthritis Surgery: Comparing Suture Button Suspensionplasty to Ligament Reconstruction and Tendon Interposition."

Plast Reconstr Surg 2022 Jul 1. Epub 2022 Jul 1.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA.

Several surgical procedures have been described for the treatment of thumb carpometacarpal (CMC) osteoarthritis (OA), including suture button suspensionplasty (SBS) and ligament reconstruction and tendon interposition (LRTI). To date, no one procedure has demonstrated clinical superiority. SBS has achieved favorable outcomes at five years in primary cases, but has not been validated in revision surgery. This study evaluated SBS for revision of failed thumb CMC OA surgery and compared these outcomes to revision using LRTI. A retrospective chart review was performed to identify patients who underwent suspensionplasty with SBS or LRTI after failure of previous thumb CMC OA surgery since 2010. Eighteen patients were included, nine undergoing revision with SBS and nine undergoing revision with LRTI. Eighteen patients had mean final follow-up of 35 months. There were two complications in the LRTI group, none in the SBS group. No patients required additional surgery. The SBS group had an average visual analog scale (VAS) pain score improvement of 2.9, compared to 2.4 in the LRTI group. Average final QuickDASH was 15.1 in the SBS group, compared to 22.6 in the LRTI group. Mean operative time of 86.3 minutes in the SBS group was significantly shorter than the 121 minute mean in the LRTI group. SBS is an effective treatment option for revision of previous thumb CMC OA surgery, with outcomes comparable to revision using LRTI, and the added benefit of shorter operative times and early mobilization.
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http://dx.doi.org/10.1097/PRS.0000000000009408DOI Listing
July 2022

Do Patients Want to be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

J Hand Surg Am 2022 Jun 4. Epub 2022 Jun 4.

Department of Orthopaedic Surgery, Value in Orthopaedics, Innovation and Choices Health Policy Research Center, Stanford University, Redwood City, CA; Hand Surgery Quality Consortium. Electronic address:

Purpose: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome.

Methods: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated.

Results: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared.

Conclusions: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions.

Clinical Relevance: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.
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http://dx.doi.org/10.1016/j.jhsa.2022.03.025DOI Listing
June 2022

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis.

Hand (N Y) 2022 May 22:15589447221092056. Epub 2022 May 22.

University of Missouri School of Medicine, Columbia, USA.

Background: Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS.

Methods: Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed.

Results: From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63.

Conclusions: PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.
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http://dx.doi.org/10.1177/15589447221092056DOI Listing
May 2022

Outcomes associated with proton pump inhibitors and distal radius fractures: A post-hoc comparative analysis.

J Plast Reconstr Aesthet Surg 2022 Apr 22. Epub 2022 Apr 22.

Department of Orthopaedic Surgery, Division of Hand Surgery, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, United States. Electronic address:

Long-term, high-dose, daily proton pump inhibitors (PPI) may impact outcomes associated with distal radius fractures (DRF). The hypothesis was that differences existed in patient demographics, but there existed no differences in injury patterns, interventions, post-operative complications, and patient-reported outcomes between patients not on a PPI and patients on a PPI with a DRF. METHODS: An IRB-approved, post-hoc analysis of patients with DRF from 2012 through 2018 was performed. Patients included were age ≥18 years, sustained a DRF, had completed medical and medication records, Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores, Global Assessment of Functioning (GAF) scores, visual analogue scale (VAS) pain scores, and a minimum of 1-year follow-up. Patients were stratified into two cohorts. Cohort one patients had no prescription or over-the-counter PPI use (no PPI cohort). Cohort two patients had adherence to a long-term, high-dose, daily PPI (PPI cohort). RESULTS: Two hundred and eighty-one DRF patients were included. Of these 281 patients, 240 were in the no PPI cohort and 41 were in the PPI cohort. Patients in the PPI cohort had more median nerve injuries (12% versus 3%, p = 0.025) and radial shaft fractures (5% versus 0%, p = 0.020), less contralateral upper extremity injuries (0% versus 4%, p = 0.001), and more post-operative nonunions (7% versus 1%, p = 0.029) compared to patients in the no PPI cohort. The results obtained suggest that a CONCLUSIONS: Long-term, high-dose, daily PPI's may be associated with more median nerve injuries and radial shaft fractures, less contralateral upper extremity injuries, and more post-operative nonunions compared to DRF patients not on a PPI.
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http://dx.doi.org/10.1016/j.bjps.2022.04.013DOI Listing
April 2022

Platelet-rich plasma vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis: a cost-effectiveness Markov decision analysis.

J Shoulder Elbow Surg 2022 May 11;31(5):991-1004. Epub 2022 Jan 11.

Division of Hand Surgery, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA. Electronic address:

Background: Both platelet-rich plasma (PRP) and corticosteroid injections may be used to treat lateral epicondylitis. We evaluated the cost-effectiveness of PRP injections vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis.

Methods: Markov modeling was used to analyze the base-case 45-year-old patient with recalcitrant lateral epicondylitis, unresponsive to conservative measures, treated with a single injection of PRP or triamcinolone 40 mg/mL. Transition probabilities were derived from randomized controlled trials, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry reported using Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and costs from institution financial records. Analyses were performed from health care and societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICERs), reported as US dollars / quality-adjusted life-year (USDs/QALY) and net monetary benefit (NMB) to represent the values of an intervention in monetary terms. Willingness-to-pay thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed over 10,000 iterations.

Results: Both PRP and triamcinolone 40-mg/mL injections were considered cost-effective interventions from a health care and societal perspective below the WTP threshold of $50,000. From a health care perspective, PRP injections were dominant compared with triamcinolone 40-mg/mL injections, with an ICER of -$5846.97/QALY. PRP injections provided an NMB of $217,863.98, whereas triamcinolone 40 mg/mL provided an NMB of $197,534.18. From a societal perspective, PRP injections were dominant compared to triamcinolone 40-mg/mL injections, with an ICER of -$9392.33/QALY. PRP injections provided an NMB of $214,820.16, whereas triamcinolone 40 mg/mL provided an NMB of $193,199.75.

Conclusions: Both PRP and triamcinolone 40-mg/mL injections provided cost-effective treatments from health care and societal perspectives. Overall, PRP injections were the dominant treatment, with the greatest NMB for recalcitrant lateral epicondylitis over the time horizon of 5 years.
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http://dx.doi.org/10.1016/j.jse.2021.12.010DOI Listing
May 2022

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of distal humerus fractures.

JSES Int 2021 Nov 17;5(6):1111-1118. Epub 2021 Sep 17.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Introduction: We hypothesized that the modified Fragility Index (mFI), which predicts surgical complications, would be applicable to surgical complications in patients older than 50 years with distal humerus fractures (DHF).

Methods: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a DHF. A 5-item mFI score was calculated. Postoperative complications, readmission and reoperation rates, and length of stay were recorded. Univariate as well as a multivariable statistical analysis was performed, controlling for age, sex, body mass index, length of stay, and operative time.

Results: We identified 864 patients (mean age, 68.6 years ± 10.4), and 74.1% were female. As the mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 3% to 10% ( value = .01), rate of discharge to rehabilitation facility increased from 12% to 32% ( value = .0), and any complication rate increased from 4% to 19% ( value = .0). Rates of pulmonary complications increased significantly in patients with the mFI of 2 or greater ( value = .047). Patients with the mFI of 2 or greater were nearly 4 times more likely to be readmitted within 30 days (odds ratio [OR] = 3.5, value = .007) and had an increased OR of 30-day reoperation and any complication (OR = 3.7, value = .02; OR = 4.5,  value = .00, respectively) on multivariate analysis.

Conclusion: A fragility state is predictive of postoperative complications, readmission, and reoperation after surgical management of DHF. Our data suggest that a fragility evaluation can help inform surgical decision-making in patients older than 50 years with DHF.
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http://dx.doi.org/10.1016/j.jseint.2021.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8569009PMC
November 2021

The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology.

J Hand Surg Am 2022 01 2;47(1):19-30.e8. Epub 2021 Sep 2.

Department of Orthopaedic Surgery, Duke University, Durham, NC.

Purpose: Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality.

Methods: A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand-adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed.

Results: All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand-adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand-adjusted life year), inclusion of MRA became the most favorable strategy.

Conclusions: Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics.

Type Of Study/level Of Evidence: Economic/Decision Analysis IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.06.027DOI Listing
January 2022

Patient Perspectives on the Cost of Hand Surgery.

J Bone Joint Surg Am 2021 11;103(22):2133-2140

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

Background: Health-care expenditures in the U.S. are continually rising, prompting providers, patients, and payers to search for solutions to reduce costs while maintaining quality. The present study seeks to define the out-of-pocket price that patients undergoing hand surgery are willing to pay, and also queries the potential cost-cutting measures that patients are most and least comfortable with. We hypothesized that respondents would be less accepting of higher out-of-pocket costs.

Methods: A survey was developed and distributed to paid, anonymous respondents through Amazon Mechanical Turk. The survey introduced 3 procedures: carpal tunnel release, cubital tunnel release, and open reduction and internal fixation of a distal radial fracture. Respondents were randomized to 1 of 5 out-of-pocket price options for each procedure and asked if they would pay that price. Respondents were then presented with various cost-saving methods and asked to select the options that made them most uncomfortable, even if those would save them out-of-pocket costs.

Results: There were 1,408 respondents with a mean age of 37 years (range, 18 to 74 years). Nearly 80% of respondents were willing to pay for all 3 of the procedures regardless of which price they were presented. Carpal tunnel release was the most price-sensitive, with rejection rates of 17% at the highest price ($3,000) and 6% at the lowest ($250). Open reduction and internal fixation was the least price-sensitive, with rejection rates of 11% and 6% at the highest and lowest price, respectively. The use of older-generation implants was the least acceptable cost-cutting measure, at 50% of respondents.

Conclusions: The present study showed that most patients are willing to pay a considerable amount of money out of pocket for hand surgery after the condition, treatment, and outcomes are explained to them. Furthermore, respondents are hesitant to sacrifice advanced technology despite increased costs.
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http://dx.doi.org/10.2106/JBJS.20.02195DOI Listing
November 2021

Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair.

J Am Acad Orthop Surg 2021 Jun;29(12):518-525

From the The Hand Center of San Antonio (Srinivasan), San Antonio, TX, the Illinois Bone and Joint Institute (Shrouder-Henry), Hinsdale, IL, and the Department of Orthopaedic Surgery (Richard, Ruch), Duke University Medical Center, Durham, NC.

Triangular fibrocartilage complex (TFCC) tears, whether acute or chronic, can result in persistent ulnar-sided wrist pain. Although diagnosis and nonsurgical management of TFCC tears is well described, there remains ongoing discussion about the optimal surgical technique, specifically open or arthroscopic. This article reviews the most up-to-date literature regarding TFCC injury including demographics, risk factors for TFCC injury, classification of acute and chronic TFCC tears, history and physical examination, appropriate diagnostic imaging, surgical indications, pertinent surgical anatomy, open and arthroscopic TFCC repair, fixation biomechanics and techniques, postoperative rehabilitation, and clinical outcomes.
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http://dx.doi.org/10.5435/JAAOS-D-20-00998DOI Listing
June 2021

Fracture location impacts opioid demand in upper extremity fracture surgery.

Injury 2021 Aug 20;52(8):2314-2321. Epub 2021 May 20.

Duke University Medical Center, Department of Orthopaedic Surgery, 200 Trent Drive, Durham, NC 27710. Electronic address:

Introduction: Opioid sparing protocols should be formulated with appropriate demand. Specific fracture location has been hypothesized as an important predictor of post-operative pain. The purpose of this study is to evaluate the impact of fracture location on perioperative opioid demand after surgery with the hypothesis that this factor would be significantly associated with perioperative opioid demand in upper extremity fracture surgery.

Methods: A national database was used to identify1-month pre-operative to 1-year postdischarge opioid demand in oxycodone 5-mg equivalents in 336,493 patients undergoing fracture fixation of the clavicle through distal radius between 2010 and 2020. Three timeframes were evaluated: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year postdischarge. Multivariable main effects linear and logistic regression models were constructed to evaluate the changes in opioids filled, opioid prescriptions, and odds of two or more opioid prescriptions in these timeframes based on fracture location with adjustment for age, sex, obesity, pre-operative opioid usage, and polytrauma.

Results: Compared to distal radius fracture fixation, fixation of elbow, distal humerus, humeral shaft, and proximal humerus fractures were associated with large, significant increases in 1-month pre-op to 1-year post-discharge opioid filling (33.5 - 63.4 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.33 - 0.92 additional prescriptions, all p<0.05) compared to patients with other operatively treated upper extremity injuries.

Discussion: Fracture location was a significant predictor of perioperative opioid demand. Elbow, distal humerus, humeral shaft, and proximal humerus fracture fixation was associated with the largest increases in opioid demand after upper extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption.

Level Of Evidence: Level III, retrospective, observational cohort study.
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http://dx.doi.org/10.1016/j.injury.2021.05.026DOI Listing
August 2021

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease.

Hand (N Y) 2021 Apr 15:15589447211006858. Epub 2021 Apr 15.

Duke University School of Medicine, Durham, NC, USA.

Background: The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis.

Methods: We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively.

Results: Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively.

Conclusions: In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.
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http://dx.doi.org/10.1177/15589447211006858DOI Listing
April 2021

Isolated Scaphoid Dislocation With Radial-Axial Instability: A Treatment Strategy Utilizing Spanning Wrist Plates.

J Hand Surg Am 2022 03 20;47(3):293.e1-293.e8. Epub 2021 Mar 20.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC.

Isolated dislocation of the scaphoid is a rare injury with only a few case reports in the literature. We report on 2 complex scaphoid dislocations demonstrating concomitant axial instability with disruption of the capitohamate articulation as well as the long-ring metacarpal relationship. Both of these patients underwent reduction and fixation using a wrist spanning plate, which was removed approximately 2 months after injury. Follow-up of these patients demonstrated maintenance of reduction, axial stability, and return of painless range of motion.
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http://dx.doi.org/10.1016/j.jhsa.2021.01.010DOI Listing
March 2022

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures.

JSES Int 2021 Mar 16;5(2):212-219. Epub 2020 Dec 16.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Hypothesis: We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture.

Methods: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time.

Results: We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (-value < .001), and rates of any complication increased from 6.5% to 13.9% (-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (-value = .042 and -value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, -value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, -value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time.

Conclusion: An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.
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http://dx.doi.org/10.1016/j.jseint.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910730PMC
March 2021

Outcomes Associated With Scapholunate Ligament Injury Following Intra-Articular Distal Radius Fractures.

J Hand Surg Am 2021 04 30;46(4):309-318. Epub 2021 Jan 30.

Department of Orthopaedic Surgery, Division of Hand Surgery, Duke University School of Medicine, Durham, NC. Electronic address:

Purpose: The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF.

Methods: A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain.

Results: One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°-68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°-87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°-87°) to 78.5° (range, 71°-107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups.

Conclusions: Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2020.12.005DOI Listing
April 2021

Heterotopic ossification formation after fractures about the elbow.

Eur J Orthop Surg Traumatol 2021 Aug 2;31(6):1061-1067. Epub 2021 Jan 2.

Department of Orthopaedic Surgery, Duke University Medical Center, 4709 Creekstone Drive, Suite 200, Durham, NC, 27703, USA.

Introduction: Heterotopic ossification (HO) is a well-known sequela after an elbow injury and is widely studied given the associated morbidity. The anatomic location of HO development for specific elbow injuries has not been reported. The purpose of this study was to describe the precise, anatomic location of HO development after different peri-articular elbow injuries.

Methods: A retrospective chart review was performed for patients with peri-articular elbow fracture and/or dislocation who underwent an elbow contracture release. The injuries were grouped into coronal shear distal humerus/AO 13.B3 (CSDH), distal humerus/AO 13.A, 13.B1, B2 or 13.C (DH), olecranon/AO 21.B1 (OL), radial head/AO 21.B2 (RH), extra-articular proximal radius and ulna/AO 21.A (EAPRU) fractures and elbow dislocations (DL). The HO location was determined by reviewing elbow radiographs and CT scans and were classified as anterior capsule, medial or lateral collateral ligaments, and posterior capsule/triceps insertion.

Results: The study consisted of 49 patients, such as 6 CSDH, 13 DH, 6 OL, 21 RH, 4 EAPRU fractures and 20 elbow DL. All CSDH and RH fractures and 19/20 elbow DL developed HO in the collateral ligaments, while 12/13 DH fractures developed an anterior capsule HO. All 6 OL fractures developed HO posteriorly, and 3/4 EAPRU fractures developed a proximal radioulnar synostosis.

Conclusions: Our findings suggest that the location of HO development is specific to the injury type and is influenced by the soft tissues involved. This is consistent with the understanding that HO is the abnormal ossification of normal structures.
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http://dx.doi.org/10.1007/s00590-020-02855-4DOI Listing
August 2021

Complications of Low-Profile Plate Fixation in Metacarpal Fractures.

Orthopedics 2021 Jan 1;44(1):e91-e94. Epub 2020 Oct 1.

High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [Orthopedics. 2021;44(1):e91-e94.].
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http://dx.doi.org/10.3928/01477447-20200925-02DOI Listing
January 2021

Return to Activities After Simultaneous Bilateral Endoscopic Carpal Tunnel Release.

Hand (N Y) 2022 Jul 17;17(4):646-651. Epub 2020 Sep 17.

Duke University Medical Center, Durham, NC, USA.

Background: Approximately 56% of patients diagnosed with carpal tunnel syndrome present with bilateral symptoms; however, few studies have investigated bilateral simultaneous endoscopic carpal tunnel release (ECTR) and postoperative effect on return to activity. The purpose of this study was to evaluate the length of recovery in patients who received bilateral simultaneous ECTR, including pain medication requirements, return to activities of daily living, return to work, and return to recreational activities.

Methods: A retrospective analysis was performed on patients who underwent bilateral ECTR by a single hand fellowship-trained surgeon from 2013 to 2019. Demographic, operative, and clinical outcomes were collected via chart review and a telephone interview. Student tests and χ tests were conducted for analysis.

Results: Eighty patients were included in the study; 40 were successfully contacted for telephone interview follow-up. Patients reported an average of 2 days of use of postoperative narcotic pain medication and an average of 5, 7, and 19 days of return to activities of daily living, work, and recreational activities, respectively. Female patients reported more days of narcotic pain medications (1 day vs 3 days, = .0483) and an average of longer return to work than men (9 days vs 5 days, = .0477). Manual laborers reported longer return to work (9 days vs 5 days, = .0500). Older patients (aged >65 years) reported longer return to recreational activities (39 days vs 11 days, = .0189).

Conclusions: Simultaneous bilateral ECTR is a successful procedure with shorter recovery times than reported previously. Female patients, manual laborers, and older patients experience a longer recovery and should be counseled appropriately.
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http://dx.doi.org/10.1177/1558944720940061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9274870PMC
July 2022

Editorial Commentary: Ulnar Variance Is Not the Sole Determinant of Arthroscopic Wrist Triangular Fibrocartilage Complex Repair Outcome: Considering the Forest From the Ulnar-Positive Tree.

Arthroscopy 2020 09;36(9):2423-2424

Duke University Medical Center.

When choosing the best treatment option for patients with tears of the triangular fibrocartilage complex, there are multiple patient factors that should be carefully considered. The role of ulnar variance is often overemphasized when attempting to predict the success of arthroscopic repair. In practice, variables such as the age of the patient and location and nature of the tear as traumatic or degenerative should primarily drive the decision between arthroscopic repair and primary ulnar-shortening osteotomy. Arthroscopic repair should generally be avoided in favor of ulnar-shortening osteotomy in patients with degenerative tears and evidence of ulnar impaction syndrome. However, for acute, traumatic, ulnar-sided tears in young patients, arthroscopic repair remains an effective treatment option regardless of ulnar variance.
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http://dx.doi.org/10.1016/j.arthro.2020.07.033DOI Listing
September 2020

Revision total elbow arthroplasty with the ulnar component implanted into the radius for management of large ulna defects.

J Shoulder Elbow Surg 2021 Apr 2;30(4):913-917. Epub 2020 Sep 2.

Department of Orthopaedic Surgery, Duke University, Durham, NC, USA. Electronic address:

Background: Total elbow arthroplasty (TEA) has a higher rate of revision and complications than other total joint arthroplasties. Salvage options for failed TEAs are limited, especially when patients have poor ulna bone stock. The purpose of this study is to describe a surgical technique and report outcomes of patients who underwent revision TEA with implantation of the ulnar component into the radius to address ulna bony defects.

Methods: A retrospective review of 5 patients at a single institution from 2014 to 2019 in which the ulnar component was implanted into the radius to address large bony defects in the setting of revision TEA was performed.

Results: At follow-up of 2.1 ± 1.9 years, patients experienced an increase in total arc of motion from 86 ± 17° to 112 ± 8°, with infection eradication and no instances of distal component loosening.

Conclusion: This salvage technique was effective at providing a stable elbow in patients with large ulna bony defects as a result of prosthetic joint infection or periprosthetic fracture.
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http://dx.doi.org/10.1016/j.jse.2020.08.018DOI Listing
April 2021

In Vivo Mechanical Function of the Distal Radial Ulnar Ligaments During Rotation of the Wrist.

J Hand Surg Am 2020 Nov 12;45(11):1012-1021. Epub 2020 Aug 12.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Purpose: The purpose of this study was to investigate changes in length of the volar and dorsal radioulnar ligaments (VRULs and DRULs), and the distal radioulnar joint (DRUJ) space during unweighted and weighted rotation of the wrist using magnetic resonance imaging and biplanar fluoroscopy.

Methods: Fourteen wrists in 7 normal adult volunteers were imaged to define the 3-dimensional geometry of the DRUJ and the insertion sites of the superficial and deep bundles of the VRULs and DRULs. Subjects were imaged at 10 positions of forearm rotation ranging from full pronation to full supination, with or without a 5-pound weight. Lengths of the superficial and deep VRUL and DRUL bundles and DRUJ space were measured (in millimeters) at each position to evaluate ligament function and DRUJ stability.

Results: In the unweighted and weighted trials, maximal elongation of both deep and superficial VRUL bundles occurred in supination and maximal lengths of the deep and superficial DRUL bundles occurred in pronation. Maximum DRUJ space occurred during pronation and a minimum occurred in 30° of supination. In weighted trials, there was a significant increase in deep and superficial VRUL bundle length at positions between 30° of pronation and 30° of supination; however, there was no effect of weight on DRULs length. In weighted trials, there was a significant increase in DRUJ space at positions between full pronation and 15° of supination.

Conclusions: This study demonstrates elongation of the VRULs in supination and the DRULs in pronation. There was no evidence of reciprocal loading of superficial/deep ligament bundles on either the dorsal or the volar aspects of the DRUJ. The effect of loading the wrist during rotation was apparent primarily in the VRULs, but not the DRULs. The DRUJ space was lowest at approximately 30° of supination.

Clinical Relevance: These results add information to the literature regarding the complicated biomechanics of the triangular fibrocartilage complex and DRUJ. Future work should evaluate changes in biomechanics caused by triangular fibrocartilage complex tears to determine how tear severity and location relate to clinical symptoms.
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http://dx.doi.org/10.1016/j.jhsa.2020.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655646PMC
November 2020

Safety of Releasing the Volar Capsule During Open Treatment of Distal Radius Fractures: An Analysis of the Extrinsic Radiocarpal Ligaments' Contribution to Radiocarpal Stability.

J Hand Surg Am 2020 Nov 31;45(11):1089.e1-1089.e16. Epub 2020 Jul 31.

Department of Orthopedic Surgery, Stanford University, Redwood City, CA. Electronic address:

Purpose: The contribution of the extrinsic radiocarpal ligaments to carpal stability continues to be studied. Clinically, there is a concern for carpal instability from release of the volar extrinsic ligaments during volar plating of distal radius fractures in which the integrity of the dorsal ligaments may be unknown. The primary hypothesis of this study was that serial sectioning of radiocarpal ligaments would lead to progressive ulnar translation of the carpus.

Methods: We studied the stabilizing roles of the radioscaphocapitate (RSC), short radiolunate (SRL), long radiolunate (LRL), and dorsal radiocarpal (DRC) ligaments. We sequentially sectioned these ligaments in 2 groups of 5 matched pairs and measured the motion of the scaphoid and lunate with the wrist in passive neutral alignment, radial deviation, ulnar deviation, and simulated grip. Displacement of the lunate in the radioulnar plane was used as a surrogate for carpal translation. The groups differed only by the order in which the ligaments were sectioned.

Results: In the intact state, the lunate translated ulnarly during simulated grip and radial deviation, whereas radial translation, relative to its position under resting tension, was observed during ulnar deviation. With serial sectioning, the lunate displayed increased ulnar translation in all wrist positions for both groups 1 and 2. The magnitude of ulnar translation exceeded 1 mm after sectioning the LRL plus RSC along with either the DRC or the SRL.

Conclusions: Sectioning of either the DRC or SRL ligaments along with release of the RSC and LRL ligaments leads to notable although minimal (<2 mm) ulnar lunate translation.

Clinical Relevance: Isolated sectioning of individual radiocarpal ligaments, such as for visualization of the articular surface of the distal radius, leads to minimal ulnar translation. Because prior clinical work found no clinical complications after volar capsule release, it is posited that translation less than 2 mm creates subclinical changes in carpal mechanics.
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http://dx.doi.org/10.1016/j.jhsa.2020.05.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080674PMC
November 2020

Association of Lunate Morphology With Progression to Scaphoid Fracture Nonunion.

Hand (N Y) 2022 05 22;17(3):452-458. Epub 2020 Jul 22.

Duke University Medical Center, Durham, NC, USA.

The purpose of our study was to review a series of patients with scaphoid fractures to determine whether there was an association between lunate morphology and progression to delayed union or nonunion when treated operatively or nonoperatively. Secondary aims included evaluation of the relationship between lunate morphology and scaphoid fracture location. A retrospective review of all patients with a diagnosis of scaphoid fracture was performed at our institution between 2014 and 2017. Medical records and radiographs were evaluated to determine lunate morphology, scaphoid fracture location, treatment, and time to union. Differences between groups were determined using χ analysis with significance set at <.05. Multiple logistic regression analyses were used to evaluate scaphoid union in the setting of lunate morphology when controlling for confounders. A total of 169 patients were included; 45.0% (n = 76) of patients had type I lunate morphology, and 55.0% (n = 93) had type II. In all, 64.5% (n = 49) of patients with type I lunate and 68.8% (n = 64) with type II lunate had a fracture at the scaphoid waist. Among all patients with a scaphoid fracture, type II lunates were more likely than type I lunates to progress to nonunion when treated both operatively and nonoperatively (18.3% vs 4.0%, = .0042). Lunate facet size was not shown to be a significant risk factor for nonunion among patients with a type II lunate ( = .4221). Patients with a scaphoid fracture and type II lunate morphology were more likely to progress to nonunion than patients with a type I lunate.
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http://dx.doi.org/10.1177/1558944720937368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9112753PMC
May 2022

Bipolar Disruption of the Lateral Ulnar Collateral Ligament of the Elbow: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0335

1Department of Orthopaedics, Italian Hospital of Buenos Aires, Buenos Aires, Argentina 2Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi," Buenos Aires, Argentina 3Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

Case: The lateral ulnar collateral ligament (LUCL) is one of the primary stabilizers of the elbow. Disruption typically occurs from the humeral origin and may be because of an elbow dislocation or fracture/dislocation. If not identified and properly managed, posterolateral rotatory instability may result from LUCL insufficiency. We describe the case of a patient with bipolar LUCL disruption consisting of an avulsion fracture of the crista supinatoris and a soft-tissue avulsion from the lateral epicondyle.

Conclusion: Bipolar disruption of the LUCL is a previously unreported injury pattern that may lead to posterolateral instability if not identified and treated.
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http://dx.doi.org/10.2106/JBJS.CC.19.00335DOI Listing
February 2021

Trends in reimbursement for primary and revision total elbow arthroplasty.

J Shoulder Elbow Surg 2021 Jan 28;30(1):146-150. Epub 2020 Jun 28.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Relative value units (RVUs) are an essential component of reimbursement calculations from the Centers for Medicare & Medicaid Services. RVUs are calculated based on physician work, practice expense, and professional liability insurance. Procedures that are more complex, such as revision arthroplasty, require greater levels of physician work and should therefore be assigned a greater RVU. The purpose of this study is to compare RVUs assigned for primary and revision total elbow arthroplasty (TEA).

Methods: The National Surgical Quality Improvement Program database was used to collect all primary and revision total elbow arthroplasties performed between January 2015 and December 2017. Variables collected included age at time of surgery, RVUs assigned for the procedure, and operative time.

Results: A total of 359 cases (282 primary TEA, 77 revision TEA) were included in this study. Mean RVUs for primary TEA was 21.4 (2.0 standard deviation [SD]) vs. 24.4 (1.7 SD) for revision arthroplasty (P < .001). Mean operative time for primary TEA was 137.9 minutes (24.4 SD) vs. 185.5 minutes (99.7 SD) for revision TEA (P < .001). The RVU per minute for primary TEA was 0.16 and revision TEA was 0.13 (P < .001). This amounts to a yearly reimbursement difference of $71,024 in favor of primary TEA over revision TEA.

Conclusion: The current reimbursement model does not adequately account for increased operative time, technical demand, and pre- and postoperative care associated with revision elbow arthroplasty compared with primary TEA. This leads to a financial advantage on performing primary TEA.
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http://dx.doi.org/10.1016/j.jse.2020.06.004DOI Listing
January 2021

Which Decisions For Management of Carpal Tunnel Syndrome and Distal Radius Fractures Should Be Shared?

J Hand Surg Am 2020 Aug 25;45(8):690-697.e7. Epub 2020 Apr 25.

Purpose: To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years.

Methods: A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria.

Results: Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients.

Conclusions: Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions.

Clinical Relevance: Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.
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http://dx.doi.org/10.1016/j.jhsa.2020.03.008DOI Listing
August 2020

Ulnohumeral Bridge Plating for Massive Distal Humerus Bone Loss: A Case Report.

JBJS Case Connect 2020 Jan-Mar;10(1):e0273

Department of Orthopaedic Surgery, Division of Hand, Upper Extremity, and Microvascular Surgery, Duke University Medical Center, Durham, North Carolina.

Case: Massive bone loss around the elbow is a challenging clinical condition. Short periarticular osseous segments present few reconstructive options in the setting of distal humerus bone loss. We report the case of a 20-year-old man who sustained an open, intra-articular distal humerus fracture with a massive metaphyseal defect of 15 cm after a motorcycle accident. The defect was reconstructed using an induced membrane technique with temporary ulnohumeral bridge plate stabilization.

Conclusion: Temporary ulnohumeral spanning plate fixation is a reliable method for periarticular reconstruction in the setting of massive distal humerus bone loss.
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http://dx.doi.org/10.2106/JBJS.CC.19.00273DOI Listing
January 2021

Metacarpal Position and Lunate Facet Screw Fixation in Dorsal Wrist-Spanning Bridge Plates for Intra-Articular Distal Radial Fracture: A Biomechanical Analysis.

J Bone Joint Surg Am 2020 Mar;102(5):397-403

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

Background: A dorsal wrist-spanning plate (DWSP) can be affixed to the second or third metacarpal, depending on the morphology of the distal radial fracture (DRF) and on surgeon preference, but comparative biomechanical analyses between these methods are limited. This biomechanical study compared fixation to the second metacarpal versus the third metacarpal as measured by lunate facet fragment displacement in a cadaveric model of an axially loaded intra-articular DRF. The construct rigidity with the addition of an intrafragmentary lunate facet locking screw was also evaluated.

Methods: A sample size of 14 cadaveric matched pairs was calculated to achieve 81.7% power. The 28 limbs were randomized to DWSP fixation to the second metacarpal (Group 1) or third metacarpal (Group 2); each wrist underwent an osteotomy simulating an unstable intra-articular DRF. Limbs were tested at axial loads of 50, 100, 150, 200, 250, and 300 N. Lunate facet displacement from the metaphyseal fragment at each load was measured with use of differential variable reluctance transducers. After initial testing, a locking screw was placed through the plate into the lunate facet fragment in the third metacarpal group (Group 3). Displacement measurements were repeated for all loads. Paired 2-tailed t tests with Bonferroni correction (significance, p < 0.008) were performed to assess differences in fragment stability between groups.

Results: The average fracture displacement at 300 N was 0.8 mm in Group 1, 0.4 mm in Group 2, and 0.2 mm in Group 3. Plating to the third metacarpal more effectively resisted displacement compared with the second metacarpal at all axial loads (p < 0.008). The addition of a lunate facet screw further stiffened the construct at loads of ≥200 N (p < 0.008).

Conclusions: Plate fixation to the third metacarpal with an intrafragmentary screw was the most biomechanically favorable construct, although other factors may favor an alternative distal fixation site. Mean displacement of the lunate facet fragment at 300 N was <1 mm in all groups.

Clinical Relevance: The present study demonstrated that a DWSP affixed to the third metacarpal with an intrafragmentary screw provides the most effective stabilization of the lunate facet fragment in intra-articular DRFs. This study validates the use of intrafragmentary screws to increase stability in DWSP fixation.
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http://dx.doi.org/10.2106/JBJS.19.00769DOI Listing
March 2020

Dorsal Wrist Spanning Plate Fixation for Treatment of Radiocarpal Fracture-Dislocations.

Hand (N Y) 2021 11 17;16(6):834-842. Epub 2019 Dec 17.

Duke University Medical Center, Durham, NC, USA.

Radiocarpal dislocations are rare injuries that result from high-energy forces across the wrist with the hallmark finding of radiocarpal ligament disruption. Published treatment methods are comprehensive with moderate-to-good outcomes. The purpose of this study was to review the treatment of radiocarpal dislocations with a dorsal wrist spanning plate. A retrospective review was conducted analyzing the radiographic and clinical outcomes of patients treated for a radiocarpal dislocation using a dorsal wrist spanning plate over a 10-year period. Outcomes assessed included radiographic joint incongruity and arthrosis, wrist range of motion, grip strength, Visual Analogue Scale (VAS) score, surgical complications, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Thirteen patients were treated with a dorsal wrist spanning plate for radiocarpal dislocation with a mean follow-up of 615 days from the time of initial surgery. Six patients (46%) had associated distal radioulnar joint instability. The mean wrist range of motion at the final follow-up was: flexion 39°, extension 44°, pronation 79°, and supination 84°. One patient (8%) developed ulnar translation of the carpus, and 11 patients (85%) developed radiographic posttraumatic wrist arthrosis. Mean VAS and DASH scores were 4 and 18, respectively. Acute treatment with a dorsal wrist spanning plate in this series resulted in comparable outcomes to what have been previously reported in the literature. The dorsal wrist spanning plate offers the surgeon a reliable method of stabilization, with minimal additional surgical trauma to the wrist, while avoiding the potential for infections that develop with other treatment methods.
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http://dx.doi.org/10.1177/1558944719893068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8647312PMC
November 2021

Hand transplantation in the United States: A review of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Database.

Am J Transplant 2020 05 21;20(5):1417-1423. Epub 2019 Dec 21.

Division of Hand Surgery, Duke University Medical Center, Durham, North Carolina.

Hand transplantation is the most common application of vascularized composite allotransplantation (VCA). Since July 3, 2014, VCAs were added to the definition of organs covered by federal regulation (the Organ Procurement and Transplantation Network (OPTN) Final Rule) and legislation (the National Organ Transplant Act). As such, VCA is subject to requirements including data submission. We performed an analysis of recipients reported to the OPTN to have received hand transplantation between 1999 and 2018. Forty-three patients were identified as having been listed for upper extremity transplantation in the United States. Of these, 22 received transplantation prior to July 3, 2014 and 10 from then to December 31, 2018. Of patients transplanted after 2014, posttransplant functional scores included a decrease in Disabilities of the Arm, Shoulder and Hand questionnaire in 3 of 10 patients, Carroll test scores ranging from 9 to 60 of 99, and monofilament testing with protective sensation achieved in 4 of 6 patients. Complications included rejection in nine recipients with Banff scores from II-IV. One patient experienced graft failure 5 days after transplantation. Of the remaining patients, two were reported as receiving monotherapy and seven receiving dual or triple immunosuppression therapy. The inclusion of VCA in the OPTN Final Rule standardized parameters for safe implementation and data collection.
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http://dx.doi.org/10.1111/ajt.15704DOI Listing
May 2020

Integrated Compression Screw Stabilization of the Dorsal Lunate Facet in Intra-Articular Distal Radius Fractures.

J Hand Surg Am 2020 Apr 24;45(4):361.e1-361.e7. Epub 2019 Oct 24.

Division of Hand Surgery, Department of Orthopaedic Surgery, Durham, NC.

Purpose: To evaluate outcomes of intra-articular distal radius fractures with displaced dorsal lunate facet fragments treated with a combination of volar plating and the use of a dorsal screw that integrates into the plate.

Methods: We reviewed a retrospective cohort of 22 patients who underwent open reduction and internal fixation of an intra-articular distal radius fracture with a volar plate in conjunction with the Frag-Loc Compression screw. Patient charts and radiographs were reviewed for clinical and radiographic outcomes.

Results: A total of 12 patients with a minimum 6-month follow-up who met all eligibility criteria were included in this study. There were 8 women and 4 men. The mean age was 55.2 years. Mean follow-up was 11.5 months (range, 6-21 months). The most common mechanism of injury was a fall from standing (75.0%). At final follow-up, all patients were able to return to their previous level of function. Bony union was achieved in all patients at the time of final follow-up. Average radiographic parameters at final follow-up were radial inclination 24.2° ± 5.3°, volar tilt 1.3° ± 5.2°, and ulnar variance 0.9 ± 1.7 mm. During the follow-up period, transient median nerve paresthesias were observed in 4 patients, with spontaneous resolution in 3 of 4 patients. Loss of articular reduction was not observed in any case.

Conclusions: This study demonstrates satisfactory clinical and radiographic results and minimal complications with utilization of a new fixation device for distal radius fractures with displaced dorsal lunate facet fragments.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2019.09.001DOI Listing
April 2020
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