Fellowship-trained Hand Surgeons Research Articles

How Accurate and Effective Are Non-image-guided Thumb Basal Joint Injections When Performed by Experienced Fellowship-trained Hand Surgeons?

Corticosteroid injections are widely used for treating thumb carpometacarpal (CMC) arthritis, yet the accuracy of non-image-guided injections in expert hands is uncertain, with prior studies reporting intraarticular placement in about 60% of thumbs when performed by physicians with different levels of training. Despite their common use, there is a need to assess both the accuracy and the short-term clinical efficacy of these injections, particularly when performed without image guidance by fellowship-trained hand surgeons. (1) What is the accuracy of thumb CMC injections performed without image guidance by fellowship-trained hand surgeons in an office setting? (2) What is the short-term efficacy of thumb CMC injections performed without image guidance? We prospectively enrolled 33 patients with a mean ± SD age of 63 ± 12 years, 76% (25) of whom were female, with symptoms of basal joint arthritis that persisted despite conservative treatment, and we administered 1.5-mL corticosteroid injections without image guidance. We used descriptive statistics to analyze the outcomes, which included VAS, QuickDASH (Q-DASH), and Thumb Disability Examination (TDX) scores. Minimum clinically important differences (MCIDs) were defined as 0.9 points for the VAS, 18 points for Q-DASH, and 17 points for TDX. Of the 33 injections analyzed, 79% (26) were intraarticular. At 6 weeks, patients reported a mean improvement of 22 points in QuickDASH, 24 points in TDX, and 4 points in VAS scores. Importantly, 73% (24 of 33), 55% (18 of 33), and 82% (27 of 33) of the patients achieved the MCID in the patient-reported outcomes, respectively, suggesting that even without image guidance, corticosteroid injections can provide effective short-term relief for thumb CMC arthritis. We found that about 79% of injections were placed intraarticularly, which was comparable with the findings of previous studies using image guidance, and provided meaningful improvements in pain and function for 6 weeks. These findings suggest that for experienced fellowship-trained hand surgeons, non-image-guided injections remain a viable option. Future studies should explore long-term outcomes and the potential role of adjunctive treatments such as antiinflammatory medications and splinting to enhance patient care. Level II, therapeutic study.

Can Patients Rely on ChatGPT to Answer Hand Pathology-Related Medical Questions?

In recent years, ChatGPT has become a popular source of information online. Physicians need to be aware of the resources their patients are using to self-inform of their conditions. This study investigates physician-graded accuracy and completeness of ChatGPT regarding various questions patients are likely to ask the artificial intelligence (AI) system concerning common upper limb orthopedic conditions. ChatGPT 3.5 was interrogated concerning 5 common orthopedic hand conditions: carpal tunnel syndrome, Dupuytren contracture, De Quervain tenosynovitis, trigger finger, and carpal metacarpal arthritis. Questions evaluated conditions' symptoms, pathology, management, surgical indications, recovery time, insurance coverage, and workers' compensation possibility. Each topic had 12 to 15 questions and was established as its own ChatGPT conversation. All questions regarding the same diagnosis were presented to the AI, and its answers were recorded. Each question was then graded for both accuracy (Likert scale of 1-6) and completeness (Likert scale of 1-3) by 10 fellowship trained hand surgeons. Descriptive statistics were performed. Overall, the mean accuracy score for ChatGPT's answers to common orthopedic hand diagnoses was 4.83 out of 6 ± 0.95. The mean completeness of answers was 2 out of 3 ± 0.59. Easily accessible online AI such as ChatGPT is becoming more advanced and thus more reliable in its ability to answer common medical questions. Physicians can anticipate such online resources being mostly correct, however incomplete. Patients should beware of relying on such resources in isolation.

Accuracy of Wrist MRI in Detecting Synovitis and Correlation with Arthroscopy

Abstract Hypothesis Wrist magnetic resonance imaging (MRI) has shown excellent diagnostic accuracy in evaluating soft-tissue pathology of the wrist including ganglion cysts, ligament tears, and triangular fibrocartilage complex (TFCC) pathology. However, it is unclear how often MRI detects synovitis that is subsequently encountered during wrist arthroscopy and may be a source of pain for patients with symptoms unresponsive to conservative treatment. The aim of this study is to assess the diagnostic accuracy of conventional MRI in the detection of wrist synovitis observed intraoperatively with wrist arthroscopy. Materials and Methods A retrospective chart review was performed on 51 patients who underwent arthroscopy for chronic wrist pain and MRI confirmed wrist pathology that did not resolve with nonoperative treatment. Wrist arthroscopy was performed by three fellowship-trained hand surgeons. While the primary pathology like TFCC or scapholunate ligament tear was identified and treated arthroscopically, it was noted that many of the patients had concomitant synovitis observed arthroscopically that was not identified preoperatively on MRI. Therefore, the diagnosis of wrist synovitis on MRI scan was compared with the observed presence of synovitis at the time of wrist arthroscopy. Results of preoperative MRI without contrast were categorized as true positive, false positive, true negative, and false negative, based upon intraoperative arthroscopic findings. Results In total, 45/51 patients were confirmed to have dorsal and ulnar synovitis on wrist arthroscopy. MRI identified 16/51 patients as having synovitis. Of those 16 patients, 2 were false positives. Conclusion The results demonstrate that conventional MRI without contrast has poor diagnostic accuracy in detecting wrist synovitis. Patients with ligament or chondral pathology or no clearly identifiable pathology on MRI whose clinical symptoms persist despite conservative treatment may have underlying dorsal and ulnar wrist synovitis that is not detected on MRI. Wrist arthroscopy facilitates the identification and treatment of synovitis in patients with concomitant wrist pathology and pain refractory to nonoperative treatment. This study suggests that MRI may have a low sensitivity for identifying wrist synovitis when compared with wrist arthroscopy during the evaluation of patients presenting with wrist pain.

Volar Wrist Arthroscopy Portals Using the NanoScope Are Safer than Traditional Arthroscopy.

The NanoScope, given its smaller size, may be further from critical structures when establishing volar wrist arthroscopy portals compared to the traditional 2.7-mm arthroscope. Ten fresh-frozen latex-injected cadaver specimens were utilized. The volar radial (VR) and volar ulnar (VU) portals were created using an inside-out approach. The volar radial midcarpal (VR-MC) and volar ulnar midcarpal (VU-MC) portals were created using an inside-out approach. The arm was then dissected under 3.5-mm loupe magnification. Digital calipers were used to measure the distance between the portals and the surrounding anatomic structures by two fellowship-trained hand surgeons. The median nerve was on average 1.6, 7.2, 1.8, and 5.6 mm away from the trochar for the VR, VU, VR-MC, and VU-MC, respectively. The median nerve fascia was pierced by the VR portal in one specimen. The radial artery, ulnar artery, and ulnar nerve were not pierced in any specimen. Compared to historical controls, for the VR-MC portal, the NanoScope was further from all critical structures, aside from the radial artery, and did not pierce any neurovascular structures. For the VU-MC portal, the NanoScope was further from the ulnar artery and median nerve and did not pierce any neurovascular structures. In developing volar portals, after placing the cannula through the volar capsule from an inside-out approach, we recommend making a volar incision and dissecting the local anatomic structures to guard against injury. Compared to historical controls, the NanoScope was typically further from neurovascular structures.

Comparison of Wound Outcomes for Absorbable versus Non-absorbable Suture after Carpal Tunnel Release

Background and Hypothesis:Carpal tunnel release (CTR) is a common hand surgery procedure. Despite the large volume of CTRs performed worldwide (400,000-600,000 cases/year), there is no consensus as to the optimal suture material for incision closure. In this study, we sought to compare outcomes of absorbable and non-absorbable suture for skin closure after CTR. Our hypothesis was that that there is no statistically or clinically significant difference in wound-related outcomes between the cohorts.
 Project Methods:All patients who underwent primary open carpal tunnel release (CTR) at a large, public county hospital in Indianapolis, IN were identified by CPT code (64721). All patients were treated by one of two fellowship-trained hand surgeons. The most recent 50 patients treated between September 2022 and May 2023 by each surgeon were identified. Surgeon “A” uses 4-0 vicryl rapide for closures (absorbable). Surgeon “B” uses 4-0 nylon for closures (non-absorbable). Adverse events (AE) were defined as infection, dehiscence, or suture granuloma observed at any follow-up appointment. This study was approved by the Institutional Review Board.
 Results:100 patients were identified - 4 patients were lost to follow-up and were excluded from the study. Of the remaining 96 patients, 46 received absorbable suture and 50 non-absorbable suture. Of the 46 patients who received absorbable suture, 8 experienced AE (17.4%). None of the 50 patients who received non-absorbable suture experienced an AE. There was a statistically significant difference in AE between the absorbable and non-absorbable suture cohorts (p=0.002). Patients with absorbable suture averaged 1.61 follow-up appointments, whereas those with non-absorbable suture averaged 2.32 (p=.0008).
 Conclusion and Potential Impact:In this study, absorbable suture resulted in more wound-related complications after CTR. However, patients with non-absorbable suture had more post-operative follow-up appointments. These findings should be considered when selecting suture material for skin closure after CTR.

Outcomes and Complications of Intramedullary Metacarpal Fixation.

Metacarpal fractures are common orthopedic injuries with potentially debilitating outcomes. Ideal surgical treatment remains a topic of debate, with intramedullary fixation becoming popular as a technique to allow for earlier mobilization with few reported complications. The aim of this study was to report observed outcomes and complications of intramedullary metacarpal fixation using the ExsoMed INnate metacarpal nail. A retrospective chart review of 37 patients with 44 metacarpals treated with the ExsoMed INnate between July 2020 and December 2021 by a single fellowship-trained hand surgeon at a single level 1 trauma center was performed. Variables recorded included both patient and injury demographics, surgical complications, and postoperative outcomes. We also measured metacarpal isthmus diameter of the second to fifth metacarpals on all patients to determine the intramedullary canal diameter to assist in implant size selection. Average follow-up was 5.84 weeks with average time to radiographic healing of 5.5 weeks, and time to full activity 6.32 weeks. The mean postsurgical active total arc of motion was 250°, while passive total arc of motion was 259.74°. A total of 10 complications (22%) were identified, including 4 bent screws which occurred as a result of a punching event postoperatively. Intramedullary fixation of metacarpal fractures using the ExsoMed INnate metacarpal nail has shown to preserve range of motion and quick return to full activity, with a low rate of major complications. Our study highlights the potential major complication of the bent intramedullary screw and its association with an initial punching mechanism.

Soong Classification Using Radiographs Only Moderately Correlates With Distal Radius Plate Position on Computed Tomography

Background: The Soong classification grades the prominence of volar locking plates used to treat distal radius fractures in relation to the volar rim. The basis of the classification scheme is that increasing plate prominence over the volar rim and distal radius watershed zone is associated with increased likelihood of flexor tendon irritation and need for plate removal. However, recent studies report mixed results on the predictive value of the Soong classification for these outcomes. We hypothesized that the decreased predictive accuracy of Soong classification is due to misclassification between Soong grades secondary to a suboptimal correlation between the Soong classification on radiographs (XRs) and computed tomography (CT). Methods: Fifty volarly displaced distal radius fractures treated with a volar locking plate in the international and publicly available ICUC database were reviewed. All cases with a postoperative XR and CT were included. Soong classification of the volar locking plate in relation to the volar ulnar rim was determined on both XR and CT by 2 independent, fellowship-trained hand surgeons using CT imaging as the gold standard. The distribution of Soong grades on XR and CT was compared using Pearson’s χ2 test, and correlation was calculated using the Matthews correlation coefficient (MCC). A multi-class confusion matrix was used to calculate each grade’s positive predictive value (PPV). Results: We found an MCC of 0.65, indicating only moderate correlation between the 2 modalities. Per individual Soong grade, the PPV was the highest for grade 2 (0.96), with lower PPVs for grade 0 (0.63) and grade 1 (0.60). Conclusions: The distribution of Soong grades was significantly different when using XR versus CT ( P < .001). Level of Evidence: Oxford Centre for Evidence-Based Medicine, diagnostic, level 2b

Fixation of Mallet Fractures Using a Modified Hook Plate Technique: A Prospective Case Series of 17 Patients.

Objective Various modalities have been suggested to manage mallet fractures; however, inappropriate treatment can lead to extension lag, a swan neck deformity, or arthritis of the distal interphalangeal joint (DIPJ). The current study aimed to evaluate the results (functional, radiological, and complications) of open reduction and internal fixation (ORIF) of mallet fractures using low-cost hook plates fabricated from low-profile titanium mini plates. Methods A prospective case series of 17 consecutive patients (average age of 32.3 years) with mallet fractures (six were Wehbe Type IB and 11 were Wehbe Type IIB). Eleven (64.7%) were males. The affected hand was dominant in all patients, and the affected digit was the index in 6 (35.3%), the ring in 5 (29.4%), the small in 3 (17.65%), and the middle in 3 (17.65%) patients. The same fellowship-trained hand surgeon performed all surgeries. Results The average operative time was 37.65 minutes. After an average follow-up of 10.94 months (range 6-27), the average DIPJ motion was 50° ° (range 20°-70°), the extensor lag was noted in 4 (23.5%) patients, and complications were reported in 6 (35.29%) patients. According to Crawford criteria, 6 (35.3%) patients achieved excellent results, 7 (41.2%) achieved good results, and 4 (23.5%) achieved fair results. Conclusion The modified hook plate technique for fixation of mallet fractures is a beneficial, economical, yet demanding technique that adequately provides stable fixation to allow early DIPJ motion with acceptable functional outcomes.

Thumb Carpometacarpal Stabilization With a Dorsal Capsule Repair Augmented With an Internal Brace.

Optimal surgical treatment of first carpometacarpal joint instability remains a subject of debate. Consensus on thumb carpometacarpal stability originating with the dorsoradial ligamentous complex has shifted reconstruction techniques towards stabilization dorsally. We describe a dorsal stabilization technique with internal brace augmentation of the dorsoradial ligamentous complex. A single fellowship-trained hand surgeon treated 10 women, average age 34 years (range, 21 to 52y) and 1 man, age 34 years, between 2019 and 2022. Average patient follow-up was 2 years. Patient satisfaction was high. Further trials are needed to determine whether the procedure will prevent or delay the presentation of thumb carpometacarpal arthrosis.

Trigger Finger Release: Are Sutures Requiring Removal Necessary?

There is no consensus regarding optimal closure for trigger finger release (TFR) surgery. The purpose of this study was to compare the number of postoperative visits and complications following TFR closure with nonabsorbable sutures versus those following TFR closure with absorbable sutures and skin glue. The hypothesis was that wound closure with absorbable sutures and glue will result in fewer postoperative visits, while having similar complication rates as that with nonabsorbable sutures. A retrospective review identified all patients undergoing open TFR over a 3-year period performed by two hand surgery fellowship-trained hand surgeons who adhered to an identical surgical protocol except for incisional closure. Patients were divided into two groups: a control group with nonabsorbable 4-0 monofilament sutures requiring removal ("suture" group) and a study group with buried absorbable 4-0 monofilament sutures not requiring removal as well as skin glue ("glue" group). The data collected included age, sex, number of postoperative visits, wound complications, infections, antibiotic use, prescribed hand therapy, hospital admission, and reoperation. A total of 305 open TFR surgeries in 278 patients were included in the study, with 155 digits in the "suture" group and 150 in the "glue" group. Both groups were similar in age and sex. The "suture" group had significantly more total postoperative visits (185 vs 42, respectively, P < .001) and postoperative visits within the first 2 weeks (155 vs 10, respectively, P < .001) than the "glue" group. Additional postoperative visits beyond 2 weeks of surgery were similar between the two groups. Three (1.9%) patients in the "suture" group and two (1.3%) patients in the "glue" group developed a superficial surgical site infection within 30 days after surgery. Neither had deep infections requiring hospitalization or reoperation. Both groups required similar rates of postoperative hand therapy. Absorbable sutures afford fewer postoperative visits while having a similar complication rate as nonabsorbable sutures requiring removal. Therapeutic IV.

Histologic Comparison of the Fascicular Area of Processed Nerve Allograft Versus Cabled Sural Nerve Autograft.

The use of multiple cables of sural nerve autograft is common for peripheral nerve reconstruction when injured nerve caliber exceeds the nerve graft caliber. Although the optimal matching of neural to nonneural elements and its association with functional outcomes are unknown, it is reasonable to consider maximizing the neural tissue structure available for nerve regeneration. No prior studies have compared directly the cross-sectional fascicular area between cabled nerve autografts and size-selected nerve allografts. This study evaluated the cross-sectional fascicular area between native nerve stumps and two reconstructive nerve grafting methods: cabled sural nerve autograft (CSNA) and processed nerve allograft (PNA). CSNA from matched cadaveric specimens and PNA were used to reconstruct nerve defects in the median and ulnar nerves of six pairs of cadaveric specimens. Nerve reconstructions were done by fellowship-trained hand surgeons. The total nerve area, fascicular area, and nonfascicular area were measured histologically. The CSNA grafts had significantly less fascicular area than PNA and caliber-matched native nerve. The PNA grafts had a significantly higher percent fascicular area compared with the intercalary CNSA graft. Fascicular area was significantly greater in PNA versus CSNA. The PNA consistently demonstrated a match in fascicular area closer to the native nerve stumps than CSNA, where CSNA had significantly smaller fascicular area compared with native nerve stumps.

Clinic Carpal Tunnel Release Surgery Outcomes and High-Value Care.

As healthcare costs continue to rise, the importance ofdelivering high-value healthcare increases.The volume of carpal tunnel release surgeries performed annually generates a significant cost burden for the healthcare system. The fundamental expenses of carpal tunnel release surgery are facility fees, anesthesia fees, and surgeon fees. Performing open carpal tunnel release surgeries in the clinic utilizing local anesthesia and field sterilization minimizes facility and anesthesia costs. We compared patient outcomes, as measured by infection and revision rates, between hospital-based, ambulatory surgery center-based, and clinic-based carpal tunnel release operations. Three hundred and eighty-eight patients were treated with isolated mini-open carpal tunnel release procedures by three fellowship-trained hand surgeons: 12 patients had hospital-based procedures, 229 had ASC-based procedures, and 147 had clinic-based procedures. All procedures were performed using amini-open approach. No patients were diagnosed with deep infections post-procedurally, irrespective of venue. Our results show no significant difference in outcomes between venues. Therefore, we conclude that the outcomes of open carpal tunnel release surgeries performed in the clinic were not inferior to carpal tunnel release operations performed at the ambulatory surgery center or the hospital. The cost savings from field sterilization, local anesthesia, and the absence of a facility fee provide an opportunity to expand high-value care.

Appropriateness of Self-Scheduled Office Visits in Outpatient Hand Surgery

Our practice recently implemented a system that enables patients to self-schedule outpatient visits through an online portal. The purpose of this study was to evaluate the appropriateness of self-scheduled appointments in the Hand and Wrist Surgery Division of our practice. Outpatient visit notes from 128 new patient visits among 18 fellowship-trained hand and upper extremity surgeons were collected; 64 visits were self-scheduled online, and 64 were scheduled using the traditional call center system. The notes were deidentified and divided among 10 hand and upper extremity surgeons, such that each note was reviewed by two different reviewers. The surgeons scored each visit on a scale of 1-10, with 1 representing a completely inappropriate visit for a hand surgeon and 10 representing a completely appropriate visit. Primary diagnoses and treatment plans were recorded, including whether surgery was planned during the visit. The final score for each visit resulted from the average of the two separate scores. The average appropriateness score for all self-scheduled visits wascompared with the average score for all traditionally scheduled visits with a two-sample ttest. The average appropriateness score for self-scheduled visits was 8.4 of 10, with seven visits resulting in a planned surgery (10.9%). Traditionally scheduled visits had an average appropriateness score of 8.4 of 10, with eight visits resulting in a planned surgery (12.5%). The average difference in the scores between reviewers for all visits was 1.7. In our practice, the appropriateness of visits that are self-scheduled is nearly identical to the appropriateness of traditionally scheduled visits. Implementation of self-scheduling systems may allow for greater patient autonomy and access to care and reduce administrative burden on office staff.

Factors Influencing Patient Experience After Cubital Tunnel Syndrome Surgery

The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care. Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved. Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution. Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery. Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care.

Inter- and Intra-observer Agreement of Visual Estimation, Goniometric and Radiographic Measurement of Passive Thumb Metacarpophalangeal Joint Hyperextension.

Background: Reliable methods for measuring range of motion is important for hand therapists. Currently, there is no gold standard for the measurement of thumb metacarpophalangeal joint (MCPJ) hyperextension. We hypothesised that visual and goniometric measurements of thumb MCPJ hyperextension vary greater than 10° from radiographic measurements, and between observers. Methods: Twenty-six fresh-frozen hands were measured by a senior orthopaedic resident and fellowship trained hand surgeon. Passive thumb MCPJ hyperextension was measured by visual estimation, goniometry and axis measurement on a lateral thumb radiograph. Raters were blinded to each other's and their own prior measurements. Descriptive statistics were recorded for measurement type and inter-observer agreement using a two-way intra-class correlation coefficient (ICC). Intra-observer agreement was calculated using concordance correlation coefficient (CCC). Bland-Altman plots identified trends, systemic differences or potential outliers. Results: Mean measurements for both raters were similar for visual estimation and radiographic measurements. Mean goniometric measurements were twice as high for Rater B, and closer to radiographic measurements. For both raters, mean radiographic measurements were 10° greater than the other two methods. For inter-rater agreement, measurements were within 10° most frequently with radiographic measurement, then visual estimates, and least by goniometer measurements. Rater B had better agreement comparing visual and goniometric to radiographic measurements. Conclusions: Radiographic measurement has the best inter-observer agreement and precision for evaluating passive thumb MCPJ hyperextension, especially considering adjunct corrective procedures when performing a soft-tissue basal joint arthroplasty. Rater experience improves precision, but there is still poor agreement between visual estimates and goniometer measurements compared to radiographic measurements, as the former two underestimate hyperextension by 10°. Development of a standard method of clinical measurement is needed to improve reliability.

Outcomes Following Repeat Collagenase Treatment of Dupuytren Contracture

Injectable collagenase Clostridium histolyticum has been an effective and well-tolerated nonsurgical treatment option for the management of Dupuytren contracture of the hand. The purpose of this study was to determine the efficacy of collagenase injection and adverse event rate in patients who had undergone previous collagenase treatment. A retrospective chart review was performed on 332 patients treated with collagenase injection for Dupuytren contracture by three fellowship-trained hand surgeons at a single institution from 2009 to 2019. Fifty-nine joints in 45 patients underwent repeat collagenase therapy for recurrent contracture in the same digit. Pretreatment and posttreatment total metacarpophalangeal and proximal interphalangeal joint flexion contractures were recorded, with complete correction defined as <5° residual digital flexion contracture. Postmanipulation skin tears and adverse events were recorded. A comparison was made between average contracture improvement after initial collagenase injection and that after repeat injection. Forty-five patients with an average duration of 30 months (range, 6-73 months) between initial and repeat collagenase therapies were identified. The mean improvement after first collagenase injection was 45° ± 24° (39° for metacarpophalangeal joint and 50° for proximal interphalangeal joint) compared with a mean improvement of 43° ± 23° (41° for metacarpophalangeal joint and 44° for proximal interphalangeal joint) after second injection. Although similar complete correction rates and skin tear rates (32.2 % for initial and 30.5% for repeat) were observed between initial (80%) and repeat injections (73%), the occurrence of adverse events was 3 times higher (3.4% for initial and 10.2% for repeat) in the latter group. Collagenase treatment of Dupuytren contracture yields effective total flexion contracture correction. Repeat collagenase treatment of previously treated digits yields similar deformity correction and complete correction rates but a higher incidence of adverse events. Therapeutic IV.

Can a Deep Learning Algorithm Improve Detection of Occult Scaphoid Fractures in Plain Radiographs? A Clinical Validation Study.

Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting. (1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level? This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured. Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures. CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective. Level II, diagnostic study.

Correlation of Carpal Tunnel Syndrome 6 Score and Physical Exam Maneuvers With Electrodiagnostic Test Severity in Carpal Tunnel Syndrome: A Blinded Prospective Cohort Study

Although carpal tunnel syndrome (CTS) can be diagnosed clinically with the Carpal Tunnel Syndrome 6 (CTS-6) evaluation tool, the relationship between disease severity and CTS-6 score has not been elucidated. The purpose of our study was to determine the correlation of the CTS-6 score and other physical examination maneuvers with the carpal tunnel severity grade by electrodiagnostic testing (EDT). We hypothesized that the CTS-6 score, Durkan test, and Semmes Weinstein Monofilament Testing (SWMT) positively correlate with EDT severity. We prospectively enrolled 105 consecutive patients who presented to the office with suspected CTS, excluding those with previous surgery, previous EDT from an outside facility, or concomitant neuropathy. Four fellowship-trained hand surgeons obtained the CTS-6 score, time to obtain a positive Durkan compression test, and SWMT of the thumb, index, and middle fingers. All patients were sent for EDT. Hand surgeons were blinded to the results of the EDT, and the electrodiagnosticians were blinded to the clinical data. We used the Bland criteria (0-6) to grade CTS severity on EDT. This grade was compared with the CTS-6 score, Durkan time, and SWMT results. Using Spearman correlation coefficients, we found a weakly positive correlation between a higher CTS-6 score and a higher severity grade on EDT. The mean CTS-6 score based on EDT grading were the following: (1) 14.8 (grade 0), (2) 16.0 (grade 1), (3) 14.8 (grade 2), (4) 16.7 (grade 3), (5) 18.7 (grade 4), (6) 18.3 (grade 5), and (7) 22.4 (grade 6). We also found a statistically significant association between the SWMT and a higher CTS-6 score as well as a higher severity grade on EDT. Durkan compression test did not appear to correlate with the EDT grade. The CTS-6 and SWMT show a positive correlation with EDT severity in CTS on the basis of the Bland criteria. The time to a positive Durkan test did not show any correlation. Diagnostic II.

Hand function following accidental automatic animal syringe injector injuries

Accidental self-injection injury is a common occurrence among veterinary and farm workers handling automatic syringe injectors. Most of the time, these injuries are asymptomatic or cause self-resolving mild symptoms, but these injuries may lead to significant morbidity. The aim of the study was to evaluate hand function after inadvertent injection of a poultry influenza or cholera vaccine in patients admitted to our department with infection. We retrospectively gathered data from admission to last follow-up. Functional assessment and physical exam of the hand were done at each stage by either an orthopedic resident or a fellowship-trained hand surgeon. The exam included evaluation of sensation using monofilament, joint range of motion using a goniometer, and a Quick DASH questionnaire. The study included 21 patients, all men, with a mean age of 33.4 years (range 23–44). Of the 21 patients only eight had attended all follow-ups. All patients had injury to the non-dominant hand. Seventeen of 21 of the cases had finger injuries, out of which 11 involved the thumb. The mean hospitalization time was 3.75 days (1–10). Of the 21 patients, seven underwent surgery to drain a collection during hospitalization. Seven out of eight patients had lowest disability scores on Quick Dash questionnaire. Three out of eight patients lost superficial sensation at the tip of the finger. The largest loss of range of motion was found in the distal interphalangeal joint in the finger or interphalangeal joint in the thumb, especially following surgical drainage. Of the eight patients presenting for follow-up, most had returned to the same job. Hand function was normal, as expressed in a DASH questionnaire. Sensory examination demonstrated that the sensation was almost unaffected over the injured finger. Range of motion of the joint closest to the injection site was usually the most impaired. Patients who underwent surgical drainage had a reduced range of motion.

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.