PURPOSE:Brachial plexus birth injury (BPBI) affects up to 3 per 1,000 live births, with many children experiencing persistent disability. Although autologous nerve grafting has traditionally served as the primary reconstructive strategy for BPBI, nerve transfers are being used with increasing frequency. We analyzed national trends in nerve reconstruction for BPBI using the Pediatric Health Information System administrative database from 2005 to 2024. METHODS:We used Current Procedural Terminology (CPT) codes associated with nerve autografting or nerve transfer to identify patients in the Pediatric Health Information System database under 24 months of age who underwent surgery for BPBI. The primary outcome was the presence of procedural CPT coding events. Trends in procedures were analyzed using Cochran-Armitage analyses. Chi-square analyses and multivariate logistic regression were used to evaluate differences between autograft and transfer groups. RESULTS:We identified 1,047 procedural coding events between 2005 and 2024, comprising 585 autografts (55.9%) and 462 nerve transfers (44.1%). Patients who underwent autografts were notably younger than patients who underwent nerve transfer at time of surgery (6.3 ± 3.5 vs 10.2 ± 4.9 months, P < .001). Multivariable analysis confirmed year, patient age, and region as independent predictors of nerve transfer. The odds of receiving a transfer increased 21% with each calendar year (P < .001). Patient age strongly influenced procedure selection, with patients older than 8 months demonstrating nearly 7-fold greater odds of undergoing a transfer. Among patients older than 8 months, treatment by orthopedic surgeons was associated was a 68-fold increase in the odds of nerve transfer during the contemporary study period, whereas treatment by plastic surgeons was associated with a 5-fold increase. Transfers predominated in the West census region and were performed less frequently in the Northeast. CONCLUSIONS:These findings demonstrate increasing adoption of nerve transfers in pediatric BPBI reconstruction across specialties and regions. Further investigation into long-term functional outcomes and subspecialty-specific training is needed to refine surgical decision making in this population. TYPE OF STUDY/LEVEL OF EVIDENCE:Prognostic III.
First web space contracture is a common and potentially debilitating condition that impairs thumb positioning and compromises pinch and grasp. The complex, three-dimensional anatomy of the web space and the intricate biomechanics of the thumb contribute to substantial variability in both assessment methods and treatment strategies. At present, there is no universally accepted framework for defining, classifying, or measuring outcomes in first web space contracture. This review aims to synthesize current strategies for assessment and outcome evaluation, highlighting their limitations and areas of inconsistency. By clarifying existing methodologies and identifying gaps in the literature, this article aims to provide a foundation for more standardized, clinically meaningful evaluation and management of first web space contracture.
Our understanding of Kienbock disease has evolved significantly over the last decade with advances in the study of basic science and advanced imaging. Some patients are predisposed to the disease, and the evolution of the disease may be influenced by the patient's demographic. Both biomechanical and biological factors play a significant role. The morphology of the wrist and lunate influence loading mechanics through the central column. Both arterial and venous factors are important in the development of ischemia and the onset of a compartment syndrome of bone. Stability of the wrist plays a role. The disease affects the ligaments within and between the carpus and radius through synovitis or avulsion, and disruption of these can leading to collapse of the lunate and carpus. Better understanding of the disease pathogenesis will improve our ability to strategize surgical management.
PURPOSE:Online health queries are often addressed by large language models (LLMs) embedded in search engines. It is possible that LLMs, like human clinicians, might be misdirected by vague symptom descriptions or inaccurate self-diagnoses. We examined patient and scenario factors associated with an LLM's ability to identify intended upper-extremity musculoskeletal diagnoses and its tendency to deviate from patient self-diagnoses in structured clinical vignettes. METHODS:ChatGPT (GPT-5) evaluated 180 randomized hypothetical clinical vignettes depicting five common upper-extremity conditions: de Quervain tendinopathy, rotator cuff tendinopathy, lateral epicondylitis, trigger digit, and trapeziometacarpal arthritis. Each vignette included randomized patient characteristics, characteristic or vague symptom descriptions, and a patient self-diagnosis (categorized as correct, a plausible alternative, or a common misconception diagnosis). The LLM was prompted to select the single most likely diagnosis. Multivariable logistic regression identified independent predictors of diagnostic accuracy and deviation. RESULTS:The LLM correctly identified the intended diagnosis in 165 of 180 scenarios (92%). Accuracy was unaffected by the patient's self-diagnosis, was higher for characteristic than vague symptom, and was lower for de Quervain tendinopathy relative to other conditions. The model deviated from the patient's proposed diagnosis in 117 scenarios (65%), of which 104 deviations (89%) appropriately aligned with the intended diagnosis. The LLM was more likely to disregard patient-provided diagnoses that did not match the intended diagnosis, regardless of whether they represented plausible alternatives or common misconceptions. CONCLUSIONS:In this experimental setting, an LLM identified simulated upper extremity conditions regardless of patient self-diagnosis, suggesting limited susceptibility to the anchoring, confirmation, and acquiescence biases known to affect human diagnostic reasoning. LLMs may therefore support debiasing and patient guidance by helping address unhealthy misconceptions and aligning tests and treatment choices with patient values. TYPE OF STUDY/LEVEL OF EVIDENCE:V (Experimental Vignette Diagnostic Accuracy Study).
PURPOSE:Although fourth generation total wrist arthroplasties (TWAs) have improved implant longevity compared to earlier generations, high failure rates persist. This study aimed to assess how a shift in the center of rotation will affect kinematic outcomes of the joint. This has been accomplished through a TWA redesign, known as the reverse total wrist arthroplasty (RTWA). METHODS:Eight cadaveric specimens (75.1 ± 10.9 years, 8 men) were implanted with both a custom load sensing TWA and a novel redesigned RTWA. For both reconstructed states, the specimens were mounted and actuated through flexion-extension (FE) and radial-ulnar deviation (RUD) using an active motion simulator. Muscle forces and articular loading patterns were recorded in both states for comparison of the implant designs. Statistical analysis completed showed RUD motion was underpowered and are therefore presented as exploratory and descriptive because of limited power. RESULTS:In general, during both FE and RUD the RTWA required a lower magnitude of force from the muscles compared to the TWA state. Throughout FE, four of the five muscles examined required less force after RTWA implantation. Through RUD, three of five required less force. In addition, through both ranges of motion the carpal component joint loading was decreased in all wrist positions (41.6 ± 8.6% and 38.1 ± 7.1% for extension and flexion motion, respectively) after implantation of the RTWA compared to the TWA. CONCLUSIONS:The redesigned RTWA performed well compared to a standard TWA implant and there was a noted decrease in both the muscle forces and joint loading following RTWA implantation. CLINICAL RELEVANCE:The new RTWA design may have the potential to reduce the magnitude of force required by muscles to actuate the joint and reduce the high loading patterns within the distal carpal component that are noted after implantation of TWA implants.
PURPOSE:Augmentation of the medial and lateral collateral ligaments using additional ligament bracing has been shown to improve primary stability in biomechanical studies considerably. However, the general indication for ligament bracing remains a topic of discussion. This study aimed to present clinical outcomes in the treatment of severe medial and lateral elbow instability using ligament bracing. METHODS:This retrospective study included patients treated for severe medial and lateral elbow instability with ligament bracing. Inclusion criteria were rupture of the medial and lateral ligaments. Severe instability was defined as recurrent dislocation during motion testing after reduction or as decentration on computed tomography or magnetic resonance imaging. Surgical treatment involved repair of the medial and lateral capsule ligament complex with additional ligament bracing. Clinical outcomes were evaluated based on range of motion, Disabilities of the Arm, Shoulder, and Hand score, and subjective satisfaction. Revisions were analyzed. RESULTS:Thirty-three patients with a mean age of 49 years and a mean follow-up of 30 months were included. The Disabilities of the Arm, Shoulder, and Hand score was 15 (range 0-71), and patient satisfaction was 80% (range 20% to 100%). The mean range of motion in extension/flexion was 117° (range 45° to 160°), and pronation/supination was 172° (range 150° to 180°). Overall, 5 revisions (15.2%) were performed, including 1 for recurrent instability 8 days after surgery. CONCLUSIONS:Ligament bracing in the treatment of severe medial and lateral elbow instabilities could restore elbow stability and show good clinical results with a low complication rate. The main reason for the revisions is elbow stiffness. It remains unclear to what extent these are a consequence of the rigid implant or significant trauma. TYPE OF STUDY/LEVEL OF EVIDENCE:Therapeutic III.
PURPOSE:Mere triangular fibrocartilage complex (TFCC) foveal repair might not be sufficient to yield a favorable prognosis in severe distal radioulnar (DRU) joint instability. In this study, we aimed to evaluate the efficacy of allogeneic tendon graft reinforcement for dorsal structure repair following arthroscopically assisted transosseous foveal reconstruction. METHODS:A total of 21 patients were enrolled in the study, and the mean follow-up duration was 44.5 months. Clinical outcomes were evaluated using multiple assessment tools, including the visual analog scale pain score, grip strength, modified Mayo wrist score, and patient-rated wrist evaluation (PRWE) score. RESULTS:All patients had a notable reduction of wrist pain at the final follow-up with the mean visual analog scale pain score decreased from 5.5 to 0.7. The grip strength increased from 75.1% to 86.6% compared with the unaffected side. The modified Mayo wrist score increased from 68.9 to 90.3 and the PRWE score decreased from 50.4 to 8.9. Using a PRWE score decrease of 24 points or more as the criterion, all patients showed clinically meaningful improvements. CONCLUSIONS:In this uncontrolled case series, transosseous TFCC foveal repair combined with dorsal DRU joint reinforcement was associated with favorable clinical outcomes in patients with chronic TFCC injury and severe DRU joint instability. Comparative studies are required to determine whether the addition of dorsal reinforcement is superior to isolated foveal repair. TYPE OF STUDY/LEVEL OF EVIDENCE:Therapeutic IV.
PURPOSE:Direct articular surface visualization may improve reduction accuracy in intra-articular distal radius fractures. A ligament-sparing volar radiocarpal arthrotomy has been described to complement the standard volar approach, but the articular surface area (SA) visualized has not been compared to the traditional dorsal radiocarpal arthrotomy. This study quantified and compared articular SA visualization through volar and dorsal ligament-sparing radiocarpal arthrotomies in a cadaveric model. METHODS:Twenty-four fresh-frozen cadaveric specimens (12 matched pairs) underwent either a volar or dorsal ligament-sparing radiocarpal arthrotomy; one wrist from each pair was randomized to each approach. Visible articular SA was calculated using photogrammetric three-dimensional models created using postarthrotomy images. Radiocarpal disarticulation was performed to calculate total articular SA. Total SA percentage was compared using paired t tests. Regional articular visualization was characterized for each approach by overlay mapping. RESULTS:Mean percentage of SA visualization was 63.7% (range, 43.9% to 90.7%) via volar radiocarpal arthrotomy and 77.3% (range, 53.1% to 90.9%) via dorsal radiocarpal arthrotomy; the dorsal arthrotomy provided a mean increase in visualization of 13.5% (P = .008). Based on overlay mapping, the volar arthrotomy improved visualization of the volar rim, whereas dorsal arthrotomy improved visualization of the dorsal rim, dorsal-radial scaphoid facet, and dorsal-ulnar lunate facet. There was similar visualization of the central third of the radius, volar-radial scaphoid facet, and volar-ulnar lunate facet. CONCLUSIONS:Both volar and dorsal arthrotomies provide excellent visualization of the distal radius articular surface, although dorsal arthrotomy provided greater overall visualization. Volar arthrotomy improved exposure of the volar rim, a region commonly involved in volar rim marginal fractures and volar shear intra-articular fractures. The dorsal arthrotomy allowed regional visualization of fracture patterns involving the dorsal-radial styloid, dorsal-ulnar lunate facet, or dorsal rim articular comminution. CLINICAL RELEVANCE:Radiocarpal arthrotomies provide a practical direct assessment of the distal radius articular surface without additional incisions or arthroscopic resources.
