Raman spectroscopy is a molecular fingerprinting technique that uses inelastic light scattering to characterize material composition and has been widely applied to bone quality assessment. In this ex vivo feasibility study, we tested whether Raman spectroscopy could predict femoral neck T-scores (n = 58) from specimens obtained during elective total hip arthroplasty and classify them as normal, osteopenic, or osteoporotic. Bone samples were excited using a near-infrared, multiple spatial mode, semiconductor laser (830 nm, 150 mW), and scattered light was collected for spectral analysis. Custom MATLAB code calculated Raman outcomes. T-scores were determined from bone mineral density acquired from dual-energy X-ray absorptiometry. Raman components were correlated with T-score using simple linear or partial least squares regressions (PLSR). Bone health classifications were assessed through receiver operating characteristic curves (ROC), area under the ROC curves (AUC), and descriptive statistics. Simple linear regression models identified mineral maturity/crystallinity (MMC) as the strongest single-variable predictor of T-score in males (R2 = 0.20, 95% CI 0.00-0.43) and females (R2 = 0.22, 95% CI 0.00-0.46). MMC showed fair discrimination between normal and osteopenic or osteoporotic groups in males (AUC = 0.76, 95% CI 0.56-0.97; 0.77, 95% CI 0.55-0.99) and females (AUC = 0.73, 95% CI 0.52-0.95; 0.70, 95% CI 0.47-0.92). PLSR (including mineral-to-matrix ratio, carbonate-to-phosphate ratio, MMC, and pyridinoline) slightly improved combined sex T-score correlation (R2 = 0.28, 95% CI 0.05-0.55) and male normal versus osteoporotic classification (AUC = 0.89, 95% CI 0.75-1.00). This ex vivo feasibility study demonstrates the potential of Raman spectroscopy to differentiate bone quality.

Purpose: The purpose of our study was to evaluate the relationship of nonsteroidal anti-inflammatory drug (NSAID) use and nonunion rates in nonoperatively and operatively managed scaphoid fractures. Methods: We queried the TriNetX database to identify all patients diagnosed with scaphoid fractures. Patients were stratified by operative versus nonsurgical management, and by a prescription for NSAIDs within 1 month of scaphoid fracture diagnosis. We then assessed the incidence of scaphoid nonunion and the rate of salvage procedures for nonunion within 3 months to 2 years of the initial diagnosis of scaphoid fracture or scaphoid surgery. Chi-squared testing and odds ratio analysis were used to determine statistical significance. Results: After matching, there were 11,629 patients in each nonsurgical group and 1,063 patients in each operative group. Within the matched nonsurgical treatment cohorts, patients with prescription NSAIDs had a significantly increased incidence of scaphoid nonunion with an odds ratio of 1.7 (95% CI: 1.4−1.9) and significantly increased incidence of salvage procedures (odds ratio: 1.5; 95% CI: 1.2−1.9). In contrast, within the matched operative fracture group with and without perioperative NSAID prescriptions, there were no notable differences between the incidence of scaphoid nonunion, or of salvage procedures. Conclusions: Among patients with nonoperatively managed scaphoid fractures, those prescribed NSAIDs within 1 month of diagnosis demonstrated an increased risk of nonunion and subsequent salvage procedures. This association was not observed in operatively managed patients with perioperative prescribed NSAIDs, suggesting that mechanical fixation may offset the potential adverse effects of NSAIDs. These findings highlight the importance of appropriate patient counseling when deciding on NSAID use in the early postinjury period after scaphoid fractures, especially when nonsurgical management is planned. Type of study/level of evidence: Prognostic IIc.

BACKGROUND:The purpose of this study was to compare the psychological outcomes following digital amputations, successful digital replantation surgeries, and failed digital replantation surgeries. METHODS:The TriNetX database was queried to identify 19,238 patients who had undergone primary digital amputations, 383 patients who had successful digital replantation surgeries, and 253 patients with failed digital replantation surgery that required revision amputation. We then queried the database for new psychiatric diagnoses and for new psychotropic medication prescriptions within 3 years after the index surgery. RESULTS:Within the primary digital amputation group, the incidence of depression, generalized anxiety disorder, substance abuse, and adjustment disorder or post-traumatic stress disorder (PTSD) was 12.4%, 11.4%, 8.8%, and 5.2%, respectively. The incidence of depression, generalized anxiety disorder, substance abuse, and adjustment disorder or PTSD for all replantation surgery patients was 6.8%, 6.5%, 4.5%, and 6.3%, respectively. The incidence of depression, generalized anxiety disorder, and substance abuse were found to be significantly lower in all patients who underwent replantation surgeries compared with the primary amputation group. Meanwhile, the incidence of depression, generalized anxiety disorder, substance abuse, and adjustment disorder or PTSD for the successful replantation group was 6.5%, 6.3%, 3.9%, and 2.9% and was 6.7%, 5.5%, 4.0%, and 9.1%, respectively, for the failed digital replantation surgery cohort. CONCLUSIONS:The 3-year incidence of depression, generalized anxiety disorder, and substance abuse were found to be significantly lower in all patients who underwent replantation surgeries compared with the primary amputation group, regardless of the replantation success. These results are especially pertinent as replantation attempts trend downward in hand surgery.

Purpose The purpose of this study was to develop a machine learning algorithm trained on ultrasound images of the cubital tunnel that can be used to automatically identify, segment, and measure the cross-sectional area (CSA) of the ulnar nerve. Methods Control subjects and patients were scanned using a Fujifilm-SonoSite ultrasound system, equipped with a high-frequency linear array probe by a trained technician or physician. The ulnar nerve was identified and segmented in individual frames using a custom graphical user interface application. A convolutional neural network (YOLOv8) was then trained on these images to automatically detect the ulnar nerve, resulting in a binary map. The CSA and Dice score were then computed using the binary map of the nerve outline from the prediction and ground truth to assess the prediction accuracy. Results In total, 34 subjects (11 patients and 23 controls) were imaged with ultrasound. A total of 2,011 ultrasound grayscale images were extracted, and the ulnar nerve was segmented from these scans. In total, 1,286 images from 23 subjects (seven patients and 16 controls) were used to train the model, 425 images from five subjects (two patients and three controls) were used for validation, and 300 images from six subjects (two patients and four controls) for testing. The machine learning model (YOLOv8) resulted in an average Dice score of 0.90 with 296 images (99%) achieving a Dice score above 0.75. When comparing the CSA predictions from the machine learning model to the area derived from the ground truth, the mean difference and mean absolute difference were 1.78 (13.80%) mm2 and 2.08 mm2 (16.05%), respectively. Conclusions Ultrasound is an emerging noninvasive modality for the diagnosis of cubital tunnel syndrome. However, its implementation remains challenging because of operator dependence and technical variability. This work establishes a foundational step toward fully automated, operator-independent ultrasound assessment of the ulnar nerve. Type of study/level of evidence Diagnostic III.

Background:Volar locked plating (VLP) and dorsal bridge plating (DBP) are both appropriate surgical strategies for the treatment of complete articular distal radius fractures (DRFs), however, direct comparisons between these fixation methods in this injury pattern is lacking. Purpose:The purpose of this study was to compare functional, radiographic, and patient-reported outcomes, for complete articular (AO/OTA 23C) DRFs treated with VLP versus dorsal bridge plating DBP. Methods:This was a retrospective cohort study that included patients aged 18-90 years old who underwent VLP or DBP fixation for AO/OTA 23C DRFs. Polytraumatized patients and those undergoing revision surgery were excluded. Wrist range of motion (ROM) and radiographic outcome measures were collected at 6-month follow-up. PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) were obtained at each follow-up. Surgical complications and patient demographic data were recorded. Results:After propensity matching, 1069 VLP patients were matched to 214 DBP individuals, rendering all demographic variables examined comparable. DBP patients had higher rates of delayed union(2.0 % vs. 4.2 %; p < 0.05) and tendon rupture (0.5 % vs. 3.3 %; p < 0.05), but similar rates of revision surgery, malunion, and infection at 6-months. Multivariate analysis demonstrated greater wrist flexion, extension, radial and ulnar deviation, supination, protonation, grip strength, PROMIS UE, and PROMIS PF among the VLP group compared to DBP (p < 0.05). VLP patients also demonstrated greater radial height and radial inclination, less articular step-off, and decreased volar tilt (p < 0.05). Conclusions:VLP was associated with greater ROM, grip strength, PROMIS UE and PF, improved radial height, radial inclination, and less articular step-off and volar tilt at 6-month follow-up compared to DBP. DBP patients also demonstrated higher rates of delayed union and tendon rupture but similar complication rates. Level of evidence:Therapeutic III.

Purpose Dorsal bridge plating (DBP) can effectively treat complex distal radius fractures (DRFs); however, techniques for metacarpal fixation vary. The purpose of our study was to compare range of motion (ROM), grip strength, patient-reported outcomes, radiographic parameters, and complication rates between patients undergoing DBP with fixation to the second versus third metacarpal for DRFs. Methods We retrospectively analyzed 432 patients with DRFs. Wrist ROM and radiographic data were calculated at the 6-month follow-up. We calculated Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity, physical function, and pain interference at each visit. Additional data collected included surgical complications and demographic data. Statistical analysis was conducted via multivariate analysis, t tests, and chi-square tests. Results A total of 329 patients underwent DBP to the second metacarpal, whereas 103 patients underwent DBP to the third. Demographics and comorbidities were similar between the groups. Tendon rupture was more common in the third metacarpal group (3.9% vs 0.9%), with two extensor pollicis longus and one extensor indicis proprius ruptures in each group and an unspecified tendon in the third metacarpal cohort. All other complication rates were similar. The second metacarpal group demonstrated greater wrist flexion (57.8° vs 56.2°), ulnar deviation (23.9° vs 20.7°), and grip strength (62.3% vs 57.8%). All other ROM measurements were similar. There was no difference in PROMIS metrics at the 6-month follow-up. The second metacarpal group demonstrated greater radial inclination (21.3° vs 19.5°) and less volar tilt (6.8° vs 7.1°). Conclusions Dorsal bridge plating to the second metacarpal demonstrated greater ROM, grip strength, and radial inclination, similar PROMIS scores, and lower extensor tendon rupture rates than third metacarpal fixation. Although there were differences between techniques, their clinical relevance is unclear. Dorsal bridge plating to the second or third metacarpal both result in acceptable outcomes and can be considered based on the fracture pattern and surgeon preference. Type of Study/level of evidence Therapeutic IV.

Satisfactory outcomes after acute tendon injuries are hampered by a fibrotic healing response. As such, modulation of extracellular matrix deposition and remodeling represents an important intervention point to improve healing. During fibrosis, matrix is deposited and remodeled by activated fibroblasts and/or myofibroblasts. Recent work has demonstrated that Ogerin, a positive allosteric modulator of the orphan proton‐sensing GPCR, GPR68, can modulate fibroblast ↔ myofibroblast dynamics in multiple fibroblast populations, including blunting myofibroblast differentiation and facilitating reversion of mature myofibroblasts to a basal fibroblast state in vitro. In the present study, we tested the ability of Ogerin to modulate tendon fibroblast ↔ myofibroblast behavior in vitro and in vivo. Consistent with prior work, Ogerin can both blunt TGF‐β induced tenocyte → myofibroblast differentiation and partially revert mature myofibroblasts to a basal tenocyte state. However, Ogerin treatment from days 8–12 after tendon repair surgery did not inhibit myofibroblast differentiation, and Ogerin treatment from post‐operative days 24–28 did not induce myofibroblast reversion. Moreover, while we expected Ogerin treatment from days 8–12 to impair healing due to blunted extracellular matrix formation, Ogerin treatment improved tendon mechanical properties and altered cell transcriptional profiles and communication patterns in a way that suggests accelerated remodeling and resolution of the repair response, identifying Ogerin as a novel therapeutic approach to improve the tendon healing process.

Purpose:The management of hand osteoarthritis is a cornerstone of hand surgery practice. Corticosteroid injections and surgical interventions form the mainstay of treatment for those patients with symptoms recalcitrant to less-invasive measures. Health care disparities have been increasingly recognized, particularly regarding variations in pain management. This study aimed to determine whether such disparities exist across different racial and ethnic groups in the treatment of hand osteoarthritis. Methods:We used the TriNetX database to evaluate patients diagnosed with hand osteoarthritis between January 1, 2010 and December 31, 2024. Diagnostic and billing codes were used to identify patients, assess overall health care utilization postdiagnosis, and gauge the use of corticosteroid injections and surgical intervention across different demographics. Outcomes were stratified based on racial and ethnic identification. Matching was performed to mitigate risk for confounding. Odds ratios were used to describe differences in the probability of receiving treatment across groups of interest. Results:A total of 896,636 patients diagnosed with hand osteoarthritis were identified. Non-Hispanic White patients had nearly twice the odds of undergoing corticosteroid injections and demonstrated consistently higher rates of surgical treatment compared with minority populations across unmatched analyses. After matching for demographic and comorbidity variables, these disparities largely persisted despite similar overall health care utilization. Conclusions:Minority demographics have lower odds of receiving corticosteroid injections for the treatment of hand osteoarthritis. Similarly, these groups undergo surgical management at considerably lower rates. These findings highlight the persistent disparities in treatment faced by underrepresented groups and underscore the critical importance of considering social determinants of health in the management of upper extremity conditions. Type of study/level of evidence:Prognosis IIC.

Flexor tendon injuries are common and heal poorly owing to both the deposition of function-limiting peritendinous scar tissue and insufficient healing of the tendon itself. Therapeutic options are limited due to a lack of understanding of the cell populations that contribute to these processes. Here, we identified the epitenon as a major source of cells that contribute to both peritendinous fibrosis and regenerative tendon healing following acute tendon injury. Using a combination of genetic lineage tracing and single cell RNA-sequencing (scRNA-seq), we profiled the behavior and contributions of each cell fate to the healing process in a spatio-temporal manner. Integrated scRNA-seq analysis of mouse healing with human peritendinous scar tissue revealed remarkable transcriptional similarity between mouse epitenon-derived cells and fibroblasts present in human peritendinous scar tissue, which was further validated by immunofluorescent staining for conserved markers. Finally, ablation of pro-fibrotic epitenon-derived cells post-tendon injury significantly improved functional recovery. Combined, these results clearly identify the epitenon as the cellular origin of an important progenitor cell population that could be leveraged to improve tendon healing.

Background The number of annual endoscopic carpal tunnel releases (ECTR) has been increasing due to comparable outcomes with open carpal tunnel release (CTR). Many studies have demonstrated cost-saving measures with open CTR, but similar studies for ECTR are lacking. Purpose The purpose of this study was to analyze differences in the costs associated with ECTR under local anesthesia and monitored anesthesia care (MAC). Materials and Methods We retrospectively compared the surgical costs of 844 patients undergoing isolated ECTR between 2018 and 2024. Patients undergoing isolated ECTR were identified using current procedural terminology code 29848. This included 187 patients undergoing ECTR with MAC and 657 with local anesthesia. The total hospital billed procedure, anesthesia, supply, and postoperative care cost was calculated for each group of patients. Total time spent at the surgical center and insurance type were also recorded. Univariate statistical analysis was completed. Results ECTR under local anesthesia was associated with shorter overall time spent in the surgical center compared to MAC anesthesia (148.12 minutes vs. 224.41 minutes). Total hospital-billed procedure cost was significantly lower in the local anesthesia group ($5,643 vs. $9,073), representing an overall cost reduction of $3,430.15. For the local group, there was also an overall lower cost of supplies ($725 vs. $811), anesthesia cost ($0 vs. $994), medication cost ($10 vs. $69.50), and operating room/recovery time cost ($4,844 vs. $6,822). The insurance type distribution between the two groups was significantly different, with the local group having a higher percentage of private insurance. Conclusion Patients undergoing ECTR with local anesthesia demonstrated overall shorter time spent in the surgical center with reduced total hospital billed procedure, anesthesia, medication/supply, and operating room/recovery room cost. ECTR with local anesthesia was associated with an overall cost reduction of $3,430.15 compared to MAC and local. Level of Evidence Therapeutic III.

Flexor tendon injuries are common and heal poorly owing to both the deposition of function- limiting peritendinous scar tissue and insufficient healing of the tendon itself. Therapeutic options are limited due to a lack of understanding of the cell populations that contribute to these processes. Here, we identified a bi-fated progenitor cell population that originates from the epitenon and goes on to contribute to both peritendinous fibrosis and regenerative tendon healing following acute tendon injury. Using a combination of genetic lineage tracing and single cell RNA-sequencing (scRNA-seq), we profiled the behavior and contributions of each cell fate to the healing process in a spatio-temporal manner. Branched pseudotime trajectory analysis identified distinct transcription factors responsible for regulation of each fate. Finally, integrated scRNA-seq analysis of mouse healing with human peritendinous scar tissue revealed remarkable transcriptional similarity between mouse epitenon- derived cells and fibroblasts present in human peritendinous scar tissue, which was further validated by immunofluorescent staining for conserved markers. Combined, these results clearly identify the epitenon as the cellular origin of an important progenitor cell population that could be leveraged to improve tendon healing.

Purpose: Patient-reported outcomes are used routinely to assess disease severity in patients with cubital tunnel syndrome (CuTS). This study aimed to compare the relationships of patient-reported outcomes with clinical examination, electrodiagnostic (EDX), and ultrasound (US) measures. Methods: Twenty-four patients presenting to an academic center with symptoms consistent with isolated CuTS were prospectively enrolled. Clinical examination measures were collected, including grip strength, key pinch, 2-point discrimination, presence of Tinel sign, and elbow flexion test result. Patients underwent EDX evaluation, and US was used to measure the cross-sectional area of the ulnar nerve around the elbow. Patients completed 3 questionnaires: Patient-Rated Ulnar Nerve Evaluation (PRUNE), Patient-Reported Outcomes Measurement Information System (PROMIS), and Disabilities of the Arm, Shoulder, and Hand (DASH). Questionnaire scores and clinical examination measurements were stratified based on EDX and US status. Pearson’s correlations were used to assess the associations of questionnaire scores with objective measures. Results: Significant correlation in PROMIS-Physical Function (PROMIS-PF), PROMIS-Pain Interference (PROMIS-PI), PROMIS-Depression (PROMIS-D), PROMIS-Upper Extremity (PROMIS-UE), and DASH scores were observed between EDX−positive and -negative groups, while no significant correlation was seen between US- positive and -negative groups. Two-point discrimination significantly correlated with PRUNE, PROMIS-PF, PROMIS-UE, and DASH scores. All patient-reported outcome measures significantly correlated with sensory amplitude. PROMIS-D weakly correlated with maximum ulnar nerve cross-sectional area. No significant correlations between patient-reported outcome measures and motor EDX outcomes were observed. Conclusions: Patient-reported symptom severity is more closely associated with EDX diagnosis than US status. PROMIS-PF and DASH displayed stronger correlations to objective measures than other patient-reported outcome measures. Sensory amplitude was the strongest predictor of subjective symptom severity relative to other measures. Type of study/level of evidence: Diagnostic II.

Background:Volar locked plating (VLP) and dorsal bridge plating (DBP) are commonly used fixation techniques for distal radial fractures (DRFs). In patients older than 65 years, DRFs account for more than 18% of all fractures; however, a comparison of outcomes of these techniques in the geriatric population is absent. Purpose:The purpose of our study was to use propensity score matching to compare both clinical and radiographic outcomes of VLP and DBP fixation of DRF in geriatric patients ≥65 years. Materials and Methods:In total, 2,181 patients at least 65 years old with closed DRFs were retrospectively analyzed. Wrist range of motion (ROM) and radiographic outcome data were calculated at 6-month follow-up. Patient Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) were calculated at each follow-up visit. Injury characteristics, surgical complications, and patient demographic data were also analyzed. A combination of propensity score matching, multivariate analysis, t -test, and chi-square tests were used to conduct the statistical analysis. Results:After propensity matching, a total of 1,375 patients underwent VLP, whereas 275 patients underwent DBP. Within the univariate analysis, the DBP demonstrated a higher proportion of AO Foundation/Orthopaedic Trauma Association (AO/OTA) 23-C fracture patterns, with fewer AO/OTA 23-A compared with VLP ( p < 0.05). Multivariate analysis demonstrated greater wrist flexion and extension, radial and ulnar deviation, supination, pronation, and grip strength, and higher PROMIS PF and PI among the VLP group ( p < 0.05). At 6-month follow-up, VLP patients demonstrated greater radial inclination (21.2 vs. 20.3 degrees), lower articular step-off (0.76 vs. 0.86 mm), with similar volar tilt and radial height ( p > 0.05). DBP patients had higher rates of malunion (6.2 vs. 3.0%), nonunion (4.0 vs. 2.0%), and tendon rupture (2.5 vs. 0.9%) but similar rates of revision surgery and infection ( p > 0.05). Conclusion:VLP was associated with greater wrist flexion, extension, radial deviation, ulnar deviation, supination, pronation, grip strength, and PROMIS PF and PI compared with DBP. There were significantly higher complication rates with DBP; however, there was a similar rate of revision surgery. While the VLP group showed significantly greater ROM and radiographic outcomes, this likely did not represent a clinically significant difference in this population. Level of Evidence:Therapeutic III.

Background Volar-locked plating has become a popular treatment option for unstable distal radius fractures. While using locking screws in the distal fragment increases the stability of the fixation, the biomechanical benefits of locking fixation in the proximal fragment have not been definitively established. Purposes This study evaluated the initial mechanical behavior of the volar plating construct with different locking screw configurations in the proximal fragment. Methods Sixteen Sawbones radius models were used. An unstable metaphyseal distal radius fracture was created and fixated with a volar-locked plate. Four different screw configurations in the proximal fragment were tested: all nonlocking screws, locking screw in the distal-most hole, locking screw in the proximal-most hole, and locking screws in both the proximal- and distal-most holes. Initial stiffness, displacement during harmonic loading, and load-to-failure were compared among the three groups. Results The initial stiffness, displacement during harmonic loading, and load-to-failure did not significantly differ among the four proximal screw configurations ( p < 0.05). Failure occurred via toggling of the screws in the configuration with all nonlocking screws and through screw breakage or locking mechanism failure in the configurations with locking screws. Conclusions The use of locking screws in the proximal fragment did not significantly affect the initial stability of volar distal radius plating. However, failure modes differed between the nonlocking and locking configurations, consistent with known mechanical properties of locking fixation. Further mechanical studies in cadaveric models and clinical trials are warranted to determine the optimal screw configuration in volar distal radius plating. Level of Evidence To be determined. Biomechanical study on synthetic models.

Purpose: Shoulder arthroscopy and arthroplasty are increasingly common procedures used to address shoulder pathologies. This study sought to evaluate the incidence of hand-related pathologies, including carpal tunnel syndrome (CTS), cubital tunnel syndrome (CuTS), trigger finger (TF), de Quervain tenosynovitis, and Dupuytren disease following shoulder arthroscopy and arthroplasty procedures. We hypothesized that patients undergoing shoulder surgery would have a higher incidence of hand-related pathologies within 1 year of surgery compared to controls. Methods: This was a retrospective analysis of 12,179 patients who underwent shoulder arthroscopy or arthroplasty surgery that were subsequently diagnosed with CTS, CuTS, TF, de Quervain tenosynovitis, or Dupuytren disease within 1 year after surgery. Relative risk of having associated hand pathologies following shoulder surgery was compared to controls. Results: In total, 10,285 patients underwent shoulder arthroscopy procedures during this period, of whom 815 (7.9%) had an associated hand pathology within 1 year from their shoulder procedure. Arthroscopic surgery was associated with an increased likelihood of having a hand pathology (RR 1.65, 95% CI 1.54–1.76), CTS (RR 1.57, 95% CI 1.42–1.73), CuTS (RR 2.25, 95% CI 1.94–2.61), TF (RR 1.76, 95% CI 1.53–2.03), and Dupuytren disease (RR 2.02, 95% CI 1.54–2.65), but was not associated with a higher likelihood of having de Quervain tenosynovitis. In total, 1,894 patients underwent shoulder arthroplasty procedures during this period, of whom 188 (9.9%) had an associated hand pathology within 1 year. Shoulder arthroplasty was associated with an increased likelihood of having a hand pathology (RR 2.04, 95% CI 1.78–2.34), CTS (RR 2.10, 95% CI 1.72–2.57), CuTS (RR 3.29, 95% CI 2.48–4.39), and TF (RR 1.99, 95% CI 1.47–2.70), but was not associated with an increased likelihood of having de Quervain tenosynovitis or Dupuytren disease. Conclusions: Shoulder arthroscopy and arthroplasty procedures were associated with an increased likelihood of having a CTS, CuTS, or a TF diagnosis made within 1 year of surgery. Only shoulder arthroscopy procedures were associated with a higher likelihood of having Dupuytren disease. Neither shoulder arthroscopy nor arthroplasty procedures were associated with an increased likelihood of a diagnosis of de Quervain tenosynovitis. These associations, however, do not necessarily imply causation, and further investigation is warranted to delineate this relationship. Type of study/level of evidence: Differential Diagnosis/Symptom Prevalence Study Level 3.

Purpose:Carpal tunnel syndrome is the most common peripheral nerve compressive neuropathy in clinical practice. Patients who fail nonsurgical management are indicated for carpal tunnel release (CTR), which can be performed open or endoscopically. Efforts have been made to utilize local anesthesia instead of monitored anesthesia care (MAC) for endoscopic release. This study seeks to compare perioperative surgical times and postoperative outcomes in patients undergoing endoscopic CTR with local anesthesia versus MAC. Methods:This is a 6-year retrospective study of 1,036 patients undergoing isolated endoscopic CTR with MAC (n = 607) versus local (n = 429) anesthesia within an outpatient surgical center. A combination of chi-square and t tests was used to compare the patient characteristics, operative details, and outcomes. Results:The local cohort demonstrated significantly shorter postoperative time to discharge (15.9 ± 9.8 vs 53.8 ± 11.0 minutes; P < .05), total time spent in surgical center (83.2 ± 18.7 vs 129.3 ± 20.7 minutes; P < .05), shorter total operating room time (26.7 ± 4.3 vs 29.0 ± 4.1 minutes; P < .05) and tourniquet time (12.4 ± 2.5 vs 13.1 ± 2.1 minutes; P < .05). Preoperative and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores were similar between the cohorts (P > .05); however, PROMIS pain interference improved to a higher degree between pre- and post-op in the local group (-1.5 vs -0.8; P = .02). Early and late surgical complications were similar between the groups (P > .05). Conclusions:Patients within the MAC cohort demonstrated longer postoperative time to discharge and total time in the surgical center. The MAC cohort had longer operating room and tourniquet time, albeit not clinically significant. Surgical complications and PROMIS scores were similar between the two groups. Our findings suggest that local anesthesia is a safe and effective option for endoscopic CTR and may offer advantages in cost and convenience for patients. Type of study/level of evidence:Retrospective cohort study/therapeutic III.

BACKGROUND:Lateral epicondylitis (LE) is a common source of elbow pain. Treatment options include physical therapy (PT), corticosteroid injection, or surgery, but the efficacy of each remains unclear. In this study, we compare Patient-Reported Outcomes Measurement Information System (PROMIS) scores between patients treated both operatively and nonoperatively for LE. METHODS:Patients presenting to a tertiary academic medical center from February 2015 to December 2018 with a diagnosis of LE were identified. Those with initial and follow-up PROMIS physical function (PF), pain interference (PI), and Depression scores were included and stratified according to treatment. Single-factor analysis of variance testing was used to compare PROMIS scores between intervention types. RESULTS:In all, 982 patients were initially identified with the diagnosis of LE and documented PROMIS scores. Initial treatment consisted of 266 patients receiving formal PT, 238 patients receiving injections, 20 patients undergoing surgery, and 296 patients receiving no formal treatment. At final follow-up, 235 (44.8%) patients had been treated with isolated PT, 237 (45.1%) with injections, and 52 (9.9%) with surgery. Patients who underwent formal PT had the highest initial PF scores when compared with all other interventions. Patients who underwent operative management had higher initial PI scores than those who pursued nonoperative management. CONCLUSIONS:Patient-Reported Outcomes Measurement Information System PF and PI may be useful for determining which treatment course patients suffering from LE are likely to pursue. Pain as a limiting factor in daily living may be a better indication for operative management as opposed to physical metrics.

Successful tendon healing requires sufficient deposition and remodeling of new extracellular matrix at the site of injury, with this process mediating in part through fibroblast activation via communication with macrophages. Moreover, resolution of healing requires clearance or reversion of activated cells, with chronic interactions with persistent macrophages impairing resolution and facilitating the conversion to fibrotic healing. As such, modulation of the macrophage environment represents an important translational target to improve the tendon healing process. Circulating monocytes are recruited to sites of tissue injury, including the tendon, via upregulation of cytokines including Ccl2, which facilitates recruitment of Ccr2+ macrophages to the healing tendon. Our prior work has demonstrated that Ccr2-/- can modulate fibroblast activation and myofibroblast differentiation. However, this approach lacked temporal control and resulted in healing impairments. Thus, in the current study we have leveraged a Ccr2 antagonist to blunt macrophage recruitment to the healing tendon in a time-dependent manner. We first tested the effects of Ccr2 antagonism during the acute inflammatory phase and found that this had no effect on the healing process. In contrast, Ccr2 antagonism during the early proliferative/granulation tissue period resulted in significant improvements in mechanical properties of the healing tendon. Collectively, these data demonstrate the temporally distinct impacts of modulating Ccr2+ cell recruitment and Ccr2 antagonism during tendon healing and highlight the translational potential of transient Ccr2 antagonism to improve the tendon healing process.

BACKGROUND:Ultrasound (US) has emerged as a promising supplement to electrodiagnostic studies (EDX) in the diagnosis of cubital tunnel syndrome (CuTS) and has potential to be performed by novice operators. Our objective is to understand the discrepancies in assessment between the two modalities and to assess the utility of US in CuTS diagnosis by a novice operator. METHODS:Patients who presented to a single tertiary academic medical center and clinically diagnosed with CuTS were prospectively enrolled. Electrodiagnostic studies were performed along with US measurements of the cross-sectional area (CSA) of the ulnar nerve by both a board-certified physiatrist and novice operator. Electrodiagnostic study and US outcomes were compared among four diagnostic impression groups: EDX-/US-, EDX+/US-, EDX-/US+, and EDX+/US+. RESULTS:Sixteen patients were classified as abnormal by both EDX and US, 14 were classified abnormal by US only, 3 were classified abnormal by EDX only, and 6 were classified normal by both EDX and US (P = .008, K = 0.14). The EDX+/US+ group had a significantly reduced sensory amplitude compared with the EDX-/US+ (P = .04) group. Diagnostic classifications between a board-certified physiatrist and novice operator were in moderate agreement (K = 0.58, P = .08). CONCLUSIONS:Ultrasound detected a greater proportion of patients as abnormal than EDX. A subset of patients with clinical diagnoses of CuTS had normal sensory amplitudes but increased maximum nerve CSAs. Competency in US may be easily acquired with minimal training, suggesting its potential to be extended for use by other members of the health care team.

Purpose:Distal radius fractures (DRFs) indicated for operative intervention are most commonly treated with volar-locked plating (VLP); however, dorsal bridge plating (DBP) has been used as an alternative fixation method. The purpose of this study was to use a propensity score to match and compare the radiographic and clinical outcomes of patients undergoing isolated VLP or DBP for DRFs. Methods:We performed a retrospective, propensity score-matched analysis of patients undergoing isolated VLP or DBP treatment for isolated DRFs from 2015 to 2022 at a single level-1 trauma center. Patients were propensity score-matched by a total of eight demographic and comorbidity factors, AO Foundation/Orthopedic Trauma Association classification, and preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Our primary outcomes included postoperative complications, wrist and forearm range of motion (ROM), grip strength, and radiographic measurements, including radial height, radial inclination, volar tilt, and articular step-off. Results:Overall, 415 DBP and 2075 VLP were successfully propensity score-matched and included in this study. Grip strength and ROM measurements at the 6-month follow-up, including wrist flexion, wrist extension, forearm pronation, forearm supination, radial deviation, and ulnar deviation, were increased in the VLP compared with DBP (P < .05). Complication rates among both the groups were relatively low; however, the rates of malunion and nonunion were significantly higher among the DBP group (P < .05). Radial height, radial inclination, and articular step-off were improved in the VLP group compared with the DBP group (P < .05); however, volar tilt was similar between groups. PROMIS upper extremity and physical function were significantly higher among the VLP group (P < .05). No significant difference was noted in PROMIS pain interference between the groups. Conclusions:When compared with DBP, patients undergoing VLP are more likely to have improved clinical and radiographic outcomes. Although improvement in wrist and forearm ROM and radiographic parameters is statistically significant, it may not be clinically relevant. Type of study/level of evidence:Therapeutic III.