Background:The complex anatomy of the acetabulum makes preoperative planning a challenging topic in orthopedic education. Effectively interpreting plain radiographs of acetabular fractures is important for time-sensitive cases and remains an initial step for guiding downstream care. Modern implementations of 3D printing include physical reconstructions from CT scans but is not easily accessible. This study aims to evaluate the value of cost-effective generic 3D printed models to improve resident performance on classifying real patient acetabular fracture examples. Methods:22 orthopaedic surgery residents (PGY 1-5) were selected as participants to classify acetabular fractures in the pre-test and post-test surveys. Participants classified 10 acetabulum fracture examples using only the five standard X-ray views in the pre-test survey, then had 3 min at each of 10 stations to review the 3D models and X-rays of acetabular fractures, and finally at the end completed a post-test survey. The total number of correct answers and average perceived confidence were calculated at the participant level for both pre-test and post-test. Results:Results showed significantly different total scores between PGY cohorts for both total score (p = 0.00729) and average confidence (p = 0.0034). Factorial ANOVA of total score against PGY and test type displayed a significant improvement in PGY test scores from pre-test to post-test (p = 0.0453), as well as a significant difference between each PGY year (p = 0.00418). Factorial ANOVA of average confidence against PGY and test type displayed no significant improvement from pre-test to post-test (0.372), however PGY cohorts were shown to be significantly different in their average confidence (0.00677). Conclusions:•This study demonstrates the effectiveness of 3D printed pelvic models in improving orthopaedic residents' ability to correctly diagnose acetabular fractures, making them an important adjunct for resident education.•Diagnostic accuracy significantly improved, but confidence levels remained unchanged.

Background:Chronic kidney disease (CKD) affects bone health and fracture healing, with limited research on distal upper extremity fractures. This study evaluated the impact of CKD on fracture outcomes, including healing time, complications, and mortality, to inform surgical management strategies. Methods:A retrospective review was conducted on patients with CKD stages 1-4 and end-stage renal disease who underwent distal upper extremity fracture repair at a level 1 tertiary hospital. Data on demographics, CKD stage, comorbidities, surgical details, and complications were analyzed. Radiographic union time was assessed. A national database was used for external validation and analysis of postoperative risks, including propensity-matched controls. Results:The CKD cohort (n = 29) showed significantly delayed fracture healing compared with controls (68.4 ± 9.2 versus 50.6 ± 8.0 d; P < 0.0001). CKD patients experienced higher rates of postoperative complications, including edema (P = 0.0001) and weakness (P = 0.0001). TriNetX database analysis corroborated these findings and revealed elevated risks for revision surgery (P = 0.018). Superficial surgical site infections were more frequent in CKD patients but did not reach statistical significance (P = 0.086). Conclusions:CKD adversely affects outcomes following distal upper extremity fracture repair, emphasizing the need for tailored perioperative management. These findings highlight the importance of early identification of CKD-related risks to optimize patient care and outcomes.

BACKGROUND:Biomechanical properties of adult femurs hold significant clinical and surgical relevance. However, a consolidated analysis of those material properties has not been established. Furthermore, the limitations of cadaveric studies and emergence of alternate methods of biomechanical femoral analyses, including synthetic femurs and modern technologies, warrant a comprehensive exploration. METHODS:Three databases were systematically reviewed for biomechanical studies of adult human femurs. Forty-two studies passed inclusion and exclusion criteria. These were categorized as cadaveric, composite, or modern/innovative, and results from these studies were aggregated and organized. FINDINGS:A total of 858 cadaveric specimens were evaluated, with a weighted average tensile modulus of 11.5 ± 1.08 GPa, compressive modulus of 683.3 ± 290.3 MPa, and ultimate stress of 2.24 ± 0.87 MPa. Analysis of 3D-printed and composite femurs exhibited substantial methodological heterogeneity, and aggregate data are presented herein. Modern technologies included finite-element analysis, x-ray/CT-based studies, fractal analysis, and scanning electron microscopy. CONCLUSION:There exists substantial heterogeneity among femoral biomechanical studies. The standardized values derived from cadaveric studies provide baseline biomechanical values for surgical populations. The variety of surrogate femurs and modern technologies necessitate greater standardization in testing methodologies and outcome reporting. A validated and comprehensive library of biomechanical values would be beneficial for future studies.

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: “scaphoid, ”u8220“scaphoid” AND “nonunion, ” and “scaphoid” AND “malunion. ” Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV

Polylactic acid (PLA) models of normal human femoral diaphyses were designed using three‐dimensional (3D) printing technology to create inexpensive, accessible, and reproducible specimens for flexural biomechanical studies. These models were subjected to three‐point bending and their response to loading was characterized. The anisotropic mechanical behavior of the 3D‐printed femurs and the influence of printing orientations, infill density, wall layers, resolution, and other printing parameters were explored to develop a design space. The objective of the design space was set to emulate the flexural biomechanical response of the normal human femur bones. Results show the 3D‐printed PLA diaphyseal femurs with 5% infill density, two–four wall layers, and a resolution of 200 µm resulted in a flexural strength of 184.8 ± 8.18 MPa. Models with 20% infill density and six wall layers resulted in a flexural modulus of 18.54 ± 0.543 GPa. These results emulate the biomechanical response of the normal human femur, as determined by historical target values derived from prior cadaveric and 3D printing data. With further research, inclusive of modeling the proximal and distal femur and more comprehensive biomechanical testing, 3D‐printed femurs may ultimately serve as a cheap, accessible biomechanical resource for surgeons and researchers.

OBJECTIVES Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining. METHODS An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes. RESULTS A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis. CONCLUSIONS This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Background Our primary aim was to identify risk factors for subsidence development in nonoperatively treated distal radius fractures (DRFs). Secondary aims of the study included comparisons of subsidence progression over time with respect to DRF radiographic parameters. Methods A retrospective cohort study of 70 patients with DRFs treated nonoperatively and followed for a minimum of 12 weeks was performed. Of the 70 patients, 29 had subsidence and 41 did not have subsidence. Radiographic measurements assessed the radial height (RH), ulnar variance (UV), volar tilt (VT), and radial inclination (RI). Outcome measures included demographics, injury characteristics, closed reduction, and radiographic measurements. Results Nearly 95% of DRF subsidence occurred within the first 6 weeks after nonoperative treatment. The mean age of the 41 patients without DRF subsidence was 57.6 +/- 16.8 years, and 31/41 (76%) patients were females. Conversely, the mean of the 29 patients with DRF subsidence was 63.8 +/- 17.5 years, and 22/29 (76%) patients were females. Fractures requiring closed reduction were associated with more overall subsidence (p = 0.0009) and subsidence within the first 2 weeks posttreatment. Type C and comminuted fractures were associated with DRF subsidence (p = 0.02 and 0.01, respectively). The initial radiographic parameters and step-off measures were not associated with a higher risk of subsidence (p >= 0.05). Significant differences between subsidence progressions with respect to RH, UV, VT, and RI were observed. Conclusion Most DRF subsidence occurs within the first 6 weeks of nonoperative treatment. Closed reduction, comminution, and AO fracture type are predictors of subsidence development. Moreover, DRF subsidence progresses at different rates depending on the radiographic parameter assessed.

Background: Standardized letters of recommendation (SLORs) were introduced to facilitate the comparison of applicants for orthopaedic surgery residency positions, but concerns have arisen regarding the prevalence of their use and potential limitations. Methods: An 11-question electronic survey was sent to all letter of recommendation (LOR) authors and program coordinators who were identified as having completed or prepared a SLOR during the 2020 orthopaedic surgery residency match cycle. A total of 740 LOR authors and 218 program coordinators were invited via initial and reminder electronic mail messages. Results: The survey response rate was 18.1% for LOR authors and 25.2% for program coordinators. The proportion of LORs written that were SLORs significantly increased from prior to the 2020 match cycle to the 2020 match cycle (72.7% to 90.2%, ratio =1.240, P<0.001). There was not a significant increase in the proportion of LORs that were SLORs prepared by program coordinators (83.7% to 77.6%, ratio =0.927, P=0.375). A majority of LOR authors and program coordinators were aware of electronic (82.1% and 76.5%, respectively) and paper SLORs (91.0% and 88.2%, respectively). Conclusions: This study found that SLOR usage increased among LOR authors. However, a parallel increase in SLOR preparation was not reported by program coordinators. Level of Evidence: Level III

Polylactic acid (PLA) models of normal human femoral diaphyses were designed using 3D printing technology to create inexpensive, accessible, and reproducible specimens for flexural biomechanical studies. These models were subjected to three-point bending at high strain rates. The anisotropic mechanical behavior of the 3D printed femurs and the influence of printing orientations, infill density, wall layers, resolution, and other printing parameters were explored to develop a design space. The objective of the design space was set to emulate the flexural biomechanical response of the normal human femur bones. Results show the 3D printed PLA diaphyseal femurs with 5% infill density, 2 to 4 wall layers, and a resolution of 200m resulted in a flexural strength of 184.8 MPa ± 8.18 MPa. Models with 20% infill density and 6 wall layers resulted in a flexural modulus of 18.54 GPa ± 0.543 GPa. These results have emulated the biomechanical response of the normal human femur.

Optimal treatment of chronic distal radioulnar joint (DRUJ) arthritis and instability remains unresolved in the literature. Specifically, no systematic comparison of two common options, Sauve-Kapandji (SK) and Darrach's, is available. A meta-analysis was performed utilizing the PUBMED and EMBASE databases and yielded a total of 47 available studies. Objective outcomes, such as wrist range of motion (ROM), forearm ROM, grip strength, and subjective outcomes, including pain and rate of return to work, were recorded. Statistical analysis was done using t test and chi-square test. For both the SK and Darrach’s procedures, forearm ROM was significantly better postoperatively in both pronation (p = 0.0001 for both groups) and supination (p = 0.0001 for both groups). Wrist flexion decreased in the SK group (p = 0.0007), but no difference was found for wrist extension (p = 0.09). The Darrach's group showed a significance improvement in wrist extension (p = 0.0001). Grip strength was improved in the SK group (p < 0.0001), but not in the Darrach's group (p = 0.7831). No difference existed between the SK and Darrach's groups in proportion of patients who were pain-free. The SK group had higher numbers of patients return to work (p = 0.0057). There was not enough data from the studies to make any meaningful analysis in term of treatment failure and complications. Overall, both the SK and Darrach's procedures helped improve pain, wrist ROM, and forearm ROM in patient with chronic DRUJ disorders. The SK procedure can have advantages over the Darrach's procedures in terms of grip strength and rate of return to work.

Background: The orthopaedic in-training examination (OITE) is an annual national assessment of knowledge in orthopaedic surgery residents. Our primary aim was to determine if intern performance in the OITE (measured by correct answers) differed before and after the adoption of a formal surgical skills month (SSM) in the residency curriculum. A secondary aim was to evaluate the relationship between intern OITE and post-graduate year two (PGY-2) scores. Methods: A single institution retrospective cohort study was performed, comparing orthopaedic surgery interns who took the OITE before (15 residents) and after (16 residents) the year 2013 (when an SSM was introduced). De-identified OITE raw and percentage correct scores were obtained from all resident records. Statistical testing included independent sample t test and linear regression, with a significance level of 0.05. Results: Comparison of OITE percentage of correct answers overall, between interns before and after 2013, showed a significant increase after initiating the SSM (44.8%±4.13% vs. 49.9%±8.44%, P =0.0414). In addition, regression analysis demonstrated a positive linear relationship between intern and PGY-2 OITE scores after the SSM was implemented ( R 2 =0.380, P =0.011, β=0.424, CI: 0.1135341 –1.190913). Conclusion: Implementation of an SSM led to increased intern OITE scores. Moreover, intern OITE scores were more predictive of PGY-2 scores after SSM implementation. Earlier education (such as a surgical skills month) for orthopaedic surgery interns can aid knowledge acquisition and career development at the beginning of their training. Level of Evidence: Level III.

BACKGROUND:The objective of this study was to understand the frequency and types of complications, and the associated postoperative outcomes within the first 5 years of practice after hand and upper extremity surgery fellowship. METHODS:This was a retrospective observational study of all patients seen and surgically treated by a single surgeon at a single institution from August 2014 to September 2019. This corresponded to the first 5 years of practice after fellowship. Data collected included patient demographics, perioperative data, complication type, and outcome of the complication (better/same/worse than preoperative status). Complications were classified using the Clavien-Dindo system and a unique, self-derived system. RESULTS:In total, 3301 surgeries were performed during the first 5 years of practice. The overall complication rate was 7.9% (261 complications from 239 patients). The 30-day complication rate was 5.2% (171/3301). Eleven (4.2%) of the 261 complications occurred intraoperatively. The total number of complications significantly declined during the first 5 years of practice as follows: 74, 71, 46, 37, and 33 (P = .010, R2 = .92). Hand and wrist were the most frequent anatomic locations involved and bone pathology was the predominant indication. CONCLUSION:The overall surgical complication rate for hand and upper extremity surgery was 7.9%, with a 30-day complication rate of 5.2% (171/3301). The rate of complications after fellowship declined over the first 5 years of independent practice. Superficial infections were the most common complication. More than 90% of patients ultimately improved after addressing the complication. LEVEL OF EVIDENCE:IV.

To determine the effect of time to surgery on outcomes following open reduction and internal fixation (ORIF) of both-bone forearm fractures (BBFFs). Ninety-nine patients who underwent ORIF of BBFFs in a single academic medical center over a 16-year time period were retrospectively reviewed. Demographic and clinical data including age, sex, current smoking status, time from injury to surgery (tsurg), presence of open injury, polytrauma status, and complications were obtained. Radiographs of the affected extremity were reviewed for fracture morphology, reduction quality, and time to union (or presence of nonunion). In addition to descriptive statistics, Chi-square and Wilcoxon–Mann–Whitney tests were used to compare categorical and interval, respectively, with a significance level of 0.05. A tsurg > 48 h was associated with increased rate of delayed unions (tsurg < 48 h: 25

Purpose To investigate the effect of dynamic stabilizers of the elbow on radiocapitellar joint alignment, before and after the administration of regional anesthesia.Methods At a single institution, 14 patients were prospectively enrolled in a study using a within-subjects control design. Before performing a supraclavicular regional block, 10 fluoroscopic images (1 anteroposterior and 9 lateral views) of the elbow were obtained for each patient. The lateral images were obtained with the forearm in maximal supination, neutral rotation, and maximal pronation, and these forearm positions were repeated for 3 elbow positions: (1) full extension; (2) flexion to 90(degrees), with 0(degrees) of shoulder internal rotation; and (3) flexion to 90(degrees), with 90(degrees) of shoulder internal rotation. After obtaining the 10 initial images, a block was performed to achieve less than 3/5 motor strength of the imaged extremity, followed by obtaining the same 10 images in each patient. Radiocapitellar ratio, defined as the minimal distance between the right bisector of the radial head and the center of the capitellum divided by the diameter of the capitellum, was measured in each image.Results The 14 patients had a mean age of 47.8 +/- 15.7 years, and 10 (71.4%) patients were women. A difference between radiocapitellar ratios measured before and after the regional block administration was observed for all lateral images (-1.0% +/- 7.2% to -2.2% +/- 8.0%), although this difference was less than the minimum clinically important difference.Conclusions Paralysis of the dynamic stabilizers of the elbow produces a difference in the radiocapitellar joint alignment, but this did not reach the minimum clinically important difference.Clinical relevance Paralysis of the dynamic stabilizers of the elbow via a supraclavicular nerve block produces no clinically relevant effect on the radiocapitellar alignment of uninjured elbows.

Introduction:Prompt diagnosis of septic arthritis is imperative to prevent irreversible joint damage. Immunocompromised patients are at an increased risk of septic arthritis as well as secondary systemic infection. Our aims were to identify features predictive of septic arthritis and to determine whether these features differed between immunocompetent and immunocompromised patients.Methods:A single institution retrospective cohort study was performed of 173 immunocompetent and 70 immunocompromised patients who underwent aspiration or arthrotomy for suspected septic arthritis from 2010 to 2018. Demographic data, symptoms, laboratory values, and imaging findings were recorded. Multiple variable logistic regression models were used to assess for predictive factors for septic arthritis in both cohorts. Results were reported as odds ratios, 95% confidence intervals, and P values.Results:In the regression analysis, independent predictive factors for septic arthritis in immunocompetent patients were younger age (P = 0.004), presence of radiographic abnormalities (P = 0.006), and C-reactive protein (CRP) (P < 0.001). For immunocompromised patients, only CRP was an independent continuous predictive factor (P = 0.008) for septic arthritis. A risk stratification tool for predicting septic arthritis in immunocompetent patients using age <55 years, CRP >100 mg/dL, and presence of radiographic abnormalities was developed. A similar tool was created using CRP >180 mg/dL and radiographic abnormalities in immunocompromised patients.Discussion:Differences in predictive factors for septic arthritis between immunocompromised and immunocompetent patients suggest dissimilar clinical presentations. The developed risk stratification tools allow one to predict the likelihood of septic arthritis in both groups. This may permit more accurate selection of patients for surgical intervention in the setting of insufficient data from synovial aspiration.

Background The purpose of this study was to determine agreement with the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for distal radius fractures (DRFs), before and after their adoption, and secondarily determine predictors of operative management. Methods A single-institution retrospective cohort study comparing patients treated either nonoperatively (115 patients) or operatively (767 patients) for DRFs between May 1, 2008, and May 1, 2018, by 8 hand surgeons was performed. Data included demographics, injury characteristics, DRF radiographic measurements, treatment rendered, and their appropriateness according to the AUC. Statistical testing used the Fisher and χ 2 tests, t test, and multiple variable logistic regression, with a significance level of .05. Results Overall, there was a significant increase in AUC agreement for operatively treated DRFs (82.7%-89.3%, P = .01), but no difference in agreement for nonoperatively treated DRFs (12.5%-10.7%, P = .77). Age <80 years, AO classes other than B, intra-articular displacement >1 mm, radial inclination <18°, high-energy mechanism of injury, and greater than 1 week to treatment were independent predictors of operative treatment. The area under the curve for the validated regression model using the aforementioned predictors was 0.82. Conclusion Agreement with AUC for DRFs increased after its adoption for operatively treated, but not for nonoperatively treated, fractures. In addition, a predictive model for operative treatment was developed and validated. Future studies may benefit from further model refinement and testing in other patient cohorts.

Background: Bioactive glass has become an increasingly used treatment of cavitary bone defects in a number of orthopaedic applications. The purpose of this study was to evaluate the clinical and radiographic outcomes of bioactive glass used for benign cavitary pediatric bone tumors. A specific focus was on radiographic filling of defects and occurrence of complications by tumor class. Methods: A single institution retrospective study was performed, which entailed review of the clinical and radiographic data of 21 patients who underwent surgical curettage and grafting of benign or low-grade malignant bone tumors from 2018 to 2020. In all the cases, 45S5 bioactive glass (Fibergraft; Prosidyan, New Providence, NJ) was used to fill the bone defects. For each patient, data on demographic, preoperative diagnosis, defect size, time to mobilization, radiographic filling grade, pain, and complications were obtained. The Wilcoxon-Mann-Whitney test and Kaplan-Meier survival analysis were used for comparisons between tumor classes. Results: In the 21 patients, 11 bone tumors were latent or active (class 1) and 10 were aggressive (class 2). The mean age was 13.0±3.7 years, 6 (28.6%) were female, and the median and interquartile range for initial tumor size were 18.8 (5.8 to 50.6) cm 3 . Tumors that were class 2 had significantly more complications with bioactive glass use compared with class 1 tumors [0 vs. 1 (0 to 1), P =0.040]. The time of persistent fill grade 1 or 2 defects up to final follow-up was less in class 1 versus class 2 lesions ( P =0.048). Conclusions: Bioactive glass agents have utility for treating a broad variety of pediatric bone tumors after curettage. However, focusing these agents’ use in treating latent or active subtypes of bone tumors may be ideal in minimizing complications and time to higher fill grade. Level of Evidence: Level III — Therapeutic.

Objective The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods A single institution study was performed, which entailed in-person reexamination of 18 patients ( n = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n(I) = 38 wrists) were noted. Results In the 18 patients, age was 47.6 +/- 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74-294). The VAS score was 0 +/- 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 +/- 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF.

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.