Rizzo, Marco

Background: Metacarpophalangeal (MCP) arthroplasty is an established surgical option for end-stage MCP arthritis. We analyzed trends in case volumes and 30-day perioperative outcomes after MCP arthroplasty performed for rheumatoid arthritis (RA) and osteoarthritis (OA). Methods: We used the National Surgical Quality Improvement Program database to identify all MCP arthroplasties performed for RA (n = 216) or OA (n = 452) between 2010 and 2023. Bivariate analysis was used to compare patient demographics, operative characteristics, and 30-day outcomes. We analyzed temporal trends in case volumes using Poisson regression models and trends in patient characteristics using linear regression. Results: Patients with RA were more likely to be female (85% vs 54%) and have a history of smoking (22% vs 10%) and chronic steroid use (58% vs 4%). Patients with OA had more prevalent comorbidities including obesity, diabetes, and hypertension. Patients with RA more frequently required multi-joint replacement, concomitant soft tissue balancing procedures, plastic surgery involvement, and inpatient admission. The annual case volume for OA increased at +5.9% per year ( P < .001), whereas the volume for RA remained steady. The outpatient case volume grew at a rate of +4.6% per year ( P < .001). Both groups had similarly low rates of 30-day complications (0.9% RA, 1.8% OA), readmission (0.5% RA, 1.5% OA), and reoperation (0% RA, 0.9% OA). Conclusions: Despite distinct patient profiles and operative complexity, both OA and RA patients experience low rates of perioperative adverse events after MCP arthroplasty. Osteoarthritis is a growing indication for this procedure, which is increasingly being performed in the outpatient setting.

The word humility is derived from the Latin word humus, meaning “ground” or “soil.” Romans equated humility with being grounded. Perhaps because it contradicts our natural tendencies toward self-preservation, humility remains an often misunderstood and underappreciated virtue. It is foreign to many, especially in today’s society, which is so focused on self-promotion. However, it is truly one of the most important and powerful virtues that a person can possess and practice. Humility is a just assessment of ourselves and the world around us. It is not thinking less of oneself; rather, it is actually thinking less about oneself. In looking beyond ourselves, we can obtain an honest estimate of our limitations and what is needed to remain patient-centered. In approaching our profession with humility, we more closely honor the privileges of caring for patients, teaching others, innovating, and advancing science. The aim of this article is to show how humility nurtures our development in all aspects of medicine. A humble clinician maintains a steadfast focus on their patient, a humble educator emphasizes the learner, a humble researcher respects science through their honesty and integrity, and a humble innovator does not let pride blind them, recognizing that innovation without humility is doomed to fail. In addition to being a superpower in medicine, humility blesses us with the wisdom and gratitude that come from experiencing, living for, and working for something bigger than ourselves. Gratitude has been considered the father of all virtues, and our ability to be truly grateful requires a core of humility.

Background: Anti-cyclic citrullinated peptide antibodies (ACPAs) are associated with more aggressive rheumatoid arthritis disease. We aimed to determine the effect of ACPA serostatus on survival free from revision, all-cause reoperation, and recurrence of coronal plane deformity in patients with rheumatoid arthritis (RA) undergoing silicone metacarpophalangeal (MCP) arthroplasty. Methods: We retrospectively identified silicone MCP arthroplasties performed in patients with RA with known ACPA serostatus from 2000 to 2022. Kaplan-Meier estimates were used to report survival free from revision, all-cause reoperation, and recurrence of coronal plane deviation >10° on postoperative radiographs. We analyzed ACPA serostatus as a risk factor for these endpoints using cluster-robust Cox proportional hazard models, adjusting for patient sex. Results: We included 133 joints in 39 ACPA seropositive patients (9.0 years mean follow-up) and 63 joints in 21 ACPA seronegative patients (5.7 years mean follow-up). Survival free from revision, all-cause reoperation, and recurrent coronal deformity was higher in seropositive patients than in seronegative patients. Anti-cyclic citrullinated peptide antibody seropositivity was significantly associated with lower risk for revision (hazard ratio [HR] = 0.16), all-cause reoperation (HR = 0.20), and recurrent coronal plane deviation >10° (HR = 0.28). Seropositive patients had longer average time to recurrent coronal deviation >10° (3.5 years vs 1.3 years) and less coronal deviation at final radiographic follow-up (15.9° vs 21.5°). Conclusions: Anti-cyclic citrullinated peptide antibody seropositivity is associated with improved silicone MCP implant survivorship and lower risk of recurrent coronal plane deformity in patients with rheumatoid arthritis. More work is needed to better understand the biologic basis of these findings.

Background: Use of pyrocarbon metacarpophalangeal (MCP) implants in rheumatoid arthritis (RA) patients has been associated with high rates of complications and reoperations. To date, few patient-specific prognostic factors have been identified. This study investigated body mass index (BMI) as a risk factor for RA patients undergoing pyrocarbon MCP arthroplasty. Methods: We included 148 joints (51 patients) that underwent pyrocarbon MCP implantation at our institution from 2000 to 2022. We analyzed survival free from revision, reoperation, and development of postoperative complications using cluster-robust Cox proportional hazard models with restricted cubic splines to plot non linear relationships. Secondarily, we compared survival above and below the World Health Organization cutoff for obesity of ≥ 30 kg/m 2 , adjusting for patient age and sex. Results: The relationship between BMI and risk for complications and revisions was J-shaped, with an increase in risk beyond 29 kg/m 2 . The relationship between BMI and late reoperations was U-shaped, with patients above 27.3 kg/m 2 and below 23.2 kg/m 2 at elevated risk. A BMI ≥ 30 kg/m 2 was associated with a 7.9-times increased risk for revision, 8.3-times increased risk for late reoperations, and 3.7-times increased risk for postoperative complications. Body mass index did not significantly influence risk for early reoperation. Conclusions: Body mass index was associated with pyrocarbon MCP implant failure in a non linear fashion, with overweight patients at risk for complications leading to revisions and late reoperations. Underweight patients may be at increased risk for late reoperations. These findings should inform patient and implant selection and help guide counseling for postoperative expectations.

Humility is one of the most powerful and sometimes least understood virtues we can possess. It is often misinterpreted as a sign of weakness, especially today, where self-promotion is encouraged and celebrated. Many people view humility as “thinking less of ourselves.” In truth, humility is not thinking less of oneself; rather it is appropriately thinking less about oneself. Our ability as caregivers in putting the needs of the patient at the center of all we do is enhanced through our humility. A steady focus on the needs of the patient helps us gain an honest assessment of both our strengths and limitations. Studies have shown that patient outcomes and experiences are strongly associated with provider humility. This article aims to shine a light on the power of humility and its impact on patient experience, psychological and cultural safety, and the provider-patient relationship.

Background: Pyrocarbon metacarpophalangeal (MCP) arthroplasty is associated with high rates of recurrent deformity and reoperation in patients with rheumatoid arthritis (RA). We sought to determine the impact of preoperative hand grip strength (HGS) on implant survivorship in these patients. Methods: We included primary pyrocarbon MCP arthroplasties in patients with RA at our single institution from 2000 to 2022. Cox proportional hazard models with restricted cubic splines were used to model the continuous relationship between HGS and hazard for revision, all-cause reoperation, and development of any complication, accounting for multiple joints per patient and adjusting for sex. Kaplan-Meier estimates were used to report survivorship at 2, 5, and 10 years. Results: We included 75 joints in 27 patients with an average preoperative HGS of 8.6 kg (11.1 years of follow-up). There were 16 (21%) total revisions, most commonly for recurrent deformity, along with 8 nonrevision reoperations, most commonly for tendon/ligamentous repair. There was a significant, J-shaped relationship between HGS and hazard for revision ( P = .001) and all-cause reoperation ( P < .001). Patients with HGS below 5.5 and 5.3 kg had an increased risk for revision (hazard ratio [HR]: 13.5) and all-cause reoperation (HR: 9.8) compared with patients with sufficiently high HGS. The 10-year revision survival was 93% in patients with HGS >5.5 kg and 63% in patients ≤5.5 kg. Hand grip strength did not significantly affect hazard for developing a first complication. Conclusion: Very low preoperative HGS is associated with worsened implant survivorship following pyrocarbon MCP arthroplasty in patients with RA.

Background: Flexor pollicis longus (FPL) palsy following both-bone forearm fracture (BBFF) is a rare complication. Methods: A retrospective review of acute BBFF treated with open reduction internal fixation by a single surgeon from 2005 to 2023 was performed. Injury and surgical characteristics of patients with documented FPL palsy were reviewed. In addition, 10 cadaveric dissections were performed to evaluate the anatomy of the anterior interosseous nerve (AIN) and its branches. The distance of these branches from palpable elbow landmarks and variability in branching pattern were evaluated. Results: Twenty-nine patients underwent surgery for acute BBFF. Of these, 5 (17%) had evidence of an FPL palsy either at the time of injury presentation (n = 2) or immediately following surgery (n = 3). All patients with FPL palsy sustained fractures in the middle one-third of the radius. All palsies resolved after an average of 33 days of observation. In cadaveric dissections, the average distance from the lateral epicondyle to the AIN takeoff and branch to the FPL was 5.5 and 7.6 cm, respectively. The AIN takeoff and branch to the FPL were never less than 4 and 7 cm from the lateral epicondyle, respectively. Conclusion: Flexor pollicis longus palsy following BBFF can occur at the time of injury or following surgery. All FPL palsies involved midshaft radial fractures and were likely neurapraxia. The etiology of FPL palsy remains unclear, but cadaveric dissection suggests the FPL motor branch may be at risk from mid-to-proximal radius fracture fragments or excessive traction during surgery.

Background: When treating upper-extremity infections, clinicians frequently must decide whether to initiate antibiotics or delay them with the goal of optimizing culture yield at the time of surgical debridement. The purpose of this study was to determine whether the administration of preoperative antibiotics affects intraoperative culture yield and whether there is a “safe” interval prior to culture acquisition within which antibiotics can be administered without affecting culture yield. Methods: We conducted a retrospective review of 470 consecutive patients who underwent debridement for a presumed acute infection of the hand, wrist, or forearm at a single tertiary care center between January 2015 and May 2020. Data including patient demographics, mechanism of infection and affected body part(s), and details of antibiotic administration, including type and timing with respect to culture acquisition, were collected. Results: Three hundred and forty-one patients (73%) received preoperative antibiotics prior to debridement and culture acquisition. The rate of positive cultures among patients who received preoperative antibiotics was 81% compared with 95% among patients who did not receive preoperative antibiotics (p < 0.01; odds ratio, 4.73). Even a single dose of antibiotics imparted a significantly increased risk of obtaining negative intraoperative cultures, and an incremental increase in the likelihood of obtaining negative cultures was seen with each preoperative dose given up to 7 doses. We did not identify a “safe” interval of time between antibiotic administration and culture acquisition such that culture yield was not affected. Conclusions: Patients who received preoperative antibiotics for the treatment of upper-extremity infections were approximately 5 times more likely to have negative cultures at the time of debridement than those who did not receive preoperative antibiotics. This effect persisted regardless of the number of doses given or the interval between antibiotic administration and culture acquisition. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Rheumatoid arthritis (RA) affecting the metacarpophalangeal (MCP) joint may warrant arthroplasty. The purpose of this study was to investigate implant survivorship, complications, radiographic outcomes, and clinical outcomes in patients undergoing MCP arthroplasty with a pyrocarbon implant to treat RA. Methods: In all, 124 MCP joint pyrocarbon arthroplasties in 40 patients performed to treat RA were reviewed. Operations were at the index (n = 43, 35%), middle (n = 33, 27%), ring (n = 27, 22%), and small (n = 21, 17%) fingers from 1998 to 2009 in 105 (85%) female and 19 (15%) male joints with a mean age of 54 ± 11 years. Mean postoperative follow-up was 6 ± 3 years. All patients achieved at least 2 years of follow-up. Results: Rates of implant survivorship at 1, 2, 5, and 10 years were 98%, 98%, 90%, and 81%, respectively. Fifteen percent (n = 18) of arthroplasties underwent revision at a mean 5 ± 3 years postoperatively. The overall reoperation rate was 29% (n = 36). Rates of survival from reoperation at 1, 2, 5, and 10 years were 85%, 84%, 76%, and 68%, respectively. Complications occurred in 32% (n = 40). Pain ratings improved postoperatively ( P < .01). Arc of motion improved from 37 ± 21 to 43 ± 19 ( P = .03). Both appositional and oppositional strength improved after surgery; however, there was no improvement in grip strength ( P < .01). Conclusions: Metacarpophalangeal arthroplasty with a pyrocarbon implant demonstrated reliable improvement in pain and arc of motion in patients with RA. Complication and overall reoperation rates were high, while 1 in 10 undergo revision within 5 years postoperatively.

Background The purpose of this study was to investigate the outcomes of surface replacement arthroplasty (SRA) for noninflammatory arthritis of the metacarpophalangeal (MCP) joint. Methods Records from 20 SRAs performed between 1995 and 2017 in 17 patients with noninflammatory arthritis affecting the MCP joint were retrospectively reviewed. The mean follow up was 6.6 years. Results Three arthroplasties (15%) underwent 4 revision operations. The 2-, 5-, 10-, and 15-year rates of survival from surface replacement implant revision were 90%, 90%, 79%, and 79%, respectively. Major complications occurring in revised joints included arthrodesis (n = 1) and amputation (n = 1). The overall reoperation rate was 35%. The 2-, 5-, 10-, and 15-year rates of overall reoperation-free survival were 75%, 69%, 60%, and 60%, respectively. Conclusions Pain ratings and MCP arc of motion significantly improved following arthroplasty. Metacarpophalangeal SRA for noninflammatory arthritis can improve arc of motion and pain. Revision is uncommon; however, 1 in 3 joints requires reoperation.