Kakar, Sanjeev

Background: There is growing evidence that social determinants of health (SDOH) are associated with disparities in access to care and hand and upper extremity health. Quality measures represent an opportunity to evaluate disparities in access and outcomes that can inform improvement interventions. We performed a systematic review of evidence regarding health disparities within hand surgery and aimed to develop suitable quality measures that are clinically important, feasible, usable, and scientifically acceptable. Methods: We performed a systematic review including common hand surgery terms to identify health disparities in hand surgery related to SDOH. Candidate quality measures were constructed based upon evidence from the systematic review. A consortium of 11 US-based hand and upper extremity surgeons completed a modified RAND/UCLA Delphi Appropriateness process to evaluate the importance, feasibility, usability, and scientific acceptability of the candidate quality measures. Panelists rated each measure on a scale of 1 ( definitely not important/feasible/usable/scientifically acceptable ) to 9 ( definitely important/feasible/usable/scientifically acceptable ) in 2 voting rounds separated by a face-to-face discussion. Agreement among panelists and validity were assessed using predetermined criteria. Results: Fourteen candidate quality measures addressing health disparities were identified based on evidence from the systematic review, including time to surgery and emergency department use after hand surgery based on insurance type, clinical outcomes based on social deprivation, among others. All 14 measures were accepted. Conclusions: Fourteen candidate quality measures were identified and accepted based upon consensus to address health disparities in hand surgery, although future investigation will be needed to evaluate their effectiveness.

Abstract Background/Purpose Diagnosing wrist ligament injuries is challenging; early detection and treatment are important to prevent osteoarthritis progression. Interosseous proximity maps, a proxy measure for joint space, can be generated from volumetric imaging data and may provide important information about wrist health. Artificial intelligence (AI) could enhance accuracy of noninvasive diagnosis based on imaging-derived metrics. This work demonstrates feasibility of AI training using synthetic proximity map data generated from finite element models (FEMs). Methods Personalized wrist FEMs for two asymptomatic participants were created from four-dimensional computed tomography-derived anatomic and kinematic data. Monte Carlo sampling varied 22 ligament material properties and simulated 7,500 unique injury scenarios generating 9,000,000 labeled red, green, and blue (RGB) images of interosseous proximity vector fields from FEM-derived motions. Images were associated with 17 descriptive metrics, including gross wrist angles and bone surface pairs, and used to develop mixed-input convolutional neural networks (CNNs). Model performance was evaluated for identifying specific ligament injuries. Results Average area under receiver operating characteristic curve (AUROC) for CNNs was 0.757 across all injury types and kinematics. In a subset with clinically-relevant functional angles, the average AUROC was 0.824. Best-performing individual ligament AUROCs ranged from 0.807 to 0.999. Sensitivities and specificities exceeded 0.99 for some ligament injury simulations under specific wrist angles and bone surface pairs. Conclusion This study demonstrates the feasibility of using synthetic data from FEMs to train AI models for classifying wrist ligament injuries. Proximity-based RGB images may be a relevant biomarker of ligamentous injury.

Abstract Background Computational modeling is a tool being deployed for orthopaedic solutions but its use in the hand and wrist remains limited. This work used a model to simulate a clinically relevant provocative scaphoid shift maneuver (SSM) with different levels of scapholunate interosseous ligament (SLIL) injuries to observe the effect on different metrics. Methods A personalized model simulated the full SSM motion cycle from ulnar deviation with extension to radial deviation with flexion informed by the participant’s motion obtained from dynamic computed tomography. Models repeated the SSM under different levels of SLIL injury and reported changes in joint kinematics, contact mechanics, and ligament forces. Results The fully injured model increased scaphoid dorsal translation, flexion, and radial deviation compared to the intact condition and caused a subluxation of the scaphoid. Radioscaphoid contact areas were approximately 200% greater in the fully injured model compared with all others and the fully injured model was the only condition where contact force decreased across the motion cycle. Ligament forces in the intact condition were on average 33.0 N and 54.2 N for the volar and dorsal SLIL, respectively. Lastly, the long radiolunate, an extrinsic stabilizer, had forces that increased following SLIL injury. Conclusions Computational models can successfully recreate clinically observed behaviors of an SSM, including scaphoid subluxation, while providing new insights via quantification of contact mechanics and ligament forces. Contact mechanics metrics may be important for understanding the long-term progression of untreated SLIL injuries to osteoarthritis. Additionally, ligament force metrics may explain the progression of SLIL injuries from volar SLIL to dorsal SLIL and highlight the importance of repairing extrinsic stabilizers of the joint, due to increased force sharing following SLIL injury. This work provides a pathway to future studies investigating the effects of SLIL injury and repair, both acutely and chronically.

Abstract Management of scapholunate advanced collapse (SLAC) wrist arthritis remains challenging in physically high-demand patients with primarily salvage options described for advanced SLAC wrist. Microfracture resurfacing of the scaphoid fossa may be a potential option for this condition. A case of a physically active farmer with advanced SLAC wrist arthritis underwent arthroscopic dorsal capsulodesis of the scapholunate interval, microfracture of the scaphoid fossa chondral defect, and application of cartilage allograft is reported. At 1-year follow-up, there is continued resolution of his wrist pain, and function had improved with increased grip strength and wrist range of motion. Radioscaphoid microfracture and dorsal capsulodesis for SLAC wrist can be a potential dual-pronged reconstructive strategy for the physically high-demand patient that may obviate the need for salvage procedures.

Background: The radiolunate joint is conventionally thought to be spared from radiocarpal osteoarthritis, but proximal lunate degenerative changes have been noted. An investigation of radiolunate arthrokinematics in ostensibly healthy wrists may improve understanding of posttraumatic and postoperative outcomes. We hypothesize that four-dimensional computed tomography (4DCT)-derived radiolunate arthrokinematics during motion will differ between wrists with type 1 and type 2 lunates. The clinical-translational relevance of this analysis is highlighted using a 4DCT case study of scaphoid excision with 4-corner arthrodesis (SEFCA). Methods: Four-dimensional computed tomography data were collected during flexion-extension and radioulnar deviation in 19 healthy wrists (mean [SD] age: 43.6 [11.7] years, 21.1% female) and 1 wrist 3 years after SEFCA (male, 52 years). Carpal osteokinematics and joint arthrokinematics were calculated to derive median radiolunate interosseous proximities at each 4DCT-captured timepoint. Results: Median radiolunate interosseous proximities during motion are well approximated by second-order regressions in uninjured wrists. In the arthrodesed wrist, closest proximities occurred at the extremes of motion except maximum radial deviation. Conclusions: This study quantifies a normative range of median radiolunate interosseous proximities during wrist motion. The normative 4DCT datasets provide a reference range for evaluating postoperative arthrokinematics, suggesting the clinical-translational potential of dynamic imaging. The case study highlights applications for patient-level postoperative evaluation, which can be expanded to other pathologies, surgeries, or conditions in the future.

Background: Proximal pole scaphoid fracture nonunions are challenging conditions to treat. When significant comminution of the proximal pole and avascular necrosis is present, scaphoid proximal pole reconstructive options are considered. The proximal pole of the hamate is a local autograft option; however, little has been described on the outcomes of this procedure. Methods: Patients who underwent proximal pole scaphoid reconstruction using proximal hamate autograft at 3 tertiary care centers were retrospectively reviewed. Radiographic union was classified by greater than 50% bony trabeculae across the reconstruction site on computed tomography scan. Results: Ten patients were included. Average age at the time of surgery was 27.9 years, and 60% were men. Average length of proximal hamate autograft harvested was 10 mm. All patients healed at an average of 14.3 weeks following surgery. At final follow-up, 3 patients reported no pain, 3 reported mild occasional pain, 2 reported moderate tolerable pain (1 at the hamate graft site), and 2 had no reports on their pain level. Conclusions: In small proximal pole scaphoid nonunions with fragmentation and avascular necrosis, ipsilateral proximal hamate autograft reconstruction of the scaphoid proximal pole is a viable and reproducible option with high rates of union and patient satisfaction.

ResumenSi bien el papel del complejos volar escafolunar en la estabilidad de la muñeca es cada vez más reconocido la literatura sobre sus técnicas de reparación y resultados sigue siendo limitada. Este artículo ofrece una visión general completa de la anatomía la biomecánica y la importancia clínica del complejo escafolunar volar junto con las técnicas de reparación artroscópica más actualizadas. Al presentar los avances y los desafíos de estos abordajes mínimamente invasivos buscamos fomentar la investigación y el desarrollo para abordar este aspecto aunque poco reconocido crucial de la inestabilidad escafolunar.

Abstract The purpose of this study was to assess the long-term clinical and radiographic outcomes after distal ulna resection (Darrach procedure) in young adults. A retrospective chart review identified all adult patients who underwent Darrach resection at 40 years of age or younger and had a minimum of 5-year follow-up. Twenty-one patients (24 wrists) were available for final follow-up. Fifteen patients (16 wrists) returned for in-person evaluation, and seven patients (eight wrists) completed questionnaires by phone. Mean PRWE and QuickDASH scores were 32 and 34, respectively. The median visual analog scale at rest was 0 and 1 with activity. In 88% of cases, patients reported they would have the same surgery again. Of those who were employed preoperatively, 81% (13/16) returned to work, with all but one patient returning to their preoperative job. Radioulnar convergence occurred in all patients, but only three (23%) were symptomatic. The Darrach procedure may be a viable surgical option for DRUJ pathology in younger adults when other options are unavailable. Therapeutic IV.

Cases: Two patients with spontaneous loss of thumb interphalangeal joint extension were referred after history, electrodiagnostic, and/or magnetic resonance imaging (MRI) findings were felt to demonstrate a posterior interosseous nerve (PIN) palsy. Subsequent physical examination and additional directed studies suggested an alternative explanation: rupture of the extensor pollicis longus (EPL) tendon, subsequently confirmed at surgery. An extensor indicis proprius to EPL transfer restored thumb function. Conclusion: Electrodiagnostic and MRI changes consistent with diffuse PIN palsy may occur in the setting of EPL rupture. An accurate diagnosis of EPL dysfunction requires careful physical examination and confirmatory imaging. Further study of this previously unreported phenomenon is required.