Hinchcliff, Katharine

Background: The NanoScope, given its smaller size, may be further from critical structures when establishing volar wrist arthroscopy portals compared to the traditional 2.7-mm arthroscope. Methods: Ten fresh-frozen latex-injected cadaver specimens were utilized. The volar radial (VR) and volar ulnar (VU) portals were created using an inside-out approach. The volar radial midcarpal (VR-MC) and volar ulnar midcarpal (VU-MC) portals were created using an inside-out approach. The arm was then dissected under 3.5-mm loupe magnification. Digital calipers were used to measure the distance between the portals and the surrounding anatomic structures by two fellowship-trained hand surgeons. Results: The median nerve was on average 1.6, 7.2, 1.8, and 5.6 mm away from the trochar for the VR, VU, VR-MC, and VU-MC, respectively. The median nerve fascia was pierced by the VR portal in one specimen. The radial artery, ulnar artery, and ulnar nerve were not pierced in any specimen. Compared to historical controls, for the VR-MC portal, the NanoScope was further from all critical structures, aside from the radial artery, and did not pierce any neurovascular structures. For the VU-MC portal, the NanoScope was further from the ulnar artery and median nerve and did not pierce any neurovascular structures. Conclusion: In developing volar portals, after placing the cannula through the volar capsule from an inside-out approach, we recommend making a volar incision and dissecting the local anatomic structures to guard against injury. Compared to historical controls, the NanoScope was typically further from neurovascular structures.

Abstract Background The inclusion of the third carpometacarpal (CMC) joint in the fusion mass in total wrist fusion (TWF) remains controversial. Our goal was to evaluate the clinical outcomes and effects of third CMC joint arthrodesis compared with bridging the CMC joint during TWF. A retrospective chart review was performed. Outcomes assessed included hardware loosening, hardware failure, symptomatic hardware necessitating removal, and need for revision arthrodesis. Case Description/Literature Review We found that concomitant third CMC joint arthrodesis was associated with a significantly reduced rate of radiocarpal and midcarpal joint nonunion, hardware loosening, and symptomatic hardware removal when compared to bridging of the CMC joint. There was no significant difference in hardware failure rates or the need for revision arthrodesis. Clinical Relevance When using a contoured dorsal spanning plate, concomitant CMC joint arthrodesis should be considered during TWF to mitigate against hardware loosening and symptomatic hardware. Level of Evidence Level IV

Abstract Background Nanoscope, given its smaller size, may be safer when establishing dorsal wrist arthroscopy portals compared with the traditional 2.7 mm arthroscope. Case Description Ten fresh frozen cadaver specimens were utilized. Dorsal radiocarpal portals were established with the Nanoscope and calipers were used to measure the distance between the portals and the surrounding anatomical structures. The only structure that was pierced during portal placement was the dorsal sensory branch of the ulnar nerve (DSUN) in one specimen when establishing the 6U portal. Our study did not note any tendon injuries. Literature Review Traditional wrist arthroscopy may be performed with a 2.7 mm arthroscope. With its larger outer sheath cannula, this may place adjacent anatomical structures at risk of injury. Clinical Relevance During wrist arthroscopy, the Nanoscope may be safer when creating portals to underlying structures. Level of Evidence This is a Level IV study.

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.

Abstract Background Some surgeons advocate for concomitant proximal row carpectomy (PRC) with total wrist arthrodesis (TWA), though there are limited data to support or oppose this view. Questions/Purposes Does concomitant PRC improve rates of union, revision, hardware loosening, hardware failure, and hardware removal in TWA? Patients and Methods A retrospective cohort study of patients who underwent TWA with and without concomitant PRC between January 2008 and December 2018 was undertaken. Patients were included if they underwent TWA using a dorsal spanning plate. Patients were excluded if they underwent partial wrist arthrodesis, revision TWA, or TWA with nondorsal spanning plate fixation. Results A total of 183 wrists in 180 patients were included in the study, 96 (52.5%) in the TWA only and 87 (47.5%) in the TWA + PRC groups. Median clinical and radiographic follow-up was 18.0 months (3.0–133.0 months) in the TWA + PRC group and 18.5 months (2.0–126.0 months) in the TWA only group (p = 0.907). No difference in nonunion (TWA + PRC: 13/87 [14.9%], TWA only: 18/96 [18.8%], odds ratio: 0.76, p = 0.494), revision (TWA + PRC: 5/87 [5.75%], TWA only: 8/96 [8.33%], hazard ratio [HR]: 0.73, p = 0.586), loosening (TWA + PRC: 4/87 [4.60%], TWA only: 6/96 [6.25%], HR: 0.74, p = 0.646), failure (TWA + PRC: 5/87 [5.75%], TWA only: 4/96 [4.17%], HR: 1.55, p = 0.530), and removal (TWA + PRC: 12/87 [13.8%], TWA only: 16/96 [16.7%], HR: 0.84, p = 0.634) were identified. Conclusion Concomitant PRC might not improve rates of union or diminish complications in patient undergoing TWA. The role of PRC and the rationale for its use in TWA need to be individualized and discussed with patients prior to surgery. Level of Evidence This is a Level IV, therapeutic study.