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Purpose: Controversy exists regarding the optimal imaging modality (magnetic resonance imaging, ultrasound, stress radiographs) for identification of patients with grossly unstable thumb metacarpophalangeal (MCP) ulnar collateral ligament (UCL) injuries or Stener lesions. We characterize a radiographic sign for this purpose. The "displaced fleck sign" is a small avulsion fracture from the ulnar proximal phalanx base that is displaced proximal to the MCP joint line., Methods: Patients with thumb UCL injuries evaluated by hand surgeons were identified at a single, tertiary institution. Patients who were skeletally immature, had chronic injuries (>3 months old), and those with MCP arthritis were excluded. Two attending hand surgeons independently reviewed radiographs to identify the displaced fleck sign. Presence/absence of a Stener lesion was extracted from operative notes., Results: Of 228 patients, 17 (7.5%) had a positive displaced fleck sign. Excellent interobserver reliability was observed (κ = 0.94). All 17 (100%) demonstrated gross instability with no end point in clinic, and all underwent surgical repair. Grade III ruptures were noted for all. Specifically, 14 (94.1%) had a Stener lesion, and one patient (7%) had a bony avulsion from the metacarpal. The displaced fleck sign had a positive predictive value of 100% for Grade III rupture and 94.1% for a Stener lesion., Conclusions: Presence of a displaced fleck sign has implications for offering surgery to patients with thumb UCL injuries because of a high likelihood of a Stener lesion. When present, surgeons may consider proceeding with surgical repair without additional imaging and associated follow-up visits., Type of Study/level of Evidence: Prognosis IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The patient-acceptable symptom state (PASS) is a threshold score on a patient-reported outcome measurement beyond which patients consider themselves "well." Our purpose was to establish the PASS for the numeric rating scale (NRS) for pain in a 1-year postoperative hand surgery population., Methods: This retrospective study included adult patients undergoing non-shoulder upper-extremity surgery at a single, tertiary medical center identified over a 9-month period. At 1 year after surgery, NRS pain and responses to a pain-specific anchor question were collected. Patients were dichotomized based on achieving "PASS(+)" or failing to achieve "PASS(-)" an acceptable symptom state based upon their response to a pain-specific anchor question. Threshold values of a PASS(+) state were calculated for the NRS pain score using the following three methods: (1) mean score of PASS(+) patients, (2) Tubach method (75th percentile threshold for PASS(+) patients), and (3) the Youden index (receiver operating curve analysis to maximize sensitivity and specificity)., Results: Of 233 included patients, mean age was 54 years (±17), and 58% (n = 136) were women. Mean NRS pain scores differed between PASS(+) and PASS(-) patients (0.7 ± 1.2 vs 3.8 ± 2.7, respectively). PASS(-) patients were more likely to be non-White and have a diagnosed psychiatric comorbidity. Patient-acceptable symptom state estimates ranged from 0.73 to 2.1 for NRS pain, depending on the calculation method (0.73 for the mean score method, 1.0 for the Tubach method, and 2.1 for the Youden index). The area under the curve for the Youden index method was 0.86 consistent with excellent discrimination., Conclusions: We propose the value of 2.1 to represent the PASS threshold for the NRS pain score in this population., Clinical Relevance: This PASS value should be used when interpreting NRS pain score outcomes at a population level. This threshold is expected to yield excellent discrimination for patient satisfaction when applied to a postoperative hand surgery population., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2025 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: There is no standardization within hand and upper-extremity surgery regarding which patient-reported outcome measures (PROMs) are collected and reported. This limits the ability to compare or combine cohorts that utilize different PROMs. The aim of this study was to develop a linkage model for the QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand) and PROMIS PF CAT (Patient-Reported Outcomes Measurement Information System Physical Function computerized adaptive testing) instruments to allow interconversion between these PROMs in a hand surgery population., Methods: A retrospective review was conducted to identify adults (≥18 years old) who had completed the QuickDASH and PROMIS PF CAT instruments at the same clinical encounter. Patients with shoulder pathology were excluded. The linear relationship between scores was evaluated with use of the Pearson correlation coefficient. Linking was performed with use of several common methods, and an optimal linkage model was recommended on the basis of a higher R2, strong intraclass correlation coefficient (ICC), and lower standard error (SE). The recommended model was further evaluated in subgroups based on age (<60 or ≥60 years), sex, etiology for presentation (traumatic versus atraumatic), and treatment type (operative versus nonoperative)., Results: A total of 15,019 patients (mean age, 49 years; 54% female; 86% White) were included. The mean QuickDASH score (and standard deviation) was 37 ± 22, and the mean PROMIS PF CAT score was 45 ± 10. There was a strong negative linear relationship between the QuickDASH and PROMIS PF CAT (r = -0.73). The circle-arc linkage model demonstrated good accuracy and reliability (R2 = 0.55; ICC = 0.71), and crosswalk tables were developed from this model. The subgroup analysis demonstrated age-related bias in the linkage model (root expected mean squared difference, 0.12). To address this, a separate crosswalk table was developed, which was dichotomized by age category., Conclusions: The QuickDASH and PROMIS PF CAT scores were successfully linked. Utilization of the developed crosswalks-one specific to patients <60 years old and another specific to patients ≥60 years old-will allow for score interconversion in future meta-analyses and multicenter hand surgery studies., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This investigation was supported by the University of Utah Population Health Research Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105, and UL1RR025764). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I345)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The sustentaculum tali is a biomechanically important stabilizer of the hindfoot and contributes to articular congruency of the subtalar joint. Sustentaculum injury associated with a talus fracture has been described infrequently and treatment of this combined injury varies. The purpose of this study was to describe and evaluate the outcomes of the combined talus and sustentaculum fracture., Methods: Retrospective chart and radiographic review was performed on all talus fractures (n = 436) requiring operative fixation over a 21-year period at a single Level-1 trauma center. All talus fractures with sustentaculum fractures were included. Statistical analysis was performed using Chi-squared and Fishers exact tests where appropriate., Results: Sustentaculum fractures occurred in 6.2 % (n = 27) of patients with talus fractures. Average follow-up was 14 months; 18.5 % were open fractures, 88.8 % were from high-energy mechanisms, and 44.4 % were polytraumas. Diagnosis of the sustentaculum fracture was missed on presenting radiographs in 69.2 % (n = 18). The most common associated talus fracture was a talar neck fracture (40.7 %) and the majority (73.7 %) were Hawkins II. Overall, 40.7 % (n = 11) of the sustentaculum fractures were treated with independent fixation and 7.4 % (n = 2) were treated with acute subtalar arthrodesis. Subtalar post-traumatic osteoarthritis (PTOA) at final follow-up was seen in 23.1 % of combined injuries. Independent sustentaculum fixation did not influence the rate of PTOA or re-operation (p = 0.92, p = 0.91, respectively)., Conclusion: Talar fractures have an associated sustentaculum fracture in approximately 6 % of cases, especially with Hawkins II fracture-dislocations. Over two-thirds of the associated sustentaculum fractures were missed on presenting radiographs, reiterating the need for heightened awareness and consideration of advanced imaging for all talus fractures. The rate of PTOA following these combined injuries at mean follow-up of 24 months does not exceed established rates after isolated talus fractures. Further research is required to determine the optimal management of the sustentaculum in these combined injuries., Level of Evidence: IV., Competing Interests: Declaration of competing interest No author received any direct funding from any agencies in the public, commercial, or not-for-profit sectors specifically for this work. DLR receives reimbursement as an educator for AO Trauma North America and has stock ownership in Purgo Scientific. TFH receives grant funding through the U.S. Department of Defense, consulting fees from DePuy Synthes and Globus, has stock ownership in Orthogrid, SMV Holdings, NT nPhase, Imagen, and has leadership roles on the Orthopedic Trauma Association Board of Directors. JMH receives grant funding through the Arthritis Foundation, consulting fees from Stryker, Orthogrid, Osteocentric, Newclip Technics, is a participant on NIAMS Safety Officer for PA-20-206 advisory board, and has leadership roles for Orthopedic Trauma Association, Western Orthopedic Association, and AO Foundation. For the remaining authors, none were declared., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: There is no gold standard patient-reported outcome measure (PROM) in hand surgery. As a result, a diverse array of PROM instruments have been utilized across centers over time. Lack of score interchangeability limits the ability to compare or conglomerate scores when new instruments are introduced. Our aim was to develop a linkage for the PROMIS UE CAT v1.2 and PROMIS PF CAT scores and develop crosswalk tables for interconversion between these PROMs., Methods: Retrospective review was conducted to identify adult (≥ 18y) patients seen by orthopaedic hand surgeons at a single academic tertiary care hospital who had completed PROMIS UE CAT v1.2 and PROMIS PF CAT score at the same visit. For those with multiple visits, only one randomly selected visit was included in the analyses. Pearson's correlation was calculated to determine the linear relationship between the scores. Linkage from PF to UE was performed utilizing several commonly utilized equating models (identity, mean, linear, equipercentile and circle-arc methods). The performance of the models was assessed using intraclass correlation (ICC) between observed PROMIS UE CAT v1.2 and estimated PROMIS UE CAT v1.2 scores generated using the model as well as Root Mean Square Error (RMSE). The model chosen as the 'best' was further assessed for population invariance using root expected mean squared difference (REMSD) where < 0.08 were considered good., Results: Of 10,081 included patients, mean age was 48.3 (SD = 17.0), and 54% were female (5,477/10,081). Mean UE CAT v1.2 and PF CAT scores were 37 (SD = 9.8) and 46 (SD = 10.0), respectively. There was a strong correlation between the scores (Pearson correlation r = 0.70). All methods performed acceptably (ICC ≥ 0.66 and RMSE < = 7.52 for all). The equipercentile method had the highest ICC (ICC = 0.70 (95% CI 0.69-0.71)) while the mean and circle arc methods had the lowest RMSE. The circle arc method is the most reliable with the smallest standard error and has satisfactory population invariance across age group (REMSD 0.065) and sex (REMSD 0.036)., Conclusions: Crosswalk tables to be used for bidirectional conversion between scores were created., Level of Evidence: III., (© 2024. The Author(s).)

Background: Musculoskeletal infections (MSKIs) are a major cause of morbidity in the pediatric population and account for nearly 1 in every 10 consultations with a pediatric orthopaedic provider at a tertiary care center. To prevent or deescalate the risk of adverse medical and musculoskeletal outcomes, timely medical intervention in the form of antibiotics and potential surgical debridement is required. While there have been numerous studies indicating the value of laboratory testing during the initial workup of a child with MSKI, few studies to date have examined the utility of longitudinal assessment of laboratory measures in the acute setting to monitor the efficacy of antibiotic therapy and/or surgical intervention. The purpose of this investigation was to retrospectively determine whether measuring changes in the inflammatory response could indicate the need for escalated care. Specifically, this study examined the hypothesis that serial measurements of C-reactive protein (CRP), immediately preoperatively and 2 days after surgical debridement, could predict the need for medical (change in antibiotics) or surgical (additional debridement) escalation., Methods: Retrospective review of pediatric patients undergoing operative debridement for the treatment of MSKI between September 2009 and December 2015 from whom laboratory data (CRP) was obtained preoperatively and at postoperative day (POD) 2. Patient demographics, the need for escalated care, and patient outcomes were evaluated., Results: Across 135 pediatric patients, preoperative CRP values >90 mg/L and a positive change in CRP at POD2 effectively predicted the need for escalation of care after initial surgical debridement (Area under the Receiver Operator Curve: 0.883). For each 10-unit increase in preoperative CRP or postoperative change in CRP, there was a 21% or 22% increased risk of needing escalated care, respectively. Stratification by preoperative CRP >90 mg/L and change in CRP postoperatively likewise correlated with increased rates of disseminated disease, percent tissue culture positivity, length of stay, and rate of adverse outcomes., Conclusions: This study demonstrates the utility of serial CRP to assess the need for escalated care in patients being treated for MSKI. As serial CRP measurements become standard of practice in the acute setting, future prospective studies are needed to optimize the timing of CRP reassessment during inpatient hospitalization to prognosticate patient outcomes, weighing both improvements of patient care and clinical burden., Level of Evidence: Level III-retrospective comparative study., Competing Interests: J.G.S. is a member of the education advisory board at OrthoPediatrics, serves as a board member of Pediatric Society of North America (POSNA) and research support from IONIS Pharmaceuticals. The remaining authors report conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the impact of acute compartment syndrome (ACS) and identify cost drivers of 1-year total treatment costs for operative tibial plateau fractures., Design: Retrospective review., Setting: Level 1 trauma center., Patients: 337 patients with tibial plateau fractures, 24 of which were complicated by ACS., Outcomes: The primary outcome was total treatment cost over the first year for operatively treated tibial plateau fractures. The secondary objective was to use regression analysis to identify significant cost drivers., Results: The diagnosis of ACS was associated with 2.85 times higher total treatment cost ( P < 0.001). ACS demonstrated increased total treatment cost when controlling for polytrauma ( P < 0.001) and postoperative infection ( P < 0.001). Regression analysis identified 5 variables significantly associated with total cost of care: body mass index, injury severity score, ACS, staged external fixation, and locking fixation ( P < 0.001; R 2 = 0.57). The diagnosis of ACS had the largest impact on total cost with a 3.5× greater impact on cost compared with the next highest variable, staged external fixation., Conclusions: Tibial plateau fractures complicated by ACS are associated with 2.85 times higher treatment costs over a 1-year period. There were 5 significant variables identified by regression analysis with ACS having the highest impact on total treatment. Together, these 5 factors account for 57% of treatment cost variability., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Dr. Justin Haller is a paid consultant for Stryker, Globus, Osteocentric, and Orthogrid. The remaining authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment., Setting: Level 1 trauma center., Design: A retrospective cohort study., Patients/participants: There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents., Main Outcome Measurements: The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans., Results: Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans ( P < 0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans and 93% of the time with reformatted CT scans ( P = 0.87). However, of those who had dysplasia (n = 22), only 12% were believed to have a safe corridor on original scans compared with 35% on reformatted scans ( P < 0.001)., Conclusions: CT scan reformatting parallel to the S1 superior end plate increases the likelihood of identifying a safe corridor for a TS screw, especially in patients with evidence of sacral dysplasia. The authors would recommend the routine use of reformatting CT scans in this manner to provide a better understanding of the upper sacral segment osseous fixation pathways., Competing Interests: P. J. Kellam, D. C. O'Neill, J. R. Daryoush, G. J. Dekeyser, L. N. Steffenson, D. L. Rothberg, and L. S. Marchand have no conflicts of interest to disclose. J. L. Gary is a paid presenter for Smith and Nephew, Stryker, and Synthes; holds stock or stock options in Summit Medventures; and is on the boards of the AO North America, Journal of Bone and Joint Surgery, Journal of the American Academy of Orthopaedic Surgeons, and Wolters Kluwer Health. T. F. Higgins is a paid consultant for DePuy Synthes, Globus Medical, and Imagen; receives IP royalties from DePuy; holds stock or stock options for NT nPhase, Orthogrid, and OsteoCentric; and is a board member for the Orthopaedic Trauma Association. J. F. Kellam is an AAOS board member and an unpaid consultant for OsteoCentric. M. Sciadini receives IP royalties from Globus Medical; holds stock or stock options for Stryker; and is a paid consultant for Stryker. S. Warner is a paid consultant for DePuy. Z. Working is a board member for the Orthopaedic Research Society and the Orthopaedic Trauma Association. J. M. Haller is a paid consultant for NewClip Technics, OsteoCentric, and Stryker and is a board member for the Orthopaedic Trauma Association and the Western Orthopaedic Association., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intraoperative fluoroscopy is an essential tool to assist orthopedic surgeons in accurately and safely implanting hardware. In arthroplasty cases, its use is on the rise with the increasing popularity of the direct anterior (DA) approach for THA. However, exposure of ionizing radiation poses a potential health risk to surgeons. While the benefits of intraoperative fluoroscopy in DA THA is becoming clearer, and are well-described in the literature, the potential health dangers associated with career-long cumulative radiation exposure are rarely discussed., Methods: In this article, we review the available literature to discuss radiation safety in orthopedics with a focus on total joint arthroplasty. We present the basic science of radiation, discuss the amount of radiation exposure in orthopedic surgery, and review the potential health risks associated with long-term exposure., Conclusion: Overall, the radiation dose exposure to arthroplasty surgeons is low and within recommendations for occupation exposure limits. However, due to the stochastic health impacts of ionizing radiation, there is no threshold dose below which radiation exposure is truly safe. Therefore, it is imperative that surgeons practice proper fluoroscopy safety habits, such as wearing proper protective equipment, minimizing fluoroscopy time and magnification, and maximizing distance from the radiation source to minimize the life-long cumulative radiation exposure and associated health risks., (Published by Elsevier Inc.)

Background: Musculoskeletal infection is a major cause of morbidity in the pediatric population. Despite the canonical teaching that an irritable joint and signs of infection likely represent an infected joint space, recent evidence in the pediatric hip has demonstrated that alternative diagnoses are equally or more likely and that combinations of pathologies are common. The knee is the second most commonly infected joint in children, yet there remains a paucity of available data regarding the epidemiology and workup of the infected pediatric knee. The authors hypothesize that there is heterogeneity of pathologies, including combinations of pathologies, that presents as a potentially infected knee in a child. The authors aim to show the utility of magnetic resonance imaging and epidemiologic and laboratory markers in the workup of these patients., Methods: A retrospective review of all consults made to the pediatric orthopaedic surgery team at a single tertiary care center from September 2009 through December 2015 regarding a concern for potential knee infection was performed. Excluded from the study were patients with penetrating trauma, postoperative infection, open fracture, no C-reactive protein (CRP) within 24 hours of admission, sickle cell disease, an immunocompromised state, or chronic osteomyelitis., Results: A total of 120 patients were analyzed in this study. There was marked variability in pathologies. Patients with isolated osteomyelitis or osteomyelitis+septic arthritis were older, had an increased admission CRP, were more likely to be infected with Staphylococcus aureus, required an increased duration of antibiotics, and had an increased incidence of musculoskeletal complications than patients with isolated septic arthritis., Conclusions: When considering a child with an irritable knee, a heterogeneity of potential underlying pathologies and combinations of pathologies are possible. Importantly, the age of the patient and CRP can guide a clinician when considering further workup. Older patients with a higher admission CRP value warrant an immediate magnetic resonance imaging, as they are likely to have osteomyelitis, which was associated with worse outcomes when compared with patients with isolated septic arthritis., Level of Evidence: Level III-retrospective research study.

Little is known about the epidemiology of orthopaedic conditions among the uninsured. This is a descriptive study of 107 patients presenting with 140 orthopaedic conditions for care at the student-run free clinic, the Shade Tree Clinic. Patients were 50.0 (± 13.0) years old with a BMI of 32.9 (± 8.60). About half were female (58.9%), of Spanish origin/Hispanic or Latino descent (50.9%), immigrants (48.3%), and non-English speaking (44.9%). Most presented with chronic (75.5%) conditions of the knee (24.3%), hand (16.4%) and spine (13.6%). While knee osteoarthritis was the most common diagnosis made (18.7%), there were 38 (35.5%) unique diagnoses with only a single occurrence. Most conditions were initially treated nonoperatively (82.9%). There was an average of 1.92 (± 1.44) visits per condition, and 74.0% of conditions had reported improvement or resolution. Though further study is needed, providing free comprehensive patient-centered orthopaedic care to uninsured individuals in a low-cost setting may prove cost-effective. (Journal of Surgical Orthopaedic Advances 29(2):112-116, 2020).