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Purpose: Scaphoid fractures in patients and assessment of healing using PCD-CT have, as far as we know, not yet been studied. Therefore, the aim was to compare photon counting detector CT (PCD-CT) with energy integrating detector CT (EID-CT) in terms of fracture visibility and evaluation of fracture healing. Method: Eight patients with scaphoid fracture were examined with EID-CT and PCD-CT within the first week posttrauma, and with additional scans at 4, 6 and 8 weeks. Our clinical protocol for wrist examination with EID-CT was used (CTDIvol 3.1 +/- 0.1 mGy, UHR kernel Ur77). For PCD-CT matched radiation dose, reconstruction kernel Br89. Quantitative analyses of noise, CNR, trabecular and cortical sharpness, and bone volume fraction were conducted. Five radiologists evaluated the images for fracture visibility, fracture gap consolidation and image quality, and rated their confidence in the diagnosis. Results: The trabecular and cortical sharpness were superior in images obtained with PCD-CT compared with EIDCT. A successive reduction in trabecular bone volume fraction during the immobilized periods was found with both systems. Despite higher noise and lower CNR with PCD-CT, radiologists rated the image quality of PCD-CT as superior. The visibility of the fracture line within 1 -week post -trauma was rated higher with PCD-CT as was diagnostic confidence, but the subsequent assessments of fracture gap consolidation during healing process and the confidence in diagnosis were found equivalent between both systems. Conclusion: PCD-CT offers superior visibility of bone microstructure compared with EID-CT. The evaluation of fracture healing and confidence in diagnosis were rated equally with both systems, but the radiologists found primary fracture visibility and overall image quality superior with PCD-CT., Funding Agencies|ALF Grants [RO-965126]

Optimal recovery of muscle function after proximal nerve injuries remains a complex and challenging problem. After a nerve injury, alterations in the affected muscles lead to atrophy, and later degeneration and replacement by fat-fibrous tissues. At present, several different strategies for the preservation of skeletal muscle have been reported, including various sets of physical exercises, muscle massage, physical methods (e.g. electrical stimulation, magnetic field and laser stimulation, low-intensity pulsed ultrasound), medicines (e.g. nutrients, natural and chemical agents, anti-inflammatory and antioxidants, hormones, enzymes and enzyme inhibitors), regenerative medicine (e.g. growth factors, stem cells and microbiota) and surgical procedures (e.g. supercharge end-to-side neurotization). The present review will focus on methods that aimed to minimize the damage to muscles after denervation based on our present knowledge.

Identifying a good research question is one of the most important steps when laying the foundation of a research project. A good research question can aim to answer a hotly debated clinical issue, challenge a pre-existing dogma or make a contribution to specific aspects of a broader field of study. The difficulty in defining the question lies with pinpointing an important research topic or an area that is characterized by a lack of knowledge (the What), grasping the significance of how a precisely defined study can potentially impact on clinical practices (the Why) and determining the optimal study design tailored to answer the specific question (the How). These three domains constitute pivotal concepts in the process of shaping the research question.

Background:Indocyanine green fluorescence angiography (ICG-FA) is used to assess tissue intraoperatively in reconstructive surgery. This requires an intra-venous dye injection for each assessment. This is not necessary in laser speckle contrast imaging (LSCI); therefore, this method may be better suited for tissue evaluation. To determine this, we compared the two methods in a porcine flap model.Methods:One random and one pedicled flap were raised on each buttock of six animals. They were assessed with LSCI at baseline, when raised (T0), at 30 minutes (T30) and with ICG-FA at T0 and T30. Regions of interest (ROI) were chosen along the flap axis. Perfusion, measured as perfusion units (PU) in the LSCI assessment and pixel-intensity for the ICG-FA video uptake, was calculated in the ROI. Correlation was calculated between PU and pixel-intensity measured as time to peak (TTP) and area under curve for 60 seconds (AUC60).Results:Correlation between LSCI and AUC60 for the ICG-FA in corresponding ROI could be seen in all flaps at all time points. The correlation was higher for T0 (r=0.7 for random flap and r=0.6 for pedicled flap) than for T30 (r=0.57 for random flap and r=0.59 for pedicled flap). Even higher correlation could be seen PU and TTP (T0: random flap r=-0.8 and pedicled flap r=0.76. T30: random flap r=-0.8 and pedicled flap r=0.71)Conclusion:There is a correlation between PU from LSCI and TTP and AUC60 for ICG-FA, indicating that LSCI could be considered for intraoperative tissue assessment.

Bioelectronic medicine can treat diseases and disorders in humans by electrically interfacing with peripheral nerves. Multielectrode cuffs can be used for selective stimulation of portions of the nerve, which is advantageous for treatment specificity. The biocompatibility and conformability of cuffs can be improved by reducing the mechanical mismatch between nerve tissue and cuffs, but selective stimulation of nerves has yet to be achieved with soft and stretchable cuff electrodes. Here, this paper reports the development of a soft and stretchable multielectrode cuff (sMEC) for selective nerve stimulation. The device is made of 50 mu m thick silicone with embedded gold nanowire conductors, which renders it functional at 50% strain, and provides superior conformability for wrapping nerves. By using different stimulation protocols, high functional selectivity is achieved with the sMECs eight stimulation electrodes in a porcine sciatic nerve model. Finite element modeling is used to predict the potential distribution within the nerve, which correlate well with the achieved stimulation results. Recent studies are showing that mechanical softness is of outermost importance for reducing foreign body response. It is therefore believed that the soft high-performance sMEC technology is ideal for future selective peripheral nerve interfaces for bioelectronic medicine., Funding Agencies|Swedish Foundation for Strategic Research; Swedish Research Council [2019-04424]; Swedish Government Strategic Research Area in Materials Science on Functional Materials at Linkoeping University (Faculty Grant SFO Mat LiU) [2009 00971]; European Research Council, "e-NeuroPharma" ERC-2018-ADG [834677]

We examined the learning curve of Motec total wrist arthroplasty (TWA) of six experienced surgeons in their first 30 cases. Three times more complications/revisions were encountered in the first half of the study compared with the second half. Motec TWA surgery should be concentrated in a smaller number of centres performing higher volumes.

The aim of this study was to analyse the short- and medium-term complications of the Motec total wrist arthroplasty (TWA). Identifying exact modes of failure and their causes should allow surgeons to avoid or mitigate these risks in the future. Retrospective analysis of prospectively collected data from six hand surgeons at five international centres provided details of 171 Motec TWAs. The mean follow-up was 5.8 years (range 18 months to 12 years). There were 33 (19%) complications within our cohort, with a revision rate of 8.2% (14 revisions). There was no difference in complication rates between metal-on-metal and metal-on-polymer articulations. Failure of osseointegration was the most common complication. Problems with soft tissue balancing, implant impingement related osteolysis, bony impingement and metacarpal fracture were found to be other preventable causes of failure in this series. Elimination of these preventable complications will improve survival rates for this implant.Level of evidence: IV

The aim of this study was to compare an early active motion (EAM) regimen to a modified Kleinert passive motion therapy in Zone 2 flexor tendon injuries with regards to range of motion (ROM), grip strength and patient-reported outcome measures (PROMs). Seventy-two patients were included. At 3 months postopera-tively, we found no difference in total active motion (TAM) between the EAM and the Kleinert groups (median 195.5 degrees, range 115 degrees -273 degrees versus median 191.5 degrees, range 113 degrees -260 degrees), but a significantly better grip strength (median 76%, range 44%-99% versus median 54%, range 19%-101%; p < 0.0005) in the EAM group. Disabilities of the Arm, Shoulder and Hand (DASH) score as well as patient-reported weakness, cold intol-erance and problems in daily activities also favoured the EAM group. At 12 months postoperatively, there was no difference in TAM, grip strength or any of the PROMs used. We conclude that EAM leads to a quicker recovery in terms of grip strength and PROMs, but that both regimens lead to similar results at 12 months., Funding Agencies|Region Ostergotland, Sweden [RO-900731, RO-973553, LIO-823361]

The aim of this study was to examine the relationship between patient-reported outcome measures (PROMs) and the original Strickland classification after flexor tendon injuries in Zones 1 and 2. Data were collected from the Swedish national health care registry for hand surgery (HAKIR). The studied PROMs were the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) and the patient questionnaire from the HAKIR (HQ-8). Complete data of both range of motion (ROM) and PROMs were available for 215 patients at 3 months after surgery, and for 150 patients at 12 months after surgery. We found that QuickDASH values were low and similar between all groups as classified by the Strickland system at 12 months. A statistically significant difference between PROM values (for stiffness and satisfaction) was found only between the Strickland groups Fair and Good, but not between Poor and Fair or Good and Excellent. This suggests that further categorization according to the Strickland classification is less important to the patients as long as they regain 70% of their ROM.

The purpose of this review article is to provide an update on the realm of emerging technology available for the assessment of dynamic functional movement of the hand and upper limb. A critical overview of the literature and a conceptual framework for use of such technologies is proposed. The framework explores three broad purpose categories including customization of care, functional surveillance and interventions through biofeedback strategies. State-of-the-art technologies are described, from basic activity monitors to feedback-enabled robotic gloves, along with exemplar trials and clinical applications. The future of technologies innovation in hand pathology is proposed in the context of the current obstacles and opportunities for hand surgeons and therapists.

Artificial intelligence (AI) in hand surgery is an emerging and evolving field that will likely play a large role in the future care of our patients. However, there remain several challenges to makes this technology meaningful, acceptable and usable at scale. In this review article, we discuss basic concepts in AI, including challenges and key considerations, provide an update on how AI is being used in hand and wrist surgery and propose potential future applications. The aims are to equip clinicians and researchers with the basic knowledge needed to understand and explore the incorporation of AI in hand surgery within their own practice and recommends further reading to develop knowledge in this emerging field.

Introduction Fractures of the distal ulna, excluding the styloid, are rare. The cause of injury is often a fall on an outstretched hand with an extended wrist, and in most cases there is a concomitant distal radius fracture. The aims of this retrospective study were to investigate the results of the current treatment of distal ulna fractures in adults, with or without a concomitant distal radius fracture, and if a recently presented fracture classification could predict outcome. Materials and methods Patients, 18 years or older, treated for a fracture of the distal third of ulna in our county, were included. Fractures of the styloid tip were excluded. The radiographs of the fractures were independently classified by two specialists in radiology according to the 2018 AO/OTA classification. Follow-up was performed 5-7 years after the injury, through the questionnaire Patient-Rated Wrist Evaluation (PRWE) and new radiographs of both wrists. Results Ninety-six patients with 97 fractures were included and filled out the PRWE. 65 patients also had new radiographs taken. 79 patients were women and the mean age at the time of injury was 63 years (SD 14.5). The most common fracture class was the extra-articular transverse fracture, 2U3A2.3 (42%). We found that 40% of the fractures had been treated by internal fixation and only 2 fractures had not healed, one conservatively treated and one operated. The median PRWE was 15 (IQR 33.5). The PRWE score was significantly worse in the operated ulna fractures (p = 0.01) and this was also true for extra-articular transverse fractures 2U3A2.3 (p = 0.001). Initial displacement was more common in operated transverse fractures, but it could not be proven that this was the reason for the inferior result. Conclusions Distal ulna fractures almost always unite and the result is comparable to that of isolated distal radius fractures when measured by PRWE. Based on the opinions of the radiologists and how often a consensus discussion was neede, Funding Agencies: Linköping University

Background and purpose - Classification of fractures can be valuable for research purposes but also in clinical work. Especially with rare fractures, such as distal ulna fractures, a treatment algorithm based on a classification can be helpful. We compared 3 different classification systems of distal ulna fractures and investigated their reliability and reproducibility. Patients and methods - patients with 97 fractures of the distal ulna, excluding the ulnar styloid, were included. All fractures were independently classified by 3 observers according to the classification by Biyani, AO/OTA 2007, and AO/OTA 2018. The classification process was repeated after a minimum of 3 weeks. We used Kappa value analysis to determine inter- and intra-rater agreement. Results - The inter-rater agreement of the AO/OTA 2007 classification was judged as fair,. 0.40, whereas the agreement of AO/OTA 2018 and Biyani was moderate at. 0.42 and 0.43 respectively. The intra-rater agreement was judged as moderate for all classifications. Interpretation - The differences between the classifications were small and the overall impression was that neither of them was good enough to be of substantial clinical value. The Biyani classification, being developed specifically for distal ulna fractures, was the easiest and most fitting for the fracture patterns seen in our material, but lacking options for fractures of the distal diaphysis. Standard radiographs were considered insufficient for an accurate classification. A better radiographic method combined with a revised classification might improve accuracy, reliability, and reproducibility.

Purpose: The aim of this study was to evaluate the effect of reconstruction parameters on image quality in wrist imaging using photon-counting detector CT (PCD-CT) and to compare the results with images from an energyintegrating detector CT (EID-CT). Methods: Twelve cadaveric wrist specimens were examined using a prototype PCD-CT and a clinical EID-CT using similar radiation dose. Reconstruction parameters were matched between scanners. Also, sharper reconstruction kernels, a larger matrix size, and smaller slice thicknesses were evaluated for PCD-CT. Image noise, contrast-tonoise ratio (CNR) and image sharpness in trabecular structures were quantitatively measured. Image quality with respect to the visibility of cortical and trabecular bone structures was assessed by six radiologists using visual grading methods.Results: Images obtained with PCD-CT had lower noise (42.6 +/- 3.9 HU vs 75.1 +/- 6.3 HU), higher CNR (38.9 +/- 4.5 vs 19.0 +/- 2.4) and higher trabecular sharpness (63.5 +/- 6.0 vs 53.7 +/- 8.5) than those obtained with EID-CT using similar scan and reconstruction parameters (p < 0.001). The image sharpness in trabecular structures was further improved by using sharper kernels, despite higher noise levels. Radiologists had a strong preference for PCD-CT images both in terms of spatial resolution and suitability for bone imaging. Visual grading analysis showed an improved visibility of cortical bone, trabeculae and nutritive canals (p < 0.005).Conclusion: PCD-CT offers improved image quality regarding bone structures in the wrist relative to EID-CT systems, particularly when sharper reconstruction kernels, smaller slice thickness and a larger image matrix size are used., Funding Agencies|ALF Grants [RO?]