Improving hand therapy delivery during care transitions in multisystem trauma patients.

High-quality hand therapy is critical to maximising functional capacity and optimising overall outcomes following hand injuries. Therapy delivery requires clear communication between surgeons and occupational therapists. At Sunnybrook Health Sciences Centre (SHSC), Canada's largest tertiary care centre, suboptimal communication is a significant barrier to efficient hand therapy delivery in acute multisystem trauma patients. A baseline audit at SHSC found that 41% of hand therapy orders required clarification and 35% of patients waited over 24 hours before their order was fulfilled. In many cases, communication errors created unacceptably long delays that were suspected by surgeon stakeholders to impede patient outcomes. This highlighted an opportunity for investigation and system improvement.Using process mapping methodology, we outlined standard process involved in patient care and identified barriers to successful communication. We collaborated with key stakeholders to codesign a standardised template for care orders. We aimed to improve order clarity and consistency with the goal of reducing the incidence of clarification and delays.Postimplementation, the percentage of hand therapy orders requiring clarification was decreased to 24%. The number of patients waiting over 24 hours for therapy was also reduced; however, further investigation is required to verify this finding. In addition, essential order components were more consistently and comprehensively included. Next steps of this work include expanding the use of the order template outside of the multisystem trauma population and improving the communication of hand therapy at discharge from hospital.

Prospective Multicenter Randomized Controlled Trial Comparing Early Protected Movement and Splinting for Fifth Metacarpal Neck Fracture.

BACKGROUND: Fifth metacarpal neck fractures account for 20% of all hand fractures, yet there remains debate with respect to management, particularly when conservative treatment is initiated. The objective of this study is to compare functional and patient-reported outcomes (PROs) in patients treated with early protected movement or splint immobilization. METHODS: This national multicenter prospective randomized controlled trial compared 2 groups; elastic bandage with early protected movement versus immobilization with splinting. Demographic characteristics were collected at baseline. Functional outcomes (grip strength testing) and PROs (Brief Michigan Hand Questionnaire [bMHQ]) were collected at 4, 8, and 12 weeks post-intervention. Grip strength values of the injured hand were normalized to both the non-injured hand (at baseline), and the Canadian reference values. RESULTS: Thirty-seven participants from 5 Canadian centers were randomized into the splint (n = 21) or elastic bandage group (n = 16). There were no significant differences in the bMHQ score between the splint (52.1 ± 27.2) or the elastic bandage (46.6 ± 20.4) groups (P = .51). There were no differences in baseline grip strength between the splint (15.3 ± 8.9 kg) and elastic bandage (19.9 ± 7.5 kg) groups. At 8 weeks, the elastic bandage group had a significantly higher grip strength than the splint group (93% vs 64%, respectively: P < .05), when standardized as a percentage of the Canadian reference values. CONCLUSION: Patients with Boxer's fractures treated with early protected movement had better functional outcomes by 8 weeks post-treatment as compared to the Canadian reference values of those treated with immobilization and splinting. Providers should manage Boxer's fractures with early protected movement.

RENSEIGNEMENTS GÉNÉRAUX: Les fractures du col du cinquième métacarpien représentent 20 % de toutes les fractures de la main, mais leur prise en charge ne fait pas l'unanimité, en particulier lorsqu'un traitement classique est instauré. L'objectif de cette étude consiste à comparer les résultats fonctionnels et les résultats déclarés par le patient traité au moyen d'une protection contre le mouvement instaurée de manière précoce ou d'une attelle pourimmobilization. MÉTHODOLOGIE: Cet essai multicentrique, national, prospectif, contrôlé et mené à répartition aléatoire a comparé 2 groupes recevant les traitements suivants: un bandage élastique et une protection contre le mouvement instaurée de manière précoce, d'une part, et une attelle pourimmobilization, d'autre part. Les caractéristiques démographiques ont été recueillies au début de l'étude. Les résultats fonctionnels (épreuve de force de préhension) et les résultats déclarés par le patient (questionnaire bMHQ [Brief Michigan Hand Questionnaire], question bref de Michigan portant sur les mains) ont été recueillis 4, 8 et 12 semaines après l'intervention. Les valeurs de la force de préhension de la main blessée ont été normalisées en fonction à la fois de la main non blessée (au départ) et des valeurs de référence canadiennes. RÉSULTATS: Trente-sept participants de cinq centres canadiens ont été répartis aléatoirement dans le groupe traité au moyen d'une attelle (n = 21) ou celui traité par un bandage élastique (n = 16). Aucune différence significative sur le plan du score bMHQ n'a été observé entre les groupes traité au moyen d'une attelle (52,1 ± 27,2) ou d'un bandage élastique (46,6 ± 20,4; P = .51). Il n'y avait aucune différence au chapitre de la force de préhension initiale entre le groupe traité au moyen d'une attelle (15,3 ± 8,9 kg) et celui traité par un bandage élastique (19,9 ± 7,5 kg). Après huit semaines, le groupe traité par un bandage élastique présentait une force de préhension significativement plus élevée que celle du groupe traité au moyen d'une attelle (93 % contre 64 %, respectivement: P < .05), après la normalizationdes valeurs en pourcentage par rapport aux valeurs de référence canadiennes. CONCLUSION: Les patients subissant une « fracture du boxeur ¼ traités au moyen d'une protection contre le mouvement instaurée de manière précoce obtenaient de meilleurs résultats fonctionnels huit semaines après le traitement, vis-à-vis des valeurs de référence canadiennes, que ceux traités par une attelle pourimmobilization. Les professionnels de la santé devraient donc prendre en charge les fractures de boxeur au moyen d'une protection contre le mouvement instaurée de manière précoce.

Role of electrodiagnosis in nerve transfers for focal neuropathies and brachial plexopathies.

Over the past 2 decades, the surgical treatment of brachial plexus and peripheral nerve injuries has advanced considerably. Nerve transfers have become an important surgical tool in addition to nerve repair and grafting. Electrodiagnosis has traditionally played a role in the diagnosis and localization of peripheral nervous system injuries, but a different approach is needed for surgical decision-making and monitoring recovery. When patients have complete or severe injuries they should be referred to surgical colleagues early after injury, as outcomes are best when nerve transfers are performed within the first 3 to 6 mo after onset. Patients with minimal recovery of voluntary activity are particularly challenging, and the presence of a few motor unit action potentials in these individuals should be interpreted on the basis of timing and evidence of ongoing reinnervation. Evaluation of potential recipient and donor muscles, as well as redundant muscles, for nerve transfers requires an individualized approach to optimize the chances of a successful surgical intervention. Anomalous innervation takes on new importance in these patients. Communication between surgeons and electrodiagnostic medicine specialists (EMSs) is best facilitated by a joint collaborative clinic. Ongoing monitoring of recovery post-operatively is critical to allow for decision making for continued surgical and rehabilitation treatments. Different electrodiagnostic findings are expected with resolution of neurapraxia, distal axon sprouting, and axonal regrowth. As new surgical techniques become available, EMSs will play an important role in the assessment and treatment of these patients with severe nerve injuries.

Comparing Flap Advancement and Wound Coverage of Anterograde Homodigital Neurovascular Island Flap Designs: A Cadaveric Model.

PURPOSE: Anterograde homodigital neurovascular island flaps are a reconstructive option for volar fingertip injuries and confer the advantage of preserving fingertip sensation after surgery. However, the amount of flap advancement and wound coverage provided by stepwise and triangular flap designs remains unknown. This study sought to investigate how incremental proximal dissection of the pedicle influences flap advancement and whether advancement and/or coverage differ between the triangular and stepwise flap designs using 22 paired cadaveric digits. METHODS: Flap advancement and wound coverage were evaluated in a pairwise design such that each pair of digits received 1 stepwise flap and 1 triangular flap. After creating a standardized injury to the volar fingertip, pedicled flaps were dissected from the middle phalanx and advanced distally under consistent tension. Advancement was measured for each 5 mm of proximal mobilization of the pedicle to a maximum of 30 mm. RESULTS: On average, 2.6 ± 0.2 mm of flap advancement could be achieved for every 10 mm of pedicle mobilization. With 30 mm of proximal mobilization of the pedicle, 11.8 ± 2.8 mm of advancement and 57.2% ± 16.1% of wound coverage could be expected. There were no significant differences between the flap designs. CONCLUSIONS: The stepwise and triangular anterograde homodigital neurovascular island flaps offer comparable and consistent reconstructive outcomes for volar fingertip injuries. CLINICAL RELEVANCE: The findings in this study suggest that the choice of flap design need not be influenced by the considerations of advancement or coverage; rather, surgeon preference or technical differences between the 2 flap designs may be of more importance.

Assessing New Technologies in Surgery: Case Example of Acute Primary Repair of the Thumb Ulnar Collateral Ligament.

PURPOSE: Health technology assessment provides a means to assess the technical properties, safety, efficacy, cost-effectiveness, and ethical/legal/social impact of a novel technology. An important component of health technology assessment is the cost-effectiveness analysis (CEA), which can be performed using model-based CEA. This study used the CEA model to compare the cost-effectiveness of a novel ligament augmentation device with the standard technique for primary repair of complete ulnar collateral ligament (UCL) tears. METHODS: A model was developed for complete UCL tear requiring acute surgical repair, comparing the cost-effectiveness of standard technique primary repair and repair using a ligament augmentation device from a societal perspective. Primary outcomes included quality-adjusted life years (QALYs), cost, net monetary benefit (NMB) and incremental NMB. A cost-effectiveness threshold of CAD $50,000/QALY was used to compare the 2 techniques. Sensitivity analyses were conducted to assess the parameter uncertainty, specifically the impact of device cost, time off work, probability of complication, and postoperative outcome. RESULTS: The NMB for the standard technique was CAD $42,598, and the NMB for repair using the ligament augmentation device was CAD $41,818. The standard technique was the preferred strategy for primary repair of complete UCL tears. One-way sensitivity analyses demonstrated that the ligament augmentation device became cost-effective if individuals return to work in <18 days (base case 23 days). The device was also favored when the cost was less than CAD $50 and the difference in time to return to work was at least 1 day. CONCLUSIONS: Our model demonstrates that there may be significant costs associated with the introduction of novel health technologies, and certain conditions, such as an earlier return to work, must be met for some devices to be a cost-effective option. This study provides an example of how model-based CEA is a useful tool to assess the cost-effectiveness of a novel device. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis II.

Integrating webinars to enhance curriculum implementation: AMEE Guide No. 136.

Webinars have been used in medical education since 2006 and are now part of the educational offerings of many organizations, including universities, societies, and industry for healthcare trainees and professionals. They are frequently used for continuing medical education (CME) and continuing professional development (CPD) for internal medicine physicians, pharmacists, nurses, and surgeons. There is very limited evidence for the positive impact of these educational events on patient care, however, there is literature that suggests they have educational value for various audiences. Based on our own extensive experience, evaluation data, and key findings over the past decade and a review of the literature, this guide proposes best practices for planning, developing, delivering and evaluating webinars as a part of your curriculum. We propose six phases with steps and questions to help achieve the key purposes of each phase.

Cost-Effectiveness Analysis of Motion-Preserving Operations for Wrist Arthritis.

BACKGROUND: The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective? METHODS: A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime. RESULTS: The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion. CONCLUSIONS: The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.

Comparative Cost-Effectiveness of Cranioplasty Implants.

PURPOSE: The aim of this study was to compare operative duration and total hospital costs incurred for patients undergoing elective cranioplasty with a variety of materials, including manually shaped autogenous bone graft and titanium mesh, custom patient-specific titanium mesh, polymethyl methacrylate (PMMA) acrylic, and polyetheretherketone (PEEK) implants. METHODS: A single-centre retrospective chart review was used. Patient demographics, defect characteristics, total operative time, and length of hospital stay were obtained. Total costs were sourced from Sunnybrook and standardized to the 2014 to 2015 year. Bivariate and age-controlled multivariate analyses were performed with (n = 119) and without (n = 101) outliers. RESULTS: When outliers were removed, an age-controlled analysis revealed that autogenous implants resulted in an operative time of 178 ± 37 minutes longer than manually shaped titanium implants (P < .01). The average cost of cranioplasty was CAD$18 335 ± CAD$10 265 for manually shaped titanium implants, CAD$31 956 ± CAD$31 206 for custom patient-specific titanium implants, CAD$20 786 ± CAD$13 075 for PMMA, CAD$14 291 ± CAD$5562 for autogenous implants, and CAD$27 379 ± CAD$4945 for PEEK implants (P = .013). When outliers were removed, cranioplasty with PMMA and PEEK incurred greater costs, CAD$4442 ± CAD$2100 and CAD$13 372 ± CAD$2728, respectively, more than manually shaped titanium implants (P < .01). CONCLUSIONS: Manually shaped titanium mesh is the most cost-effective implant choice for small cranial defects. Large unknown defects and frontal paranasal sinus defects are most effectively treated with autogenous bone or titanium mesh. Despite prolonged operative duration and inpatient admission, total costs were not significantly increased. Both PMMA and PEEK implants were significantly more costly, which may be a result of higher complications necessitating reoperation.

OBJECTIF: La présente étude visait à comparer la durée de l'opération et les coûts hospitaliers totaux engagés pour les patients qui subissaient une cranioplastie non urgente faisant appel à divers matériaux : greffon osseux autologue et treillis de titane façonnés à la main, implant PMMA et implant PEEK. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective monocentrique des dossiers. Ils ont colligé les renseignements démographiques sur les patients, les caractéristiques de l'anomalie, la durée totale de l'opération et la durée du séjour hospitalier. Ils ont extrait les coûts totaux de Sunnybrook et les ont standardisés pour l'année 2014-2015. Ils ont effectué des analyses bivariées et multivariées contrôlées selon l'âge en incluant (n=119) et en excluant (n=101) les valeurs aberrantes. RÉSULTATS: Après l'élimination des valeurs aberrantes, une analyse contrôlée selon l'âge a révélé que les implants autologues s'associaient à une opération plus longue de 178 ± 37 min que les implants de titane façonnés à la main (p<0,01). Le coût moyen de la cranioplastie s'élevait à 18 335 CAD$ ± 10 265 CAD$ pour les implants de titane façonnés à la main, à 31 956 CAD$ ± 31 206 CAD$ pour les implants de titane adaptés aux patients, à 20 786 CAD$ ± 13 075 CAD$ pour les implants en PMMA, à 14 291 CAD$ ± 5 562 CAD$ pour les implants autologues et à 27 379 CAD$ ± 4 945 CAD$ pour les implants en PEEK (p=0,013). Une fois les valeurs aberrantes éliminées, la cranioplastie par PMMA ou PEEK étaient les plus coûteuses, à 4 442 CAD$ ± 2 100 CAD$ et 13 372 CAD$ ± 2 728 CAD$ de plus que les implants de titane façonnés à la main (p<0,01). CONCLUSIONS: Les treillis de titane façonnés à la main présentent le meilleur rapport coût-efficacité en cas d'anomalies crâniennes bénignes. Le traitement des graves anomalies d'origine inconnue et des anomalies des sinus paranasaux frontaux les plus efficaces sont l'os autologue ou le treillis de titane. Malgré une opération et un séjour hospitalier prolongés, les coûts totaux n'augmentaient pas de manière significative. Les implants de PMMA et de PEEK étaient considérablement plus cher, peut-être à cause du plus fort taux de complications donnant lieu à une réopération.

Outcomes of Secondary Combined Proximal Interphalangeal Joint Release and Zone II Flexor Tenolysis.

Background: Tendon adhesions and capsular contractures following trauma to the proximal interphalangeal joint (PIPJ) may significantly reduce hand function. Traditional, staged surgical management prioritizes restoration of PIPJ passive range of motion with joint release prior to restoration of active range of motion (AROM) with tenolysis. This is expensive and burdensome for patients. Our objective was to evaluate functional outcomes of combined PIPJ release and zone II flexor tenolysis. Methods: We retrospectively reviewed patients who underwent combined PIPJ release and flexor tenolysis. Replantation and tendon graft cases were excluded. Data were collected on pre- and postoperative AROM, total active motion (TAM), tip to distal palmar crease (DPC) distance, and grip strength. Functional outcomes were graded using the Boyes, American Society for Surgery of the Hand, and modified Strickland scores. Results: Twelve patients (9 men and 3 women, median age = 40 years) with a total of 15 digits underwent combined PIPJ release and flexor tenolysis a median of 10.1 months after injury. At a median follow-up of 4.0 months, there were significant improvements in median PIPJ AROM (15° to 70°), TAM (105° to 223°), tip to DPC distance (6.0 to 2.0 cm), and grip strength (35% to 54% of unaffected hand). Modified Strickland score was good in 46% of digits and excellent in 38%. There were no tendon ruptures, surgical site infections, or devascularized digits. Conclusion: Proximal interphalangeal joint stiffness is a challenging complication of hand trauma. Although a complete return to premorbid range of motion and function is rarely attained with surgery, improved outcomes may be consistently achieved with secondary combined PIPJ release and zone II flexor tenolysis.

Suitability of Using the Hamate for Reconstruction of the Finger Middle Phalanx Base: An Assessment of Cartilage Thickness.

BACKGROUND: Osteochondral grafts are indicated for reconstructing the finger middle phalanx base when there is greater than 50% involvement of the articular surface and significant comminution. This study aims to compare the cartilage thickness of the distal surface of the hamate to the finger middle phalanx base to assess its suitability as an osteochondral graft. METHODS: A 3-dimensional laser scanner and computer modelling techniques were utilized to determine the cartilage thickness of the distal surface of the hamate, and finger middle phalanx base using cadaver specimens. The mean, maximum, and coefficient of variation (CV%; a measure of uniformity of cartilage distribution), as well as cartilage distribution maps were determined. RESULTS: The mean cartilage thickness of the hamate was 0.73 ± 0.08 mm compared to the average mean thickness of the finger middle phalanx base of 0.40 ± 0.12 mm. The maximum cartilage thickness of the hamate was 1.27 ± 0.14 mm compared to the average maximum of the finger middle phalanx base of 0.67 ± 0.14 mm. The CV% of the hamate was 27.8 ± 4.2 compared to the average CV% for the finger middle phalanx base of 26.6 ± 8.1. The hamate and finger middle phalanx base have maximum areas that were most frequently at or spanning the median ridge; however, this was more consistently observed with the hamate. CONCLUSION: The distal surface of the hamate is a suitable osteochondral graft with respect to cartilage thickness and distribution providing sufficient cartilage for reconstruction of the finger middle phalanx base.

HISTORIQUE: Les greffes ostéochondrales sont indiquées pour reconstruire la phalange médiane du doigt qui touche plus de 50 % de la surface articulaire et comporte une pulvérisation importante. La présente étude vise à comparer l'épaisseur du cartilage de la surface distale de l'os unciforme à la base de la phalange médiane du doigt (BPMD) pour en évaluer la pertinence comme greffe ostéochondrale. MÉTHODOLOGIE: Les chercheurs ont utilisé un lecteur laser tridimensionnel et des techniques de modélisation informatique pour déterminer l'épaisseur du cartilage de la surface distale de l'os unciforme et de la phalange médiane du doigt sur des spécimens cadavériques. Ils ont déterminé la variation moyenne, la variation maximale et le coefficient de variation (% CV; une mesure d'uniformité de la répartition du cartilage) de même que des cartes de répartition du cartilage. RÉSULTATS: L'épaisseur moyenne du cartilage de l'os unciforme était de 0,73 ± 0,08 mm par rapport à celle de la BPMD de 0,40 ± 0,12 mm. L'épaisseur maximale du cartilage de l'os unciforme était de 1,27 ± 0,14 mm par rapport au maximum moyen de la BPMD de 0,67 ± 0,14 mm. Le % CV de l'os unciforme était de 27,8 ± 4,2 par rapport à celui de la BPMD de 26,6 ± 8,1. Tant l'os unciforme que la BPMD ont des zones maximales sur la crête médiane ou qui recouvrent celle-ci, mais on l'observait davantage sur l'os unciforme. CONCLUSION: La surface distale de l'os unciforme est une greffe ostéochondrale pertinente qui assure une réserve d'épaisseur et de répartition du cartilage suffisante pour reconstruire la BPMD.

Modeling the Articular Surface of the Hamate with the Fourth and Fifth Metacarpal Bases with Three-dimensional Laser Scanning.

Introduction Our purpose is to highlight the articulating surfaces between the hamate and fourth and fifth metacarpal (MC) bases of the hand using three- dimensional (3D) laser scanning. This joint surface is used for osteochondral grafting of small joints such as the proximal interphalangeal joint using the hamate articular surface. It is an important joint for hand function and can develop osteoarthritis.  Methods NextEngine (NextEngine, Santa Monica, CA) 3D laser scanner (accurate to ±100 µm) was used to capture the articular surfaces of the hamate with the fourth and fifth MC bases of 10 embalmed cadaver right hands. Articular surfaces were defined and modeled using Amira (Visage Imaging, Andover, MA) and MatLab7 (MathWorks, Natick, MA). Articular surfaces were evaluated in terms of size, shape, the radius of curvature (ROC) by three points and sphere-fit (SF) and inter-facet angles. Results In the fourth carpometacarpal (CMC) joint, the hamate articular surface with the 4th MC was single, concave, and well approximated by SF ROC (mean: 11.18 mm). The fourth MC base was convex; SF ROC mean was 9.94 mm. Six of the 10 articulations flattened from volar to dorsal. In the fifth CMC joint, we noted a bicondylar construct. The two hamate surfaces were concave while MC bases were convex. The joint surface was best approximated with two overlapping spheres. Ulnar sphere averaged 30.21% of the surface of the hamate and 29% of the MC base. Ulnar hamate SF ROC mean was 11.63 mm, and ulnar fifth MC SF ROC mean was 8.07 mm. Radial SF hamate mean was 7.92 mm, and the radial fifth MC SF mean was 7.47 mm. The mean of the angle of divergence between the condylar spheres represented on the hamate surface was 21.4°, while that of the fifth MC base angle of divergence was 10.99°. The mean of the angle formed between the fourth and fifth CMC joints at the hamate was 31.69°. A single articular facet between the fourth and fifth MC bases was concave on fourth and convex on the fifth MC base. Conclusions and clinical relevance Laser scanning of cadaver fourth and fifth CMC joints clarified the normal anatomy of the osteochondral joint surface. The topography of the joints was well-approximated by SF with curved surfaces in both the anteroposterior and radial-ulnar planes with the fifth CMC having two unique surfaces for articulation. We noted the distinct radial and ulnar articulating surfaces of the fifth CMC joint, which would permit flexion and limited supination.

Are We Over Treating Hand Fractures? Current Practice of Single Metacarpal Fractures.

PURPOSE: We conducted a national survey of Canadian plastic surgeons to assess if inconsistencies in management strategies exist for single metacarpal fractures. METHODS: A cross-sectional study of Canadian plastic surgeons who perform hand surgeries was conducted. A 15-question survey was distributed to all members of the Canadian Society of Plastic Surgeons. Participants' demographics, practice settings, and current treatment strategies for patients presenting with single metacarpal fractures were evaluated. RESULTS: A total of 113 Canadian plastic surgeons met inclusion criteria. The majority of respondents were male (76%), with 50% in practice for more than 15 years. Canadian surgeons used a wide variety of surgical techniques for the management of single metacarpal fractures, with close reduction (94%), Kirshner wires (94%), and splinting and immobilization (89%) being the most common. The majority of plastic surgeons stated that rotational deformity (81%) was the most important indication for surgery. Surgeons demonstrated a trend toward immobilization after splinting (48%), instead of early mobilization after splinting (21%). When results were stratified by years in practice, no differences in surgical and non-surgical management were found, although surgeons in practice for less than 15 years were more likely to suggest hand therapy. CONCLUSION: These findings demonstrate inconsistencies in management of single metacarpal fractures among Canadian plastic surgeons. Surprisingly, surgeons in the survey tended to favor immobilization, as oppose to the literature that favors mobilization. The study highlights the lack of clear guidelines dictating treatment, possibly leading to these inconsistencies.

OBJECTIF: Les auteurs ont réalisé un sondage national auprès des plasticiens canadiens afin d'évaluer s'il y a des incohérences dans les stratégies de prise en charge des fractures fermées des métacarpiens. MÉTHODOLOGIE: Les auteurs ont mené une étude transversale des plasticiens canadiens qui effectuent des interventions chirurgicales de la main. Ils ont distribué un sondage de 15 questions à tous les membres de la Société canadienne des chirurgiens plasticiens. Ils ont évalué les données démographiques, les lieux d'exercice et les stratégies de traitement actuelles des participants auprès des patients qui consultent à cause d'une fracture fermée des métacarpiens. RÉSULTATS: Au total, 113 plasticiens canadiens respectaient les critères d'inclusion. La majorité des répondants étaient de sexe masculin (76 %), et 50 % exerçaient depuis plus de 15 ans. Les chirurgiens canadiens utilisent un vaste éventail de techniques chirurgicales pour prendre en charge les fractures fermées des métacarpiens. La réduction à peau fermée (94 %), les broches de Kirschner (94 %) et la pose d'attelles et l'immobilisation (89 %) sont les plus courantes. La majorité des plasticiens affirmaient qu'une déformation en rotation (81 %) était la principale indication d'opérer. Après la pose d'attelles, les chirurgiens avaient tendance à procéder à l'immobilisation (48 %) plutôt qu'à privilégier une mobilisation rapide (21 %). Lorsque les résultats étaient stratifiés par années de pratique, il n'y avait pas de différence entre la prise en charge chirurgicale et non chirurgicale, même si les chirurgiens en exercice depuis moins de 15 ans étaient plus susceptibles de proposer une thérapie de la main. CONCLUSION: Ces observations démontrent des incohérences dans la prise en charge des fractures fermées des métacarpiens chez les plasticiens canadiens. Fait surprenant, les chirurgiens du sondage tendaient à favoriser l'immobilisation, alors que les publications scientifiques préconisent la mobilisation. L'étude fait ressortir l'absence de lignes directrices claires en matière de traitement, qui est peut-être responsable de ces incohérences.

Comparative Outcomes of Dupuytren Disease Treatment.

Despite more than a hundred years of publications on Dupuytren disease, there has been a lack of consensus on definitions and outcomes until recently. Staging and classifications systems have an important historical context; however, more recently, outcomes rely on patient-reported outcomes, angular correction, and definitions of recurrence. This article reviews commonly used assessments, classifications, and staging systems for Dupuytren disease.

Risk Factors for Titanium Mesh Implant Exposure Following Cranioplasty.

PURPOSE: Titanium mesh is used to reconstruct the neurocranium in cranioplasties. Though it is generally well-tolerated, erosion of the overlying soft tissue with exposure of the implant is a complication that adversely affects patient outcomes. The purpose of this study is to investigate potential risk factors for titanium mesh exposure. METHODS: This study comprises all consecutive patients who underwent titanium mesh cranioplasty between January 2000 and July 2016. A retrospective chart review was conducted to extract demographics, details of management, and outcome. Latest postoperative computed tomography scans were reviewed to document the thickness of soft tissue coverage over the implant and the presence of significant extradural dead space deep to it. RESULTS: Fifty patients were included. Implant exposure occurred in 7 (14%), while threatened exposure was observed in 1 additional patient, for a total complication count of 8 (16%).Four (50%) exposure and 3 (7.1%) nonexposure patients underwent preoperative radiotherapy (odds ratio [OR] = 19.67, P = 0.018). Similarly, 4 (50%) exposure and 5 (11.9%) nonexposure patients had a free flap tissue transfer for implant coverage (OR = 6.50, P = 0.046). Postoperative computed tomography scans revealed significant thinning of soft tissues over titanium mesh in 7 (87.5%) exposure and 15 (35.7%) nonexposure patients (OR = 10.71 P = 0.040). No significant association was found between transposition/rotation flap, postoperative radiotherapy, or the presence of significant extradural dead space, and exposure (P = 0.595, P = 0.999, P = 0.44). CONCLUSION: Preoperative radiotherapy, free flap coverage, and soft tissue atrophy resulted in greater odds of titanium mesh exposure. The findings of this study provide important considerations for reconstructive surgeons using titanium mesh for cranioplasty.

Comparison of Computed Tomography Articular Surface Geometry of Male Versus Female Thumb Carpometacarpal Joints.

BACKGROUND: Given the predilection of first carpometacarpal (CMC) joint osteoarthritis in women compared with men, we aim to determine the differences in first CMC joint surface geometry and congruence between young healthy males and females. METHODS: Wrist computed tomographic scan data of 11 men and 11 women aged 20 to 35 years were imported into 3-dimensional software programs. The first metacarpal and the trapezium were aligned in a standardized position according to landmarks at key points on Gaussian and maximum curvature maps. Measurements of joint congruence and surface geometry were analyzed, including joint space volume, distance between the bones at the articular surface edges, area of the joint space, and radii of curvature in the radial-ulnar and volar-dorsal planes. RESULTS: The mean thumb CMC articular space volume was 104.02 ± 30.96 mm3 for females and 138.63 ± 50.36 mm3 for males. The mean first metacarpal articular surface area was 144.9 ± 10.9 mm2 for females and 175.4 ± 25.3 mm2 for males. After normalizing for size, the mean thumb CMC articular space volume was 119.4 ± 24.6 mm3 for females and 117.86 ± 28.5 mm3 for males. There was also no significant difference for the articular space volume, articular surface distances, articular space, and mean radii of curvatures. CONCLUSIONS: This study found that there are sex differences in the first CMC joint articular volume without normalizing for size; however, there are no sex differences in first CMC joint articular volume, curvature characteristics, or joint congruence of young, healthy patients after normalizing for joint size.

Variation in Treatment Recommendations for Dupuytren Disease.

PURPOSE: To examine agreement on Dupuytren disease (DD) treatment recommendations in an international sample of hand surgeons. METHODS: A survey was developed to determine expertise in needle aponeurotomy, surgery, and collagenase injection to treat DD and to examine treatment recommendations for 16 case scenarios. Case scenarios were predeveloped using expert input. Each case represented a unique combination of 4 dichotomous variables including cord thickness, contracture severity, patient age, and joint involvement. Interrater reliability statistics were calculated and multinomial logistic regression modeling and analysis of variance were used to examine the impact of surgeon- and case-related variables on treatment recommendations. RESULTS: A total of 36 hand surgeons from 9 countries (mean experience, 17 years) participated. Average pairwise percent agreement and Krippendorff's alpha were 26% and .012, respectively. Predictors of a recommendation for surgery over multiple options were a total contracture of greater than 70°, a thick precentral cord, involvement of the metacarpophalangeal and proximal interphalangeal joints, and greater years in practice. A greater number of years in practice predicted recommendation for collagenase injection and the presence of a thick precentral cord predicted a recommendation for needle aponeurotomy. CONCLUSIONS: Little agreement exists on treatment recommendations for common presentations of DD in this sample. CLINICAL RELEVANCE: Further investigation into the sources of potential widespread discrepancies in the management of DD may improve the capacity to make evidence-based recommendations.

Surgeon-Reported Needs for Improved Training in Identifying and Managing Free Flap Compromise.

Background This study examined the need for improved training in the identification and management of free flap (FF) compromise and assessed a potential role for simulated scenario training. Methods Online needs assessment surveys were completed by plastic surgeons and a subsample with expertise in microsurgery education participated in focus groups. Data were analyzed using descriptive statistics and mixed qualitative methods. Results In this study, 77 surgeons completed surveys and 11 experts participated in one of two focus groups. Forty-nine (64%) participants were educators, 65 and 45% of which reported having an insufficient volume of FF cases to adequately teach the management and identification of compromise, respectively. Forty-three percent of educators felt that graduating residents are not adequately prepared to manage FF compromise independently. Exposure to normal and abnormal FF cases was felt to be critical for effective training by focus group participants. Experts identified low failure rates, communication issues, and challenging teaching conditions as current barriers to training. Most educators (74%) felt that simulated scenario training would be "very useful" or "extremely useful" to current residents. Focus groups highlighted the need for a widely accepted algorithm for re-exploration and salvage on which to base the development of a training adjunct consisting of simulated scenarios. Conclusion Trainee exposure to FF compromise is inadequate in existing plastic surgery programs. Early exposure, high case volume, and a standardized algorithmic approach to management with a focus on decision making may improve training. Simulated scenario training may be valuable in addressing current barriers.

Surgical Excision of Mycosis Fungoides Using Thumb-Sparing Reconstruction.

Background: The differential for soft tissue tumors of the hand and upper limb is broad. Hematologic malignancy remains quite low on the differential for soft tissue tumors involving the hand, and there is little in the literature describing surgical management of such cutaneous manifestations. When the tumor is large or involves the thumb, careful consideration of reconstructive options is required. Methods: We present a rare case of an aggressively enlarging mycosis fungoides, a cutaneous T-cell lymphoma tumor, involving the thumb. This tumor had a history of multiple failed treatment attempts, including radiation and chemotherapy. Results: Our surgical plan was a reverse radial forearm osteocutaneous flap. Conclusion: A reverse radial osteocutaneous forearm flap was successfully used to avoid thumb amputation and preserve thumb function.

Developing Cognitive Task Analysis-based Educational Videos for Basic Surgical Skills in Plastic Surgery.

OBJECTIVE: To describe the development of cognitive task analysis (CTA)-based multimedia educational videos for surgical trainees in plastic surgery. DESIGN: A needs assessment survey was used to identify 5 plastic surgery skills on which to focus the educational videos. Three plastic surgeons were video-recorded performing each skill while describing the procedure, and were interviewed with probing questions. Three medical student reviewers coded transcripts and categorized each step into "action," "decision," or "assessment," and created a cognitive demands table (CDT) for each skill. The CDTs were combined into 1 table that was reviewed by the surgeons performing each skill to ensure accuracy. The final CDTs were compared against each surgeon's original transcripts. The total number of steps identified, percentage of steps shared, and the average percentage of steps omitted were calculated. SETTING: Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, an urban tertiary care teaching center. PARTICIPANTS: Canadian junior plastic surgery residents (n = 78) were sent a needs assessment survey. Four plastic surgeons and 1 orthopedic surgeon performed the skills. RESULTS: Twenty-eight residents responded to the survey (36%). Subcuticular suturing, horizontal and vertical mattress suturing, hand splinting, digital nerve block, and excisional biopsy had the most number of residents (>80%) rank the skills as being skills that students should be able to perform before entering residency. The number of steps identified through CTA ranged from 12 to 29. Percentage of steps shared by all 3 surgeons for each skill ranged from 30% to 48%, while the average percentage of steps that were omitted by each surgeon ranged from 27% to 40%. CONCLUSIONS: Instructional videos for basic surgical skills may be generated using CTA to help experts provide comprehensive descriptions of a procedure. A CTA-based educational tool may give trainees access to a broader, objective body of knowledge, allowing them to learn decision-making processes before entering the operating room.