Fungal Infections of the Hand.

Clinically significant fungal infections of the upper extremity are uncommon but increasing They are classified based on anatomic location and epidemiology. The anatomic categories that affect the hand include cutaneous, subcutaneous, and deep. Cutaneous infections are caused by organisms that metabolize keratin and can cause serious morbidity but are rarely fatal. Subcutaneous infections are similar to the cutaneous infections and are produced by low virulence organisms. Cutaneous and subcutaneous infections are most common and can be treated by primary care physicians and dermatologists. Deep infections are less common but can be fatal. Epidemiologic classifications include endemic and opportunistic infections.

Unplanned Reoperation After Surgery for Scapholunate Interosseous Ligament Insufficiency: A Retrospective Review of 316 Patients.

Background: The purpose of this study was to identify factors associated with unplanned reoperation after surgery for scapholunate interosseous ligament (SLIL) insufficiency. Methods: Using Current Procedural Terminology (CPT) codes from 3 hand surgery centers across 2 metropolitan areas, we identified 316 patients undergoing surgery for SLIL insufficiency from 2000 to 2014. Medical records were manually reviewed to collect data on factors that might be associated with unplanned reoperation, including age, sex, tobacco use, occupation, acuity of treatment, and reconstruction method. Results: Thirty-eight patients (12%) had an unplanned reoperation; most of them (65%) were a secondary reconstruction or salvage procedure (eg, 6 proximal row carpectomies, 9 revision reconstruction, and 10 partial carpal arthrodeses), while 5 (13%) were for unplanned screw removal. The median time between the index and second surgery was 16 months (range, 2-97 months). The type of index procedure was not associated with reoperation. The only factor associated with reoperation was cigarette smoking, and this association persisted when looking specifically at reoperations for revision or salvage. Conclusions: Patients should be counseled that smoking is associated with reoperation after SLIL surgery. Smoking cessation or decreasing nicotine usage may be beneficial prior to surgery. With the numbers available, there was no association between surgical technique and reoperation.

Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures: A Nationwide Survey Comparing Attending Surgeons and Trainees.

BACKGROUND: Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees. METHODS: Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure. RESULTS: A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons. CONCLUSIONS: Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.

Late Reconstruction of the Interosseous Membrane with Bone-Patellar Tendon-Bone Graft for Chronic Essex-Lopresti Injuries: Outcomes with a Mean Follow-up of Over 10 Years.

BACKGROUND: The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries. METHODS: We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores. RESULTS: IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to -1.6 mm (95% CI, -2.3 to -0.9 mm) immediately postoperatively and -1.1 mm (95% CI, -1.8 to -0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively. CONCLUSIONS: IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Platelet-Rich Plasma Injection With Percutaneous Needling for Recalcitrant Lateral Epicondylitis: Comparison of Tenotomy and Fenestration Techniques.

BACKGROUND: Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance. PURPOSE: To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction. RESULTS: At a mean follow-up of 40 months, significant improvements in VAS-P (mean, -6.1; 95% CI, -6.8 to -5.5; P < .0001), QuickDASH (mean, -46; 95% CI, -52 to -40; P < .0001), and PRTEE (mean, -57; 95% CI, -64 to -50; P < .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P < .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group (P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course. CONCLUSION: A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm.

Osteochondral Autograft Transplantation for Proximal Lunate Articular Defects.

BACKGROUND: No consensus treatment option for focal osteochondral defects of the proximal lunate exist in the literature. Surgical management has thus far been limited to salvage procedures such as proximal row carpectomy and partial arthrodesis. CASE DESCRIPTION: We report our experience using the osteochondral autograft transplantation surgery (OATS) procedure in two young, active patients with focal osteochondral defects of the proximal lunate. At mean follow-up of 6 years, sustained improvements in pain, motion, and function were observed. Both patients reported high levels of satisfaction and neither experienced any complications. LITERATURE REVIEW: To our knowledge, this is the first report describing the use of OATS to treat proximal lunate defects. CLINICAL RELEVANCE: OATS is a valuable surgical option for treating focal chondral defects of the proximal lunate, with positive outcomes at greater than 5 years postoperatively. This may be an especially useful technique for younger, active patients, and those wishing to maintain maximum functionality.

Prognostic Variables for Patient Return-to-Work Interval Following Carpal Tunnel Release in a Workers' Compensation Population.

BACKGROUND: We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery. METHODS: We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW. RESULTS: Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval. CONCLUSIONS: WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Friction Blisters on the Hands Treated Successfully Using 2-Octyl Cyanoacrylate: A Case Report.

BACKGROUND: Friction blisters on the hand are challenging to treat as conventional dressings are prone to saturation, contamination, and loosening with active hand use and other mechanical stresses. Alternative methods and materials for dressing hand blisters warrant exploration. CASE SUMMARY: A 48-year-old male surgeon presented with friction blisters over his bilateral thumbs. The patient complained of significant difficulty in keeping his dressings clean and dry, significant pain with hand hygiene, and functional limitations at work. The patient's blisters were dressed with 2-octyl cyanoacrylate (Dermabond; Ethicon US LLC, Somerville, New Jersey), applied directly onto the wound bed. The patient was able to perform his normal duties immediately, without the need for additional intervention. Six days postapplication, the Dermabond sloughed off, revealing an epithelialized surface. CONCLUSION: Dermabond is a promising agent for dressing unroofed blisters of the hand, as it provides a barrier to moisture and contamination, while allowing the wound to epithelialize, without functional cost.

Geographic and Age-Based Variations in Medicare Reimbursement Among ASSH Members.

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members' Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). "Hand-surgeons-per-capita" and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state's average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus number of hand surgeons per capita, and (3) total reimbursement from Medicare versus number of years in practice. Analysis of variance (ANOVA) was used to detect a difference in reimbursement based on categorical range of years as an ASSH member. Results: A total of 1667 ASSH members satisfied inclusion in this study. Although there was significant variation among states' average reimbursement, reimbursement was not significantly correlated with the state's hand surgeons per capita or total number of hand surgeons in that given state. Correlation between years as an ASSH member and average reimbursement was significant but non-linear; the highest reimbursements were seen in surgeons who had been ASSH members from 8 to 20 years. Conclusions: Peak reimbursement from Medicare for ASSH members appears to be related to the time of surgeons' peak operative volume, rather than any age-based bias for or against treating Medicare beneficiaries. In addition, though geographic variation in reimbursement does exist, this does not appear to correlate with density or availability of hand surgeons.

Evaluation and Management of Sleep Disorders in the Hand Surgery Patient.

Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition.

Novel Treatment of a Scapholunate Ligament Injury with Proximal Pole Scaphoid Nonunion.

BACKGROUND: Nonunion of scaphoid proximal pole fractures presents a challenging management dilemma to hand surgeons. This problem is further complicated in the uncommon concurrence of scapholunate (SL) ligament disruption. CASE DESCRIPTION: A 39-year-old male patient presented with new-onset wrist pain following a remote history of a proximal pole scaphoid fracture sustained as a teenager, which was treated nonoperatively. Six months before presentation, the patient sustained a fall while snowboarding. The patient was found to have a chronic nonunion of his scaphoid proximal pole with an associated SL ligament disruption. As the proximal fragment was too small to be amenable to fixation, the patient was treated with an arthroscopic partial scaphoid excision and SL ligament reconstruction using a scapholunateintercarpal screw placed percutaneously. At 26 months, the patient exhibited no pain, near-normal strength, and wrist motion, and expressed a high-level of satisfaction from his surgery. LITERATURE REVIEW: Although cases of SL ligament disruption with concomitant proximal scaphoid fractures have been reported, to our knowledge, this is the first report of SL ligament rupture occurring in the setting of a preexisting proximal pole scaphoid nonunion. CLINICAL RELEVANCE: We report the use of SL ligament reconstruction augmented with intercarpal screw fixation, and excision of the proximal pole scaphoid nonunion. This minimallyinvasive approach may be a particularly useful option in young, active patients such as our own, where a motion-sacrificing salvage procedure would be less than ideal.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability.

BACKGROUND: The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. METHODS: We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. RESULTS: Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. CONCLUSION: IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

Arthroscopic Trapeziectomy With Suture Button Suspensionplasty: A Retrospective Review of 153 Cases.

BACKGROUND: Arthroscopic trapeziectomy with suture button suspensionplasty (ATBS) is a relatively new surgical option for the treatment of thumb carpometacarpal (CMC) osteoarthritis. Although ATBS has many potential benefits over alternative surgical treatments for CMC arthritis, little data exist regarding its safety and complication rates. The purpose of this study was to demonstrate that ATBS is associated with a low risk of complications within 1 year of surgery. METHODS: A retrospective review of patients treated with ATBS by one senior hand surgeon over a span of 3 years was performed. RESULTS: A total of 153 cases of ATBS were performed in 136 patients. Ninety-seven cases involved arthroscopic hemitrapeziectomies, and 56 involved arthroscopic complete trapeziectomies. There were 44 males and 92 females with a mean age of 62. Thirty-eight percent of the cases were graded as Eaton stage IV, 46% stage III, and 14% stage II CMC arthritis, while 3 cases (2%) were performed as revisions. Mean follow-up duration was 58 weeks. Mean preoperative key pinch strength of the affected versus the unaffected side was 92% compared with 95% postoperatively. Revision surgery was performed in 9 out of 153 cases (<6%). Of those 9 cases, 5 had additional minor bony debridement with subsequent improvement in pain, 3 had the implant repositioned due to button prominence, and 1 patient presented with osteomyelitis of the first and second metacarpals that was successfully treated with button removal and an antibiotic regimen. CONCLUSIONS: ATBS is a safe, minimally invasive procedure for treatment of symptomatic stages II through IV thumb CMC arthritis.

Predicting Revision Following In Situ Ulnar Nerve Decompression for Patients With Idiopathic Cubital Tunnel Syndrome.

PURPOSE: To determine the incidence of revision and potential risk factors for needing revision surgery following in situ ulnar nerve decompression for patients with idiopathic cubital tunnel syndrome (CTS). METHODS: We conducted a retrospective chart review of all patients treated at 1 specialty hand center with an open in situ ulnar nerve decompression for idiopathic CTS from January 2006 through December 2010. Revision incidence was determined by identifying patients who underwent additional surgeries for recurrent or persistent ulnar nerve symptoms. Bivariate analysis was performed to determine which variables had a significant influence on the need for revision surgery. RESULTS: Revision surgery was required in 3.2% (7 of 216) of all cases. Age younger than 50 years at the time of index decompression was the lone significant predictor of need for revision surgery. Other patient factors, including gender, diabetes, smoking history, and workers' compensation status were not predictive of the need for revision surgery. Disease-specific variables including nerve conduction velocities, McGowan grading, and predominant symptom type were also not predictive of revision. CONCLUSIONS: For patients with idiopathic CTS, the risk of revision surgery following in situ ulnar nerve decompression is low. However, this risk was increased in patients who were younger than 50 years at the time of the index procedure. The findings of this study suggest that, in the absence of underlying elbow arthritis or prior elbow trauma, in situ ulnar nerve decompression is an effective, minimal-risk option for the initial surgical treatment of CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome.

BACKGROUND: Medial epicondylectomy (ME) is one of several accepted surgical options for the treatment of cubital tunnel syndrome (CuTS). Although reported outcomes after ME are generally favorable, few data exist regarding which patients are prone to poorer outcomes requiring revision surgery. The goal of this study was to identify risk factors predicting the need for revision surgery after ME for the treatment of CuTS. METHODS: We conducted a retrospective chart review of all patients treated at our institution with ME for CuTS from 2006 through 2011. We identified patients who underwent additional operations for recurrent or persistent ulnar nerve symptoms as the revision cohort. We performed bivariate analysis to determine which variables had a significant influence on the need for revision surgery. We examined qualitative factors associated with revision, including the degree of bony resection performed during the index ME, and intraoperative findings at the time of revision surgery. RESULTS: Revision surgery was required in 13.3% of cases (11 of 83). On bivariate analysis, younger age, associated workers' compensation claims, lesser disease severity, and preoperative opioid use were all significant predictors of the need for revision surgery. Perineural scarring and heterotopic bone formation about the elbow were the 2 most common findings at the time of revision. CONCLUSIONS: For patients with CuTS, the risk of revision surgery after ME is higher in younger patients, patients with less severe disease, patients taking opioid medications preoperatively, and patients with associated workers' compensation claims. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Variables Prognostic for Delayed Union and Nonunion Following Ulnar Shortening Fixed With a Dedicated Osteotomy Plate.

PURPOSE: To examine potential risk factors for the development of delayed or nonunion following elective ulnar shortening osteotomy using a dedicated osteotomy plating system. METHODS: We performed a retrospective review of all patients who underwent elective ulnar shortening using the TriMed single osteotomy dynamic compression plating system by 1 of 2 fellowship-trained hand surgeons over a 5-year period. Demographic data and medical, surgical, and social histories were reviewed. Time to bony union was determined radiographically by a blinded reviewer. Bivariate statistical analysis was performed to examine the effect of explanatory variables on the time to union and the incidence of delayed or nonunion. Those variables associated with the development of delayed or nonunion were used in a multivariate logistic regression model. Complications, including the need for additional surgery, were also recorded. RESULTS: Seventy-two ulnar shortening osteotomy procedures were performed in 69 patients. Delayed union, defined as ≥ 6 months to union, occurred in 8 of 72 cases (11%). Of 72 surgeries, 4 (6%) resulted in nonunions, all of which required additional surgery. Hardware removal was performed in 13 of 72 (18%) of the cases. Time to union was significantly increased in smokers (6 ± 3 months) versus nonsmokers (3 ± 1 months). On multivariable analysis, diabetics and active smokers demonstrated a significantly higher risk of developing delayed union or nonunion. Patient age, sex, body mass index, thyroid disease, worker's compensation status, alcohol use, and amount smoked daily did not have an effect on the time to union or the incidence of delayed or nonunion. CONCLUSIONS: Despite the use of an osteotomy-specific plating system, smokers and diabetics were at significantly higher risk for both delayed union and nonunion following elective ulnar shortening osteotomy. Other known risk factors for suboptimal bony healing were not found to have a deleterious effect.

Complications Following Partial and Total Wrist Arthroplasty: A Single-Center Retrospective Review.

PURPOSE: To describe our institution's experience with complications following partial and total wrist arthroplasty (TWA). METHODS: We performed a retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with prosthetic replacement of the distal radius, the proximal carpus, or both at a single institution. Patient factors including age, sex, body mass index, handedness, underlying disease, and previous injury were recorded. Outcomes focused particularly on postoperative complications and need for revision surgery. RESULTS: Forty-seven TWAs, 52 distal radius hemiarthroplasties, and 6 proximal carpal hemiarthroplasties were reviewed with a mean follow-up duration of 35 ± 28 months. Overall complication and revision rates were 51% (53 of 105) and 39% (41 of 105), respectively. Postoperative contracture accounted for the largest number of complications needing additional surgery (20%), followed by component failure (15%). Deep infections occurred in 2 TWAs and 1 distal radius hemiarthroplasty and required removal of hardware, antibiotic spacer placement, and a prolonged course of intravenous antibiotics prior to a definitive operation. Of those patients requiring additional surgery, 41% (n = 10) underwent at least 2 procedures, and 10% (n = 4) underwent at least 6 additional surgeries. CONCLUSIONS: Although TWA and partial wrist arthroplasty are attractive treatment options for the painful arthritic wrist, there remains a noteworthy potential for complications requiring additional surgery. A detailed understanding of these risks is essential for surgeons so that patients may be counseled accordingly and that alternative treatment options may be considered. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Perceptions of Emergency Medicine Residency and Hand Surgery Fellowship Program Directors in the Appropriate Disposition of Upper Extremity Emergencies.

PURPOSE: To survey emergency medicine (EM) residency and hand surgery fellowship program directors (PDs) to identify consensus in their perceptions of appropriate emergency care of upper extremity emergencies. METHODS: We created a framework to group common upper extremity emergency diagnoses and surveyed PDs to evaluate the training background--EM, general orthopedic or plastic surgery, or hand fellowship--most appropriate to provide acute, point-of-care management for each of these diagnostic groupings. Responses were pooled and consensus was established with greater than 75% agreement between groups. RESULTS: We received 79 responses from hand fellowship PDs (90% response rate) and 151 responses from EM PDs (49% response rate). We identified consensus for the training background that PDs in both specialties felt was appropriate to care for 17 of 21 diagnostic groupings in the framework. CONCLUSIONS: There was a high level of consensus between EM and hand surgery PDs regarding diagnoses that acutely require training in hand surgery versus those that can be managed by an EM physician. Our diagnostic framework may help reduce unnecessary hand surgery consultation and may help to identify patients who do not require more specialized acute care and thus decrease unnecessary transfers. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses IV.

Mini-open versus extended open release for severe carpal tunnel syndrome.

BACKGROUND: This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release. METHODS: The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ). RESULTS: Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision. CONCLUSION: No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.