Time to surgery and outcomes following open reduction and internal fixation of both-bone forearm fractures.

PURPOSE: To determine the effect of time to surgery on outcomes following open reduction and internal fixation (ORIF) of both-bone forearm fractures (BBFFs). METHODS: Ninety-nine patients who underwent ORIF of BBFFs in a single academic medical center over a 16-year time period were retrospectively reviewed. Demographic and clinical data including age, sex, current smoking status, time from injury to surgery (tsurg), presence of open injury, polytrauma status, and complications were obtained. Radiographs of the affected extremity were reviewed for fracture morphology, reduction quality, and time to union (or presence of nonunion). In addition to descriptive statistics, Chi-square and Wilcoxon-Mann-Whitney tests were used to compare categorical and interval, respectively, with a significance level of 0.05. RESULTS: A tsurg > 48 h was associated with increased rate of delayed unions (tsurg < 48 h: 25% vs tsurg > 48 h: 59%, p = 0.03), but not complications (tsurg < 48 h: 44% vs tsurg > 48 h: 47%, p = 0.79). Open BBFFs were not associated with increased rates of delayed unions (closed: 16% vs open: 19%, p = 0.77) or complications (closed: 42% vs open: 53%, p = 0.29). A trend toward increased time to union with tsurg > 48 h was also seen, but did not reach significance (tsurg < 48 h: 13.5 weeks vs tsurg > 48 h: 15.7 weeks, p = 0.11). CONCLUSION: A tsurg > 48 h is associated with an increased rate of delayed union, but not complications, after ORIF of BBFFs. LEVEL OF EVIDENCE: Therapeutic Level III (Retrospective Cohort).

The Relationship Between the Wrist Flexion Creases and the Volar Radiocarpal Joint: A Cadaveric Study.

BACKGROUND: Surgical approaches to the volar radiocarpal joint have historically entailed wide exposure, possibly contributing to poor wound healing and wrist denervation. To avoid wound complications and wrist denervation, minimally invasive and percutaneous approaches to the volar radiocarpal joint have been proposed. To help guide these minimally invasive or percutaneous approaches to the joint, we sought to characterize the relationship between the volar wrist flexion creases and the volar radiocarpal joint. We propose that the wrist flexion creases will be a reliable method for localizing the joint. METHODS: Ten cadaveric upper-extremity specimens consisting of fingertip to mid forearm were obtained. Measurements from the proximal and distal wrist flexion creases were taken via fluoroscopy and gross dissection. RESULTS: The wrist flexion creases were located distal to the volar radiocarpal joint in all specimens. The volar radiocarpal joint was located 7 and 16 mm proximal to the proximal and distal wrist flexion creases, respectively. The radiographic anatomy correlated well with the underlying deep anatomy. CONCLUSIONS: The wrist flexion creases can serve as a reliable superficial landmark for the identification of the volar radiocarpal joint. These landmarks aid clinicians in performing or interpreting a physical examination or in performing minimally invasive or percutaneous approaches to the volar radiocarpal joint.

Challenges in Nerve Repair and Reconstruction.

Peripheral nerve injuries may substantially impair a patient's function and quality of life. Despite appropriate treatment, outcomes often remain poor. Direct repair remains the standard of care when repair is possible without excessive tension. For larger nerve defects, nerve autografting is the gold standard. However, a considerable challenge is donor site morbidity. Processed nerve allografts and conduits are other options, but evidence supporting their use is limited to smaller nerves and shorter gaps. Nerve transfer is another technique that has seen increasing popularity. The future of care may include novel biologics and pharmacologic therapy to enhance regeneration.

Darrach vs. Sauve-Kapandji: A Comprehensive Meta-Analysis of Surgical Outcomes in Distal Radioulnar Joint (DRUJ) Dysfunction.

Introduction: Optimal treatment of chronic distal radioulnar joint (DRUJ) arthritis and instability remains unresolved in the literature. Specifically, no systematic comparison of two common options, Sauve-Kapandji (SK) and Darrach's, is available. Methods: A meta-analysis was performed utilizing the PUBMED and EMBASE databases and yielded a total of 47 available studies. Objective outcomes, such as wrist range of motion (ROM), forearm ROM, grip strength, and subjective outcomes, including pain and rate of return to work, were recorded. Statistical analysis was done using t test and chi-square test. Results: For both the SK and Darrach's procedures, forearm ROM was significantly better postoperatively in both pronation (p = 0.0001 for both groups) and supination (p = 0.0001 for both groups). Wrist flexion decreased in the SK group (p = 0.0007), but no difference was found for wrist extension (p = 0.09). The Darrach's group showed a significance improvement in wrist extension (p = 0.0001). Grip strength was improved in the SK group (p < 0.0001), but not in the Darrach's group (p = 0.7831). No difference existed between the SK and Darrach's groups in proportion of patients who were pain-free. The SK group had higher numbers of patients return to work (p = 0.0057). There was not enough data from the studies to make any meaningful analysis in term of treatment failure and complications. Conclusions: Overall, both the SK and Darrach's procedures helped improve pain, wrist ROM, and forearm ROM in patient with chronic DRUJ disorders. The SK procedure can have advantages over the Darrach's procedures in terms of grip strength and rate of return to work. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00826-5.

Role of Dynamic Stabilizers of the Elbow in Radiocapitellar Joint Alignment: A Prospective In Vivo Study.

PURPOSE: To investigate the effect of dynamic stabilizers of the elbow on radiocapitellar joint alignment, before and after the administration of regional anesthesia. METHODS: At a single institution, 14 patients were prospectively enrolled in a study using a within-subjects control design. Before performing a supraclavicular regional block, 10 fluoroscopic images (1 anteroposterior and 9 lateral views) of the elbow were obtained for each patient. The lateral images were obtained with the forearm in maximal supination, neutral rotation, and maximal pronation, and these forearm positions were repeated for 3 elbow positions: (1) full extension; (2) flexion to 90°, with 0° of shoulder internal rotation; and (3) flexion to 90°, with 90° of shoulder internal rotation. After obtaining the 10 initial images, a block was performed to achieve less than 3/5 motor strength of the imaged extremity, followed by obtaining the same 10 images in each patient. Radiocapitellar ratio, defined as the minimal distance between the right bisector of the radial head and the center of the capitellum divided by the diameter of the capitellum, was measured in each image. RESULTS: The 14 patients had a mean age of 47.8 ± 15.7 years, and 10 (71.4%) patients were women. A difference between radiocapitellar ratios measured before and after the regional block administration was observed for all lateral images (-1.0% ± 7.2% to -2.2% ± 8.0%), although this difference was less than the minimum clinically important difference. CONCLUSIONS: Paralysis of the dynamic stabilizers of the elbow produces a difference in the radiocapitellar joint alignment, but this did not reach the minimum clinically important difference. CLINICAL RELEVANCE: Paralysis of the dynamic stabilizers of the elbow via a supraclavicular nerve block produces no clinically relevant effect on the radiocapitellar alignment of uninjured elbows.

Open Versus Endoscopic Carpal Tunnel Release: A Comparison of Opioid Prescription Patterns and Occupational Therapy Referrals.

BACKGROUND: Endoscopic and open carpal tunnel releases (ECTR and OCTR) are safe and effective operations. We compared the approaches in terms of postoperative opioid refills and occupational therapy (OT) referrals. METHODS: We conducted a retrospective study of patients with carpal tunnel syndrome (CTS) treated with ECTR or OCTR. Patients with isolated idiopathic CTS were included; patients undergoing simultaneous bilateral carpal tunnel release (CTR), revision CTR, and additional procedures at time of CTR were excluded. Outcomes included number of patients requiring an opioid refill and/or an OT referral within 6 months of surgery. RESULTS: A total of 1125 patients met inclusion criteria. Endoscopic release was performed in 634 (56%) cases and open release in 491 (44%). Unadjusted analysis revealed no difference in number of patients requiring refills (6.0% vs 7.1%, P = .44), mean number of refills among those requiring one (1.29 vs 1.23, P = .69), total oral morphine equivalents (45.1 vs 44.7, P = .84), number of patients calling regarding pain (12.8% vs 14.7%, P = .36), OT referrals (12.1% vs 11.4%, P = .71), or average number of OT visits (4.5 vs 4.2, P = .74) for endoscopic and open techniques, respectively. Adjusted analysis revealed lower age, lower body mass index, and history of muscle relaxant as predictors of opioid refills, and in contrast to the unadjusted analysis, operating surgeon and surgical technique were predictors of referral to OT. CONCLUSION: Endoscopic CTR and OCTR did not differ in terms of unadjusted postoperative patient calls for pain, number of opioid refills, or OT referrals. After correcting for individual surgeon practice, endoscopic was associated with decreased odds of requiring postoperative OT.

Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft.

BACKGROUND: Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA. METHODS: Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale. RESULTS: Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs. CONCLUSION: Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.

Comparison of Postoperative Occupational Therapy and Narcotic Use in Two Carpometacarpal Arthroplasty Approaches.

BACKGROUND: The authors sought to determine whether differences exist in (1) the number of postoperative occupational therapy visits and (2) narcotic use in two carpometacarpal arthroplasty groups. METHODS: A retrospective study comparing patients undergoing abductor pollicis longus (APL) suspensionplasty (154 patients) or flexor carpi radialis ligament reconstruction and tendon interposition (FCR LRTI) techniques (40 patients) between January 1, 2012, and August 1, 2018, was performed. Data included demographics, procedure performed, complications, number of postoperative occupational therapy visits, and postoperative morphine equivalent dosage used. Statistical testing used the chi-square test for proportions and the Wilcoxon-Mann-Whitney test for nonnormal data. The significance level was 0.05. RESULTS: The APL suspensionplasty and FCR LRTI groups had similar ages (58.1 ± 7.8 years versus 58.1 ± 7.7 years), sex ratios (73 percent female versus 75 percent female), and preoperative narcotic user proportions (1 percent versus 3 percent). Complication rates following the procedures were similar (21 percent and 18 percent, respectively). The number of postoperative occupational therapy visits following APL suspensionplasty (median, 0; interquartile range, 0 to 4) and FCR LRTI (median, 0; interquartile range, 0 to 4) were not significantly different (p = 0.961). There was less use of narcotics following APL suspensionplasty (median, 375 morphine equivalent dosage; interquartile range, 241.9 to 525 morphine equivalent dosage) compared with FCR LRTI (median, 462.5 morphine equivalent dosage; interquartile range, 375 to 768.8 morphine equivalent dosage), and this difference was significant (p = 0.0007). CONCLUSIONS: The APL suspensionplasty technique had less narcotic use and similar complication rates and occupational therapy visits compared to FCR LRTI. Prospective studies comparing postoperative pain control and function with these two carpometacarpal arthroplasty techniques may be beneficial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Pain Management following Open Reduction and Internal Fixation of Distal Radius Fractures.

Background Distal radius fractures (DRF) are commonly treated with open reduction and internal fixation (ORIF). Few studies address perioperative and postoperative pain control for this procedure. Questions/Purpose We attempt to demonstrate efficacy of pain management modalities during the perioperative and acute postoperative period after ORIF. Specifically, does the type of perioperative anesthesia used during fixation of DRF affect pain control postoperatively? Does the quantity of narcotic pain medication prescribed or type of pain medication given postoperatively affect pain management? Methods We retrospectively reviewed 294 adult (≥18 years old) patients who underwent outpatient ORIF of acute DRF between December 2012 and December 2014. All procedures were performed with a standard volar plating technique through a flexor carpi radialis approach. Patient demographics, fracture laterality, severity of fracture, type of operative anesthesia, and details regarding postoperative oral pain medications were recorded. We reviewed the number and timing of patient phone calls regarding postoperative pain and refills of pain prescriptions. Results Two-hundred ninety-four patients (average age 48.7 years) were included. One-hundred twenty-two injuries were right-sided (41.5%), 168 were left-sided (57.1%), and four were bilateral (1.4%). One-hundred fifty-one patients (51.4%) received regional anesthesia prior to surgery. Average number of narcotics tablets prescribed was 58. There were 66 patients who called the orthopaedic patient hotline regarding pain-control issues at a median of 7.0 days postoperatively. One-hundred twenty-nine (43.9%) patients required refills of narcotic pain medication postoperatively. There was no significant difference in the number of calls or refills given with regard to the type of anesthesia used or postoperative pain regimen prescribed. Conclusions More than one-fifth of patients who underwent ORIF experienced pain severe enough to call our institution's orthopaedic hotline to ask for help at a median of 7 days after fixation. Clinical Relevance Our study demonstrates poor pain control regardless of intraoperative anesthesia or utilization of varying postoperative pain regimens.

Social Media Use Among Academic Hand Surgeons.

Purpose: Social media has become increasingly prevalent among the general population in the past decade. We examined the current prevalence of social media use among academic orthopedic-trained and plastic surgery-trained hand surgeons in the United States. Methods: All publicly available hand surgery faculty across the nation were analyzed for their public social media usage, including Instagram, Facebook, Twitter, LinkedIn, and personal websites. Comparisons of social media usage between orthopedic-trained and plastic surgery-trained hand surgeons, male and female academic hand surgeons, hand surgeons from different regions of the United States (East, West, Midwest, and South), and years of experience were analyzed. Results: A total of 469 academic hand surgeons were included. Among academic hand surgeons in the United States, LinkedIn was the most common platform used (40.3%), followed by Facebook (15.78%), a personal website (13.86%), Twitter (12.37%), and Instagram (4.05%). Plastic surgery hand surgeons had more of a presence than orthopedic hand surgeons on Instagram (8.26% vs 2.59%, P < .01)) and Twitter (19.01% vs 10.06%, P < .01). Male hand surgeons were more likely than female hand surgeons to use LinkedIn (41.19% vs 34.85%, P = .04). Southern (18.89%) and Eastern (14.36%) surgeons used personal websites more than Western (6.52%) and Midwestern (4.60%) surgeons (P = .03). Conclusions: Despite the widely known use of social media among plastic and aesthetic surgeons, this study shows the use of web-based marketing strategies to be quite rare in the academic hand surgery setting. Clinical Relevance: Our study shows that throughout the United States, academic hand surgeons use social media at low rates. We suggest that academic plastic surgery and orthopedic hand surgeons throughout the United States consider having a larger social media presence to expand advertising, improve patient education, and enhance networking among their practices. Social media can be a valuable tool and will likely only increase in popularity in the coming years.

ASSH 75 Years: An Update of Progress Over the Past 25 Years.

This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided.

Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release: A Randomized Trial.

Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.

Reduction of Opioid Use After Upper-Extremity Surgery through a Predictive Pain Calculator and Comprehensive Pain Plan.

PURPOSE: For outpatient hand and upper-extremity surgeries, opioid prescriptions may exceed the actual need for adequate pain control. The purposes of this study were to (1) determine rates of opioid wasting and consumption after these procedures and (2) create and implement a patient-specific calculator for opioid requirements with a detailed multimodal analgesic plan to guide postoperative prescriptions. METHODS: Patients undergoing hand and upper-extremity surgery at a single ambulatory surgery center were recruited before (n = 305) and after (n = 221) implementation of a postoperative pain control program. On the first postoperative visit, patients were given a questionnaire regarding opioid use and pain control satisfaction. Demographic and procedural data were collected via chart review. With these data from the first cohort, we developed a patient-specific opioid calculator and pain plan that was implemented for the second cohort of patients. Bivariate analysis and multivariable regression analysis were used to determine the effect of the intervention. RESULTS: Pre-intervention data suggested that younger age; baseline opioid use; use of regional block; unemployment; procedures involving bony, tendinous, or ligamentous work (as opposed to soft tissue alone); and longer procedure time were predictive of higher opioid consumption. Pre- and post-intervention cohorts had similar age and sex distributions as well as procedure length. After the intervention, opioids prescribed decreased 63% from a mean of 32.0 ± 15.0 pills/surgery or 194.5 ± 120.2 morphine milligram equivalents (MMEs) to 11.7 ± 8.9 pills/surgery or 86.4 ± 67.2 MMEs. Opioid consumption decreased 58% from a mean of 21.7 ± 25.0 pills/surgery (137.7 ± 176.4 MMEs) to 9.3 ± 16.7 (64.4 ± 113.4 MMEs). Opioid wastage decreased 62% from 13.8 ± 13.5 pills/surgery (62.8 ± 138.0 MMEs) to 5.2 ± 10.3 (24.8 ± 89.9 MMEs). Implementation of the pain plan and calculator did not affect the odds of unsatisfactory patient-rated pain control or unplanned opioid refills. CONCLUSIONS: With implementation of a comprehensive pain plan for ambulatory upper-extremity surgery, it is possible to reduce opioid prescription, consumption, and wastage rates without compromising patient satisfaction with pain control or increasing rates of unplanned pain medication refills. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Patients admitted for treatment of traumatic finger amputations: Characteristics, causes, and prevention.

BACKGROUND: The aim of this study was to analyze the epidemiology of patients admitted with finger amputations in the U.S., as well as to evaluate and propose prevention strategies. METHODS: The National Electronic Injury Surveillance System was queried to obtain data on patients that presented to, and were admitted from US emergency departments for treatment of traumatic finger amputations during the period of 2002-2016. The Haddon Matrix, a framework that can be used to analyze the host, agent, and environmental factors of an injury relative to its timing, was then used to evaluate possible contributing factors of amputation events, and thereby explore plausible prevention interventions. RESULTS: From 2002 to 2016, approximately 348,719 people were admitted from the ED for traumatic amputations. The majority were Caucasian and were male. The mean age was 42.3 years old. This was significantly older than those who were not admitted. The top five products responsible for amputations in admitted patients were power saws (40.9% of cases), doors (10.3%), lawn mowers (7.4%), snow blowers (4.3%), and bicycles (2.4%). This list included a higher proportion of powered tools than those with finger amputations who were discharged from the ED with a finger amputation. CONCLUSION: Patients admitted with finger amputations from the ED were older, more likely to be male, and more likely to be victims of powered tools than those that were discharged. Table saws are responsible for a high proportion of the finger amputations that result in hospital admissions. The Haddon Matrix helps us identify factors (host, agent, physical environment, and social environment) to be addressed in prevention strategies. Such approaches might include championing education campaigns, policy measures, and equipment safety features. The effectiveness of such strategies warrants further investigation.

Effects of the Affordable Care Act on Payer Mix and Physician Reimbursement in Hand Surgery.

PURPOSE: To evaluate the effect of the Affordable Care Act (ACA) on the payer distribution and reimbursement rate for hand surgery at our institution. METHODS: We reviewed records of 4,257 patients who underwent hand surgery at our institution between January 2008 and June 2016; 2,601 patients underwent surgery before the implementation of the ACA, and 1,656 patients after. Type of procedure, insurance status, amount of money billed, and amount collected were recorded. RESULTS: After the implementation of the ACA, we performed fewer metacarpal fracture repairs, distal radius fracture repairs, and abscess incision and drainage procedures. We performed more endoscopic carpal tunnel releases. The proportion of uninsured patients decreased significantly (15% to 6.4%), and the proportion of patients on Medicare (15.4% to 20.3%) and Medicaid (9.5% to 17.8%) increased significantly. The overall reimbursement rate did not change significantly (32.3% to 30.3%) between the 2 time periods. CONCLUSIONS: After the implementation of the ACA, we observed a significant reduction in the number of uninsured patients and an increase in Medicaid and Medicare patients. However, this led to no significant change in reimbursement rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and design analysis II.

Role of the sagittal view of computed tomography in evaluation of the nasofrontal ducts in frontal sinus fractures.

PURPOSE: Frontal sinus fractures are relatively uncommon due to the high-impact force required to produce these. However, their management is quite complex, with the treatment algorithm incorporating many factors in which the status of the nasofrontal ducts is critically important. Traditionally, this has been evaluated by both axial and coronal computed tomographic (CT) scan views. Anatomically, we propose that this is better evaluated by coronal and sagittal CT views. We evaluated the role of sagittal CT scan views in determining the status of the nasofrontal ducts in patients with frontal sinus fractures. METHODS: A retrospective analysis examining 8 patients with frontal sinus fractures, from August 2004 to January 2008, was performed. Axial, coronal, and sagittal CT scan views were obtained routinely as part of the facial trauma workup. These views were assessed to determine the status of the nasofrontal ducts. The operative findings were also reviewed. RESULTS: Five of the 8 patients had displaced anterior and posterior table frontal sinus fractures. Of these, 4 required surgical intervention that included addressing the nasofrontal ducts. Two of the 8 patients had displaced anterior table fractures that required no intervention of the nasofrontal ducts. One patient had nondisplaced anterior and posterior table fractures and did not require surgery. The sagittal CT view clearly demonstrated the anatomy of the nasofrontal ducts in all 8 patients, including patients in whom the axial and/or coronal views were questionable. Intraoperatively, where the patency of the nasofrontal ducts was directly evaluated, there was a direct correlation with the sagittal image findings. CONCLUSIONS: The sagittal CT view provides invaluable information for evaluating the patency of the nasofrontal ducts in frontal sinus fractures. The ability to evaluate the frontal sinus in an anteroposterior dimension (the usual vector of the injury) and in a superoinferior dimension (the anatomic pathway of the ducts) is the reason for this imaging advantage.