Trends in Orthopedic Management of Distal Radius Fractures Among Medicare Beneficiaries From 2019 to 2020: A Claims Analysis.

Purpose: Radius and ulna fractures are among the most common fractures. These fractures are managed through operative or nonsurgical treatment, with varying implications in terms of cost and functional outcome. There are few studies that robustly characterize the management of distal radius fractures (DRFs) in the United States during the COVID-19 pandemic. Furthermore, this has not been studied among the Medicare patient population, who are particularly vulnerable to fragility fractures and COVID-19. The purpose of this study is to analyze the services provided to Medicare beneficiaries both before and during the COVID-19 pandemic to determine how procedure volume was affected in this patient population. Methods: We retrospectively analyzed services using the physician or supplier procedure summary data from the Centers for Medicare and Medicaid Services. All services provided by physicians between January 1, 2019, and December 31, 2020, were included. The data were stratified by US census region using insurance carrier number and pricing locality codes. We also compared data between states that maintained governors affiliated with the Democratic or Republican parties for the duration of the study. Results: There was an overall decrease in claims regarding DRFs management from 2019 to 2020. There was a dramatic decline in procedure volume (-6.3% vs -12.9%). Of all distal radius related claims there was a relative increase in the proportion of operatively managed DRFs in 2020, from 50.2% to 52.0%. The Midwest saw the greatest decline in operatively managed DRFs, whereas the West experienced the smallest per-capita decline across all procedures. After separating the data by party affiliation, it was also found that operative and nonsurgical procedure volumes fell more sharply in states with Democratic governors. Conclusions: This study shows a decrease in DRF procedural volume among Medicare beneficiaries. This data suggests that the operative and nonsurgical management of DRFs may have been affected by pandemic factors such as quarantine guidelines and supply chain or resource limitations. This may assist surgeons and health care systems in predicting how similar crises may affect operative volume. Type of study/level of evidence: Therapeutic IV.

PROMIS Global Physical Health Subscale Strongly Correlates and Performs Similarly to the QuickDASH in Hand and Upper Extremity Patients.

BACKGROUND: The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) is a validated, static hand and upper extremity patient-reported outcome measure (PROM) commonly used. However, with the growth of PROM implementation across orthopedic and plastic surgery clinics, it is beneficial to determine whether a more general PROM can be used to capture the same insights. This would ease implementation broadly. There is a paucity of literature assessing whether the QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 are correlated and perform similarly. METHODS: Between June 2016 and December 2020, hand and upper extremity patients seeking care at clinics associated with a single quaternary academic medical center were identified. Those who completed the PROMIS Global-10 and QuickDASH as part of routine care were identified. The PROMIS Global-10 is divided into the PROMIS Global Physical Health and PROMIS Global Mental Health subscores. Spearman rho (ρ) correlations were calculated across PROMs, and ceiling and floor effects were determined. RESULTS: Across the 18 744 included patients, there was a strong correlation and strong-moderate correlation found between the QuickDASH and PROMIS Global Physical Health (ρ = 0.70, P < .001) and PROMIS Global Mental Health (ρ = 0.69, P < .001), respectively. Although small, QuickDASH demonstrates the worst floor effect (2.6%, [n = 478]), whereas PROMIS Global Mental Health demonstrated a much more notable ceiling effect (11%, [n = 2034]). CONCLUSIONS: The PROMIS Global-10 can be used to assess the functional status of patients presenting for hand and upper extremity concerns, while also capturing aspects of mental health. The PROMIS Global-10 may ease PROM implementation broadly.

Quantitative 3-D CT Demonstrates Distal Row Pronation and Translation and Radiolunate Arthritis in the SNAC Wrist.

BACKGROUND: In scaphoid nonunion advanced collapse (SNAC) wrist arthritis, we analyzed the 3-dimensional (3-D) deformity patterns of carpal alignment secondary to scaphoid nonunion and quantified subchondral arthritis by investigating alterations in bone density. METHODS: We constructed 3-D models of the carpal bones and radius from 51 patients with scaphoid nonunion (nonunion group) and 50 healthy controls (control group). We quantified the differences in 3-D geometric position of the distal carpal row relative to the distal radius in SNAC wrists versus controls. In addition, we assessed the bone density of anatomic regions of interest in the radiocarpal and capitolunate joints relative to the pisiform bone density to characterize degenerative changes in SNAC wrists. RESULTS: The distal carpal row pronated by a difference of 14° (7.2° versus -6.7°; p < 0.001), deviated ulnarly by a difference of 19° (7.7° versus -11.2°; p < 0.001), shifted dorsally by a difference of 17% of the dorsovolar width of the distal radius (21.0% versus 4.4%; p < 0.001), shifted radially by a difference of 8% of the radioulnar width of the distal radius (13.2% versus 5.3%; p < 0.001), and migrated proximally by a difference of 12% of the lunate height (96.3% versus 108.8%; p < 0.001) in the nonunion group compared with the control group. Additionally, it was found that bone density was greater at the capitolunate joint (capitate head: 140.4% versus 123.7%; p < 0.001; distal lunate: 159.9% versus 146.3%; p < 0.001), the radial styloid (157.0% versus 136.3%; p < 0.001), and the radiolunate joint (proximal lunate: 134.8% versus 122.7%; p < 0.001; lunate fossa: 158.6% versus 148.1%; p = 0.005) in the nonunion group compared with the control group. CONCLUSIONS: Scaphoid nonunion exhibited a unique deformity pattern and alteration in bone-density distributions. The distal carpal row not only shifted dorsally and migrated proximally but also pronated, deviated ulnarly, and shifted radially. Bone density was greater at the capitolunate joint, the radial styloid, and surprisingly, the radiolunate joint. Our findings give insight into the natural history and progression of arthritis of the SNAC wrist. Additionally, future studies may give insight into whether successful treatment of scaphoid nonunion arrests the progression of arthritis. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty.

Background Higher rates of prolonged opioid use have been reported in patients who undergo thumb carpometacarpal (CMC) arthroplasty compared with other hand procedures. Therefore, the aim of this study is to identify the risk factors associated with prolonged postoperative opioid use after CMC arthroplasty, along with reporting the number of patients who filled an opioid prescription more than 30 days postoperatively. Materials and Methods Retrospectively, 563 opioid-naïve patients who underwent CMC arthroplasty were included. A manual chart review was performed to collect patient characteristics, and opioid use was determined based on opioid prescription by a physician. Prolonged opioid use was defined as an opioid prescription at 90 to 180 days postoperatively. A multivariable analysis was performed to identify independent factors associated with an opioid prescription at 90 to 180 days postoperatively. Patients had a median age of 60.4 years (interquartile range [IQR]: 55.5-66.9) and had a median follow-up of 7.6 years (IQR: 4.3-12.0). Results The rates of postoperative opioid use ranged from 6.2% (53 out of 563 patients) at 30 to 59 days postoperatively to 3.9% (22 out of 563 patients) at 150 to 180 days postoperatively. In total, 17.1% (96 out of 563 patients) received a second opioid prescription more than 30 days following surgery, of which 10.8% (61 out of 563 patients) were between 90 and 180 days postoperatively. Older age, defined as a median of 63 years (IQR: 57.10-69.88) ( p = 0.027, odds ratio [OR] = 1.04) and a history of psychiatric disease ( p = 0.049, OR = 1.86) were independently associated with prolonged opioid use. Conclusion A prolonged opioid use rate of roughly 11% was found in opioid-naïve patients who underwent CMC arthroplasty. In patients at risk (older patients or psychiatric history) of prolonged opioid use, careful postoperative pain management is recommended.

Outcomes of Flexor Pollicis Longus Reconstruction for Volar Plate Related Ruptures.

Aim A rare complication following volar plate fixation of a distal radius fracture is flexor pollicis longus (FPL) rupture. This study aims primarily to analyze the radiographic features and secondly to report the patient-reported outcomes of FPL reconstruction after volar plate fixation. Methods Ten patients were retrospectively identified and contacted for follow-up. Seven patients participated in the study and completed the numeric rating scale (NRS) for pain, patient-reported outcome measurement information system-upper extremity (PROMIS-UE), and quick disability of arm, shoulder, and hand (QuickDASH) questionnaires at a median of 3.4 years following FPL reconstruction. Soong grade was determined on preoperative radiographs. Results Six patients were classified as Soong grade 1 and two patients had a screw or wire protruding volarly. The median time to tendon rupture was 21.6 months. At final follow-up, the median NRS pain score was 0 (range: 0-7); the median PROMIS-UE score was 47.1 (range: 25.9-61); and the median QuickDASH-score was 12.5 (range: 4.5-75). Conclusions The outcome of FPL reconstruction after volar plate fixation is highly variable. All ruptures in our cohort occurred in patients with plate positioning classified as Soong grade 1 and occurred at up to 3 years following distal radius fixation.

Reintervention, PROMs, and Factors Influencing PROMs Following Surgery for de Quervain's Tenosynovitis.

Objective The aims of this study are to describe and identify the factors that influence patient reported outcomes following surgery of de Quervain's tenosynovitis. The secondary objective is to report the rate of reintervention following surgery of de Quervain's tenosynovitis. Patients and Methods Outcomes using the numerical rating scale (NRS) for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Rated Wrist Evaluation (PRWE), the Patients Reported Outcome Measurement Information System Pain Interference (PROMIS PI), and a custom de Quervain's questionnaire were obtained. A multivariable linear regression analysis was performed to identify independent factors associated with patient-reported outcomes. Results Seventy-six patients who underwent de Quervain's release participated. The average age was 52.8 years (95% confidence interval: 49.6-56.1) and median follow-up age was 7.0 years (interquartile range [IQR]: 4.3-12.0). Outcomes were: NRS of pain was 0 (IQR: 0.0-3.0), the median QuickDASH was 6.82 (IQR: 0.00-28.41), the median PRWE score was 4.0 (IQR: 0.00-18.50), and the median PROMIS PI score was 43.90 (IQR: 38.70-53.90). Eighteen (23.7%) of the patients reported pain with thumb activities, four of whom had a reintervention. Additionally, 21 (26.9%) patients reported decreased strength in the thumb compared to the contralateral side, of which two underwent a reintervention. In total, eight patients underwent reintervention of which seven had a second surgery and one had a cortisone injection. Conclusion Roughly 1 in 20 patients following de Quervain's release undergoes reintervention. Patients with high PROMIS PI scores report poor surgical outcomes more frequently. Patients with high PROMIS PI scores report higher NRS pain scores ( p < 0.05), higher QuickDASH scores ( p < 0.05), and higher PRWE scores ( p < 0.05). In practice, careful consideration of PROMIS PI scores and psychosocial factors are recommended before considering reintervention.

Joint depression in tibial plateau fractures: To bone graft or not to bone graft?

Tibial plateau fractures with significant joint depression and metaphyseal comminution pose a challenge. In order to prevent the collapse of the articular surface, some authors propose filling the subchondral void created during reduction with bone graft/substitute, which can add further complications. We present two cases of tibial plateau fractures with severe joint depression of the lateral condyle; both treated with a periarticular rafting construct, in one caseadditional bone substitute was used and in the other case no bone graft/substitute was used; their final outcomes were reported. The treatment of joint depression in tibial plateau fractures using periarticular rafting constructs without bone graft, may be also a valid option, to achieve good final results without the morbidity associated with the use of bone graft/substitutes.

A Systematic Review and Meta-Analysis of Nerve Gap Repair: Comparative Effectiveness of Allografts, Autografts, and Conduits.

BACKGROUND: Ideal nerve repair involves tensionless direct repair, which may not be possible after resection. Bridging materials include nerve autograft, allograft, or conduit. This study aimed to perform a systematic literature review and meta-analysis to compare the meaningful recovery (MR) rates and postoperative complications following autograft, allograft, and conduit repairs in nerve gaps greater than 5 mm and less than 70 mm. A secondary aim was to perform a comparison of procedure costs. METHODS: The search was conducted in MEDLINE from January of 1980 to March of 2020, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included whether they reported nerve injury type, repair type, gap length, and outcomes for MR rates. Thirty-five studies with 1559 nerve repairs were identified. RESULTS: Overall MR for sensory and motor function was not significantly different between autograft ( n = 670) and allograft ( n = 711) across both short and long gaps. However, MR rates for autograft (81.6%) and allograft (87.1%) repairs were significantly higher compared with conduits (62.2%) ( P < 0.05) in sensory short gap repairs. Complication rates were comparable for autograft and allograft but higher for conduit with regard to pain. Analysis of costs showed that total costs for allograft repair were less than autograft in the inpatient setting and were comparable in the outpatient setting. CONCLUSIONS: Literature showed comparable rates of MR between autograft and allograft, regardless of gap length or nerve type. Furthermore, the rates of MR were lower in conduit repairs. In addition, the economic analysis performed demonstrates that allograft does not represent an increased economic burden compared with autograft.

Reoperation Following Zone II Flexor Tendon Repair.

BACKGROUND: The goal of zone II flexor tendon surgery is to perform a repair with sufficient strength to withstand the forces encountered during rehabilitation. Postoperative rerupture and adhesion formation may lead to reoperation. This study aimed to determine the factors associated with reoperation after primary zone II flexor tendon repair. METHODS: In this retrospective case series, a total of 252 fingers in 201 patients underwent zone II flexor tendon repair. A medical record review was performed to collect data regarding patient demographics, injury and treatment characteristics and postoperative complications including reoperation. Reoperation was defined as any unplanned surgical procedure performed after initial flexor tendon repair. RESULTS: There were 49 fingers (19%) in 42 patients that underwent reoperation at a median of 5.5 (interquartile range: 2.8-7.9) months. Older age, workers' compensation, and a Kessler-type repair of the flexor digitorum profundus were independently associated with reoperation. CONCLUSIONS: In vitro studies suggest that Kessler-type repairs are inferior compared with other suture configurations. Our study demonstrates a clinical correlation to these biomechanical studies. Our results suggest that Kessler-type repairs are inferior compared with non-Kessler-type repairs, due to postoperative complications requiring secondary surgeries.

Patient-Reported Outcomes After Surgical Treatment of Early Osteoarthritis of the First Carpometacarpal Joint.

BACKGROUND: The goals of this study are to describe the reoperation rates in patients who underwent Wilson osteotomy compared with patients who underwent carpometacarpal (CMC) arthroplasty for early-stage arthritis and to evaluate the factors influencing the patient-reported outcomes. METHODS: Retrospectively, 52 patients who underwent surgery for stage I/II osteoarthritis of the thumb carpometacarpal were identified, consisting of 17 (33%) patients who underwent Wilson osteotomy and 35 (67%) who underwent carpometacarpal arthroplasty. A total of 28 (55%) patients completed the outcome questionnaires, consisting of 11 (39%) patients who underwent Wilson osteotomy and 17 (61%) patients who underwent carpometacarpal arthroplasty. We performed a multivariable linear regression model to identify factors associated with the Numeric Rating Scale (NRS) pain intensity at final follow-up. RESULTS: Among the patients who underwent CMC arthroplasty, 2 had a reoperation. Among the patients who underwent Wilson osteotomy, 3 had a reoperation. Among the patients who completed the outcome questionnaires, the median quick Disabilities of the Arm, Shoulder and Hand score was 10 and the median NRS Pain Intensity score was 0. In multivariable analysis, the postoperative Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI) was independently associated with higher postoperative NRS pain scores. CONCLUSION: In younger patients with stage I/II CMC osteoarthritis, Wilson osteotomy may be a reasonable alternative to CMC arthroplasty. Outcomes were similar between both groups at mid-term follow-up, with only a slightly higher pain score in the osteotomy group. In patients with stage I/II carpometacarpal osteoarthritis, the PROMIS PI is the main factor indicating successful outcomes.

Quantitative Analysis of the Volar Ulnar Corner of the Distal Radius: A Reference for Intraoperative Distal Radius Fracture Reduction.

PURPOSE: The reduction of distal radius fractures using volar locking plate fixation can be performed by securing the plate to the distal fragments and then levering the plate to the radial shaft. Oblique placement of the plate on the radial shaft may lead to malreduction. The aim of this study was to evaluate parameters that can be used for the assessment of intraoperative distal radius fracture reduction using "distal-first" volar plate fixation, especially the geometry of the ulnar corner. The prevalence of Tolat distal radioulnar joint (DRUJ) types was determined, and the angles of the volar corner were quantitatively described. METHODS: Three hundred seventy-five adult patients with a conventional wrist radiograph in their medical chart were identified. From this cohort, 50 radiographs of each Tolat DRUJ type were quantitatively analyzed using 4 angles. The probability density of each angle was described using Kernel density estimation graphs. A multivariable analysis was used to study the association between the 4 angles and Tolat DRUJ types and other patient factors. RESULTS: One hundred fifty-one patients (40%) had a wrist with type 1 DRUJ, 147 (39%) had a wrist with type 2 DRUJ, and 77 (21%) had a wrist with type 3 DRUJ. The measurements of the distal ulnar corner, volar ulnar corner, and DRUJ angulation were significantly different among each Tolat DRUJ type. The median lunate facet inclination, relative to the axis of the radial shaft, measured 14° (interquartile range, 12°-16°) across all the Tolat DRUJ types. CONCLUSIONS: The prevalence of Tolat type 1, 2, and 3 DRUJ was 40%, 39%, and 21%, respectively. The angles of the volar ulnar corner varied with each DRUJ type. CLINICAL RELEVANCE: Because the lunate facet inclination was relatively consistent among all the Tolat DRUJ types, this angle may be useful as a reference for "distal-first" distal radius volar plating.

Additional Treatment after Collagenase Injections and Needle Fasciotomy for Dupuytren's Disease: A Retrospective Cohort Study.

Introduction The aim of this study was to assess the rate of additional treatment after collagenase injection and needle fasciotomy, and what factors are associated with additional procedures for recurrence. Materials and Methods We retrospectively identified 201 adult patients who underwent collagenase injection and 19 patients who underwent needle fasciotomy for Dupuytren's disease from 2012 to 2014. Outcomes included additional treatment of the same ray for either recurrence or persistence of contracture. To evaluate associated factors, we performed a bivariate analysis. Results Additional treatment after collagenase injection for recurrence was performed in 24% of fingers at a median of 23 months (interquartile range [IQR]: 10.8-36.1) and was associated with bilateral disease ( p = 0.008). Additional treatment for persistence was performed in 5.6% at a median of 1.9 months (IQR: 1.1-3.2). Additional treatment for recurrence after needle fasciotomy was performed in 13% of fingers at a median of 28.2 months (IQR: 27.5-28.2) and 4.2% for persistence at 1.1 months. Fingers treated with needle fasciotomy were more likely to undergo secondary open fasciectomy (13% vs. 5.1%, p = 0.022). Conclusion Additional treatment after collagenase injections was performed in 29% of fingers, mostly another collagenase injection, and was associated with bilateral disease. After needle fasciotomy, 17% of patients underwent additional treatment, primarily open partial fasciectomy.

Migraine Headaches in Patients with Upper Extremity Compressive Neuropathy.

BACKGROUND: Upper extremity nerve compression syndromes and migraines caused by nerve entrapment have many similarities, including patient presentation, anatomical findings, and treatment by surgical decompression of affected nerves. Parallels between the two conditions point toward the possibility of shared predisposition. The aim of this study was to evaluate the relationship between migraine and upper extremity nerve compression. METHODS: Nine thousand five hundred fifty-eight patients who underwent nerve decompression surgery of the upper extremity (median, ulnar, and radial nerves and thoracic outlet syndrome) as identified by CPT and International Classification of Diseases codes were included in the analysis. International Classification of Diseases codes for migraine and comorbidities included as part of the Elixhauser Comorbidity Index were identified. Bivariate and multivariable logistic regression was performed. RESULTS: Median nerve decompression (OR, 1.3; 95 percent CI, 1.0 to 1.8; p = 0.046) and multiple nerve decompressions (OR, 1.7; 95 percent CI, 1.2 to 2.5; p = 0.008) were independently associated with higher rates of migraine compared to ulnar nerve decompression and thoracic outlet syndrome. Older age and male sex had a negative association with migraine. History of psychiatric disease, rheumatoid arthritis/collagen vascular diseases, hypothyroidism, hypertension, and chronic pulmonary disease were independently associated with migraine headache. CONCLUSIONS: Patients who undergo median and multiple nerve decompression are more likely to experience migraine headache. It is important to recognize this overlap and provide comprehensive patient screening for both conditions. This shared predisposition and better understanding of a common disease mechanism and genetics may provide greater insight into the pathogenesis and therefore treatment of these clinical problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Performance of Diagnostic Tests for Identifying Periprosthetic Joint Infection After Failed Partial Knee Arthroplasty.

BACKGROUND: Indications for unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty are expanding. Despite the lower published infection rates for UKA and patello-femoral arthroplasty than total knee arthroplasty, periprosthetic joint infection (PJI) remains a devastating complication and diagnostic thresholds for commonly utilized tests have not been investigated recently. Thus, this study evaluated if diagnostic thresholds for PJI in patients who had a failed partial knee arthroplasty (PKA) align more closely with previously reported thresholds specific to UKA or the 2018 International Consensus Meeting on Musculoskeletal Infection. METHODS: We identified 109 knees in 100 patients that underwent PKA with eventual conversion to total knee arthroplasty within a single healthcare system from 2000 to 2021. Synovial fluid nucleated cell count and synovial polymorphonuclear percentage in addition to preoperative serum erythrocyte sedimentation rate, serum C-reactive protein, and serum white blood cell count were compared with Student's t-tests between septic and aseptic cases. Receiver operating characteristic curves and Youden's index were used to assess diagnostic performance and the optimal cutoff point of each test. RESULTS: Synovial nucleated cell count, synovial polymorphonuclear percentage, and serum C-reactive protein demonstrated excellent discrimination for diagnosing PJI with an area under the curve of 0.97 and lower cutoff values than the previously determined UKA specific criteria. Serum erythrocyte sedimentation rateESR demonstrated good ability with an area under the curve of 0.89. CONCLUSION: Serum and synovial fluid diagnostic thresholds for PJI in PKAs align more closely with the thresholds established by the 2018 International Consensus Meeting as compared to previously proposed thresholds specific to UKA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

An experienced surgeon's take on scapho-lunate diastasis with distal radius fracture: What does this mean? Does this influence functional outcome?

Radiographic evidence of scapho-lunate diastasis associated with a displaced distal radius fracture has been well recognized yet the clinical significance remains in question. If left untreated, will this progress to both radiographic and clinical changes consistent with intercarpal arthritis? Using the accumulated data of over 400 surgically treated distal radius fractures in the ICUC database, 16 cases of untreated scapho-lunate diastasis were followed on an average of 8 years without evidence of progressive functional or radiographic deterioration. In 50% of these cases, incidental findings of similar scapho-lunate diastasis was noted in the opposite uninjured wrist.

Factors Related to Neuropathic Pain following Lower Extremity Amputation.

BACKGROUND: Lower extremity amputations are common, and postoperative neuropathic pain (phantom limb pain or symptomatic neuroma) is frequently reported. The use of active treatment of the nerve end has been shown to reduce pain but requires additional resources and should therefore be performed primarily in high-risk patients. The aim of this study was to identify the factors associated with the development of neuropathic pain following above-the-knee amputation, knee disarticulation, or below-the-knee amputation. METHODS: Retrospectively, 1565 patients with an average follow-up of 4.3 years who underwent a primary above-the-knee amputation, knee disarticulation, or below-the-knee amputation were identified. Amputation levels for above-the-knee amputations and knee disarticulations were combined as proximal amputation level, with below-the-knee amputations being performed in 61 percent of patients. The primary outcome was neuropathic pain (i.e., phantom limb pain or symptomatic neuroma) based on medical chart review. Multivariable logistic regression was performed to identify independent factors associated with neuropathic pain. RESULTS: Postoperative neuropathic pain was present in 584 patients (37 percent), with phantom limb pain occurring in 34 percent of patients and symptomatic neuromas occurring in 3.8 percent of patients. Proximal amputation level, normal creatinine levels, and a history of psychiatric disease were associated with neuropathic pain. Diabetes, hypothyroidism, and older age were associated with lower odds of developing neuropathic pain. CONCLUSIONS: Neuropathic pain following lower extremity amputation is common. Factors influencing nerve regeneration, either increasing (proximal amputations and younger age) or decreasing (diabetes, hypothyroidism, and chronic kidney disease) it, play a role in the development of postamputation neuropathic pain. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Forearm Plate Fixation: Should Plates Be Removed?

Background: Refracture after both bone forearm fracture fixation may vary with or without plate removal. We tested the null hypothesis that there is no difference in the rate of refracture in patients who have undergone open reduction and internal fixation of a diaphyseal forearm bone who have retained implants versus removed implants. We also studied factors associated with plate removal. Methods: We retrospectively identified 645 adult patients with a total of 925 primary fractures that underwent primary plate fixation of an ulnar or radial shaft fracture between 2002 and 2015 at a single institutional system. Patients with nonunion, pathological fracture or infection were excluded. Independent factors associated with refracture and plate removal were identified using multivariable analysis. Results: Refractures occurred in 6.3% of the fractures that had forearm implant removal, compared to 2.1% of the fractures with retained plates. Refractures were independently associated with plate removal (OR: 3.7, 95% CI: 1.2-11.7, P=0.023) and was more frequent in the radius (OR: 2.4, 95% CI: 1.0-5.8, P=0.06). A refracture after implant removal occurred within 3 months after removal. Ulnar plates were removed more often compared to radial plates (OR: 2.6, 95% CI: 1.4-4.7, P=0.002) as were plates used for type A fractures compared to type C fractures (OR: 3.2, 95% CI: 1.1-9.2, P=0.032). Conclusion: The rate of refracture is higher after plate removal compared to patients who did not have plates removed. Although uncommon, refractures of the radius tend to be more common than a refracture of the ulna. If the implant is symptomatic on the ulnar side, it may be preferable to remove the ulnar implant and retain the radius implant rather than remove both plates when possible. Furthermore, limiting strenuous activity for three months after implant removal is a consideration.

Prolonged Opioid Use following Hand Surgery: A Systematic Review and Proposed Criteria.

Prolonged opioid use after surgery has been a contributing factor to the ongoing opioid epidemic. The purpose of this systematic review is to analyze the definitions of prolonged opioid use in prior literature and propose appropriate criteria to define postoperative prolonged opioid use in hand surgery. Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 130 studies were included for review. The primary outcome was the timepoint used to define prolonged opioid use following surgery. The proportion of patients with prolonged use and risk factors for prolonged use were also collected for each study. Included studies were categorized based on their surgical specialty. Results: The most common timepoint used to define prolonged opioid use was 3 months (n = 86, 67.2% of eligible definitions), ranging from 1 to 24 months. Although 11 of 12 specialties had a mean timepoint between 2.5 and 4.17 months, Spine surgery was the only outlier with a mean of 6.90 months. No correlation was found between the definition's timepoint and the rates of prolonged opioid use. Conclusions: Although a vast majority of the literature reports similar timepoints to define prolonged postoperative opioid use, these studies often do not account for the type of procedures being performed. We propose that the definitions of postoperative prolonged opioid use should be tailored to the level and duration of pain for specific procedures. We present criteria to define prolonged opioid use in hand surgery.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty.

BACKGROUND: Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA. METHODS: We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores. RESULTS: Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS. CONCLUSION: Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

Long-Term Opioid Use Following Surgery for Symptomatic Neuroma.

BACKGROUND: Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery. METHODS: After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments. RESULTS: Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3, p = 0.013). CONCLUSION: Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.