Predictors of adequate pain control after outpatient hand and upper extremity surgery.

PURPOSE: The opioid epidemic has changed practice, though there remains a paucity of data regarding prescribing habits and pain control following outpatient hand surgery. We sought to evaluate patient-related predictors of adequate postoperative pain control. METHODS: A retrospective review was performed of a single-center prospectively collected database of elective outpatient surgery on the elbow, forearm, wrist, and/or hand. Patients were asked to complete preoperative and postoperative questionnaires to capture their perception of anticipated pain levels, expected prescription quantity/duration, additional medications used, and overall pain satisfaction. Patient demographics collected included, sex, age, race, tobacco use, and recreational drug use. Further, the questionnaire included the Brief Resilience Score (BRS), EuroQol 5-dimension health-related QOL measure (EQ-5D), and an assessment of patient-reported limitations secondary to their pain. RESULTS: Ninety-six patients completed the pre/postoperative questionnaires and were eligible for analysis. Of these patients, 80% reported adequate pain control. The sex, age, and race of those who reported adequate pain control and inadequate control were not significantly different. BRS scores were not found to be significantly different between groups, although EQ-5D QOL scores were significantly lower in the inadequately controlled group. Tobacco use was more prevalent in the inadequately controlled group. Marijuana use and the presence of a chronic pain diagnosis were not significantly different between groups. CONCLUSION: Preoperative self-reported quality of life measures and tobacco use appear to have significant effects on postoperative opioid use, suggesting further areas of optimization which may ensure patients are safe and minimize the number of opioid pills required.

Intercarpal Angles on Hand Versus Wrist Films: Are Hand Radiographs Sufficient for Assessing Intercarpal Angles?

PURPOSE: Carpal angles traditionally are measured on the lateral projection of a standard wrist series; however, this often necessitates obtaining additional radiographic views resulting in additional radiation exposure and increased cost. We aimed to determine whether carpal angles could be measured accurately on a standard series of hand radiographs when compared to wrist radiographs. METHODS: Carpal indices were measured on lateral wrist and hand radiographs of 40 patients by three orthopedic upper extremity surgeons. Inclusion criteria were no metabolic disease, no hardware, no fractures, radiographic positioning of the wrist in flexion/extension <20°, minimum 3 cm of distal radius visible, and acceptable scaphopisocapitate relationship (defined as the volar cortex of the pisiform lying between the volar cortices of the distal pole of the scaphoid and capitate). Angles measured included radioscaphoid (RSA), radiolunate (RLA), scapholunate (SLA), capitolunate (CLA), and radiocapitate (RCA). Measurements on wrist versus hand radiographs were compared for each patient. Interclass correlation coefficients (ICCs) were computed to assess interrater and intrarater agreement. RESULTS: Interrater agreement for hand and wrist radiographs were (respectively): SLA 0.746 and 0.763, RLA 0.918 and 0.933, RCA 0.738 and 0.538, CLA 0.825 and 0.650, RSA 0.778 and 0.829. Interrater agreement was superior in favor of hand radiographs for the RCA (0.738 [0.605-0.840] vs 0.538 [0.358-0.700]) and CLA (0.825 [0.728-0.896] vs 0.650 [0.492-0.781]), but not the SLA, RLA, or RSA. Two of the three raters had excellent intrarater agreement for all hand radiograph measures (ICC range, 0.907-0.995). The mean difference in measured angles on hand versus wrist radiographs was <5° for all angles. CONCLUSIONS: Carpal angles may be measured reliably on hand radiographs with an acceptable scaphopisocapitate relationship and wrist flexion/extension of <20°. CLINICAL RELEVANCE: By mitigating the need to obtain additional radiographic views, surgeons may be able to reduce the cost and radiation exposure to their patients.

Self-reported cannabis use is not associated with greater opioid use in elective hand surgery patients.

BACKGROUND: The purpose of this study was to examine the influence of preoperative marijuana use on postoperative opioid use during the first three postoperative days (POD 1-3) after surgery, and on expectations of pain control, resiliency, and quality-of-life scores. METHODS: All patients presenting to a single institution undergoing elective hand or upper extremity outpatient surgery were asked to complete pre- and postoperative questionnaires. Preoperative questionnaires collected information on demographics, marijuana use, tobacco use, procedure type, self-assessed health, pain control expectations, and EuroQol-5D (EQ-5D) scores. At the first postoperative visit, patients self-reported opioid consumption from POD 1-3. Multivariate linear regression analysis was used to determine which patient characteristics were predictive of greater postoperative opioid consumption during POD 1-3. RESULTS: Self-reported marijuana users were younger, less healthy, and more likely to use tobacco compared to non-users. Marijuana users and non-users were comparable in their use of pain medication (including non-opioids), rates of chronic pain diagnoses, and self-reported pain tolerance. EQ-5D scores were lower in marijuana users than non-users (0.64 vs. 0.72). Marijuana users and non-users were prescribed comparable quantities of opioids during the first 14 days after surgery (176 ± 148 vs 115 ± 87). Multiple linear regression analysis revealed that lower preoperative EQ-5D scores, rather than marijuana use, were associated with increased opioid consumption during POD 1-3. CONCLUSIONS: Preoperative marijuana use was not independently associated with increased opioid use during POD 1-3 after elective hand and upper extremity surgery; instead, an association with lower preoperative EQ-5D scores was identified. LEVEL OF EVIDENCE: II, prospective cohort study.

Role of Laser Pointer in Budgeting Fluoroscopy-Time and Radiation Exposure.

BACKGROUND: Literature on radiation exposure with use of the mini C-arm and value of having built-in laser guidance is limited. The purpose of this study was to determine whether laser guidance use on a mini C-arm fluoroscopy unit can reduce radiation exposure. METHODS: Surgeons (N = 25) performed the same simulated surgical task, which involved obtaining "perfect circle" views of 2 cannulated screws placed into a cadaveric wrist, done with and without C-arm laser guidance. The testing order was randomized. Main outcomes were time to complete the task, number of shots required to complete the task, number of blank shots taken, radiation exposure, total dose area product (DAP), and total exposure time. RESULTS: Laser guidance significantly reduced the percentage of surgeons who took blank shots, from 88% of the group without the laser to 12% of the group with the laser, and decreased the total average blank shots in the group from 3.5 to 0.1. While we found laser guidance led to shorter time to complete the task, decreased shots taken, and decreased exposure time and DAP, these findings only approached significance. CONCLUSION: While debate continues regarding whether mini or standard C-arm is safest, it is clear that decreasing the overall number of exposures limits potential adverse effects. Our study demonstrated that when using a mini C-arm, laser guidance decreases the number of exposures required to capture an image. These findings warrant a larger study to define the specific exposure savings and indicate potential benefit of mini C-arm use with laser guidance.

Swing Type and Batting Grip Affect Peak Pressures on the Hook of Hamate in Collegiate Baseball Players.

BACKGROUND: Bat swing and grip type may contribute to hook of hamate fractures in baseball players. PURPOSE: To compare the effects of swing type and batting grip on the pressure and rate of pressure development over the hook of hamate in collegiate baseball players. STUDY DESIGN: Descriptive laboratory study. Level of evidence, 3. METHODS: This was an experimental quasi-randomized study of bat grip and swing differences in National Collegiate Athletic Association Division I baseball players (N = 14; age, 19.6 ± 1.1 years [mean ± SD]). All participants performed swings under 6 combinations: 3 grip types (all fingers on the bat shaft [AO], one finger off the bat shaft [OF], and choked up [CU]) and 2 swing types (full swing and check swing). Peak pressure and rate of pressure generation over the area of the hamate were assessed using a pressure sensor fitted to the palm of the bare hand over the area of the hamate. Wrist angular velocities and excursions of radial ulnar deviation were obtained using 3-dimensional motion analysis. RESULTS: The OF-check swing combination produced the highest peak pressure over the hamate (3.72 ± 2.64 kg/cm2) versus the AO-full swing (1.36 ± 0.73 kg/cm2), OF-full swing (1.68 ± 1.17 kg/cm2), and CU-full swing (1.18 ± 0.96 kg/cm2; P < .05 for all). There was a significant effect of condition on rate of pressure development across the 6 conditions (P = .023). Maximal wrist angular velocities were 44% lower in all check swing conditions than corresponding full swing conditions (P < .0001). The time to achieve the maximal wrist angular velocity was longest with the AO-full swing and shortest with the CU-check swing (100.1% vs 7.9% of swing cycle; P = .014). CONCLUSION: The OF-check swing condition produced the highest total pressure reading on the hook of hamate. Check swing conditions also had the steepest rate of pressure development as compared with the full swing conditions. CLINICAL RELEVANCE: Batters who frequently check their swings and use an OF or AO grip may benefit from bat modifications or grip adjustment to reduce stresses over the hamate. Athletic trainers and team physicians should be aware of these factors to counsel players in the context of previous or ongoing hand injury.

Dynamic Nerve Compression of Guyon Canal Secondary to Variation of the Deep Branch of the Ulnar Artery: Etiology, Diagnosis, Treatment, and Outcome.

A patient presented with an ulnar-sided left wrist injury that was sustained while batting. Advanced imaging was obtained to rule out common causes of nerve compression and evaluate the patient's anatomy. Dynamic nerve conduction studies were necessary to confirm a diagnosis of nerve compression. Failing conservative treatments, the patient underwent exploration of Guyon canal and decompression of the ulnar nerve with complete symptom resolution. The patient presented a unique diagnostic challenge because he did not display the typical findings of chronic nerve entrapment syndromes. To the best of our knowledge, dynamic nerve compression at Guyon's canal has not previously been described. It is important to use a systematic approach to diagnosis, eliminating all other sources of compression. With appropriate diagnostic tools, nerve decompression can result in symptom relief.

Buckling Down on Torus Fractures - Assessing Treatment Preferences and Perceived Management Barriers at a Single Institution.

Background: Pediatric buckle fractures of the wrist can be safely managed in 'minimalist' fashion with splinting and limited follow-up; however, traditional means of treatment remain prevalent. The purpose of this study was to 1) evaluate preferences for buckle fracture management among providers at a single institution and 2) identify factors influencing clinical decision-making and barriers to implementation of minimalist practices. Methods: A 13 question survey was developed split into three sections: 1) Demographics, 2) Preferred management, and 3) Influential factors. The survey was distributed to 32 providers within our hospital system involved in buckle fracture management via email over a 1 year period. Descriptive statistics of responses were performed to address study aims. Results: The survey participation rate was 72%. Respondents had 12.2+/-12.5 (Range: 1-41) years of experience. Casting of buckle fractures was preferred by 56.5% of providers. Most (77%) were aware of literature supporting minimalist strategies. Family preferences (59.1%) and compliance concerns (54.5%) were cited as the biggest barriers to implementing these practices. Colleague recommendations and patient and caregiver preferences had the strongest influence on providers' practice. Following completion, 88.2% of providers stated they would change or consider changing their practices. Discussion: Despite awareness of the evidence base, a casting preference still exists. While other aspects of the minimalist approach were popular, prior work suggests this does not necessarily translate into practice. Commonly cited barriers include family preferences and compliance concerns; however, awareness of these issues may enable change. Level of Evidence: III.

Outcomes of Revisions for Failed Trapeziometacarpal Joint Arthritis Surgery.

PURPOSE: We compare outcomes of revision surgery for trapeziometacarpal (TM) arthritis with outcomes for both primary and revision surgery for TM arthritis reported in the literature. We hypothesized that patients undergoing revision surgery for TM arthritis would demonstrate pain and functional outcome scores that were worse than those of patients undergoing primary TM surgery. METHODS: A retrospective analysis of all patients undergoing revision TM surgery at a single institution from 1995 to 2015 was performed. Eighty-three patients (86 hands) met the inclusion criteria. Of these, 25 patients (27 hands) were available for follow-up via phone survey or clinical examination; 58 patients (59 hands) were available for chart review only. Patients available for phone survey or clinical examination were evaluated with the visual analog scale, Disabilities of the Arm, Shoulder, and Hand score, and the Conolly-Rath evaluation method. Patients available for clinical examination were also evaluated with grip strength, pinch strength, and radiographs. RESULTS: Median follow-up was 8.5 years (range, 2.0-21.2 years). Twenty percent of patients experienced postoperative complications, most commonly pin problems (7%). Of the 27 hands available for interview or clinical examination, 15 were dominant and 12 were nondominant. The average visual analog scale was 28.2 (SD, 29.7). Disabilities of the Arm, Shoulder, and Hand scores averaged 32.0 (SD, 20.8). According to the Conolly and Rath criteria, 10 patients had a good outcome, 7 were fair, and 10 were poor. For the group of 13 patients who underwent physical examination, average adduction was 42° in the affected side versus 51° in the nonaffected side. Radial abduction was 58° in the affected side versus 65° in the nonaffected side. Palmar abduction was 53° versus 85° in each group, respectively. Tip finger pinch was 3.4 kg for the affected hand versus 4.0 kg for the nonaffected side. Key pinch was 4.7 and 5.5 kg, respectively. Grip strength was measured as 22.1 kg in the affected side versus 27.6 kg in the contralateral side when adjusted for dominance. CONCLUSIONS: In our study group, revision surgery for unsuccessful primary TM surgery demonstrated results inferior to those previously reported for primary surgery for TM arthritis but similar to prior studies of revision TM surgery. Revision surgery, however, can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.