Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures.

BACKGROUND: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE: Level IV.

Limb Necrosis in the Setting of Vasopressor Use.

BACKGROUND: It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis. OBJECTIVE: To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy. METHODS: A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded. RESULTS: The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups. CONCLUSION: The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches.

BACKGROUND: Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes. METHODS: A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD. RESULTS: Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%. CONCLUSION: Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability. LEVEL OF EVIDENCE: I, Systematic Review.

Tourniquet Use in Extremity-Based Microsurgery.

BACKGROUND: The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. METHODS: A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. RESULTS: A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. CONCLUSION: Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

The Creation of Data-Driven Preoperative Hemoglobin A1c and Same-Day Glucose Strata to Stratify Complication Risk Following Total Hip Arthroplasty.

BACKGROUND: This study identifies data-driven strata for preoperative Hemoglobin A1c (HbA1c) and same-day glucose levels that maximize differences in the likelihood of complications following total hip arthroplasty (THA). METHODS: Patients who underwent THA from 2013 to 2022 were identified using a national database. In total, 18,728 patients were identified with a mean age of 67 years (range, 18 to 80). Stratum specific likelihood ratio (SSLR) analysis determined separate strata for HbA1c and same-day glucose levels that minimized the likelihood of 90-day complications following THA. Each stratum was propensity-score matched based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disease, and obesity to the lowest respective stratum. The risk ratio (RR) with respect to the lowest matched stratum was observed. RESULTS: Our SSLR analysis identified 3 data-driven HbA1c strata (4.5 to 5.9, 6.0 to 6.9, and 7.0+) and two same-day glucose strata (60 to 189 and 190+) that predicted 90-day major complications. For HbA1c, when compared to the lowest strata (4.5 to 5.9), the risk of 90-day major complications sequentially increased as the HbA1c strata increased: 6.0 to 6.9 (RR: 1.21; P = .041), 7+ (RR: 1.82; P < .001). For same-day glucose, when compared to the matched lowest strata (60 to 189), the risk of 90-day major complications was higher for the 190+ strata (RR: 1.5; P < .001). CONCLUSIONS: Our results support the use of multiple HbA1c strata that can be incorporated into preoperative risk-stratification models. Additionally, we identified a single cut-off level of 190 as a maximum target blood glucose level perioperatively.

Osteolysis Following the Use of Polyetheretherketone Suture Anchors in Hand and Wrist Surgery: A Preliminary Study.

PURPOSE: The objective of this study was to investigate and describe the presence of osteolysis after implantation of polyetheretherketone (PEEK) suture anchors in the hand and wrist. METHODS: Patients who underwent hand or wrist surgery using PEEK suture anchor(s) at a large academic institution from January 2019 to January 2021 were identified. Patients without accessible intraoperative fluoroscopic imaging were excluded. Patient demographics, type of procedure, and suture anchor material were recorded. The suture anchor tunnel size was measured on sequential radiographs and recorded as percentage change. Descriptive statistics were used to summarize findings. RESULTS: A total of 26 PEEK suture anchors in 14 patients were included, with an average follow-up of 12.0 months (range, 1.5-24.1 months). Twenty-seven percent of the anchors (7/26) demonstrated osteolysis at final follow-up, as defined by enlargement of tunnel size by >30%. In all anchors, the tunnel size increased by 19.1% on average (range, -7.7% to 56.1%) by final follow-up. CONCLUSIONS: Polyetheretherketone suture anchors may be associated with the development of osteolysis in hand and wrist surgery. The clinical implications of osteolysis in the smaller bones of the hand and wrist remain unclear. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Determining the Optimal Dosage of Corticosteroid Injection in Trigger Finger.

BACKGROUND: Corticosteroid injection is the mainstay of nonoperative treatment for trigger finger (stenosing tenosynovitis), but despite substantial experience with this treatment, there is minimal available evidence as to the optimal corticosteroid dosing. The purpose of this study is to compare the efficacy of 3 different injection dosages of triamcinolone acetonide for the treatment of trigger finger. METHODS: Patients diagnosed with a trigger finger were prospectively enrolled and treated with an initial triamcinolone acetonide (Kenalog) injection of 5 mg, 10 mg, or 20 mg. Patients were followed longitudinally over a 6-month period. Patients were assessed for duration of clinical response, clinical failure, Visual Analog Scale (VAS) pain scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. RESULTS: A total of 146 patients (163 trigger fingers) were enrolled over a 26-month period. At 6-month follow-up, injections were still effective (without recurrence, secondary injection, or surgery) in 52% of the 5-mg group, 62% of the 10-mg group, and 79% of the 20-mg group. Visual Analog Scale at final follow-up improved by 2.2 in the 5-mg group, 2.7 in the 10-mg group, and 4.5 in the 20-mg group. The QuickDASH scores at final follow-up improved by 11.8 in the 5-mg group, 21.5 in the 10-mg group, and 28.9 in the 20-mg group. CONCLUSIONS: Minimal evidence exists to guide the optimal dosing of steroid injection in trigger digits. When compared with 5-mg and 10-mg doses, a 20-mg dose was found to have a significantly higher rate of clinical effectiveness at 6-month follow-up. The VAS and QuickDASH scores were not significantly different between the 3 groups.

General Population and Surgeon Preferences for Pollicization Versus Toe-To-Thumb Transfer for Reconstruction of Traumatic Thumb Loss in Adults: An International, Multi-Center Survey Study.

PURPOSE: Data objectively comparing outcomes following pollicization versus toe-to-thumb transfer for reconstruction after traumatic thumb amputation in adults remains sparse. Given that this decision is reliant on personal preference, it is important to understand the subjective nature of these preferences, particularly in the context of culture. The purpose of this study was to compare Eastern and Western societal and hand surgeon preferences for pollicization versus toe-to-thumb transfer for traumatic thumb reconstruction. METHODS: Investigators from 6 international locations recruited local hand surgeons and members of the general population. Austria, Germany, the United States, and Spain were grouped as "Western" nations. China and India separately represented "Eastern" nations. Participants completed a questionnaire evaluating their personal preferences for pollicization and toe-to-thumb transfer. The questions posed to the general population and hand surgeons were identical. Demographic data were also collected. RESULTS: When comparing the Western nations, China, and India, there was no difference in personal preferences within the general population for pollicization versus toe-to-thumb transfer. In contrast, most Indian hand surgeons favored toe-to-thumb transfer and most Western surgeons were uncertain about which procedure they would favor. Surgeons had more optimistic expectations regarding postoperative hand function, new thumb sensation, and hand appearance following pollicization than the general population. Similarly, for toe-to-thumb transfer, a greater proportion of surgeons predicted good-to-excellent function, sensation, and appearance. CONCLUSIONS: There was no clear, observed "East" versus "West" difference in the general population's personal preferences for pollicization versus toe-to-thumb transfer among study participants. The members of the general population and hand surgeons had different outcome expectations. CLINICAL RELEVANCE: Understanding how culture influences patient and hand surgeon preferences for pollicization versus toe-to-thumb transfer may help guide future decision-making for traumatic thumb reconstruction.

A Prospective Analysis of Patient Characteristics Affecting the Outcome of Dorsal Splinting for Soft Tissue Mallet Injuries.

BACKGROUND: Much has been written about the diagnosis and treatment of soft tissue mallet injuries. However, there has been little regarding the characteristics of this injury affecting patients' prognosis. The purpose of this prospective study was to identify factors influencing the outcome of treatment of soft tissue mallet injuries. METHODS: Patients diagnosed with soft tissue mallet injuries were enrolled prospectively in a protocol of dorsal splinting for 6 to 12 weeks, followed by weaning over 2 weeks and then evaluated at 6, 9, and ≥12 months. RESULTS: Thirty-seven patients (38 digits) completed the study. Treatment success was defined as a final extensor lag of <15° and failure as a final extensor lag of ≥15°. Those failing splint treatment were older compared with those successfully treated. Patient compliance was significantly associated with a successful outcome. Factors that did not significantly affect success included time to treatment, initial injury severity, splinting duration, sex, and ligamentous laxity. Disabilities of Arm, Shoulder, and Hand scores >0 were not associated with treatment failure. Radiographic and clinical extension lag were statistically comparable. CONCLUSIONS: This study shows strong association between the success of splint treatment, younger patient age, and compliance with the treatment protocol. Despite this finding, most patients did not report any functional limitations, irrespective of the treatment success. In contrast to prior results, time to treatment and initial extensor lag did not significantly affect treatment success.

Specific Factors Affecting Operating Room Efficiency: An Analysis of Case Time Estimates.

PURPOSE: Operating room (OR) efficiency has an impact on surgeon productivity and patient experience. Accuracy of case duration estimation is important to optimize OR efficiency. The purpose of this study was to identify factors associated with inaccurate case time estimates in outpatient hand surgery. A better understanding of these findings may help to improve OR efficiency and scheduling. METHODS: All outpatient hand surgical cases from 2018 to 2019 were reviewed. Poorly-estimated cases (i.e., poor scheduling accuracy) were defined as those cases where the actual operative time differed from the predicted time by >50% (either quicker by >50% or slower by >50% than the predicted time). The percentages of poorly-estimated cases were analyzed, categorized, and compared by surgeon, procedure type, and scheduled case length. RESULTS: A total of 6,620 cases were identified. Of 1,107 (16.7%) cases with poorly estimated case durations, 75.2% were underestimated. There was no difference in the likelihood of poor estimation related to start time. Well-estimated cases tended to have longer scheduled case duration, but shorter realized case duration and surgical time. Our systems analysis identified specific surgeons and procedures as predictable outliers. Cases scheduled for 15-30 minutes frequently were inaccurate, whereas cases scheduled for 30-45 and 106-120 minutes had accurate estimates. CONCLUSIONS: The accuracy of case time estimations in a standard outpatient hand surgery practice is highly variable. Nearly one-fifth of outpatient hand surgery case durations are poorly estimated, and inaccurate case time estimation can be predicted based on surgeon, procedure type, and case time. CLINICAL RELEVANCE: Maximizing OR efficiency should be a priority for surgeons and hospital systems. With multiple surgeries done per day, the efficiency of the OR has an impact on surgeon productivity and patient experience.

Iliac Crest and Distal Radius Autografts Exhibit Distinct Cell-Intrinsic Functional Differences.

PURPOSE: Autologous bone grafts demonstrate osteoconductive, osteoinductive, and osteogenic properties. Hand surgeons commonly augment surgical fixation with autografts to promote fracture healing. This study compared the intrinsic stem cell-like properties of 2 commonly used autograft sources in hand surgery: the iliac crest and distal radius. METHODS: A total of 9 subjects who received an iliac crest bone graft and distal radius bone graft harvest as a part of the standard care of distal radius malunion or nonunion correction or scaphoid nonunion open reduction and internal fixation were enrolled in the study. Cells were isolated by serial collagenase digestion and subjected to fibroblast colony-forming units, osteogenesis, and adipogenesis assays. The expression levels of genes involved in osteogenesis and adipogenesis were confirmed using quantitative polymerase chain reaction. RESULTS: The cells isolated from the iliac crest bone graft compared with those isolated from the distal radius bone graft demonstrated significantly higher mean fibroblast colony-forming unit efficiency; increased osteogenesis, as measured using alizarin red quantification; increased adipogenesis, as measured using oil red O quantification; and higher expression levels of genes involved in osteogenesis and adipogenesis under the respective differentiation conditions. CONCLUSIONS: The cells isolated from the iliac crest bone graft demonstrated a higher fibroblast colony-forming unit capacity and an increased capability to undergo both osteogenesis and adipogenesis. CLINICAL RELEVANCE: Limited evidence exists comparing the intrinsic stem cell-like properties of the iliac crest and distal radius despite the widespread use of each source in hand and wrist surgery. The information from this investigation may assist hand and wrist surgeons with the selection of a source of autograft.

Demographics of Common Compressive Neuropathies in the Upper Extremity.

BACKGROUND: The purpose of this study was to compare the demographic differences of the most common peripheral nerve compressions in the upper extremity-carpal tunnel syndrome (CTS), ulnar nerve compression (UNC) at the elbow, combined CTS and UNC, radial tunnel syndrome (RTS), and posterior interosseous nerve syndrome (PINS)-as a means to better understand the etiologies of each. METHODS: A retrospective chart review was performed of all patients over the age of 18 years seen at our institution in the 2018 calendar year. International Classification of Diseases, Tenth Revision codes were used to identify patients with diagnoses of upper extremity peripheral nerve compressions. Demographic details and relevant comorbidities were recorded for each patient and compared with controls, who were seen the same calendar year with no neuropathies. χ2 analyses, independent-samples t tests, and multivariate logistic regressions were performed (P < .05). RESULTS: A total of 7448 patients were identified. Those with CTS were mainly women, former smokers, and diabetic (all P < .001) and with a greater average body mass index (BMI) (P = .006) than controls. Patients with UNC were more often men and younger when compared with controls (both P < .001). A history of smoking, diabetes, and average BMI were similar between patients with UNC and controls (all P > .05). Those patients with combined CTS/UNC were mainly men, former smokers, and diabetic (all P < .001) when compared with controls. Patients with RTS/PINS were also mostly men (P = .007), diabetic (P = .042), and were more often current smokers (P < .001). CONCLUSIONS: The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies.

Proximal Hamate Autograft for Proximal Scaphoid Pole Reconstruction A Case Report.

Avascular necrosis (AVN) and subsequent fragmentation of the proximal pole of the scaphoid following fracture is a challenging problem to treat. Multiple treatment methods have been described, although they have been shown to have varying degrees of success and are associated with donor site morbidities. This case report demonstrates a technique and the excellent radiographic and clinical outcome at 8 months postoperatively for reconstruction of the proximal pole of the scaphoid using an ipsilateral proximal pole of the hamate autograft.