Abnormal Patterns of Biceps and Triceps Co-Contraction Following Elbow Surgery May Result in Elbow Stiffness.

Objectives: This study examines the pattern of muscular contraction and the intensity of this contraction of the biceps and triceps following elbow surgery. Methods: We performed a prospective electromyographic study of 16 patients undergoing 19 surgical procedures on the elbow joint. We measured the resting EMG signal intensity of the biceps and triceps of the operated and the normal sides at 90 degrees. We then calculated the peak EMG signal intensity during passive elbow flexion and extension of the operated side. Results: Seventeen of 19 elbows (89%) displayed a co-contraction pattern of the biceps and triceps near the end of flexion and extension during the passive range of motion. The co-contraction pattern was observed near the end of the range of motion in both flexion and extension. In addition to the observed co-contraction patterns, we detected higher contraction intensities for the biceps and triceps muscles in all patients in both flexion and extension for the elbows, which had been treated surgically. Further analysis suggests an inverse correlation between the biceps contraction intensity and the arc of motion measured at the latest follow-up. Conclusion: The co-contraction pattern and increased contraction intensity of periarticular muscle groups may result in internal splinting mechanisms, contributing to the development of elbow joint stiffness, which is frequently observed following elbow surgery.

A Prospective Evaluation of the Prevalence of Persistent Median Artery in Patients with Carpal Tunnel Syndrome.

Background: The median artery is an embryonic structure that typically regresses during gestation. Occasionally, the artery remains and is then termed a persistent median artery (PMA). A PMA can be associated with other anatomic anomalies, and has been known to contribute to carpal tunnel syndrome (CTS). Recent literature has observed an increase in PMA prevalence, speculated to indicate microevolutionary change. We performed a prospective observational study to investigate the current prevalence rate of PMA in patients undergoing carpal tunnel release (CTR). Methods: Institutional review board approval was obtained. From October 2020 to January 2021, patients ≥18 years old undergoing open CTR by 9 orthopaedic hand surgeons were included in analysis. Patients undergoing endoscopic CTR were excluded. Intraoperatively, the carpal tunnel was evaluated for the presence of a PMA, median nerve anomalies, or any other anatomic anomalies. If a patient underwent bilateral CTR during the study, only one side was included in analysis as determined randomly. Results: Three hundred and sixty open CTRs in 327 patients were performed during the study. Twenty-seven PMAs were identified, for an overall prevalence rate of 8.3%. The average age of patients with a PMA was 63.6 years (SD 13.3 years), consisting of 15 men and 12 women. There were no statistical differences in age, gender, or laterality between patients that did and did not have a PMA. Thirty-three patients underwent bilateral CTR during the study, with 3 being found to have a PMA unilaterally, and zero having a PMA bilaterally. Two bifid median nerves (0.6%) were also identified. Conclusion: This study represents the highest prevalence rate of PMA directly observed in CTR patients reported to date (8.3%). A PMA is not a rare finding, and it should be recognized and protected during CTR. Occasionally, a PMA can be the cause of an acute presentation of CTS.

The Incidence of Psychologic Stress following a Fall and Surgical Treatment of Distal Radius Fractures.

Background and Purpose Experiencing a fall and a subsequent distal radius fracture can have a major impact not only on patients' physical function, but also on their emotional state. The purpose of this project was to describe the prevalence of fear of falling (FoF) and posttraumatic stress disorder (PTSD) following surgically managed distal radius fractures due to a fall. Methods Patients who underwent surgery for a distal radius fracture due to a fall were identified by a database query. Patients were divided into three groups based on time from surgery: 0 to 2 weeks (acute), 3 to 6 months (mid-term), and 12 to 15 months (long-term). FoF was measured using the Falls Efficacy Scale-International (FES-I) questionnaire. PTSD was measured using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM) Text Revision-5 (PCL-5) questionnaire. A total of 239 patients who met inclusion criteria were consented via phone and completed the emailed surveys. Results FES-I scores were significantly higher in the acute group versus the long-term group ( p = 0.04). High concern for FoF was observed in 63% (19/30) of patients in the acute group, in 35% (14/40) in the mid-term group ( p = 0.019 vs. acute), and in 19% (8/42) in the long-term group ( p < 0.001 vs. acute). Probable PTSD was observed in 2.3% (1/44) of patients in the acute group, in 4.8% (2/42) in the mid-term group, and in 7.3% (3/41) in the long-term group. Conclusion Patients who undergo surgical fixation of a distal radius fracture due to a fall are subject to FoF and PTSD symptoms. To maximize postoperative outcomes, it is important for surgeons to be aware of these psychological effects and know how to screen for them. Level of Evidence This is a Level III study.

A Prospective Evaluation of Postoperative Readmissions After Outpatient Hand and Upper Extremity Surgery.

Introduction Hand and upper extremity surgeries are largely performed in free-standing ambulatory surgery centers (ASCs). Rates of unexpected hospitalizations or visits to the urgent care or emergency departments in the month following hand and upper extremity surgery have been widely varied in the literature. We prospectively followed patients after hand and upper extremity outpatient surgery to determine the rate of unplanned health care utilization with the hypothesis that hospital admissions, emergency room visits, and urgent care center visits would be higher than the rates currently reported by retrospective studies. Methods All patients undergoing outpatient hand and upper extremity surgery by five hand surgeons were prospectively followed to monitor for hospital readmissions, emergency room visits, and urgent care presentations. The patients' postoperative course was evaluated for direct transfers from the surgical center to the hospital. In addition, any urgent care or emergency room visits and hospital admissions for the first month after surgery were tabulated. Points of review of the patients' postoperative course included the following: (1) phone contact on the first postoperative day, (2) routine ASC postoperative phone calls two to three days postoperatively, (3) first postoperative office at approximately one to two weeks, and (4) phone contact or office evaluation one-month postoperatively based on surgeon preference for follow-up. Results A total of 583 patients were identified for participation, of whom 22 patients were excluded; thus, 561 patients were included for evaluation, with 47.2% women (n=265) and 52.8% men (n=296). The average age was 54 years (range: 14-102 years). Nine (1.6%) patients presented postoperatively for further evaluation at an urgent care or hospital (95% C.I. 0.8-3.1%). Five patients presented to an emergency room and four patients presented to an urgent care facility. Of those patients, two were admitted to the hospital due to shortness of breath (0.35%; 95% CI: -0.08 to 1.4%). Emergency room and urgent care visits that did not lead to admission accounted for 1.25% (95% CI: 0.6-2.6%). No patients were transferred from the ASC to the hospital or emergency room. Conclusion There was a low rate of postoperative utilization of urgent care and emergency room services with hand and upper extremity surgery performed at free-standing, ASCs. Hospital readmissions were rare, and no patients required transfer from an ambulatory care center to the hospital. Outpatient hand and upper extremity surgery is safe in an ambulatory care center, with low postoperative transfers and readmissions in the month following surgery.

An Evaluation of Digital Imaging Studies in an Outpatient Orthopedic Setting.

BACKGROUND: Distribution of radiographic images in the outpatient setting on compact discs-recordable (CD-R) is commonplace. Opening, manipulating and interpreting these can be challenging. This study evaluated the availability and ease of use of CD-R to evaluate digital images in an outpatient orthopedic setting. METHODS: 118 CD-R containing diagnostic studies were evaluated by seven board certified orthopaedic surgeons. Surgeon age and self-perceived "tech savvy" scores were tabulated using a visual analog scale (VAS). Surgeons evaluated: ability and number of computers to open, autorun, and specific reader software. Time to load was recorded in seconds, type of study, presence of "not for diagnostic use", and if the disc required additional software. Studies were graded using a VAS for ease of opening, ability to move from image to image and/or between series, to manipulate the image, and to zoom and pan. RESULTS: There were 79 radiographs, 29 MRI's, and 10 CT scans. Seven (6%) had to be manually opened and four (3%) required software installation. Thirteen (11%) contained a warning that the studies should not be used for diagnostic purposes. Six (5%) of the studies could not be opened. For the opened studies, average time from disk insertion to image was 43.7 seconds overall (range 3-350), 65.3 seconds (range 21-191) for MRI and CT, and 35.2 seconds (range 5-177) for radiographs. CONCLUSION: The present digital imaging systems include different software types and a variety of interfaces. Improving this would decrease time and effort necessary to open and evaluate these studies, and improve efficiency. LEVEL OF EVIDENCE: III.

Patient Satisfaction in the Preoperative Period: Preparing for Hand Surgery.

Background: The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling and medical clearance encounters. Methods: Questionnaires investigating satisfaction with the preoperative process were collected for 200 patients presenting for elective hand surgery. The number of telephone, surgeon, and medical clearance encounters were recorded, and satisfaction was determined for each type based on a 4-category Likert scale. All patients 18 years or older were included, while only patients providing incomplete questionnaires were excluded. Outcome data were assessed for associations between different encounter totals or types and satisfaction rates. Results: Among 200 patients, 197 completed the questionnaire and were included. Overall satisfaction with the preoperative process was 92.9%, with only 3% of patients dissatisfied. There was a significant association between satisfaction and the number of telephone and total encounters. Satisfaction fell below 90% after 4 or more telephone calls (66.6%, P = 0.005) and 5 or more total encounters (80%, P = 0.008). When considered individually, there was no significant association between satisfaction and the number of surgeon (P = 0.267) or medical office encounters (P = 0.087), or a patient's perceived health status (P = 0.14). Conclusions: Greater than 3 telephone or 4 total encounters significantly decreases patient satisfaction, while surgeon and medical office visits are not associated with satisfaction rates when considered individually. This suggests the number, not the type, of preoperative encounters impact satisfaction and highlight the importance of efficient communication between patients and providers.