Effects of Postoperative Splinting on Outcomes following Digital Mucous Cyst Excision: A Retrospective Review.

Background: Digital mucous cysts (DMCs) are masses on the fingers that can be definitively managed with surgical excision. Though uncommon, surgical site infections can develop into septic arthritis. We sought to determine whether postoperative splinting decreases rates of postoperative infection and the need for postoperative antibiotics. We also explored the effect of age, gender, obesity, and preoperative antibiotic administration on infectious complications. Methods: Patients who underwent DMC excision between 2011 and 2021 were retrospectively identified. Chi-squared and Fisher's exact tests were used to analyze the complication rates including documented infection, postoperative antibiotic administration, mass recurrence, and return to operating room. Associations were analyzed between both preoperative antibiotic administration and postoperative splinting with respect to postsurgical complications. Results: The database search identified 373 patients who underwent 394 DMC excisions. Postoperative antibiotics were given in splinted patients at lower rates than their nonsplinted counterparts with a small-to-moderate effect size, but the difference was not statistically significant (2.7 vs. 7.5%). Preoperative antibiotic administration was not found to significantly affect the prescription of postoperative antibiotics. Splinting did not reduce rates of DMC recurrence. Patients who were splinted were more likely to have also received preoperative antibiotics. Males were given postoperative antibiotics more frequently than females (12.6 vs. 4.0%). Conclusions: Though not statistically significant, splinted patients were prescribed postoperative antibiotics less frequently. Postoperative antibiotics were utilized more frequently than the rate of infections typically reported following this procedure, possibly indicating overcautious prescription habits or underreported suspected infections.

Evaluation of Patient Expectations and Outcomes after Distal Radius Fractures.

BACKGROUND: Patient expectations influence patient-reported outcomes after musculoskeletal injuries. The goal of this study is to determine how pretreatment expectations correlate with outcomes in patients with distal radius fractures. METHODS: Seventy-five patients with an isolated distal radius fracture were prospectively enrolled into nonoperative and operative cohorts. The Trauma Expectation Factor-Trauma Outcome Measure (TEF-TOM) score was the primary outcome measure. Trauma Expectation Factor scores were recorded at the time of enrollment, and TOM scores were recorded at 3, 6, and 12 months. Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) and Patient-Rated Wrist Evaluation (PRWE) scores were also recorded. RESULTS: Trauma Outcome Measure scores at all time points were worse than expected (P < .01). Expectations were higher for patients younger than 65 years than for the 65+ group (P = .02). In patients aged 65+ years, mean TOM at 3 months was not significantly different than expected (P = .11) but decreased by 6 (P = .04) and 12 months (P < .01). Baseline TEF and TEF-TOM scores were not significantly different between operative and nonoperative groups (P = .37). Quick Disabilities of the Arm, Shoulder, and Hand and PRWE scores were not significantly different between age or treatment groups at the final follow-up. CONCLUSIONS: The overall treatment of distal radial injuries in our study did not meet patient expectations. Patients aged 65 years or older had lower expectations but were not able to predict their outcomes better than patients aged <65 years. There were no differences in TEF or TOM by treatment method. Patients demonstrated improved functional outcomes (qDASH/PRWE) at all time points regardless of age and treatment method.

Incisional Negative Pressure Wound Therapy Does Not Affect Deep Surgical Site Infection Rates in Neuromuscular Scoliosis Surgery.

Surgical site infection (SSI) is a devastating complication in patients with neuromuscular scoliosis (NMS) undergoing posterior spinal instrumented fusion (PSIF) for progressive scoliosis. Incisional negative pressure wound therapy (INPWT) has been used in other surgical fields to reduce SSI. Our purpose was to examine the prophylactic use of INPWT after NMS surgery to decrease SSI. At a single institution, 71 consecutive patients with NMS underwent PSIF from 2015 to 2019. Starting in 2017, all patients with NMS received INPWT postoperatively until discharge. Rates of deep SSI were compared between the two cohorts of patients. Additionally, patient demographic and operative factors such as American Society of Anesthesiologists score, number of levels instrumented, need for an anterior spinal release, need for spinal fusion to pelvis, blood loss, operative time, fluoroscopy time, length of stay, and transfusion requirement were analyzed for potential influence on deep SSI. There was no significant difference in deep SSI rates between patients who received INPWT (2 of 41) and those treated with a standard postoperative dressing (2 of 30; P=1.0). Although INPWT theoretically can stabilize the wound environment and prevent deep SSI, our findings do not support this. More research is needed to evaluate the efficacy of INPWT after PSIF for NMS. [Orthopedics. 2023;46(6):373-378.].

Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies.

BACKGROUND: Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper extremity. Electrodiagnostic studies (EDSs) are often used to confirm diagnosis. However, negative EDSs can present a difficult clinical challenge. The purpose of this study was to determine the functional outcomes and symptom improvement for patients with a clinical diagnosis of CuTS, but with negative EDSs, who are treated surgically. METHODS: Patients who had EDSs before ulnar nerve surgery were identified by means of database search. Chart review was performed on 867 cases to identify those with negative EDSs. Twenty-five ulnar nerve operations in 23 patients were included in analysis. Chart review was performed to record preoperative and postoperative symptoms, physical examination findings, and outcome measures (ie, Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Ulnar Nerve Evaluation). RESULTS: At a mean follow-up period of 20.7 ± 14.9 months, 15 of 25 cases (60.0%) had complete resolution of all preoperative symptoms. All 10 patients who had residual symptoms endorsed improvement in their preoperative complaints. The median preoperative Disabilities of the Arm, Shoulder and Hand score was 40.0 [interquartile range (IQR), 23.9 to 58.0], which significantly decreased to a median of 6.8 (IQR, 0 to 22.7) at final follow-up ( P < 0.01). The median postoperative Patient-Rated Ulnar Nerve Evaluation score was 9.5 (IQR, 1.5 to 19.5). CONCLUSIONS: Patients with CuTS and normal EDSs treated surgically can be expected to have favorable outcomes with respect to symptoms and improvement in functional outcome scores. After ruling out confounding diagnoses, the authors continue to offer surgical intervention for these patients when nonoperative treatment has failed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Distal Radioulnar Joint Osteoarthritis: An Update on Treatment Options.

The distal radioulnar joint (DRUJ), the articulation between the sigmoid notch of the radius and the distal ulna, plays a pivotal role in stability and load bearing and allows for pronation and supination of the forearm. Osteoarthritis (OA) of the DRUJ commonly occurs due to distal radius trauma but may also be the result of conditions such as joint instability, septic arthritis, or primary OA. It is initially managed with conservative therapy, but surgery is often considered when nonoperative methods fail. The surgical approaches available to treat this pathology have grown over the years. The procedures have generally favorable outcomes, each with their own unique complications and considerations. This paper comprises a review of the outcomes and complications for the different procedures commonly used to surgically treat DRUJ OA.

Patient Comprehension of Operative Instructions With a Paper Handout Versus a Video: A Prospective Randomized Control Trial.

PURPOSE: The purpose of this study was to evaluate the efficacy of a video versus that of a paper handout for explaining operative instructions for hand and upper extremity surgeries to patients. We aimed to compare patient performance using a knowledge-based questionnaire. In addition, we aimed to compare how helpful patients found their assigned operative instructions. METHODS: This was a randomized trial of 60 patients undergoing same-day hand and upper extremity surgeries. The patients were randomized to receive educational material outlining operative instructions, either in the form of a video link or a paper handout. At the first postoperative visit, the patients' comprehension of the content was evaluated using a questionnaire. The primary outcomes included the number of questions answered correctly and patient-reported evaluation of the provided instructions on a scale of 1-5. RESULTS: Patients who received video instructions scored higher in the questionnaire than those in the paper instructions group (paper: 58% correct; video: 76% correct). Moreover, patients in the video group were significantly more likely to answer questions pertaining to opioid use correctly. A higher proportion of patients in the video group than in the paper group found the information "extremely" or "very" helpful. CONCLUSIONS: This study found that the patients demonstrated greater comprehension of the operative instructions when these were administered in a video format than when these were administered as a printed handout. In particular, the results suggest that video-based education specifically improves patients' comprehension of proper opioid use. CLINICAL RELEVANCE: There appears to be utility in implementing videos for patient education purposes, particularly in the setting of operative instructions for same-day surgical procedures.

Patient Comprehension of Trigger Finger Concepts Based on Distribution Format: A Randomized Controlled Trial of Handout Versus Video.

BACKGROUND: Patient comprehension is an essential part of optimizing medical outcomes. It is unknown which format is most effective in delivering this information. In addition to a face-to-face conversation, a paper handout is often given as an educational supplement at the conclusion of a visit. Secondary to advances in technology and the ubiquity of the Internet, medical videos have gained popularity. The purpose of this randomized controlled trial was to determine whether the educational material format (paper handout vs video) resulted in a difference in either comprehension of the condition or satisfaction with the delivery of the information. METHODS: Patients aged ≥18 years with a diagnosis of trigger finger were prospectively enrolled and randomized to receive either a paper handout or video link with information regarding the pathophysiology, diagnosis, and treatment of trigger finger. Survey assessments were then distributed, consisting of 7 questions related to trigger finger and 1 question related to patient satisfaction. Continuous data were compared using 2-sample t tests, and categorical data were compared with χ2 tests. Alpha was 0.05. RESULTS: Seventy-one patients were enrolled, and 60 completed their survey (response rate: 85%). The video group had significantly higher comprehension scores (82% vs 71%, P = .04) and significantly higher satisfaction scores (9.4 vs 8.6, P = .02). CONCLUSIONS: Those who received their educational material in a video format had greater comprehension of their condition and higher satisfaction compared with those receiving a paper handout. Medical providers should consider using video formats to provide supplemental educational materials to their patients.

The Effect of Thumb Carpometacarpal Joint Corticosteroid Injections on Outcomes Following Arthroplasty.

BACKGROUND: Prior studies suggest steroid injections may affect infection rates following thumb carpometacarpal joint (CMCJ) arthroplasty. However, it is unclear whether injections prior to CMCJ arthroplasty affect functional outcomes, primarily Quick Disabilities of the Arm, Shoulder, and Hand (qDASH). METHODS: We retrospectively identified patients who underwent thumb CMCJ arthroplasty from 2015 to 2019. Patients who had qDASH scores reported preoperatively, and at 5 and 11 months postoperatively were included. Charts were reviewed for the presence or absence of prior corticosteroid injection to the CMCJ and complications. Delta qDASH was calculated by subtracting the patients' postoperative qDASH scores from the preoperative qDASH scores. RESULTS: In all, 350 CMCJ arthroplasty patients were identified, 177 who had received at least 1 steroid injection and 173 who were steroid-naïve. No significant differences existed in delta qDASH scores postoperatively between the injection and naïve groups at 5 months (28.5 vs 28.6) or 11 months (31.2 vs 31.9). Whereas there were no significant differences in rates of major complications between the 2 groups, minor complications were higher in the injection group (16.4% vs 9.2%). Patients who received more than 3 injections did not have worse 5-month or 11-month delta qDASH scores or complication rates than those with fewer than 3. CONCLUSIONS: Preoperative CMCJ steroid injection status does not affect major complication rates or functional outcomes following CMCJ arthroplasty. However, injections increase the rate of minor complications. The qDASH and complication rates following CMCJ arthroplasty are not affected by receiving greater than 3 injections preoperatively.

The Efficacy of Intra-Articular Versus Extra-Articular Corticosteroid Injections in the Thumb Carpometacarpal Joint.

Purpose: This study evaluated whether the location of steroid deposition (intra-articular vs extra-articular) for thumb carpometacarpal (CMC) joint arthritis affects clinical outcomes. Methods: We prospectively enrolled 102 hands (82 patients) with thumb CMC joint arthritis. Patients received a CMC joint injection with Triamcinolone and radiopaque contrast. Wrist radiographs were used to visualize the injection location. Patients completed Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) questionnaires and visual analog scale (VAS; scale, 1-100) pain scores before injection and then at 1 week and 1, 3, and 6 months after injection. Generalized linear regression models were constructed to identify variables associated with clinical outcomes. Results: The rate of intra-articular injection was 80%. No differences were found between the 2 groups in preinjection DASH or VAS scores. After 1 week, both the intra-articular and extra-articular groups showed improvements of DASH (14.2 and 11.2, respectively) and VAS (15.5 and 15.0, respectively) scores. Although both groups were worse at 3 months, the intra-articular group had significantly lower DASH (26.7 vs 37.5, respectively) and VAS (26.5 vs 39.0, respectively) scores than the extra-articular group. There were no differences between the intra-articular and extra-articular groups for DASH (33.8 vs 42.5, respectively) or VAS scores at 6 months. The intra-articular group maintained significant improvements in outcomes for up to 6 months, while the extra-articular group only maintained them for up to 1 month. The Eaton-Littler classification was found to be a predictor of DASH and VAS scores at 3 and 6 months. Conclusions: Intra-articular injection in the thumb CMC joint provides significantly greater pain relief and functional improvement compared to extra-articular injection at 3 months. Inadvertent extra-articular injection is common and appears to provide short-term pain relief and functional improvement. Some patients receiving intra-articular injections continue experiencing relief for up to 6 months. Type of study/level of evidence: Therapeutic II.

Social Media and the Orthopaedic Surgery Residency Application Process.

INTRODUCTION: Social media use in the residency application process has been on the rise, yet applicant and program director (PD) perspectives in orthopaedic residency have not been explored in depth. Our objective is to evaluate perspectives of orthopaedic residency applicants and PDs on social media usage and its impact on the residency application process. METHODS: Cross-sectional survey study conducted in 2021 with two related, anonymous surveys sent to residency applicants and PDs. One hundred thirteen of 562 (20.1%) applicants to our institution and 29 of 148 (19.6%) PDs listed on the Accreditation Council for Graduate Medical Education (ACGME) website responded to our survey and were included in the analysis. RESULTS: Applicants reported learning about residency programs through Instagram (69.2%), the program website (58.9%), and Doximity (29.9%). Thirty-four percent of applicants reported social media influencing their rank list, with non-training-related posts being the most impactful. PDs reported that 97% of their programs have an official web page, 41% have an active Instagram site, 27% have a Twitter account but none regularly update Doximity. Just over 48% of PDs reported institutional support for online content creation. Financial investment varied, with 35% reporting no spending, and 24% spending over $2501. In response to coronavirus disease 2019 (COVID-19) restrictions, 79% of PDs reported generating increased social media content. DISCUSSION: Social media provides a low-cost but far-reaching opportunity for PDs to recruit residents and highlight their respective programs. Social media content should display the culture and lifestyle of the program, with consistency in content creation. PDs should also ensure accuracy on external sites such as Doximity.

The Effects of Sleeper and Superman Stretches on Time-Zero Shoulder Range of Motion in Collegiate Athletes.

Purpose This study aimed to determine whether prone cross-body adduction (superman stretch) improves range of motion (ROM) more than the sleeper stretch. Methods Collegiate overhead athletes were randomized to either a sleeper group or a superman stretch group. ROM measurements were collected before and after stretches by three orthopedic surgeons. Results We assessed a total of 212 shoulders. Both stretches demonstrated significant improvements in ROM, except horizontal adduction, which only improved in the superman stretch group. Conclusions The superman stretch may be superior in producing immediate improvements in horizontal adduction when compared to the traditional sleeper stretch.

Perspectives on the Orthopaedic Surgery Residency Application Process During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has led to the cancellation of away rotations and other experiences fundamental to orthopaedic surgery residency application. Limited information is available on the experiences of applicants and program directors (PDs) during the COVID-19 pandemic residency application cycle. This study aimed to evaluate the current perspectives of applicants and PDs regarding the orthopaedic surgery residency application process. METHODS: This was a cross-sectional study using 2 independent but similar surveys that addressed multiple aspects of the application process during the COVID-19 pandemic, including perceived effect of virtual experiences. Between February and March 2021, the surveys were distributed to orthopaedic surgery applicants and orthopaedic residency PDs. RESULTS: In total, 113 applicants (20.1%) and 29 PDs (19.6%) completed the survey. Applicants applied to 97.6 programs and received 13.3 interviews. They participated in 2.4 virtual away rotations. In total, 79.3% of programs reported offering some form of virtual opportunity, including virtual away rotations (24.0%), virtual happy hours (64.0%), and virtual conferences (64.0%). Programs offering virtual away rotations hosted 46.8 rotators and only invited back 54.5% for an interview. Applicants were most concerned about the lack of away rotations, the interview, and networking during this cycle, and 51% reported less confidence in matching. The most important factors for influencing applicant rank lists were perceived happiness of residents, resident camaraderie, and geographic location. However, residency program social events were not well replicated in a virtual setting. DISCUSSION: The COVID-19 pandemic presented new challenges for applicants and PDs. Applicants had less clinical exposure and received less interview invites after virtual away rotations. Despite applying to more programs, applicants received fewer interviews than in previous years. The virtual experiences adopted in this cycle did not adequately replicate the social factors that applicants found most important when ranking a program. Even during the COVID-19 pandemic, PDs most highly valued away rotation performance, clinical rotation performance, and board examination scores when offering interviews.

Impending Upper Arm Compartment Syndrome Secondary to Intravenous Fluid Infiltration.

We report the case of an 81-year-old female who developed an upper arm anterior compartment syndrome from the mass effect caused by an infiltrated intravenous access catheter. The patient's anterior compartment became tense and uncompressible, and the patient developed radial nerve palsy. A fasciotomy was performed, resulting in the evacuation of 100 mL of fluid. Over the course of the patient's follow-up, motor and sensory function slowly returned. In atraumatic patients with intravenous access, the development of a tense compartment with developing nerve palsies should warrant workup for possible compartment syndrome due to mass effect. If treated promptly with fasciotomy, the complications of this limb-threatening condition can be minimized or possibly reversed.

Wire Extrusion After Flexor Tendon Repair with a Multifilament Stainless Steel Cable-Crimp Suture System: A Case Report.

CASE: We report the case of a 22-year-old man with a ruptured flexor tendon repair associated with wound drainage. The patient subsequently underwent flexor tendon revision with a multifilament stainless steel cable-crimp suture system. Two years after the revision repair, a blister ruptured over the patient's operative site, exposing the stainless steel wire from the revision repair. The wire was removed, and the patient regained full flexion. CONCLUSIONS: As extrusion of metallic suture material from the skin represents a complication, surgeons should be prepared to recognize this rare complication and to preoperatively counsel patients as to this risk.

Patient Perceptions of COVID-19 Precautions and Their Effects on Experiences With Hand Surgery.

PURPOSE: The purpose of this study is to evaluate patient perceptions of COVID-19 precautions and how these precautions have affected their hand and upper extremity surgery experience. METHODS: We sent an 18-item survey to 1,213 patients who underwent elective hand and upper extremity surgery at 1 academic institution from October 2020 to January 2021. The survey consisted of questions related to patient demographics, treatment delays due to COVID-19, and patient perceptions of COVID-19 precautions. Descriptive statistics were performed to analyze the survey responses. Responses for patients aged 18-50 and 51+ were compared using a chi-square analysis for categorical variables and a Student t-test for continuous variables. RESULTS: Out of 1,213 invitations, 384 survey respondents completed the survey (31.6%). Of the respondents, 16.8% reported delaying medical treatment for an average of 123.2 days because of COVID-19. The preventative measures were found to be adequate by 95% of patients. Only 2.6% of patients reported experiencing surgical delays due to preoperative COVID-19 testing or other COVID-19-related precautions. COVID-19 testing was seen as necessary by 88% of patients, and 74% did not find COVID-19 testing to be a barrier to their surgery. Patients aged 51+ were more likely to delay seeking medical treatment than younger patients (19.3% vs 9.1%, respectively). Furthermore, those that did delay seeking treatment waited longer on average than their younger counterparts (136.1 vs 72.9 days, respectively). CONCLUSIONS: In conclusion, patients undergoing hand and upper extremity surgery typically do not find COVID-19 precautions to be a significant barrier to care and understand their importance. Despite this, many patients, particularly older ones, are delaying medical care for extended periods of time. It is important for hand surgeons to acknowledge their patients' perspectives and work to educate patients on evolving surgical safety guidelines. CLINICAL RELEVANCE: Patient perspectives of current COVID-19 precautions can help inform hand surgeons on areas for continued patient education.

A Study on the Incidence of Hand or Wrist Injuries in CrossFit Athletes.

Purpose The purpose of this study was to investigate the reported rates and characteristics of injuries among CrossFit athletes with specific attention to the hand and wrist. We further sought to identify trends and associations of these injuries by examining demographic data. Methods A questionnaire was created to capture self-reported information on the incidence of hand or wrist injuries and their associations in CrossFit athletes. It was distributed between April 2020 and July 2020 to athletes training at CrossFit affiliated gyms in the New York and Pennsylvania regions. Bivariate logistic regression analysis was used to identify factors correlated with an injury. Results A total of 270 responses (97.5% response rate) were available for final analysis. The median age of respondents was 34 years and 72.2% had been participating in CrossFit for at least two years. CrossFit athletes reported injury rates of 62.2% while engaged in CrossFit training and 20.4% reported an injury specific to the hand or wrist. The majority of hand or wrist injuries occurred after one year of CrossFit training (65.4%). The majority of reported initial injuries occurred to the wrist (75.4%); subsequently, 29.1% reported reinjuring the same region. While 58.2% reported not yet having healed or taking longer than one month to feel fully healed, 72.8% reported returning to unmodified training within one month. Only 15 respondents reported seeking medical attention from a physician for their injury. Physicians generally recommended a training break of over one month, but only two patients reported taking a break this long. Male sex and length of participation in CrossFit were associated with an increased risk of developing a hand or wrist injury. Discussion Hand and wrist injuries represent a significant proportion of injuries among CrossFit athletes. CrossFit practitioners are potentially returning to unmodified training too early following injury, leaving them susceptible to further injury. Physicians and therapists must consider these findings and address both therapies and preventative measures for these types of injuries with their patients.

The Planning Fallacy in the Orthopedic Operating Room.

The planning fallacy posits that humans tend to underestimate the amount of time needed to complete a project and that greater complexity results in a larger difference in that estimation. If this phenomenon is present in the orthopedic operating room, it could lead to negative impacts on patients, their families, and physicians themselves. Nine fellowship-trained orthopedic surgeons at one institution were asked to give an estimate of their operative and total room times over the course of three months. Over 759 cases, the surgeons underestimated the total room times by 17.3% (p = 0.034) but did not underestimate their operative times (p = 0.590). The surgeons improved estimation of their operative time for all cases from 13.6 to 10.9 minutes of their actual time (p = 0.031) by comparing the absolute difference for the surgeons' first 25% to the last 25% of cases. Procedures performed at the hospital underestimated operative and total room times by 8.9% and 7.4% compared to the ambulatory center, which overestimated operative times by 6.0% and underestimated total room times by 3.8% (p < 0.001). We found that the planning fallacy does exist in certain situations within the orthopedic operating room.

Techniques for Injection of the Scaphotrapezium-Trapezoid Joint Without Image Guidance.

Purpose: Scaphotrapezium-trapezoid (STT) joint arthritis is one of the most common forms of wrist arthritis. Conservative management often involves corticosteroid injection. Despite this, there is a scarcity of literature on palpation-guided injection techniques for the STT joint. We aimed to determine a standardized palpation-guided injection method that is easily reproducible and poses minimal risk to local anatomic structures. Methods: Six fresh-frozen cadaveric upper extremity specimens were tested. Access to the STT joint was attempted with dorsal, volar, and radial approaches. Fluoroscopy was used to confirm accurate placement within the joint. Needle placement was documented in relation to the surrounding soft tissue and bony landmarks were measured with a ruler, and the angle of the needle entry was recorded using a goniometer. The cadavers were carefully dissected to identify the surrounding neurovascular structures at risk of injury. Results: To access the STT joint with the dorsal approach, the needle was angled at 90º and inserted one-third of the distance from the prominence of the base of the second metacarpal to Lister tubercle. No neurovascular structures were found in the immediate vicinity of the needle. For the volar approach, the needle was angled at 65º and inserted at the distal wrist crease, 1 cm ulnar to the radial border of the wrist, in line with the second metacarpal. The volar branch of the radial artery was at risk with this approach. For the radial approach, the needle was angled at 60º and inserted immediately dorsal to the extensor pollicis brevis tendon, midway between the radial styloid and the prominence of the thumb metacarpal base. The dorsal branch of the radial artery was at risk with this approach. Conclusions: In a clinical setting where fluoroscopy or ultrasound is not readily available, the dorsal approach may allow for safe and accurate placement of the injectate into the STT joint. Type of study/level of evidence: Therapeutic IV.

Coding Practices in Hand Surgery and Their Relationship to Surgeon Compensation Structure.

Purpose: To evaluate the coding practices of hand surgeons in the American Society for Surgery of the Hand with respect to practice compensation structure using common, representative hand surgery cases. Methods: We developed a survey of demographic factors and 4 commonly encountered hypothetical hand surgery cases. This survey was emailed to the members of the American Society for Surgery of the Hand. Respondents were asked to code these cases using prepopulated applicable Current Procedural Terminology codes or any other codes of their choosing. The membership responses were then compared with those of 3 independent orthopedic coders. Results: Of the 4,477 invitations sent, a total of 421 (9.4%) respondents completed the survey. There was notable heterogeneity in the Current Procedural Terminology code choices for the trapeziectomy and distal radius fracture cases. Physicians with a collections-based model coded for significantly higher work-related value units on average compared with the fixed salary- and relative value unit-based physicians for the trapeziectomy case (14.41 vs 13.65 and 13.67, respectively; P < .05). The 3 independent coders all chose a single Current Procedural Terminology code for the carpal tunnel release, distal radius fracture, and scaphoid nonunion cases. The percentages of physician responses that selected only these codes were 84.6% (carpal tunnel release), 61.0% (distal radius fracture), and 73.6% (scaphoid nonunion). Physicians were less likely to code in line with the independent coders for the distal radius fracture case compared with other cases, particularly those physicians with a collections-based model. Conclusions: The compensation model may be associated with coding practices for more complicated hand cases. The additional work-related value units potentially billed can quickly accumulate for frequently performed procedures. This wide variation supports a need for more frequent and accessible communication and education on coding practices in hand surgery. Clinical relevance: Improved communication and education regarding appropriate coding practices as well as easily accessible reference material may assist in minimizing coding discrepancies for surgical hand procedures.