Nontraumatic Pseudoaneurysm of the Deep Palmar Arch in a 10-Month-Old Infant: A Case Report.

CASE: Pseudoaneurysms of the hand are rare among the adult population and even more rare in pediatric patients. We report a case of a 10-month-old boy who presented with a nontraumatic pseudoaneurysm of the deep palmar arch, likely of congenital etiology. Magnetic resonance imaging and angiography identified the growing left hand palmar mass. Surgical excision without the need for vascular reconstruction was performed successfully with no recurrence or complications at 1-year follow-up. CONCLUSION: Surgical excision is an effective treatment for large or symptomatic palmar pseudoaneurysms of likely congenital origin. Vascular reconstruction after excision must be considered on a case-by-case basis to ensure adequate hand perfusion.

Erratum: 404 Mechanisms of a Dynamic Stability Protocol for Persons with Thumb Osteoarthritis - CORRIGENDUM.

[This corrects the article DOI: 10.1017/cts.2024.351.].

The Effects of Radial Longitudinal Deficiency on Long-Term Use of the Thumb in Pediatric Patients Following Index Pollicization.

PURPOSE: To assess the effect of radial longitudinal deficiency on the function of pollicized digits as determined by the Thumb Grasp and Pinch (T-GAP) assessment. METHODS: We retrospectively evaluated 25 hands with thumb hypoplasia that underwent index finger pollicization. Patients were followed for an average of 10.4 years. Hands were divided by severity into two groups: no or mild radial longitudinal deficiency (RLD) (Group 1 = 16) and moderate to severe RLD (Group 2 = 9). We collected demographic information and completed physical examination measures, including hand strength, elbow, wrist, and hand range of motion, the Kapandji opposition score, active grasp span, and T-GAP total score. RESULTS: Patients with moderate to severe forms of RLD had stiffer long fingers, lower Kapandji opposition scores, and limited active and passive range of motion for elbow flexion, wrist ulnar deviation, and pollicized thumb interphalangeal flexion. They had shorter forearms, decreased active grasp span, and fewer thumb creases at the interphalangeal thumb joint. In addition, the T-GAP total score was significantly lower when comparing the two groups. Children with mild dysplasia were able to achieve 32% of age-matched normal grasp strength. Patients with more severe radial dysplasia averaged 17% less grasp strength compared with children with mild dysplasia. Patients with moderate to severe RLD also had lower T-GAP total scores and strength measurements if they had limited wrist ulnar deviation. CONCLUSIONS: Individuals with moderate to severe RLD have unique anatomical factors that affect outcomes after pollicization. These individuals use their thumbs for fewer activities, have weaker grasp, and retain more primitive grasp patterns compared with those who have milder forms of RLD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Syndromic Involvement of Patients Presenting With Congenital Upper Limb Anomalies: An Analysis of 4,317 Cases.

PURPOSE: This study investigated the patterns of syndromic involvement for patients with congenital upper limb anomalies (CULAs). We hypothesize that patients with CULAs will present with predictable syndromic patterns. METHODS: This retrospective study queried the multicenter Congenital Upper Limb Differences (CoULD) Registry. Of the 4,317 patients enrolled, 578 (13%) reported one or more syndromes. Syndromes were confirmed to be recognized by the Online Mendelian Inheritance in Man. Demographics were reviewed and compared with the full CoULD registry group. Syndromes reported by five or more patients were examined to determine the type of CULA according to Oberg/Manske/Tonkin classifications. RESULTS: Of the 578 children with one or more reported syndromes, 517 had Online Mendelian Inheritance in Man recognized syndromes (cohort A), In cohort A, 58 syndromes were each represented by a single patient within the registry. Forty-eight syndromes in cohort A were reported by two or more patients, which accounted for 461 of the total patients with reported syndromes. However, VACTERL and Poland syndromes were the most commonly reported syndromes. Patients with CULAs and syndromes frequently exhibited bilateral involvement (61%), compared with the entire CoULD group (47%) and other orthopedic (50%) and medical conditions (61%) compared with the entire CoULD group (24% and 27%, respectively). Additionally, they exhibited a lower frequency of family history of a congenital orthopedic condition (21%) or a family member with the same CULA (9%) compared with the entire CoULD group (26% and 14%, respectively). CONCLUSIONS: Associated syndromes were recorded in 578 patients (13%) in the CoULD registry as follows: 58 syndromes represented by a single patient, 48 by 2 or more patients, and 23 syndromes by 5 or more patients. Rare syndromes that are only represented by a single patient are more likely to be unknown by a pediatric hand surgeon, and consultation with a geneticist is advised. TYPE OF STUDY/LEVEL OF EVIDENCE: Differential Diagnosis/Symptom Prevalence Study IV.

Congenital Upper-Limb Differences: A 6-Year Literature Review.

➤ The Oberg-Manske-Tonkin (OMT) classification of congenital hand and upper-limb anomalies continues to be refined as our understanding of the genetic and embryonic etiology of limb anomalies improves.➤ We have conducted an evaluation of graft and graftless techniques for syndactyly reconstruction; strengths and drawbacks exist for each technique.➤ Treatment for radial longitudinal deficiency remains controversial; however, radialization has shown promise in early follow-up for severe deformities.➤ Recent emphasis on psychosocial aspects of care has demonstrated that children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability.

AOA Critical Issues: Gender Justice in Academic Medicine: What It Might Look Like in Orthopaedic Surgery.

ABSTRACT: As the number of women entering medicine has increased, so has the number of women entering orthopaedics; however, many orthopaedic programs struggle to create an equitable space for women, particularly in leadership. Struggles experienced by women include sexual harassment and gender bias, lack of visibility, lack of well-being, disproportionate family care responsibilities, and lack of flexibility in the criteria for promotions. Historically, sexual harassment and bias has been a problem faced by women physicians, and often the harassment continues even when the issue has been reported; many women find that reporting it results in negative consequences for their career and training. Additionally, throughout medical training, women are less exposed to orthopaedics and lack the mentorship that is given to their colleagues who are men. The late exposure and lack of support prevent women from entering and advancing in orthopaedic training. Typical surgery culture can also result in women orthopaedic surgeons avoiding help for mental wellness. Improving well-being culture requires systemic changes. Finally, women in academics perceive decreased equality in promotional considerations and face leadership that already lacks representation of women. This paper presents solutions to assist in developing equitable work environments for all academic clinicians.

Do Nails and Nubbins Matter? A Comparison of Symbrachydactyly and Transverse Deficiency Phenotypes.

PURPOSE: Transverse deficiency (TD) and symbrachydactyly may be difficult to distinguish due to shared phenotypes and a lack of pathognomonic features. The 2020 Oberg-Manske-Tonkin classification update modified these anomalies to include "with ectodermal elements" for symbrachydactyly and "without ectodermal elements" for TD as a defining differentiating characteristic. The purpose of this investigation was to characterize ectodermal elements and the level of deficiency and to examine whether ectodermal elements versus the level of deficiency was a greater determining factor for Congenital Upper Limb Differences (CoULD) surgeons making the diagnosis. METHODS: This was a retrospective review of 254 extremities from the CoULD registry with a diagnosis of symbrachydactyly or TD by pediatric hand surgeons. Ectodermal elements and the level of deficiency were characterized. A review of the registry radiographs and photographs was used to classify the diagnosis and compare it with the diagnosis given by the pediatric hand surgeons. The presence/absence of nubbins versus the level of deficiency as the determining factor to differentiate the pediatric hand surgeons' diagnosis of symbrachydactyly (with nubbins) versus TD (without nubbins) was analyzed. RESULTS: Based on radiographs and photographs of the 254 extremities, 66% had nubbins on the distal end of the limb; of the limbs with nubbins, nails were present on 51%. The level of deficiency was amelia/humeral (n = 9), <1/3 transverse forearm (n = 23), 1/3 to 2/3 transverse forearm (n = 27), 2/3 to full forearm TD (n = 38), and metacarpal/phalangeal (n = 103). The presence of nubbins was associated with a four times higher likelihood of a pediatric hand surgeon's diagnosis of symbrachydactyly. However, a distal deficiency is associated with a 20-times higher likelihood of a diagnosis of symbrachydactyly than a proximal deficiency. CONCLUSIONS: Although both the level of deficiency and ectodermal elements are important, the level of deficiency was a greater determining factor for a diagnosis of symbrachydactyly versus TD. Our results suggest that the level of deficiency and nubbins should both be described to help provide greater clarity in the diagnosis of symbrachydactyly versus TD. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Reliability of the Masada Classification for Forearm Involvement in Patients With Hereditary Multiple Osteochondromas (HMO).

BACKGROUND: Classifications describing forearm lesions in patients with Hereditary Multiple Osteochondromatosis (HMO) have been used to recommend surgical intervention and stratify outcomes; however, there is no consensus on which classification offers greater reliability. The purpose of this study was to determine the reliability of the Masada classification and newer classifications among pediatric hand surgeons. METHODS: One hundred one patients with HMO between June 2014 and October 2019 were enrolled in the Congenital Upper Limb Differences (CoULD) Registry. Of those, 67 patients with 101 forearms were included. Four pediatric hand surgeons from the CoULD study group undertook an online evaluation. Each rater classified radiographs according to the Masada classification. Six weeks later, raters were asked to reclassify images according to the Masada, Gottschalk, and Jo classifications. Rater agreement for these classifications was assessed by estimating Fleiss kappa along with a 95% CI. RESULTS: Interrater agreement for Masada classification after the first reading was poor (κ=0.35; 95% CI=0.30-0.41) across all raters. Interrater agreement across the 4 raters decreased for the Masada classification from the first to the second reading (κ=0.35 vs 0.21; P <0.001). Intrarater agreement for the Masada classification ranged from 0.32 to 0.63 from the first to the second study reading. Gottschalk and Jo classifications yielded significantly better interrater agreement compared with Masada (κ=0.43 vs 0.21; P <0.001). Unclassifiable cases were highest in the Masada classification (34% to 44%) and lower in the Jo (17%) and Gottschalk (14%) classifications. CONCLUSION: Despite wide use, the Masada classification was found to have low reliability when classifying forearm deformities in HMO. Gottschalk offered more options for location, yet lacked deformity description including radial head dislocation. Jo classification offered more locations than Masada and incorporated radial head dislocation in some patterns. Based on the shortcomings in all 3 classification systems, the development of a more inclusive and reliable classification is warranted. LEVEL OF EVIDENCE: Level II; Diagnostic.

Complications in the 2-Year Postoperative Period Following Pediatric Syndactyly Release.

PURPOSE: Syndactyly surgical release is one of the most common congenital hand surgeries performed by pediatric hand surgeons. The purpose of our study was to evaluate the complications associated with syndactyly release and determine factors that correlate with higher complication rates within the 2-year postoperative period. METHODS: A retrospective chart review was completed for patients who underwent syndactyly release at a single pediatric center between 2005 and 2018. Patients were included if they had a diagnosis of syndactyly and underwent surgical release, and excluded for a diagnosis of cleft hand, incomplete surgical documentation, surgery performed at an outside institution, or follow-up care that did not extend beyond the first postoperative visit. Complications were classified using the Clavien-Dindo (CD) system. RESULTS: Fifty-nine patients met the inclusion criteria, which included 143 webs released in 85 surgeries. A total of 27 complications occurred for the 85 surgeries performed. The severity of complications was CD grade I or II in 23% of surgeries, most commonly unplanned cast changes, and CD grade III in 8% of surgeries. No CD grade IV or V complications occurred. The CD grade III complications included 6 reoperations. The complication rate was higher when performing >1 syndactyly release per surgery. It also was higher for patients undergoing >1 surgical event. Rates of complication per surgery were similar between patients with multiple surgeries compared with those with a single surgery. Concomitant diagnoses and complexity of syndactyly was not associated with a higher complication rate. CONCLUSIONS: Syndactyly release was associated with a complication rate of 31% per surgical event with 44% of these complications related to unplanned cast changes and 8% of complications that required admission or reoperation. Risk factors for complications following syndactyly release include >1web operated on per surgery and undergoing >1 surgical event. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Orthopaedic Society Leadership Diversity and Academic Participation: Where Do We Stand Now?

BACKGROUND: In the United States, female and minority representation in the field of orthopaedic surgery remains low, and there are few reports regarding orthopaedic society leadership composition, selection criteria, and academic participation. We aimed to determine the demographic composition of national orthopaedic societies and report the academic participation metrics of leadership. METHODS: This was a mixed-methods study using surveys and publicly available data from national orthopaedic societies for the 2020 to 2021 year. Twenty-four orthopaedic society websites were queried for their transparency in leadership selection and demographic information, including sex, racial, and ethnic composition of overall society and board membership. Data were collected regarding the academic participation of board leadership. RESULTS: In total, 19 (79%) of the 24 national orthopaedic societies publish survey data regarding sex and racial demographics. One society elected not to participate, and there was no response from 4 others. Sixteen (89%) of the societies collect sex-related data from their membership, and 19 (100%) report sex-related data for their board members. Five (28%) collect data regarding the race and ethnicity of their general membership, and 10 (53%) report data regarding the race and ethnicity of board members. The average membership was 89% male and 11% female, and the leadership boards were 86% male and 14% female. In the societies that reported on race and ethnicity, on average, 80% of the members were White and 85% of the board members were White. Few societies (13%) publicly list their presidential nominating criteria, and none list their criteria for nonpresidential-line positions. Female sex and ≤10 years in practice were significantly associated with lower Hirsch index (h-index) scores, but these differences dissipated beyond 10 years. CONCLUSIONS: There is a lack of sex, racial, and ethnic diversity in orthopaedic society leadership. More robust recording of these data by societies can help track improvements in diversity among members and leaders. Academic participation may be one component of leadership selection, but other factors play an important role. Overall transparency of leadership selection criteria could be clarified among orthopaedic societies.

American Board of Orthopaedic Surgery's Initiatives Toward Competency-Based Education.

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

Does the Preferred Study Source Impact Orthopedic In-Training Examination Performance?

OBJECTIVE: This study examines the role of electronic learning platforms for medical knowledge acquisition in orthopedic surgery residency training. This study hypothesizes that all methods of medical knowledge acquisition will achieve similar levels of improvement in medical knowledge as measured by change in orthopedic in-training examination (OITE) percentile scores. Our secondary hypothesis is that residents will equally value all study resources for usefulness in acquisition of medical knowledge, preparation for the OITE, and preparation for surgical practice. DESIGN: 9 ACGME accredited orthopedic surgery programs participated with 95% survey completion rate. Survey ranked sources of medical knowledge acquisition and study habits for OITE preparation. Survey results were compared to OITE percentile rank scores. PARTICIPANTS: 386 orthopedic surgery residents SETTING: 9 ACGME accredited orthopaedic surgery residency programs RESULTS: 82% of participants were utilizing online learning resources (Orthobullets, ResStudy, or JBJS Clinical Classroom) as primary sources of learning. All primary resources showed a primary positive change in OITE score from 2018 to 2019. No specific primary source improved performance more than any other sources. JBJS clinical classroom rated highest for improved medical knowledge and becoming a better surgeon while journal reading was rated highest for OITE preparation. Orthopedic surgery residents' expectation for OITE performance on the 2019 examination was a statistically significant predictor of their change (decrease, stay the same, improve) in OITE percentile scores (p<0.001). CONCLUSIONS: Our results showed that no specific preferred study source outperformed other sources. Significantly 82% of residents listed an online learning platform as their primary source which is a significant shift over the last decade. Further investigation into effectiveness of methodologies for electronic learning platforms in medical knowledge acquisition and in improving surgical competency is warranted.

Do Orthopaedic In-Training Examination Scores Predict the Likelihood of Passing the American Board of Orthopaedic Surgery Part I Examination? An Update With 2014 to 2018 Data.

INTRODUCTION: Previous research shows a correlation in performance between the Orthopaedic In-Training Examination (OITE) and the American Board of Orthopaedic Surgery (ABOS) Certifying Examination Part I; however, these studies are not current, with the most recent data from 2009. The purpose of this study was to update the relationship between the OITE and ABOS Part I scores with the five most recent nationwide cohorts of Part I scores and their corresponding OITE scores. METHODS: The American Academy of Orthopaedic Surgeons provided the results for each resident taking the OITE from 2013 to 2017. The ABOS provided the results for each resident taking the Part I examination from 2014 to 2018. These two datasets were matched at the individual level and analyzed. RESULTS: Between 2014 and 2018, 3,502 first-time test-takers were present for the ABOS Part I Examination. A 96.6% pass rate was noted (3,383 of 3,502). A statistically significant correlation between the OITE score and ABOS Part I score was observed at all levels of training: postgraduate year (PGY) 1 r = 0.380, PGY2 r = 0.463, PGY3 r = 0.498, PGY4 r = 0.504, and PGY5 r = 0.504 (P < 0.001 for all correlations). CONCLUSION: The OITE scores continue to correlate with the ABOS scores and the pass rate for the ABOS with moderate strength correlation. However, although a correlation of the examinations exists when evaluated as a group, the predictive value of the OITE for passing the Part I examination for any specific individual is far from perfect. Individuals with PGY5 OITE percentile scores less than 10 pass the Part I examination, and individuals with PGY5 OITE percentile scores greater than 90 fail the Part I examination.

A 15-Year Report on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States.

This study was undertaken to update reports from 2004 to 2005 through 2008 to 2009, and 2009 to 2010 through 2013 to 2014, including 5 additional years of GME Track data. Our hypothesis is there have been no significant changes during the past 5 years in the distribution of Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics residency programs that train female residents, compared with the previous 10 years. METHODS: Data for ACGME-accredited orthopaedics residency training programs in the United States were analyzed for 5 consecutive academic years (2014-2015 through 2018-2019). Programs were classified as having no women, 1 woman, 2 women, or greater than 2 women in training. Programs were analyzed for percentage of female residents and classified as having above the national average (>20%), similar to the national average (between 10 and 20%), or below the national average (<10%). RESULTS: Analysis of the original 5 years (2004-2009) compared with the most recent data (2014-2019) demonstrated a statistically significant improvement in the number of programs training women (p < 0.001). From 2004 to 2009 to 2014 to 2019, the absolute number and percent of female trainees have increased (p < 0.001). Similar analysis of the middle 5 years (2009-2014) compared with the most recent 5 years (2014-2019) did not demonstrate a statistically significant change (p = 0.12). From 2014 to 2019, residency programs in the United States continue to train women at unequal rates: 37 programs had no female trainees, while 53 programs had >20% female trainees during at least one of these 5 years. CONCLUSIONS: Female medical students continue to pursue orthopaedics at rates lagging behind all other surgical specialties. Not all residency programs train women at equal rates. If the rate of training of female residents over the past 15 years were projected over time, we would not achieve 30% women within orthopaedics residency training programs until approximately 2060. LEVEL OF EVIDENCE: III.

Trend and Economic Implications of Implant Selection in the Treatment of Intertrochanteric Hip Fractures: A Review of the American Board of Orthopaedic Surgery Database From 2007 to 2017.

INTRODUCTION: Intertrochanteric (IT) fractures are estimated to burden the healthcare system six billion dollars annually. Previous studies have documented a trend of early-career orthopaedic surgeons favoring intramedullary nails (IMNs) for these fractures, despite multiple randomized controlled trials demonstrating no evidence for improved patient outcomes when compared with sliding hip screws (SHSs). The purpose of this study was to report the trend of implant utilization for IT fracture fixation from 2007 to 2017. METHODS: The American Board of Orthopaedic Surgery (ABOS) Part II (oral) database was used to identify IT fractures (International Classification of Diseases, 9th revision, code 820.21 or 820.31, and 10th revision, code S72.14) over a 10-year period (2007 to 2017). The cases were categorized by IMN or SHS fixation by surgeon-reported Current Procedural Terminology codes. Utilization of the devices was analyzed according to year, and the implants were compared for outcomes, complications, and cost. RESULTS: As of 2017, 92.4% of IT fractures were being fixed through IMN, representing a 49.1% increase in the number of IMN devices used during the course of this study. SHS had significantly lower medical complication rate (21.3%) and readmittance rate (4.0%) compared with the IMN (medical complication: 26.9%; P < 0.01) (readmittance rate: 5.4%; P = 0.02). SHS also had significantly lower rates of anemia (5.2%) and patient expiration (4.8%) compared with IMN (anemia: 10.2%; P < 0.01) (patient expiration: 6.1%; P = 0.01). Overall surgical complication rates, reoperative rates, and anesthetic complications did not differ between constructs. A cost differential of $671,812 was found from the 2007-projected distribution, which rose to $3,911,211.00 across the entire 11-year duration of the study for the population. DISCUSSION: Early-career orthopaedic surgeons continue to use a more expensive implant for IT fractures despite limited evidence for improved outcomes. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Study.

COVID-19: Impact on Orthopaedic Graduate Medical Education in the U.S.: AOA Critical Issues Symposium.

ABSTRACT: The COVID-19 crisis has challenged the U.S. health-care system in a variety of ways, including how we teach and train orthopaedic surgery residents and fellows. During the spring of 2020, the cessation of all elective surgical procedures and the diminished number of outpatient visits challenged graduate medical education. While residency programs in less affected areas may not have had to make many dramatic adjustments, some of those located in pandemic hotspots had to redirect trainees from orthopaedic rotations to COVID-19 units. No matter the region, the time that trainees have spent in rotations has been altered, and absences have occurred due to quarantines. This symposium summarizes the impact of restrictions related to the COVID-19 pandemic on residency and fellowship programs from the perspectives of the Accreditation Council for Graduate Medical Education (ACGME), a program director, and a graduating resident. Although new opportunities for virtual curricula, virtual surgical simulation, and virtual interviews have been innovated, residency programs and residents report primarily a negative effect from the pandemic due to decreased surgical volumes and the limitation of patient-care experiences. Ultimately, program directors have an obligation to the program, the trainee, and the general public to graduate only those residents and fellows who are truly prepared to practice independently; they have the responsibility of making the final decision regarding graduation. The COVID-19 pandemic has continued to underscore the need for competency-based medical education. Assessing competency includes evaluation of the knowledge, the operative skills, the nonoperative patient-care skills, and the professional behavior of each and every individual graduating from orthopaedic residency and fellowship training programs. A hybrid model for time and competency-based training, with established national standards not only for accreditation for our training programs but also for board certification of our graduating residents, was enhanced by the COVID-19 pandemic and is highlighted in this symposium.

Cost Comparison of Botulinum Toxin Injections Versus Surgical Treatment in Pediatric Patients With Cerebral Palsy: A Markov Model.

PURPOSE: The purpose of this study was to compare the cost-effectiveness of surgical release to botulinum toxin injections in the treatment of upper-extremity (UE) cerebral palsy (CP). METHODS: A Markov transition-state model was developed to assess the direct and indirect costs as well as accumulated quality-adjusted life-years associated with surgery (surgery group) and continuous botulinum toxin injections (botulinum group) for the treatment of UE CP in children aged 7 to 12 years. Direct medical costs were obtained from institutional billing departments. The number of parental missed workdays associated with each treatment was estimated and previously published regressions were used to calculate indirect costs associated with missed work. Total costs, cost-effectiveness, and incremental cost-effectiveness ratios were calculated. Incremental cost-effectiveness ratios and willingness to pay thresholds were used to make decisions regarding society's willingness to pay for the incremental cost of each treatment given the incremental benefit. RESULTS: The surgery group demonstrated lower direct, indirect, and total costs compared with the botulinum group. Direct costs were $29,250.50 for the surgery group and $50,596.00 for the botulinum group. Indirect costs were $9,467.46 for the surgery group and $44,428.60 for the botulinum group. Total costs were $38,717.96 for the surgery group and $95,024.60 for the botulinum group, a difference of $56,306.64. The incremental cost-effectiveness ratio was -$42,019.88, indicating that surgery is a less costly and more effective treatment and that botulinum injections fall outside the societal willingness to pay threshold. Excluding indirect costs associated with parental missed work during home occupational therapy did not have a significant impact on the model. CONCLUSIONS: Surgery is associated with lower direct, indirect, and total costs, as well as a greater number of accumulated quality-adjusted life-years. Surgery provides a greater benefit at a lower cost, which suggests that botulinum injections should be used sparingly in this population. Treatment with surgery could represent savings of $5.6 to $11.3 billion annually in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis II.

A Comparative Analysis of 150 Thumb Polydactyly Cases from the CoULD Registry Using the Wassel-Flatt, Rotterdam, and Chung Classifications.

PURPOSE: Three commonly used classifications for thumb polydactyly are the Wassel-Flatt, Rotterdam, and Chung. The ideal classification system would have high validity and reliability and be descriptive of the thumb anomaly. The purposes of this investigation were to (1) compare the inter- and intrarater reliability of these 3 classifications when applied to a large sample of patients enrolled in the Congenital Upper Limb Differences (CoULD) Registry and (2) determine the prevalence of radial polydactyly types when using the various classifications in a North American population. METHODS: Inter- and intrarater reliability were determined using 150 cases of radial polydactyly presented in a Web-based format to 7 raters in 3 rounds, a preliminary training round and 2 observation rounds. Raters classified each case according to the Wassel-Flatt, Rotterdam, and Chung classifications. Inter- and intrarater reliability were evaluated with the intraclass correlation coefficient (ICC) calculated using 2-way random measures with perfect agreement. RESULTS: For Wassel-Flatt, both the interrater (ICC, 0.93) and the intrarater reliability (ICC, 0.91) were excellent. The Rotterdam classification had excellent reliability for both interrater reliability (ICC, 0.98) and intrarater reliability (ICC, 0.94), when considering type alone. Interrater analysis of the additional subtypes demonstrated a wide range of reliabilities. The Chung classification had good interrater (ICC, 0.88) and intrarater reliability (ICC, 0.77). Within the Wassel-Flatt classification, the most frequent unclassifiable thumb was a type IV hypoplastic thumb as classified by the Rotterdam classification. CONCLUSIONS: The Wassel-Flatt and Rotterdam classifications for radial polydactyly have excellent inter- and intrarater reliability. Despite its simplicity, the Chung classification was less reliable in comparison. The Chung and Rotterdam classification systems capture the hypoplastic subtypes that are unclassifiable in the Wassel-Flatt system. Addition of the hypoplastic subtype to the Wassel-Flatt classification (eg, Wassel-Flatt type IVh) would maintain the highest reliability and classify over 90% of thumbs deemed unclassifiable in the Wassel-Flatt system. CLINICAL RELEVANCE: The Wassel-Flatt and Rotterdam classifications have excellent inter-and intrarater reliability for the hand surgeon treating thumb polydactyly. Addition of a hypoplastic subtype to the Wassel-Flatt (Type 4h) allows classification of most previously unclassifiable thumbs.

Defining Features of Hand Anomalies in Severe Thumb Hypoplasia: A Classification Modification.

PURPOSE: To investigate morphologic hand anomalies in children with severe but unclassifiable forms of thumb hypoplasia and radial-sided hand deficiency. METHODS: We identified 15 extremities in 13 patients with severe thumb hypoplasia and associated absent radial-sided digits through the Congenital Upper Limb Differences registry. All patients had forearm involvement. Medical records, clinical photographs, and radiographs were evaluated. Radial longitudinal deficiency (RLD) and thumb hypoplasia were classified according to the Bayne and Klug classification and modified Blauth classification, respectively. Unusual or defining associated hand characteristics were identified and categorized. RESULTS: The most common type of forearm abnormality was absence of the radius (Bayne and Klug type IV), which was present in 10 extremities in the cohort. All 15 extremities had absent thumbs with loss of additional digits. In 6 patients, RLD was part of a syndrome (46%). CONCLUSIONS: Severe forms of thumb hypoplasia in RLD are uncommon. We propose a further modification of the Blauth classification of thumb hypoplasia, type VI, for improved communication regarding this severe type of radial deficiency involving the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.