Upper-extremity Surgeon Research Articles

Development of International Quality Measures Targeting Low-Value Care in Hand Surgery.

Low-value care, defined as care in which there is no evidence of benefit, increases the risk of harm, or adds unnecessary costs, persists in hand and upper extremity care globally. To date, there are no quality measures to measure low-value care for a global setting. We aimed to develop international quality measures that are important, feasible, usable, and scientifically acceptable for reducing low-value care in hand surgery. We performed a literature review to identify areas of potential low-value care for hand surgery. A consortium of 11 United States-based surgeons with experience in hand and upper-extremity surgery and/or quality measure development completed a modified Research and Development (RAND)/ University of California, Los Angeles (UCLA) Delphi Appropriateness process to evaluate the importance, feasibility, usability, and scientific acceptability of 10 candidate quality measures to reduce low-value hand surgical care. A modified RAND/UCLA Delphi Appropriateness process was subsequently conducted that included a panel of 20 international hand surgeons who voted on the same 10 measures using the same voting criteria. Panelist agreement or disagreement was assessed using predetermined criteria. United States and international panelists achieved agreement on the four criteria for five of the 10 measures; thus, these five measures were deemed valid. These measures include minimizing the unnecessary use of immobilization for fifth metacarpal neck fractures, postinjury imaging of distal radius fractures, perioperative antibiotics for soft tissue hand surgery, pre-operative testing, and opioid use after hand surgery. Two measures were deemed valid by the US panelists only, and two measures were deemed valid by the international panel only. United States- and international-based hand and upper-extremity surgeons achieved consensus on an international quality measure portfolio to reduce low-value care in hand surgery, which may vary in practices settings globally. These quality measures may be used to reduce low-value care in many types of health systems globally.

Assessing Long-Term Outcomes after Operative Management of Elbow Stiffness Secondary to Heterotopic Ossification.

Heterotopic ossification (HO) of the elbow resulting in limited motion is a relatively uncommon condition often caused by burns, trauma, and central nervous system injuries. This retrospective study presents the long-term outcomes of 51 cases of elbow HO treated with surgical excision and regimented postoperative rehabilitation protocol. A retrospective case series was conducted on 48 patients (51 elbows) who underwent surgical excision of elbow heterotopic ossification. All procedures were performed in the inpatient setting at an Academic Level I Trauma Center between September 1999 and August 2022 by fellowship-trained upper extremity surgeons. Patient demographics and case characteristics such as age, gender, mechanism of injury, and comorbidities were collected for comparison. Long-term follow-up examinations were elbow flexion-extension arcs, pronosupination arcs, Visual Analog Scale (VAS) pain scores, and Mayo Elbow Performance Scores (MEPS). Patients were followed for a minimum of 2 years with an average follow-up of 8 years (range, 2-24 years). The median flexion-extension arc at final follow-up was 110° (95°-130°), which was maintained at 85% of the intraoperative arc achieved. Pronosupination arc at final follow-up was 170° (105°-180°), which was maintained at 97% of intraoperative levels. The median reported MEPS and VAS scores were 80 (70-93) and 2 (0-4), respectively. Although it wasn't statistically significant, patients diagnosed with type II diabetes had the worst flexion-extension arcs at final follow-up and highest complication rates compared to other risk factors. Surgical excision coupled with HO prophylaxis and a regimented rehabilitation program resulted in a lasting improvement in functional outcomes for patients with elbow dysfunction secondary to heterotopic ossification at long term follow-up. Overall, patients maintained substantial reductions in pain, improvement in elbow range of motion, and increased overall elbow function.

A Survey of Upper Extremity Musculoskeletal Ultrasound Use in a Surgical Practice.

Purpose: The purpose of this study is to gather the practices and perceptions among upper extremity surgeons regarding the use of musculoskeletal ultrasound for diagnostic and therapeutic intervention. Methods: A 36-question survey was developed from a literature review and author consensus. This survey was then piloted among a small group of hand surgeons prior to distribution. The survey included respondent characteristics, use of ultrasound in their current practice, referral patterns for ultrasound, and interest in incorporating ultrasound into practice and residency training. The refined survey was distributed to the Canadian Society of Plastic Surgeons, and Wrist and Elbow Society of Canada, as well as plastic surgery training programs. A reminder email was sent at 3 weeks and again at 8 weeks. Results: There were 152 responses after 505 survey invitations (30% response rate). Of these responses, 140 were complete (92%). Diagnostic ultrasound was used by 16 respondents (11%) for a myriad of pathologies. Only 5% used ultrasound for guided injections in a clinic or office setting. Money, time, lack of training, and lack of billing code were the major barriers to ultrasound implementation for 124 (89%) hand surgeons. Most respondents (84%) believe that ultrasound training should be incorporated into residency training. Ninety-one respondents (60%) are interested or very interested in incorporating ultrasound into their current practice. Conclusions: Ultrasound is a valuable resource that is seldom used as a point of care by Canadian hand surgeons due to several barriers. Survey results suggest that upper extremity surgeons are keen to have ultrasonography be part of residency education and most wish to adopt it into their future practice.

Evaluation of the Dysfunctional Scapula.

Periscapular pain and dysfunction are relatively common complaints in the practice of upper extremity surgeons. However, evaluation of the dysfunctional scapula is intimidating for most. Physical examination of the periscapular muscles is very rich, and a systematic approach provides the opportunity to establish a diagnosis for most patients. Conditions underlying scapular dysfunction include trapezius palsy, serratus palsy, brachial plexus injuries, muscular dystrophy, snapping scapula, pectoralis minor syndrome, congenital undescended scapula, and functional scapular dyskinesis, among others. Patients should be examined with their torso uncovered and assessed from the front and back. Inspection, evaluation of motion, and strength testing may be followed by certain examination maneuvers specific for each condition. The scapular assistance test may help predict the outcome of treatment for certain conditions. Plain radiographs oftentimes need to be complemented with magnetic resonance of the chest to capture periscapular muscles as well as an electromyogram with nerve conduction studies. Computed tomography is particularly helpful for skeletal abnormalities. Ultrasound is used to assess certain peripheral nerve injuries and to guide diagnostic and therapeutic injections. A focused evaluation of the scapula followed by a more specific and directed approach for each condition suspected will allow upper extremity surgeons to approach the evaluation of the dysfunctional scapula with much more confidence.

Prevalence and Practice Characteristics of Advanced Practice Providers in Upper-Extremity Surgery, 2013–2021

This study evaluated the prevalence, characteristics, and reimbursement of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to the diagnosis and treatment of diseases and conditions of the hand, wrist, and upper extremities in the United States from 2013 to2021. Our analysis was a retrospective cohort study evaluating the diagnostic, procedural, and therapeutic services provided by advanced practice providers from 2013 to 2021 using the Medicare Provider Utilization and Payment Data Public Use Files from the Centers for Medicare and Medicare Services. The reported provider type and billing codes were used to identify health care professionals providing upper-extremity care such as ordering radiographs, applying casts and splints, and performing procedures on the hand, wrist, or other anatomic regions of the upper extremity. Trends over the study period and available data about services provided were analyzed. From 2013 to 2021, providers of upper-extremity care included 19,525 (64.7%) doctor of medicine or doctor of osteopathic medicine upper-extremity surgeons, 7,612 (25.2%) physician assistants, and 3,042 (10.1%) nurse practitioners. The nonsurgeon providers were more likely to be women and provide care in micropolitan areas with less than 50,000 people compared with upper-extremity surgeons. Overall, the number of advanced practice providers who billed for upper-extremity care increased by 170.9% from 1,965 in 2013 to 5,324 in 2021. Based on these trends, the growth of APPs providing upper-extremity care is expected to continue. There is a growing prevalence of advanced practice providers in upper-extremity care, and this trend is expected to continue. With a growing need for upper-extremity care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

The Orthopedic Upper Extremity Surgeon's Role in the Diagnosis and Treatment of Osteoporosis: Making Use of Opportunistic Imaging.

Osteoporosis is an underdiagnosed and undertreated public health issue that contributes to a high financial burden on the healthcare system and imposes significant morbidity and mortality on the patient population. Upper extremity orthopedic surgeons are in a unique position to diagnose osteoporosis prior to patients suffering a fragility fracture by using imaging that they already obtain in their current workflow. The use of X-rays and CT scans can effectively diagnose osteoporosis with high sensitivity and specificity. By incorporating these diagnostic methods into standard practice, upper extremity orthopedic surgeons can play a critical role in the early diagnosis and treatment of osteoporosis. This can prevent severe fractures, improve patient outcomes, and reduce the overall healthcare burden by initiating timely treatment and patient education. This review emphasizes the importance of opportunistic imaging in enhancing osteoporosis management and suggests that upper extremity surgeons can significantly and effectively contribute to primary and secondary fracture prevention.

Vascularized Bone Graft in Mangled Hand Reconstruction

Extensive bone defects especially in conjunction with associated coverage involvement in mangled hands, pose significant challenges to hand and upper extremity surgeons. Vascularized bone grafts often play a vital role for effective treatment now-a-days. It not only bypasses the drawbacks of conventional grafts but also allows for simultaneous one stage reconstruction of its coverage as well as repairs other injured structures.Preoperative evaluation of mangled hand is crucial, the injury extent, including circulation, patient expectations and clinical reality should be all taken into consideration before finalizing the reconstruction plan. The fibula bone and other vascularized bone flaps such as iliac crest bone and medial femoral condyle and some others as well as corresponding spare part can provide effective solutions. Especially important considerations about surgeons’ experience and expertise , donor site morbidity , postoperative care and rehabilitation are essential for optimal outcomes. In this article , we would like to share our current practicing vascularized bone flaps in mangled hand reconstructions.

Variation in Interpretation of Provocative Tests for Carpal Tunnel Syndrome

We studied variation in interpretation of specific symptoms during clinical tests for carpal tunnel syndrome to estimate the degree to which surgeons consider pain without paresthesia characteristic of median neuropathy. We invited all upper-extremity surgeon members of the Science of Variation Group to complete a scenario-based experiment. Surgeons read 5-10 clinical vignettes of patients with variation in patient demographics and random variation in symptoms and signs as follows: primary symptoms (nighttime numbness and tingling, constant numbness and loss of sensibility, pain with activity), symptoms elicited by a provocative test (Phalen, Durkan, or Tinel) (tingling, pain), and location of symptoms elicited by the provocative test (index and middle fingers, thumb and index fingers, little and ring fingers, entire hand). Patient factors associated with surgeon interpretation of provocative tests as negative included pain rather than paresthesia during the Phalen, Durkan, or Tinel test and location of symptoms in the entire hand rather than the median nerve distribution. Specialists do not consider pain without paresthesia or a noncharacteristic symptom distribution as characteristic of carpal tunnel syndrome. Awareness that elicitation of pain with Phalen, Durkan, and Tinel tests is regarded by specialists as relatively uncharacteristic of median neuropathy can help limit the potential for both overdiagnosis and overtreatment of median neuropathy as well as underdiagnosis and undertreatment of mental and social health contributions to illness (notable correlates of the intensity and distribution of pain).

Poster 104: Lower trapezius tendon transfer improves range of motion, function, and restores external rotation in patients with a massive, irreparable, posterosuperior rotator cuff tear

Objectives: Massive, irreparable rotator cuff tears can cause severe pain and weakness. In younger, more active patients, joint salvage interventions are the preferred treatment. Over the last decade, lower trapezius tendon transfer (LTTT) has increasingly been used to reduce pain and improve function in patients with massive posterosuperior rotator cuff tears. Few studies have reported outcomes following LTTT or examined risk factors for failure and poor patient reported outcomes The objective of this study was to report on failure rate, patient reported outcomes, and possible risk factors up to 2-years postoperative in those undergoing LTT in the management of massive, irreparable, posterosuperior rotator cuff tears. Methods: This is a prospective longitudinal observational study conducted between 2018 and 2023. All patients undergoing arthroscopic assisted LTTT by 2 fellowship trained upper extremity surgeons from two sites were screened. Inclusion criteria were patients with massive (2+ tendons), irreparable rotator cuff tears in the primary or revision setting. Irreparable was defined as two or more of the following: grade 3 or higher fatty infiltration, patte grade 3, tendon length < 15mm, previous rotator cuff repair surgery. Exclusion criteria were prisoners, military, non-English speakers, and patients <18 years old. Consented patients completed a demographic form, the Single Assessment Numeric Score (SANE), 4-point satisfaction scale (poor, fair, good, excellent), and the American Shoulder and Elbow Surgeon test at baseline at 12- and 24-months postoperative. A clinical assessment was conducted at all time points including range of motion and lag sign. Surgical failure was defined as reoperation, LTTT failure, SANE score of <50%, or forward flexion of less than 90°. Descriptive statistics were generated for all measures. Independent t tests were performed between time points for patient-reported outcomes. Exploratory logistic regression was conducted to evaluate risks of failure with age, sex, workers’ compensation benefits (WCB), primary or revision surgery, subscapularis status, and subscapularis repair as possible predictors. Linear regression was conducted to evaluate possible predictors of 12-month postoperative SANE scores including WCB status and revision or primary surgery. Results: Seventy-four patients were recruited to this study and completed 1-year follow-up. Fifty-one patients reached 24 months of follow-up. Twenty-six had previous rotator cuff procedures before undergoing LTTT. The mean (SD) age was 58.3 (7.8) years with 17 (23%) females and 57 (77%) males. Seven patients were WCB clients and 10 patients were smokers. Five patients had a complete full tear of subscapularis and 19 had a tear of the upper 50% or less. Ten (14%) LTTT surgeries were considered failures by 24-months postoperative, of which 5 had a subscapularis repair during their LTTT procedure, and 5 had a normal subscapularis. Table 1 presents patient reported outcomes and active range of motion scores pre- and postoperatively. Lag sign was positive in 42 of 74 patients preoperatively, with 32 patients corrected with surgery, 4 patients remaining positive, and 6 patients who did not attend in-person postoperative follow-up. The 4 patients with persistent lags were identified as failures. A complete full-thickness subscapularis tear was predictive of failure (p=0.009) despite full repair. WCB status was predictive of 12-month SANE score (p=0.006). Other variables were not predictive. Conclusions: Most patients experience improved range of motion, functional outcomes and restoration of external rotation at up to 2 years post-LTTT surgery. However, those that have a complete full-thickness subscapularis tear may be at greater risk of failure despite undergoing repair, and WCB patients may have lower SANE scores at 12-months postoperative.

The Scratch-Collapse Test: Are Electrodiagnostic Changes Measurable?

Carpal tunnel syndrome is commonly managed by hand and upper extremity surgeons. Though electrodiagnostics are considered the gold standard diagnosis, the scratch collapse test (SCT) was introduced to address uncertainty, despite remains controversial. To address this, we sought to identify if the SCT can correlate with EDS studies if the SCT can identify actual changes in measures of nerves. We reviewed patients who underwent electrodiagnostic studies (EDX) and SCT for carpal tunnel syndrome (CTS). Demographic data as well as sensorimotor amplitudes, latencies, and velocities on nerve conduction and electromyography were collected. Analogous values based on SCT findings were analyzed for statistical significance. Three hundred fifty patients with CTS were included. Sensory and motor velocities and amplitudes were significantly lower in patients with a positive SCT. Motor values were independent of age, though younger patients had larger measured changes. Obese patients did not show any motor EDX changes with the scratch collapse test, though thinner patients did. All changes were seen in nerve conduction only. Carpal tunnel can be a difficult problem to diagnose as one study does not singularly determine the condition. The SCT was introduced to facilitate easier diagnosis. We demonstrate that the SCT correlates with changes on nerve conduction studies, especially in relation to decreased amplitudes and velocities, suggesting that it does identify changes in nerve with compression, specifically axonal, and myelin damage. These findings support the use of the SCT maneuver to evaluate and diagnose in appropriate patients.

Sensitivity, Specificity, and Reliability of the CTS-6 for Carpal Tunnel Syndrome Administered by Medical Assistants

The CTS-6 can be used clinically to diagnose carpal tunnel syndrome (CTS) and has demonstrated high levels of interrater reliability when administered by nonexpert clinicians. Our purpose was to assess sensitivity (Sn), specificity (Sp), and interrater reliability of the CTS-6 when administered by medical assistants (MAs). A series of patients presenting to an academic, upper-extremity surgery clinic were screened using CTS-6 between May and June of 2023. The CTS-6 was first administered by one of seven MAs and then by one of four fellowship-trained upper-extremity surgeons. In addition to recording baseline demographics, the results of each of the six history and examination components of the CTS-6 were recorded, as was the cumulative CTS-6 score (0-26). Surgeons were blinded to the scores obtained by the MAs. Interrater reliability (Cohen's kappa) was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 items. Sensitivity/specificity was calculated for the MA-administered CTS-6, using the score obtained by the surgeon as the reference standard. A CTS-6 score >12 was considered diagnostic of CTS. Two hundred eighteen patients were included, and 26% had a diagnosis of CTS. The MA group demonstrated a Sn/Sp of 84%/91% for the diagnosis of CTS. Interrater reliability was substantial (Cohen's kappa: 0.72, 95% confidence interval: 0.62-0.83) for MAs compared with hand surgeons for the diagnosis of CTS. For individual CTS-6 components, agreement was lowest for the assessment of two-point discrimination (fair) and highest for the assessment of subjective numbness (near perfect). The CTS-6 demonstrates substantial reliability and high Sn/Sp when administrated by MAs in an upper-extremity clinic. These data may be used to inform the development of CTS screening programs and future investigations in the primary care setting. Diagnostic II.

Potential Misinformation in the Official Disability Guidelines About the Diagnosis and Treatment of Rotator Cuff Tendinopathy.

We selected statements in the Official Disability Guidelines that had the potential to reinforce misconceptions regarding symptoms from rotator cuff tendinopathy. These statements were revised and presented with the original statement to specialists. Twelve statements regarding rotator cuff tendinopathy were identified as deviating from principles based on ethics, values, and the evidence regarding both pathophysiology and human illness behavior. One hundred fifteen upper extremity surgeons reviewed both original and revised versions of the statements and indicated their preference. We found that upper extremity surgeons preferred 3 revised statements, 4 Official Disability Guidelines statements, and 5 were rated as neutral between the 2 statements. Statements revised for evidence, ethics, and healthy mindset were not preferred by specialists, which may indicate limited awareness about how negative thoughts and distressing symptoms impact human illness.

Use of Nerve Wraps in the Upper Extremity

Objectives Nerve wraps have been used to potentially decrease perineural scarring and to create a local environment conducive to nerve healing, but no consensus exists on the indications for their use. The primary purpose of this study is to assess the operative indications for using the porcine extracellular matrix (PEM) nerve wrap in the upper extremities at a single center. Methods A retrospective review of all patients that underwent PEM nerve wrapping over eight years by hand and upper extremity surgeons at a single orthopaedic practice yielded 104 procedures in 102 patients for analysis. Results The most common indication for surgery was for nerve wrapping of acute traumatic nerve injuries in 57 patients (55%), most frequently involving lacerations of the hand and forearm. Neurolysis and nerve wrapping for cases of chronic nerve compression with perineural scarring and fibrosis was the second most common indication, involving 41 patients (39%), most frequently for revision carpal and cubital tunnel release surgery. Six patients (5.8%) underwent mass removal or contracture release involving neurolysis with nerve wrapping. Three patients (2.9%) required reoperation, two in the acute group and one in the chronic group. However, there were no cases of nerve wrap rejection or extrusion. Conclusion PEM nerve wrapping was used for various nerve injuries, from acute lacerations to recalcitrant chronic compression and mass excision. Further studies are necessary to determine whether patient outcomes are improved with the PEM nerve wrap. Level of Evidence Level 4

Early Results in Total Replacement of the Distal Radioulnar Joint.

Pathology of the distal radioulnar joint (DRUJ) including instability and arthritis presents a challenge for hand and upper extremity surgeons. Surgical options include a Darrach procedure and similar resections, soft tissue interposition arthroplasty, and a one-bone forearm. In 2005, a prosthesis for DRUJ arthroplasty was approved for use in the United States. The authors hypothesize that DRUJ arthroplasty will lead to improved pain and range of motion (ROM) with a moderate, but manageable, complication rate. A retrospective review of 46 patients who underwent DRUJ arthroplasty by a single private group of hand surgeons was performed. Demographics, complications, postoperative visual analog scale (VAS), and postoperative ROM were obtained and analyzed. The patients were followed up for a mean of 60 weeks. The implant was used both as primary surgical treatment for DRUJ pathology and as salvage for previous failed procedures. Twenty-two percent of patients experienced complications: 15% required revision surgery. No patients were converted to another type of implant, including those who underwent revision surgery. Prominent hardware was the most common indication requiring revision. Patients achieved an improvement in supination of 17° and extension of 5°. They additionally achieved a decrease in average VAS score from 7.1 to 2.3. Distal radioulnar joint arthroplasty reduces pain and improves ROM in patients with DRUJ pathology with a 22% complication rate. This cohort demonstrates improved pain, modest improvement in ROM, but a 22% complication rate for this implant. Further long-term studies are encouraged.

Ultrasonographic examination of acute soft tissue lesions in the elbow has good inter-rater reliability and acceptable agreement with magnetic resonance imaging

BackgroundUltrasound (US) has been suggested a valuable complement to clinical and radiological examinations in elbow trauma. Magnetic resonance imaging (MRI) has been the method of choice, despite fair to moderate interrater reliability (IRR). US has potential advantages but is assessor dependent and IRR scarcely examined. The primary aim of the present study was to investigate IRR for US and secondarily inter-observer agreement (IOA) between US and MRI in the acute phase after elbow trauma. Acute phase was defined as 2 weeks and, if applicable, the following weekend. The hypothesis was that US reliability would be at least substantial for complete muscle or ligament lesions. Methods116 patients (50 men, median age 47 [range 19-87] years) suffering an elbow trauma with dislocation and/or fracture were included. Exclusion criteria were prior injury to the same elbow, and US and/or MRI not possible within 16 days. During US the condition of muscle origins at the epicondyles and collateral and annular ligament complexes was recorded in a pre-designed protocol, with the alternatives intact, partially or completely torn. 72 patients had a second US examination the same day by an independent upper extremity surgeon. 58 of the 116 patients underwent an MRI before or after the US, evaluated by 2 radiologists using the same protocol. IOA and IRR between assessors and modalities were analyzed with kappa statistics and interpreted according to Landis and Koch. Perfect agreement (PA) was reported in percent. ResultsUS examination within 2 weeks was feasible with tolerable discomfort. Defining muscle origins and ligaments as intact or completely torn the US IRR ranged from substantial to near perfect (kappa 0,63-1; PA 93-100%). Intact tissues vs tear (partial and complete tear combined) or intact vs partial vs complete tear resulted in kappa values from moderate to substantial and PA 74%-96% with lowest reliability for the muscle origins. The IOA between MRI and US ranged from fair to near perfect for no tear vs complete tear (kappa 0,25-1; PA 65-100%). Agreement between no tear and tear (partial and complete together) ranged from fair to substantial (0,25-0,66; PA 63-89%) and no tear vs partial or complete tear ranged from fair to moderate (0,25-0,53; PA 50-79%). ConclusionUS in the acute setting is suitable and reliable for diagnosis of ligament injuries in the elbow and is in addition fast, cheap and easily accessible. The agreement with MRI seems to vary with the structure assessed and severity of the lesions, ranging from fair to near perfect.

A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release

Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR. We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases. A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%). Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous. Prognostic II.

Examining One-Star Reviews in Orthopaedic Hand Surgeons in Large U.S. Cities

Abstract Introduction Physician-review websites are a commonly used resource by patients when choosing a surgeon. While data exist regarding some surgical specialties, no study has examined negative one-star reviews for orthopaedic-trained hand surgeons. The goal of this study was to investigate one-star reviews regarding orthopaedic-trained hand and upper extremity surgeons in the 10 largest cities in the United States to determine the associated factors behind unsatisfied patients to improve patient care. Methods Patient reviews and narratives of orthopaedic-trained hand surgeons were collected from the 10 largest cities in the United States using Vitals.com. One-star reviews (out of a five-star maximum) with comments were identified and classified as operative or nonoperative. These reviews were further subclassified based on the nature of the comment. Results A total of 830 one-star reviews with 1,662 complaints were included in this study. Of these complaints, 557 (33.5%) were from patients who received operative care and 1,105 (66.5%) were from nonoperative care patients. Nonoperative patient one-star reviews had a significantly higher proportion of complaints related to bedside manners (37.6 to 19.6%, p < 0.001), not enough time spent with the provider (18.1 to 4.5%, p < 0.001), and wait time (13.3 to 3.2%, p < 0.001) as compared with operative patient one-star reviews. Operative patient one-star reviews had a higher proportion of complaints related to disagreement with the physician's decision or plan (15.6 to 10.2%, p = 0.002); uncontrolled pain (14.4 to 7.9%, p < 0.001); and medical staff or institution (17.2 to 12.9%, p = 0.018) as compared with nonoperative patients. Discussion Most one-star reviews regarding orthopaedic-trained hand surgeons referenced nonclinical components—bedside manner was the most common complaint. It was determined that surgical patients were less likely to leave a one-star review; however, if they did, the most common complaint was in reference to a disagreement with the physician's decision or uncontrolled pain postoperatively. Type of Study Outcomes 2c.

Arthroscopic Assistance and Percutaneous Fixation of Complex Intraarticular Metacarpophalangeal Fracture

AbstractComminuted fractures involving the metacarpophalangeal joint are a real challenge for the hand surgeon due to the complexity of their management and the high frequency of functional sequelae caused by the incongruence of the joint surfaces and the injury of soft tissues requiring repair. Metacarpophalangeal joint arthroscopy is an emerging and useful tool for the upper extremity surgeon allowing assisted reduction and percutaneous fixation of these fractures since it permits a complete evaluation of the joint fragments and enables precision in the reduction with the advantage of being a minimally invasive and safe technique. This technique was performed in two patients with complex fractures of the metacarpophalangeal joint with good functional results. In conclusion, this technique is reproducible, with good results and minimal soft-tissue morbidity. It allows a stable osteosynthesis, enabling early joint mobility and rehabilitation, which is essential for function recovery.

Surgeons Have an Implicit Preference for Specific Disease Over Nonspecific Illness.

Many symptoms are not associated with a specific, measurable pathophysiology. Such nonspecific illnesses may carry relative social stigma that biases humans in favor of specific diseases. Such a bias could lead musculoskeletal surgeons to diagnose a specific disease in the absence of a specific, measurable pathology, resulting in potential overdiagnosis and overtreatment. (1) What factors are associated with surgeon implicit preference for specific disease over nonspecific illness? (2) What factors are associated with surgeon explicit preference for specific disease over nonspecific illness? (3) Is there a relationship between surgeon implicit and explicit preferences for specific disease over nonspecific illness? One hundred three members of the Science of Variation Group participated in a survey-based experiment that included an Implicit Associations Test (IAT) to assess implicit preferences for specific, measurable musculoskeletal pathophysiology (specific disease) compared with symptoms that are not associated with a specific, measurable pathophysiology (nonspecific illness), and a set of four simple, face valid numerical ratings of explicit preferences. The Science of Variation Group is an international collaborative of mostly United States and European (85% [88 of 103] in this study), mostly academic (83% [85 of 103]), and mostly fracture and upper extremity surgeons (83% [86 of 103]), among whom approximately 200 surgeons complete at least one survey per year. The human themes addressed in this study are likely relatively consistent across these variations. Although concerns have been raised about the validity and utility of the IAT, we believe this was the right tool, given that the timed delays in association that form the basis of the measurement likely represent bias and social stigma regarding nonspecific illness. Both measures were scaled from -150, which represents a preference for nonspecific illness, to 150, which represents a preference for specific disease. The magnitude of associations can be assessed relative to the standard deviation or interquartile range. We used multivariable linear regression to identify surgeon factors associated with surgeon implicit and explicit preference for specific disease or nonspecific illness. We measured the relationship between surgeon implicit and explicit preferences for specific disease or nonspecific illness using Spearman correlation. Overall, there was a notable implicit bias in favor of specific diseases over nonspecific illness (median [IQR] 70 [54 to 88]; considered notable because the mean value is above zero [neutral] by more than twice the magnitude of the IQR), with a modestly greater association in the hand and wrist subspecialty. We found no clinically important explicit preference between specific disease and nonspecific illness (median 8 [-15 to 37]; p = 0.02). There was no correlation between explicit preference and implicit bias regarding specific disease and nonspecific illness (Spearman correlation coefficient -0.13; p = 0.20). Given that our study found an implicit bias among musculoskeletal specialists toward specific diseases over nonspecific illness, future research might address the degree to which this bias may account, in part, for patterns of use of low-yield diagnostic testing and the use of diagnostic labels that imply specific pathophysiology when none is detectable. Patients and clinicians might limit overtesting, overdiagnosis, and overtreatment by anticipating an implicit preference for a specific disease and intentionally anchoring on nonspecific illness until a specific pathophysiology accounting for symptoms is identified, and also by using nonspecific illness descriptions until objective, verifiable pathophysiology is identified.

Principles of microvascular surgery in the upper extremity.

Upper extremity replantation and microsurgery can be challenging even for the experienced hand and upper extremity surgeon and requires thoughtful consideration and evaluation. This review aims to discuss the general considerations in upper extremity replantation management from the preoperative through the postoperative period.