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Objective To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction.

Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired ttests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient–physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient–physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315–319.]

Both rotator cuff repair (RCR) and reverse total shoulder arthroplasty (RTSA) are effective treatment options for chronic large degenerative rotator cuff tear (RCT) in the elderly. The goal of this study was to evaluate national trends for surgical management of chronic RCT among patients without glenohumeral arthritis. The authors conducted a retrospective review from 2007 to 2015 using the PearlDiver database. The study included patients who had the Both rotator cuff repair (RCR) and reverse total shoulder arthroplasty (RTSA) are effective treatment options for chronic large degenerative rotator cuff tear (RCT) in the elderly. The goal of this study was to evaluate national trends for surgical management of chronic RCT among patients without glenohumeral arthritis. The authors conducted a retrospective review from 2007 to 2015 using the PearlDiver database. The study included patients who had the International Classification of Diseases, Ninth Revision,diagnosis of chronic RCT without shoulder arthritis. Procedural codes from the Current Procedural Terminologyand the International Classification of Diseases, Ninth Revision,were used to identify patients undergoing RCR or RTSA. Chi-square analysis assessed differences between the groups, and Cochran-Armitage trend tests were used to evaluate trends over time. Overall, 428,651 patients had chronic RCT without arthritis; 364,141 (84.9%) were treated nonoperatively, 53,566 (12.5%) underwent RCR, and 10,944 (2.6%) underwent RTSA. Patients who were 60 to 79 years old had the highest rate of surgical intervention (70.8% of all surgical patients), with 69.2% and 78.4% who underwent RCR and RTSA, respectively. A 3-fold increase in RTSA use was noted among patients 60 years and older vs patients younger than 60 years. Overall revision rates 2 years after RCR and RTSA among patients 60 to 79 years old were 13.0% and 3.7%, respectively. Revision rates after RCR remained constant over time (9.3% to 13.0%; P=.082), whereas revision rates after RTSA decreased significantly over time (12.1% to 2.2%; P=.016). Older patients were more likely to be treated nonoperatively compared with younger patients, but among those patients treated with RTSA, there was a 3-fold increase in the use of RTSA in patients older than 60 years compared with patients younger than 60 years. Further, the authors found that revision rates after RTSA decreased over time (from 12% to 2%), suggesting better implant design, improved knowledge of implant positioning, and increased surgical proficiency. [Orthopedics. 2020;43(5):e409–e414.]

Health policy is a complex and fluid topic that addresses care delivery with the goal of improving patient care. Understanding health policy initiatives, their motivation, and their effects, can help ensure hand surgeons are prepared for the changing health care landscape.

Flexor tendon and pulley injuries in athletes present a unique challenge to the treating clinician. An understanding of the anatomy and mechanism of injury helps the clinician appropriately diagnose and treat the injury. Treatment may become more complicated when associated with delays in diagnosis, in-season considerations, and an athlete’s desire to return to play. Two injuries involving the flexor tendon-pulley system, avulsion injuries of the flexor digitorum profundus tendon from its insertion onto the base of the distal phalanx and flexor pulley injuries, are examined in detail in this article.

While initial nonoperative management is the conventional approach for superficial triangular fibrocartilage complex (TFCC) tears, a substantial portion of these cases go on to require surgery, and the optimal duration of nonoperative treatment is unknown. In this study, we evaluate the cost-effectiveness of early versus late arthroscopic debridement for the treatment of superficial TFCC tears without distal radioulnar joint (DRUJ) instability.

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Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (P<.004). Analysis using Mann-Whitney Utest suggested that those who expressed interest were more likely to believe IHEs are important to resident training (P<.0011; mean Likert scale score of 3.7 vs 2.6), provide valuable experience (P<.001; mean Likert scale score of 4.2 vs 3.2), and should be required for orthopedic residencies (P<.001; mean Likert scale score of 2.8 vs 1.9). Residents are strongly interested in participating in IHEs during their training, and many may integrate global health into future practices. Residents perceive lack of funding and scheduling flexibility as barriers preventing them from participating. Prior experience abroad influences level of interest, and international clinical experience may enhance future perception of its value. [Orthopedics.2016; 39(4):e680–e686.]

Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multi-disciplinary approaches that tie risk modification with risk stratification is needed.

The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors’ institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors’ institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

IMPORTANCE: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. OBJECTIVE: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. EXPOSURES: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. MAIN OUTCOMES AND MEASURES: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). RESULTS: A total of 69?070 cataract procedures were identified among 50?106 patients (66?282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53?837 [77.9%] White, 10?292 [14.9%] Black). Most of the patient population had either overweight (23?292 [33.7%] patients) or obesity (27?799 [40.2%] patients). Approximately 49% of surgical procedures (33?424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2?597?623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P?&lt;?.001) at the facility level and 0.06 (P?&lt;?.001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. CONCLUSIONS AND RELEVANCE: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone—such as the Choosing Wisely campaign—may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.