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Background: Despite the recent trend toward internal fixation of distal radial fractures, few randomized trials have examined whether volar plate fixation is superior to other stabilization techniques. The purpose of the present study was to compare (1) open reduction and internal fixation with use of a volar plate and early mobilization with (2) percutaneous fixation and casting or external fixation for the treatment of dorsally displaced unstable extra-articular and simple intra-articular fractures of the distal part of the radius, with a specific emphasis on early functional recovery.Methods: A prospective randomized study was performed at two institutions. Forty-five consecutive patients with a displaced, unstable fracture of the distal part of the radius were randomized to closed reduction and pin fixation (n = 22) or open reduction and internal fixation with a volar plate (n = 23). Clinical and radiographic assessments were conducted at six, nine, and twelve weeks after surgery and at one year. Outcome was measured on the basis of range of motion; grip and pinch strength; and Disabilities of the Arm, Shoulder and Hand scores. A questionnaire was used to determine patient satisfaction, and a detailed analysis of complications was performed.Results: Patients in the open reduction and internal fixation group had superior Disabilities of the Arm, Shoulder and Hand scores at six, nine, and twelve weeks. At six weeks, the average Disabilities of the Arm, Shoulder and Hand score was 27 in the open reduction and internal fixation group as compared with 53 in the closed reduction and pin fixation group (p < 0.01). At nine and twelve weeks, patients in the open reduction and internal fixation group continued to have lower scores (17 compared with 39 [p < 0.01] and 11 compared with 26 [p = 0.01], respectively). At one year, there was no significant difference between the two groups in terms of the Disabilities of the Arm, Shoulder and Hand scores. Patients in the open reduction and internal fixation group had greater range of motion and strength than patients in the closed reduction and pin fixation group at six and nine weeks, and more patients in the open reduction and internal fixation group were very satisfied with the overall wrist function and motion. Eight complications occurred, two in the open reduction and internal fixation group and six in the closed reduction and pin fixation group.Conclusions: Both closed reduction with percutaneous pin fixation and open reduction with internal fixation with use of a volar plate are effective methods for the treatment of dorsally displaced, unstable, extra-articular or simple intra-articular fractures of the distal part of the radius. Better functional results can be expected in the early postoperative period in association with open reduction and internal fixation, and this form of treatment should be considered for patients requiring a faster return to function after the injury. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the perioperative complication rate of surgical fasciectomy following previous treatment with collagenase clostridium histolyticum (CCH) treatment in patients with Dupuytren disease., Methods: A retrospective review of all patients at a large health system undergoing CCH treatment and subsequent limited surgical fasciectomy for recurrence on the same digit between 2010 and 2020 was performed. Fifty-two patients with 62 affected digits met inclusion criteria, and cases were reviewed for preoperative demographics, treatment characteristics, clinical outcomes, and perioperative complications., Results: Fifty-five digits in 48 patients were treated with CCH and underwent subsequent limited surgical fasciectomy. Of all digits in the present study, 3 (6.3%) had a documented surgical complication following open surgical fasciectomy. There were zero postoperative infections, vascular injuries, or tendon injuries. The rate of nerve injury was 2.1%. The rate of postoperative skin necrosis was 4.2%. These rates were comparable or lower than those of historical published data., Conclusions: The rate of perioperative complications in patients undergoing limited surgical fasciectomy after previous CCH treatment is low. The findings of this study will aid the counseling of Dupuytren patients in deciding whether to pursue treatment with CCH versus open surgical fasciectomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Summary: Rheumatoid arthritis (RA) is a common inflammatory condition that can lead to debilitating hand and wrist deformity. Since the introduction of disease-modifying antirheumatic drugs in the 1990s, the rate of surgery for rheumatoid arthritis has dramatically decreased 1. Nonetheless, surgical intervention remains an important tool in the management of patients with RA, and young surgeons must seek out expertise in this domain due to diminished exposure during their training. In this article, we provide a comprehensive review of the evaluation and management of patients with wrist pathology due to RA as well as surgical technical pearls., Competing Interests: Financial Disclosure Statement: The authors have no financial interests or conflicts of interest to declare in relation to the content of this article., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: The purpose of this study was to identify factors that influence preoperative patient preferences toward anesthesia in patients in a hand and upper extremity clinic., Methods: A survey was administered to consecutive patients in a hand and upper extremity orthopedic clinic at an urban tertiary academic institution. The survey addressed presenting clinical complaint, anesthesia preference for minor soft tissue hand and wrist procedures, factors influencing anesthesia preference, and patient history of anesthesia and surgical treatment. The primary outcome measure was anesthesia preference: local-only or local with sedation., Results: Surveys were completed by 219 patients over a 1-month period with a mean patient age of 55 years. Most patients presented with a hand/wrist complaint (56%). One hundred fifty-two patients (71%) preferred local anesthesia with sedation and 61 patients (29%) preferred local-only anesthesia. Patients who preferred local-only anesthesia reported being more likely to be influenced by surgeon preference and cost, and also were more likely to have had prior experience with local-only anesthesia. In contrast, patients who preferred local anesthesia with sedation were more likely to be concerned about pain or were nervous about surgery. Prior surgical experience did not influence preference for anesthesia., Conclusion: Patient preferences for local-only anesthesia versus local anesthesia with sedation for ambulatory hand surgery are mixed, with most patients preferring sedation. Understanding patient preferences for anesthesia can better inform preoperative discussions and shared decision-making in anesthesia choice., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract: We present the case of a near-miss in clinical research to illustrate a situation in which errors in data collection would have led to different results in the data analysis, with the potential for drawing incorrect conclusions. Conclusions based on data errors may adversely influence future medical decision-making in patient care. In the interest of presenting this as an educational, nonpunitive, quality-improvement report, the study and the involved researchers remain anonymous, and the specific details and exact number of patients are not reported., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H684 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Isolated ulnar shaft fractures are frequently managed nonsurgically. However, rates of nonsurgical treatment failure remain substantial, and risk factors for the failure of nonsurgical management are not well described. This study investigated radiographic and patient-specific risk factors for the failure of nonsurgical management of isolated ulnar shaft fractures., Methods: A retrospective review of patients with ulnar shaft fractures initially treated nonsurgically was performed at two tertiary referral centers over a 19-year period from 2001 to 2020. Patient- and injury-related variables, surgical interventions, and plain radiographic measurements were recorded. The outcome of interest was failure of nonsurgical management, defined as failure to achieve fracture union nonsurgically within 3 months of injury., Results: One hundred fifty four patients initially treated nonsurgically for isolated ulnar shaft fractures were included. Twenty six patients (17%) experienced failure of nonsurgical management; these included five nonunions, 16 delayed unions, and 10 conversions to surgical management. Patients who experienced failure of nonsurgical management had a higher prevalence of diabetes mellitus, a higher employment rate, and fractures with higher initial median posteroanterior and lateral translations, fracture gap, and angulation; 83% of the patients with an initial fracture gap of ≥4 mm and 41% of the patients with an initial fracture angulation of >10° failed nonsurgical management., Conclusions: Although most ulnar shaft fractures heal successfully with nonsurgical management, a substantial percentage of these fractures do not. Patients who are currently working, have diabetes mellitus, or have fractures with an initial fracture gap of ≥4 mm or an initial fracture angulation of > 10° may be more likely to fail nonsurgical treatment, although additional studies with larger sample sizes are needed to confirm these associations., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome., Methods: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated., Results: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared., Conclusions: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions., Clinical Relevance: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Telemedicine is an effective, emerging interface to connect practitioners with patients. It facilitates access to healthcare expertise, reduces costs, time demands and health disparities while improving satisfaction. This pilot study evaluated the feasibility, effectiveness and patient satisfaction of telerehabilitation for thumb carpometacarpal (CMC) arthroplasty and reverse shoulder arthroplasty (rTSA)., Methods: This prospective investigation was performed at a single academic institution with two hand and upper extremity fellowship-trained orthopaedic surgeons. All patients undergoing CMC arthroplasty or rTSA were eligible for inclusion. Telerehabilitation was delivered by a hybrid model including an in-person post-operative visit, followed by alternating in-clinic and virtual videoconference visits. All patients were offered participation in the study arm; those that preferred in-person therapy were included as a control group. Therapy was initiated two weeks post-operative with an in-clinic evaluation. Patients then participated in alternating in-clinic and virtual visits weekly for eight weeks, followed by one virtual visit at 14-weeks post-operative and one clinical visit at 16-weeks post-operative. Patient reported and functional outcomes were collected at each visit., Results: In the CMC group, 19 study and 11 control patients were enrolled. In the rTSA group, five study and 14 control patients were enrolled. No statistically significant differences between telerehabilitation and control for range-of-motion, pain and patient-reported functional outcomes was noted. All patients in the telerehabilitation arms reported high satisfaction., Discussion: Utilizing telehealth in rehabilitation may be a viable option in upper extremity recovery. We hope this pilot programme can be a model for development of future telerehabilitation programmes.

Purpose: Trigger finger release (TFR) is one of the most commonly performed hand surgeries; nevertheless, the time until patients subjectively feel recovered has not been well documented. The limited literature on patient perceptions of recovery after any type of surgery has described that patients and surgeons may have differing views on the time until full recovery. Our primary study question was to determine how long it takes for patients to subjectively feel fully recovered after TFR., Methods: In this prospective study, patients who underwent isolated TFR completed questionnaires before surgery and at multiple time points following surgery until they reported full recovery. Patients completed visual analog scale (VAS) pain scores and QuickDASH (Disabilities of the Arm, Shoulder, and Hand) and were asked if they felt fully recovered at 4 weeks, 6 weeks, and 3, 6, 9, and 12 months., Results: The average time to self-reported full recovery was 6.2 months (SD 2.6), and the median time to self-reported full recovery was 6 months (IQR 4 months). At 12 months, four out of 50 patients (8%) did not feel fully recovered. QuickDASH and VAS pain scores improved significantly from preoperative assessment to final follow-up. All patients reported improvement in both VAS pain scores and QuickDASH scores greater than the minimal clinically important difference between 6 weeks and 3 months after surgery. Higher preoperative VAS and QuickDASH scores were associated with failure to fully recover by 12 months after surgery., Conclusions: The length of time after surgery until patients felt fully recovered after isolated TFR is longer than the senior authors' expectations. This suggests that patients and surgeons may consider distinctly different parameters when discussing recovery. Surgeons should be aware of this discrepancy when discussing recovery after surgery., Type of Study/level of Evidence: Prognostic II., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to analyze the ability of patients to return to work after ORIF of isolated capitellar shear fractures and assess long-term functional outcomes., Methods: We retrospectively reviewed the cases of 18 patients with isolated capitellar shear fractures with or without lateral trochlear extension and investigated demographic data, occupation, worker's compensation status, injury characteristics, surgical details, motion, radiographic appearance at final in-person follow-up, complications, and return to work status via in-person and long-term telemedicine follow-ups., Results: Final follow-up was at an average of 76.6 (7-222.6) months or 6.4 (0.58-18.6) years. Of the 14 patients working at the time of injury, 13 patients had returned to work at final clinical follow-up. The work status of the remaining patient was not documented. Mean elbow motion at final follow-up was 4° (range, 0-30) to 138° (range, 130-145) of flexion, 83° of supination, 83° of pronation. Two patients had complications that required reoperation but had no further complications. For the 13 of 18 patients with long-term telemedicine follow-up, the average Quick Disabilities of the Arm, Shoulder, and Hand score was 6.8 (0-25)., Conclusions: In our series, rates of return to work were high after ORIF of coronal shear fractures of the capitellum with or without lateral trochlear extension. This was true across all occupational classes including manual labor, clerical, and professional. With anatomic restoration of articular congruity, stable internal fixation, and postoperative rehabilitation, these patients had excellent ROM and functional scores at an average of 7.9 years of follow-up., Clinical Relevance: After ORIF of isolated capitellar shear fractures with or without lateral trochlear extension, patients can expect a high rate of return to work with excellent ROM and functionality and low long-term disability., (© 2023 The Authors.)

Background: The purpose of this study was to evaluate the impact of pronator quadratus (PQ) repair on reoperation rates after distal radius open reduction internal fixation (ORIF) using a volar locking plate., Methods: A retrospective study of all patients undergoing distal radius ORIF with a volar locking plate between January 2012 and December 2016 at 2 urban, academic level I trauma centers was performed. Patient demographics, fracture and procedure characteristics, surgeon subspecialty, PQ repair, and reoperations were recorded. Descriptive statistics were used to determine whether patient-related or injury-related characteristics were associated with PQ repair. Bivariate and multivariable regression analyses were used to assess the effect of PQ repair on subsequent reoperations., Results: In total, 509 patients were included, including 31 patients with bilateral injuries. The average follow-up time was 3.7 ± 2.8 years. Patients undergoing PQ repair were younger (57 ± 17 years vs 61 ± 17 years) and were more likely to have a lower Soong grade (53% vs 44% with Soong grade 0) than patients without PQ repair. Pronator quadratus repair was not found to have a significant impact on hardware removal, reoperations for flexor tendon pathology, or overall reoperations., Conclusions: Pronator quadratus repair was more commonly performed in younger patients and in patients with a lower Soong grade. Hand-subspecialized surgeons are more likely to pursue PQ repair than trauma-subspecialized surgeons. This study did not detect statistically significant differences in hardware removal, flexor tendon pathology, or overall reoperations between groups.

Purpose: The purpose of this study was to evaluate factors that influence surgeons' decision-making in the treatment of distal radius fractures in older patients., Methods: Fourteen clinical vignettes of a 72-year-old patient with a distal radius fracture were sent to 185 orthopedic hand and/or trauma surgeons. The surgeons were surveyed regarding the demographic/practice details, treatment decision (surgical or nonsurgical), and factors that influenced management, including the Charlson Comorbidity Index, functional status, radiographic appearance, and handedness. Multivariable regression analyses were used to assess the effect of both surgeon-described (explicit) and given clinical (implicit) factors on the treatment decision and to evaluate for discrepancies., Results: Sixty-six surgeons completed the survey, and 7 surgeons completed 10-13 vignettes. Surgeons made the explicit determination to pursue nonsurgical treatment based on the presence of comorbidities (odds ratio [OR], 0.02 for surgery; 95% confidence interval [CI], 0.01-0.05), but the observation of the underlying clinical data suggested that the recommendation for surgical treatment was instead based on a higher functional status (OR, 3.54/increase in functional status; 95% CI, 2.52-4.98). Those employed by hospitals/health systems were significantly less likely to recommend surgery than those in private practice (OR, 0.42; 95% CI, 0.23-0.79) CONCLUSIONS: This study demonstrates that the presence of comorbidities, functional status, and practice setting has a significant impact on a surgeon's decision to treat distal radius fractures in older patients. The discrepancy between the surgeon-described factors and underlying clinical data demonstrates cognitive bias., Clinical Relevance: Surgeons should be aware of cognitive biases in clinical reasoning and should work through consequential patient decisions using an analytical framework that attempts to reconcile all available clinical data., (Copyright © 2022. Published by Elsevier Inc.)

Background: Surgeons are sometimes presented with patients with distal radius fractures who present in a delayed fashion or lose reduction after several weeks of attempted closed management. There are limited studies on delayed surgical treatment of distal radius fractures to assist providers in decision-making., Methods: We conducted a matched cohort study to compare radiographic outcomes and complications for patients with a distal radius fracture treated with delayed (3-5 weeks) or early (0-2 weeks) surgical fixation. Patients ages 18+ who underwent open reduction and internal fixation of distal radius fractures by a volar approach at 2 Level I trauma centers between 2003 and 2015 were eligible. We measured radiographic outcomes and reviewed medical records to determine operative approach and complications., Results: There were 25 cases and 50 controls matched for age (18-87), sex, and AO fracture type. The delayed group had surgery at a mean of 24.8 days from injury and the early group at 5.6 days. There was no statistically significant difference between the delayed and early cohorts in radiographic parameters on injury x-rays, in improvement in radiographic parameters on first postoperative x-rays, or in maintenance of radiographic parameters at union., Conclusion: We did not find significant differences in radiographic outcomes or complication rates between patients with delayed versus early surgical treatment for distal radius fracture. Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury., Level of Evidence: III (Retrospective matched cohort study).

Purpose: This study sought to determine the impact of volar plate prominence on reoperation rates after open reduction and internal fixation of distal radius fractures with volar locking plates and to identify other factors associated with removal of hardware (ROH) or a reoperation., Methods: A retrospective study of patients who underwent distal radius open reduction and internal fixation between 2012 and 2016 at 2 level I trauma centers was conducted. Plate prominence was evaluated using the Soong index at the first postoperative visit. The details of patient demographics, fracture and plate characteristics, complications, and reoperations were recorded. Bivariate and multivariable regression analyses were used to identify factors associated with increased rates of ROH and overall reoperation., Results: A total of 732 (70.2%) of 1,042 patients completed follow-up at an average of 38.2 months, including 34 patients with bilateral operations, yielding 766 distal radius fractures. One hundred sixteen (15.1%) patients underwent reoperation at an average of 12.1 ± 13.6 months after the index surgery. Removal of hardware was the most commonly performed reoperation (77 patients, 10%). The multivariable regression analysis revealed significantly higher rates of ROH in Soong grade 1 or 2 patients (odds ratio 16, 95% CI 5.8-47; odds ratio 44, 95% CI 14-140, respectively) than in Soong grade 0 patients. Plate type, younger age, bilateral injuries, and concomitant procedures at the time of the index operation were all associated with increased risk of ROH. There were significant differences between individual surgeons the in rates of ROH (range 2.1%-22%) and overall reoperation (range 5.2%-36%). Compared with other hand surgeons, fellowship-trained hand surgeons had lower rates of ROH (8% vs 14%, respectively) and overall reoperation (12% vs 22%, respectively)., Conclusions: The rates of ROH and overall reoperation increase with increasing Soong grade. Plate type is independently predictive of future ROH. Older patients and those undergoing open reduction and internal fixation experience lower rates of subsequent reoperation., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The impact of the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) has been felt worldwide. We examined the quantitative impact during the first 4 weeks of hospital system and state-mandated restrictions on an academic, urban hand surgery practice. We hypothesized that the volume of clinic encounters, office procedures, and surgical cases would decrease and that the volume of nonelective care would remain unchanged., Methods: We retrospectively reviewed all encounters at a hand surgery practice from March 16, 2020, through April 12, 2020 and compared those to two 4-week control time periods. Weekly encounter volumes and work relative value units (RVUs) were obtained for clinic encounters, office procedures, and surgical cases. The type of ambulatory visit was also identified. Surgical cases were categorized into 4 types (fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/nonurgent) for the most recent time periods. We performed  t  tests to compare weekly volumes and RVUs between time periods., Results: After the implementation of mandated restrictions on elective health care, ambulatory hand surgery clinic encounters decreased 72% to 73%, clinic procedures decreased by 87% to 90%, and surgical cases decreased by 87% to 88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. Surgeries for fractures and dislocations declined by 58% and those for acute soft tissue or nerve injury declined by 40%; the number of surgical procedures for infection remained unchanged., Conclusions: The coronavirus restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There were significant decreases in the volumes of ambulatory encounters, office procedures, and surgical cases. The long-term financial impact of this change in practice is still to be determined but, based on the quantitative impacts seen, is likely to be significant., Type of Study/level of Evidence: Economic/Decision Analysis IV., (© 2021 The Authors.)

Background: Total wrist arthroplasty (TWA) is a treatment option for many debilitating wrist conditions. With recent improvements in implant design, indications for TWA have broadened. However, despite these improvements, there are still complications associated with TWA, such as unplanned reoperation and eventual implant removal. The goal of this study was to identify risk factors for an unplanned reoperation or implant revision after a TWA at 2 academic medical centers between 2002 and 2015. Methods: In this retrospective study, 24 consecutive TWAs were identified using CPT codes. Medical records were manually reviewed to identify demographic, patient- or disease-related, and surgery-related risk factors for reoperation and implant removal after a primary TWA. Results: Forty-six percent of wrists (11 of 24 TWAs performed) had a reoperation after a median of 3.4 years, while 29% (7 of 24) underwent implant revision after a median of 5 years. Two patients had wrist surgery prior to their TWA, both eventually had their implant removed ( P = . 08). There were no risk factors associated with reoperation or implant removal. Conclusion: Unplanned reoperation and implant removal after a primary TWA are common. Approximately 1 in 3 wrists are likely to undergo revision surgery. We found no factors associated with reoperation or implant removal; however, prior wrist surgery showed a trend toward risk of implant removal after TWA.

Background: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables., Questions/purposes: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?, Methods: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized β coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics., Results: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did., Conclusion: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases., Clinical Relevance: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic., Competing Interests: This study received funding from NCATS/NIH (award number UL1TR000445). Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: Silastic metacarpophalangeal arthroplasty (SMPA) has proven to be a durable option for end-stage arthritis in the non-thumb digits, while fusion has been the mainstay procedure for the thumb metacarpophalangeal joint (MP). Few studies exist to comment on the viability of thumb MP arthroplasty. This study reports both survival and objective outcomes following SMPA of the thumb. Methods: In an institutional review board-approved retrospective study, we identified 18 patients who underwent thumb SMPA at a tertiary academic center by 3 board-certified hand surgeons. Primary outcome measures were implant survival and post-operative complications. Secondary outcomes measures were quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) scores, brief Michigan Hand Questionnaire (bMHQ), and postoperative pain as rated by the numerical rating scale. Results: Mean quickDASH and bMHQ scores at final follow-up were 35.6 and 70.6, respectively. The most common short-term complication was clinical deformity, followed by instability. The sole long-term complication was an implant dislocation in a previously asymptomatic patient. All patients reported reduction in pain. Three patients were indicated for revision surgery, 2 for persistent instability, and 1 for implant dislocation. Primary survivorship was 83% at mean follow-up of 5.8 years. Conclusions: Thumb SMPA is a viable option for end-stage arthritis. Pain relief in our series was unanimous. Among those that reported persistent symptoms or required revision, a majority had one or more key preoperative risk factors for failure as currently reported in literature. Larger, prospective series are needed to prove superior longevity and functional outcomes of thumb SMPA versus fusion.

Background: Range of motion (ROM) measurements of the fingers are frequently obtained during hand physical examinations. While traditionally measured by manual goniometry, smartphone photography introduces an alternative method of ROM measurement that also has potential telemedicine applications. The purpose of this study was to evaluate the reliability of smartphone photography measurements as an alternative to traditional goniometry, using the patient with Dupuytren disease as a model. Methods: Patients with a confirmed Dupuytren contracture were prospectively enrolled in this study. Range of motion measurements of the affected joints were obtained prior to any invasive treatments. Two sets of photographs were taken by both a clinical staff member and a nonclinical individual unaffiliated with the study. Both sets of photos were analyzed for degree of contracture via software analysis and compared against traditional goniometer measurements. Results: The study prospectively enrolled 50 consecutive patients with Dupuytren disease, comprising 123 affected joints. The mean contractures of all affected joints as measured by manual goniometry, trained photograph goniometry, and untrained photograph goniometry were 38.5, 35.3, and 35.5, respectively. The mean difference in contracture measurement was 3.2° between manual and trained photograph goniometry and 3.0° between manual and untrained photograph goniometry. There was no statistically significant difference between trained and untrained photo set measurements. Photograph measurements between separate raters demonstrated high consistency (intraclass correlation coefficient = 0.92). Conclusions: Smartphone photography provides contracture measurements equivalent to the accepted error of a finger goniometer (3.2° compared with 5°). The accuracy of smartphone photography in measuring contractures offers potential telemedicine applications for both clinical and research needs.

Introduction: Insurance claim rejections represent a challenge for healthcare providers because of the potential for lost revenue and administrative costs of reworking claims., Methods: The billing records of five hand and upper extremity surgeons at a tertiary academic center were queried for all patient billing activity over a 1-year period yielding a total of 14,421 unique patient encounters., Results: A total of 11,839 unique patient encounters were included, and the overall claim rejection rate was 19.3%. Claim rejection rate varied significantly by payer (P < 0.0001) and was lowest in private insurance (14.0%) and highest in Medicare (31.2%). The use of multiple Current Procedure Terminology codes for an encounter was independently associated with an increased risk of claim rejection for both office (25.6%, relative risk [RR] 1.27, 95% confidence interval [CI] 1.03 to 1.49, P = 0.0032) and surgical (25.6%, RR 1.67, 95% CI 1.28 to 2.18, P = 0.0002) settings. After multivariate regression adjustment, modifier 25 was associated with a decreased risk of claim rejection (23.3%, RR 0.72, 95% CI 0.61 to 0.85, P < 0.0001)., Discussion: Insurance claim rejection occurs frequently (19.3%) in hand/upper extremity surgery and varies by insurance type, with the highest rejection rate occurring in Medicare (31.2%). For a given encounter, the use of multiple Current Procedure Terminology codes and specific modifiers are predictive of rejection risk., Level of Evidence: Level III, prognostic.

The SARS-CoV-2 (COVID-19) pandemic has had a global influence on health care. The authors examined the early effect of hospital- and state-mandated restrictions on an orthopedic surgery department and hypothesized that the volume of ambulatory clinic encounters, office and surgical procedures, and cases would dramatically decrease. A retrospective review was performed of all encounters in an orthopedic surgery department at a level I academic trauma center during a 4-week period, from March 16, 2020, to April 12, 2020. The results were compared with two control 4-week periods, February 17, 2020, to March 15, 2020, and March 16, 2019, to April 12, 2019. Weekly volume and work relative value units (RVUs) of clinic encounters, office and surgical procedures, and cases were assessed. The type of ambulatory visit also was recorded. Comparisons of mean weekly volume and RVUs between the study and control periods were performed with Student's t test. Surgical cases were categorized into fracture or dislocation, acute soft tissue or nerve injury, infection, oncology, and elective or nonurgent. After implementation of hospital- and state-mandated restrictions on elective health care, the volume of ambulatory orthopedic surgery clinic encounters decreased by 74% to 77%, the volume of clinic procedures decreased by 95%, and the volume of surgical cases decreased by 88%. The percentage of clinic visits performed via telemedicine increased from 0.3% to 81.2%. Elective surgical cases ceased, and the volume of nonelective surgical cases decreased by 51%. During the first 4 weeks after COVID-19-related restrictions were imposed, an immediate and dramatic effect was observed. Compared with the control periods, significant reductions were seen in the volume of ambulatory encounters, office-based procedures, and surgical cases. In addition, the volume of nonelective surgical cases decreased by 51%. [Orthopedics. 2020;43(4):228-232.]., (Copyright 2020, SLACK Incorporated.)

The synovium is a mesenchymal tissue composed mainly of fibroblasts, with a lining and sublining that surround the joints. In rheumatoid arthritis the synovial tissue undergoes marked hyperplasia, becomes inflamed and invasive, and destroys the joint 1,2 . It has recently been shown that a subset of fibroblasts in the sublining undergoes a major expansion in rheumatoid arthritis that is linked to disease activity 3-5 ; however, the molecular mechanism by which these fibroblasts differentiate and expand is unknown. Here we identify a critical role for NOTCH3 signalling in the differentiation of perivascular and sublining fibroblasts that express CD90 (encoded by THY1). Using single-cell RNA sequencing and synovial tissue organoids, we found that NOTCH3 signalling drives both transcriptional and spatial gradients-emanating from vascular endothelial cells outwards-in fibroblasts. In active rheumatoid arthritis, NOTCH3 and Notch target genes are markedly upregulated in synovial fibroblasts. In mice, the genetic deletion of Notch3 or the blockade of NOTCH3 signalling attenuates inflammation and prevents joint damage in inflammatory arthritis. Our results indicate that synovial fibroblasts exhibit a positional identity that is regulated by endothelium-derived Notch signalling, and that this stromal crosstalk pathway underlies inflammation and pathology in inflammatory arthritis.

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P<.003; TB, P<.004). Age and body mass index (BMI) were associated with ROH plus symptomatic hardware after P&S. Age (but not BMI) was associated with ROH/symptomatic hardware after TB. Measured hardware prominence was not associated with ROH or ROH plus symptomatic hardware for either the P&S or the TB cohort. Risk factors including patient age and BMI were found to be significantly associated with hardware-related complications. [Orthopedics. 2020;43(3):141-146.]., (Copyright 2020, SLACK Incorporated.)

Purpose: The use of pyrolytic carbon arthroplasty (PCA) for the proximal interphalangeal (PIP) joint is controversial. The goal of this study was to evaluate the clinical and radiographic midterm outcomes of PIP joint PCA., Methods: Patients were contacted after PIP PCA at 6.4 ± 1.9 years (mean ± SD). Evaluation included grip and pinch strength and digital range of motion (ROM). Radiographs and patient reported outcomes surveys were obtained., Results: This study included 29 PIP joint PCA devices implanted in 23 hands among 19 patients. Seven devices underwent subsequent procedures. Three were removed and revised to silicone implants because of 2 dislocations and one implant migration. One underwent revision to a larger distal component. Three required soft tissue surgical revisions in which the implant was retained (one flexor digitorum superficialis tenodesis and 2 capsulectomies). At the time of latest follow-up, there was 86.2% original implant survivorship. The most recent radiographic review of the remaining 26 implants revealed 2 swan neck deformities and 2 implant migrations. Postoperative grip (38.4 ± 16.8 lb) and pinch (13.8 ± 2.7 lb) strength were 92% and 91%, respectively, of nonsurgical grip and pinch strength. Final mean ROM (range) for the metacarpophalangeal joint was 82.1° (60° to 100°) and for the PIP joint was 60.6° (20° to 110°). Mean outcome scores were: visual analog scale, 1.6 (± 2.4), Michigan Hand Questionnaire, 71.6 (± 17.6), and Disabilities of the Arm, Shoulder, and Hand, 24.7 (± 14.5)., Conclusions: Midterm follow-up (mean, 6.4 years) for 29 PCA implants in 19 patients revealed a surgical revision rate of 24.1%. Of the 29 implants, 13.8% were removed at a mean of 4.6 years (range, 1.3-7.9 years). Strength, ROM, and pain relief were all satisfactory., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: Despite the high prevalence, morbidity, and treatment costs for osteoporosis-related fractures, studies have shown that patients infrequently receive the recommended treatment for low bone density (LBD). This study investigated patient perceptions about evaluation, management, and willingness to pursue osteoporosis treatment to further elucidate potential barriers to LBD treatment., Methods: A survey was prospectively administered to patients over 50 years old addressing patient history of fragility fractures and osteoporosis evaluation and treatment, medication administration preferences, and willingness to start a new medication to treat or prevent future fragility fractures., Results: Three hundred twenty-five patients completed surveys (63.1% women, 36.9% men; mean age, 64.1 years). Patients reported the following: 50.8% had taken supplements or medication for LBD. Patients who had never taken LBD prescription medications were asked about their willingness to take these medications if physician-recommended. The mean response on a 0 to 10 scale was 7.3 ± 3.2, which was not significantly different between fracture or bone density subgroups. Several barriers to taking LBD medications were identified: 85.7% said no medical provider had prescribed them; 14.0% stated they already took too many medications; 10.4% were afraid of potential side effects; 4.3% had conflicting provider recommendations; and 1.8% cited financial concerns., Conclusions: Patients held a favorable opinion on taking LBD medications when prescribed. Although 29.8% of patients had an abnormal dual-energy x-ray absorptiometry (DEXA) result, 85.7% of all patients reported that no medical provider had prescribed LBD medications. A sizeable gap remains between current practice and optimal osteoporosis education and management., Clinical Relevance: Despite the large reported and increasing prevalence of osteoporosis in patients with upper extremity fragility fractures, the rate of treatment for LBD remains suboptimal., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The objective of this study was to evaluate and characterize the professional and educational information provided online by US orthopaedic surgeons., Methods: The American Academy of Orthopaedic Surgeons (AAOS) membership directory was used to randomly select 1% of physicians from each state. Name, sex, state, and date of membership were recorded from the AAOS online public membership directory. A Google search was conducted for each member of this cohort. Specific data gathered from each website included practice type, physician subspecialty, website focus (commercial or educational), and the quality of patient education presented were evaluated., Results: The cohort consisted of 246 orthopaedic surgeons, including 93.1% men and 6.9% women. The AAOS membership duration was less than 10 years for 48.0% of surgeons, 11 to 20 years for 28.9% of surgeons, and greater than 20 years for 23.2% of surgeons. At least one online profile was found for 94.3% of orthopaedic surgeons. Most surgeons, 66.8%, were identified as belonging to a group or solo private practice, although nearly half (48.7%) of all surgeons were also based out of a hospital. Most website profiles, 62.5%, were found to have an intermediate level of educational content, whereas 18.1% of website profiles did not provide any., Discussion: The clear majority of US-based orthopaedic surgeons have a professional presence online. Focus on social media or educational content differs regionally, but not based on years in practice., Level of Evidence: Level V, prognostic.

Since the advent of disease-modifying antirheumatic drugs for rheumatoid arthritis, orthopedic surgeons see fewer patients in the office who require hand surgery. However, a significant number of patients still seek surgical intervention to improve pain and function. These patients often present with isolated soft tissue pathologies, but even bone and joint pathology require meticulous soft tissue handling in this cohort. This review highlights the principles and techniques relevant to the management of soft tissue deformity in rheumatoid hand and wrist surgery, as exposure in training and practice continues to decrease.

Introduction: The purpose of this study was to assess whether median nerve ultrasonography (US) measurements correlate with the severity scale of electrodiagnostic studies (EDS) of carpal tunnel syndrome (CTS)., Methods: A retrospective review was conducted of patients aged ≥18 years who underwent both median nerve US and EDS. US measurements of the median nerve cross-sectional area at the distal wrist crease and forearm were used to calculate the median nerve wrist-to-forearm ratio. EDS severity was classified according to guidelines from the American Association of Electrodiagnostic Medicine., Results: A total of 112 wrists (n = 112) in 78 consecutive patients with a mean age of 59 (range, 26 to 88) years were included. Increased cross-sectional area at the distal wrist crease and wrist-to-forearm ratio were significantly correlated with increased EDS severity (P < 0.0001)., Discussion: Median nerve US measurements not only distinguished between normal and abnormal EDS but also correlated with the category of EDS severity., Level of Evidence: Diagnostic III.

Background: Opioid-prescribing patterns have been implicated as a contributing factor to the opioid epidemic, yet few evidence-based guidelines exist to assist health-care providers in assessing and possibly modifying their prescribing practices., Methods: Five orthopaedic hand surgeons at a level-I trauma center developed a postoperative prescribing guideline for 25 common hand and upper-extremity outpatient procedures, which were delineated into 5 tiers. Postoperative opioid prescriptions in a 3-month period after implementation of the protocol were compared with those from a 3-month period before implementation of the protocol., Results: There were 231 patients in the pre-implementation group and 287 patients in the post-implementation group. Each individual opioid protocol tier showed a significant decrease in the mean morphine milligram equivalents (MME) prescribed, ranging from a minimum decrease of 97.8% to a maximum decrease of 176.0%. After implementation, adherence to protocol was achieved in 55.1% of patients; the MME amounts prescribed were below protocol for 28.6% and above for 16.4%. The number of additional opioid prescriptions in the 1-month postoperative period was significantly less in the post-implementation group than in the pre-implementation group (p < 0.001). The total number of pills prescribed was reduced by a theoretical equivalent of over three thousand 5-mg oxycodone pills for the 287 patients in the 3-month period., Conclusions: By utilizing a simple consensus protocol, we have demonstrated success diminishing the number of opioids prescribed without leading to an increase in the number of secondary prescriptions written by our providers. These findings are encouraging and suggest that fewer opioids were left in the possession of patients, leaving fewer pills vulnerable to misuse, abuse, and diversion.

Fibroblasts regulate tissue homeostasis, coordinate inflammatory responses, and mediate tissue damage. In rheumatoid arthritis (RA), synovial fibroblasts maintain chronic inflammation which leads to joint destruction. Little is known about fibroblast heterogeneity or if aberrations in fibroblast subsets relate to pathology. Here, we show functional and transcriptional differences between fibroblast subsets from human synovial tissues using bulk transcriptomics of targeted subpopulations and single-cell transcriptomics. We identify seven fibroblast subsets with distinct surface protein phenotypes, and collapse them into three subsets by integrating transcriptomic data. One fibroblast subset, characterized by the expression of proteins podoplanin, THY1 membrane glycoprotein and cadherin-11, but lacking CD34, is threefold expanded in patients with RA relative to patients with osteoarthritis. These fibroblasts localize to the perivascular zone in inflamed synovium, secrete proinflammatory cytokines, are proliferative, and have an in vitro phenotype characteristic of invasive cells. Our strategy may be used as a template to identify pathogenic stromal cellular subsets in other complex diseases.

Purpose: To evaluate the efficacy of needle-free jet lidocaine (J-tip) administration for pain reduction in trigger finger corticosteroid injection compared with simultaneous lidocaine injection with corticosteroid., Methods: A prospective randomized clinical trial was performed in which patients received either 0.25 mL of 2% lidocaine administered by J-tip just prior to 0.5 mL of corticosteroid injection by needle or 0.5 mL of 1% lidocaine and 0.5 mL of corticosteroid administered simultaneously through a needle for the treatment of trigger finger. Both the expected pain preinjection and the actual pain experienced postinjection were measured with a visual analog scale (VAS). Pain catastrophizing scale (PCS) scores were recorded before injection., Results: The use of the J-tip demonstrated a lower mean actual pain, 3.3 VAS, compared with the control group, 4.6 VAS. Both study groups anticipated more pain than they actually experienced. The PCS did not correlate to pre- or post-injection scores., Conclusions: Needle-free jet administration of lidocaine reduces the pain associated with trigger finger injection. Patients anticipate more pain than they experience with trigger finger injection., Type of Study/level of Evidence: Therapeutic I., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Technology has enhanced modern health care delivery, particularly through accessibility to health information and ease of communication with tools like mobile device messaging (texting). However, text messaging has created new risks for breach of protected health information (PHI). In the current study, we sought to evaluate hand surgeons' knowledge and compliance with privacy and security standards for electronic communication by text message., Methods: A cross-sectional survey of the American Society for Surgery of the Hand membership was conducted in March and April 2016. Descriptive and inferential statistical analyses were performed of composite results as well as relevant subgroup analyses., Results: A total of 409 responses were obtained (11% response rate). Although 63% of surgeons reported that they believe that text messaging does not meet Health Insurance Portability and Accountability Act of 1996 security standards, only 37% reported they do not use text messages to communicate PHI. Younger surgeons and respondents who believed that their texting was compliant were statistically significantly more like to report messaging of PHI (odds ratio, 1.59 and 1.22, respectively)., Discussion: A majority of hand surgeons in this study reported the use of text messaging to communicate PHI. Of note, neither the Health Insurance Portability and Accountability Act of 1996 statute nor US Department of Health and Human Services specifically prohibits this form of electronic communication. To be compliant, surgeons, practices, and institutions need to take reasonable security precautions to prevent breach of privacy with electronic communication., Clinical Relevance: Communication of clinical information by text message is not prohibited under Health Insurance Portability and Accountability Act of 1996, but surgeons should use appropriate safeguards to prevent breach when using this form of communication., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: As health care costs continue to rise, providers must increasingly identify and implement cost-effective practice measures without sacrificing quality of care. Corticosteroid injections are an established treatment for trigger finger; however, numerous clinical trials have documented the limited efficacy of these injections in the diabetic population. Furthermore, the most cost-effective treatment strategy for diabetic trigger finger has not been determined. The purpose of this study was to perform a decision analysis to identify the least costly strategy for effective treatment of diabetic trigger finger using existing evidence in the literature., Methods: Four treatment strategies for diabetic trigger finger were identified: (1) 1 steroid injection followed by surgical release, (2) 2 steroid injections followed by surgical release, (3) immediate surgical release in the operating room, and (4) immediate surgical release in the clinic. A literature review was conducted to determine success rates of the different treatment strategies. Costing analysis was performed using our institutional reimbursement from Medicare. One-way sensitivity and threshold analysis was utilized to determine the least costly treatment strategy., Results: The least costly treatment strategy was immediate surgical release in the clinic. In patients with insulin-dependent diabetes mellitus, this strategy results in a 32% and a 39% cost reduction when compared with treatment with 1 or 2 corticosteroid injections, respectively. For 1 or 2 corticosteroid injections to be the most cost-effective strategy, injection failure rates would need to be less than 36% and 34%, respectively. The overall cost of care for immediate surgical release in the clinic was $642., Conclusions: Diabetic trigger finger is a common problem faced by hand surgeons, with a variety of acceptable treatment algorithms. Management of diabetic trigger finger with immediate surgical release in the clinic is the most cost-effective treatment strategy, assuming a corticosteroid injection failure rate of at least 34%., Type of Study/level of Evidence: Economic/decision III., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The U.S. Food and Drug Administration approved the use of collagenase Clostridium histolyticum (CCH) in the United States in February 2010. This study addresses the impact of that approval on the number of Dupuytren contracture (DC) encounters and treatment patterns in the United States., Methods: Using the Intercontinental Marketing Services Health Office-Based Medical Claims database, we identified the monthly number of DC encounters and DC procedures between January 2007 and December 2013. Collagenase Clostridium histolyticum usage data from March 2010 to December 2013 was derived from the U.S. CCH manufacturer's data warehouse. Using the combined data, the yearly increasing trends in DC encounters and treatment volume were compared before and after the introduction of CCH. Time trends in the relative procedure frequencies were then examined. Finally, the presence of seasonal variation was tested for in each treatment type., Results: Dupuytren contracture encounters increased on average by 19,015 per year between 2007 and 2009, whereas between 2011 and 2013, DC encounters increased on average by 34,940 per year. In terms of absolute procedure counts, the surgery trend line began decreasing in 2010 with the release of CCH. Meanwhile, CCH continuously increased between 2010 and 2013, and needle aponeurotomy (NA) remained relatively stable. By the year 2013, minimally invasive techniques (NA and CCH) comprised 39% of all treatment, compared with only 14% in 2007. Lastly, there was a statistically significant seasonal increase in the number of surgical procedures during the wintertime but no seasonal variation in NA or CCH., Conclusions: After the introduction of CCH, the number of Dupuytren encounters increased at a greater annual rate. The introduction and growth of CCH coincided with a decrease in surgery. The number of NA procedures remained steady throughout the study period. The number of open surgery cases followed a predictable seasonal variation with more procedures during the winter months, but this seasonal variation was not seen with less invasive techniques., Type of Study/level of Evidence: Economic/Decision Analysis II., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Controversy exists regarding intra-operative treatment of residual proximal interphalangeal joint contractures after Dupuytren's fasciectomy. We test the hypothesis that a simple release of the digital flexor sheath can correct residual fixed flexion contracture after subtotal fasciectomy. We prospectively enrolled 19 patients (22 digits) with Dupuytren's contracture of the proximal interphalangeal joint. The average pre-operative extension deficit of the proximal interphalangeal joints was 58° (range 30-90). The flexion contracture of the joint was corrected to an average of 28° after fasciectomy. In most digits (20 of 21), subsequent incision of the flexor sheath further corrected the contracture by an average of 23°, resulting in correction to an average flexion contracture of 4.7° (range 0-40). Our results support that contracture of the tendon sheath is a contributor to Dupuytren's contracture of the joint and that sheath release is a simple, low morbidity addition to correct Dupuytren's contractures of the proximal interphalangeal joint. Additional release of the proximal interphalangeal joint after fasciectomy, after release of the flexor sheath, is not necessary in many patients., Level of Evidence: IV (Case Series, Therapeutic)., (© The Author(s) 2015.)

Purpose: To understand the ethical and professional implications of physician behavior changes secondary to online physician-rating Web sites (PRWs)., Methods: The American Society for Surgery of the Hand (ASSH) Ethics and Professionalism Committee surveyed the ASSH membership regarding PRWs. We sent a 14-item questionnaire to 2,664 active ASSH members who practice in both private and academic settings in the United States., Results: We received 312 responses, a 12% response incidence. More than 65% of the respondents had a slightly or highly unfavorable impression of these Web sites. Only 34% of respondents had ever updated or created a profile for PRWs, although 62% had observed inaccuracies in their profile. Almost 90% of respondents had not made any changes in their practice owing to comments or reviews. One-third of respondents had solicited favorable reviews from patients, and 3% of respondents have paid to improve their ratings., Conclusions: PRWs are going to become more prevalent, and more research is needed to fully understand the implications. There are several ethical implications that PRWs pose to practicing physicians. We contend that it is morally unsound to pay for good reviews. The recourse for physicians when an inaccurate and potentially libelous review has been written is unclear. Some physicians have required patients to sign a waiver preventing them from posting negative comments online. We propose the development of a task force to assess the professional, ethical, and legal implications of PRWs, including working with companies to improve accuracy of information, oversight, and feedback opportunities., Clinical Relevance: It is expected that PRWs will play an increasing role in the future; it is unclear whether there will be a uniform reporting system, or whether these online ratings will influence referral patterns and/or quality improvement., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: A single volar locking plate (VLP) is now frequently used for open reduction and internal fixation (ORIF) of many types of distal radius fractures. Comminuted intra-articular distal radius fractures (AO C3-type) are typically the most challenging to surgically treat. No studies directly address the adequacy of a VLP alone for maintaining reduction of AO C-type fractures. We hypothesized that a single VLP provides an effective method for maintaining reduction for these fractures., Methods: We retrospectively evaluated radiographs of a series of AO C-type fractures. Seventy-seven patients with 77 AO C3-type fractures were identified from billing records and were eligible for the study. All patients were treated by fellowship-trained hand surgeons. Radiographs at the time of union were compared to those from immediately postoperatively., Results: Sixty-nine of 77 (89.6 %) fractures treated with VLP fixation alone for AO C3-type distal radius fractures united without loss of reduction. Eight of 77 (10.4 %) patients treated with VLP for AO C3 fractures lost reduction. The most common fracture fragment to lose reduction was the lunate fossa (5 of 8); loss of reduction of the scaphoid fossa die-punch fragment (2 of 8) and the radial styloid (1 of 8) were also seen., Conclusions: The majority (89.6 %) of AO C3-type fractures treated with a single volar locking plate come to union without loss of reduction., Level of Evidence: Level IV.

Collagenase enzymatic fasciotomy is an accepted nonsurgical treatment for disabling hand contractures caused by Dupuytren disease. We conducted a study to investigate use of collagenase in an immunosuppressed population. We retrospectively reviewed data from 2 academic hand surgical practices. Eight patients on chronic immunosuppressive therapies were treated with collagenase for digital contractures between 2010 and 2011. Thirteen collagenase enzymatic fasciotomies were performed in these 8 patients. Mean preinjection contracture was 53.0°. At mean follow-up of 6.7 months, mean magnitude of contracture improved to 12.9°. Mean metacarpophalangeal joint contracture improved from 42.0° to 4.2°. Mean proximal interphalangeal joint contracture improved from 65.8° to 21.7°. Three of the enzymatic fasciotomies were complicated by skin tears. There were no infections. As more patients seek nonsurgical treatment for Dupuytren disease, its safety and efficacy in select cohorts of patients should continue to be evaluated prospectively.

Background: Corticosteroid injections are commonly used in the treatment of carpal tunnel syndrome in adults. This study sought to determine success rates early on and at one year postoperatively of a single corticosteroid injection while identifying prognostic indicators for symptom recurrence and repeat intervention., Methods: Fifty-four consecutive wrists in forty-nine patients with carpal tunnel syndrome treated with a single corticosteroid injection were prospectively enrolled. Demographic data and information on comorbidities were identified with a study-specific questionnaire. The Boston Carpal Tunnel Questionnaire was administered prior to injection. Patients returned to clinic at six weeks and were contacted at three, six, nine, and twelve months post-injection to determine symptom and intervention status. Kaplan-Meier analysis and Cox regression modeling were used to estimate recurrence rates and to identify predictors of symptom recurrence and repeat intervention., Results: Fifty-four symptomatic wrists in forty-nine patients with a mean age of fifty-three years were included. Two patients (two wrists) were lost to follow-up. Patients reported symptom recurrence in thirty-one wrists at a median duration of 155 days post-injection. Nineteen wrists underwent carpal tunnel release at a median time of 181 days after the injection. No patient underwent a repeat injection. In our study, diabetic patients were at a 2.6-fold greater risk of reporting recurring symptoms within a one-year follow-up period. Survivorship free from symptom recurrence was 53% at six months and 31% at twelve months; survivorship from repeat intervention was 81% at six months and 66% at twelve months., Conclusions: A single injection achieved symptom relief in 79% of patients at six weeks; these results were maintained in 31% of patients at twelve months. Diabetic patients were at higher risk of symptom recurrence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

The value of post-operative radiographs following stabilization of Arbeitsgemeinschaft für Osteosynthesefragen (AO) type A distal radius fractures with volar locking plates is unclear. We examined the value of post-operative radiographs of type A fractures treated with volar locking plates. A retrospective review was performed on all AO type A distal radius fractures treated with volar locking plates between 2007 and 2010 at two institutions. A total of 158 patients receiving 446 sets of post-operative radiographs were included. Reviewing all clinic, emergency, and operative notes, we found that 94% of radiographs were performed as routine follow-up, with no set of post-operative radiographs demonstrating findings of hardware/fracture site complications. All cases requiring further workup or interventions were heralded by patient complaints. Routine post-operative radiographs following volar locking plates for extra-articular distal radius fractures did not demonstrably alter clinical decision making; this is an area where a reduction in resource utilization would not seem to alter clinical quality care, but further studies with larger populations are needed to establish the incidence of radiographic problems prior to symptom occurrence. Level of evidence: Diagnostic III., (© The Author(s) 2014.)