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The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse total shoulder arthroplasty (rTSA) for proximal humerus fracture. We performed a retrospective study of 153 patients who underwent rTSA for proximal humerus fracture at two level 1 trauma centers from 2003 to 2018 with minimum 2-year follow-up. Frailty was assessed using the modified 5-item frailty index (mFI). The primary outcome variable was the American Shoulder and Elbow Surgeons (ASES) shoulder score at minimum 2-year follow-up. The secondary outcome variables were the Shoulder Pain and Disability Index (SPADI), the Shoulder Subjective Value (SSV), the 0 to 10 numeric rating scale (NRS) pain score, surgical complication, and reoperation. Bivariate comparisons were made between mFI and outcome variables. The mean age of the 153 patients was 70 years, and 76% were women. Forty patients (26%) had a mFI score of 0, 65 patients (42%) had a mFI score of 1, 40 patients (26%) had a mFI score of 2, and 8 patients (5%) had a mFI score of 3. Twenty-seven patients (18%) had complications, and 21 patients (14%) underwent reoperation. At minimum 2-year follow-up, mFI was not associated with ASES shoulder score, SPADI, SPADI pain or disability subscales, SSV, NRS pain score, active and passive shoulder forward flexion, abduction, and external rotation, complication, or reoperation. Provided they survive the initial physiologic insults of trauma and surgery, patients with higher mFI scores treated with rTSA for proximal humerus fracture can expect similar medium-term restoration of shoulder function. [ Orthopedics . 202x;4x(x):xx–xx.]

The objective of this study was to identify factors independently associated with complications, hospital readmission, reoperation, and death in the 30-day period after surgical treatment of isolated olecranon fractures. A retrospective case-control study was performed using the National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for patients who underwent surgical treatment of isolated olecranon fractures from 2011 to 2020. A total of 4404 patients were included. The main study outcomes were 30-day medical or wound complications, hospital readmission, reoperation, and death. A bivariate screen was performed for explanatory variables associated with our outcome variables, and variables with P Orthopedics . 202x;4x(x):xx–xx.]

The neuroinflammatory response to surgery can be characterized by peripheral acute plasma protein changes in blood, but corresponding, persisting alterations in cerebrospinal fluid (CSF) proteins remain mostly unknown. Using the SOMAscan assay, we define acute and longer-term proteome changes associated with surgery in plasma and CSF. We hypothesized that biological pathways identified by these proteins would be in the categories of neuroinflammation and neuronal function and define neuroinflammatory proteome changes associated with surgery in older patients.SOMAscan analyzed 1305 proteins in blood plasma (n = 14) and CSF (n = 15) samples from older patients enrolled in the Role of Inflammation after Surgery for Elders (RISE) study undergoing elective hip and knee replacement surgery with spinal anesthesia. Systems biology analysis identified biological pathways enriched among the surgery-associated differentially expressed proteins in plasma and CSF.Comparison of postoperative day 1 (POD1) to preoperative (PREOP) plasma protein levels identified 343 proteins with postsurgical changes (P.05; absolute value of the fold change [|FC|]1.2). Comparing postoperative 1-month (PO1MO) plasma and CSF with PREOP identified 67 proteins in plasma and 79 proteins in CSF with altered levels (P.05; |FC|1.2). In plasma, 21 proteins, primarily linked to immune response and inflammation, were similarly changed at POD1 and PO1MO. Comparison of plasma to CSF at PO1MO identified 8 shared proteins. Comparison of plasma at POD1 to CSF at PO1MO identified a larger number, 15 proteins in common, most of which are regulated by interleukin-6 (IL-6) or transforming growth factor beta-1 (TGFB1) and linked to the inflammatory response. Of the 79 CSF PO1MO-specific proteins, many are involved in neuronal function and neuroinflammation.SOMAscan can characterize both short- and long-term surgery-induced protein alterations in plasma and CSF. Acute plasma protein changes at POD1 parallel changes in PO1MO CSF and suggest 15 potential biomarkers for longer-term neuroinflammation that warrant further investigation.

Background: Ulnar neuropathy at the elbow is the second most common upper extremity compressive neuropathy and surgical treatment often involves surgical trainee involvement. The primary aim of this study is to determine the effect of trainees and surgical assistants on outcomes surrounding cubital tunnel surgery. Methods: This retrospective study included 274 patients with cubital tunnel syndrome who underwent primary cubital tunnel surgery at two academic medical centres between 1 June 2015 and 1 March 2020. The patients were divided into four main cohorts based on primary surgical assistant: physician associates (PA, n = 38), orthopaedic or plastic surgery residents (n = 91), hand surgery fellows (n = 132), or both residents and fellows (n = 13). Exclusion criteria included patient age Results: Patients in all cohorts had similar demographic and clinical characteristics. There was a significantly higher rate of subcutaneous transposition in the PA cohort (39.5% PA vs. 13.2% Resident vs. 19.7% Fellow vs. 15.4% Resident + Fellow). Presence of surgical assistants and trainees had no association with length of surgery, complications and reoperation rates. Although male sex and ulnar nerve transposition were associated with longer operative times, no explanatory variables were associated with complications or reoperation rates. Conclusions: Surgical trainee involvement in cubital tunnel surgery is safe and has no effect on operative time, complications or reoperation rates. Understanding the role of trainees and measuring the effect of graduated responsibility in surgery is important for medical training and safe patient care. Level of Evidence: Level III (Therapeutic)

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)

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a rare but serious complication of total shoulder arthroplasty (TSA). Owing to limited evidence, Clinical Practice Guideline recommendations for VTE chemoprophylaxis after TSA rely heavily on the risk stratification of individual patients. The objectives of this study were to identify the prevalence and risk factors independently associated with VTE, PE, and DVT in the 30-day postoperative period after TSA.A retrospective case-control study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for total shoulder arthroplasty from 2011 to 2020. The initial query resulted in 33,089 patients. After applying exclusion criteria for age younger than 50 years, emergency surgery, and open wound or infection, a final cohort of 31,918 patients who underwent TSA were included. The primary outcome was venous thromboembolism, and secondary outcome variables were PE and DVT. A bivariate screen was done for explanatory variables associated with our outcome variables, and variables with P0.1 in the bivariate screen were included in a multivariable logistic regression model.Of the 31,918 patients in our cohort, 183 patients (0.573%) developed VTE, 92 patients (0.29%) developed PE, and 104 patients (0.326%) developed DVT during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, higher body mass index, longer surgical time, and longer hospital length of stay were associated with VTE and PE and that hypertension and shorter hospital length of stay were associated with DVT.The prevalence of VTE after TSA is low. Older patients, patients with higher body mass index, and patients with longer surgical durations are at higher risk for VTE after TSA. Our findings are relevant for preoperative risk stratification and the decision for chemoprophylaxis.Level III Prognostic.

Background: The objective of this study was to assess whether resident involvement in distal radius fracture open reduction internal fixation (ORIF) affect 30-day postoperative complication, hospital readmission, reoperation and operative time. Methods: A retrospective study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database by querying the Current Procedural Terminology (CPT) codes for distal radius fracture ORIF from 1 January 2011 to 31 December 2014. A final cohort of 5,693 adult patients who underwent distal radius fracture ORIF during the study period were included. Baseline patient demographics and comorbidities, intraoperative factors, including operative time and 30-day postoperative outcomes, including complications, readmission and reoperations, were collected. Bivariate statistical analyses were performed to identify variable associated with complication, readmission, reoperation and operative time. The significance level was adjusted using a Bonferroni correction as multiple comparisons were performed. Results: In this study of 5,693 patients who underwent distal radius fracture ORIF, 66 patients had a complication, 85 patients were readmitted and 61 patients underwent reoperation within 30 days of surgery. Resident involvement in the surgery was not associated with 30-day postoperative complication, readmission or reoperation, but was associated with longer operative time. Moreover, 30-day postoperative complication was associated with older age, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension and bleeding disorder. Thirty-day readmission was associated with older age, ASA classification, diabetes mellitus, COPD, hypertension, bleeding disorder and functional status. Thirty-day reoperation was associated with higher body mass index (BMI). Longer operative time was associated with younger age, male sex and the absence of bleeding disorder. Conclusions: Resident involvement in distal radius fracture ORIF is associated with longer operative time, but no difference in rates of episode-of-care adverse events. Patients may be reassured that resident involvement in distal radius fracture ORIF does not negatively impact short-term outcomes. Level of Evidence: Level IV (Therapeutic)

Purpose The impact of the SARS-CoV-2 (COVID-19) coronavirus has been felt worldwide, impacting all aspects of healthcare. We examined the quantitative impact during the first four weeks of hospital system and state-mandated restrictions on elective healthcare on an academic urban hand surgery practice. We hypothesized that the volume of overall ambulatory clinic encounters, office procedures, and surgical procedures and cases would dramatically decrease during this time and that the volume of non-elective care would remain unchanged. Methods We retrospectively reviewed all patient encounters in a 4-week time period from March 16, 2020 through April 12, 2020 for an academic orthopedic hand surgery practice and compared those to two control 4-week time periods: February 17, 2020 through March 15, 2020 and March 16, 2019 through April 12, 2019. Weekly encounter volumes and work relative value units (RVUs) were obtained for ambulatory clinic encounters, office procedures, and surgical procedures and cases. The type of ambulatory visit, in-person or telemedicine was also identified. Surgical cases were categorized into four types: fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/non-urgent for the two most recent time periods. T-tests were performed to compare weekly volume and RVUs between time periods. Results After the implementation of mandated restrictions on elective healthcare, ambulatory hand surgery clinic encounters decreased 72-73%, clinic procedures decreased by 87-90%, and surgical cases decreased by 87-88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. All elective surgery was deferred. 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 COVID-19 restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There was a significant decrease in ambulatory encounter volume, office procedures, and surgical cases. Non-elective surgical case volume also decreased by 47%. The long-term financial impact of this change in practice on providers, practices, patients and hospitals is still to be determined but based on the quantitative impacts seen, is likely to be substantial.

The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables.We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables.Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51).Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.

Background: The outcomes of cubital tunnel syndrome surgery are affected by preoperative disease severity. The aim of this study was to identify factors associated with clinical and electrodiagnostic severity of cubital tunnel syndrome at presentation. Methods: We retrospectively identified 213 patients with electrodiagnostically confirmed cubital tunnel syndrome who underwent cubital tunnel surgery from July 2008 to June 2013. Our primary response variable was clinical cubital tunnel syndrome severity assessed by the McGowan grade. Our secondary response variables were sensory nerve action potential (SNAP) recordability, presence of fibrillations, and motor nerve conduction velocities (CVs) in the abductor digiti minimi (ADM) and first dorsal interosseous (FDI). Bivariate analysis was used to screen for factors associated with disease severity; significant variables were selected for multivariable regression analysis. Results: Older age was associated with higher McGowan grade and diabetes mellitus was associated with unrecordable SNAPs on bivariate analysis. No other variables met inclusion criteria for multivariable regression analysis for McGowan grade or unrecordable SNAPs. Multivariable regression analysis showed older age and higher Distressed Communities Index (DCI) to be associated with decreased motor nerve CVs in ADM. Multivariable regression analysis showed higher body mass index (BMI) and higher DCI to be associated with decreased motor nerve CVs in FDI. No variable was associated with the presence of fibrillations. Conclusions: A subset of patients with cubital tunnel syndrome may benefit from earlier referral for hand surgery evaluation and earlier surgery. Older patients, with higher BMI, with diabetes mellitus, and with economic distress are at higher risk for presentation with more severe disease.

The medical application of 3-dimensional printing technology has evolved in the last decade, with an increasing variety of uses in hand surgery. The ability for patient-specific design, rapid prototyping, and low cost of production of 3-dimensional printed materials has led to this rise in clinical applications, both for common procedures and complex reconstructions. Within hand surgery, 3-dimensional printing can be applied in several broad categories: to construct patient-specific models for preoperative planning, to design orthotics and prosthetics to meet specific patient demands, to create patient-specific aids for intraoperative use, to generate patient-specific hardware and prostheses for implantation, and for applications for trainee education.

Background Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures. Methods Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation. Results Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture. Conclusions Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk. Level of evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. Questions/purposes (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. Methods In an institutional review board-approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. Results The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. Conclusion Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. Level of evidence Level IV, therapeutic study.

Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications.Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups.Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group.Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group.Prognostic IV.

Background: The objective of this study was to determine whether economic well-being is associated with patient-reported functional outcomes and range of motion 1 year following volar plate fixation of distal radius fracture. Methods: A retrospective study was performed on 200 patients with distal radius fractures treated with volar plate fixation at two Level 1 trauma centres from 2006 to 2017 with 1-year clinical follow-up using a previously published cohort. The economic well-being of patients was assessed using the Distressed Communities Index (DCI). Our outcome variables were patient-reported functional outcomes assessed by QuickDASH score and wrist and forearm range of motion 1 year after surgery. The analysis of variance (ANOVA) test was used to compare outcome variables across pre-established tiers of economic well-being. Results: The mean QuickDASH score at 1 year following distal radius fracture volar plate fixation was 10.8 and ranged from 7.3 to 12.2 across tiers of economic well-being. QuickDASH score and wrist range of motion were not significantly different across all tiers of economic well-being. However, wrist flexion–extension arc at 1 year following surgery was significantly decreased in the economically at-risk group compared with the remaining cohort. Conclusions: Patient-reported functional outcomes 1 year after volar plate fixation of distal radius fracture are similar across tiers of economic well-being. Economically disadvantaged patients are at risk for poorer wrist motion following distal radius fracture surgery, though it is not clear if this difference is clinically significant. Level of Evidence: Level II (Prognostic)

Despite increased utilization, recent temporal trends in patient comorbidities and episode-of-care outcomes for distal radius fracture open reduction and internal fixation (ORIF) have not been studied. The objective of this study was to assess 10-year national trends in (1) patient characteristics and comorbidities and (2) 30-day postoperative adverse outcomes for patients who underwent distal radius fracture ORIF using a large patient database.A retrospective study was conducted using the National Surgical Quality Improvement Program database by querying the procedural codes for distal radius fracture ORIF from January 1, 2011, to December 31, 2020. A cohort of 28,616 adult patients who underwent distal radius fracture ORIF during the study period was included. Baseline patient characteristics and 30-day postoperative outcome data were collected for each year of the study. Temporal trends from 2011 to 2020 for all variables were assessed using the two-tailed Mann-Kendall trend test.Of the 28,616 patients in the study cohort, the mean age was 56.4 years and 73.1% were female. Demographically, there was a trend toward higher body mass index, higher American Society of Anesthesiologists classification, and lower proportions of active smokers; functionally dependent patients; and patients with hypertension, chronic obstructive pulmonary disease, and bleeding disorder. There was a trend toward worse sepsis physiology and wound classification on presentation. There was a trend toward fewer blood transfusions, hospital readmissions, and revision surgeries; however, there was an increasing trend for the development of a superficial surgical site infection.Ten-year national trends in distal radius fracture ORIF demonstrated improvements in several important patient comorbidities and the rates of readmission and revision surgery. However, overall patient comorbidities, sepsis physiology, and wound classification have worsened, and the rate of superficial surgical site infections has increased. Trends in patient comorbidities and episode-of-care outcomes should be considered when transitioning toward value-based care models.

BACKGROUND The diagnosis of bone mineral density (BMD) abnormalities involves dual-energy x-ray absorptiometry (DXA), but few patients complete this after a fragility fracture. The assessment of BMD using Hounsfield unit (HU) measurements from computed tomography (CT) scans has been correlated with DXA results in previous studies. We aimed to evaluate the correlation between shoulder CT HU and DXA scores. METHODS Billing databases of 3 academic institutions were queried for patients who underwent both DXA and CT scan of the upper extremity within 1 year of each other. DXA T-scores for spine, hip, and femoral neck were recorded. BMD status was defined based on composite T-scores, using the lowest T-score in the spine, hip, or proximal femur. CT scans were measured for HU over 4 slices, recorded to create a bone column, then averaged. The patients' risks of major osteoporosis-related fracture and hip fracture were calculated using the Fracture Risk Assessment Tool. RESULTS In total, 300 patients were included. A positive correlation was found between composite T-scores and HU for glenoid and proximal humerus (0.36; 0.17). The proximal humerus HU was significantly associated with the BMD T-score for the hip (P = 0.01); the glenoid HU was significantly associated with BMD T-scores for the hip, spine, and femoral neck (P = 0.002; P = 0.001; P = 0.002). A 10-year risk of hip fracture >3% was associated with lower proximal humerus HU. CONCLUSIONS Our study is the first to discover significant correlations between HU at the glenoid and proximal humerus and risk factors as established by the Fracture Risk Assessment Tool scoring system. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective The objectives of this study were 1) to assess the long-term patient-reported outcomes of carpal tunnel release (CTR) in patients 80 years of age or older, and 2) to determine the long-term mortality rate of this population after CTR. Methods We performed a retrospective study of 96 patients who underwent CTR at 80 years of age or older from July 2008 to June 2013. Mortality was assessed by medical records, the Social Security Death Index, and telephone contact. Living patients were contacted for long-term follow-up, and functional outcomes and patient satisfaction were assessed. Results The mean age of the 96 patients at time of CTR was 84.1 years, including 89 octogenarian patients and 7 nonagenarian patients, and 67% were female. At an average of 9 years from surgery, the mortality rate of our cohort was 53% (51 of 96 patients). Five patients died within 1 year after CTR; no factor associated with early mortality after CTR was identified in the bivariate analysis. Telephone follow-up at an average of 9 years after CTR was available for 15 patients. Mean Boston Carpal Tunnel Syndrome Questionnaire symptom severity score was 1.6 points, mean Boston Carpal Tunnel Syndrome Questionnaire functional status score was 1.8 points, mean Quick Disabilities of the Arm, Shoulder and Hand score was 27.9, and mean satisfaction was 7.1. Eighty percent of patients reported that they would rechoose CTR. Conclusions There are long-term benefits from CTR in patients 80 years of age or older. The mortality rate of this cohort mirrors that of the general population, and CTR is justified in this elderly age group both for the magnitude and duration of treatment effect.

Midshaft clavicle fractures are common injuries that traditionally have been managed nonoperatively. However, recent literature has shown lower rates of nonunion and improved patient-reported outcomes with surgical management. The rate of implant removal after surgical fixation varies across the literature from 5% to 82%, depending on the method of fixation. We performed a retrospective review of all patients who underwent open reduction and internal fixation (ORIF) with plate-and-screw constructs for midshaft fractures of the clavicle at 2 level I trauma centers to determine the rate of implant removal and identify variables associated with implant removal. We collected all patient-, injury-, and treatment-specific factors as well as information on reoperation for removal of implants. Bivariate analysis and multivariable logistic regression analysis were used to assess whether explanatory factors were associated with removal of implants after ORIF for midshaft clavicle fractures. Of the 146 patients who were treated with ORIF for midshaft clavicle fractures with plate-and-screw constructs, 41 (28%) underwent removal of the implant. The median follow-up was 836 days (interquartile range, 457–1567 days). Variables associated with increased risk of implant removal included anterior plate position (odds ratio, 5.32; 95% CI, 2.01–14.1) and number of holes in the plate (odds ratio, 1.28; 95% CI, 1.00–1.63). These results question whether anterior plating results in less implant prominence and less subsequent removal of implants. [ Orthopedics . 2022;45(4):e201–e206.]

OBJECTIVE The primary objective of this study was to identify differences in the treatment approach for isolated, displaced midshaft clavicle fractures in adolescent patients 15-18 years of age at adult versus pediatric hospitals. The secondary objective of this study was to identify factors associated with the surgical treatment of these fractures in this age group. DESIGN Retrospective cohort study. SETTING Two adult and one pediatric tertiary care referral hospitals. PATIENTS/PARTICIPANTS Adolescent patients 15-18 years of age with isolated, displaced midshaft clavicle fractures treated at 2 adult tertiary care referral hospitals and one pediatric tertiary care referral hospital were identified. A total of 214 patients, 105 from the adult hospitals and 109 from the pediatric hospital, were included. INTERVENTION Nonoperative versus surgical treatment of clavicle fractures. MAIN OUTCOME MEASUREMENT Surgical treatment. RESULTS A multivariable logistic regression analysis showed that superior-inferior fracture displacement [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06-1.20], dominant upper extremity injury (OR 2.60, 95% CI 1.19-5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28-12.2) were independently associated with the surgical treatment of adolescent displaced midshaft clavicle fractures. CONCLUSIONS After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high-quality prospective outcome studies. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: De Quervain tenosynovitis of the wrist is a common pathology. The primary aim of this study is to determine the prevalence of extensor pollicis brevis and abductor pollicis longus (APL) anatomical variations in association with de Quervain tenosynovitis. The secondary aim was to compare additional patient-specific factors associated with de Quervain tenosynovitis. Methods: This retrospective study included 172 patients with de Quervain tenosynovitis who underwent first dorsal compartment release and 179 patients with thumb carpometacarpal (CMC) arthritis who underwent thumb CMC arthroplasty between August 1, 2007, and May 1, 2022. The CMC group was chosen as the control group because the study surgeons perform APL suspensionplasty as the primary procedure for thumb CMC arthritis, allowing for a comparison group without de Quervain tenosynovitis. Exclusion criteria included patients undergoing revision surgery, patients undergoing thumb CMC procedure other than APL suspensionplasty, and patients with both CMC and first dorsal compartment diagnoses. Demographics, clinical variables, and intraoperative findings were collected through retrospective chart reviews. Results: Patients in the de Quervain tenosynovitis group tended to be younger (51 years, range: 23-92 years vs 63 years, range: 28-85 years), women (86.1% vs 77.1%), and more commonly of African American or black race (15.7% vs 3.9%) and Asian race (5.2% vs 0%). There was a higher prevalence of tendon subcompartments (79.1% vs 64.2%), but fewer number of APL slips (38.3% vs 20.7% 2 or fewer slips) seen in the de Quervain tenosynovitis group. Conclusion: Anatomical variation exists between patients with and without de Quervain tenosynovitis. The presence of tendon subcompartments but not an increased number of tendon slips is associated with de Quervain tenosynovitis.

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.

Introduction The objectives of this study were to assess long-term outcomes, complications, and reoperations after open reduction internal fixation (ORIF) of radial head fractures. Materials and Methods 35 adult patients, who underwent ORIF of an isolated, displaced radial head fracture without elbow instability (Mason classification type II or III) at two tertiary care referral centers from 2000 to 2017, were identified. Patient satisfaction, pain, and QuickDASH scores were assessed by telephone follow-up at median 12.9 years. Results The mean age of the 35 patients in our study was 39 years, and 54% were women. The median length of clinical follow-up was 175 days. Postoperative complications occurred in 54% of patients, and reoperations in 23% of patients. Multivariable logistic regression identified fixation with plate and screws versus screws alone as a risk factor for complications and reoperations. The long-term telephone follow-up response rate was 54%. At 13-year median follow-up, the average patient satisfaction was 9.6/10, the average patient-reported pain was 0.7/10, and the average QuickDASH score was 10.5. Conclusion The long-term outcomes of ORIF of Mason classification type II and III radial head fractures are favorable; however, rates of complication and reoperation are notable and may be higher with plate-and-screw fixation.

Background: The primary objective of this study was to assess patient preferences for collagenase Clostridium histolyticum (CCH) treatment versus limited surgical fasciectomy in a cohort that has undergone both treatments for Dupuytren contracture. Methods: We retrospectively identified 68 patients who have undergone both limited surgical fasciectomy and CCH treatment for digital flexion contractures from Dupuytren disease. Patients were contacted by telephone and asked whether they preferred surgery or CCH treatment for their Dupuytren contracture. Multivariable logistic regression was used to determine factors associated with preference for surgery versus CCH treatment. Results: Of the 68 patients who were treated with both CCH and surgery, 37 patients (54.4%) preferred CCH treatment over surgery, 26 (38.2%) preferred surgery over CCH treatment, and 5 (7.4%) were unable to decide. Patients expressed common themes of the perceived ease of recovery following CCH treatment versus the perceived durability of contracture correction with surgery. Preference for surgical fasciectomy over CCH treatment was associated with lower American Society of Anesthesiologists Physical Status Classification (ASA) [odds ratio (OR): 0.32, 95% confidence interval (CI): 0.14–0.75]. The order of treatment was also associated with the treatment preference; treatment with surgery after CCH compared to treatment with CCH after surgery was associated with a preference for surgery (OR: 6.51, 95% CI: 2.15–19.7). Conclusions: In a cohort of patients who have undergone both treatments, patients were divided in their preferences, with a slight majority preferring CCH treatment over surgery. Treatment recommendations should be individualised to each patient’s long-term goals and expectations. Level of Evidence: Level III (Therapeutic)

Introduction The objective of this study was to assess the usefulness of Instagram posts for users seeking information about common hand conditions. Materials and Methods An internet-based study was performed of the top 200 trending posts on Instagram for each of the tags #carpaltunnel and #triggerfinger. The trending position (1 through 200), number of likes (for all posts), and number of views (for video posts only) were recorded. Each post was assessed to determine whether it would be useful for a user seeking medical information. Useful and not useful posts were further classified into thematic categories. Results Useful posts comprised only 21% of #carpaltunnel posts and 12% of #triggerfinger posts. #carpaltunnel had a significantly higher proportion of useful posts than #triggerfinger. For both #carpaltunnel and #trigger finger, useful posts were not associated with trending position or number of likes. Useful posts commonly provided a clinical image or an anatomical diagram. Posts that were not useful were generally irrelevant to the hand condition, but a minority provided information not supported by evidence or were solely advertising material. Conclusion Hand surgery patients can be educated that, in its current form, Instagram is not a source of useful information about common hand conditions.

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.]

BACKGROUND Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation. QUESTIONS/PURPOSES (1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries? METHODS Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow. RESULTS Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]). CONCLUSION The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options. LEVEL OF EVIDENCE Level III, therapeutic study.

Purpose The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale. Methods We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008–2018). Preoperative and postoperative range of motion, Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed. Results We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry’s translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen. Conclusions The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis. Type of study/level of evidence Therapeutic IV.

Objective Although the number of female medical school graduates has dramatically increased over the last decades, Orthopaedic surgery continues to struggle in attracting women and under-represented minorities to the field. Potential barriers include limited exposure during medical school and the scarcity of female mentors. We hypothesized that a structured, low-cost, workshop for medical students allowing exposure to orthopaedic surgery would increase students’ interest in the field. Our primary outcome was the perceived satisfaction with the program and the number of students who subsequently expressed an interest in pursuing a career in orthopaedic surgery. Our secondary outcome was the number of student participants who subsequently matched in orthopaedic surgery. Design Combining female faculty from surrounding hospitals, we developed a free half-day program including skills workshops and panel discussions for women medical students in the region. Participants were asked to complete an anonymous survey grading their satisfaction with the utility of the information presented, the comfort level in interacting with faculty and how the experience may have impacted their potential interest in orthopaedic surgery. Eligible participants were contacted by email to determine their ultimate career choices and match results. Furthermore, participants were followed over time to determine how many chose and matched into an orthopaedic surgery residency. Setting The workshop took place in Boston at the Harvard Medical School affiliated hospitals. Participants Student participants were invited from all New England allopathic and osteopathic medical schools. Faculty participants included staff, residents and fellows from the Harvard Combined Orthopaedic Residency Program. Results Over 3 years, 155 female medical students participated in the program and 97% found it useful. Among 59 students who have since become eligible for the match, 22 matched into an orthopaedic surgery residency. Eight of 36 (22%) match eligible first and second year participants matched in orthopaedic surgery while 14 of 23 (61%) match eligible third and fourth year student attendees successfully matched in orthopaedic surgery programs. Conclusions Taking advantage of local resources, we demonstrated that outreach is effective in enhancing students’ interest in the field. We encourage as many programs as possible to consider similar initiatives.

Purpose The aim of this study was to determine factors associated with presentation of carpal tunnel syndrome for carpal tunnel release (CTR) in the advanced electrodiagnostic stages. Methods We identified 920 patients with preoperative electrodiagnostic studies (EDSs) who underwent CTR at a tertiary-care referral center from July 2008 to June 2013. Patients were divided into 2 groups: those in the advanced electrodiagnostic stage, defined as those with unrecordable nerve potentials on preoperative EDSs (group 1), and those with recordable nerve potentials on preoperative EDSs (group 2). Logistic regression was used to determine factors that were associated with presentation in the advanced stages of the disease. Results Multivariable regression analysis showed older age (odds ratio [OR] 1.05; 95% confidence interval [95% CI], 1.04–1.07), diabetes mellitus (OR, 1.72; 95% CI, 1.13–2.62), and hypertension (OR, 1.88; 95% CI, 1.25–2.84) to be associated with advanced presentation for CTR. Conclusions A 10-year increase in age results in a 1.6-times increase in the odds of advanced presentation. Diabetes mellitus or hypertension independently doubles the odds of advanced presentation. A subset of symptomatic patients with carpal tunnel syndrome may benefit from earlier referral for hand surgery evaluation and earlier CTR. Older patients with diabetes mellitus and hypertension are at increased risk for advanced presentation. Type of study/level of evidence Therapeutic II.

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.

Background: Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture. Methods: In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture. Results: The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group. Conclusions This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.

Distal radius fractures are the most common type of upper extremity fractures, and their incidence is increasing. There has been a rise in the surgical treatment of distal radius fractures, primarily with volar locking plate fixation. Although this procedure is commonly done among orthopaedic surgeons, the role of pronator quadratus repair after fixation remains controversial. The pronator quadratus serves as a secondary forearm pronator and a dynamic stabilizer of the distal radioulnar joint. Aside from a functional role, repair of the pronator quadratus has been proposed to serve as a biologic barrier between the volar locking plate and the flexor tendons to minimize tendon irritation. In this narrative review, we discuss the current treatment trends, the surgical approach for volar locking plate treatment of distal radius fractures, and the anatomy and function of the pronator quadratus. We discuss the case for and against the repair of the pronator quadratus, both for function and prevention of flexor tendon irritation and rupture. The preponderance of high-level evidence demonstrates no benefit to pronator quadratus repair for pain relief or function. The current evidence does not conclusively support or refute pronator quadratus repair as a biologic barrier from the flexor tendons.

Purpose To determine factors associated with skin tearing at the time of manipulation in patients undergoing collagenase Clostridium histolyticum (CCH) treatment for Dupuytren contractures. Methods We identified 368 digits in 261 patients who underwent a total of 469 CCH treatments at a tertiary care referral center from April, 2010 to December, 2013. Medical records were reviewed for the primary outcome, skin tearing at manipulation. Patient-related and disease-specific explanatory variables were collected. We used bivariate analysis to screen for risk factors and multivariable logistic regression to determine associated risk factors for skin tearing. Results The overall rate of skin tearing with CCH treatment was 12%. Multivariable logistic regression analysis showed older age (odds ratio = 1.04; 95% confidence interval, 1.00–1.07) and amount of contracture correction (odds ratio = 1.02; 95% confidence interval, 1.01–1.04) to be associated with skin tearing at manipulation. Conclusions A 10-year increase in age results in a 1.5 times increase in the odds of skin tearing. A 30° increase in contracture correction results in a 1.8 times increase in the odds of skin tearing. Patients can be counseled before CCH treatment that older age and increased contracture correction are risk factors for this common complication. Type of study/level of evidence Prognostic II.

Purpose Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR. Methods Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study–confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease , hypertension, hypothyroidism, cervical radiculopathy , tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities. Results Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered. Conclusions Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors. Type of study/level of evidence Prognostic II.

Dupuytren's contracture is a common hand pathology for which consultation and treatment are largely at the patient's discretion. The objective of this study was to evaluate the readability of current online patient information regarding Dupuytren's contracture. The largest public search engines (Google, Yahoo, and Bing) were queried using the search terms “Dupuytren's contracture,” “Dupuytren's disease,” “Viking's disease,” and “bent finger.” The first 30 unique websites by each search were analyzed and readability assessed using five established algorithms: Flesch Reading Ease, Gunning-Fog Index, Flesch–Kincaid Grade level, Coleman–Liau index, and Simple Measure of Gobbledygook grade level. Analysis of 73 websites demonstrated an average Flesch Reading Ease score of 48.6 ± 8.0, which corresponds to college reading level. The readability of websites ranged from 10.5 to 13.3 reading grade level. No article was written at or below the recommended sixth grade reading level. Information on the internet on Dupuytren's contracture is written at higher than recommended reading grade level. There is a need for high-quality patient information on Dupuytren's contracture at appropriate reading grade levels for patients of various health literacy backgrounds. Hospitals, universities, and academic organizations focused on the development of readable online information should consider patients’ input and preferences.

Background. Given the current available evidence, surgical treatment of radial head fracture with acute resection is controversial. The aim of this study was to determine whether acute resection of the radial head for a radial head fracture leads to longitudinal forearm instability due to a missed Essex-Lopresti injury. Material and methods. A retrospective review was conducted of radial head resections performed for acute radial head fractures at two Level I trauma centers from 2000 to 2018. A total of 11 patients met inclusion criteria. Our primary outcome was a missed Essex-Lopresti injury at time of final clinical follow-up. Long-term telephone follow-up was attempted for QuickDASH, pain scores, and satisfaction scores. Results. Of the 11 radial head fractures in this study, intraoperative radial pull tests were performed and normal in 6 patients. No patient was found to have a missed Essex-Lopresti injury at a mean of 36.2 months’ clinical follow-up after radial head resection. At a mean telephone follow-up of 12.6 years in available patients, mean QuickDASH was 3.4, mean satisfaction was 9.75 out of 10, and no further complication or reoperation was reported. Conclusion. Our findings challenge the dogma that the radial head cannot be safely excised in the setting of acute fracture, even with elbow instability and/or wrist pain, particularly when intraoperative longitudinal stability is assessed by a stress maneuver.