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Benjamin A McArthur, Christopher J Dy, Peter D Fabricant, Alejandro Gonzalez Della ValleDepartment of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USAAbstract: The increasing prevalence of painful knee osteoarthritis has created an additional demand for pharmacologic management to prevent or delay surgical management. Viscosupplementation, via intraarticular injection of hyaluronic acid (HA), aims to restore the favorable milieu present in the nonarthritic joint. The safety profile of intraarticular HA injections for painful knee osteoarthritis is well established, with the most common adverse effect being a self-limited reaction at the injection site. Although acceptance of the early literature has been limited by publication bias and poor study quality, more recent and rigorous meta-analysis suggests that intraarticular HA injection is superior to placebo injection for pain relief and matches, if not surpasses, the effect size of other nonoperative treatments, such as nonsteroidal anti-inflammatory medication. Intraarticular HA injection is effective in providing temporary pain relief in patients with painful knee osteoarthritis. Future investigations should focus on optimizing the composition and administration of HA agents to provide prolonged relief of painful osteoarthritis in the knee and other joints.Keywords: intraarticular injection, hyaluronate, viscosupplementation, osteoarthritis, knee

Grant D Shifflett, Christopher J Dy, Aaron DaluiskiDepartment of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY, USAAbstract: Carpal tunnel syndrome is a debilitating disease of the upper extremity affecting patient function and quality of life. Surgical interventions have been developed that effectively treat this disease. However, there remains a subset of patients who are not fully satisfied with their outcome. Extensive investigation has been undertaken to analyze preoperative factors predictive of higher patient satisfaction. This review summarizes the role of unique patient characteristics and patient psychology, worker’s compensation, patient demographics, certain clinical features, and patient preferences and expectations regarding patient satisfaction following carpal tunnel surgery. Understanding the complex nature of patient satisfaction will enable surgeons to indicate patients for surgical intervention better, provide appropriate preoperative counseling, and manage expectations postoperatively.Keywords: outcome, workers’ compensation, biopsychosocial, patient demographics

Background: Osteoporosis remains underrecognized and undertreated in both men and women, but men who sustain fragility fractures experience greater morbidity and mortality. While men exhibit advanced comorbidity at the time of hip fracture presentation, there are distinct sex- and gender-specific factors related to the pathophysiology and treatment of osteoporosis that further influence morbidity and mortality.Questions/purposes: With a selective review of the literature, we evaluated sex- and gender-based differences contributing to increased morbidity and mortality in men with osteoporosis. WHERE ARE WE NOW?: Sex-specific differences in bone biology and morphology may affect the pathophysiology of osteoporosis, choice of pharmacotherapy, and surgical implant selection. Additionally, estrogen metabolism may play a key role in both fracture prevention and healing. Gender-based differences in recommendations for screening and prevention between men and women may influence the severity at which osteoporosis is recognized. Primary, secondary, and tertiary prevention efforts in men lag behind those of women. This may be due to a lack of consensus regarding screening guidelines for osteoporosis in men but may be attributed to lack of awareness in the physician and patient about osteoporosis and its potentially debilitating consequences. WHERE DO WE NEED TO GO?: These disparities are a call to action for healthcare providers to raise awareness for early prevention and treatment of this potentially debilitating disease, particularly in men. HOW DO WE GET THERE?: Continued prospective research on the differences between men and women diagnosed with osteoporosis is needed, as well as sex-specific stratification of data in all studies on osteoporosis. [ABSTRACT FROM AUTHOR]

Background: Men with hip fractures are more likely to experience postoperative complications than women. The Medical Orthopaedic Trauma Service program at New York Presbyterian Hospital utilizes a multidisciplinary team approach to care for patients with hip fractures. The service is comanaged by an attending hospitalist and orthopaedic surgeon, with daily walking rounds attended by the hospitalist, orthopaedic resident, physical therapist, social worker, and a dedicated Medical Orthopaedic Trauma Service physician assistant.Questions/purposes: We asked whether a multidisciplinary service for patients with hip fracture decreases (1) the incidence of inpatient complications in men, (2) the length of hospitalization, and (3) 90-day and 1-year mortality.Patients and Methods: We retrospectively reviewed the charts of 74 men who had surgery for a nonperiprosthetic femoral neck, intertrochanteric, or subtrochanteric fracture for two 7-month periods before and after implementation of the Medical Orthopaedic Trauma Service. Age, ethnicity, comorbidity status, time to surgery, and postoperative complication data were collected. Regression modeling was used to evaluate the likelihood of postoperative complications, length of hospitalization, and 90-day and 1-year mortality while controlling for age, Charlson Comorbidity Index score, fracture type, and time from admission to surgery.Results: We observed a decrease in the likelihood of experiencing at least one inpatient complication in male patients after implementation of the Medical Orthopaedic Trauma Service (odds ratio = 0.264). There was no difference in length of hospitalization, 90-day mortality, or 1-year mortality.Conclusions: Multidisciplinary collaboration for patients with hip fractures can decrease the likelihood of experiencing inpatient complications in male patients.Level Of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Peripheral nerve injuries (PNI) range from mild neurapraxia to severe transection, leading to significant morbidity. Despite their impact, the societal implications of PNI in the United States are not well understood. This study aims to systematically review the literature on PNI epidemiology in the United States. We hypothesize that this review will reveal significant gaps in the understanding of PNI incidence, demographics, and economic impact., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried the literature for studies on PNI that reported at least one of the following: incidence rates, demographics, affected nerve distribution, injury mechanisms, surgical intervention rates, and associated direct costs. Exclusion criteria included non-English publications, abstracts, conference proceedings, reviews, or editorials, studies published before 2000, non-US studies, or studies focusing solely on digital nerves or plexus injuries., Results: Fifteen studies met the inclusion criteria. Data indicate a higher incidence of upper extremity nerve injuries compared with lower extremity injuries. The literature lacks comprehensive reporting on surgical intervention rates, with no recent data since 2013. There is a notable absence of nationwide epidemiological data on PNI mechanisms and recent cost data, with most information over a decade old and primarily focused on inpatient costs, neglecting outpatient visits, physical therapy, and medication expenses., Conclusion: The epidemiological data on PNI are limited and outdated, highlighting the need for further research. Future studies should focus on recent trends in PNI incidence, injury mechanisms, and financial burden, including comprehensive reporting on surgical interventions, to inform strategies aimed at improving patient outcomes and health care resource allocation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ZDR and BJN do not have any potential conflicts of interest with respect to this manuscript. CJD and DMB report the following potential conflict of interest: Research funding from the National Institutes of Health, the Department of Defense and American Foundation for Surgery of the Hand; research funding and speaker fees from Checkpoint Surgical and both are on the Medical Advisory Board of OrthoCell.

Background: Three-dimensional (3D) printer technology has seen a surge in use in medicine, particularly in orthopedics. A recent area of research is its use in peripheral nerve repair, which often requires a graft or conduit to bridge segmental defects. Currently, nerve gaps are bridged using autografts, allografts, or synthetic conduits. Purpose : We sought to improve upon the current design of simple hollow, cylindrical conduits that often result in poor nerve regeneration. Previous attempts were made at reducing axonal dispersion with the use of multichanneled conduits. To our knowledge, none has attempted to mimic and test the anatomical topography of the nerve. Methods : Using serial histology sections, 3D reconstruction software, and computer-aided design, a scaffold was created based on the fascicular topography of a rat sciatic nerve. A 3D printer produced both cylindrical conduits and topography-based scaffolds. These were implanted in 12 Lewis rats: 6 rats with the topographical scaffold and 6 rats with the cylindrical conduit. Each rodent's uninjured contralateral limb was used as a control for comparison of functional and histologic outcomes. Walking track analysis was performed, and the Sciatic Functional Index (SFI) was calculated with the Image J software. After 6 weeks, rats were sacrificed and analyses performed on the regenerated nerve tissue. Primary outcomes measured included nerve (fiber) density, nerve fiber width, total number of nerve fibers, G-ratio (ratio of axon width to total fiber width), and percent debris. Secondary outcomes measured included electrophysiology studies of electromyography (EMG) latency and EMG amplitude and isometric force output by the gastrocnemius and tibialis anterior. Results : There were no differences observed between the cylindrical conduit and topographical scaffold in terms of histological outcomes, muscle force, EMG, or SFI. Conclusion : This study of regeneration of the sciatic nerve in a rat model suggests the feasibility of 3D-printed topographical scaffolds. More research is required to quantify the functional outcomes of this technology for peripheral nerve regeneration., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CJD, MD, MPH, reports relationships with National Institutes of Health, Sonex Healthcare, American Foundation for Surgery of the Hand, Orthopaedic Research and Education Foundation, Springer, Orthocell, Johnson and Johnson, Checkpoint Surgical, American Orthopaedic Association, American Society of Peripheral Nerve, OrthoCell. JA, MD, reports relationships with Smith + Nephew. DMB, MD, MSc, reports relationships with Checkpoint Surgical, National Institutes of Health, Neuraptive Therapeutics, American Society for Surgery of the Hand, Department of Defense, Springer Publishing, OrthoCell, Missouri State Orthopedic Association. The other authors report no potential conflicts of interest., (© The Author(s) 2024.)

Purpose: The surgical management of adult traumatic brachial plexus injuries (BPI) is challenging, with no consensus on optimal strategies. This study aimed to gather preferred reconstructive strategies from BPI surgeons for actual cases from a multicenter cohort to identify areas of agreement., Methods: Four case files (history, physical examination, and imaging and electrodiagnostic testing results) were distributed to eight self-designated Level IV expert BPI surgeons in the United States. Each surgeon independently reviewed the cases and provided a preferred reconstructive plan via free text response., Results: For a pan-plexus case after blunt trauma (67 years old; 3 months from injury): three surgeons recommended nerve grafting upper trunk roots to distal targets. There was disagreement in shoulder reconstruction: one suggested early shoulder fusion, two preferred cranial nerve XI to suprascapular nerve (SSN) transfer, and two anticipated future salvage shoulder fusion. For elbow reconstruction, six surgeons preferred intercostal nerve to musculocutaneous nerve transfer. For an upper trunk injury from a motorcycle accident (33 years old; 6 months from injury), only one surgeon recommended nerve grafting, six preferred XI to SSN transfer, all recommended triceps-to-axillary transfer, and all but one favored a double fascicular transfer., Conclusions: There is inconsistency in the use of nerve grafting for BPI patients, especially in pan-plexus injuries where options are limited. Variability exists in shoulder reconstruction and stability management, with some advocating early glenohumeral arthrodesis. Although single fascicular and triceps-to-axillary transfers are consistently favored, there is no consensus for restoring shoulder and elbow function when intraplexal transfers are unavailable., Clinical Relevance: This study highlights substantial variability in surgical approaches to BPI among experts, underscoring the need for standardized treatment protocols. Understanding these diverse strategies can inform clinical decision making and help develop more uniform guidelines to improve patient outcomes., Competing Interests: Conflicts of Interest Author C.J.D. received grant funding from the American Foundation for Surgery of the Hand (clinical research grant) and National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases) - R01 AR079139-01 to support this work. No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Radiation induced brachial plexopathy represents a constellation of symptoms that present in a delayed manner because of peri-plexus progressive fibrosis or direct neural injury with demyelination. Symptom onset is typically delayed months to years after radiotherapy. Patients may report neuropathic pain, weakness, or extremity dysfunction associated with morbidity and diminished quality of life. Reported surgical interventions include plexus neurolysis, nerve transfers, and vascularized free tissue transfer. In this review, we aim to present the practicing hand surgeon with an update and analysis on the current state of the radiation induced brachial plexopathy literature., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The use of telemedicine increased greatly following the onset of the COVID-19 pandemic. It is unclear whether and how sociodemographic factors have affected orthopedics patients' use of this technology in the pandemic., Purpose: The aim of this study was to determine how patient demographic variability in telemedicine use is influenced by the Area Deprivation Index (ADI) and distance to clinical site among patients seeking care for hip and knee arthritis from orthopedic surgeons., Methods: Demographic data and visit type were collected from the electronic medical record for patients seen in our academic medical center either before or during the COVID-19 pandemic by orthopedic surgeons who specialize in hip and knee arthroplasty. Univariate and multivariate analyses were performed regarding age, race, insurance status, ADI, and distance to a clinical site., Results: In the COVID era, among 4901 visits with 3124 unique patients, those using telemedicine were younger and more likely to be White compared to those who did not use telemedicine. There was no significant difference in telemedicine use based on ADI, distance to a clinical site, or insurance status., Conclusions: This retrospective analysis suggests that orthopedic patients who were White and of younger age were more likely to use telemedicine in the first year of the COVID-19 pandemic. There was no statistically significant relationship between distance from a clinical site or ADI and telemedicine use, suggesting that factors other than these are greater contributors to telemedicine utilization in our cohort. Further information is needed to determine how telemedicine may disproportionately limit access to orthopedic care according to these and other patient factors., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Christopher Dy reports relationships with the National Institutes of Health, the American Foundation for Surgery of the Hand, the Orthopaedic Research and Education Foundation, Sonex Healthcare, Springer, Orthocell, Johnson and Johnson, the American Orthopaedic Association, and the American Society of Peripheral Nerve. The other authors declared no potential conflicts of interest., (© The Author(s) 2023.)

Purpose of Review: Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes., Recent Findings: Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Adult traumatic brachial plexus injuries (tBPI) are devastating physically and emotionally. In addition to the physical loss of function and pervasive neuropathic pain, patients describe difficulty with negative self-image and social relationships. Our goal was to gain an initial understanding of body image and satisfaction with appearance among tBPI patients., Methods: Among 126 patients in a prospective cohort study, 60 completed a brachial plexus injury-specific modification of the Satisfaction with Appearance survey. The survey encompasses three major domains: social discomfort because of the affected limb, interference with relationships because of the affected limb, and appearance of the affected limb. We performed a cross-sectional descriptive analysis to provide an initial understanding of these domains among brachial plexus injury patients., Results: Among all 60 patients, nearly half (27/60, 45%) reported they are satisfied with their overall appearance. The appearance of their affected hand(s) was the body part with which patients expressed the most concern. Patients also reported feeling increasingly uncomfortable among those less familiar to them: 11/60 (18%) were uncomfortable around family, 18/60 (30%) were uncomfortable around friends, and 19/60 (32%) were uncomfortable around strangers. One-quarter (15/60, 25%) of brachial plexus injury patients agreed that their injury interfered with relationships and that their tBPI was unattractive (16/60, 27%) to others., Conclusions: Almost half of patients who have experienced tBPI endorse dissatisfaction with their appearance, which can subsequently interfere with their personal relationships. Further, tBPI may influence patients' comfort levels in unfamiliar social surroundings and may influence how patients feel they are perceived by others., Clinical Relevance: The patient's perception of their affected limb and its influence on their daily social interactions should be recognized by their tBPI care team, noting opportunities for improved counseling., Competing Interests: Conflicts of Interest Dr Dy reports receiving support from a grant from the American Foundation for Surgery of the Hand and grant AR079139-01 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. No benefits in any form have been received or will be received by the other authors related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care., Methods: Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved., Results: Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution., Conclusions: Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery., Clinical Relevance: Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

With an estimated 2 million major limb amputees and projections reaching 3.6 million by 2050, the increasing prevalence of limb loss in the United States underscores the importance of addressing complications associated with limb loss. Phantom limb pain (PLP) is a common and often chronic condition affecting 40% to 80% of amputees. The heterogeneous pathology of PLP encompasses cortical, spinal, and peripheral mechanisms that present a challenge to providing effective treatments. The spectrum of available treatments spans pharmacologic interventions, noninvasive modalities like mirror therapy, and surgical techniques. A review of the current body of evidence on the treatment of PLP favors novel methods of surgical management. Nonetheless, a majority of literature pushes for the evaluation of other methods of ameliorating PLP as imperative to offering patient-centered options that address the myriad of etiologies that contribute to this pathology. More extensive research, especially randomized controlled trials, is needed to establish the long-term efficacy of interventions, compare the impact of different treatments, and identify which modalities are most effective in various patient populations., Competing Interests: Conflicts of Interest Ms Spezia was supported by a TL1 summer position funded by CTSA Grants UL1TR002345, KL2TR002346, TL1TR002344. Dr Brogan's time was supported by a NIAMS K08 grant K08AR080260-01. No benefits in any form have been received or will be received by the other author related directly or indirectly to the subject of this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Compressive neuropathy of the common fibular nerve (CFN) is increasingly recognized as an etiology for foot drop and falls. Electrodiagnostic (EDX) studies are widely used to evaluate this condition, but such tests are invasive and costly. As with carpal and cubital tunnel syndromes, there may be patients with characteristic symptoms of CFN compressive neuropathy but normal EDX studies in which ultrasound may aid in decision-making., Purpose: We sought to examine the association between ultrasound and nerve conduction studies (NCS) and electromyography (EMG) in the diagnosis of compressive neuropathy of the CFN., Methods: We performed a retrospective review identifying 104 patients who underwent CFN decompression from January 1, 2015, to June 30, 2023. Patients were included if they had both ultrasound and NCS/EMG prior to CFN decompression for compressive neuropathy and if they were older than 18 years at time of surgery. Patients were excluded if they had entrapment secondary to trauma, iatrogenic injury, or if they had had superficial fibular decompression alone without CFN decompression. After applying exclusion criteria, 17 patients remained in the cohort., Results: Mean ultrasound cross-sectional area and side-to-side (STS) ratios were significantly higher in those with abnormal compound muscle action potential (CMAP) amplitudes versus those with normal CMAP amplitudes. The probability of having an abnormal CMAP amplitude when STS ratio was abnormal was 18 times greater compared with those with normal STS ratio. With each unit increase in STS ratio, CMAP amplitude was reduced by 2.79 mV., Conclusions: This retrospective review found that ultrasound may provide complementary diagnostic information to EMG/NCS for compressive neuropathy of the CFN. Further study is needed to examine the relationship between ultrasound findings for CFN compressive neuropathy and results of surgical decompression., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Christopher J. Dy, MD, MPH, has relationships with Sonex Healthcare, Springer, Orthocell, Johnson and Johnson, and Checkpoint Surgical. The other authors declared no potential conflicts of interest., (© The Author(s) 2024.)

Background: Advances in treatment philosophies and microsurgical techniques for peripheral nerve injuries (PNI) have led to improved outcomes. However, lack of standardisation in the evaluation of clinical outcomes after PNI treatment precludes the ability to compare reconstruction methods, such as nerve transfer, nerve grafting, free functioning muscle transfers and tendon transfers. To this end, our goal is to work collaboratively to establish a core outcome set to evaluate outcomes after PNI. Methods: The protocol for this arc of work, delineated in this manuscript, consists of two phases: (1) conducting a systematic review of how outcomes are currently reported following PNI and (2) a Delphi process to gain consensus on the measures to include in the core outcome set for PNI. In the Delphi process, two online rounds will be used to gather consensus on the importance of each outcome measure. A final round will be conducted in person to discuss and resolve measures for which there is not yet consensus and to finalise the core outcomes set. Conclusions: Through this process, a common standard for reporting outcomes after PNI will be created, facilitating collaboration and future research.

Peripheral nerve surgeries for compressive neuropathy in the upper extremity are generally successful. However, cases that either fail or have complications requiring revision surgery are challenging. During revision consideration, surgeons should perform a comprehensive preoperative workup to understand the etiology of the patient's symptoms and categorize symptoms as persistent, recurrent, or new in relation to the index procedure. Revision surgery often requires an open, extensile approach with additional procedures to optimize outcomes. Even with proper workup and treatment, clinical outcomes of revision surgeries are inferior compared to primary surgeries and patients should be well informed prior to undergoing such procedures., Competing Interests: Disclosure The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Electrical stimulation has been integrated in recent decades into rehabilitation protocols following neuromuscular injuries. Existing literature supports the utilisation of prolonged or continuous stimulation generated by implantable or transcutaneous devices for chronic pain subsidence and muscle trophism maintenance, which improve outcomes following microsurgical interventions. Newer uses include brief electrical stimulation for peripheral nerve injury. Brief electrical stimulation has shown promise in expediting regeneration of both torn and crushed nerve axons in the murine model and has been incorporated into a limited number of clinical studies. Augmentation of the natural response of an injured peripheral nerve by electrical stimulation has the potential to accelerate regeneration, presumably leading to improved function and clinical outcomes. We review the existing literature on intraoperative utilisation of electrical stimulation to enhance regeneration, such as neural mechanisms of action and their microscopic effect in animal models, as well as results from initial human studies. Level of Evidence: Level V (Therapeutic).

Purpose: We performed a randomized controlled trial assessing patient-reported outcome measures following trapeziectomy with ligament reconstruction and tendon interposition (LRTI) or suture tape suspensionplasty (STS) for treatment of thumb carpometacarpal joint osteoarthritis., Methods: Patients undergoing surgery for thumb carpometacarpal joint osteoarthritis were prospectively randomized to LRTI or STS. Outcome measures were collected at 2 weeks, 4 weeks, 3 months, and 1 year and included visual analog scale pain, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity, return to work/activity, range of motion, grip/pinch strength, and complications., Results: Thirty-one patients (32 thumbs) were randomized from 51 patients offered participation over two years. One-year follow-up was 97%. Both groups had a decrease in visual analog scale pain scores at all postoperative time points. The trajectory of postoperative Patient-Reported Outcomes Measurement Information System Upper Extremity scores was similar, and both groups achieved the meaningful clinically important difference for improvement in PROMIS Upper Extremity by three months. Grip strength was substantially increased in both groups at one year. Return to work/activity and surgical complications favored the LRTI group., Conclusions: Our study did not suggest any clinically relevant differences in the postoperative patient-reported outcome measures or objective clinical measurements between LRTI and STS, although LRTI patients had a faster return to work/activity and lower complication rates., Type of Study/level of Evidence: Therapeutic IIB., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Pain after brachial plexus injury (BPI) can be severely debilitating and is poorly understood. We hypothesized that pain interference (PI) ("the extent to which pain hinders engagement in life") would be predicted by depression, anxiety, severity of pain symptoms, and poorer preoperative muscle function., Methods: Among patients in a prospective multicenter BPI cohort study, 37 completed Patient-Reported Outcomes Measurement Information System (PROMIS) PI questionnaires before and 1 year after surgery. At both times, participants completed anxiety and depression questionnaires and BPI-specific measures of pain symptoms, physical limitations, and emotional recovery. Surgeon-graded muscle testing, injury severity, age at the time of injury, body mass index, and time from injury to surgery were included. We performed a bivariate analysis of predictors for preoperative and 1-year PROMIS PI followed by multivariable regression modeling using stepwise selection and Bayesian Information Criterion to select covariates., Results: Before surgery, the mean PROMIS PI score was 60.8 ± 11.0, with moderate correlations between PROMIS PI and depression, as well as between PROMIS PI and functional limitations. At 1 year after surgery, the mean PROMIS PI score was 59.7 ± 9.5. There was no difference in preoperative and 1-year PROMIS PI. There were strong correlations between PROMIS PI and pain symptoms, functional limitations, and emotional aspects of recovery at the 1-year follow-up that remained significant in multivariable regression. There were no notable associations between muscle testing and PI., Conclusions: Pain interference remained substantial and elevated in BPI patients 1 year after surgery. We noted strong associations between PI and pain symptoms, functional limitations, and emotional aspects of recovery. These findings demonstrate the persistence of pain as a feature throughout life after BPI and that its treatment should be considered a priority alongside efforts to improve extremity function., Type of Study/level of Evidence: Prognosis IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Despite its widespread prevalence, the cost of cubital tunnel syndrome (CuTS) in the United States to patients and insurers is not well understood. The purpose of this study was to quantify the direct payments associated with operative treatment of CuTS. We hypothesized that CuTS represents a substantial cost to the payer in facility fees, surgeon fees and other expenses., Methods: Utilizing the MarketScan database of insured patients (commercial and Medicaid), we identified a cohort of 41,777 patients aged 18-64 years with surgically treated CuTS from 2006 to 2018. We estimated the median 90-day payments from encounters associated with cubital tunnel release (CuTR) and/or ulnar nerve transposition surgery by summing all payments for claims within 90 days after the index surgery. Published estimates of the annual number of cubital tunnel surgeries were used to calculate the annual expenditure., Results: Of 41,777 patients, the median (interquartile range [IQR]) values of total direct payments were $5,522 [$3,426, $9,541]. With an estimated 94,645 cases/year, this leads to an annual payment of more than $522 million. Index facility payments (median[IQR] $2,555 [$1,359, $4,708] were the highest, followed by index provider payments ($1,691 [$1,328, $2,217]). The median index surgeon payment (median[IQR] $905 [$707, $1,184]) represented just over half of the provider payments. Post-operative care had a median [IQR] payment of $377 ($424, $1,987). Limitations of claims databases prevented assessment of other indirect costs associated with cubital tunnel surgery., Conclusions: Payments for the surgical treatment of CuTS from the index surgery to 90 days post-operatively have an estimated median of $5,522 per patient, totaling $52 million annually. Index facility fees are responsible for more than 46% of payments, while index payments to surgeons represent approximately 16%. Defining this data is critical to understanding one component of the economic impact of CuTS., Level of Evidence: Level IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Flexor pollicis longus rupture is an uncommon but potentially debilitating complication after volar locking plate fixation of distal radius fractures, occurring secondary to tendon attrition against the implant. This nature of tendon injury typically precludes primary repair. This paper will illustrate 2 reconstruction techniques, an interpositional tendon graft and a tendon transfer, that have been utilized successfully by the authors., Competing Interests: Conflicts of Interest and Source of Funding: C.J.D. is on the editorial board for HSS Journal. R.P.C. is the Deputy Editor-in-Chief of the Journal of Hand Surgery. For the remaining authors none were declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tourniquet-related nerve ischemia has been well studied in several reconstructive procedures, but the time-course of impaired response to intraoperative stimulation is unclear. The present study evaluated ischemic effects on conduction during ulnar nerve transposition and examined the relationship between intra- and pre- operative diagnostics. We hypothesized that intraoperative ischemia would have minimal impact on conduction., Methods: Thirty patients scheduled for anterior transposition were enrolled after preoperative examination, electrodiagnostic testing, and ultrasound. Demographic and symptom severity data were recorded. A handheld biphasic nerve stimulator was used intraoperatively to assess minimum amplitude and pulse duration needed for muscle response. Measurements were taken at 15-minute intervals after placement., Results: Changes in threshold amplitude and pulse duration were calculated between each 15-minute interval; no significant difference was found in the change of either value (p = 0.70 and 0.178). A weak negative correlation existed between preoperative CMAP amplitudes and average intraoperative pulse duration, which increased to a moderate correlation when compared to 45-minute pulse duration (r=-0.62, p<0.01). Preoperative ulnar nerve cross-sectional area (CSA) demonstrated no significant correlation with average pulse duration but a moderate correlation with pulse duration at 45 minutes (r=0.63, p=0.01)., Conclusions: Tourniquet use did not prevent effective intraoperative stimulation of the ulnar nerve for at least 45 minutes. The window for meaningful stimulation with tourniquet usage appears to be greater than previously thought. Preoperative nerve CMAP amplitude and CSA does appear to influence pulse duration required after 45 minutes of ischemia, suggesting that injured nerves are more susceptible to ischemia., Level of Evidence: 1., Competing Interests: Conflict of Interest Disclosure: DMB and CJD are both paid educational consultants for Checkpoint Surgical Inc. No other authors have any relevant conflicts of interest., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Ultrasound and magnetic resonance neurography are useful modalities to aid in the assessment of compressive neuropathies, although they are still limited in their resolution of nerve microstructure and their capacity to monitor postoperative nerve recovery. Optical coherence tomography, a preclinical imaging modality, is promising in its ability to better identify structural and potential physiologic changes to peripheral nerves, but requires additional testing and research prior to widespread clinical implementation. Further advances in nerve imaging may elucidate the ability to visualize the zone of nerve injury intraoperatively, monitor the progression of nerve regeneration, and localize problems during nerve recovery., Competing Interests: Disclosure Dr C.J. Dy is on the Medical Advisory Board for Orthocell. He receives speakers’ fees from Johnson and Johnson/DePuy Synthes. He has research support from the National Institutes of Health and Sonex Healthcare. Dr D.M. Brogan serves as a committee chair in the American Society for Surgery of the Hand and an officer of the Missouri State Orthopedic Association. He receives royalties from Springer and is a paid consultant for Checkpoint Surgical. He has additional research funding from the National Institutes of Health, Department of Defense, United States, American Foundation for Surgery of the Hand, United States, Orthopedic Research and Education Foundation, United States,Checkpoint Surgical, and Neuraptive Therapeutics., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery., Methods: We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race., Results: Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race., Conclusions: Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased., Type of Study/level of Evidence: Prognostic II., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: There are substantial costs associated with orthopedic injury and management. These costs are likely not experienced equally among patients. At the level of the healthcare and hospital systems, disparities in financial burden and patient demographics have already been identified among orthopedic trauma patients. Accordingly, disparities may also arise at the level of the patient and how they experience the cost of their care. We sought to determine (1) how patient demographics are associated with financial burden/toxicity and (2) if patients experience disproportionate financial burden/toxicity and social support secondary to their economic standing., Recent Findings: It has been described that there is an inequitable experience in clinical and economic outcomes in certain socioeconomic demographics leading to disparities in financial burden. It has been further reported that orthopedic injury, management, and outcomes are not experienced equitably among all demographic and socioeconomic groups. Ten articles met inclusion criteria, among which financial burden was disproportionately experienced amid orthopedic trauma patients across age, gender, race, education, and marital status. Financial hardship was also unequally distributed among different levels of income, employment, insurance status, and social deprivation. Younger, female, non-White, and unmarried patients experience increased financial burden. Patients with less education, lower income, limited or no insurance, and greater social deprivation disproportionately experienced financial toxicity compared to patients of improved economic standing. Further investigation into policy changes, social support, and barriers to appropriate care should be addressed to prevent unnecessary financial burden and promote greater patient welfare., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The use of ultrasound in the diagnosis of cubital tunnel syndrome (CuTS) is an attractive alternative to electrodiagnostic (EDX) studies, but its utility is binary with poor severity correlation. We hypothesize that increasing ulnar nerve cross-sectional area (CSA) and power Doppler measurement of intraneural vascularity may predict the extent of disease., Methods: We identified 20 elbows from patients with a history of CuTS and 20 elbows in 10 asymptomatic controls. Electrodiagnosis was performed for symptomatic patients. Gray-scale ultrasound and power Doppler ultrasound were performed to measure CSA and intraneural vascularity in all participants. Functional measures, Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System surveys were also completed., Results: A strong positive correlation was found between CSA and motor nerve conduction velocity (MNCV) decrease between elbow and forearm, which increased when BCTQ >2 was used as a screening criterion. Increased CSA also demonstrated a high positive predictive value (PPV) in predicting MNCV changes, but poor ability to predict axonal loss. In contrast, power Doppler ultrasound demonstrated 100% PPV and 94% negative predictive value (NPV) in predicting severe CuTS (defined as compound motor action potential [CMAP] amplitude <6 mV and electromyography [EMG] findings)., Conclusions: Cross-sectional area is a sensitive method for identifying changes in MNCV and amplitude but does not stratify disease severity, as defined by diminished CMAP amplitude and/or evidence of denervation on EMG. The presence of increased intraneural vascularity is relatively sensitive but highly specific for axonal loss. The combination of nerve CSA, BCTQ screening, and power Doppler ultrasound may provide an alternative means for CuTS assessment., 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.

Purpose: A systematic review to identify treatment approaches for the management of pain following peripheral nerve injury., Methods: A published literature search was performed for the concepts of peripheral nerve injury and pain management with related synonyms. The strategies were created using a combination of controlled vocabulary terms and keywords and were executed in Embase.com, Ovid-Medline All, and Scopus from database inception. Database searches were completed on August 22, 2023., Results: The initial search resulted in a total of 1,793 citations. In total, 724 duplicates were removed, leaving 1,069 unique citations remaining for analysis. This review excluded all papers that were not specific to pain following peripheral nerve injury. Case and cohort studies (n < 5) were also excluded. Thirty-two articles on pain management strategies after peripheral nerve injury remained, with years of publication ranging from 1981 to 2023. An additional four articles were identified by manual search. Of the 36 articles reviewed, 15 articles reported on the approach to the treatment of pain after a peripheral nerve injury, and the other 22 articles consisted of cohort and case series studies., Conclusions: There is a lack of literature describing efficacy of various treatment strategies for pain following peripheral nerve injuries. Few studies provide clear, stepwise clinical guidance for practicing physicians and other health care providers on the treatment of these complicated patients., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Background: There is increasing interest in the evaluation and management of compressive neuropathy of the common peroneal nerve (CPN)., Purpose: We sought to determine demographic and electrodiagnostic predictors for resolution of symptoms after CPN decompression for compressive neuropathy. We hypothesized that severity of neuropathy (as measured by compound motor amplitudes and active or chronic denervation on electromyography) would be associated with symptom resolution after CPN decompression., Methods: We performed a retrospective review of patients who underwent CPN decompression and had preoperative electrodiagnostic (EDX) studies at a single institution from January 1, 2015, to April 30, 2023. We performed independent samples t -test and logistic regression to evaluate demographic and EDX study factors associated with symptom resolution., Results: Of the 44 patients identified, 33 reported resolution of preoperative symptoms, with no differences based on EDX findings. The likelihood of symptom resolution was significantly higher in men than women (OR = 10.62; 95% CI = 1.218, 92.677). Patient demographics were otherwise not predictive of symptom resolution., Conclusion: Three-quarters of our patients reported symptom resolution after CPN decompression for compressive neuropathy. While EDX studies were not predictive of outcomes, our findings suggest that sex-based factors may be contributing to outcomes. This deserves further investigation, as outcomes after surgery may be driven by preoperative characteristics such as surgeon counseling, patient expectations, or other biologic factors., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Christopher J. Dy, MD, MPH, reports relationships with National Institutes of Health, Sonex Healthcare, American Foundation for Surgery of the Hand, Orthopedic Research and Education Foundation, Springer, Orthocell, Johnson and Johnson, Checkpoint Surgical, American Orthopedic Association, and American Society for Peripheral Nerve. The other authors report no potential conflicts of interest., (© The Author(s) 2024.)

Peripheral nerve injuries affect a significant number of patients who experience trauma affecting the hand and upper extremity. Improving unsatisfactory outcomes from repair of these injuries remains a clinical challenge despite advancements in microsurgical repair. Imperfections of the nerve regeneration process, including imprecise reinnervation, distal axon degradation, and muscular atrophy, complicate the repair process. However, the capacity for peripheral nerves to regenerate offers an avenue for therapeutic advancement. Regeneration is a temporally and spatially dynamic process coordinated by Schwann cells and neurons among other cell types. Neurotrophic factors are a primary means of controlling cell growth and differentiation in the repair setting. Sustained axon survival and regrowth and consequently functional outcomes of nerve repair in animal models are improved by the administration of neurotrophic factors, including glial cell-derived neurotrophic factor, nerve growth factor, sterile alpha and TIR motif containing 1, and erythropoietin. Targeted and sustained delivery of neurotrophic factors through gelatin-based nerve conduits, multiluminal conduits, and hydrogels have been shown to enhance the innate roles of these factors to promote expedient and accurate peripheral nerve regeneration in animal models. These delivery methods may help address the practical limitations to clinical use of neurotrophic factors, including systemic side effects and the need for carefully timed, precisely localized release schedules. In addition, tacrolimus has also improved peripheral nerve regrowth in animal models and has recently shown promise in addressing human disease. Ultimately, this realm of adjunct pharmacotherapies provides ample promise to improve patient outcomes and advance the field of peripheral nerve repair., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Background: Studies comparing carpal tunnel release with ultrasound guidance (CTR-US) to mini-open CTR (mOCTR) are limited. This randomized trial compared the efficacy and safety of these techniques., Methods: In this multicenter randomized trial, patients were randomized (2:1) to unilateral CTR-US or mOCTR. Outcomes included Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), numeric pain scale (0-10), EuroQoL-5 Dimension 5-Level (EQ-5D-5L), scar outcomes, and complications over 1 year., Results: Patients received CTR-US (n = 94) via wrist incision (mean 6 mm) or mOCTR (n = 28) via palmar incision (mean 22 mm). Comparing CTR-US with mOCTR, the mean changes in BCTQ-SSS (-1.8 versus -1.8; P = 0.96), BCTQ-FSS (-1.0 versus -1.0; P = 0.75), numeric pain scale (-3.9 versus -3.8; P = 0.74), and EQ-5D-5L (0.13 versus 0.12; P = 0.79) over 1 year were comparable between groups. Freedom from scar sensitivity or pain favored CTR-US (95% versus 74%; P = 0.005). Complications occurred in 2.1% versus 3.6% of patients ( P = 0.55), all within 3 weeks postprocedure. There was one revision surgery in the CTR-US group, and no revisions for persistent or recurrent symptoms in either group., Conclusions: CTR-US and mOCTR demonstrated similar improvement in carpal tunnel syndrome symptoms and quality of life with comparable low complication rates over 1 year of follow-up. CTR-US was performed with a smaller incision and associated with less scar discomfort., Competing Interests: Larry Miller reports consultancy with Sonex Health, Inc. The other authors have no financial interest to declare in relation to the content of this article. This study was funded by Sonex Health, Inc. (Eagan, MN). The sponsor was involved in trial design and article review but was not involved in data analysis or the final decision to submit the article for publication. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: There are notable differences in how adult patients with traumatic brachial plexus injuries (BPI) are evaluated and treated., Purpose: To better understand existing philosophies, we used the Delphi method to measure and foster consensus on routine use of electrodiagnostic testing, ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) myelograms prior to surgery. Panelists were 10 peripheral nerve surgeons board certified in their respective specialties at 5 academic medical centers in the United States., Methods: We presented 2 cases (1 complete/pan-BPI and 1 upper trunk BPI) to panelists and asked how often they would order the following preoperative diagnostic tests: electrodiagnostic studies; ultrasound of the brachial plexus; MRI of the brachial plexus; CT myelogram. Our Delphi process included an initial survey with videoconference discussion after the first round. A second survey/videoconference round was conducted to further probe the items that did not reach consensus during the first round., Results: Among the 10 surgeons, there was consensus that prior to brachial plexus surgery electrodiagnostic studies and MRI should be routinely ordered and ultrasound of the brachial plexus should not be routinely ordered. The group did not reach consensus on whether CT myelogram should or should not be routinely ordered., Conclusions: Based on our panel's discussion, future work should focus on comparing the accuracy of CT myelogram and MRI for evaluation of cervical nerve root presence and viability., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Purpose: Preoperative expectations play a major role in determining patient satisfaction after surgery. The aim of this study was to characterize patient's preoperative expectations and postoperative perceptions of nerve gap repair surgery., Methods: We conducted a search of Embase, Scopus, and Web of Science databases for peer-reviewed articles that studied patient expectations, perceptions, and impressions of nerve gap repair in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies related to lumbar plexus radiculopathy, reimplantation, or patient satisfaction scores without patient testimony were excluded. Primary and secondary outcomes were patient's preoperative expectations and postoperative perceptions of nerve gap repair surgery, respectively., Results: We included 11 studies evaluating a total of 462 patients. One study evaluated only patient expectations, six studies evaluated only patient perspectives, and four studies evaluated both. Patients were generally overly optimistic in their expectations of surgery. Postoperative satisfaction ranged from 82% to 86%, and 81% to 87% of patients would choose to undergo their surgery again knowing what they know now., Conclusions: Patient expectations in nerve gap repair are optimistic, and at times unrealistic. Patient satisfaction with nerve gap repair is high and subject to influence from preoperative education and postoperative outcomes of functional and sensory recovery., Clinical Relevance: Surgeons should be aware that patient expectations of their postoperative outcomes can have substantial impacts on their perceived management and overall satisfaction. More emphasis should be placed on preoperative education and expectation management to optimize patient satisfaction., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Orthopaedic surgery lags in recruiting women and under-represented minorities (URMs). In addition, women and URMs hold fewer leadership roles across orthopaedic subspecialties. This inequity is geographically heterogeneous, with female URM residents and attendings being more concentrated in some areas of the country. For instance, practicing female orthopaedic surgeons are more prevalent in Northeast and Pacific programs. Mentorship and representation in leadership positions play a notable role in trainee recruitment. Video communication platforms offer a novel mechanism to reach historically under-represented students across the country. We reviewed five established mentorship programs focused on women and URMs. Each program emphasized a longitudinal relationship between mentors and mentees. In reviewing these programs, we sought to identify the successful components of each program. Leveraging and integrating effective components already established by conventional mentorship programs into virtual programming will aid in optimizing those programs and improve geographic equity in access to mentorship resources. It is critical to extend the principles of successful mentorship programs to technology-enabled programs moving forward., Competing Interests: 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., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Nerve transfer surgery is commonly used to treat patients with brachial plexus injuries. However, guidelines on postoperative rehabilitation are not clearly established. Nerve transfers require the patient to relearn how to recruit newly innervated muscle(s), which may not occur naturally or intuitively. Supervised therapy is a valuable resource to guide patients through their lengthy recovery (often >12 months) because target muscle strength is both obtained and functionally used in daily life. This article highlights 10 key principles that provide the foundation for rehabilitation following nerve transfer surgery after a brachial plexus injury. Due to the shortcomings of the current evidence base for nerve transfer rehabilitation, we have included our anecdotal experience to augment the existing literature. It is important to have a collaborative surgeon-therapist relationship to communicate regarding operative details, expected timelines for reinnervation, patient needs, and realistic expectations. We provide examples of how to tailor the exercise program to synergistically recruit both the donor and target muscle action, including how to appropriately advance exercises based on the current level of nerve return. We also discuss the role that fatigue plays in denervated muscle and how fatigue may affect the exercise demands placed on the target muscle during specific stages of recovery., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Chat Generative Pre-Trained Transformer (ChatGPT) is a novel artificial intelligence chatbot that is changing the way humans gather information online. The purpose of this study was to investigate ChatGPT's ability to appropriately and reliably answer common questions regarding distal radius fractures., Methods: Thirty common questions regarding distal radius fractures were presented in an identical manner to the online ChatGPT-3.5 interface three separate times, yielding 90 unique responses because ChatGPT produces an original answer with each query. All responses were graded as "appropriate," "appropriate but incomplete," or "inappropriate" by a consensus discussion among three hand surgeon reviewers. The questions were additionally subcategorized into one of four domains based on Bloom's cognitive learning taxonomy, and descriptive statistics were reported., Results: Seventy of the 90 total responses (78%) produced by ChatGPT were "appropriate," and 29 of the 30 questions (97%) had at least one response considered appropriate (of the three possible). However, only 17 of the 30 questions (57%) were answered appropriately on all three iterations. The test-retest reliability of ChatGPT was poor with an intraclass correlation coefficient of 0.12. Finally, ChatGPT performed best answering questions requiring lower-order thinking skills (Bloom's levels 1-3) and less well on level 4 questions., Conclusions: This study found that although ChatGPT has the capability to answer common questions regarding distal radius fractures, caution should be taken before implementing its use, given ChatGPT's inconsistency in providing a complete and accurate response to the same question every time., Clinical Relevance: As the popularity and technology of ChatGPT continue to grow, it is important to understand the potential and limitations of this platform to determine how it may be best implemented to improve patient care., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance., Methods: A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants' knowledge and skills were assessed using pre- and postcourse questionnaires., Results: A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives., Conclusions: This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated., Competing Interests: Esser Masterclass (EM) and Global Nerve Foundation (GNF) are nonprofit independent organizations. Participants were charged €1250. The course was subsidized by Axogen, Osteotec, JB Implants and Ploganics NL for a total sum of €7409. None of the faculty members received any financial incentives. No industry funding was received for this article. A founding member of GNF is Axogen. DMP is a board member of GNF and an advisory member of EM. Authors AM, LSD and JMZ are members of the Education Committee of GNF. JMZ and LD are Board Directors of EM. All the other authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Patients with a traumatic brachial plexus injury (BPI) have previously identified the need for improved patient education tools, emphasizing the importance of communicating outcome expectations, providing attention to the emotional aspects of the injury and the treatment of pain, and acknowledging the needs of caregivers. We created a journey guide, a BPI-specific educational tool, to address these deficiencies. In this study, we determined the acceptability of the journey guide through surveys of and semistructured interviews with patients with a BPI., Methods: The journey guide was created by a multidisciplinary team focusing on previously defined areas for the improvement of patient education and care delivery related to BPI. To assess the acceptability of the journey guide, we recruited 19 participants from the brachial plexus clinic of our institution and the United Brachial Plexus Network to complete a series of surveys and semistructured interviews. Participants completed surveys regarding their satisfaction with the journey guide, and we conducted semistructured interviews to assess patient BPI experiences and impressions of the journey guide and to seek feedback. Interview transcripts were qualitatively analyzed to determine common themes for improvement., Results: A total of 19 participants with a mean age of 44.7 years were included. The cohort was predominantly male (13 participants) and White (16 participants). The mean time since BPI was 12.9 years, ranging from 2.0 to 39.7 years. On a visual analog scale, satisfaction with the journey guide was given a mean score of 8.4; expected usefulness when a patient is first injured, 8.7; potential for continued use, 7.3; and the fit for the BPI community, 8.8. Qualitative analysis demonstrated a primarily positive view of the guide and identified 4 major themes: (1) visuals and quotes improve clarity and engagement, (2) the journey guide would be most useful immediately following an injury, (3) the journey guide is an effective organizational tool, and (4) it is difficult to orient patients toward future hardships., Conclusions: The journey guide successfully filled a gap in the current care for BPI and was largely deemed acceptable by patients with a BPI. Specifically, participants found the journey guide to be a concise educational resource and an effective organizational tool. Participants also indicated that areas for improvement include the increased use of graphics and images and recognition of the greater BPI community with which patients can engage., 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/H716 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Distal radius fracture is one of the most common upper-extremity traumatic injuries. These injuries result in time off work and potential financial consequences for patients. Therefore, we aimed to understand the risk of catastrophic health expenditures (CHEs) after open reduction and internal fixation of distal radius fractures and examine the association between patient characteristics and the risk of CHE., Methods: We used data from patients undergoing open reduction and internal fixation of a distal radius fracture from a large, urban, level I trauma center (2018-2020). The risk of CHE was defined as out-of-pocket expenses of ≥40% of postsubsistence income. We used multivariable logistic regression to assess the impact of age, sex, race, and insurance status on the risk of CHE., Results: In our cohort of 394 patients, 121 patients (30.7%) were at risk of CHE after their distal radius fracture. After controlling for patient characteristics and insurance status, patients aged 26-34 years were 5.7 times more likely to be at risk of CHE (odds ratio, 5.73; 95% CI, 1.81-18.13) than patients aged ≥65 years. Patients who were uninsured were six times more likely to be at risk of CHE than patients with employer-sponsored health insurance (odds ratio, 6.02; 95% CI, 1.94-18.66). Lastly, non-White patients were at a higher risk of CHE (odds ratio, 3.63; 95% CI, 1.70-7.79) than White patients., Conclusions: Distal radius fractures are unexpected and place patients at risk of financial harm, with one in three patients at risk of CHEs. Policies aimed at minimizing cost-sharing after traumatic injury may help alleviate the financial consequences of health care delivery and reduce disparities., Type of Study/level of Evidence: Economic and Decision Analysis II., (Copyright © 2023. Published by Elsevier Inc.)

Background: Peer support is widely recognized as an important aspect of health promotion for individuals with spinal cord injury (SCI). Reports indicate positive effects for the recipients of either informal and formal peer support. The experience can also be meaningful to the person(s) providing support, although the value to providers is not well studied., Objective: This study examines the experience of provision of and receipt of informal peer support for individuals with SCI through semi-structured interviews., Methods: Data were analysed using a qualitative phenomenological approach. 16 participants with SCI participated in the study., Results: Three main themes were developed, each describing different benefits of peer support from the perspective of both members of the peer support dyad. First, participants found personal satisfaction from using their own experiences to help others adjust to their disability. Participants also noted that they learned how to complete activities of daily living as well as how to be autonomous in travel from others with SCI. Finally, participants spoke of the intrinsic benefit in teaching others with SCI., Conclusions: This study provides a novel understanding of the importance of informal peer support for individuals with SCI. Practitioners should provide opportunities for individuals with SCI to develop informal peer relationships with others who have sustained SCI., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Chronic entrapment neuropathy results in a clinical syndrome ranging from mild pain to debilitating atrophy. There remains a lack of objective metrics that quantify nerve dysfunction and guide surgical decision-making. Mechanomyography (MMG) reflects mechanical motor activity after stimulation of neuromuscular tissue and may indicate underlying nerve dysfunction., Objective: To evaluate the role of MMG as a surgical adjunct in treating chronic entrapment neuropathies., Methods: Patients 18 years or older with cubital tunnel syndrome (n = 8) and common peroneal neuropathy (n = 15) were enrolled. Surgical decompression of entrapped nerves was performed with intraoperative MMG of the hypothenar and tibialis anterior muscles. MMG stimulus thresholds (MMG-st) were correlated with compound muscle action potential (CMAP), motor nerve conduction velocity, baseline functional status, and clinical outcomes., Results: After nerve decompression, MMG-st significantly reduced, the mean reduction of 0.5 mA (95% CI: 0.3-0.7, P < .001). On bivariate analysis, MMG-st exhibited significant negative correlation with common peroneal nerve CMAP ( P < .05), but no association with ulnar nerve CMAP and motor nerve conduction velocity. On preoperative electrodiagnosis, 60% of nerves had axonal loss and 40% had conduction block. The MMG-st was higher in the nerves with axonal loss as compared with the nerves with conduction block. MMG-st was negatively correlated with preoperative hand strength (grip/pinch) and foot-dorsiflexion/toe-extension strength ( P < .05). At the final visit, MMG-st significantly correlated with pain, PROMIS-10 physical function, and Oswestry Disability Index ( P < .05)., Conclusion: MMG-st may serve as a surgical adjunct indicating axonal integrity in chronic entrapment neuropathies which may aid in clinical decision-making and prognostication of functional outcomes., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Purpose: Trapeziectomy with tendon reconstruction/suspensionplasty (TRS) is the most commonly performed surgical procedure in the United States for treatment of thumb carpometacarpal (CMC) osteoarthritis (OA). Trapeziectomy with suture tape suspensionplasty (STS) has been used recently at the study institution as an alternative surgical treatment option with perceived benefits of earlier return to function and reduced operative time. The purpose of this study was to compare patient outcomes following TRS versus STS for treatment of thumb CMC OA., Methods: All patients who underwent primary, isolated TRS or STS for treatment of thumb CMC OA between 1/1/2014 and 9/1/2020 were analyzed. We assessed demographics and preoperative and postoperative patient-rated outcome scores including Patient-reported outcomes measurement information system scores as well as pain outcomes, satisfaction, and appearance at a mean of 2.6 years after surgery (minimum 6 months). Time to return to work and activities was compared between groups. Bivariate statistics compared outcomes between groups., Results: Ninety-four patients were included in the final study cohort, of which 53 underwent TRS and 41 underwent STS. There were no differences in preoperative, postoperative, or final patient-rated outcome scores between groups. Patients reported high global and appearance satisfaction scores at final follow-up in both groups. Mean tourniquet time was 15 minutes (26%) shorter and return to work was on average 3 weeks faster for the STS group., Conclusions: There were no differences in postoperative patient-rated outcome scores between the STS and TRS groups. The STS group had a shorter surgical time and faster return-to-work after surgery., Type of Study/level of Evidence: Therapeutic III., (© 2023 The Authors.)

The proper technique for flexor tendon repair has been well established through numerous bench science and clinical studies. However, less is known about strategies to avoid and manage postoperative complications. This article discusses the common complications after flexor tendon repair, such as repair site rupture and adhesion formation. This article also addresses strategies to prevent and manage these complications. The foundation for preventing many of these complications is ensuring a strong repair without gapping at time zero, which will enable the accrual of tensile strength through early initiation of motion., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Across virtually all orthopaedic subspecialties, symptoms of depression, anxiety, and unhelpful thinking are associated with worse patient-reported satisfaction with orthopaedic treatment and increased postoperative complications. In the orthopaedic community, there is growing interest in patients' mental health in the orthopaedic care setting, but addressing mental health is still not a focus of orthopaedic clinical training. There is a persistent awareness gap about how to address mental health in orthopaedic care in a manner that is simultaneously feasible in a busy orthopaedic practice and acceptable to patients who are presenting for treatment of a musculoskeletal condition., Questions/purposes: (1) What are orthopaedic patients' and clinical team members' current perceptions and motivators regarding addressing mental health as part of orthopaedic care? (2) What barriers do patients and clinicians face regarding addressing mental health as part of orthopaedic care? (3) What are facilitators for patients and clinicians related to addressing mental health as part of orthopaedic care? (4) What are practical, acceptable implementation strategies to facilitate addressing mental health as part of orthopaedic care?, Methods: This was a single-center, qualitative study conducted from January through May 2022 in the orthopaedic department of a large, urban, tertiary care academic medical center. Semistructured interviews were conducted with members of two stakeholder groups: orthopaedic patients and orthopaedic clinical team members. We interviewed 30 adult patients (of 85 patients who were eligible and approached) who had presented to our orthopaedic department for management of neck or back pain lasting for 3 or more months. By prescreening clinic schedules, patients were purposively sampled to include representatives from varied sociodemographic backgrounds and with a range of severity of self-reported symptoms of depression and anxiety (from none to severe on the Patient-Reported Outcomes Measurement Information System Depression and Anxiety measures) (mean age 59 ± 14 years, 70% [21 of 30] women, 60% [18 of 30] White, median pain duration 3.3 [IQR 1.8 to 10] years). We also interviewed 22 orthopaedic clinicians and clinical support staff members (of 106 team members who were eligible and 25 who were approached). Team members were purposively sampled to include representatives from the full range of adult orthopaedic subspecialties and early-, mid-, and late-career physicians (11 of 22 were women, 16 of 22 were White, and 13 of 22 were orthopaedic surgeons). Interviews were conducted in person or via secure video conferencing by trained qualitative researchers. The interview guides were developed using the Capability, Opportunity, Motivation, Behavior model of behavior change. Two study team members used the interview transcripts for coding and thematic analysis, and interviews with additional participants from each stakeholder group continued until two study team members independently determined that thematic saturation of the components of the Capability, Opportunity, Motivation, Behavior model had been reached. Each participant statement was coded as a perception, motivator, barrier, facilitator, or implementation strategy, and inductive coding was used to identify themes in each category., Results: In contrast to the perceptions of some orthopaedic clinicians, most patients with orthopaedic conditions expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopaedic care plan. Motivation to address mental health was expressed the most strongly among orthopaedic clinical team members who were aware of high-quality evidence that demonstrated a negative impact of symptoms of depression and anxiety on metrics for which they are publicly monitored or those who perceived that addressing patients' mental health would improve their own quality of life. Barriers described by patients with orthopaedic conditions that were related to addressing mental health in the context of orthopaedic care included clinical team members' use of select stigmatizing words and perceived lack of integration between responses to mental health screening measures and the rest of the orthopaedic care encounter. Orthopaedic clinical team members commonly cited the following barriers: lack of available mental health resources they can refer patients to, uncertainty regarding the appropriateness for them to discuss mental health, and time pressure and lack of expertise or comfort in discussing mental health. Facilitators identified by orthopaedic clinical teams and patients to address mental health in the context of orthopaedic care included the development of efficient, adaptable processes to deliver mental health interventions that preferably avoid wasted paper resources; initiation of mental health-related discussion by an orthopaedic clinical team member in a compassionate, relevant context after rapport with the patient has been established; and the availability of a variety of affordable, accessible mental health interventions to meet patients' varied needs and preferences. Practical implementation strategies identified as suitable in the orthopaedic setting to increase appropriate attention to patients' mental health included training orthopaedic clinical teams, establishing a department or institution "mental health champion," and integrating an automated screening question into clinical workflow to assess patients' interest in receiving mental health-related information., Conclusion: Orthopaedic patients want their mental health to be acknowledged as part of a holistic orthopaedic care plan. Although organization-wide initiatives can address mental health systematically, a key facilitator to success is for orthopaedic clinicians to initiate compassionate, even if brief, conversations with their patients regarding the interconnectedness of mental health and musculoskeletal health. Given the unique challenges to addressing mental health in the orthopaedic care setting, additional research should consider use of a hybrid effectiveness-implementation design to identify effective methods of addressing mental health that are feasible and appropriate for this clinical setting., Clinical Relevance: Orthopaedic clinicians who have had negative experiences attempting to address mental health with their patients should be encouraged to keep trying. Our results suggest they should feel empowered that most patients want to address mental health in the orthopaedic care setting, and even brief conversations using nonstigmatizing language can be a valuable component of an orthopaedic treatment plan., Competing Interests: 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 © 2022 by the Association of Bone and Joint Surgeons.)

Background: Comparative studies of carpal tunnel release with ultrasound guidance (CTR-US) vs. mini-open CTR (mOCTR) are limited, prompting development of this randomized trial to compare efficacy and safety of these techniques., Research Design and Methods: Patients were randomized (2:1) to CTR-US or mOCTR, treated by experienced hand surgeons (median previous cases: 12 CTR-US; 1000 mOCTR), and followed for 3 months., Results: Among 149 randomized patients, 122 received CTR-US ( n  = 94) or mOCTR ( n  = 28). Mean incision length was 6 ± 2 mm in the wrist (CTR-US) vs. 22 ± 7 mm in the palm (mOCTR) ( p  < 0.001). Median time to return to daily activities (2 vs. 2 days; p  = 0.81) and work (3 vs. 4 days; p  = 0.61) were similar. Both groups reported statistically significant and clinically important improvements in Boston Carpal Tunnel Questionnaire Symptom Severity and Functional Status Scales, Numeric Pain Scale, and EuroQoL-5 Dimension 5-Level, with no statistical differences between groups. Freedom from wound sensitivity and pain favored CTR-US (61.1% vs. 17.9%; p  < 0.001). Adverse event rates were low in each group (2.1% vs. 3.6%; p  = 0.55)., Conclusions: The efficacy and safety of CTR-US were comparable to mOCTR despite less previous surgical experience with CTR-US. The choice of CTR technique should be determined by shared decision-making between patient and physician., Clinical Trial Registration: www.clinicaltrials.gov identifier is NCT05405218.

Background: Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care., Methods: This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention., Results: Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care., Conclusions: Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients., Trial Registration: Not applicable., (© 2023. The Author(s).)

Background: After a radial nerve injury, patients must weigh a complicated set of advantages and disadvantages to observation or surgery. We conducted semistructured interviews to characterize the decision-making process that these patients undertake., Methods: We recruited participants who were treated with expectant management (nonoperatively), received only a tendon transfer, or received a nerve transfer. Participants completed a semistructured interview that was transcribed and coded to identify recurring themes, to describe the influence of qualitative findings on treatment decision-making., Results: We interviewed 15 participants (5 expectant management, 5 tendon transfer only, and 5 nerve transfer). Participants' primary concerns were returning to work, hand appearance, regaining motion, resuming activities of daily living, and enjoying hobbies. Delayed diagnosis and/or insurance coverage led 3 participants to change treatment from nerve transfer to isolated tendon transfer. Interactions with providers early in diagnosis and treatment had strong effects on how members of the care team were perceived. The hand therapist was the primary person who shaped expectations, provided encouragement, and prompted referral to the treating surgeon. Participants valued debate among the care team members regarding treatment, provided that medical terminology was explained., Conclusions: This study highlights the importance of initial, collaborative care in setting expectations for patients with radial nerve injuries. Many participants named returning to work and hand appearance as primary concerns. Hand therapists were the primary source of support and information during recovery., Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence., 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/H432 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery., Methods: Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis., Results: Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE., Conclusions: Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery., Clinical Relevance: Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs., (Copyright © 2023. Published by Elsevier Inc.)

Background: Health-care expenditures are a leading contributor to financial hardship in the United States. Traumatic orthopaedic injuries are unpredictable and result in substantial expense. Our objectives were to quantify the catastrophic health expenditure (CHE) risk of patients with orthopaedic trauma and to examine the impact of insurance status, socioeconomic status, sex, and race on CHE., Methods: We identified all isolated lower-extremity orthopaedic trauma cases at a safety-net, Level-1 trauma center from 2018 to 2020. We queried an institutional charge database to obtain total hospital charges, insurance status, and ZIP Code to determine out-of-pocket (OOP) expenditures. To evaluate financial hardship, we calculated the CHE risk as defined by the World Health Organization's threshold of OOP expenditures, ≥40% of estimated household post-subsistence income., Results: In our cohort of 2,535 patients, 33% experienced a risk of CHE. A risk of CHE was experienced by 99% of patients who were uninsured, 35% of patients with private insurance, 2% of patients with Medicare, and 0% of patients with Medicaid. Multivariable regression modeling showed that patients who were uninsured were significantly more likely to experience a risk of CHE compared with patients with private insurance (odds ratio, 107.68 [95% confidence interval, 37.20 to 311.68]; p < 0.001)., Conclusions: One-third of patients with lower-extremity orthopaedic trauma experience a risk of CHE, with patients who are uninsured facing a disproportionately higher risk of CHE compared with patients who are insured. Our results suggest that the expansion of public insurance options may provide substantial financial protection for those at the greatest risk for CHE., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., 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/H374 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)