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BACKGROUND The Michigan Hand Outcomes Questionnaire is a patient-reported outcome measure that has been validated in many upper extremity disorders using classic test theory. Rasch measurement analysis is a rigorous method of questionnaire validation that offers several advantages over classic test theory and was used to assess the psychometric properties of the Michigan Hand Outcomes Questionnaire. This study used Rasch analysis to evaluate the questionnaire for distal radius fractures in older adults. The incidence and costs of distal radius fractures are rising, and reliable assessment tools are needed to measure outcomes in this growing concern. METHODS Rasch analysis was performed using 6-month assessment data from the Wrist and Radius Injury Surgical Trial. Each domain in the Michigan Hand Outcomes Questionnaire was independently analyzed for threshold ordering, person-item targeting, item fit, differential-item functioning, response dependency, unidimensionality, and internal consistency. RESULTS After collapsing disordered thresholds and removing any misfitting items from the model, five domains (Function, Activities of Daily Living, Work, Pain, and Satisfaction) demonstrated excellent fit to the Rasch model. The Aesthetics domain demonstrated high reliability and internal consistency but had poor fit to the Rasch model. CONCLUSIONS Rasch analysis further supports the reliability and validity of using the Michigan Hand Outcomes Questionnaire to assess hand outcomes in older adults following treatment for distal radius fractures. Results from this study suggest that questionnaire scores should be interpreted in a condition-specific manner, with more emphasis placed on interpreting individual domain scores, rather than the summary Michigan Hand Outcomes Questionnaire score.

BACKGROUND: Optimal treatment for distal radius fractures (DRFs) in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, though the sustained benefits of surgery are uncertain. METHODS: The Wrist and Radius Injury Surgical Trial (WRIST), randomized, multicenter trial, enrolled 304 adults age 60 years and older with isolated, unstable DRFs at 24 institutions. Patients who wanted surgery (n=187) were randomized to internal fixation with volar plate (VLPS), external fixation (EFP), or percutaneous pinning; patients who preferred conservative management (n=117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes included MHQ domain scores and radiographic parameters. RESULTS: At 12 months, there were no differences by treatment in primary or the majority of secondary outcomes. Twelve-month MHQ Summary scores differed between VLPS and EFP by 3 points (97.5% CL: −6.0, 11.5) and between VLPS and pinning by −0.14(−9.2,8.9). However, at 6 weeks, mean MHQ Summary score for VLPS was greater than EFP by 19(p

Randomized controlled trials are becoming increasingly difficult to organize and conduct efficiently. This, in turn, hinders the ability to derive the highest level of evidence. Often, investigators forget or remain unaware of essential practices that will help them fulfill their study goals. This article emphasizes the common issues that a study team experiences during the planning and conducting of randomized controlled trials. The authors sought to share remedies to overcome these issues with the experience garnered in conducting several multicenter clinical trials and observational studies. In addition, the authors list resources from sponsors such as the National Institutes of Health and the U.S. Food and Drug Administration that study teams can apply to undertake studies effectively.

© 2019 American Society for Surgery of the Hand Purpose: Current evidence on predictors of outcomes after distal radius fracture is often based on retrospective analyses or may be confounded by fracture type. Using data from the Wrist and Radius Injury Surgical Trial (WRIST), a 24-site randomized study of distal radius fracture treatment, in which all fractures are severe enough to warrant surgery, we set out to perform a secondary data analysis to explore predictors of better or worse hand outcomes. Methods: The primary outcome measure was the Michigan Hand Outcomes Questionnaire (MHQ) summary score 12 months after treatment. We used a regression tree analysis with recursive partitioning to identify subgroups of participants who experienced similar outcomes (ie, MHQ score) and to determine which baseline or treatment factors they had in common. Results: Factors most predictive of 12-month MHQ score were pain at enrollment, education, age, and number of comorbidities. Specifically, participants who had a high school education or less and also reported severe pain had the lowest MHQ scores. Conversely, participants with less pain and more education and who were age 87 years or younger with one or no comorbid condition had the highest MHQ scores. Treatment type or radiographic measurements assessed on post-reduction films did not affect 12-month outcomes. Conclusions: These results identified patient characteristics that can be used by surgeons to identify subgroups of patients who may experience similar hand outcomes. Type of study/level of evidence: Prognostic III.

Background As many as 34 percent of nonfatal firearm injuries involve the upper extremity. Although not lethal, these injuries cause substantial morbidity. The authors conducted an epidemiologic study characterizing upper extremity firearm-related injuries presenting to U.S. trauma centers over a 10-year period. Methods The authors used the National Trauma Databank from 2007 to 2017 to identify isolated upper extremity firearm-related injuries. Descriptive statistics were performed to characterize patient demographic data, firearm type, extremity injury patterns, treatments received, hospital length of stay, and regional variation. Results The authors identified 48,254 upper extremity firearm-related injuries. The patients were largely male patients (85 percent), and over half were between the ages of 20 and 39 years. Handguns (34 percent) were the most frequently used firearm. Shoulder and upper arm were the most frequently injured areas (54 percent); however, 18 percent of patients injured two or more areas. Patients were most often treated at university hospitals (59 percent) with Level I or II trauma designation. Seventy percent were admitted and/or taken directly to the operating room. The mean hospital length of stay was 3 days. Payer mix among these patients was variable: Medicaid, 20 percent; private insurance, 20 percent; and self-pay, 29 percent. Conclusions Upper-extremity firearm injuries are resource intensive, with three-quarters of patients requiring operative intervention and/or hospitalization. Level I and II trauma centers were the site of care for the majority of patients. Targeted gun policy reform and prevention measures directed toward at-risk groups have the potential to limit the unnecessary morbidity and costs associated with these injuries.

Importance Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce. Objective To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial. Design, Setting, and Participants The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021. Interventions Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting. Main Outcomes and Measures The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion. Results A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P

Approximately 10,000 firework-related injuries were treated in US emergency departments in 2019.1 Although published reports use sources ranging from nationally representative datasets to single center censuses, patient demographic factors remain consistent. Patients are 70-90% male and approximately 50% are under the age of 20.1-4 Injuries are most common to the hands, face, and eyes and are most often burns and lacerations. Although most injuries are minor, 11% of patients require admission or transfer to a higher-level facility and critical care admissions and deaths do occur.1,2 Canner et al., using the Nationwide Emergency Department Sample, estimated $8 million in annual charges for firework-related emergency department visits.2.

BACKGROUND This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio. RESULTS Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Background Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice. Methods In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment. Results Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection. Conclusions Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

Background The Michigan Hand Outcomes Questionnaire has been widely used for nearly 20 years to assess patients with a variety of hand and upper extremity conditions. However, normative data have not previously been collected, limiting interpretation. Methods The Michigan Hand Outcomes Questionnaire was administered to 579 participants recruited from the general population. In addition, participants were asked to identify any problem affecting their hand(s), including trauma, hand disease/condition, systemic illness, or nonspecific symptoms. Comorbidities and demographic data were also collected. Results Total Michigan Hand Outcomes Questionnaire score for healthy individuals was indicative of generally good hand function (95.2; 95 percent CI, 94.3 to 96.1). Individuals with unilateral trauma scored for their affected hand (90.3; 95 percent CI, 87.9 to 92.6) lower than their healthy hand (mean difference, 5.7; 95 percent CI, 3.2 to 8.3). For individuals with and without hand trauma, total Michigan Hand Outcomes Questionnaire score decreased with increasing number of comorbidities. Many of the differences in Michigan Hand Outcomes Questionnaire score between the problem hand and unaffected hand were smaller than the minimal clinically important difference of 3.0 to 23.0 for known abnormalities of the hand and upper extremity. Conclusions These normative data provide appropriate baseline information for individuals with and without underlying hand conditions. Most notably, these findings suggest that individuals with a unilateral problem establish new subnormative values for both their affected and unaffected hands. These data will encourage an appropriate understanding of the results of future studies using the Michigan Hand Outcomes Questionnaire.

Introduction One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients. Methods This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores. Results 280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p

Importance The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase. Objective To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients. Design, Setting, and Participants Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment. Interventions Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts. Main Outcomes and Measures Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment. Results Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76;P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, −16.84 to −3.86;P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores. Conclusions and Relevance The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment. Trial Registration ClinicalTrials.gov identifier:NCT01589692

The Wrist and Radius Injury Surgical Trial (WRIST) collaboration is the largest clinical trial ever conducted in hand surgery. We applied data from this study to examine the relationship between functional outcomes and patient satisfaction after treatment of distal radial fractures. Patients aged 60 years and older with isolated distal radial fractures were enrolled at 24 health systems. Grip strength and the arc of wrist motion were measured after treatment. The Michigan Hand Outcomes Questionnaire was used to measure patient satisfaction. Receiver operating characteristic curves were created using patient satisfaction as the reference standard and each functional measure as a predictor. At 12 months after treatment, mean grip strength was 82% of normal and mean arc of motion was 88% of normal. The optimal cut-off points to distinguish satisfaction from dissatisfaction occurred when patients recovered 59% of hand strength and 79% of wrist motion. Continuing therapy to increase functional gains beyond this point unnecessarily utilizes healthcare resources without additional patient-reported gains. Level of evidence: IV

IMPORTANCE: Optimal treatment for traumatic digit amputation is unknown. OBJECTIVE: To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. EXPOSURES: Revision amputation or replantation of traumatic digit amputations. MAIN OUTCOMES AND MEASURES: The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. RESULTS: Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P = .02), DASH (−4.29; 95% CI, −8.45 to −0.12; P = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P = .03 for DASH and 61 vs 36, P = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P = .03). CONCLUSIONS AND RELEVANCE: When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatization of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatization. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

Large geographic differences in procedure utilization draw into question its appropriate use. In Japan, replantation is frequent for even very distal finger amputations. In the United States, revision amputation is far more common. There has been no detailed investigation into the drivers of these differences.The authors created a survey to assess experience with replantation, estimates of physical and functional outcomes, attitudes toward amputees, and preferences in several injury scenarios. The survey was distributed to members of the Finger Replantation and Amputation Multicenter Study and to hand surgeons making podium presentations at the Thirty-Second Annual Meeting of the Central Japanese Society for Surgery of the Hand.One hundred percent of both groups responded. There were no significant differences in surgeon experience. Japanese surgeons were significantly more likely to recommend replantation in all scenarios, despite 62 percent ranking function 6 months after replantation as "poor." Japanese surgeons also rated the appearance of a hand with an amputated finger significantly poorer. Finally, Japanese surgeons were significantly more likely to report stigmatization against finger amputees.There is no study with a high level of evidence comparing outcomes following replantation and revision amputation. The lack of evidence results in surgeons basing recommendations on personal preference. In this case, Japanese surgeons preferred replantation despite agreeing that functional outcomes were suboptimal. This may be because of Japanese cultural beliefs. Comparative effectiveness research, such as that planned by the Finger Replantation and Amputation Multicenter Study, can provide evidence toward the appropriate use of replantation.

BACKGROUND Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises. METHODS The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. RESULTS The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. CONCLUSIONS The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.

BACKGROUND: It remains unknown whether treatment trends for distal radius fracture (DRF) have changed in light of value-based care initiatives during recent years. We aimed to characterize modern practice patterns for DRF management. METHODS: We used 2009–2015 Truven MarketScan databases to extract data on several variables comprising of demographic characteristics, geographic location, and comorbidities for patients receiving treatment for a DRF. Regression analysis and Joinpoint analysis were used to assess trends over the study period. We analyzed the association of patient factors with type of treatment provided using logistic regression modeling. RESULTS: Among all 499,766 eligible encounters, the rate of internal fixation fluctuated around 13%. Casting/splinting remained the most frequent treatment across all populations. Treatment trends varied by age; children and adolescents were treated almost exclusively with closed treatment (mean: 97%), yet rates of internal fixation increased among adults and elderly patients. Patients age 55 to 64 were most likely to undergo internal fixation (OR: 1.89; 95%CI:1.82–1.96). Higher median household income also significantly increased one’s odds of receiving internal fixation (p

Background Distal radius fracture treatments provide similar functional outcomes. It has been hypothesized that the use of internal fixation is increasing because of physician preferences. The multisite randomized Wrist and Radius Injury Surgical Trial provides a unique opportunity to examine patient preferences in the absence of surgeon influence. The authors' objective was to investigate patient preference for internal fixation even after being informed of the equipoise among treatments. Methods The authors performed 30 semistructured interviews with older individuals, all older than 60 years, approached at their institution for the Wrist and Radius Injury Surgical Trial. The authors' sample included three groups: those with a preference for internal fixation (n = 11), those with preference for nonsurgical treatment (n = 6), and those without a preference who consented to surgical randomization (n = 13). We used grounded theory for data collection and analysis. Results All participants indicated their chief concern was regaining full function. Patients based their preferences for internal fixation on multiple values, including obstacles to recovery, autonomy, aesthetics, and pain relief. Some patients who did not select internal fixation reflected on their experiences, questioning whether they would have had a potentially different outcome with internal fixation treatment. Conclusions Without evidence for a superior treatment, patients focus on factors that pertain to recovery rather than outcomes, with most preferring the volar locking plating system. To best align with patient values, physicians should focus their discussion with patients on aspects of the recovery period rather than functional outcomes. Evidence from the Wrist and Radius Injury Surgical Trial will provide high-level information about patient-reported, functional, and radiographic outcomes.

Background:The review process can be completely open, double-blinded, or somewhere in between. Double-blinded peer review, where neither the authors’ nor peer reviewers’ identities are shared with each other, is thought to be the fairest system, but there is evidence that it does not affect reviewer

The occurrence of a low energy fracture of the distal radius increases the risk for another, more serious fracture, such as a proximal femoral fracture. Early mortality after a proximal femoral fracture has been widely studied, but the association between a distal radial fracture and mortality is unknown. The date of death for all Medicare beneficiaries who sustained an isolated distal radial fracture in 2007 was determined using Medicare Vital Statistics files. The adjusted mortality rate for each age–sex group was calculated and compared with published US mortality tables. Distal radial fractures were not associated with an increased mortality rate. In fact, beneficiaries had a significantly lower mortality rate after distal radial fractures than the general population. This may be related to the injured beneficiaries’ involvement in the healthcare system. Mortality rate did not vary significantly based on time from injury. Our results indicate that any mortality is unlikely to be attributable to the distal radial fracture or its treatment. Level of Evidence: III

Background Quality normative data requires a diverse sample of participants and plays an important role in the appropriate use of health outcomes. Using social media and other online resources for survey recruitment is a tempting prospect, but the effectiveness of these methods in collecting a diverse sample is unknown. The purpose of this study is to pilot test four methods of recruitment to determine their ability to produce a sample representative of the general US population. Methods This project is part of a larger study to gather normative data for the Michigan Hand Outcomes Questionnaire (MHQ). We used flyers, e-mail, Facebook, and an institution-specific clinical research recruitment Web site to direct participants to complete an online version of the MHQ. Participants also provided comorbidity and demographic information. Results The institution-specific recruitment Web site yielded the greatest number of respondents in an age distribution that mirrored the US population. Facebook was effective for recruiting young adults, and e-mail was successful for recruiting the older adults. None of the methods was successful in reaching an ethnically diverse sample. Conclusions Obtaining normative data that is truly representative of the US population is a difficult task. The use of any one recruitment method is unlikely to result in a representative sample, but a greater understanding of these methods will empower researchers to use them to target specific populations. This pilot analysis provides support for the use of Facebook and clinical research sites in addition to traditional methods of e-mail and paper flyers.

Survey research is a commonly used research tool used to gather opinions regarding emerging technologies and current practices. As randomized clinical trials rose to prominence, the Consolidated Standards of Reporting Trials Study Group created a checklist of items necessary for the complete and transparent reporting of randomized clinical trials. Similar checklists have been created for a variety of research methodologies. Notably missing is a checklist for the reporting of survey studies. This article examines the conduct of survey research publications and proposes a checklist to evaluate the validity of survey studies published in Plastic and Reconstructive Surgery.

Purpose We sought to compare preferences for arthroplasty versus arthrodesis among patients with proximal interphalangeal (PIP) joint osteoarthritis (OA) by quantifying the patient-assigned utility of each operation's attributes. Methods We undertook a multistep process to identify relevant surgical attributes, including a literature review, surgeon survey, and pretest patient pilot test to build a set of discrete choice experiments. Patients with PIP joint osteoarthritis were identified using a single university electronic medical record and were recruited via electronic message or postcard. Participants completed a demographic survey and 11 discrete choice experiments designed using Sawtooth Software's Discover tool. Utility and importance scores were generated for each attribute. Results Pretest analysis identified out-of-pocket cost, joint stiffness, need for future surgery, change in grip strength, and total recovery time as the most important surgical attributes. Initial response rate to the conjoint survey was 75% and survey completion rate was 61%. The study sample was predominantly white (91%) and female (72%), mean age 64.3 years (range, 34–90 years), and mean daily pain score was 4.32 (range, 0–10). Attribute importance scores demonstrated that joint stiffness (32%) and grip strength (29%) were most important to patients. Cost (17%) and need for future surgery (19%) were intermediate patient-preference drivers. Recovery time was the least important attribute (2%). Conclusions In aggregate, patients prefer surgical attributes characteristic of arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times). Type of study/level of evidence Economic/Decision Analysis III.

Objectives To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization. Design A qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews. Setting Community. Participants A sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%). Interventions Not applicable. Main Outcome Measures Participants' self-report of their medical experiences from the time of injury through the early recovery period. Results We identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care). Conclusions In appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.

Purpose Understanding patient preferences for shared decision making is valuable for surgeons to advance patient-centered care, particularly in cases where there is not a clearly superior treatment option, like distal radius fracture. The existing evidence presents conflicting views on the desired role of the provider among older patients when making medical decisions. We aimed to investigate the perceived versus desired role of the provider in older adult patients with distal radius fracture. Methods Thirty patients (≥62 years old) who had sustained a distal radius fracture within the past 5 years were recruited from the screening process of the Wrist and Radius Injury Surgical Trial at the principal investigator's site using purposive sampling. A trained member of the research team conducted interviews in a semistructured format with the help of an interview guide. Findings were derived following the principles of grounded theory. Results Participants experienced varied levels of shared decision making with the hand surgeon. Subjects' perceived role of the surgeon did not always match their desired role. Most patients placed distinct trust in the recommendations of hand specialists regarding the technical aspects of the treatment. Nonetheless, respondents wanted to provide input when decisions pertained to outcomes or functionality. Many patients sought outside support from family or friends in the health care field, regardless of the outside source's medical specialty. Conclusions Despite conflicting evidence, most older adult patients desire a shared approach when making treatment decisions. Exchanging information and preferences on outcomes of each treatment option may be more important to the patient than detailing the specific technical aspects of their care. Clinical relevance To provide high quality care, surgeons should evaluate the desired role of the patient to make treatment decisions at the start of their interaction. Surgeons must be aware of outside medical influences that guide their patients' decision-making processes.

Background Patients who receive workers' compensation often display worse surgical results, such as prolonged pain or reduced functional ability. The outcomes of surgery can be assessed using a variety of surveys, assessments, and measurements. It is unknown whether the confounding effect differs based on how results are measured. The aim of this study was to determine whether these variations exist. Methods A search of full-length articles published between January 1, 1995, and December 31, 2015, was conducted using 3 online databases. The authors performed a systematic review and meta-analysis using unique inclusion criteria for each. Results A total of 101 articles were included in the systematic review; 62 of them were retained for the meta-analysis. In the systematic review, 70 percent of studies found that patients receiving workers' compensation had significantly worse postoperative results than uncompensated patients, whereas only 42 percent of studies that measured preoperative versus postoperative improvement were influenced by workers' compensation. The meta-analysis found that uncompensated patients were more likely to experience improvement after surgery than patients receiving workers' compensation (summary OR, 3.17; 95 percent CI, 2.47 to 4.08). A subgroup analysis demonstrated that functional measures, such as grip strength or nonunion, were least affected by workers' compensation, compared with other outcome measures such as patient-reported outcomes questionnaires or time off work. Conclusion Potential bias introduced by workers' compensation can be mitigated by evaluating surgical treatment of work-related upper extremity disorders using preoperative versus postoperative improvement or functional measures.

Purpose This study attempted to determine the extent to which surgeon age influences treatment patterns for distal radius fractures (DRFs). We hypothesized that younger surgeons perform open reduction internal fixation (ORIF) for DRFs among elderly individuals more frequently than older surgeons, who employ a wider range of treatment modalities. Methods We identified 61,314 Medicare beneficiaries who experienced DRFs and the 12,823 surgeons who performed ORIF, external fixation, pinning, or closed reduction on them during 2007. We examined the effect of surgeon age on DRF treatment pattern, controlling for patient characteristics and other surgeon factors using multinomial logistic regression. We then stratified our analysis by American Society for Surgery of the Hand membership to more closely examine the influence of surgeon specialization on the association between surgeon age and DRF treatment. Results Surgeons aged 40 years and younger were more likely to perform ORIF and less likely to choose external fixation and percutaneous pinning to treat DRFs, compared with older surgeons. Surgeon specialization mitigated this relationship, and American Society for Surgery of the Hand members were more likely to choose ORIF compared with nonmembers. However, surgeon age remained a significant predictor of treatment choice after controlling for other factors and surgeon specialization. Conclusions Younger surgeons are more likely to perform ORIF for DRFs among Medicare beneficiaries over 65 years of age. Given the lack of evidence supporting any single treatment option for DRF, understanding the factors that drive dissemination of operative techniques may provide insight into treatment disparities within the Medicare population. Type of study/level of evidence Therapeutic III.

Background:. This multicenter study aimed to examine the reasons for prosthesis rejection and assess the quality of life (QOL) among patients with upper limb deficiency. Methods:. Three rehabilitation centers in Japan and 1 academic medical center in the United States participated. Patients between the age of 12 and 75 years with unilateral or bilateral upper limb absence from the level of wrist to shoulder disarticulation were included. Two questionnaires were used, an original questionnaire on prosthesis use and the EQ-5D, which were completed by both the participant and a live-in proxy. Results:. Of the 367 patients with upper limb loss invited, 174 patients participated in this study. Eighty percent of the study population were male patients. The most common amputation level was transradial. Trauma was the most common cause of limb loss. The prosthesis rejection rate was 9% (n = 16). The most common reason for abandonment was a lack of prosthesis functionality. Ten of 16 prosthesis nonusers (63%) and 59 prosthesis users (38%) were unemployed or students. The mean EQ-5D utility score was significantly higher in prosthesis users than in nonusers (0.762 versus 0.628, P < 0.01). Live-in proxies significantly overestimated QOL in male patients (0.77 versus 0.807, P=0.01). Conclusions:. The current prosthesis rejection rate is low. QOL was significantly higher in prosthesis users than in nonusers. More prosthesis users were employed compared with nonusers. Care should be taken not to overestimate the QOL of male patients with upper limb loss as their proxies often did.

Distal radius fractures are costly and debilitating injuries, especially for the elderly. These fractures often occur from falls and commonly occur outdoors. Inclement weather may increase the risk of fall-related injuries. Small studies have reported an increased risk of distal radius fracture caused by inclement winter weather; larger studies are lacking.The authors analyzed a sample of 2007 Medicare claims for distal radius fracture. Weather data were collected for the date and location of each distal radius fracture in the authors' analysis cohort. A novel slipperiness score was used as a measure of the severity of slippery outdoor conditions. Negative binomial regression models evaluated the correlation between slipperiness and distal radius fracture occurrence.Risk of distal radius fracture was higher in winter months (incidence rate ratio, 1.2; p0.001). Days with average temperature less than or equal to 32°F (incidence rate ratio, 1.36; p0.001), snow/ice on the ground at the start of the day (incidence rate ratio, 1.45; p0.001), and freezing rain (incidence rate ratio, 1.24; p = 0.025) all had an increased risk of distal radius fracture. The risk of sustaining a distal radius fracture was increased 21 percent on days with a slipperiness score above 4 (incidence rate ratio, 1.21; p = 0.007). For each increase in slipperiness score above 4, the incidence rate ratio of distal radius fracture increased as well.Weather events that create slippery walking conditions, often in the winter, result in an increased risk of distal radius fracture in the elderly. This finding can be used to support resource allocation and awareness and prevention campaigns.Risk, IV.

Background The Michigan Hand Outcomes Questionnaire has been used to assess a variety of hand and upper extremity injuries and conditions for nearly 15 years. It has been included in several overviews of upper extremity outcomes measures, but it has not been systematically examined regarding its clinometric properties during field trials. Methods The authors conducted a review of the Michigan Hand Outcomes Questionnaire in the English language literature from 1998 through March of 2012. Data from clinical studies were abstracted and compiled. Results The Michigan Hand Outcomes Questionnaire has been used in 58 clinical studies, and its clinometric properties have been analyzed in an additional 18 publications. The Michigan Hand Outcomes Questionnaire compares favorably with other hand outcomes instruments in the areas of test-retest reliability, validity, and responsiveness. High internal consistency may indicate redundancy within the items in the Michigan Hand Outcomes Questionnaire. The strength of the Michigan Hand Outcomes Questionnaire is its multidimensional construct in measuring patient-rated outcomes in symptom, function, aesthetics, and satisfaction. Conclusions The Michigan Hand Outcomes Questionnaire has been applied across a variety of conditions affecting the hand and upper limb. Its psychometric properties have been tested through field trials in various clinical settings around the world.

PurposeThe purpose of this study was to conduct a systematic review of outcomes of fingertip revision amputation for fingertip amputation injuries in the English-language literature to provide best evidence of functional outcomes.MethodA MEDLINE literature search was performed to identify studies that met the following criteria: (1) reported primary data; (2) included at least five cases of primary revision amputation treatment following digit amputation injury; (3) reported finger or thumb amputation at or distal to the distal interphalangeal (DIP) joint or interphalangeal (IP) joint, respectively; (4) presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, arc of motion (AOM) of metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIP), DIP joints, or return-to-work time.ResultsThirty-eight studies met the inclusion criteria. Twenty-seven studies reported 2PD, 20 studies reported cold intolerance, eight studies reported AOM, and 18 studies reported return-to-work time after revision amputation of fingertip injuries. The mean 2PD was 5.6 mm. On average, 24 % of patients experienced cold intolerance. AOM at the PIP joint was reported in four studies and averaged 94°. DIP joint AOM was presented in four studies and averaged 66°. Thumb MCP and IP joint AOM was presented in three and four studies, respectively. Mean thumb MCP joint AOM was 54° and that of the IP joint was 71°. The mean return-to-work time was 47 days.ConclusionsOn average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery.

Aim In China, hand surgeons treat fewer rheumatoid arthritis (RA) patients compared to other countries. We investigated whether physician and surgeon knowledge, attitudes and practices regarding RA hand deformities reflect current evidence and may contribute to the low utilization of surgery. Method We surveyed hand surgeons and rheumatologists at three tertiary hospitals in Beijing, China. Questionnaires were developed from literature and expert review to assess their knowledge, attitudes and practice patterns related to rheumatoid hand surgery. Results Thirty-five hand surgeons and 59 rheumatologists completed the survey. Roughly one-third felt that the rheumatologists and hand surgeons agree on how to manage RA hand deformities. One-fifth of rheumatologists and 29% of hand surgeons believed that drug therapy can correct hand deformities, which contradicts current evidence. Likewise, 30% and 14%, respectively, recommended surgery for early-stage hand sequelae that do not meet current indications for surgery. Over 80% of surgeons and rheumatologists had no exposure to the other specialty during training and felt their training on the treatment of rheumatoid hand deformities was inadequate. Conclusion Although we found similar interspeciality disagreement in China as is seen in the United States, there appears to be less interaction through training and consultations. Our results also indicate potential deficits in training and unawareness of evidence and indications for rheumatoid hand surgery. These findings help to explain why surgery for rheumatoid hand deformities is rare in China; doctors have fewer opportunities to collaborate across specialties and may not be able to select appropriate candidates for surgery.

In 2006, the U.S. Food and Drug Administration recommended screening of all women with silicone gel breast implants with magnetic resonance imaging 3 years after implantation and every 2 years thereafter to assess their integrity. The cost for these serial examinations over the lifetime of the breast implants is an added burden to insurance payers and to women. The authors performed an economic analysis to determine optimal screening strategies by considering the diagnostic accuracy of the screening tests, costs of the tests, and subsequent implant removal.The authors determined aggregate/pooled values for sensitivity and specificity of the screening tests of ultrasound and magnetic resonance imaging in detecting silicone breast implant ruptures from the data obtained from published literature. They compiled costs, based on Medicare reimbursements for 2011, for the following elements: imaging modalities, anesthesia, and three surgical treatment options for detected ruptures. A decision tree was used to compare three alternate screening strategies of ultrasound only, magnetic resonance imaging only, and ultrasound followed by magnetic resonance in asymptomatic and symptomatic women.The cost per rupture of screening and management of rupture with ultrasound in asymptomatic women was $1090; in symptomatic women, it was $1622. A similar cost for magnetic resonance imaging in asymptomatic women was $2067; in symptomatic women it was $2143. A similar cost for ultrasound followed by imaging in asymptomatic women was $637; in symptomatic women, it was $2908.Screening with ultrasound followed by magnetic resonance imaging was optimal for asymptomatic women, and screening with ultrasound was optimal for symptomatic women.

Short-term results after proximal interphalangeal joint arthroplasty with pyrolytic carbon (pyrocarbon) implant have shown that this implant has high complication rates, but patient satisfaction is high. The authors evaluated the effectiveness of the implant for use in proximal interphalangeal joint at a minimum of 2 years of follow-up.Thirteen consecutive candidates who underwent 21 proximal interphalangeal joint arthroplasty procedures with pyrocarbon implant were evaluated prospectively. Functional measurements and the Michigan Hand Outcomes Questionnaire were administered preoperatively and at 12 months and intermediate term (2 years) postoperatively. Preoperative and intermediate-term mean data for all functional measures and questionnaire scores were compared.Thirteen patients were treated, with a mean follow-up of 44 months. Grip strength, key pinch strength, and active arc of motion demonstrated no statistical difference between preoperative and intermediate-term assessment. All domains of the Michigan Hand Outcomes Questionnaire showed improved large effect size at intermediate-term follow-up, especially pain and satisfaction. There were 10 complications in nine joints (complication rate, 42.9 percent). Patients without complications had better functional outcomes; however, there were no statistical differences in questionnaire scores between patients with and without complications, except for pain (p = 0.04).Proximal interphalangeal joint arthroplasty with pyrocarbon implant seems to be an effective way of reducing pain without sacrificing active arc of motion. Despite a high complication rate, patients were generally satisfied, especially with pain relief, and complications did not affect patients' satisfaction even when hand function was affected. Further decision-making analysis to compare arthroplasty and fusion for each finger may help surgeons to select the appropriate operative procedures.Therapeutic, IV.

Background The American Board of Plastic Surgery Maintenance of Certification program includes the submission of 10 consecutive cases in one of 20 tracer modules for Performance in Practice evaluation. This has resulted in a wealth of data on the practice patterns of Board diplomates. The specific aim of this project was to examine these data to determine whether diplomates are adhering to evidence-based practice guidelines. Methods The authors searched the Agency for Healthcare Research and Quality National Guideline Clearinghouse for guidelines. Once the guidelines were identified, the authors compared the recommendations with data entered by Board diplomates for the tracer modules in question. It is important to note that guidelines are recommendations based on the best available evidence and that all guidelines are subject to change, pending periodic reexamination of the evidence. Results Diplomates are adhering to guidelines regarding age of cosmetic breast augmentation patients, use of prophylactic antibiotics and deep venous thrombosis prophylaxis in abdominoplasty patients, and use of carpal tunnel release in the treatment of carpal tunnel syndrome. Half the diplomates, however, are using splints following carpal tunnel release, despite recommendations to the contrary. In addition, only half the diplomates are following guidelines recommending mammography before breast augmentation. Furthermore, 90 percent of diplomates are not following recommendations against the use of deep venous thrombosis prophylaxis for patients with acute lower limb trauma. Conclusions This study revealed that there were few guidelines with which to compare diplomate performance. Steps should be taken to increase the number of evidence-based practice guidelines for plastic surgery procedures.

Key Points Question Do rates or types of complications after distal radius fractures depend on treatment type? Findings In this secondary analysis of a randomized clinical trial of 304 adults from 24 health systems, the method of treatment participants received was associated with the rate or type of complications. Compared with participants who received internal fixation, participants who received any other treatments experienced complications at significantly higher rates. Meaning Choice of distal radius fracture treatment method in older patients should be specific to individual goals to minimize complication risks and improve outcomes., Importance Complications affect treatment outcomes and quality of life in addition to increasing treatment costs. Objectives To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications. Design, Setting, and Participants The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018. Interventions Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting. Main Outcomes and Measures Complication rate. Results The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants’ mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants’ mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09). Conclusions and Relevance The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved. Trial Registration ClinicalTrials.gov Identifier: NCT01589692, This secondary analysis of the WRIST (Wrist and Radius Injury Surgical Trial) randomized clinical trial evaluates complication rates among older patients receiving treatment for a distal radius fracture and whether the rate or complication type is associated with treatment method.

Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations.One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results.For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY.Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.

Decision analysis is a method of probabilistic reasoning and decision-making under conditions of uncertainty. These methods are being used increasingly in hand surgery and medicine in general. It is important for hand surgeons to understand these techniques and how to interpret the results from these studies. Performing a decision analysis involves (1) defining a specific question, (2) creating a model to frame the question, (3) assigning value to outcomes in the model, (4) assigning probabilities to chance events in the model, (5) identifying the best strategy within the model, (6) sensitivity analysis, and (7) model refinement. It is important to recognize the limitations inherent in decision analysis but also to understand its value in overcoming clinical uncertainty by employing a practical technique of modeling choices and outcomes.

Purpose To examine the utilization and cost of post–acute care following isolated distal radius fractures (DRFs) among Medicare beneficiaries. Methods We examined utilization of post–acute care among Medicare beneficiaries who experienced an isolated DRF (n = 38,479) during 2007 using 100% Medicare claims data. We analyzed the effect of patient factors on hospital admission following DRF and the receipt of post–acute care delivered by skilled nursing facilities, inpatient rehabilitation facilities, home health care agencies, and outpatient occupational therapy/physical therapy for the recovery of DRF. Results In this cohort of isolated DRF patients, 1,694 (4.4%) were admitted to hospitals following DRF, and 20% received post–acute care. Women and patients with more comorbid conditions were more likely to require hospital admission. The utilization of post–acute care was higher among women, patients who resided in urban areas, and patients of higher socioeconomic status. The average cost per patient of post–acute care services from inpatient rehabilitation facilities and skilled nursing facilities ($15,888/patient) was significantly higher than the average cost other aspects of DRF care and accounted for 69% of the total DRF-related expenditure among patients who received inpatient rehabilitation. Conclusions Sociodemographic factors, including sex, socioeconomic status, and age, were significantly correlated with the use of post–acute care following isolated DRFs, and post–acute care accounted for a substantial proportion of the total expenditures related to these common injuries among the elderly. Identifying patients who will derive the greatest benefit from post–acute care can inform strategies to improve the cost efficiency of rehabilitation and optimize scarce health care resources. Type of study/level of evidence Therapeutic III.

Purpose In January 2006, the American College of Emergency Physicians released updated guidelines for air transfer. Digit amputation and near-amputation were no longer an indication for this costly service. We analyzed the effect of this update on the use of air transport and associated care outcomes for finger amputation patients and examined factors involved in providing follow-up care for these patients. Methods A retrospective chart review identified all patients treated for traumatic finger amputation between 1995 and 2012 at a major hand trauma referral center. Analysis of available outcome measures was conducted using multiple logistic and linear regression models. Analysis of factors affecting frequency of return visits was performed via negative binomial regression. Results We identified 724 patients with isolated traumatic finger amputations. A total of 267 patients (37%) were transferred from an outside hospital. Patients injured after 2006 were less likely to be transferred via air, with a decrease from 29.5% pre-2006 to 14.9% post-2006. There was no difference in likelihood of replantation success, length of hospital stay, or number of return visits pre- versus post-2006. Patients transferred via helicopter after 2006 were more likely to be younger than 20 years of age and injured in a winter month. Following successful replantation, work-relatedness was associated with a higher number of return visits, whereas increasing age and transfer from farther than 100 miles away were associated with fewer. Conclusions After the American College of Emergency Physicians policy update, decreased use of emergency air transport to a hand trauma referral center for patients with traumatic finger amputations did not adversely affect care delivery and outcomes. These changes may be successfully implemented on a center-by-center basis to reduce costs without detriment to patient care; however, coordination of follow-up care for long-distance transport patients may require special focus when designing policy around referral centers. Type pf study/level of evidence Therapeutic IV.

Purpose Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients. Methods Nineteen patients with C4–8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology. Results Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients’ ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants. Conclusions We built a conceptual model that outlines how patients’ personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills. Clinical relevance To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.

Purpose Outcomes of distal radius fractures can be measured radiographically, functionally, or via patient-rated questionnaires, but previous studies report conflicting results regarding the relationship between these outcomes. Our specific aim was to explore the role that functional outcomes have in the score of the Michigan Hand Outcomes Questionnaire (MHQ), a patient-rated hand instrument. Methods We obtained data for 207 patients. Demographic information was collected as part of the MHQ. Function (wrist motion and grip and pinch strength) was assessed 3 and 6 months after fracture fixation. We applied linear regression analysis to determine each item's contribution to the total MHQ score. Results After we applied linear regression analysis, we determined that 3 months after fixation, all included factors contributed 37% of the MHQ score. Only the grip strength difference between the injured and uninjured hands was significantly associated, contributing 22% of the MHQ score. Six weeks and 6 months after fixation, all included factors contributed 43% and 34%, respectively, of the MHQ score. No individual factors were significant contributors. Conclusions Measured functional outcomes variables account for less than 40% of the total MHQ score. Identifying the unmeasured factors that make up the additional 60% of the total MHQ score would be beneficial in the continued examination of patient-rated outcomes. Furthermore, the use of multiple outcomes assessment modalities should be considered in any study measuring patient-rated outcomes. Type of study/level of evidence Prognostic II.

The table saw is a commonly used tool in both professional and hobby woodworking. Although there are a variety of models available, from portable table-top saws to professional-grade cabinet saws, all table saws have the same basic design: a flat surface through which a saw blade protrudes. The operator of the saw pushes the item to be cut toward and through the rapidly spinning blade. The potential for injury is evident. In addition to contact with the blade, saw operators may be struck by material being kicked back out of the saw or sustain eye or respiratory injuries due to rapidly flying sawdust and other debris. Modern saws have safety features designed to prevent injuries. Underwriters Laboratory 987 Standards for Stationary and Fixed Electric Tools requires that all new saws sold in the US have permanent riving knives to reduce kickback and modular blade guards.1 Riving knives have a barbed end that prevents materials being cut from being thrown back toward the operator. A blade guard is a clear plastic housing that completely covers the blade when not in use. (Figure 1) When an item is pushed toward the blade the blade guard rides up and over the item (Figure 2) and drops down to cover the blade again when the cut is complete. Blade guards prevent contact with the blade from the top, but cannot prevent contact to the front of the blade. Furthermore, the blade guard must be removed to make certain types of cuts. It can also hinder visibility so operators may remove it to make precision cuts. Removing the blade guard is not complicated but replacing it correctly can be time-consuming, requiring the use of tools. For instance, the owners’ manual for a Ryobi 10 in tabletop saw gives the following instructions for removing the blade guard and riving knife: “With the box end of the small hex wrench, loosen the two hex nuts at the base of the riving knife. Remove the riving knife/guard assembly. Retighten the two hex nuts on the base.” However, there are 7 separate steps involved in reinstalling and realigning the riving knife and blade guard assembly.2 This can lead to saw owners leaving the blade guard off permanently. Figure 1 Table saw with blade guard in place Figure 2 Blade guard action while cutting. Note that there is no protection from front-approach blade contact Saw purchasers receive an owners’ manual detailing not only the features and abilities of their new saws, but also safety information. The manual for the previously mentioned Ryobi 10 in saw contains 66 numbered safety points, 7 individual boxed warnings, labeled with the universal exclamation point in triangle symbol, and one illustration with a pun about eye injuries (“Foresight is better than no sight”).2 Even if one were inclined to read the entire owners’ manual, the sheer volume of safety information is overwhelming. Television programs, books, and websites also encourage safe saw usage behaviors, but users must seek this information out individually. Local woodworking clubs may provide instruction and training as well, but these may not be well-advertised. The current safety equipment and instruction is clearly not enough; table saw injuries are still regularly seen in emergency departments and hand surgery clinics. These injuries vary from simple lacerations to amputations and can cost millions in medical care and wage loss. Despite the frequent occurrence of table saw injuries, the topic has not been well explored in the literature. We performed a review of the literature to better describe the epidemiology of these injuries as well as current and future prevention measures.

Purpose Reconstructive surgery for complete brachial plexus avulsion injuries only partially restores function, and many patients are dissatisfied with results that surgeons consider good. Preoperative expectations have been shown to influence postoperative satisfaction but are poorly understood in patients with complete brachial plexus avulsion injuries. Qualitative methodology can elucidate patient beliefs and attitudes, which are difficult to quantify. The purpose of this study was to examine patient-reported outcomes, including satisfaction, and to understand the patient perspective. Methods We used qualitative interviews and questionnaires to assess patient-reported outcomes. Two members of the research team analyzed interview data using Grounded Theory methodology. Data from participants who had and did not have reconstructive surgery were compared. Results Twelve patients participated in this study. Of the 7 participants who had reconstructive surgery, 4 felt their expectations had been met and 5 were satisfied with their outcomes. Reconstruction did not produce statistically significant improvements in upper extremity function, pain, or work ability. All patients reported dissatisfaction with upper extremity ability, and 9 expressed hope for innovative treatments (eg, stem cell therapy, nerve reinsertion) that could potentially provide better outcomes than existing procedures and enable return to work. Conclusions Satisfaction with surgical outcomes after complete avulsion brachial plexus injury depends heavily on whether preoperative expectations are met, but patients are unfamiliar with nerve avulsion and do not always know what to expect. Low satisfaction with upper extremity ability and the lack of statistically significant differences produced by reconstruction suggest that current treatments may not be meeting patients' needs. Physicians must provide robust preoperative education to encourage realistic expectations and direct patients toward resources for pain management to facilitate comprehensive rehabilitation. Type of study/level of evidence Therapeutic III.